ALOPECIA AREATA

Synonyms.—Area Celsi; Alopecia circumscripta; Porrigo decalvans; Tinea decal-
vans; Fr., Pelade.

Definition.—Alopecia areata is an affection of the hairy system,
most commonly of the scalp, characterized by one or more usually cir­
cumscribed, rounded or oval patches of complete baldness, unattended
by any apparent alteration in the skin.

Symptoms.—In the large majority of cases the malady is limited
to the scalp, but it may invade other parts, as the bearded region, eye­
brows, eyelashes, and, in
rare instances, the entire
surface. The disease be­
gins either insidiously or
suddenly, and usually
without any premonitory
symptoms. Occasionally
patients note a precursory
feeling of slight irritation
or insignificant itchiness
at the point at which
the area is to develop,
and in some instances the
appearance of the patches
is preceded for several
days or a few weeks by
slight or severe headache,
itching, burning, or other
manifestation of disturbed innervation. As a rule, however, and
with but few exceptions, the first evidence of disease is the bald
patch. If developing suddenly, the hair falls out with great rapidity,

Fig. 246.—Alopecia areata of a common type, in
a man of forty-five, of several months’ duration; his
son, aged twenty, had a short time previously, accord­
ing to the statement of the patient, the same malady.

996                       DISEASES OF THE APPENDAGES

in fact, almost as a mass or lock, one or several typical areas
being formed within a few hours. If occurring at night, the patient
awakes to find a lock of hair on the pillow, slight or consider­
able in amount. Generally, however, and according to my observa­
tions in most instances, several days or a few weeks elapse before
the bald spots are sufficiently large to become noticeable. The patches
continue to extend peripherally for a variable period, and then often
remain stationary for some days or weeks or indefinitely; if there are
several, and in close proximity, from gradual extension they may fuse
together, and there results a large, irregular, bald area, involving a con­
siderable portion of the scalp. If the patches are numerous, or sometimes
when in small number and spreading rapidly, the whole scalp may be­
come involved, and completely or almost wholly devoid of hair. In

average cases, however, there, are
usually two or three areas, and
these are commonly, when fully
developed, about 1 to 2 inches in
diameter.

The skin of the affected areas
is apparently unaltered, showing
no departure from the normal,
presenting merely the hair loss,
usually with slight depression; it
is smooth, milky white, or some­
times, in the early period of forma­
tion, faintly pink; at the peripheral
part quite frequently some pro­
jecting stumps are to be seen,
which may be readily extracted,
and which are noted to be club-
shaped, or, as Crocker says, bear
some resemblance to an exclama­
tion point, with the broad end
externally and the small end with
the constricted neck within the
follicle. These stumps are rarely
seen in the clearly neurotic cases,
such as follow fright, nervous
shock, accidents, etc The bordering hairs, if the patch is still in
process of advancing, are found to be loose or relatively so. There
is no inflammation and, except as an accidental coincidence, no scali-
ness. Not infrequently, however, an oily seborrhea, usually of trifling
character, is present. If the disease is of considerable duration, and also
in some of the recent cases, the follicles are observed to be less prominent
than normally, and slight atrophy or thinning sometimes occurs; the
plaques are noted to be slightly depressed, this being more noticeably
so at the central part. The malady, which is almost invariably chronic,
may continue after well developed, without exhibiting progressive or
retrogressive tendency. As a rule, however, after the lapse of a variable

Fig. 247.—Alopecia areata, showing a
large, elongated area, resulting from the
coalescence of several rounded patches.
The patient was a woman aged thirty-two,
in whom the disease had lasted ten years,
areas filling up with regrowth of hair, but
with the recurrence of new patches at the
same and other parts of the scalp at irreg­
ular intervals.

ALOPECIA AREATA

997

period the patches cease to extend, the hairs at the margins no longer
exhibit any loosening tendency, and remain firmly fixed in the follicles;
sooner or later a fine white lanugo or down shows itself, which is generally
of extremely slow growth, and which may continue to develop until it is
about ½ inch or so in length, and then disappoint expectations by
dropping out again; or it may remain and become stronger, coarser, and
pigmented, and the malady thus come gradually to an end. Not in­
frequently after growing for a time the new hairs fall out, and this may
happen once or twice before finally recovery is permanently established.
In other patients weeks or months elapse before a disposition to renewal
of the hair sets in; and occasionally the new-grown hair remains unpig-
mented for a long while, and exceptionally indefinitely.

Thus run the majority
of cases encountered. Occa­
sionally conjointly with or
independently of scalp in­
volvement the male bearded
region is the seat of one or
more variously sized plaques,
which follow about the same
course as observed in the
scalp patches. In the less
favorable instances, in addi­
tion to several or more
sprea­ding scalp plaques, the
eyebrows are invaded, to­
ward the outer side most
frequently, and a portion of
the hair falls out; or the
greater part or all may go.
In others, instead of dis­
tinct bald spot the eye­
brow is noted to undergo
general thinning. In more
severe cases the lashes also fall out, in part or completely. Even
without involving these regions, however, the scalp disease may be
of a severe type, may extend, gradually or rapidly, and sweep off
every hair. In other cases, still more extreme in degree, not only
do the scalp, brow, and eyelid regions become devoid of hair, but
the malady may finally invade other parts, as the axilla, pubic region,
and, in rare instances, the hairy growth of the entire surface, whether
lanugo or coarse hair, disappears (alopecia universalis). In such
instances there is usually a cropping-up here and there, but most
frequently on the scalp, of sparse, weak, downy hair, scattered or
in ill-defined tufts; these, however, often drop out, and thus the case
continues, with, in such instances, very little, if any, tendency to
recovery.

As a less frequent clinical variety is that in which, instead of well-
defined areas, the hair loss is in the form of a band, most commonly

Fig. 248.—Alopecia areata in a young man
aged twenty; a wide band-like area involving the
outer portion of the entire scalp, beginning as
typical plaques similar to that now seen higher
up.

998                       DISEASES OF THE APPENDAGES

occurring about the border¹ of the scalp, although the scalp region in
extreme instances of this kind may be completely grooved with these
band- or ribbon-like bald patches or streaks. Another variety is that
in which there are observed numerous small rounded or irregularly
outlined spots scattered over the entire scalp. In a few instances there
may be small irregularly shaped, sometimes ill-defined, spots (scarcely
patches) scattered thinly, occasionally in number, as to be here and there
almost coalescent, over the scalp, especially the posterior half; this

type, giving the scalp “a moth-
eaten and mangy appearance,” is
considered by some observers as
always syphilitic, but it may occur
also independently of that disease.
In other cases—the universal form
-—instead of distinct patch-forma-
tion there may be a rapid thinning
of the hair on all parts and its
final disappearance. In my ex­
perience, however, in these latter,
there are at first one or two well-
defined spots, not necessarily large,
and these are soon followed, and
rapidly, with general thinning and
involvement of the hairs of the
entire surface. In another class
of cases, instead of irregular distri­
bution of the patches, they occur
at or near the site of an injury or in
the course of a nerve. In still an­
other group are those first described
by Neumann as alopecia circum-
scripta seu orbicularis, in which
the areas are small, quite distinctly
depressed, and atrophic, and usually anesthetic, and run a persistent
and unfavorable course.

In some instances associated conditions, neurotic in character, other
than those described are noted. Thus occasionally vitiligo has been
observed (Besnier, Feulard, Duhring, Senator, Dubreuilh, Thibiérge,
and others),² and the vitiligo areas themselves may be the seat of the
alopecia, as in a case recorded by Eddowes.³ In several instances the
coexistence of these two diseases has come under my observation, all
patients of a nervous type. Nail changes have also been noted, the
nails, sometimes of both fingers and toes, becoming white, spotty, gran-

Fig. 249.—-Alopecia areata in a female
child aged four and one-half years, begin­
ning when two and one-half years old as
several typical rounded patches, which ex­
tended, and, with new areas, swept off the
entire scalp hair; the hair of the right eye­
brow has also almost completely gone, and
that of the left is already thinned; the eye­
lashes are also partly involved.

¹ Heidingsfeld’s case, Cincinnati Lancet-Clinic, March 3, 1900 (with illustration), is
a good example, associated with rounded areas.

² Feulard, Annales, 1892, p. 842, and 1893, pp. 31 and 1311; Besnier, ibid., 1892,
p. 845 (discussion also refers to two brothers, one of whom had vitiligo, the other alo­
pecia areata); Dubreuilh, ibid., 1893, p. 375; Morel Lavallée, ibid., p. 376; Thibiérge,
quoted by Crocker.

³ Eddowes, Brit. Jour. Derm., 1898, p. 465 (case demonstration).

ALOPECIA AREATA

999

ular, several examples of which have been described by Darier and Le
Sourd,¹ Audry,² Abraham,³ Crocker, and others.⁴ Morphea, another
neurotic disease, has also been observed in a few instances to coexist.⁵
Quite recently a case came under Eddowes’s⁶ notice in which alopecia,
general in character, was later associated with scleroderma and vitiligo.
Its coexistence with disease of the thyroid has also been exceptionally
recorded (Bazin, Kaposi, Berliner).⁷

Etiology.—The disease occurs in both sexes, and at almost all
ages. It is, however, rare before the age of five, and uncommon after
forty, being most frequent be­
tween ten and twenty-five.
While met with in all stations
of life, there is a preponderance,
according to my observations,
among the poorer classes.
Bulkley has found it more com­
mon in private practice. The
malady is not so frequent in
our country—being somewhat
less than 1 case in 100—as
abroad, more especially in
France and England.

There are two prevailing
theories as to the cause of the
disease: one of these regards it
as parasitic and the other as
neurotic I feel confident that
both are right, as a study of
the literature, taken with per­
sonal observation, would indi­
cate that there are, as regards

etiology, two varieties—the contagious or parasitic and the non-con-
tagious or the trophoneurotic

There are numerous cases on record in which the malady followed
nervous shock, fright, accidents, etc. Several years ago such an example
came under my observation: A man, while driving at night in an open
wagon along a country road, was thrown from the vehicle by an over­
hanging branch, striking upon his head; he was unconscious for some
hours; within a week or ten days a rapidly spreading alopecia areata
had denuded almost the entire scalp, and later involved the eyebrows
and eyelashes. A somewhat similar case, in which, however, the hair
loss occurred later after the accident, is referred to by Stowers.⁸ In-

¹ Darier and Le Sourd, Annales, 1898, p. 1009 (1 case fully reported, and Darier
refers to 6 others).

² Audry, Jour, des mal. cutan., 1900, p. 161 (2 cases).

³ Abraham, Brit. Jour. Derm., 1900, p. 100 (case demonstration).

⁴ G. W. Wende, Jour. Cutan. Dis., 1905, p. 517 (with illustration and review of some
other cases reported).                                 ⁵ Jamieson, Arch. Derm., 1881, p. 141.

⁶ Eddowes, Brit. Jour. Derm., 1899, p. 325, and 1900, p. 137 (case demonstrations).

⁷ Berliner, Monatshefte, 1896, vol. xxiii, p. 361.

⁸ Stowers, Brit. Jour. Derm., 1897, p. 44 (case demonstration).

Fig. 250.—Alopecia areata in a man of
thirty, of about one year’s duration, showing
in some parts a regrowth of hair which still
remains uncolored.

1OOO                    DISEASES OF THE APPENDAGES

stances following injuries to the scalp are also reported by Schütz,¹ and
extensive development—universal alopecia—has been recently observed
after severe fright by Boisser² and Bidon.³ Malcolm Morris⁴ mentions
a case in which total alopecia occurred in a woman within forty-eight
hours of receiving news of the death of her son. Other examples have
been referred to by Duhring, Crocker, Duckworth, Steppe, and many

others. Indeed, the clinical
proof that fright, shock, acci­
dents, great anxiety, and men­
tal worry, etc, are the causa­
tive factors in many cases
is overwhelming.⁵ Jacquet’s⁶
belief, that it may be due to
peripheral irritation from de­
fective teeth has not received
much support, nevertheless it
is not impossible that such
reflex irritation as from this
source as well as from defect­
ive vision, nasopharyngeal
disorders, etc, may be in­
fluential in some cases. In
occasional instances of direct
scalp injury alopecia does not
appear to result so much from
the effect, which may be slight,
upon the general nervous sys­
tem, but occurs apparently in
consequence of induced local neuritic changes. In 2 of Schütz’s cases fol­
lowing scalp wounds the ensuing hair loss was in streaks diverging from

Fig. 251.—Alopecia areata, in a man of
twenty-eight, showing a rather common site at
the nape, with small ill-defined areas above
which have partly filled in with new hair; dura­
tion, some months.

¹  Schütz, Milnchener med. Wochenschr., 1889, No. 8, p. 124.

² Boisser, La progrés mêd., June 17, 1899, p. 380.

³ Bidon, La France mêd., 1899, p. 269.

⁴ Malcolm Morris, Diseases of the Skin.

⁵ Meachen and Provis, Brit. Jour. Derm., 1912, p. 272 (case demonstration, woman
aged thirty-one), record an instance of alopecia areata involving the whole scalp, in
which a complete or almost complete regrowth took place during pregnancy, and
relapsing with the establishment of the menses; this had occurred upon several occa­
sions; her finger-nails shared the atrophic changes; later, hairs of some other parts of
the body were also involved; the first signs of falling out usually were noticed toward the
end of the pregnancy. In the discussion of this case Sequeira referred to an instance
in which the loss was complete after each of three pregnancies, twice the hair growing in
again, but after the third the loss was permanent; and Leslie Roberts, cited the case
of a patient under his care with total alopecia areata of the scalp, who subsequently mar­
ried, and while pregnant all the hairs came rapidly back.

⁶ Jacquet, “La pelade d’origine dentaire,” Annales, 1902, p. 362; Jones, “On Reflex
Irritation as a Cause of Alopecia Areata,” Brit. Jour. Derm., 1912, p. 362. found in his
examination of 50 consecutive cases of alopecia areata that carious teeth were quite
common, but not more common than in fifty consecutive full-haired individuals, and
that, moreover, he found in his analysis of cases in which the bald areas were considered
in relation to their nerve-supply that there was a great preponderance of areas in the
regions which are not supplied by the trigeminal nerve. On the other hand, Jourdenet,
Bull. Soc. franc, de derm, et de syph., April, 1910, p. 77, cites his own case (one patch) of
dental origin, and, Rousseau-Decelle, ibid., Jan. 21, 1909, gives résumé and 8 detailed
cases of alleged dental origin.

ALOPECIA AREATA

IOOI

the seat of injury. Schütz states that hair loss noted in German students
from wounds received in the sword duels doubtless belongs in the same
class. The question of heredity in the extensive or generalized examples
has received no attention, and yet, personally, I have observed 2 in­
stances in which the family history disclosed a similar condition in a
member of a preceding generation. In these 2 were involved 3 cases,
all males, 2 of whom were brothers. The alopecia, beginning as an ordi­
nary case of alopecia areata, in all about the age of three or four years,
rapidly spread, and involved the entire scalp, eyebrows, and eyelashes,
and the down on some other parts. Inquiry elicited the fact that in both
instances a grand-uncle had had the same misfortune, likewise develop­
ing it early in life.

On the other hand, one cannot deny that there is also a contagious
or parasitic class, and this cause probably accounts for the majority of
cases, although the contagiousness, except under some unknown favoring
circumstances, is usually extremely slight. These cases are, I believe,
commonly represented by the type with the peripheral stumpy hair often
noticeable in the early stages, and are generally characterized by one to
several small or moderately sized areas, or by numerous scattered pea-
to dime-sized rounded or irregularly outlined spots, as in many of the
patients in the epidemics reported by Putnam¹ and Bowen.² The spread
of the disease, starting from 1 case in one of these epidemics, was re­
markable, finally 63 out of the 69 girls in the institution presenting areas.
These are the first and, so far as my knowledge goes, the sole epidemics
ever recorded in this country. In France epidemics have been observed
in schools among children, and in barracks among soldiers. Besnier,³
Merklen,⁴ Brocq,⁵ and other French observers have collected a number
of instances in illustration of its contagious character. The towels,
brushes, barber­shops, and hair-clipping instruments were variously
thought to be the means of communication. English observers do not
share the extreme views of the French as to its contagiousness, but
Crocker⁶ is a strenuous advocate of the parasitic and contagious character
of most cases; and recently Colcott Fox,⁷ although disclaiming any belief
in the contagiousness of ordinary alopecia areata, has reported a small
epidemic in a school. This observer and also Pye-Smith refer to several
instances of its appearance in two or more members of the same family.
The Germans have been reluctant to accept this view, but in late years

¹ Putnam, Archives of Pediatrics, August, 1892.

² Bowen, “Two Epidemics of Alopecia Areata in an Asylum for Girls,” Jour. Cutan.
Dis., 1899, p. 399; and also concerning first (Putnam’s) epidemic, Brit. Jour. Derm._y
1894, p. 80; and 3 cases in same family (father and 2 children), Jour. Cutan. Dis., 1904,
p. 37; and Boston Med. and Surg. Jour., 1912, vol. clxv, p. 937 (citation of some instances
suggesting communicability).

³ Besnier, “Sur la pelade,” Bull. Acad. de Méd., 1888, p. 182.

⁴ Merklen, “Etiologie et prophylaxis de la Pelade,” Annales, 1888, p. 813.

⁵ Brocq, “Clinical Facts Bearing on the Contagious Nature of Alopecia Areata,”
Paris letter in Brit. Jour. Derm., 1889, p. 479; Moty describes, Annales, May, 1902, epi­
demics occurring among troops.

⁶ Crocker, “Alopecia Areata, its Pathology and Treatment,” Lancet, Feb. 28, 1891,
Brit. Jour. Derm., 1891, p. 197; also in treatise on Diseases of the Skin.

⁷ Colcott Fox, “On a Small Epidemic of an Areate Alopecia,” Brit. Jour. Derm.,
1913, p. 51 (in a school for girls—21 cases in all, ages from nine to fourteen).

I002                     DISEASES OF THE APPENDAGES

suggestive cases have been reported, and recently an epidemic of the
disease in an asylum has been recorded by Ehrenhaft.¹ Plonski² and
others have observed its transmission from one member of a family to
another. American dermatologists³ have, upon the whole, accepted
the view of two classes of the disease, the trophoneurotic and the para­
sitic or contagious, but have very little clinical evidence of the latter to
offer. Duhring, Bulkley, and a few others hold strictly to its nervous
origin. Crocker believes the disease, as exemplified in the majority of
cases, related to ringworm, and Hutchinson’s theory as to its occurring
in those who had previously had ringworm is well known. Syphilis has
been suggested as etiologic in some instances, but cannot, I believe, be
considered more than a predisposing or contributing factor, although there
is a pervading, but ill-defined, acceptance of such cause in some cases
by the general profession, notwithstanding that there is a remarkable
dearth of reliable literature observation to support it.⁴

Pathology.—Clinical observations, together with experimental
investigation, leave but little if any doubt that the malady or, more
properly speaking, the bald areas which we are accustomed to place
under the one class name alopecia areata, is the result of at least two
pathologic processes—trophoneurotic and parasitic—and this is the
opinion held by the large majority of dermatologists. In addition to the
evidence already quoted in etiology as indicating local or general nerve
influence, and the occasional association of other nervous diseases, such
as vitiligo, nail changes, Graves⁷ disease, etc., must be mentioned the
animal experiments made by Joseph⁵ and Moskalenko and Ter-Gregory-
anetz,⁶ in which, in a large proportion, excision of the second cervical
ganglion was followed by bald areas in the region covered by the dis­
tribution of the second cervical, the great auricular, and the occipital
nerves. While these experiments were also partly confirmed by Mibelli,
others—Behrend⁷ and Samuel⁸—were not successful. The observations

¹ Ehrenhaft, Klin.-therap. Wochenschr., 1899, p. 358; abs. in Monatshefte, 1899,
vol. xxix, p. 340.

²Plonski, Dermatolog. Zeitschrift, 1898, p. 371.

³ See discussion on “Alopecia Areata,” Trans. Amer. Derm. Assoc. for 1892. In a
recent paper, Jour. mal. cutan., May, 1906, Hallopeau goes over the contagious grounds
pretty thoroughly.

⁴ Sabouraud (“Nouvelles recherches sur l’étiologie de le pelade,” Annales, 1910, p.
545) and DuBois (“Reaction de Wassermann chez peladiques,” ibid., 1910, p. 555) are
both inclined to view extensive cases of alopecia areata as of syphilitic origin, acquired
or hereditary; the former claims sufficient success with antisyphilitic remedies to
warrant such belief, and the latter in an examination of 14 cases found a positive
Wassermann in 11, although there were no symptoms of either hereditary or acquired
syphilis; the 3 negative cases presented only single patches. Sampelayo (“Actas Der-
mo-sifiliograficas,” Feb. to March, 1912, No. 2, abs. in Jour. Cutan. Dis., Feb., 1913,
p. 131) reports a cured universal alopecia areata occurring in the course of a syphilitic
infection cured after two injections of salvarsan.

On the other hand, Sequeira (Brit. Jour. Derm., 1911, p. 265, case demonstration of
alopecia areata in a frank syphilitic) states that he applied the Wassermann test in a
number of cases and, with the exception of the case shown, always with negative
reaction.

⁵ M. Joseph, Monatshefte, 1886, p. 483, and Centralblatt med. Wissensch., 1886,
vol. xxiv, p. 178.

⁶ Moskalenko and Ter-Gregoryanetz, Vratch, 1899, p. 541; abs. in Jour. Cutan.
Dis., 1899, p. 432.                     ⁷ Behrend, Virchow’s Archiv, 1889, vol. cxvi, p. 173.

⁸ Samuel, ibid., 1888, vol. cxiv, p. 378.

ALOPECIA AREATA

1003

of Pontoppidan¹ and Bender,² of the development of alopecia patches
after operations on the neck, are somewhat confirmatory of the experi­
mental investigations. Crocker believes the neurotic class can be sub­
divided into three divisions—alopecia universalis, in which general nerv­
ous shock of various kinds is causative, and in some of which cases the
nails also suffer; alopecia localis seu neuritica, consisting of but few
patches, and presenting at the site of an injury or in the course of a nerve
distribution; alopecia circumscripta seu orbicularis, characterized by the
marked depression of the bald areas, usually with nail involvement, and
of which the causes are unrecognized. As already remarked, his other
division of the disease is the largest, and which he designates true alopecia
areata, and which he thinks might properly be called alopecia parasitica,
or by the old name, tinea decalvans. Leloir,³ in an analysis of 142 cases,
of which 92 were subjected to close inquiry and study, concluded that
some cases must be included under a trophoneurotic class, some under
a class in which all etiologic factors seemed wanting, and a third
class which comprised the cases which were contagious. In histologic
examinations of a case of the trophoneurotic class the nerves pre­
sented all signs of a degenerative atrophic neuritis (parenchymatous
neuritis).

While doubtless future investigations will finally disclose the true
parasitic element in the contagious class, that end can scarcely be said
as yet to have been reached. From time to time a specific parasite
has been heralded by different observers, but, in the main, that found
by each observer was unlike that discovered by the other. Thus Gruby⁴
has been credited with the statement that he had discovered it in the
“microsporon Audouini,” and this may be responsible for some cases
of bald plaques, properly belonging, however, to the ringworm group;
ringworm cases, according to Sabouraud, are those which Gruby had in
mind, and not an investigation of true alopecia areata. Later Bazin
(1862) attributed the disease to the “microsporon decalvans,” and
Thin⁵ still later described another fungus—minute schizomycetes—
which he denominated the “bacterium decalvans.’' Von Sehlen⁶ added
still another, which, however, seems similar to that found by Thin.
Later Robinson,⁷ in an elaborate investigation, found cocci in masses and
rows, and chiefly in the lymph-spaces of the corium and subpapillary
layer, and also in the root-sheaths of the hair around the affected areas.⁸

¹ Pontoppidan, Monatshefte, 1889, vol. iii, p. 51.

² Bender, Dermatolog. Centralbl., October, 1898.

³Leloir, “Etudes sur la pelade,” Bull, de l' Acad. de Méd., 1888; good abs. in Brit.
Jour. Derm., 1889, p. 67, and Monatshefte (with some case details), 1888, p. 857.

⁴ Gruby, Compt. rend. d. l`Acad. des Sci., 1843, p. 301.

⁵ Thin, Trans. Royal Soc’y, 1881-82, vol. xxxiii, p. 247.

⁶ Von Sehlen, Virchow’s Archiv, 1885, vol. xcix, p. 327.

⁷ Robinson, Monatshefte, “Pathologie und Therapie der Alopecia Areata,” 1888, pp.
409, 476, 525, 582, 735, and 771 (an exhaustive study of the disease, with a review of
the observations and work of others, with numerous references). See also his article on
“Alopecia Areata,” Morrow’s System, vol. iii (Dermatology), p. 862.

⁸ These are now believed to be an ordinary skin coccus, and are apparently the same
as found by Norman Walker and Marshall-Rockwell (“Alopecia Areata; A Clinical and
Experimental Study” (63 cases), Scot. Med. and Surg. Jour., July, 1901, p. 12). Their
studies led them to believe in its contagiousness, and that the nervous element in the
etiology of the disease is greatly overrated.

I004                     DISEASES OF THE APPENDAGES

More recently Sabouraud,¹ after a careful and prolonged investigation,
states the disease to be caused by a microbacillus, present in the earliest
and progressive stages of the disease, and found in the upper part of the
follicle, massed together with the fatty secretion of the neighboring glands
and the vestiges of the dead hair. The bacillus is minute, often comma-
shaped, ½-1 µ in length, and ¼ µ in thickness, lying side by side, or occa­
sionally two or three attached together. It is the same microbacillus
found in the sebaceous discharge of seborrhœa oleosa and in comedo,
which throws doubt upon its pathogenic influence in alopecia areata,
although it is possible that a different degree of virulence might exist,
or, in other words, it is possible that though morphologically identical,
the toxic nature of their secretions may vary. Sabouraud regards the
disease as a seborrhœa oleosa of an acute type. This writer states that
he has succeeded in experimental animal inoculations with pure cultures
in producing characteristic areas. Jacquet,² on the contrary, reports
negative results in direct inoculation experiments.

Several investigators other than those here named have also dis­
covered organisms, among whom may be mentioned Bazin, Eichhorst,⁵
Malassez,⁴ Kazanli,⁵ Vaillard and Vincent,⁶ Bowen, Crocker, and a
few others.⁷ Vaillard and Vincent’s investigations of cases from an epi­
demic affecting 44 soldiers pointed to micrococci as the pathogenic factor;
the germ was cultivated in the laboratory, and in experimental animal
inoculation it was shown to have peladogenic properties. In Roberts’
review he suggests the possibility that we have to do with three organ­
isms which may produce the disease: (1) Bacillary alopecia (Sabouraud);

(2)  coccogenous alopecia (Vaillard and Vincent, von Sehlen, Robinson);

(3)  hyphogenous alopecia—trichophytic alopecia, secondary to tricho-
phytosis capitis (Crocker and others). It is certainly true that perfectly
bald plaques, indistinguishable from ordinary alopecia areata, are occa­
sionally seen as the result of ringworm fungi invasion. Such was Hil-
lier’s⁸ epidemic, so much quoted as examples of epidemic alopecia areata.
But that the larger proportion of cases are thus to be explained, as
Crocker intimates, is not, I believe, sustained by the experience of other
observers.

So far as one is able to draw inference from the somewhat conflicting
evidence, it seems probable that the bald areas, which may be more
properly considered only as a symptom, result from whatever influences
the hair-growing process, be it sudden withdrawal or perversion of the

¹ Sabouraud, Annales, March, April, May, and June, 1896; good review by Leslie
Roberts, in Brit. Jour. Derm., 1896, p. 444; and by Brocq, in Paris letter, in Jour.
Cutan. Dis., 1896, p. 366. See also Sabouraud’s later paper (on fatty seborrhea and
alopecia areata), Annales, de l' lnstitut Pasteur, 1897, p. 134, and his still more recent
book publication.

² Jacquet, La presse méd., Dec 12, 1903 (100 attempts in 6 individuals, with scrap­
ings from areas in several cases).

³ Eichhorst, Virchow’s Archiv, 1879, vol. lxxviii, p. 197.

⁴ Malassez, Arch, de phys. norm, et path.. 1874, p. 203.

⁵ Kazanli, Vratch, 1888, p. 763; abs. in Brit. Jour. Derm., 1889, p. 132.

⁶ Vaillard and Vincent, Annales de l' lnstitut Pasteur, 1890, vol. iv, p. 446.

⁷ See Robinson’s paper, loc. cit.

⁸ Hillier, Handbook of Skin Diseases, p. 286; also Lancet, 1864, ii, p. 374.

ALOPECIA AREATA

1005

innervation of the part due to shock,¹ etc, to injury of the cutaneous
nerves, to peripheral irritation by parasites or their toxins, either directly
upon the trophic nerves or primarily upon the tissues. It was formerly
believed that no textural or inflammatory changes occurred except slight
atrophy in old cases, and to the unaided eye this seems usually true, but
histologic investigations (Giovannini, Robinson, Sabouraud, Unna,
Harris, and a few others)² show that primarily the condition is an inflam­
matory one, involving the corium. In 7 cases investigated by Robinson
he always found appearances of inflammation, as well as a perivascular
infiltration with round cells; in recent examples lymph had coagulated
in the dilated lymphatics, and some of the larger and small arteries
contained thrombi. In those of longer standing thickening of the blood-
vessels was always noted. Later the sebaceous glands undergo atrophy,
and later still the fatty tissue. Robinson considers the primary changes
to be in the blood­ and lymph-vessels; the subsequent glandular atrophy
to be due to the chronic obliterative disease of the vessels. The fall of
hair in the beginning he attributes to the acute thrombotic closure of the
vessels. The inflammatory process has its seat in the corium, especially
in the subpapillary layer. The slight depression noted he believes, like
Hutchinson, to be due to the absence of the hair, and does not agree with
Michelson, who ascribes it to the loss of fat—this latter not taking place
until late in the disease. According to Giovannini, an infiltration of
white blood-corpuscles around the deep part of the hair-follicle precedes
and accompanies the disease, suggesting to him a deep-lying folliculitis,
the other phenomena being secondary to this local leukocytosis. De­
generative changes ensue in the hair-bulb, and also in the suprabulbar
part, or the neck of the hair.³ Similar changes are also noted sometimes
in the hair just beyond the neck and follicle, somewhat similar to the
fibrillar breaking-up noted in trichorrhexis nodosa.

Diagnosis.—The malady with which alopecia areata is most
likely to be confused is ringworm, but in the latter the scaliness, though
slight, the broken-off or nibbled-looking hairs, incomplete baldness,
rather prominent follicular openings, often stuffed with projecting débris,
and often visible inflammatory signs distinguish it from alopecia areata,
which, on the contrary, presents smooth, scaleless plaques, generally
completely devoid of hair, and with the follicular openings frequently
less conspicuous than normally. It is the beginning and spreading
circumscribed patches of alopecia areata, with some stumps peripherally,
which suggest ringworm, but the other differential features named, with
the history of the case, usually indicating rapid development, will, as
a rule, suffice to reach a correct diagnosis. The bald type of ringworm is
often difficult to distinguish from the patch of alopecia areata, but the

¹ Among these can be, doubtless, included dental irritation and, possibly, visual
defects, but scarcely to the extent believed by Jacquet (Annales, Feb. and March, 1902)
and Trémolieres (La presse méd., June 14, 1902, and Jan. 1, 1903).

² Giovannini, Annales, 1891, p. 921; Robinson, loc. cit., and Morrow’s System, vol.
iii, p. 865; Sabouraud, loc. cit.; Unna, Histopathology; Harris, quoted by Crocker,
Diseases of the Skin, third edit., p. 1226.

³ In addition to those referred to, Behrend, Virchow’s Archiv, 1887, vol. cix, p. 493,
has also investigated the hair changes.

1006                   DISEASES OF THE APPENDAGES

beginning features, and often a history of another case in the family pre­
senting the usual ringworm features, will be of aid. In these instances
ordinarily the first symptoms are distinctly those of ringworm, later dis­
appearing and leaving the confusing bald plaque. In doubtful cases
examination of the border or stump-like hairs can be resorted to (see
Ringworm). Another disease in which plaque-like hair loss, more or less
pronounced, is noted, is favus, but this, unlike alopecia areata, presents
crusts, mild inflammatory symptoms, and usually incomplete baldness.
If the crusts are temporarily wanting, owing to previous removal by
washing, the atrophic or scar-like character of the patch, together with
the history, will be sufficient to distinguish it. The bald areas of lupus
erythematosus, which are more or less cicatricial, with follicular destruc­
tion and a mildly or moderately inflammatory border, can scarcely be
confounded with alopecia areata, in which these features are absent.
The bald spot or spots left on the scalp of children of the poorer classes
from a preceding cutaneous abscess or blind boil might, if the case is
carelessly examined and considered, be mistaken for the disease. In
folliculitis decalvans the central part of the bald plaque is distinctly
atrophic or cicatricial, and the border shows follicular inflammation.

Prognosis.—The outlook for recovery in children and young
adults in cases in which but several patches are present is favorable.
In such variety, too, in older patients, those not over forty, the result
is almost always a regrowth. In more extensive involvement of the
scalp the prognosis in those under twenty or thirty is usually good, but
in older people an opinion is to be given with considerable qualification.
In those instances involving scalp, eyebrows, and eyelashes, if only
partial, and in young individuals, recovery may take place, but it is
best not to be too positive; when the hair fall on these parts is complete,
the chances are much less favorable; in such type in adults past thirty
the prognosis becomes even less hopeful. In the more or less generalized
cases of the malady one cannot be too cautious in expressing an opinion,
as in but few of these instances does a regrowth ever take place. Alopecia
areata of the bearded region usually runs a favorable course. A hopeful
feature in all instances of the disease is the presence of a downy growth;
if no tendency to such appearance, after some weeks or a few months, is
manifested, the outlook is not so promising; and it is still less so if atrophic
changes have ensued, and the follicular openings become less and less
visible. In all cases of the malady, however, the uncertain duration
must be borne in mind; several months, and in some instances one or
two years, may elapse before complete and permanent restoration of
hair takes place. The malady, moreover, is one in which relapses are
not uncommon.

Treatment.—The necessity of systemic measures in alopecia
areata is somewhat in question at the present day, owing to the diverse
views held regarding the nature of the disease. Those who consider it of
neurotic origin place great stress upon the value of constitutional treat­
ment, whereas those that contend that the malady is essentially parasitic
have recourse to exclusively local measures. Inasmuch as it is now gen­
erally admitted that we have cases which may be due to one or the other

ALOPECIA AREATA

1007

of these causes, and as in many instances it would be somewhat difficult
to classify them, the safer course to pursue is to prescribe both consti­
tutional and local measures; the former having as their object the cor­
rection of any defective condition of the general health, and more espe­
cially the invigoration of the nervous system, and the local treatment hav­
ing in view a stimulation of and parasiticide action upon the affected
areas. Fortunately almost all, if not all, the external remedies employed
are active parasiticides as well as stimulants, and their use meets, in
reality, both the neurotic and parasitic views. While the possibility of
its origin from peripheral nerve irritation as from dental caries, defective
sight, nasopharyngeal disorders, etc, is slight, nevertheless such factors,
if present, should receive attention.

The principal remedies prescribed in the constitutional treatment
are arsenic, quinin, nux vomica, phosphorus, pilocarpin, ferruginous
tonics, and cod-liver oil, the choice depending upon a study of the in­
dividual case. Arsenic has been highly extolled by several writers, and
Duhring¹ especially is warm in praise of its value in this disease; it appears
to be of distinct benefit in some cases, and more especially in those which
are apparently truly neurotic in origin. It should be given in moderate
dosage, from 3 to 5 drops (0.2-0.33) of Fowler’s solution or the solution
of sodium arsenate three times daily or its equivalent of arsenious acid,
long continued. Nux vomica and ferruginous tonics are also often of
service either directly or indirectly, and can be advised conjointly with
the arsenic. Pilocarpin or the fluidextract of jaborandi has had some
advocates. The former, in the more extensive scalp cases, injected sub-
cutaneously in the affected part, in the dose of ¹/₃₀ to ¹/₁₀ of a grain (0.002-
0.006) of the hydrochlorate, is, I believe, occasionally of some service;
Pringle,² Crocker,³ and others have also observed a beneficial effect. In
debilitated subjects the building-up influence of cod-liver oil is often of
marked value. The benefit from outdoor life, relaxation from excessive
mental work or worry, is of essential importance in the neurotic cases.
Morrow,⁴ who is probably next to Robinson, among Americans, firmest
in his opinion as to the local nature of the malady, believes, however,
especially in cases where the disease is generalized and protracted, the
effect of local treatment to be materially aided and energized by the ex­
hibition of tonics and reconstituent remedies; and in all cases where
there is evidence of a loss of nerve tone he is accustomed to give the
phosphid of zinc and strychnin, a combination of phosphorus, iron, and
strychnin, or phosphoric acid with strychnin.

While constitutional remedies are, therefore, to be prescribed accord­
ing to individual indications, with a possible trial of arsenic and pilocar-
pin, nevertheless external treatment is to be looked upon as an essential
part in the management of every case. As some of the cases are conta­
gious, the same measures to prevent its spread and communications as
suggested in ringworm are to be advised: the patient should have his

¹ Duhring, discussion in Trans. Amer. Derm. Assoc. for 1892, p. 36.

² Pringle, Brit. Jour. Derm., 1898, p. 198.

³ Crocker, Diseases of the Skin.

⁴ Morrow, “The Treatment of Alopecia Areata—with Cases,” Jour. Cutan. Dis.,
1891, p. 381.

1008

DISEASES OF THE APPENDAGES

own towel, brush, comb, etc., and a weak sulphur or sulphur and naphthol
ointment or a carbolic acid wash applied to the scalp generally every
two or three days; and once in five to ten days the parts should be washed
with the tincture of green soap or with a sulphur-naphthol soap. The
object of local treatment is twofold—a stimulation of the part, promoting
a flux of blood and aiding the nutrition of the affected area, and an inhibi-
tive or destructive influence upon any possible pathogenic parasite which
may be seated there. The skin of the affected areas will usually stand
strong remedies and show no irritation compared to that of the imme­
diately adjacent skin. The choice and strength of the application ad­
vised will depend upon the extent of the disease and the frequency of
inspection. The strong remedies can be used from the start in cases
of limited extent, and to small parts successively in the more extensive
types, along with the general application of the milder remedies. The
loose hairs of the outlying border should, as suggested by Besnier, Mor­
row, and others be extracted, which can be done by grasping the hairs
between the fingers and exerting gentle traction, the loose hairs alone
coming out, while those that are firm slip through the fingers. The
remedial application should always be carried \ or \ inch beyond the
patch. In extensive cases or with patients who can be seen only at
intervals of one or two weeks, the most efficient local remedies are:
ointments of tar and sulphur, weakened and of full strength; 5 to
15 per cent. ß-naphthol ointments; the tar oils, either pure or with
1 or 2 parts of alcohol, or in ointment form, from 1 to 3 drams (4.-
12.) to the ounce (32.); and stimulating lotions containing varying pro­
portions of tincture of cantharides, tincture of capsicum, aqua ammoniæ,
or oil of turpentine, such as prescribed in ordinary alopecia. Of these
I have most frequently prescribed an ointment made up of both sulphur
and naphthol: R. Sulphur, præcip., 3j-ij (4.-8.); ß-naphthol, gr. xxx-
3j (2.-4.); lanolin, 3ij (8.); vaselin, q. s. ad 3j (32.); and if the tar odor
is unobjectionable, an oily application, composed of equal parts of oil
of cade, oil of turpentine, and olive oil, lessening the turpentine if the
skin is sensitive. In addition, at each inspection of the patient an area
of 1 or 2 square inches can be treated by a strong application of car­
bolic acid, chrysarobin, or tincture of iodin containing 2 to 4 grains
(0.135-0.25) of biniodid of mercury to the ounce (32.).

If there are but two or three areas, the stronger remedies can be
regularly employed. Of these, I place most faith in an ointment of
chrysarobin, 10 to 60 grains (0.65-4.) to the ounce (32.) of lard
as recommended by Robinson; and painting over the areas with pure
liquid carbolic acid, as suggested by Bulkley,¹ or a similar preparation,
known as trikresol, recommended by MacGowan,² can be used. If in
children or those of sensitive skin, the carbolic acid is weakened with 1
to 3 parts alcohol. It is to be painted over, and then gently but thor­
oughly rubbed in. There is, in some cases, considerable pain, which,
however, as a rule, soon subsides. A good deal of irritation results, and

¹ Bulkley, “A Therapeutic Note on Alopecia Areata,” Jour. Cutan. Dis., 1892, p. 47.

² MacGowan, “A New Agent for the Treatment of Alopecia Areata,” ibid., 1899,
p. 217.

ALOPECIA AREATA

1009

the skin gradually exfoliates. An excellent method of applying chrysaro-
bin is as a saturated solution in chloroform, and then over the film re­
sulting 2 or 3 coatings of collodion. If the chrysarobin ointment is used
only occasionally, the strongest is to be employed—60 grains (4.) to the
ounce (32.)—and well and energetically rubbed in. It is a remedy which
requires some caution (see Psoriasis). Another strong application which
I have found useful is one consisting of equal parts of oil of turpentine,
tincture of capsicum, and tincture of cantharides; it is to be employed
with care, and often needs weakening with almond or olive oil.

In addition to these measures I now make use of the high-frequency
current, both with the vacuum electrode and carbon-point, and apply it
long enough to produce considerable reaction. The galvanic current can
also be applied, with an electrode pressed upon the patch, and the current
gradually increased by means of a rheostat up to several milliampères.
Care must be used, however, with this current about the head, and the
current increased cautiously and gradually withdrawn—never increasing
or decreasing rapidly or breaking it; a rheostat and a milliampèremeter
are necessities for its proper application. I have also seen good effects
in extensive cases from the application of a static current by means of
the crown electrode.

For alopecia areata of the bearded portions and the eyebrows, etc,
the same applications as advised for the scalp can be employed, but, as
a rule, not more than one-half to two-thirds as strong. Carbolic acid, if
used, must be diluted with several parts of alcohol. The sulphur and
tar applications are the most satisfactory, all things considered. One
of precipitated sulphur, 3ij (8.), salicylic acid, gr. x-xxx (0.65-2.), vase-
lin, sufficient to make an ounce (32.), is also serviceable.

There are many other local stimulating and parasiticide applications
which would probably be as effectual as those mentioned. Morrow
—adopting the plan practised by French observers, Besnier, Vidal,
Brocq, and others—in recent cases, is accustomed to employ chrysarobin,
40 to 50 grains (2.65-3.35), with or without 10 to 25 grains (0.65-1.65)
of salicylic acid, in the ounce (32.) of liquor gutta-perchæ or lard; to be
applied every three or four days in sufficient strength to excite and main­
tain a moderate dermatitis.

Hyde and Montgomery¹ give the following formula, the proportions
of the various ingredients being varied according to the case and in­
dividual peculiarities: R. 01. ricini, f3ss (16.); acid, carbolic, 3j (4.);
tinct. cantharid., f3ss (16.); ol. rosmarin., gtt. xv (1.); spts. vin. rectif.,
ad f3iv (128.). Jackson² speaks well of a pomade of jaborandi made by
boiling down the fluidextract to one-half its volume, and adding this to
4 parts of lard; this is to be rubbed in twice daily. He also recommends
a lotion of corrosive sublimate, 1½ grains (0.1) to the ounce (32.) of water,
not on account of its parasiticide qualities, but solely for its stimulating
effect. Hardaway’s³ usual plan is to blister the patches every two weeks

¹ Hyde and Montgomery, Diseases of the Skin.

² G. T. Jackson, “Alopecia Areata: Its Etiology and Treatment,” New York Med.
Jour., Feb. 20, 1886.

³ Hardaway, Manual of Skin Diseases.

64

IOIO

DISEASES OF THE APPENDAGES

with acetic cantharidal collodion after thorough washing with soap and
water, and in the intervals to rub in morning and evening a lotion con­
sisting of equal parts of tincture of cantharides and glycerin; if there are
several areas, and of large extent, the vesicant is applied to one or two
places only at a time. Jamieson¹ states that of all the stimulants he
has used, the one which has given him the most satisfactory results has
been that originally suggested by Sir Erasmus Wilson: R. Liq. ammon.
fort., chloroformi, ol. sesami, ää 3ss (16.); ol. limonum, 3ss (2.); spts.
rosmarini, ad f3iv (128.). This is rubbed gently into the bald part at
first once, and then, as tolerance becomes established, twice daily, and
steadily persevered in. Sabouraud’s plan is to blister the patches and
then to paint the denuded surface with 5 to 6 per cent, solution of silver
nitrate.

It will be noted that all the preparations in common use are those
which possess both parasiticide and stimulating properties, and to these
can be added lactic acid, with which Rietema,² Balzer and Stoianowitch³
have recently had good results, using it with an equal part of water, and
increasing the strength if no positive irritation is produced. Jersild,⁴
of Finsen’s institute, Copenhagen, has lately published his results from
treatment by the concentrated light rays, and which he considered
satisfactory; a daily exposure of an hour each, for a period varying
from one to seven or eight weeks, being required. For this disease
the light from the iron electrode lamp would be sufficiently pene­
trating, and would require but several minutes’ application to bring
about a decided reaction; Jackson⁵ speaks of favorable influence
with the Piffard lamp for this purpose. The x-ray also has advocates,
with short exposure and with intermittent flashes, but has possi­
bilities of making matters worse.

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