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斑秃的鉴别诊断-晨读报告

admin6个月前 (12-07)皮肤科22

下期预告：创伤性脱发（Traumatic alopecia)

keywords:

anagen(生长期）, catagen（退行期）, telogen（休止期）

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斑秃的鉴别诊断 Differential diagnosis

The differential diagnosis of alopecia areata is based on whether the clinical pattern of hair loss is localized or diffuse.

斑秃的鉴别诊断根据脱发的模式是局限性还是弥漫性来判断。

In cases with localized areas of hair loss,the differential diagnosis includes trichotillomania,triangular temporal alopecia,syphilis,discoid lupus erythematosus,lichen planopilaris,frontal fibrosing alopecia,pseudopélade,and tinea capitis.

对于局限性脱发，鉴别诊断包括拔毛癖，颞部三角形脱发，梅毒，盘状红斑狼疮，毛发扁平苔藓，前额纤维化脱发，假性斑秃和头癣。

Trichotillomania may closely simulate alopecia areata but microscopic examination of the former condition shows more pigmented casts,an absence of miniaturized hairs,and minimal inflammatory infiltrate. Triangular temporal alopecia shows no clinical or histological evidence of i nflammation and there is no excess of hair follicles in telogen or catagen. Alopecia syphilitica may be very similar but clinically the plaques rarely show complete absence of hairs. Histological examination can also be problematical since both conditions show a peribulbar inflammatory cell infiltrate containing plasma cells. Serology is sometimes essential in difficult cases.

拔毛癖可以和斑秃十分相似，但前者显微镜检查显示有更多的色素，没有微小化的毛发，轻微的炎症浸润。颞部三角形脱发临床及组织学上没有任何炎症表现，而且在毛发静止期或退行期没有多余的毛囊。梅毒性脱发可以和斑秃非常相似，但临床上脱发斑中的头发很少全部脱落。由于两者都显示毛球周围有包括浆细胞在内的炎症细胞浸润，所以组织学检查也难以区分。对于难以鉴别的病例，血清学检查有时候是必要的。

Discoid lupus erythematosus,lichen planopilaris,and frontal fibrosing alopecia display more prominent inflammation in the superior segment of the follicle,and result in scarring alopecia with interface change and permanent loss of terminal hair follicles. Direct immunofluorescence is useful to confirm the diagnosis in the first two conditions. Equally,the presence of dermal deposition of mucin is a diagnostic clue in discoid and systemic lupus. It is important to keep in mind that both entities may coexist. The incidence of alopecia areata in patients with lupus erythematosus may even reach 10%. Cases of lupus panniculitis clinically simulating alopecia areata have also been described. In pseudopélade there is extensive scarring,with loss of terminal hair follicles and a mild inflammatory cell infiltrate localized to the upper segment of the follicle. Tinea capitis also shows an inflammatory infiltrate in the upper segment of the hair follicle with neutrophils,lymphocytes,and histiocytes. The fungi are usually easily found adherent to the hair shaft with a periodic acid-Schiff(PAS)stain and may be cultivated in Sabourauds agar.

盘状红斑狼疮，毛发扁平苔藓和额部纤维化脱发显示更显著的毛囊上段炎症，导致疤痕性脱发，伴有界面改变和终毛毛囊的永久性脱失。直接免疫荧光检查对于前两者的确诊很有帮助。

同样地，粘蛋白的皮肤沉积是盘状和系统性红斑狼疮的一条诊断线索。值得记住的是两种情况是可以共存的。在红斑狼疮患者中，斑秃的发生率甚至可能达到10%。狼疮性脂膜炎脱发类似于斑秃的病例也有描述。在假性斑秃中有广泛的疤痕形成，伴随着终毛毛囊消失和毛囊上段轻度炎症细胞浸润。头癣也显示毛囊上段的炎症浸润，包括中性粒细胞，淋巴细胞和组织细胞。用PAS染色很容易发现发干上的真菌，在Sabouraud琼脂中也可能培养出。

The differential diagnosis of diffuse alopecia areata is mainly telogen effluvium and androgenetic alopecia. Clinically,even in the most severe variants of alopecia totalis and alopecia universalis,small isolated clumps of hair are seen that allow distinction from telogen effluvium. Histologically,telogen effluvium lacks inflammation and there is an increase in the number of telogen hair follicles. In androgenetic alopecia,the histologic image may be very similar to that of chronic areata alopecia as in the former the miniaturization of hairs may be very extensive. Nevertheless,the lack of lymphoid infiltration and the different clinical picture may help in the differential diagnosis.

弥漫性斑秃的鉴别诊断主要是休止期脱发和雄激素源性脱发。临床上，即使是最严重的全秃和普秃，也会看到孤立的小丛头发，可以据此与休止期脱发相鉴别。组织学上，休止期脱发没有炎症，并且休止期毛囊的数量增加。雄激素源性脱发组织学表现可能与慢性斑秃十分相似，因为前者毛囊小型化十分广泛。然而，淋巴浸润的缺乏和不同的临床表现可能有助于鉴别诊断。

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（斑秃章节全文完）

（浙江省人民医院皮肤科丁扬医生译）2017-11-17