Archives of Dermatological Research
https://doi.org/10.1007/s00403-021-02199-x
LETTER TO THE EDITOR
Alopecia areata incognita: an oxymoron?
Hudson Dutra Rezende1 · Maria Fernanda Reis Gavazzoni Dias2 · Ralph M. Trüeb3,4
Received: 27 August 2020 / Accepted: 6 February 2021
© The Author(s), under exclusive licence to Springer-Verlag GmbH, DE part of Springer Nature 2021
Second thoughts are best as the proverb says
Cicero
Alopecia areata represents a common autoimmune hair
loss condition characterized by a usually acute onset of non-
scarring alopecia in sharply defined areas [1]. Occasionally,
alopecia areata can present as a diffuse alopecia, originally
recognized by Braun-Falco and Zaun [2], and may then be
misdiagnosed as telogen effluvium. Sato-Kawamura et al.
[3] reported a peculiar type of inflammatory non-cicatricial
alopecia that is characterized by female predominance and a
short clinical course with a good prognosis as acute diffuse
and total alopecia of the female scalp. In its lesser dramatic
presentation, diffuse alopecia areata has been deemed as
alopecia areata incognita (AAI) by Rebora [4], a term that
is popularly being reiterated today, as evidenced by a rise of
respective peer-reviewed publication counts since 2008 with
the introduction of dermoscopy for the diagnosis of hair and
scalp disorders [5] (Fig. 1). Rakowska et al. [6] eventually
proposed to classify the condition as a new disease based on
dermoscopic findings, until more research data were avail-
able to elucidate the underlying pathomechanism. And yet,
there are no reasons beyond doubt to classify the three afore-
mentioned clinical presentations of diffuse alopecia areata as
distinct nosological entities, except for variations in acuity
and severity of the hair loss. In fact, Moftah et al. [7] demon-
strated in their respective publication in the Arch Dermatol
Res expression of UL16 binding protein-3 (ULBP3) in AAI
* Ralph M. Trüeb
r.trueeb@derma-haarcenter.ch
1 of hair loss.
Department of Dermatology, Alvaro Alvim School Hospital,
Campos dos Goytacazes, RJ, Brazil
2
Department of Dermatology, Centro de Ciências Médicas,
Hospital Universitário Antonia Pedro, Universidade Federal
Fluminense, Niterói, RJ, Brazil
3
University of Zurich, Zurich, Switzerland
4
Center for Dermatology and Hair Diseases Professor Trüeb,
Bahnhofplatz 1A, CH‑8304 Wallisellen, Switzerland
as a marker for alopecia areata and distinct from telogen
effluvium and androgenetic alopecia.
On the occasion of a recent own case observation, we take
the opportunity to comment on this condition and its nomen-
clature. Patients present with a diffuse alopecia (Fig. 2a).
Following a completed dystrophic anagen effluvium, the
remaining hairs on the scalp appear as telogen bulbs in the
hair pluck (Fig. 2b), and may be misinterpreted as telogen
effluvium. Presence of yellow dots and short regrowing min-
iaturized hairs seen by dermoscopy (Fig. 2c), and occasion-
ally associated autoimmune phenomena such as Hashimoto
thyroiditis and/or circulating antithyroid or anti-parietal
cell antibodies may represent clues to the diagnosis and an
autoimmune pathogenesis. The diagnosis is confirmed by
histopathology consistent with alopecia areata, although
the lymphocytic infiltration may be sparse (Fig. 2d), and/or
usually excellent response with complete hair regrowth to a
course of systemic corticosteroids.
In our opinion, the designation of this condition as AAI
represents an oxymoron, from Greek ὀξύμωρον for “pointed
foolishness”. The oxymoron is a rhetorical device in speech
or writing that uses an apparent self-contradiction to illus-
trate a rhetorical point or to reveal a paradox. Unfortunately,
oxymora can also refer to unintentional contradictions that
are neither of scientific nor of stylistic value. This par-
ticularly applies to AAI, which in fact is diffuse alopecia
areata, since once the condition is identified, it is no longer
unrecognized, and the designation as such is no more than
oxymoronic. In conclusion, we challenge the use of AAI in
trichological terminology for the sake of a firm nosological
classification and patent nomenclature of the alopecias based
on our understanding of the underlying pathomechanisms
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Fig. 1  Peer-reviewed publications on alopecia areata incognita by

year since the introduction of the term in 1987, and of dermoscopy
for diagnosis in 2008 (from PubMed)

Fig. 2  a–d Diffuse alopecia

areata: (a) clinical presenta-
tion as diffuse alopecia, (b)
predominant telogen hairs in
a hair pluck, (c) dermoscopic
finding of yellow dots and short
regrowing miniaturized hairs,
(d) histopathological finding of
hair follicles in catagen with a
sparse peribulbar inflammatory
infiltrate. In the Arch Derma-
tol Res in 2016, Moftah et al.
demonstrated in an identically
illustrated case, expression of
UL16 binding protein-3 as a
marker for alopecia areata

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Archives of Dermatological Research
Author contributions HD and T and G and take responsibility for
the integrity of the data and the accuracy of the data analysis. Study
concept and design: not applicable. Acquisition, analysis, and inter-
pretation of data: Dutra, Trüeb, and G. Drafting of the manuscript: T.
Critical revision of the manuscript for important intellectual content:
Gavazzoni and Dutra. Statistical analysis: not applicable. Obtained
funding: not applicable. Administrative, technical, or material support:
not applicable. Study supervision: not applicable.
Funding Funding/sponsor was involved? NO. Design and conduct of
the study? NO. Collection, management, analysis, and interpretation
of data? NO. Preparation, review, or approval of the manuscript? NO,
Decision to submit the manuscript for publication? NO.
References
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review of pathogenesis and management. Clin Rev Allergy Immu-
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2. Braun-Falco ZO (1962) Über die beteiligung des gesamtencapil-
litiumsbei alopecia areata. Hautarzt 13:342–348
3. Sato-Kawamura M, Aiba S, Tagami H (2002) Acute diffuse
and total alopecia of the female scalp. A new subtype of dif-
fuse alopecia areata that has a favorable prognosis. Dermatology
205:367–373
4. Rebora A (1987) Alopecia areata incognita: a hypothesis. Derma-
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5. Tosti A, Whiting D, Iorizzo M, Pazzaglia M, Misciali C, Vincenzi
C, Micali G (2008) The role of scalp dermoscopy in the diagnosis
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Czuwara J, Rudnicka L (2009) Alopecia areata incognita: true or
false? J Am AcadDermatol 60:162–163
7. Moftah NH, El-Barbary RA, Rashed L, Said M (2016) ULBP3:
a marker for alopecia areata incognita. Arch Dermatol Res
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