Attitudes and perceptions of school-aged children toward alopecia areata.

Discussion | Our study used visible rather than palpable neck texture because we found visible texture grading to be more reproducible. Consensus was obtained for all visible neck and axillary features, but Burke et al4 have noted that reproducibility of palpable texture was limited (κ≤0.68). In our study also, neck texture was determined to be the most sensitive marker: 8 patients with elevated HOMA-IR showed neck texture change without pigment change. Puri et al5 found hyperkeratosis (thickened stratum corneum) to be the most common histopathological feature of AN: all AN lesions in that study exhibited hyperkeratosis, whereas 90% exhibited papillomatosis (histopathologic equivalent of wartiness). The use of visible neck texture as an indicator of AN is advantageous because the visible roughness of the neck is recognizable without touching the skin or requiring the patient to disrobe, affording an instant assessment of AN. Texture grading also avoids possible confounding by sun-induced pigmentation. Thus, neck texture exhibits both greater sensitivity and specificity than neck pigment for AN detection. This study clinic’s patient population was approximately 92%white, limiting theapplicationofour results tootherpopulations. With HOMA-IR varying among populations,6 there is noagreementonHOMA-IRcutoffs.Accordingly, themost sensitive among suggested HOMA-IR cutoffs was used in this study.3 Results of this study confirm those of Stuart et al,1 who found IR in 93% to 99% of patients with AN of the neck. Kong et al7 stated that AN was most difficult to detect in fair-skinned persons, indicating the need for measures with greater sensitivity in these persons. The use of neck texture, rather than pigment on the neck or other anatomic locations, yields this increased clinical sensitivity. Although many physicians observe the axilla to determine AN, 4 patients with IR would have been missed with only axillary observation (Figure 2). Because neck texture is the most sensitive finding for AN, we propose the term insulin neck for this finding. All patients with elevated BMI should be examined for insulin neck. This research report has 3 take-home points for the clinician: 1. Insulin neck (visibly increased texture on the posterolateral neck) is the most sensitive physical finding for IR. 2. Insulin neck appears as visible lines and/or furrows and ridges on the posterolateral neck. 3. If neck texture is normal, IR is less likely to be present.