Case report
Syphilitic Alopecia: A Report of 5 Cases and a Review of the Literature
Alopecia sifilítica: presentación de 5 casos y revisión de la literatura
P. Hernández-Bel
, B. Unamuno, J.L. Sánchez-Carazo, I. Febrer, V. Alegre
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Servicio de Dermatología, Consorcio Hospital General Universitario de Valencia, Valencia, Spain
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Hernández-Bel, B. Unamuno, J.L. Sánchez-Carazo, I. Febrer, V. Alegre" "autores" => array:5 [ 0 => array:4 [ "nombre" => "P." "apellidos" => "Hernández-Bel" "email" => array:1 [ 0 => "pablohernandezbel@hotmail.com" ] "referencia" => array:1 [ 0 => array:2 [ "etiqueta" => "<span class="elsevierStyleSup">*</span>" "identificador" => "cor0005" ] ] ] 1 => array:2 [ "nombre" => "B." "apellidos" => "Unamuno" ] 2 => array:2 [ "nombre" => "J.L." "apellidos" => "Sánchez-Carazo" ] 3 => array:2 [ "nombre" => "I." "apellidos" => "Febrer" ] 4 => array:2 [ "nombre" => "V." "apellidos" => "Alegre" ] ] "afiliaciones" => array:1 [ 0 => array:2 [ "entidad" => "Servicio de Dermatología, Consorcio Hospital General Universitario de Valencia, Valencia, Spain" "identificador" => "aff0005" ] ] "correspondencia" => array:1 [ 0 => array:3 [ "identificador" => "cor0005" "etiqueta" => "⁎" "correspondencia" => "Corresponding Author." ] ] ] ] "titulosAlternativos" => array:1 [ "es" => array:1 [ "titulo" => "Alopecia sifilítica: presentación de 5 casos y revisión de la literatura" ] ] "resumenGrafico" => array:2 [ "original" => 0 "multimedia" => array:7 [ "identificador" => "fig0010" "etiqueta" => "Figure 2" "tipo" => "MULTIMEDIAFIGURA" "mostrarFloat" => true "mostrarDisplay" => false "figura" => array:1 [ 0 => array:4 [ "imagen" => "gr2.jpeg" "Alto" => 707 "Ancho" => 950 "Tamanyo" => 117519 ] ] "descripcion" => array:1 [ "en" => "<p id="spar0020" class="elsevierStyleSimplePara elsevierViewall">Multiple desquamating lesions in the occipital region associated with extensive, diffuse alopecia in a patient with human immunodeficiency virus infection (case 1).</p>" ] ] ] "textoCompleto" => "<span class="elsevierStyleSections"><span id="sec0005" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0030">Introduction</span><p id="par0005" class="elsevierStylePara elsevierViewall">Syphilis, also known as the great imitator, has not been eradicated and physicians should maintain a high level of diagnostic suspicion.<a class="elsevierStyleCrossRef" href="#bib0005"><span class="elsevierStyleSup">1</span></a> In addition to the usual forms of presentation, very rare cutaneous manifestations can appear and sometimes make diagnosis difficult.<a class="elsevierStyleCrossRef" href="#bib0010"><span class="elsevierStyleSup">2</span></a></p><p id="par0010" class="elsevierStylePara elsevierViewall">Syphilitic alopecia (SA) is an unusual manifestation of syphilis infection we should be familiar with, given the progressive rise in the number of cases of syphilis in Spain in recent years. This increase in the incidence of syphilis means we are more likely to see patients with atypical manifestations or with neurological complications in our routine clinical practice.<a class="elsevierStyleCrossRefs" href="#bib0005"><span class="elsevierStyleSup">1,2</span></a> We present 5 cases of SA and review the literature.</p></span><span id="sec0010" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0035">Case Descriptions</span><p id="par0015" class="elsevierStylePara elsevierViewall">For this study, we gathered all cases of SA diagnosed in the dermatology department of Hospital General Universitario de Valencia, Spain, between May 2007 and May 2011. Of a total of 81 patients diagnosed with syphilis, 57 had secondary syphilis. Alopecia was observed in 6.17% of all 81 cases of syphilis. The most relevant characteristics of the patients with SA are summarized in <a class="elsevierStyleCrossRef" href="#tbl0005">Table 1</a>. All were men aged between 31 and 46 years and, on questioning, all reported high-risk sexual behavior. Serology was positive for reagin and antitreponemal antibodies in all patients, and 2 of them were also found to be positive for human immunodeficiency virus (HIV) infection, a new finding for case 1.</p><elsevierMultimedia ident="tbl0005"></elsevierMultimedia><p id="par0020" class="elsevierStylePara elsevierViewall">Physical examination revealed multiple plaques of nonscarring alopecia, predominantly affecting the parieto-occipital region. The plaques varied in size, did not present signs of inflammation or desquamation, and were not completely devoid of hair—they had the characteristic moth-eaten or patchy appearance (<a class="elsevierStyleCrossRef" href="#fig0005">Fig. 1</a>, A and B). One patient initially presented with diffuse alopecia associated with numerous desquamating erythematous lesions on the scalp (<a class="elsevierStyleCrossRef" href="#fig0010">Fig. 2</a>); after the first dose of antibiotic he developed a Jarisch-Herxheimer reaction with high fever, malaise, generalized joint and muscle pain, and marked worsening of the alopecia. On detailed questioning, the majority of patients reported other associated manifestations that could have suggested syphilis. Patient 4 had been completely unaware of the hair loss, and the diagnosis was made by chance; he presented no other symptoms of syphilis.</p><elsevierMultimedia ident="fig0005"></elsevierMultimedia><elsevierMultimedia ident="fig0010"></elsevierMultimedia><p id="par0025" class="elsevierStylePara elsevierViewall">The skin biopsy in case 1 showed marked hyperkeratosis with areas of follicular keratosis and a diffuse granulomatous dermatitis with the presence of numerous plasma cells.</p><p id="par0030" class="elsevierStylePara elsevierViewall">Histology in case 2 revealed irregular epidermal hyperplasia and a dense lymphohistiocytic inflammatory infiltrate with a lichenoid distribution that was prominent at the dermoepidermal junction. Immune staining showed the presence of numerous spirochetes with evident tropism for blood vessels and the perifollicular epithelium (<a class="elsevierStyleCrossRef" href="#fig0015">Fig. 3</a>).</p><elsevierMultimedia ident="fig0015"></elsevierMultimedia><p id="par0035" class="elsevierStylePara elsevierViewall">The patients who attended follow-up (cases 1 through 4) presented clinical improvement after the intramuscular administration of penicillin G benzathine, 2.4 million units (<a class="elsevierStyleCrossRef" href="#fig0020">Fig. 4</a>, A and B). It was decided to treat case 4 as syphilis of unknown duration and administer a weekly dose for 3 weeks. The serological response was adequate in all of the patients.</p><elsevierMultimedia ident="fig0020"></elsevierMultimedia></span><span id="sec0015" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0040">Discussion</span><p id="par0040" class="elsevierStylePara elsevierViewall">SA is an unusual manifestation that only occurs in 4% of cases of syphilis.<a class="elsevierStyleCrossRef" href="#bib0015"><span class="elsevierStyleSup">3</span></a> In 1940, McCarthy<a class="elsevierStyleCrossRef" href="#bib0020"><span class="elsevierStyleSup">4</span></a> described 2 types of secondary SA, and that classification continues to be used, practically unchanged, to this day. Symptomatic SA is an extremely rare manifestation in which there are associated skin lesions on the scalp, usually in the form of papulosquamous lesions. The second type, essential SA, is characterized by hair loss with no other visible syphilitic lesions on the scalp. Essential SA has 3 distinct clinical patterns<a class="elsevierStyleCrossRefs" href="#bib0015"><span class="elsevierStyleSup">3,5,6</span></a>:</p><p id="par0045" class="elsevierStylePara elsevierViewall"><span class="elsevierStyleItalic">Moth-eaten or patchy</span>: This pattern is the most common and is characterized by the presence of small scattered plaques of nonscarring alopecia that are not completely hairless and show no signs of inflammation or desquamation. The plaques are irregular in size and have poorly defined borders. They occur mainly in the parieto-occipital region, possibly due to a greater load of treponemes because of the rich local blood supply to this area, but they can also arise in other areas of hairy skin, such as the beard, eyelashes, axillas, pubis, trunk, and even on the legs.</p><p id="par0050" class="elsevierStylePara elsevierViewall"><span class="elsevierStyleItalic">Diffuse</span>: In this pattern, alopecia is diffuse, caused by widespread telogen effluvium-type hair loss, and there are no obvious plaques.</p><p id="par0055" class="elsevierStylePara elsevierViewall"><span class="elsevierStyleItalic">Mixed</span>: Small, irregular plaques of alopecia develop on a background of diffuse alopecia.</p><p id="par0060" class="elsevierStylePara elsevierViewall">The moth-eaten pattern is the most common form of presentation on the scalp and is considered one of the most characteristic signs of secondary syphilis.<a class="elsevierStyleCrossRefs" href="#bib0025"><span class="elsevierStyleSup">5,7</span></a> Other clinical entities (e.g., alopecia areata, trichotillomania, or tinea capitis) can also produce localized, nonscarring alopecia that clinically can mimic moth-eaten alopecia.<a class="elsevierStyleCrossRef" href="#bib0015"><span class="elsevierStyleSup">3</span></a> In addition, syphilis must be included in the differential diagnosis when patients have rapid diffuse hair loss of unknown etiology.<a class="elsevierStyleCrossRef" href="#bib0035"><span class="elsevierStyleSup">7</span></a> The diffuse pattern of SA can be considered a reactive phenomenon of the telogen effluvium type rather than a direct effect of the treponeme on the follicle. In primary syphilis, however, hair loss is very rare, and is only seen when the primary chancre occurs on the scalp. Scarring alopecia has been described in patients with tertiary syphilis.<a class="elsevierStyleCrossRef" href="#bib0040"><span class="elsevierStyleSup">8</span></a></p><p id="par0065" class="elsevierStylePara elsevierViewall">The different clinical forms of SA can be associated with systemic manifestations such as general malaise, low-grade fever, lymphadenopathies, asthenia, anorexia, and various mucosal and cutaneous manifestations, some of which are highly characteristics, such as a generalized nonpruritic papulosquamous rash predominantly affecting the trunk, palmoplantar lesions with Biett collarettes, ulceration of the oral mucosa, and condylomata lata. Less commonly, annular figurate plaques with central hyperpigmentation, granulomatous nodules and plaques, and the so-called corona veneris (numerous papules along the frontal hairline) may be observed.<a class="elsevierStyleCrossRef" href="#bib0045"><span class="elsevierStyleSup">9</span></a></p><p id="par0070" class="elsevierStylePara elsevierViewall">SA should be suspected when the typical lesions are present, possibly accompanied by other cutaneous or systemic manifestations; the diagnosis is confirmed by laboratory studies such as serology (reagin and antitreponemal antibodies), which is always positive in secondary syphilis.<a class="elsevierStyleCrossRefs" href="#bib0010"><span class="elsevierStyleSup">2,5</span></a> The histology of SA lesions usually shows preservation of the epidermis with areas of follicular hyperkeratosis. Psoriasiform epidermal hyperplasia with a lichenoid infiltrate has occasionally been reported.<a class="elsevierStyleCrossRef" href="#bib0045"><span class="elsevierStyleSup">9</span></a> Other characteristic features are a marked reduction in the number of terminal hairs in anagen, associated with an increase in the number of hair follicles in telogen and catagen.<a class="elsevierStyleCrossRefs" href="#bib0050"><span class="elsevierStyleSup">10,11</span></a></p><p id="par0075" class="elsevierStylePara elsevierViewall">According to Ackerman,<a class="elsevierStyleCrossRef" href="#bib0060"><span class="elsevierStyleSup">12</span></a> SA should be classified as a nonscarring inflammatory alopecia with the presence of a perivascular and perifollicular lymphohistiocytic dermal infiltrate with plasma cells.<a class="elsevierStyleCrossRef" href="#bib0045"><span class="elsevierStyleSup">9</span></a> A similar pattern can be observed in alopecia areata, but there is a series of findings that are highly suggestive of alopecia areata, such as the presence of miniaturized hair follicles, peribulbar eosinophils, and a honeycomb-pattern lymphocytic infiltrate.<a class="elsevierStyleCrossRefs" href="#bib0035"><span class="elsevierStyleSup">7,9,11</span></a> Recent molecular studies have identified <span class="elsevierStyleItalic">Treponema pallidum</span> in affected follicles, supporting the theory of a specific immunological reaction to the treponemal antigens.<a class="elsevierStyleCrossRef" href="#bib0035"><span class="elsevierStyleSup">7</span></a> Immunohistochemistry can show the presence of spirochetes in the hair follicles, usually in the perifollicular and peribulbar regions, indicating that the treponeme has a direct pathogenic role in alopecia.<a class="elsevierStyleCrossRef" href="#bib0065"><span class="elsevierStyleSup">13</span></a></p><p id="par0080" class="elsevierStylePara elsevierViewall">The therapeutic approach to SA is identical to that for other patients with secondary syphilis.<a class="elsevierStyleCrossRef" href="#bib0030"><span class="elsevierStyleSup">6</span></a> The treatment of choice in immunocompetent individuals is an intramuscular dose of 2.4 million units of penicillin G benzathine.<a class="elsevierStyleCrossRef" href="#bib0015"><span class="elsevierStyleSup">3</span></a> In HIV-infected patients, weekly doses must be administered for 3 weeks.<a class="elsevierStyleCrossRefs" href="#bib0070"><span class="elsevierStyleSup">14,15</span></a> Greater hair loss, and even the possibility of telogen effluvium, have been reported secondary to a Jarisch-Herxheimer reaction after starting treatment (case 1).<a class="elsevierStyleCrossRef" href="#bib0045"><span class="elsevierStyleSup">9</span></a> However, the hair loss is reversible and typically resolves completely within 8 to 12 weeks after treatment.<a class="elsevierStyleCrossRef" href="#bib0015"><span class="elsevierStyleSup">3</span></a> It is important to initiate early treatment to avoid possible late complications, as the association between alopecia and cerebrospinal neurosyphilis has traditionally been assumed.<a class="elsevierStyleCrossRefs" href="#bib0020"><span class="elsevierStyleSup">4,5</span></a></p><p id="par0085" class="elsevierStylePara elsevierViewall">SA may sometimes be the only manifestation of secondary syphilis,<a class="elsevierStyleCrossRefs" href="#bib0025"><span class="elsevierStyleSup">5,6</span></a> as in our case 4, and it is therefore important to maintain a high level of diagnostic suspicion in order to avoid a late or incorrect diagnosis. In patients with other skin manifestations, systematic examination of the scalp and other areas of hairy skin could reveal that SA is more common than is described in the literature and that it is underdiagnosed at the present time.</p><p id="par0090" class="elsevierStylePara elsevierViewall">The dermatologist can play a very important role in the diagnosis of SA. Serological screening for syphilis, in addition to studies of thyroid hormones and antinuclear antibodies, must be performed in all cases of patchy or diffuse alopecia.<a class="elsevierStyleCrossRefs" href="#bib0025"><span class="elsevierStyleSup">5,7</span></a> We consider it important for dermatologists to be aware of this condition in order to correctly identify this type of alopecia and the other cutaneous manifestations as part of a single systemic disease, given that early treatment will lead to complete recovery and will prevent potentially serious complications.<a class="elsevierStyleCrossRefs" href="#bib0070"><span class="elsevierStyleSup">14,16,17</span></a></p></span><span id="sec0020" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0045">Conflicts of Interest</span><p id="par0095" class="elsevierStylePara elsevierViewall">The authors declare that they have no conflicts of interest.</p></span></span>" "textoCompletoSecciones" => array:1 [ "secciones" => array:10 [ 0 => array:3 [ "identificador" => "xres1777513" "titulo" => "Abstract" "secciones" => array:1 [ 0 => array:1 [ "identificador" => "abst0005" ] ] ] 1 => array:2 [ "identificador" => "xpalclavsec1560680" "titulo" => "Keywords" ] 2 => array:3 [ "identificador" => "xres1777512" "titulo" => "Resumen" "secciones" => array:1 [ 0 => array:1 [ "identificador" => "abst0010" ] ] ] 3 => array:2 [ "identificador" => "xpalclavsec1560679" "titulo" => "Palabras clave" ] 4 => array:2 [ "identificador" => "sec0005" "titulo" => "Introduction" ] 5 => array:2 [ "identificador" => "sec0010" "titulo" => "Case Descriptions" ] 6 => array:2 [ "identificador" => "sec0015" "titulo" => "Discussion" ] 7 => array:2 [ "identificador" => "sec0020" "titulo" => "Conflicts of Interest" ] 8 => array:2 [ "identificador" => "xack628114" "titulo" => "Acknowledgments" ] 9 => array:1 [ "titulo" => "References" ] ] ] "pdfFichero" => "main.pdf" "tienePdf" => true "fechaRecibido" => "2011-09-01" "fechaAceptado" => "2012-02-18" "PalabrasClave" => array:2 [ "en" => array:1 [ 0 => array:4 [ "clase" => "keyword" "titulo" => "Keywords" "identificador" => "xpalclavsec1560680" "palabras" => array:3 [ 0 => "Alopecia" 1 => "Syphilis" 2 => "Lues" ] ] ] "es" => array:1 [ 0 => array:4 [ "clase" => "keyword" "titulo" => "Palabras clave" "identificador" => "xpalclavsec1560679" "palabras" => array:3 [ 0 => "Alopecia" 1 => "Sífilis" 2 => "Lúes" ] ] ] ] "tieneResumen" => true "resumen" => array:2 [ "en" => array:2 [ "titulo" => "Abstract" "resumen" => "<span id="abst0005" class="elsevierStyleSection elsevierViewall"><p id="spar0005" class="elsevierStyleSimplePara elsevierViewall">Syphilitic alopecia occurs in only 4% of patients with syphilis. We present 5 cases of this uncommon manifestation and review the corresponding literature. All of the patients in our series were men aged between 31 and 46 years. The lesions, which were located mainly in the parieto-occipital area of the scalp, manifested as multiple, irregular, nonscarring patches of alopecia that adopted a characteristic patchy moth-eaten pattern. One patient initially presented diffuse alopecia with multiple erythematous scaling lesions. Immunohistochemical staining revealed the presence of numerous spirochetes in the hair follicles in the 2 patients in whom skin biopsy was performed. The lesions improved with treatment in all the patients who attended follow-up. Dermatologists should maintain a high level of clinical suspicion for this uncommon manifestation of syphilis, particularly when it is the only symptom.</p></span>" ] "es" => array:2 [ "titulo" => "Resumen" "resumen" => "<span id="abst0010" class="elsevierStyleSection elsevierViewall"><p id="spar0010" class="elsevierStyleSimplePara elsevierViewall">La alopecia sifilítica es una manifestación infrecuente de la sífilis, que solo aparece en un 4% de los pacientes. Presentamos 5 casos de alopecia sifilítica y realizamos una revisión de la literatura. Todos los pacientes eran varones, con edades comprendidas entre los 31 y los 46 años. Las lesiones consistían en múltiples placas alopécicas de predominio en la región parietooccipital, irregulares, no cicatriciales, que adoptaban el característico patrón apolillado o en trasquilones. Un paciente comenzó con una alopecia difusa asociada a múltiples lesiones eritematosas y descamativas en el cuero cabelludo. En los 2 casos en que se realizó biopsia cutánea se detectó, mediante tinciones inmunohistoquímicas, la presencia de numerosas espiroquetas en el folículo piloso. Todos los pacientes en seguimiento clínico mejoraron sus lesiones tras el tratamiento. Los dermatólogos deben estar alerta ante esta manifestación infrecuente de la enfermedad, que todavía adquiere mayor relevancia clínica cuando aparece de forma aislada.</p></span>" ] ] "NotaPie" => array:1 [ 0 => array:2 [ "etiqueta" => "☆" "nota" => "<p class="elsevierStyleNotepara" id="npar0005">Please cite this article as: Hernández-Bel P, et al. Alopecia sifilítica: presentación de 5 casos y revisión de la literatura. Actas Dermosifiliogr. 2013;104:512–7.</p>" ] ] "multimedia" => array:5 [ 0 => array:7 [ "identificador" => "fig0005" "etiqueta" => "Figure 1" "tipo" => "MULTIMEDIAFIGURA" "mostrarFloat" => true "mostrarDisplay" => false "figura" => array:1 [ 0 => array:4 [ "imagen" => "gr1.jpeg" "Alto" => 1996 "Ancho" => 950 "Tamanyo" => 352840 ] ] "descripcion" => array:1 [ "en" => "<p id="spar0015" class="elsevierStyleSimplePara elsevierViewall">Characteristic plaques of alopecia in the parieto-occipital region of 2 patients. A, Moth-eaten alopecia (case 2). B, Patchy alopecia (case 5).</p>" ] ] 1 => array:7 [ "identificador" => "fig0010" "etiqueta" => "Figure 2" "tipo" => "MULTIMEDIAFIGURA" "mostrarFloat" => true "mostrarDisplay" => false "figura" => array:1 [ 0 => array:4 [ "imagen" => "gr2.jpeg" "Alto" => 707 "Ancho" => 950 "Tamanyo" => 117519 ] ] "descripcion" => array:1 [ "en" => "<p id="spar0020" class="elsevierStyleSimplePara elsevierViewall">Multiple desquamating lesions in the occipital region associated with extensive, diffuse alopecia in a patient with human immunodeficiency virus infection (case 1).</p>" ] ] 2 => array:7 [ "identificador" => "fig0015" "etiqueta" => "Figure 3" "tipo" => "MULTIMEDIAFIGURA" "mostrarFloat" => true "mostrarDisplay" => false "figura" => array:1 [ 0 => array:4 [ "imagen" => "gr3.jpeg" "Alto" => 706 "Ancho" => 950 "Tamanyo" => 149750 ] ] "descripcion" => array:1 [ "en" => "<p id="spar0025" class="elsevierStyleSimplePara elsevierViewall">Biopsy from case 2. Numerous spirochetes can be seen invading the hair follicle. There is marked epidermal and perifollicular epitheliotropism (immunohistochemistry stain for antitreponemal antibodies, original magnification ×<span class="elsevierStyleHsp" style=""></span>200).</p>" ] ] 3 => array:7 [ "identificador" => "fig0020" "etiqueta" => "Figure 4" "tipo" => "MULTIMEDIAFIGURA" "mostrarFloat" => true "mostrarDisplay" => false "figura" => array:1 [ 0 => array:4 [ "imagen" => "gr4.jpeg" "Alto" => 2574 "Ancho" => 950 "Tamanyo" => 465012 ] ] "descripcion" => array:1 [ "en" => "<p id="spar0030" class="elsevierStyleSimplePara elsevierViewall">Case 4. A, Moth-eaten alopecia prior to treatment. B, Follow-up 3 months after treatment shows marked improvement.</p>" ] ] 4 => array:7 [ "identificador" => "tbl0005" "etiqueta" => "Table 1" "tipo" => "MULTIMEDIATABLA" "mostrarFloat" => true "mostrarDisplay" => false "tabla" => array:1 [ "tablatextoimagen" => array:1 [ 0 => array:1 [ "tabla" => array:1 [ 0 => """ <table border="0" frame="\n \t\t\t\t\tvoid\n \t\t\t\t" class=""><thead title="thead"><tr title="table-row"><th class="td" title="\n \t\t\t\t\ttable-head\n \t\t\t\t " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t" scope="col" style="border-bottom: 2px solid black">Case \t\t\t\t\t\t\n \t\t\t\t\t\t</th><th class="td" title="\n \t\t\t\t\ttable-head\n \t\t\t\t " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t" scope="col" style="border-bottom: 2px solid black">Age, y/Sex \t\t\t\t\t\t\n \t\t\t\t\t\t</th><th class="td" title="\n \t\t\t\t\ttable-head\n \t\t\t\t " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t" scope="col" style="border-bottom: 2px solid black">Sexual Behavior \t\t\t\t\t\t\n \t\t\t\t\t\t</th><th class="td" title="\n \t\t\t\t\ttable-head\n \t\t\t\t " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t" scope="col" style="border-bottom: 2px solid black">Serology \t\t\t\t\t\t\n \t\t\t\t\t\t</th><th class="td" title="\n \t\t\t\t\ttable-head\n \t\t\t\t " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t" scope="col" style="border-bottom: 2px solid black">Duration of the Alopecia \t\t\t\t\t\t\n \t\t\t\t\t\t</th><th class="td" title="\n \t\t\t\t\ttable-head\n \t\t\t\t " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t" scope="col" style="border-bottom: 2px solid black">Associated Lesions \t\t\t\t\t\t\n \t\t\t\t\t\t</th><th class="td" title="\n \t\t\t\t\ttable-head\n \t\t\t\t " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t" scope="col" style="border-bottom: 2px solid black">Type of Syphilitic Alopecia \t\t\t\t\t\t\n \t\t\t\t\t\t</th><th class="td" title="\n \t\t\t\t\ttable-head\n \t\t\t\t " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t" scope="col" style="border-bottom: 2px solid black">Biopsy \t\t\t\t\t\t\n \t\t\t\t\t\t</th><th class="td" title="\n \t\t\t\t\ttable-head\n \t\t\t\t " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t" scope="col" style="border-bottom: 2px solid black">Treatment \t\t\t\t\t\t\n \t\t\t\t\t\t</th><th class="td" title="\n \t\t\t\t\ttable-head\n \t\t\t\t " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t" scope="col" style="border-bottom: 2px solid black">Follow-up at 3 Months \t\t\t\t\t\t\n \t\t\t\t\t\t</th></tr></thead><tbody title="tbody"><tr title="table-row"><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">1 \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">41/male \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">Homosexual \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">RPR 1/32TPHA (+)HIV (+) \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">2 months \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">Papular-necrotic lesions on the trunkPalmoplantar lesions \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">Symptomatic SA \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">Spirochetesin the hair follicle \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">Three doses of penicillin G benzathine 2.4<span class="elsevierStyleHsp" style=""></span>×<span class="elsevierStyleHsp" style=""></span>10<span class="elsevierStyleSup">6</span> IU \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">Clinical resolutionRPR 1/4 \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">2 \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">46/male \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">Homosexual \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">RPR 1/32TPHA (+)HIV (+) \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">2 weeks \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">Fever and myalgiaUlcer on glans penisPalmoplantar lesionsRash on the trunk \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">Essential SAMoth-eaten pattern \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">Spirochetes in the hair follicle \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">Three doses of penicillin G benzathine 2.4<span class="elsevierStyleHsp" style=""></span>×<span class="elsevierStyleHsp" style=""></span>10<span class="elsevierStyleSup">6</span> IU \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">Clinical resolutionRPR 1/2 \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">3 \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">40/male \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">Unknown \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">RPR 1/32TPHA (+)HIV (-) \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">1 month \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">Oral ulcerPalmoplantar lesions \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">Essential SAMixed pattern \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">Not performed \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">Single dose of penicillin G benzathine 2.4<span class="elsevierStyleHsp" style=""></span>×<span class="elsevierStyleHsp" style=""></span>10<span class="elsevierStyleSup">6</span> IU \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">Clinical resolutionRPR negative \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">4 \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">34/male \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">Heterosexual contactwith prostitutes \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">RPR 1/16TPHA (+)HIV (-) \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">Unknown \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">No \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">Essential SAMoth-eaten pattern \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">Not performed \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">Three doses of penicillin G benzathine 2.4<span class="elsevierStyleHsp" style=""></span>×<span class="elsevierStyleHsp" style=""></span>10<span class="elsevierStyleSup">6</span> IU \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">Clinical resolutionRPR 1/4 \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">5 \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">31/male \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">Heterosexual \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">RPR 1/32TPHA (+)HIV (-) \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">1 month \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">Ulcer on glans penisPalmoplantar lesionsRash on the trunk \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">Essential SAMoth-eaten pattern \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">Not performed \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">Single dose of penicillin G benzathine 2.4<span class="elsevierStyleHsp" style=""></span>×<span class="elsevierStyleHsp" style=""></span>10<span class="elsevierStyleSup">6</span> IU \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">Unknown \t\t\t\t\t\t\n \t\t\t\t</td></tr></tbody></table> """ ] ] ] ] "descripcion" => array:1 [ "en" => "<p id="spar0035" class="elsevierStyleSimplePara elsevierViewall">Characteristics in the 5 Cases of Syphilitic Alopecia.</p>" ] ] ] "bibliografia" => array:2 [ "titulo" => "References" "seccion" => array:1 [ 0 => array:2 [ "identificador" => "bibs0005" "bibliografiaReferencia" => array:17 [ 0 => array:3 [ "identificador" => "bib0005" "etiqueta" => "1" "referencia" => array:1 [ 0 => array:2 [ "contribucion" => array:1 [ 0 => array:2 [ "titulo" => "El resurgir de la sífilis" "autores" => array:1 [ 0 => array:2 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"serieFecha" => "2005" ] ] ] ] ] ] ] ] ] ] "agradecimientos" => array:1 [ 0 => array:4 [ "identificador" => "xack628114" "titulo" => "Acknowledgments" "texto" => "<p id="par0100" class="elsevierStylePara elsevierViewall">We would like to thank Drs Javier López, Juan Vilata, Antonio Martínez, and Juan Ignacio Marí for their collaboration in some of the cases.</p><p id="par0105" class="elsevierStylePara elsevierViewall">We would also like to thank Dr. Arantxa Torrijos for her critical reading of the article and her valuable corrections.</p>" "vista" => "all" ] ] ] "idiomaDefecto" => "en" "url" => "/15782190/0000010400000006/v2_202210010908/S1578219013001212/v2_202210010908/en/main.assets" "Apartado" => array:4 [ "identificador" => "6183" "tipo" => "SECCION" "en" => array:2 [ "titulo" => "Case Reports" "idiomaDefecto" => true ] "idiomaDefecto" => "en" ] "PDF" => "https://static.elsevier.es/multimedia/15782190/0000010400000006/v2_202210010908/S1578219013001212/v2_202210010908/en/main.pdf?idApp=UINPBA000044&text.app=https://actasdermo.org/" "EPUB" => "https://multimedia.elsevier.es/PublicationsMultimediaV1/item/epub/S1578219013001212?idApp=UINPBA000044" ]
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| 2024 Junio | 258 | 97 | 355 |
| 2024 Mayo | 236 | 63 | 299 |
| 2024 Abril | 236 | 43 | 279 |
| 2024 Marzo | 280 | 54 | 334 |
| 2024 Febrero | 333 | 38 | 371 |
| 2024 Enero | 385 | 49 | 434 |
| 2023 Diciembre | 309 | 31 | 340 |
| 2023 Noviembre | 321 | 61 | 382 |
| 2023 Octubre | 249 | 53 | 302 |
| 2023 Septiembre | 284 | 45 | 329 |
| 2023 Agosto | 204 | 38 | 242 |
| 2023 Julio | 236 | 68 | 304 |
| 2023 Junio | 232 | 39 | 271 |
| 2023 Mayo | 193 | 67 | 260 |
| 2023 Abril | 145 | 39 | 184 |
| 2023 Marzo | 259 | 61 | 320 |
| 2023 Febrero | 182 | 42 | 224 |
| 2023 Enero | 167 | 71 | 238 |
| 2022 Diciembre | 157 | 66 | 223 |
| 2022 Noviembre | 118 | 53 | 171 |
| 2022 Octubre | 135 | 44 | 179 |
| 2022 Septiembre | 135 | 57 | 192 |
| 2022 Agosto | 72 | 29 | 101 |
| 2022 Julio | 50 | 69 | 119 |
| 2022 Junio | 53 | 70 | 123 |
| 2022 Mayo | 174 | 70 | 244 |
| 2022 Abril | 272 | 65 | 337 |
| 2022 Marzo | 282 | 86 | 368 |
| 2022 Febrero | 278 | 54 | 332 |
| 2022 Enero | 351 | 79 | 430 |
| 2021 Diciembre | 240 | 57 | 297 |
| 2021 Noviembre | 281 | 78 | 359 |
| 2021 Octubre | 256 | 103 | 359 |
| 2021 Septiembre | 247 | 74 | 321 |
| 2021 Agosto | 328 | 62 | 390 |
| 2021 Julio | 244 | 80 | 324 |
| 2021 Junio | 286 | 67 | 353 |
| 2021 Mayo | 247 | 82 | 329 |
| 2021 Abril | 994 | 158 | 1152 |
| 2021 Marzo | 452 | 76 | 528 |
| 2021 Febrero | 241 | 84 | 325 |
| 2021 Enero | 223 | 51 | 274 |
| 2020 Diciembre | 236 | 48 | 284 |
| 2020 Noviembre | 171 | 39 | 210 |
| 2020 Octubre | 185 | 40 | 225 |
| 2020 Septiembre | 226 | 34 | 260 |
| 2020 Agosto | 171 | 31 | 202 |
| 2020 Julio | 130 | 28 | 158 |
| 2020 Junio | 139 | 42 | 181 |
| 2020 Mayo | 133 | 41 | 174 |
| 2020 Abril | 87 | 47 | 134 |
| 2020 Marzo | 49 | 33 | 82 |
| 2020 Febrero | 6 | 12 | 18 |
| 2020 Enero | 3 | 11 | 14 |
| 2019 Diciembre | 8 | 5 | 13 |
| 2019 Noviembre | 4 | 5 | 9 |
| 2019 Octubre | 0 | 17 | 17 |
| 2019 Septiembre | 8 | 29 | 37 |
| 2019 Agosto | 4 | 11 | 15 |
| 2019 Julio | 4 | 14 | 18 |
| 2019 Junio | 6 | 18 | 24 |
| 2019 Mayo | 4 | 17 | 21 |
| 2019 Abril | 2 | 19 | 21 |
| 2019 Marzo | 2 | 13 | 15 |
| 2019 Febrero | 2 | 10 | 12 |
| 2019 Enero | 5 | 10 | 15 |
| 2018 Diciembre | 1 | 11 | 12 |
| 2018 Noviembre | 4 | 0 | 4 |
| 2018 Octubre | 4 | 0 | 4 |
| 2018 Septiembre | 1 | 0 | 1 |
| 2018 Abril | 0 | 4 | 4 |
| 2018 Marzo | 14 | 3 | 17 |
| 2018 Febrero | 336 | 5 | 341 |
| 2018 Enero | 342 | 7 | 349 |
| 2017 Diciembre | 274 | 8 | 282 |
| 2017 Noviembre | 319 | 9 | 328 |
| 2017 Octubre | 306 | 5 | 311 |
| 2017 Septiembre | 235 | 20 | 255 |
| 2017 Agosto | 270 | 19 | 289 |
| 2017 Julio | 236 | 12 | 248 |
| 2017 Junio | 291 | 29 | 320 |
| 2017 Mayo | 276 | 28 | 304 |
| 2017 Abril | 221 | 21 | 242 |
| 2017 Marzo | 255 | 66 | 321 |
| 2017 Febrero | 242 | 19 | 261 |
| 2017 Enero | 320 | 17 | 337 |
| 2016 Diciembre | 441 | 19 | 460 |
| 2016 Noviembre | 561 | 17 | 578 |
| 2016 Octubre | 530 | 15 | 545 |
| 2016 Septiembre | 625 | 24 | 649 |
| 2016 Agosto | 576 | 10 | 586 |
| 2016 Julio | 254 | 7 | 261 |
| 2016 Junio | 7 | 15 | 22 |
| 2016 Mayo | 6 | 21 | 27 |
| 2016 Abril | 4 | 14 | 18 |
| 2016 Marzo | 4 | 4 | 8 |
| 2016 Febrero | 8 | 1 | 9 |
| 2016 Enero | 7 | 2 | 9 |
| 2015 Diciembre | 9 | 3 | 12 |
| 2015 Noviembre | 33 | 16 | 49 |
| 2015 Octubre | 23 | 1 | 24 |
| 2015 Septiembre | 11 | 9 | 20 |
| 2015 Agosto | 13 | 1 | 14 |
| 2015 Julio | 338 | 20 | 358 |
| 2015 Junio | 260 | 11 | 271 |
| 2015 Mayo | 222 | 12 | 234 |
| 2015 Abril | 268 | 5 | 273 |
| 2015 Marzo | 333 | 6 | 339 |
| 2015 Febrero | 333 | 4 | 337 |
| 2015 Enero | 275 | 6 | 281 |
| 2014 Diciembre | 222 | 5 | 227 |
| 2014 Noviembre | 191 | 6 | 197 |
| 2014 Octubre | 193 | 3 | 196 |
| 2014 Septiembre | 154 | 3 | 157 |
| 2014 Agosto | 160 | 16 | 176 |
| 2014 Julio | 153 | 6 | 159 |
| 2014 Junio | 139 | 9 | 148 |
| 2014 Mayo | 104 | 12 | 116 |
| 2014 Abril | 91 | 5 | 96 |
| 2014 Marzo | 71 | 15 | 86 |
| 2014 Febrero | 60 | 2 | 62 |
| 2014 Enero | 55 | 13 | 68 |
| 2013 Diciembre | 68 | 11 | 79 |
| 2013 Noviembre | 45 | 5 | 50 |
| 2013 Octubre | 15 | 3 | 18 |
| 2013 Septiembre | 4 | 5 | 9 |
| 2013 Agosto | 3 | 4 | 7 |
| 2013 Julio | 6 | 4 | 10 |
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