Generic selectors
Exact matches only
Search in title
Search in content
Search in posts
Search in pages
Filter by Categories
15th National Conference of the IAOMFP, Chennai, 2006
Abstracts from current literature
Acne in India: Guidelines for management - IAA Consensus Document
Art & Psychiatry
Association Activities
Association Notes
Award Article
Book Review
Brief Report
Case Analysis
Case Letter
Case Letters
Case Notes
Case Report
Case Reports
Clinical and Laboratory Investigations
Clinical Article
Clinical Studies
Clinical Study
Conference Oration
Conference Summary
Continuing Medical Education
Cosmetic Dermatology
Current Best Evidence
Current View
Derma Quest
Dermato Surgery
Dermatosurgery Specials
Dispensing Pearl
Do you know?
Drug Dialogues
Editor Speaks
Editorial Remarks
Editorial Report
Editorial Report - 2007
Editorial report for 2004-2005
Fourth All India Conference Programme
From Our Book Shelf
From the Desk of Chief Editor
Get Set for Net
Get set for the net
Guest Article
Guest Editorial
How I Manage?
IADVL Announcement
IADVL Announcements
IJDVL Awards
IJDVL Awards 2018
IJDVL Awards 2019
IJDVL Awards 2020
IJDVL International Awards 2018
Images in Clinical Practice
In Memorium
Inaugural Address
Knowledge From World Contemporaries
Leprosy Section
Letter in Response to Previous Publication
Letter to Editor
Letter to the Editor
Letter to the Editor - Case Letter
Letter to the Editor - Letter in Response to Published Article
Letter to the Editor - Observation Letter
Letter to the Editor - Study Letter
Letter to the Editor - Therapy Letter
Letter to the Editor: Articles in Response to Previously Published Articles
Letters in Response to Previous Publication
Letters to the Editor
Letters to the Editor - Letter in Response to Previously Published Articles
Letters to the Editor: Case Letters
Letters to the Editor: Letters in Response to Previously Published Articles
Medicolegal Window
Miscellaneous Letter
Net Case
Net case report
Net Image
Net Letter
Net Quiz
Net Study
New Preparations
News & Views
Observation Letter
Observation Letters
Original Article
Original Contributions
Pattern of Skin Diseases
Pediatric Dermatology
Pediatric Rounds
Presedential Address
Presidential Address
Presidents Remarks
Report of chief editor
Report of Hon : Treasurer IADVL
Report of Hon. General Secretary IADVL
Research Methdology
Research Methodology
Resident page
Resident's Page
Resident’s Page
Residents' Corner
Residents' Corner
Residents' Page
Review Article
Review Articles
Revision Corner
Self Assessment Programme
Seminar: Chronic Arsenicosis in India
Seminar: HIV Infection
Short Communication
Short Communications
Short Report
Special Article
Specialty Interface
Study Letter
Symposium - Contact Dermatitis
Symposium - Lasers
Symposium - Pediatric Dermatoses
Symposium - Psoriasis
Symposium - Vesicobullous Disorders
Symposium Aesthetic Surgery
Symposium Dermatopathology
Symposium-Hair Disorders
Symposium-Nails Part I
Symposium-Nails-Part II
Therapeutic Guidelines
Therapeutic Guidelines - IADVL
Therapy Letter
View Point
What’s new in Dermatology
View/Download PDF
Letter to the Editor
doi: 10.4103/ijdvl.IJDVL_234_16
PMID: 28366907

Leaving a mark: Multiple geometric areas of alopecia

Hima Gopinath1 , Maria Kuruvila2 , Ramadas Naik3 , Suja Sreedharan4
1 Department of Dermatology, Venereology and Leprosy, Sri Manakula Vinayagar Medical College and Hospital, Pondicherry University, Puducherry, India
2 Department of Dermatology and STD, Kasturba Medical College, Manipal University, Mangalore, Karnataka, India
3 Department of Pathology, Yenepoya Medical College, Manipal University, Mangalore, Karnataka, India
4 Department of Otorhinolaryngology, Kasturba Medical College, Manipal University, Mangalore, Karnataka, India

Correspondence Address:
Hima Gopinath
Department of Dermatology, Venereology and Leprosy, Sri Manakula Vinayagar Medical College and Hospital, Madagadipet, Puducherry - 605 107
How to cite this article:
Gopinath H, Kuruvila M, Naik R, Sreedharan S. Leaving a mark: Multiple geometric areas of alopecia. Indian J Dermatol Venereol Leprol 2017;83:373-375
Copyright: (C)2017 Indian Journal of Dermatology, Venereology, and Leprology


Post-operative alopecia is a rarely reported group of scarring and non-scarring alopecia.[1] It usually presents as a solitary oval patch, most commonly on the occiput.[2] We report a case, where a patient developed multiple geometric areas of alopecia following contact with objects on the scalp during the intra-operative and post-operative period, corresponding to the shape and area of pressure from the objects.

A 13-year-old boy presented with a 1-month history of patchy hair loss. Two months prior to the presentation, he had undergone an 8 hours long endoscopic nasal and nasopharyngeal extended skull-based resection, for extensive nasopharyngeal angiofibroma. His head was positioned on a “ring” shaped head rest [Figure 1a] throughout the surgery, during which repositioning was not done. There was massive blood loss (estimated loss of 3 L) and hypotension (30–90 mmHg systolic and 20–60 mmHg diastolic) in the intraoperative period, followed by postoperative intubation and immobilization in the intensive care unit for 1 day.

Figure 1a: "Ring" shaped headrest

On examination, there were multiple well-defined areas of cicatricial and noncicatricial alopecia in the parieto-occipital region of the scalp. The central areas within the lesions were indurated and had a brownish hue. Central confluent circles of alopecia were surrounded by peripheral arcuate areas [Figure 1b]. The areas of alopecia corresponded to the areas of pressure from the “ring” shaped head rest (arcuate lesions) and the bed (central confluent lesions). Cicatricial hair loss was seen in the central portions of the arcuate lesions, corresponding to the areas of maximum pressure from the convexity of the ring-shaped head rest.

Figure 1b: Central confluent circles and peripheral arcuate areas of scarring and nonscarring alopecia

A biopsy revealed decreased number of hair follicles, predominantly in the telogen phase, focal fat necrosis, dermal fibrosis and granulomatous inflammation. The findings were consistent with pressure alopecia [Figure 2a],[Figure 2b],[Figure 2c]. The patient was counseled regarding the likelihood of spontaneous regrowth, and as expected, spontaneous regrowth was seen in most areas except for some islands of scarring in the right parietal and occipital regions, on follow-up after 3½ months [Figure 1c].

Figure 2a: Telogen hair surrounded by fibrosis (H and E, ×100)
Figure 2b: Focal fat necrosis (H and E, ×400)
Figure 2c: Hair follicle with granuloma. Giant cell in the inset
Figure 1c: Regrowth in most areas on follow-up after 3½ months

Postoperative (pressure) alopecia was first described by Abel and Lewis in 1959.[1] It occurs following major surgical procedures (cardio-thoracic, gynecological, abdominal, plastic and reconstructive and neurological), prolonged immobilization and rarely, after blunt trauma.[2],[3] Pressure alopecia has also been reported with the use of headband, headrest and orthodontic head gear. Tissue hypoxia and ischemia secondary to continuous pressure on the selected regions has been suggested as one of the etiological factors. It has been compared to a healed pressure ulcer. The duration of pressure is also an important risk factor. Intraoperative hypotension can exacerbate the tissue ischemia.[1],[3]

Pressure alopecia mainly affects the posterior region of the scalp.[3] There is no age predilection and has been reported even in neonates.[1] Early manifestations in the first few days can include swelling, pain, exudation, crusts, central erythema and induration. Rapid, sharply demarcated hair loss ensues usually within 28 days.[2],[4]

Histopathological changes vary with the evolution of alopecia. Synchronized conversion of most or all terminal hairs to catagen/telogen phase is characteristic. Alopecia areata can be differentiated by the absence of nanogen hairs, miniaturization and focal peribulbar inflammation. Absence of distorted follicles and incomplete follicular anatomy may help in excluding trichotillomania. Other reported changes in postoperative alopecia include vasculitis, thrombosis, vascular congestion, fat necrosis, trichomalacia, pigment casts, loss of hair follicles, chronic inflammation, foreign body granulomas and dermal fibrosis.[1],[2],[5]

Postoperative application of topical minoxidil or corticosteroids is of doubtful efficacy.[3] The time under general anesthesia has also been reported to be a risk factor for permanent alopecia. Severe hypoxia can cause inflammation and fibrosis and result in permanent alopecia.[6]

Increased awareness about pressure alopecia and more vigilance regarding the objects in contact with the scalp during prolonged surgeries or immobilization are needed. The headrest, often used as a pressure-relieving device, can result in additional areas of alopecia. Although our patient had unusual multiple areas of alopecia, the history, location, geometric shapes, presence of scarring and histopathology helped in the diagnosis of this rare alopecia. Pressure ulcer prevention strategies such as frequent repositioning and support surfaces might prevent this cosmetic mishap.


We thank Dr. Soujanya Gandla, Department of Otorhinolaryngology, Kasturba Medical College, for her help in the preparation of this manuscript.

Financial support and sponsorship


Conflicts of interest

There are no conflicts of interest.

Davies KE, Yesudian P. Pressure alopecia. Int J Trichology 2012;4:64-8.
[Google Scholar]
Sperling LC, Cowper SE, Knopp EA, editors. An Atlas of Hair Pathology with Clinical Correlation. 2nd ed. New York: CRC Press; 2012.
[Google Scholar]
Domínguez-Auñ ón JD, García-Arpa M, Pé rez-Suárez B, Castañ o E, Rodríguez-Peralto JL, Guerra A, et al. Pressure alopecia. Int J Dermatol 2004;43:928-30.
[Google Scholar]
Abel RR, Lewis GM. Postoperative (pressure) alopecia. Arch Dermatol 1960;81:34-42.
[Google Scholar]
Siah TW, Sperling L. The histopathologic diagnosis of post-operative alopecia. J Cutan Pathol 2014;41:699-702.
[Google Scholar]
Loh SH, Lew BL, Sim WY. Pressure alopecia: Clinical findings and prognosis. J Am Acad Dermatol 2015;72:188-9.
[Google Scholar]

Fulltext Views

PDF downloads
Show Sections