Intended for healthcare professionals

Endgames Spot Diagnosis

Hair loss and lymphadenopathy

BMJ 2019; 366 doi: (Published 29 August 2019) Cite this as: BMJ 2019;366:l4555
  1. Sheng Li, resident, dermatology1,
  2. Liming Wu, surgical consultant2
  1. 1Department of Dermatology, The First Affiliated Hospital, School of Medicine, Zhejiang University, Zhejiang, China
  2. 2Division of Hepatobiliary and Pancreatic Surgery, Department of Surgery, The First Affiliated Hospital, School of Medicine, Zhejiang University, Zhejiang, China
  1. Correspondence to L Wu wlm{at}

A 19 year old man presented with a two month history of lumps behind the ears and in the groin, and scalp hair loss. He had felt generally unwell during the past month. Physical examination revealed painless generalised lymphadenopathy in the postauricular (fig 1), posterior cervical, and inguinal regions. He had patchy, non-cicatricial (non-scarring) alopecia with a moth eaten appearance (5 mm diameter patches) all over the scalp (fig 1). Fungal microscopy was negative. Dermoscopy revealed yellow dots and broken hairs in the alopecia area. A reactive rapid plasma reagin (RPR) test was positive with a titre of 1:64 and the Treponema pallidum agglutination test was positive.

Fig 1
Fig 1

Alopecia with a moth eaten appearance

What is the diagnosis?


Syphilitic alopecia.1

The RPR and Treponema pallidum agglutination results indicate that this patient had syphilis. Alopecia occurs in patients with secondary syphilis in 2.9% to 7% of cases.2 The alopecia can be patchy (with a moth eaten appearance) as in figure 2, or diffuse. It can also be associated with a non itchy rash.

Fig 2
Fig 2

Tiny patches of non-cicatricial alopecia (red arrows) over the scalp (giving a moth eaten appearance) and an enlarged lymph nodule (white arrow) in the postauricular region

Painless lymphadenopathy is a common feature in both primary and secondary syphilis; however, in some cases alopecia is the only clinical sign of syphilis.3

Differential diagnoses include

  • Tinea capitis

  • Alopecia areata

  • Trichotillomania

Fungal microscopy, dermoscopy, RPR, and Treponema pallidum agglutination tests can help distinguish syphilitic alopecia from these entities.4

Intramuscular penicillin G benzathine is recommended as the first line therapy for syphilis.5

Patient outcome

The patient reported no history of genital ulceration or cutaneous rash. He recalled having unprotected sexual intercourse with a female partner approximately two months earlier. The lymphadenopathy resolved within two weeks of starting treatment with intramuscular penicillin G benzathine. When he was reviewed three months later, hair growth was normal.

Learning points

  • Lymphadenopathy and alopecia may be the only presenting feature of secondary syphilis.

  • Moth eaten alopecia is a pathognomonic manifestation of secondary syphilis. 3



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