Australasian Journal of Dermatology (2021) , – doi: 10.1111/ajd.

13597

LETTER TO THE EDITOR

disease including alopecia areata (AA).1,2 Moreover, psori-

Research Letter
asis associated with Turner syndrome has also been
reported.1 However, coexistence of AA and psoriasis is
Dear Editor,
rarely reported. We report a case of psoriasis vulgaris and
AA associated with Turner syndrome.
Alopecia areata and psoriasis vulgaris associated with
A 58-year-old woman with Turner syndrome presented
Turner syndrome
with a more than ten-year history of alopecia totalis,
refractory to treatment including squaric acid dibutylester.
Turner syndrome is a chromosomal abnormality caused by
Additionally, she had a background of Hashimoto’s thy-
the absence or abnormality of the X chromosome.1 Turner
roiditis on levothyroxine. On examination of the scalp, only
syndrome is often associated with autoimmune skin

Figure 1 Clinical and histological features of alopecia areata and psoriasis before the occurrence of psoriasis lesions on her scalp. (a,b)
Total hair loss with telangiectasia on the scalp. (c) Lymphocytic inflammation is observed around the hair follicle (hematoxylin–eosin,
original magnification 9200). (d,e) Psoriasis lesions on her legs. (f) Histopathological findings from her psoriasis lesions showing confluent
parakeratosis, absent granular layers, acanthosis with club-shaped rete ridges of even length (hematoxylin–eosin, original magnification
9100).

© 2021 Australasian College of Dermatologists

2 Letter to the Editor

a single hair was detected (Fig. 1a,b). Scalp punch biopsy contributed to hair regrowth. The therapeutic efficacy of
showed lymphocytic inflammation around the hair follicle squaric acid dibutylester in AA is hypothesised to involve
(Fig. 1c). General skin examination revealed scaly erythe- myeloid-derived suppressor cells (MDSCs) which increase
matous plaques on her extremities (Fig. 1d,e). Biopsy from TNF-a expression and suppress autoreactive T-cell prolif-
the right knee revealed confluent parakeratosis, absent eration.4,5 In our case squaric acid, dibutylester treatment
granular layers and acanthosis with club-shaped rete may have exacerbated psoriasis and contributed to the
ridges of even length (Fig. 1f). Based on these findings, the refractory nature of psoriatic plaques on the scalp.
patient was diagnosed with psoriasis vulgaris and AA. Our In summary, we report a woman with Turner syndrome
patient presented with three-year history of treatment by who developed the concurrent autoimmune conditions AA,
squaric acid dibutylester and scalp psoriasis appeared dur- psoriasis and Hashimoto’s thyroiditis. In this case, develop-
ing the treatment. We started excimer laser therapy (308- ment of scalp psoriasis resulted in improvement of AA,
nm) and discontinued squaric acid dibutylester. At consistent with Renbo € k phenomenon.
5 months after the induction of excimer light therapy,
growth of vellus and terminal hairs was noted (Fig. 2).
Genetic disorders characterised by chromosomal abnor- ACKNOWLEDGEMENTS
malities, such as Turner syndrome, are often associated
We thank Dr. Taisuke Ito for the helpful discussions. The
with autoimmune diseases.1 The high risk of autoimmune
patient in this manuscript has given written informed con-
diseases in women with Turner syndrome is hypothesised
sent to the publication of her case details.
to be due to multiple factors including haploinsufficiency
of genes on the single X chromosome, constitutional up-
regulation of IL-6 and TNF-a and oestrogen deficiency.3 FUNDING
The Renbo € k phenomenon describes the disappearance
No Funding.
of a skin condition when another appears; for example,
active psoriatic lesions on the scalp may induce hair
regrowth in AA.3 Our patient initially presented with alope- CONFLICT OF INTEREST
cia totalis; however, following the development of scalp
The authors declare no conflict of interest.
psoriasis, new hair growth appeared within psoriatic pla-
ques, a pattern consistent with Renbo € k phenomenon. A
Rei Yokoyama1 | Ryota Hayashi1 | Osamu
charge is cytokine balance may be responsible for the
Ansai1 | Akito Hasegawa1 | Satoru Shinkuma1 |
Renbo € k phenomenon; AA is driven by a Th1 response
Yutaka Shimomura2 | Riichiro Abe1
whereas psoriasis is driven by Th1, Th17 and Th22. Fur-
thermore, excimer light treatment in our case may have

Figure 2 Clinical findings after the development of psoriasis lesions on her scalp. (a-c) Vellus and terminal hair remarkably grew on
psoriasis lesions.

© 2021 Australasian College of Dermatologists

 Letter to the Editor
1
Division of Dermatology, Niigata University Graduate
School of Medical and Dental Sciences, Niigata and
2
Department of Dermatology, Yamaguchi University
Graduate School of Medicine, Ube, Yamaguchi, Japan
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© 2021 Australasian College of Dermatologists