Alopecia as the main manifestation of syphilis

Introduction. Alopecia is one of the clinical manifestations of syphilis, often called “the great imitator”. Hair loss in syphilis occurs infrequently, various sources have reported an incidence of 2.9-7%, and it is most common in heterosexual (7%) vs. homosexual men (4%), and women (5%). In 1940, McCarthy described two types of syphilitic alopecia: symptomatic alopecia associated with other lesions of secondary syphilis, and essential syphilitic alopecia in patients without any other cutaneous or mucosal manifestations of the disease.
Objective. The aim of the study was to present hair loss as the main or sole manifestation of syphilis in 5 cases.
Case report. Five patients (1 woman and 4 men) aged of 21-51 years reported to our dermatology department due to extensive hair loss observed for some months. In 3 cases, apart from diffuse or patchy alopecia changes characteristic for secondary syphilis were present. In one case alopecia was the only clinical symptom of T. pallidum infection, while in another one cutaneous and mucosal signs of syphilis coexisted with typical psoriatic papules. In all cases the diagnosis of secondary syphilis was confirmed by serological tests. In two cases abnormalities in cerebrospinal fluid were disclosed and secondary syphilis with nervous system involvement was diagnosed.
Conclusions. Our observations strongly indicate that in all patients with sudden, unexplained hair loss, serological tests for syphilis should be performed.