Patchy Alopecia in a Patient with Rheumatoid Arthritis: A Pr
Rheumatoid arthritis (RA) is a chronic autoimmune disease affecting various organs. Although scalp involvement is not common in RA, drug adverse effects and also other concomitant conditions such as hypothyroidism and alopecia areata may result in hair loss in patients with RA. Meanwhile, using immunosuppressive agents makes patients with RA prone to various infections. Trichoscopy is a noninvasive diagnostic procedure that is increasingly used in dermatological practice while assessing hair disorders.

A 56-year-old woman with a history of RA for 10 years presented to our outpatient clinic, complaining of patchy hair loss and slight pruritus of the scalp for 3 months. She was referred by the rheumatology service to perform a skin biopsy to exclude cutaneous lupus erythematosus. She was living alone and did not have any pets at her home. The underlying disease had been controlled with oral prednisolone (10 mg/day) and methotrexate (12.5 mg/week). On examination, there were several erythematosquamous alopecic patches with a positive pull test on her vertex. Trichoscopy examination revealed scant scalp scaling alongside comma-shaped, corkscrew, and zigzag hairs, pustules, and also peripilar casts.

According to the trichoscopic findings, TC was considered and a KOH smear test was performed immediately, which revealed spores and hyphae of dermatophyte inside the hair shafts. Based on trichoscopy and direct smear findings, the diagnosis of TC was confirmed and the patient was commenced on oral itraconazole (100 mg/daily) and topical clotrimazole. After 6 weeks of treatment, her symptoms alleviated, alopecia resolved gradually, and the KOH smear became negative.