Table 1. Clinical differential diagnosis of moth-eaten alopecia syphilitica


Clinical Presentation




Alopecia areata

Exclamation mark hairs
Sudden loss, well-demarcated

A “swarm of bees” appearance of T lymphocyte infiltrates in the peribulbar region

CBC 2, TFT, Thyroid antibodies

Corticosteriods (intralesional, systemic, or topical)

Alopecia neoplastica

Presents months to years after diagnosis of primary malignancy

Infiltration of tumor cells from primary malignancy


Treatment of primary malignancy

Alopecia syphilitica

Moth-eaten or diffuse pattern, or combination of both Other symptoms or lesions of secondary syphilis

No dermoepidermal changes
Sparse lymphocytic infiltrate
Absence or rare peribulbal eosinophils
Absence of small or abnormal anagen hair follicles
Plasma cells may be present


Benzathine penicillin G
2.4 million units, 1-3 weekly
intramuscular injection(s)

Tinea capitis

Erythematous patch with scaling
Brittle and broken hair
“Black dot” appearance
Kerion, if superinfected
Cervical lymphadenopathy

Endothrix-hair shaft filled with hyphae and spores
Ectothrix-hyphae and spores outside of hair

Culture KOH stain of scalp scrapings
Wood’s light

Systemic antifungals for 6-8 weeks


Irregular, localized patches
Broken hairs of varying lengths
Patient admits to pulling on hairs

Empty follicles with remnant hair bulb with exudates or hemorrhage
Complete distortion of a fully developed termina hair in the bulb
No inflammation of hair bulb or atrophic anagen hairs


Parental support/education, Parental support/education, pharmacotherapy, depending on age and severity; may need psychiatric consultation

1.     CBC, complete blood count and platelets; KOH, potassium hydroxide; TFT, thyroid function test

2.     If a macrocytic anemia is present, vitamin B12 level and patietal cell antibodies might be considered.