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Introduction: Alopecia areata (AA) is a type of nonscarring alopecia that has autoimmune etiology, in which the hair follicle, usually an immune-privileged site, becomes the target of attack. Alopecia totalis (AT) is a subset of AA in which patients completely lose hair on the scalp. Initial hair regrowth is often fine and without pigment. We present a case of AT in which pigmented hair grew only overlying superficial veins, a finding which has not been previously reported. Case Presentation: An adult female with brown hair presented with AA that progressed to AT despite the use of triamcinolone ointment and topical 2% tofacitinib ointment. She was treated with nightly augmented betamethasone dipropionate 0.05% ointment under occlusion. Two months later, she noticed diffuse regrowth of thin hair on her scalp, most of which was depigmented. However, linear bands of darkly pigmented hairs were noted overlying superficial scalp veins. Discussion/Conclusion: Loss of pigmentation and subsequent repigmentation of the hair shaft in regrowing AA is not entirely understood. Initial hair regrowth in AA tends to be fine and depigmented, although the hair will usually regain normal texture and color. Pigmentation following a vein suggests that local temperature may play a role, possibly augmented by corticosteroid induced reduced expression of inflammatory cytokines and endothelial release of the vasoconstrictor hormone endothelin, which stimulates melanogenesis.

Healthy hair results from a combination of good generalized health and mindful health care practices. Many nutritional deficiencies lead to poor hair health and include changes to hair structure, texture, and viability. Although the mechanisms by which individual nutrients contribute to hair growth and maintenance have yet to be fully resolved, there are a variety of risk factors that predispose an individual to a nutritional deficiency; age, malnutrition, malabsorption, and medication use are among the most common. A thorough history should be taken in a patient with a hair disturbance to identify risk factors for a nutritional deficiency, which will then guide directed laboratory testing and treatment.

Sebaceous gland (SG) atrophy is well-documented in scalp lesions of psoriasis and has been considered as an important clue to psoriatic alopecia. However, its specificity for psoriasis has been questioned over the years. We hypothesize that SG atrophy is not specific for psoriasis and looked for its presence in biopsies of seborrheic dermatitis of the scalp.We conducted a retrospective study of biopsy specimens of clinically suspected and histopathologically proven seborrheic dermatitis of the scalp for changes in SGs between January 1, 2014 and August 6, 2021.SGs lobules were smaller and narrower in five of the six cases of seborrheic dermatitis, and SG atrophy was present in four out of six cases.SG atrophy is observed in seborrheic dermatitis and is not specific for psoriasis or psoriatic alopecia.

Lymphomatoid papulosis (LyP) type E is a rare variant of the primary cutaneous CD30+ lymphoproliferative disorders, characterized clinically by large necrotic eschar-like lesions and histopathologically by angiodestructive and angioinvasive infiltrates of CD30+ lymphocytes. As in other forms of lymphomatoid papulosis, type E lesions may undergo spontaneous regression after weeks, with frequent recurrences. We report a 21-year old male with an angiodestructive infiltrate of CD30+ lymphocytes manifesting as a papular eruption rather than ulceration, and suggest that this clinical phenotype might be related to the presence of CD4+ lymphocytes in the inflammatory cell infiltrate. This article is protected by copyright. All rights reserved.

Three hundred thousand new cases of Lyme disease are diagnosed annually in the United States. The earliest manifestation of the disease, erythema migrans, occurs earlier than serologic conversion, and skin biopsies can be very helpful in suggesting the diagnosis. Histopathologic findings vary depending on where in the lesion the specimen is taken, but typically consist of a superficial and deep perivascular and interstitial lymphocytic infiltrate with eosinophils centrally and with histiocytes and plasma cells at the periphery. Rare cases with interstitial histiocytes and rare-to-sparse plasma cells exist. We present a 67-year-old man whose skin biopsy, taken on day 2 of his eruption, demonstrated a subtle perivascular and interstitial infiltrate of histiocytes without plasma cells. Dermatopathologists need to be aware of this pattern and consider the diagnosis of erythema migrans, despite negative initial serologic testing.

Superficial temporal artery pseudoaneurysm is a rare complication of arterial injury developing on the forehead following blunt trauma. There is little written on this entity in the dermatopathology literature. We describe two cases of superficial temporal artery pseudoaneurysm in two men aged 53 and 25 years, one of whom had a recent history of head trauma. This report reviews the classic histopathologic findings of STA pseudoaneurysm and highlights ways to distinguish it from other entities in the differential diagnosis.

BACKGROUND: Aging is an unavoidable biological process with many influencing factors, accounting for a multitude of visible manifestations on the hair as well as the skin. As the population ages while becoming more diverse, it is increasingly important to better understand the hair aging process. METHODS: A literature search was performed to review what is known about changes in hair structure over time, focusing on the differences in hair aging according to ethnic background. RESULTS: Sixty-nine publications were selected and information regarding hair structure, aging characteristics, and responses to extrinsic damage together with differences between races and ethnicities was collected. Hair-graying onset varies with race, with the average age for Caucasians being mid-thirties, that for Asians being late thirties, and that for Africans being mid-forties. Caucasians and Asians typically experience damage to the distal hair shaft, while African-Americans see damage occurring closer to the hair root. Postmenopausal changes include decreased anagen hairs in the frontal scalp, lower growth rates, and smaller hair diameters. CONCLUSION: There is a paucity of literature examining the characteristics of hair aging across all races. The unique characteristics of hair aging in different ethnicities provides information that will aid in a culturally sensitive approach and recommendations.

Background Exogenous ochronosis (EO) is a deposition disease associated with application of hydroquinone-containing preparations. Characteristic ochronotic bodies (OBs) arise from endogenous connective tissues, most often reported as collagen. We highlight a significant role for elastic fibers as a precursor tissue. Objective To evaluate elastic tissue pathology in EO, specifically as it relates a precursor role in ochronotic body formation. Methods In this retrospective observational study, a literature review using PubMed/MEDLINE database was conducted to ascertain the most commonly ascribed precursor connective tissue. Eleven histopathologic cases of EO were identified. Patient demographics and clinical characteristics were recorded. Slides were reviewed for the presence and grade of solar elastosis (SE), the relationship of OBs to elastotic material, the presence of elastotic fibers transitioning to OBs, and positivity of bodies with Verhoeff-van Gieson elastic tissue stain. Results Elastic fibers are uncommonly reported as the major precursor tissue of OBs. SE was uniformly present in our cases, and the majority demonstrated heavy/high-grade elastosis. Elastotic fibers transitioning to OBs were observed in all cases, and the bodies demonstrated Verhoeff-van Gieson positivity. Limitations Small sample size. Conclusions Ochronotic body formation is associated with SE, and bodies appear to arise from damaged elastic fibers.

Since the initial description of frontal fibrosing alopecia (FFA) in 1994, increasingly more cases of FFA have been reported in literature. Although clear epidemiologic data on the incidence and prevalence of FFA is not available, it is intriguing to consider whether FFA should be labeled as an emerging epidemic. A medline trend analysis as well as literature review using keywords “alopecia,” “hair loss,” and “cicatrical” were performed. Medline trend analysis of published FFA papers from 1905 to 2016 showed that the number of publications referenced in Medline increased from 1 (0.229%) in 1994 to 44 (3.5%) in 2016. The number of patients per published cohort also increased dramatically since the first report of FFA. Over the time period of January 2006–2016, our multi hair-referral centers collaboration study also showed a significant increase in new diagnoses of FFA. At this juncture, the cause for the rapid rise in cases is one of speculation. It is plausible that a cumulative environmental or toxic factor may trigger hair loss in FFA. Once perhaps a “rare type” of cicatricial alopecia, FFA is now being seen in a frequency in excess of what is expected, thus suggestive of an emerging epidemic.

Epidermodysplasia verruciformis (EV) is a genodermatosis characterized by overgrowth of flat warts, pityriasis versicolor-like lesions and an increased propensity for developing cutaneous squamous cell carcinomas due to abnormal susceptibility to infection with beta-human papilloma viruses. Adnexal tumors are not typically associated with EV. Here we report a spectrum of hybrid adnexal tumors with divergent eccrine and folliculosebaceous differentiation, and cytologic features ranging from benign to frankly atypical, in a patient with inherited EV.

Background Anagen effluvium with reversible scalp alopecia is a known side effect of chemotherapy. However, there are an increasing number of reports in the literature documenting permanent alopecia in patients treated with taxanes. Objective We sought to describe the clinicopathologic features in breast cancer patients who underwent treatment with taxanes and adjuvant hormonal chemotherapy. Methods We reviewed the clinical and histopathologic information of a cohort of 10 patients treated with taxanes and adjuvant hormonal chemotherapy. Results We have observed 3 types of clinical patterns of alopecia (types A, B, and C), and have validated the histopathologic features showing alopecia areata–like and female pattern hair loss. Limitations The study was based on a small sample size and retrospective retrieval of clinical information and histopathologic review of posttreatment slides. Conclusions We hypothesize a clinicopathologic model of hair follicle cycle disruption in response to the chemoinflammatory and hormonal insults to the hair follicles resulting in permanent alopecia. Clinicopathologic correlation is paramount to the understanding of the morphobiologic pathways in chemotherapy-induced alopecia caused by taxanes and adjuvant hormonal treatment.

Discoid lupus erythematosus (DLE), a type of chronic cutaneous lupus erythematosus, is an important cause of scarring alopecia. The incidence of DLE is higher among women than men, and it tends to occur most commonly in the fifth decade of life. It is an autoimmune condition triggered by environmental stressors in individuals with an unknown underlying genetic predisposition. Environmental stressors implicated in this condition include ultraviolet irradiation, hormones, medications, infections, and cigarette smoking. The characteristic erythematous, scaly plaques frequently appear first on the scalp and may be misdiagnosed as alopecia areata, lichen planopilaris, or pseudopelade of Brocq. Scalp trichoscopy can be helpful to identify the characteristic features of scalp DLE: loss of follicular orifices, follicular keratotic plugs, large yellow dots, and thick arborizing vessels. Biopsy of scalp lesions is important to differentiate among various causes of inflammatory alopecia, and direct immunofluorescence can be helpful to confirm the diagnosis. Treatment involves removal of environmental triggers and a tiered therapeutic approach. First-line therapies include high-potency topical steroids and topical calcineurin inhibitors. Patients who fail topical treatments can be treated with an antimalarial medication as first-line systemic treatment. Some evidence supports the use of oral retinoids or methotrexate for refractory cases. There are no biologic agents approved for the treatment of DLE, but case reports indicate that antiinterferon-α monoclonal antibodies may be effective. Identification of alopecia caused by DLE is important because untreated lesions may rarely progress to malignancy.

Anaplastic large cell lymphoma (ALCL) is a rare type of non-Hodgkin lymphoma that can involve the skin primarily or secondarily. Our case describes an unusual presentation of eruptive tumors localized to the leftbreast region several years following breast cancer surgery and radiation for carcinoma of the breast. This report highlights the challenges in reachingthe diagnosis of an aggressive systemic lymphoma presenting on the skin.

There is a significant need for the development of diagnostic tools that can precisely distinguish Spitz nevi and spitzoid melanomas. Here, we report the development of a PCR-based quantitative diagnostic assay for spitzoid melanocytic lesions utilizing the expression ratio of neuropilin-2 and melan-A genes in primary tumor specimens. We find that the expression ratio of neuropilin-2/melan-A is significantly increased in spitzoid melanomas compared with Spitz nevi. The diagnostic potential of this quantitative assay was validated in two independent sets of patient samples as demonstrated in a receiver operating characteristic curve analysis showing an area under the curve value of 91.8%. Furthermore, the assay was found to quantitatively distinguish the clinical nature of atypical spitzoid melanocytic lesions that were diagnostically undetermined using histopathologic criteria alone. Our data indicate that this quantitative assay may be used as a tool in determining the diagnostic classification of histologically challenging spitzoid tumors.

Background: The rate of intravenous drug use (IVDU) has been increasing nationally; however, cutaneous manifestations of IVDU have infrequently been investigated. We report a series of the clinicopathological correlation of IVDU in the skin. Methods: A search of surgical pathology files between the years 2000 and 2014 was performed for cutaneous specimens from patients with a reported history of IVDU for which the histopathological findings could not be attributed to another etiology. Ten cases for which slides were available were included in the study. Results: Patients had an average age of 39.7 years and had active or recent history of IVDU. Clinical impressions included ulcer, granulomatous dermatitis, vasculitis, pyoderma gangrenosum and hyperpigmentation at injection sites. Histopathology revealed leukocytoclastic vasculitis (n = 2), dermal pigment deposition (n = 3), non-specific ulceration/scarring (n = 4) and necrobiosis lipoidica-like dermatitis (n = 1). No infectious etiology or polarizable foreign material was identified in any case. Conclusions: Cutaneous manifestations of IVDU should be considered in the differential as an etiology for dermatopathologic findings in high-risk patients. We report histopathological findings beyond the scope of those most commonly associated with IVDU. We aim to raise awareness of the cutaneous manifestations of IVDU to improve clinicopathological correlation and patient management in light of the ongoing epidemic.

Cutaneous myopericytoma is a rarely reported mesenchymal neoplasm with a benign biologic behavior. It is seen more commonly in males and typically occurs in adults on the distal extremities. To the best of our knowledge, there are only 13 reports describing 45 cases of cutaneous myopericytoma in the literature. The 3 cases in this report expand the clinical presentation and reinforce the histopathologic features of cutaneous myopericytoma. While the clinical presentation in 2 cases (located on the scalp and heel) was in keeping with that reported previously of a slow-growing painless firm nodule, the third case, located on the dorsal wrist, presented as a scaly keratotic nodule. Histopathologic examination of all 3 cases revealed an unencapsulated dermal nodule with concentric perivascular arrangement of plump, spindle-shaped myoid cells admixed with thin-walled blood vessels. Immunohistochemical staining revealed the lesional cells to be actin- (3/3) and caldesmon- (2/3) positive and negative for other smooth muscle markers, compatible with perivascular myopericytic differentiation.

Lichen nitidus typically presents as shiny pin-head sized papules on the trunk and extremities, often affecting children and young adults. In this prototypical form, it rarely presents a diagnostic challenge being characterized by distinctive clinical and histopathologic findings. We describe a rare variant of lichen nitidus, which we term "hyperkeratotic and hypertrophic lichen nitidus."

Disseminated superficial actinic porokeratosis (DSAP) is the most common variant of porokeratosis with a potential for malignant transformation. Its association with malignant melanoma, however, is exceedingly rare. Treatment of DSAP is often ineffective. We report a unique case of amelanotic melanoma arising within a lesion of DSAP. The melanoma was managed surgically, and her DSAP were treated successfully with a novel approach utilizing 5-fluorouracil chemowraps.

Luteinized thecomas with sclerosing peritonitis (LTSP) is a rare disease characterized by ovarian luteinized thecomas and associated fibrosing peritonitis. Cutaneous involvement has never been reported. We report a case of classical LTSP with skin involvement, outlining the clinical and histopathologic features of this novel presentation of a rare syndrome.

A 66-year-old woman, who underwent natural menopause over 10 years ago, presented to her endocrinologist reporting progressive increase in facial and bodily hair growth most notable on the upper lip, chin, mid-chest, and inner thighs. She also acknowledged new-onset acne affecting her face and upper back as well as bothersome and progressive thinning of her scalp hair; these symptoms had become noticeable over the past 1 year. On questioning, she acknowledged noticing an increase in the size of her clitoris over the 1–2 years prior to this presentation; while she denied any change in her breast size, libido, or occurrence of vasomotor symptoms, some family members had commented on a change in her voice.

A 62-year-old postmenopausal woman presents with a complaint of scalp hair loss. It has been present for several years, but worsened recently several months after a hospital admission for pneumonia, prompting the visit. She noticed an abrupt onset of hair shedding beginning 3 months after her hospitalization, and which lasted for almost 3 months. She reports that her shedding has since slowed and is back to baseline. She is otherwise healthy except for a history of recently diagnosed mild hypertension and osteoarthritis. Her medications include lisinopril, which she has been on for 6 months, and ibuprofen. She reports that her father became bald at a young age, but denies any hair loss complaint among women in her family.

Human hair has commonly been classified based on ethnic origin, with three conventional subgroups recognized, including Caucasian, Asian, and African hair (Franbourg et al. in J Am Acad Dermatol 48:S115–S119, 2003; McMichael in Dermatol Clin 21(4):629–644, 2003; Loussouarn et al. in Int J Dermatol 46:2–6, 2007). These ethnic subgroups have compositional and structural variations, as well as distinct hair-grooming practices (Rook in Br J Dermatol 92(5):599–600, 1975). Such broad classification does not account for the great complexity of human hair but provides a basic framework for description. These ethnic differences are important to comprehend the pathophysiology of scalp and hair disorders in the context of ethnicity.

Extraocular sebaceous carcinoma is a rare neoplasm. Purely in situ extraocular sebaceous carcinoma is extremely rare and somewhat controversial. Review of the literature reveals only three reported cases, two of which involved the head and neck and one the arm. The ones on the head and neck arose in association with an actinic keratosis. We report three cases of extraocular sebaceous carcinoma in situ and describe the first report of immunoperoxidase screening for mismatch repair proteins in such tumors.

Background Chronic cutaneous lupus erythematosus (CCLE) often affects the scalp resulting in scarring alopecia. While histopathologic findings of CCLE have been well described, there is little written on the morphologic changes to the hair follicles in this condition. Objective We aim to determine the histopathologic findings of hair follicles in CCLE of the scalp. Methods We conducted a retrospective study of 33 transversely sectioned skin biopsy specimens of CCLE of the scalp at the Skin Pathology Laboratory at Boston University between April 2005 and March 2015. Results New findings include basaloid follicular epithelium lacking hair follicles at deep levels, follicular miniaturization, increased catagen/telogen hair follicles, and pigment casts. Two histopathologic patterns could be discerned, an alopecia areatalike pattern and a lichen planopilarislike pattern. Limitations Generalizability of a single-center experience may be limited. Conclusion Follicular findings in CCLE of the scalp are reported. We hypothesize that the basaloid aggregates are remnants of hair follicles that are no longer actively cycling.

Sclerotic bodies are round to oval structures made up of collagen with entrapped elastic fibers, which may be sometimes ossified. These bodies may be found in skin biopsies from patients with nephrogenic systemic fibrosis (NSF), a disease linked to the use of gadolinium in radiologic procedures and chronic renal failure. Sclerotic bodies have not been reported in other diseases. Herein, we report sclerotic bodies as an incidental finding in a re-excision specimen of a squamous cell carcinoma (SCC) from the forearm of an 85-year-old man with chronic renal failure. The patient had had multiple SCC removed over time. Additional clinical history revealed patient having received gadolinium in 2003 and 2004, preceding his dialysis that began in 2009. All of his excision specimens revealed sclerotic bodies in 20 of 30 specimens from 2008. None of the 26 re-excision specimens prior to gadolinium exposure had these bodies. Our findings suggest that sclerotic bodies are the result of gadolinium exposure in patients with chronic renal insufficiency. Because the bodies were found near the re-excision scar, it may be that gadolinium or its metabolites activate fibroblasts in the setting of wound healing. The reasons why this patient did not develop NSF are unclear.

Platelet-rich plasma (PRP) is a solution derived from whole blood that is enriched in the platelet fraction. Platelets serve as a reservoir of growth factors and cytokines. When platelets are activated in vivo, signaling molecules are released into the immediate microenvironment and activate receptors for various pathways. Historically, PRP has been applied to wound beds to promote healing of complex wounds. Over the last decade, it has served as a valuable therapeutic tool in various specialties such as maxillofacial surgery, plastic surgery, orthopedics and sports medicine. Only recently has PRP been utilized for dermatologic purposes, more specifically, for the treatment of male and female pattern hair loss. In this review, we discuss molecular and cellular pathways upregulated by PRP important in hair folliculogenesis, and examine clinical evidence from all previously published studies involving the use of PRP for pattern hair loss.

Alopecia is a disorder that affects all patients, young and old. Many diagnoses, particularly the scarring alopecias, are more common in adults; however, others, such as tinea capitis, are more common in children, and some, such as alopecia areata, often affect both age groups. The approach to, and evaluation of, an alopecia patient is thus highly dependent on his or her age. In adults with diffuse, non-scarring hair loss, a part-width examination can help detect pattern hair loss, the most common cause of diffuse loss in this age group. In children this is much less likely, and a careful evaluation for tinea capitis is in order. The same holds true for patchy alopecia in children, as well as scarring alopecia-tinea needs to always be considered. In adults, patchy alopecia is often due to alopecia areata and sometimes to one of the primary scarring alopecias. A laboratory evaluation, and especially a biopsy, would be a more appropriate undertaking for an adult than a child, and an adult would be more likely to tolerate certain therapeutic regimens such as intralesional injections. In a conversational manner, the authors discuss their individual approaches to the alopecia patient, highlighting the differences in diagnosis, workup, and management that depend on whether the affected individual is an adult or a child.

Reversible alopecia following chemotherapy is well recognized and typically not evaluated by dermatologists. However, there are an increasing number of reports of permanent chemotherapy-induced alopecia, typically following high-dose chemotherapy and subsequent bone marrow transplantation. We describe an unusual case of permanent alopecia in a patient who received adjuvant chemotherapy for breast carcinoma, and not a conditioning regimen before bone marrow transplantation. A unique histologic finding of replacement of anagen hair follicles by linear columns of basaloid epithelium is reported. We review the clinical and histologic findings of permanent chemotherapy-induced alopecia and speculate on its pathogenesis.

Background: Elastophagocytosis, or elastic fiber phagocytosis by multinucleate macrophages, has been observed in different skin conditions that may or may not occur on sun-exposed skin. Although loss of elastic fibers has been well documented in the homogenized papillary dermal zone in lichen sclerosus (LS), elastophagocytosis, to the best of our knowledge, has never been observed. Methods: We encountered striking elastophagocytosis in a case of extragenital LS which prompted us to review all cases of LS diagnosed at the Skin Pathology Laboratory at Boston University over a 2-year period to assess for the presence of elastophagocytosis. Results: In 7 of 35 patients diagnosed with LS (20%), we found prominent elastophagocytosis to be present either immediately below or at the junction of the homogenized collagen and the normal underlying reticular dermis. Interestingly, all the cases in which elastophagocytosis was observed were in extragenital locations. Conclusion: Elastophagocytosis was observed in 20% of LS cases, all of which were extragenital. We hypothesize that elastophagocytosis in LS, especially in extragenital sites, may not be an epiphenomenon but rather represents a contributing factor to elastic fiber loss in the hyalinized papillary dermal collagen that typifies this disease. Abbas O, Chatrath V, Goldberg LJ. Elastophagocytosis in lichen sclerosus.

Background Epidermolytic acanthoma (EA) is an uncommon cutaneous entity that typically presents as a solitary lesion, or, less commonly, as multiple or disseminated discrete lesions. It usually appears at or after middle-age, and has been reported in various locations including the face, trunk, extremities and genitalia. Histopathologically, EA shows epidermolytic hyperkeratosis (EHK) involving either the entire thickness of the epidermis or just the granular and upper spinous layers. Objective and methods To describe the clinical and microscopic features of EA, we retrospectively reviewed all cases diagnosed as EA at the Skin Pathology Laboratory at Boston University between 1999 and 2009. Results Solitary EA is more common in men (65%) and usually presents as a hyperkeratotic papule on the trunk (45%) or extremities (25%). Histopathologically, all cases of solitary EA showed the classical features of hyperkeratosis, acanthosis and EHK. Three architectural patterns were observed on scanning magnification: papillomatous (55%), cup-shaped (40%) and acanthotic (15%). Additional common features encountered included focal parakeratosis (85%), and a sparse to mild superficial perivascular lymphocytic infiltrate (90%). Conclusion This large case series of solitary EA reviews the clinical features of this entity and describes several new histological variants.

Based upon the thermal relaxation time of the hair follicle (10-50 ms), most lasers and light devices use relatively long pulse widths for hair removal. This study was conducted to evaluate a shorter pulsed, 0.65 ms Nd:YAG laser for hair removal.One half of each axilla of six female participants was treated and the other half was monitored as a control. The treatment sites were treated with a fluence of either 21 J/cm(2) or 36 J/cm(2) using an Nd:YAG laser with a wavelength of 1064 nm and a pulse duration of 0.65 ms. A manual hair count was done before treatment and at each follow-up visit.Four months after four monthly treatments, the hair reduction was graded as 5 (75-100% reduction) on the high fluence side and 4 on the low fluence side (50-75% reduction) by individuals and investigators. The average hair count 4 months after four treatments in the sites treated with a high fluence went from 114 to 28 (76% reduction) and in the low fluence areas from 135 to 38 (72% reduction).This well-controlled study shows that a 0.65 ms Nd:YAG laser is effective and safe for hair removal.

Alopecia areata is an autoimmune disease causing patchy hair loss, which occurs with an increased incidence in patients with lupus erythematosus. We report a 27-year-old African-American female with systemic lupus erythematosus and alopecia areata, whose biopsy showed a marked increase in mucin in the deep dermis and subcutis. Archival biopsies of alopecia areata were then reviewed to see if this finding occurs in patients without systemic lupus. Of 13 recent biopsies diagnostic of alopecia areata, we detected deposition of mucin in 3 (23%), but all mild in degree and in a superficial location. We speculate that the marked deposition of mucin in this patient's biopsy of alopecia areata may be related to her underlying systemic lupus, and that the presence of marked, deep dermal deposition of mucin might serve as a diagnostic clue for the presence of underlying systemic lupus in patients with alopecia areata.