We performed a retrospective chart review of patients seen in our combined rheumatology-dermatology clinic from Nov 2012 to Dec 2017. This dataset is ideal for this study as all patients had their diagnosis of SLE confirmed by a board-certified rheumatologist and the status of their hair evaluated by a boardcertified dermatologist.
We identified 70 SLE patients who at the time of evaluation met American College of Rheumatology 1997 (ACR’97) SLE criteria. After review of clinical history, timing, and any histopathological data, we excluded from our analysis alopecia due to other causes such as discoid lupus, lichen planopilaris, scarring alopecia on clinical exam, androgenetic alopecia, and alopecia secondary to medications.
Of the 70 patients, 36% presented with non-scarring alopecia, not attributable to other causes. The most common pattern and location of SLE-associated alopecia was: multiple patches all over scalp in 48%, patchy pattern of posterior scalp in 20%, patchy pattern of temporal scalp in 16%, and patchy pattern of central scalp in 12% of patients (Figure 1). The duration of alopecia in our patients ranged from 2 months to 30 years. Clinically alopecia increased during flares of underlying disease with 20% of patients noting it as significant but did not significantly precede other clinical features, making it less useful as an early sign of flare. There also appeared to be no relation to duration of disease in terms of their risk of experiencing alopecia: 38% with alopecia had had SLE for less than 2 years, 36% for 3 to 10 year, and 26% for more than 10 years. Some patients with SLE over 10 years had had prior episodes of alopecia, while others noted no such history, suggesting that even in those with alopecia it may not be a consistent feature of any individual’s disease. While we did exclude telogen as a cause based on a hair pull test, by simple clinical exam diffuse alopecia all over scalp can be seen in other forms of alopecia including telogen effluvium. However, patches with diffuse alopecia within them, which we identified in SLE patients, is not typical of telogen. Patchy alopecia of temporal and central scalp can be seen in androgenetic alopecia. Interestingly, patchy alopecia of posterior scalp is not preponderant in other forms of alopecia, and we therefore identify this as a potentially characteristic type of alopecia in SLE.
2. Yun SJ, Lee JW, Yoon HJ, et al. Cross-sectional study of hair loss patterns in 122 Korean systemic lupus erythematosus patients: a frequent finding of non-scarring patch alopecia. J Dermatol. 2007 Jul;34(7):451-5.