Pseudo Alopecia Areata Caused by Skull-caps with Metal Pin Fasteners used by Orthodox Jews in Israel

BACKGROUND Alopecia Areata (AA) is a disease characterized by hair loss that is widely believed to be autoimmune in origin. Thus treatment is generally aimed in this direction using immune inhibitors such as steroids and PUVA. OBJECTIVE To describe a variant of AA, Pseudo Alopecia Areata, caused by a particular cupola pin holder (tic-tac) and to offer a non-pharmacological treatment option (NPT). METHODS A prospective open label study in 37 Jewish religious patients (34 males, 3 females, mean 35 +/- 2 years), previously diagnosed and treated for scalp AA were randomly referred to one of the three NPT intervention methods: small cupola held by two pins, large cupola held by one pin and similar cupola held by a different pin. RESULTS Three of the ten patients (33.3%) from the first group developed secondary AA from the additional pin. No changes were seen in the second group. Ten of the seventeen patients (58.8%) from the third group achieved immediate improvement subsequent to replacing the original pin with a new one on a larger cupola. CONCLUSIONS Conservative pharmacological treatment failed to repair the lesions. The addition of a second pin caused an additional lesion. In contrast, replacing the cupola with a larger one and the original pin-fastener with a different type, successfully reduced the lesions.