Case Reports

Pityriasis Amiantacea Following Bone Marrow Transplant

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Pityriasis amiantacea (PA) is a hair disorder characterized by matting of multiple hair shafts, typically occurring as an idiopathic condition. A 67-year-old woman with multiple myeloma who developed PA following a bone marrow transplant with melphalan conditioning is described.She noted initial changes in scalp hair regrowth 4 weeks posttransplant. During the next 4 months she developed multiple lesions of PA that rapidly responded to management, including mineral oil under occlusion in the evening followed by daily shampooing with alternating coal tar, salicylic acid, and ketoconazole shampoos. We review medications that have been associated with PA and conditions related to PA, including atopic dermatitis, bacterial infection, fungal infection, psoriasis, and seborrheic dermatitis. Our patient developed PA that was associated with either melphalan conditioning, bone marrow transplant, or both.

Practice Points

  • Pityriasis amiantacea (PA) is associated with several dermatologic conditions, including atopic dermatitis, bacterial and fungal infections, psoriasis, and seborrheic dermatitis.
  • Drug-induced PA is rare, but the condition has been reported in the context of treatment with tumor necrosis factor Symbol Stdα inhibitors and vemurafenib.
  • Our report suggests that PA may be associated with either melphalan conditioning, bone marrow transplant, or both.


 

References

Pityriasis amiantacea (PA) is characterized by adherence of hair shafts proximally.1 It has been associated with dermatologic conditions and rarely with medications. We describe a woman who developed PA following a bone marrow transplant with melphalan conditioning. We also review drug-induced PA and disorders that have been linked to this condition.

Case Report

A 67-year-old woman with a history of multiple myeloma was treated with 7 courses of chemotherapy (cyclophosphamide, bortezomib, prednisone). One month later, the patient underwent a bone marrow transplant with melphalan conditioning due to residual plasma cell myeloma. Following the transplant, she developed complete scalp alopecia. Prior to and following transplant, the patient’s hair care regimen included washing her hair and scalp every other day with over-the-counter “natural” shampoos. During drug-induced alopecia, the hair washing became less frequent.

The patient left the hospital 4 weeks posttransplant; her hair had started to regrow, but its appearance was altered. Posttransplant, the patient was maintained on bortezomib every other week and zoledronate once per month. She continued to develop multiple lesions in the scalp hairs during the following 4 months.

Eight months posttransplant she presented for evaluation of the scalp hair. Clinical examination showed hairs that were entwined together proximally, resulting in matting of the hair (Figure 1). A diagnosis of PA was established based on the clinical examination.

Treatment included mineral oil application to the scalp under occlusion each evening, followed by morning washing with coal tar 0.5%, salicylic acid 6%, or ketoconazole 2% shampoo in a repeating sequential manner. Within 1 month there was complete resolution of the scalp condition (Figure 2).

Figure 1. A, Distant view of the scalp of a 67-year-old woman showed pityriasis amiantacea presenting as proximal matting of hair with concretions around multiple hair follicles. B, Closer view showed the same.

Figure 2. A, Distant view of scalp after resolution of pityriasis amiantacea showed the hair without any matting. B, Closer view showed the same.

Comment

Clinical Presentation
Pityriasis amiantacea is characterized by thick excessive scale of the scalp1; it was initially described by Alibert2 in 1832. He described the gross appearance of the scales as resembling the feathers of young birds, which naturalists dub “amiante” or asbestoslike.1,2 In 1917, Gougerot3 explored infectious etiologies of this condition by describing cases of impetigo that transitioned into PA.1 Later, in 1929, Photinos4 described fungal origins of PA, giving credence to “tinea amiantacea.”1 However, more recent analyses failed to isolate fungus.5-7 As such, pityriasis (scaling) amiantacea is the more appropriate term, as emphasized by Brown8 in 1948. The cause of PA remains unclear; it is hypothesized that the condition is a reaction to underlying inflammatory dermatoses, though concurrent bacterial or fungal infection may be present.5,9

Prevalence
Pityriasis amiantacea is considered to be most prevalent in pediatric patients and young adults; it is more common in females.1,9,10 In a review of 85 PA patients, more than 80% were women (n=69), and the mean age at presentation was 23.8 years. Approximately half of these patients had widespread scalp lesions (n=42); however, focal localized lesions were common.9 No hereditary patterns have been described, though 3 pairs of the 10 patients with PA in Ring and Kaplan’s7 review were siblings.

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