A 73-year-old woman being monitored for psoriasis received acitretin therapy reported increased hair loss with diffuse thinning and curling of her hair (figure 1A). On examination, her hair appeared dry, curly, and lackluster, and the trichoscopy revealed flattened and twisted shafts. The patient insisted that she had previously had straight hair and due to the possible association with the start of systemic therapy, we replaced acitretin with apremilast, which solved the case 6 months later (figure 1B). The progressive and acquired curling of the hair is considered a variant of woolly hair, and occurs due to a change in the inner root sheath of the hair follicle. Although it is more common in men, some cases have also been reported in postmenopausal women associated with the use of oral retinoids (mainly acitretin, etretinate, alitretinoin, and isotretinoin), which resolve 3 to 6 months after discontinuing the drug. Clinically, it is characterized by the appearance of curly, fine, and flattened hairs with longitudinal twists. Pili torti is defined as a flattened and twisted hair shaft on its own axis with angles of 90°, 180°, and up to 360°. Acquired cases are also associated with the use of oral retinoids, mainly isotretinoin.
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