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She came to our clinic because of severe pain and thickening of the scalp&#44; which had started some 3 months earlier&#44; and more recent hair loss in the occipital region&#46; Three weeks earlier&#44; the patient had visited the emergency department of our hospital complaining of severe scalp pain&#46; A computed tomography scan revealed asymmetry in soft tissue volumes&#44; with significant thickening of the subcutaneous layer &#40;3&#46;12<span class="elsevierStyleHsp" style=""></span>cm&#41; in the vertex and left occipital area &#40;<a class="elsevierStyleCrossRef" href="#fig0005">Fig&#46; 1</a>&#41;&#46;</p><elsevierMultimedia ident="fig0005"></elsevierMultimedia><p id="par0015" class="elsevierStylePara elsevierViewall">On physical examination&#44; the skin of the parieto-occipital area was found to be edematous and boggy&#44; and 2 hairless patches each measuring about 2<span class="elsevierStyleHsp" style=""></span>&#215;<span class="elsevierStyleHsp" style=""></span>2<span class="elsevierStyleHsp" style=""></span>cm and similar in appearance to alopecia areata plaques were observed in the left parietal region&#46; There were also several psoriatic lesions on the scalp&#44; which the patient said had been stable without treatment for several months &#40;<a class="elsevierStyleCrossRef" href="#fig0010">Fig&#46; 2</a>&#41;&#46;</p><elsevierMultimedia ident="fig0010"></elsevierMultimedia><p id="par0020" class="elsevierStylePara elsevierViewall">A particularly thick area of the subcutaneous tissue in the left occipital area was biopsied&#46; Histology showed thickened subcutaneous fatty tissue&#44; dermal edema&#44; and a mild perivascular lymphocytic infiltrate in the superficial dermis&#46; There was no evidence of an increase in mucin deposition in the dermis or subcutaneous tissue&#46; Epidermal hyperplasia and keratin plugs in the follicular infundibula were observed&#46; The number of terminal hair follicles in the anagen phase was normal&#44; and dermal blood vessels were telangiectatic &#40;<a class="elsevierStyleCrossRef" href="#fig0015">Fig&#46; 3</a>&#41;&#46; No significant abnormalities were found in the blood count&#44; biochemistry&#44; antinuclear antibody test&#44; or thyroid profile&#46; On the basis of this evidence&#44; the diagnosis was lipedematous scalp with areas of lipedematous alopecia&#46;</p><elsevierMultimedia ident="fig0015"></elsevierMultimedia><p id="par0025" class="elsevierStylePara elsevierViewall">The alopecic plaques and psoriatic lesions were treated with a topical corticosteroid&#44; and hair regrowth was evident within 6 weeks&#46; Oral nonsteroidal antiinflammatory drugs were prescribed for pain control&#44; to be taken as needed&#46;</p><p id="par0030" class="elsevierStylePara elsevierViewall">On follow-up at 9 months&#44; no alopecia was evident&#44; and the pain had lessened considerably&#46; At her final visit&#44; the patient reported that she had had surgery for chronic right-arm lymphedema &#40;a side effect of her breast cancer surgery&#41; with a very satisfactory functional outcome some 6 weeks earlier&#44; and that the scalp discomfort had disappeared entirely&#46;</p><p id="par0035" class="elsevierStylePara elsevierViewall">Lipedematous scalp was first described in a black woman in 1935 by Cornbleet&#46;<a class="elsevierStyleCrossRef" href="#bib0010"><span class="elsevierStyleSup">2</span></a> In 1961&#44; reporting the cases of 2 black women&#44; Coskey et al&#46;<a class="elsevierStyleCrossRef" href="#bib0015"><span class="elsevierStyleSup">3</span></a> coined the term <span class="elsevierStyleItalic">lipedematous alopecia</span> to refer to thickening of the subcutaneous tissue on the scalp coinciding with the inability of the hair to grow more than 2<span class="elsevierStyleHsp" style=""></span>cm&#46; To date only 19 cases of lipedematous alopecia and 16 cases of lipedematous scalp have been reported &#40;<a class="elsevierStyleCrossRef" href="#tbl0005">Table 1</a>&#41;&#44; none associated with any pathology of relevance&#46; In addition to a localized or generalized thickening of subcutaneous tissue&#44; patients may report diffuse pain&#44; numbness&#44; and itching&#46; The thickness of subcutaneous tissue can be measured using ultrasound&#44; magnetic resonance&#44; or computed tomography&#59; a normal thickness in healthy adults is 5&#46;8 <span class="elsevierStyleHsp" style=""></span>&#177;<span class="elsevierStyleHsp" style=""></span>0&#46;12<span class="elsevierStyleHsp" style=""></span>mm at the bregma&#46; Lipedematous scalp and lipedematous alopecia are probably underdiagnosed&#59; indeed&#44; there is still no agreement on whether they are different processes or simply different stages of the same process&#46;<a class="elsevierStyleCrossRef" href="#bib0005"><span class="elsevierStyleSup">1</span></a></p><elsevierMultimedia ident="tbl0005"></elsevierMultimedia><p id="par0040" class="elsevierStylePara elsevierViewall">Histological findings for lipedematous alopecia are a thickening of the subcutaneous cell tissue&#44; variable dermal edema&#44; a perivascular lymphocytic infiltrate&#44; an absence of abnormal deposition&#44; no evidence of panniculitis&#44; epidermal hyperplasia&#44; and keratin plugs in the follicular infundibula&#46; Terminal hair follicles may be reduced in number or preserved&#46; Dermal blood vessels are often dilated and telangiectatic in appearance&#46;<a class="elsevierStyleCrossRef" href="#bib0020"><span class="elsevierStyleSup">4</span></a></p><p id="par0045" class="elsevierStylePara elsevierViewall">The pathogenesis of lipedematous scalp and lipedematous alopecia is unknown&#46; Some authors have suggested that there may be a hormonal factor because most cases are diagnosed in women&#46; Race&#44; once thought to be a key factor&#44; is now considered less important because of the growing number of cases reported in white&#44;<a class="elsevierStyleCrossRef" href="#bib0025"><span class="elsevierStyleSup">5</span></a> Asian&#44;<a class="elsevierStyleCrossRef" href="#bib0030"><span class="elsevierStyleSup">6</span></a> and Middle Eastern<a class="elsevierStyleCrossRef" href="#bib0035"><span class="elsevierStyleSup">7</span></a> women&#46;</p><p id="par0050" class="elsevierStylePara elsevierViewall">One theory proposed to explain hair loss is that the thickening of the subcutaneous tissue may place pressure on the hair follicles&#44; restricting hair growth or shortening anagen cycles&#46;<a class="elsevierStyleCrossRef" href="#bib0040"><span class="elsevierStyleSup">8</span></a> Lymph vessels were dilated in our patient&#44; and Mart&#237;n et al<a class="elsevierStyleCrossRef" href="#bib0045"><span class="elsevierStyleSup">9</span></a> reported the same for 2 patients with lipedematous alopecia&#44; suggesting that this effect might play an important role in the pathogenesis of the alopecia&#46; Regarding the association with other systemic diseases&#44; cases have been reported of patients with a history of diabetes mellitus&#44;<a class="elsevierStyleCrossRef" href="#bib0015"><span class="elsevierStyleSup">3</span></a> joint and skin hyperelasticity&#44; and acute kidney failure&#46;<a class="elsevierStyleCrossRef" href="#bib0040"><span class="elsevierStyleSup">8</span></a></p><p id="par0055" class="elsevierStylePara elsevierViewall">No case has been reported to date of lipedematous alopecia in a patient with comorbid scalp psoriasis or a history of malignancy&#46; Noteworthy in our patient was the intense scalp pain&#44; the very thick subcutaneous layer&#44; the rapid resolution of the alopecic plaques&#44; and the favorable course after surgical treatment of the chronic lymphedema of the arm&#46; Since the patient was already responding to treatment we do not know if the apparently favorable post-surgical response was a coincidence or whether&#44; given the histological evidence of dilated lymph vessels&#44; there was an actual causal relationship between the events&#46;</p></span>"
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        "etiqueta" => "&#9734;"
        "nota" => "<p class="elsevierStyleNotepara">Please cite this article as&#58; V&#46; Fuentelsaz-del Barrio&#44; V&#46; Parra-Blanco&#44; P&#46; Borreg&#243;n-Nofuentes&#44; R&#46; Su&#225;rez-Fern&#225;ndez&#46; Alopecia lipedematosa concomitante con psoriasis del cuero cabelludo&#46; Actas Dermosifiliogr&#46; 2012&#59;103&#58;551-4&#46;</p>"
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        "identificador" => "fig0005"
        "etiqueta" => "Figure 1"
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          "en" => "<p id="spar0005" class="elsevierStyleSimplePara elsevierViewall">Computed tomography scan showing thickening &#40;3&#46;12<span class="elsevierStyleHsp" style=""></span>cm&#41; of the subcutaneous cell tissue in the left occipital area of the scalp&#46;</p>"
        ]
      ]
      1 => array:7 [
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        "etiqueta" => "Figure 2"
        "tipo" => "MULTIMEDIAFIGURA"
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        "figura" => array:1 [
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        "descripcion" => array:1 [
          "en" => "<p id="spar0010" class="elsevierStyleSimplePara elsevierViewall">Clinical image of an alopecic plaque in the left parietal region&#46;</p>"
        ]
      ]
      2 => array:7 [
        "identificador" => "fig0015"
        "etiqueta" => "Figure 3"
        "tipo" => "MULTIMEDIAFIGURA"
        "mostrarFloat" => true
        "mostrarDisplay" => false
        "figura" => array:1 [
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            "imagen" => "gr3.jpeg"
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        "descripcion" => array:1 [
          "en" => "<p id="spar0015" class="elsevierStyleSimplePara elsevierViewall">A&#44; Biopsy of the scalp showing the thickened layer of subcutaneous cell tissue with normal follicle morphology &#40;H&#38;E&#44; original magnification x4&#41;&#46; B&#44; Epidermal hyperplasia with keratin plugs in the follicular infundibula &#40;H&#38;E&#44; original magnification x20&#41;&#46; C&#44; Dilated dermal blood vessels with a telangiectatic appearance &#40;H&#38;E&#44; original magnification x10&#41;&#46; D&#44; No evidence of abnormal deposition or panniculitis &#40;H&#38;E&#44; original magnification x10&#41;&#46; Abbreviation&#58; H&#38;E&#44; hematoxylin-eosin&#46;</p>"
        ]
      ]
      3 => array:7 [
        "identificador" => "tbl0005"
        "etiqueta" => "Table 1"
        "tipo" => "MULTIMEDIATABLA"
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        "tabla" => array:2 [
          "leyenda" => "<p id="spar0025" class="elsevierStyleSimplePara elsevierViewall">Abbreviations&#58; Asn&#44; Asian&#59; Blk&#44; Black&#59; Egy&#44; Egyptian&#59; F&#44; female&#59; Ira&#44; Iranian&#59; LA&#44; lipedematous alopecia&#59; LS&#44; lipedematous scalp&#59; M&#44; male&#59; Wh&#44; White&#46;</p>"
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            0 => array:2 [
              "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"><td 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" style="border-bottom: 2px solid black">Author&#47;Year&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td 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" style="border-bottom: 2px solid black">Condition&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td 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" style="border-bottom: 2px solid black">Patient Characteristics&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td 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" style="border-bottom: 2px solid black">Duration&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td 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" style="border-bottom: 2px solid black">Thickness&#44; mm&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td 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" style="border-bottom: 2px solid black">History&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></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">Cornbleet<a class="elsevierStyleCrossRef" href="#bib0010"><span class="elsevierStyleSup">2</span></a>&#47;1935&nbsp;\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">LS&nbsp;\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">F&#47;Blk&#47;44 y&nbsp;\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">6 y&nbsp;\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">-&nbsp;\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">None&nbsp;\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">Coskey et al&#46;<a class="elsevierStyleCrossRef" href="#bib0015"><span class="elsevierStyleSup">3</span></a>&#47;1961&nbsp;\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">LALA&nbsp;\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">F&#47;Blk&#47;28 yF&#47;Blk&#47;75 y&nbsp;\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 y1 y&nbsp;\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">1510&nbsp;\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">Diabetes mellitus&nbsp;\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">Curtis and Heising&#47;1964&nbsp;\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">LA&nbsp;\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">F&#47;Blk&#47;62 y&nbsp;\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">15 y&nbsp;\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">15&nbsp;\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">Skin and joint hyperelasticity&nbsp;\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">Lee et al&#46;&#47;1994&nbsp;\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">LS&nbsp;\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">F&#47;Blk&#47;32 y&nbsp;\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">3 y&nbsp;\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">10&#46;7&nbsp;\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">None&nbsp;\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">Kane et al&#46;&#47;1998&nbsp;\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">LA&nbsp;\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">F&#47;Blk&#47;49 y&nbsp;\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">4 mo&nbsp;\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">12&#46;6&nbsp;\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">None&nbsp;\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">Fair el al&#46;<a class="elsevierStyleCrossRef" href="#bib0020"><span class="elsevierStyleSup">4</span></a>&#47;2000&nbsp;\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">LA&nbsp;\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">F&#47;Blk&#47;18 y&nbsp;\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">6 mo&nbsp;\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">9&nbsp;\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">None&nbsp;\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">Bridges et al&#46;<a class="elsevierStyleCrossRef" href="#bib0040"><span class="elsevierStyleSup">8</span></a>&#47;2000&nbsp;\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">LA&nbsp;\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">F&#47;Blk&#47;48 y&nbsp;\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">6 y&nbsp;\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">12&nbsp;\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">Kidney failure&nbsp;\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">Ikejima et al&#46;<a class="elsevierStyleCrossRef" href="#bib0030"><span class="elsevierStyleSup">6</span></a>&#47;2000&nbsp;\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">LA&nbsp;\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">M&#47;Asn&#47;30 y&nbsp;\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">7 y&nbsp;\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">16&nbsp;\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">None&nbsp;\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">Tiscornia et al&#46;<a class="elsevierStyleCrossRef" href="#bib0025"><span class="elsevierStyleSup">5</span></a>&#47;2002&nbsp;\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">LA&nbsp;\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">F&#47;Wh&#47;69 y&nbsp;\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">6 mo&nbsp;\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">10&nbsp;\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">None&nbsp;\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">Scheufler et al&#46;&#47;2003&nbsp;\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">LS&nbsp;\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">F&#47;Wh&#47;51 y&nbsp;\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 y&nbsp;\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">15&nbsp;\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">Neck rigidity&nbsp;\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">Bukhari et al&#46;<a class="elsevierStyleCrossRef" href="#bib0035"><span class="elsevierStyleSup">7</span></a>&#47;2004&nbsp;\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">LS&nbsp;\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">F&#47;Asn&#47;57 y&nbsp;\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">-&nbsp;\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">19&#46;2&nbsp;\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">None&nbsp;\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">Mart&#237;n et al&#46;<a class="elsevierStyleCrossRef" href="#bib0045"><span class="elsevierStyleSup">9</span></a>&#47;2005&nbsp;\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">LALALS&nbsp;\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">F&#47;Wh&#47;77 yF&#47;Wh&#47;59 yF&#47;Wh&#47;48 y&nbsp;\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 y1 y2 mo&nbsp;\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">119&#46;210&#46;8&nbsp;\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">NoneSjogren syndromeNone&nbsp;\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">High and Hoang&#47;2005&nbsp;\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">LALS&nbsp;\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">F&#47;Blk&#47;57 yF&#47;Blk&#47;55 y&nbsp;\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">10 y-&nbsp;\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">12-1510-15&nbsp;\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">Discoid lupusNone&nbsp;\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">Piraccini et al&#46;&#47;2006&nbsp;\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">LALA&nbsp;\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">M&#47;Wh&#47;48 yM&#47;Wh&#47;53 y&nbsp;\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">10 y4 y&nbsp;\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">1112&nbsp;\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">Androgenic alopeciaAndrogenic alopecia&nbsp;\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">Rowan et al&#46;&#47;2006&nbsp;\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">LS&nbsp;\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">F&#47;Blk&#47;9 y&nbsp;\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">6 mo&nbsp;\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">9&#46;8&nbsp;\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">None&nbsp;\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">Yasar et al&#46;&#47;2007&nbsp;\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">LALALS&nbsp;\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">F&#47;Wh&#47;45 yM&#47;Wh&#47;49 yF&#47;Wh&#47;62 y&nbsp;\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">-&nbsp;\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">101218&nbsp;\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">None&nbsp;\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="" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">&nbsp;\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">LA&nbsp;\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">F&#47;Ira&#47;45 y&nbsp;\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">5 y&nbsp;\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">10&#46;7&nbsp;\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">None&nbsp;\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">El Darouti et al&#46;&#47;2007&nbsp;\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">LALALALSLSLSLSLSLSLS&nbsp;\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">F&#47;Egy&#47;50 yF&#47;Egy&#47;30 yF&#47;Egy&#47;40 yF&#47;Egy&#47;36 yF&#47;Egy&#47;17 yF&#47;Egy&#47;21 yF&#47;Egy&#47;39 yF&#47;Egy&#47;11 yF&#47;Egy&#47;35 yF&#47;Egy&#47;40 y&nbsp;\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">5 y2 y2 y2 y2 mo1 y2 y1 y-2 y&nbsp;\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">8&#46;54&#46;64&#46;65&#46;14&#46;83&#46;12&#46;54&#46;52&#46;24&#46;6&nbsp;\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">None&nbsp;\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">Mart&#237;nez-Mor&#225;n et al<a class="elsevierStyleCrossRef" href="#bib0005"><span class="elsevierStyleSup">1</span></a>&#47;2007&nbsp;\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">LS&nbsp;\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">F&#47;Wh&#47;77 y&nbsp;\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">6 mo&nbsp;\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">15&nbsp;\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">None&nbsp;\t\t\t\t\t\t\n
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                  \t\t\t\t">Gonz&#225;lez-Guerra et al&#46;<a class="elsevierStyleCrossRef" href="#bib0050"><span class="elsevierStyleSup">10</span></a>&#47;2008&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
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                  \t\t\t\t  " align="left" valign="\n
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                  \t\t\t\t">LA&nbsp;\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">F&#47;Wh&#47;52 y&nbsp;\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">5 y&nbsp;\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">15&nbsp;\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">Polycystic ovary&nbsp;\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
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                  \t\t\t\t">Case described&nbsp;\t\t\t\t\t\t\n
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                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">LA&nbsp;\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">F&#47;Wh&#47;49 y&nbsp;\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">3 mo&nbsp;\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
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                  \t\t\t\t  " align="left" valign="\n
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                  \t\t\t\t">Scalp psoriasisBreast cancer&nbsp;\t\t\t\t\t\t\n
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Vol. 103. Núm. 6.
Páginas 551-554 (julio - agosto 2012)
Vol. 103. Núm. 6.
Páginas 551-554 (julio - agosto 2012)
Case and Research Letters
Acceso a texto completo
Lipedematous Alopecia in a Patient With Scalp Psoriasis
Alopecia lipedematosa concomitante con psoriasis del cuero cabelludo
Visitas
12245
V. Fuentelsaz-del Barrioa,
Autor para correspondencia
victoriafuentelsaz@hotmail.com

Corresponding author.
, V. Parra-Blancob, P. Borregón-Nofuentesa, R. Suárez-Fernándeza
a Servicio de Dermatología, Hospital Gregorio Marañón, Madrid, Spain
b Servicio de Anatomía Patológica, Hospital Gregorio Marañón, Madrid, Spain
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Table 1. Reported Cases of Lipedematous Scalp and Lipedematous Alopecia.
Texto completo
To the Editor:

Lipedematous scalp is a rare condition of unknown etiology characterized by a thickening of the subcutaneous tissue on the scalp. It typically affects the occipital region, and may be accompanied by pain and itching in the affected area. When the condition is associated with hair loss, it is called lipedematous alopecia.1 We report a case of lipedematous alopecia and briefly review the literature.

The patient was a 49-year-old Spanish woman with a history of mild to moderate psoriasis involving both the scalp and the nails since the age of 20 years. She had had surgery for breast cancer (T3 N1 M0) 3 years before this consultation and had been receiving treatment with tamoxifen for about 6 months. She came to our clinic because of severe pain and thickening of the scalp, which had started some 3 months earlier, and more recent hair loss in the occipital region. Three weeks earlier, the patient had visited the emergency department of our hospital complaining of severe scalp pain. A computed tomography scan revealed asymmetry in soft tissue volumes, with significant thickening of the subcutaneous layer (3.12cm) in the vertex and left occipital area (Fig. 1).

Figure 1.

Computed tomography scan showing thickening (3.12cm) of the subcutaneous cell tissue in the left occipital area of the scalp.

(0.08MB).

On physical examination, the skin of the parieto-occipital area was found to be edematous and boggy, and 2 hairless patches each measuring about 2×2cm and similar in appearance to alopecia areata plaques were observed in the left parietal region. There were also several psoriatic lesions on the scalp, which the patient said had been stable without treatment for several months (Fig. 2).

Figure 2.

Clinical image of an alopecic plaque in the left parietal region.

(0.22MB).

A particularly thick area of the subcutaneous tissue in the left occipital area was biopsied. Histology showed thickened subcutaneous fatty tissue, dermal edema, and a mild perivascular lymphocytic infiltrate in the superficial dermis. There was no evidence of an increase in mucin deposition in the dermis or subcutaneous tissue. Epidermal hyperplasia and keratin plugs in the follicular infundibula were observed. The number of terminal hair follicles in the anagen phase was normal, and dermal blood vessels were telangiectatic (Fig. 3). No significant abnormalities were found in the blood count, biochemistry, antinuclear antibody test, or thyroid profile. On the basis of this evidence, the diagnosis was lipedematous scalp with areas of lipedematous alopecia.

Figure 3.

A, Biopsy of the scalp showing the thickened layer of subcutaneous cell tissue with normal follicle morphology (H&E, original magnification x4). B, Epidermal hyperplasia with keratin plugs in the follicular infundibula (H&E, original magnification x20). C, Dilated dermal blood vessels with a telangiectatic appearance (H&E, original magnification x10). D, No evidence of abnormal deposition or panniculitis (H&E, original magnification x10). Abbreviation: H&E, hematoxylin-eosin.

(0.5MB).

The alopecic plaques and psoriatic lesions were treated with a topical corticosteroid, and hair regrowth was evident within 6 weeks. Oral nonsteroidal antiinflammatory drugs were prescribed for pain control, to be taken as needed.

On follow-up at 9 months, no alopecia was evident, and the pain had lessened considerably. At her final visit, the patient reported that she had had surgery for chronic right-arm lymphedema (a side effect of her breast cancer surgery) with a very satisfactory functional outcome some 6 weeks earlier, and that the scalp discomfort had disappeared entirely.

Lipedematous scalp was first described in a black woman in 1935 by Cornbleet.2 In 1961, reporting the cases of 2 black women, Coskey et al.3 coined the term lipedematous alopecia to refer to thickening of the subcutaneous tissue on the scalp coinciding with the inability of the hair to grow more than 2cm. To date only 19 cases of lipedematous alopecia and 16 cases of lipedematous scalp have been reported (Table 1), none associated with any pathology of relevance. In addition to a localized or generalized thickening of subcutaneous tissue, patients may report diffuse pain, numbness, and itching. The thickness of subcutaneous tissue can be measured using ultrasound, magnetic resonance, or computed tomography; a normal thickness in healthy adults is 5.8 ±0.12mm at the bregma. Lipedematous scalp and lipedematous alopecia are probably underdiagnosed; indeed, there is still no agreement on whether they are different processes or simply different stages of the same process.1

Table 1.

Reported Cases of Lipedematous Scalp and Lipedematous Alopecia.

Author/Year  Condition  Patient Characteristics  Duration  Thickness, mm  History 
Cornbleet2/1935  LS  F/Blk/44 y  6 y  None 
Coskey et al.3/1961  LALA  F/Blk/28 yF/Blk/75 y  2 y1 y  1510  Diabetes mellitus 
Curtis and Heising/1964  LA  F/Blk/62 y  15 y  15  Skin and joint hyperelasticity 
Lee et al./1994  LS  F/Blk/32 y  3 y  10.7  None 
Kane et al./1998  LA  F/Blk/49 y  4 mo  12.6  None 
Fair el al.4/2000  LA  F/Blk/18 y  6 mo  None 
Bridges et al.8/2000  LA  F/Blk/48 y  6 y  12  Kidney failure 
Ikejima et al.6/2000  LA  M/Asn/30 y  7 y  16  None 
Tiscornia et al.5/2002  LA  F/Wh/69 y  6 mo  10  None 
Scheufler et al./2003  LS  F/Wh/51 y  1 y  15  Neck rigidity 
Bukhari et al.7/2004  LS  F/Asn/57 y  19.2  None 
Martín et al.9/2005  LALALS  F/Wh/77 yF/Wh/59 yF/Wh/48 y  1 y1 y2 mo  119.210.8  NoneSjogren syndromeNone 
High and Hoang/2005  LALS  F/Blk/57 yF/Blk/55 y  10 y-  12-1510-15  Discoid lupusNone 
Piraccini et al./2006  LALA  M/Wh/48 yM/Wh/53 y  10 y4 y  1112  Androgenic alopeciaAndrogenic alopecia 
Rowan et al./2006  LS  F/Blk/9 y  6 mo  9.8  None 
Yasar et al./2007  LALALS  F/Wh/45 yM/Wh/49 yF/Wh/62 y  101218  None 
  LA  F/Ira/45 y  5 y  10.7  None 
El Darouti et al./2007  LALALALSLSLSLSLSLSLS  F/Egy/50 yF/Egy/30 yF/Egy/40 yF/Egy/36 yF/Egy/17 yF/Egy/21 yF/Egy/39 yF/Egy/11 yF/Egy/35 yF/Egy/40 y  5 y2 y2 y2 y2 mo1 y2 y1 y-2 y  8.54.64.65.14.83.12.54.52.24.6  None 
Martínez-Morán et al1/2007  LS  F/Wh/77 y  6 mo  15  None 
González-Guerra et al.10/2008  LA  F/Wh/52 y  5 y  15  Polycystic ovary 
Case described  LA  F/Wh/49 y  3 mo  31 mm  Scalp psoriasisBreast cancer 

Abbreviations: Asn, Asian; Blk, Black; Egy, Egyptian; F, female; Ira, Iranian; LA, lipedematous alopecia; LS, lipedematous scalp; M, male; Wh, White.

Histological findings for lipedematous alopecia are a thickening of the subcutaneous cell tissue, variable dermal edema, a perivascular lymphocytic infiltrate, an absence of abnormal deposition, no evidence of panniculitis, epidermal hyperplasia, and keratin plugs in the follicular infundibula. Terminal hair follicles may be reduced in number or preserved. Dermal blood vessels are often dilated and telangiectatic in appearance.4

The pathogenesis of lipedematous scalp and lipedematous alopecia is unknown. Some authors have suggested that there may be a hormonal factor because most cases are diagnosed in women. Race, once thought to be a key factor, is now considered less important because of the growing number of cases reported in white,5 Asian,6 and Middle Eastern7 women.

One theory proposed to explain hair loss is that the thickening of the subcutaneous tissue may place pressure on the hair follicles, restricting hair growth or shortening anagen cycles.8 Lymph vessels were dilated in our patient, and Martín et al9 reported the same for 2 patients with lipedematous alopecia, suggesting that this effect might play an important role in the pathogenesis of the alopecia. Regarding the association with other systemic diseases, cases have been reported of patients with a history of diabetes mellitus,3 joint and skin hyperelasticity, and acute kidney failure.8

No case has been reported to date of lipedematous alopecia in a patient with comorbid scalp psoriasis or a history of malignancy. Noteworthy in our patient was the intense scalp pain, the very thick subcutaneous layer, the rapid resolution of the alopecic plaques, and the favorable course after surgical treatment of the chronic lymphedema of the arm. Since the patient was already responding to treatment we do not know if the apparently favorable post-surgical response was a coincidence or whether, given the histological evidence of dilated lymph vessels, there was an actual causal relationship between the events.

References
[1]
C. Martínez-Morán, C. Sanz-Muñoz, A. Miranda-Sivelo, I. Torné, A. Miranda- Romero.
Cuero cabelludo lipedematoso.
Actas Dermosifiliogr, 100 (2009), pp. 69-72
[2]
T. Cornbleet.
Cutis verticis gyrata? Lipoma?.
Arch Dermatol Syphilol, 32 (1935), pp. 688
[3]
R.J. Coskey, R.P. Fosnaugh, G. Fine.
Lipedematous alopecia.
Arch Dermatol, 84 (1961), pp. 619-622
[4]
K.P. Fair, K.A. Knoell, J.W. Patterson, R.J. Rudd, K.E. Greer.
Lipedematous alopecia: a clinicopathologic, histologic and ultrastructural study.
J Cutan Pathol, 27 (2000), pp. 49-53
[5]
J.E. Tiscornia, A. Molezzi, H.I. Hernández, M.C. Kien, E.N. Chouela.
Lipedematous alopecia in a white woman.
Arch Dermatol, 138 (2002), pp. 1517-1518
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A. Ikejima, M. Yamashita, S. Ikeda, H. Ogawa.
A case of lipedematous alopecia occurring in a male patient.
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[7]
I. Bukhari, F.A. Muhlim, R.A. Hoqail.
Hyperlipidemia and lipedematous scalp.
Ann Saudi Med, 24 (2004), pp. 484-485
[8]
A.G. Bridges, L.C. Kuster, S.A. Estes.
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Cutis, 201 (2000), pp. 168-170
[9]
J.M. Martín, C. Monteagudo, E. Montesinos, E. Jorda.
Lipedematous scalp and lipedematous alopecia: a clinical and histologic analysis of 3 cases.
J Am Acad Dermatol, 52 (2005), pp. 152-156
[10]
E. González- Guerra, R. Haro, J. Angulo, M.C. Fariña, L. Martin, L. Requena.
Lipedematous alopecia: an uncommon clinicopathologic variant of nonscarring but permanent alopecia.
Int J Dermatol, 47 (2008), pp. 605-609

Please cite this article as: V. Fuentelsaz-del Barrio, V. Parra-Blanco, P. Borregón-Nofuentes, R. Suárez-Fernández. Alopecia lipedematosa concomitante con psoriasis del cuero cabelludo. Actas Dermosifiliogr. 2012;103:551-4.

Copyright © 2011. Elsevier España, S.L. and AEDV
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