Moth-eaten alopecia and beyond: Syphilitic alopecia - Revisited

Alopecia is usually an overlooked manifestation of syphilis commonly seen in secondary syphilis with a prevalence of 2.9%-7%. It is broadly classified into symptomatic and essential alopecia and the observed patterns include moth-eaten type, generalized thinning, and mixed pattern. Here, we report a 38-year-old male who presented with mixed pattern alopecia of the scalp and bilateral postauricular lymphadenopathy. Toluidine red unheated serum test and Treponema pallidum hemagglutination were positive in a titer of 1:128 and 1:720, respectively. Trichoscopy showed empty follicles, perifollicular and interfollicular scales, faint reddish-brown pigmentation, black dots, and broken and regrowing hairs. The patient was treated with a single dose of benzathine penicillin 2.4 million IU intramuscular injection. The patient was regularly followed up and showed marked regrowth of hairs and resolution of postauricular lymphadenopathy. Lymph node and hair examination and trichoscopy as a noninvasive tool could aid in the diagnosis of alopecia syphilitica.