J AM ACAD DERMATOL

VOLUME 55, NUMBER 5

Letters S103

Telogen effluvium associated with thedopamine agonist pramipexole in a 55-year-old woman with Parkinson’s disease

To the Editor: A 55-year-old woman with Parkinson’sdisease of 3 years’ duration noticed gradual scalphair loss over a 2-month period. Her scalp wasasymptomatic. Three years earlier she had takenthe dopamine agonist pramipexole, 0.5 mg 3 timesdaily, for 6 months. Her neurologist then switchedher from pramipexole to ropinirole, another dopa-mine agonist, which she took for 20 months at amaximum dose of 4 mg 3 times daily. Eight monthsbefore noticing hair loss, she discontinued ropiniroleand restarted pramipexole, ultimately taking 1 mg3 times daily. Other medications included a multi-vitamin with iron, vitamin B complex, vitamin B2,vitamin E, coenzyme Q10, and calcium. She deniedhospitalizations or serious illnesses in the previous2 years. Physical examination revealed diffuse non-cicatricial hair loss (Fig 1, A), and several telogenhairs were seen on multiple hair pulls. Levels offerritin (64 ng/mL; normal range, 10-232 ng/mL),dihydroepiandosterone sulfate (39 �g/dL; normalrange, 29-183 �g/dL), total testosterone (30 ng/dL;normal range, 20-76 ng/dL), and thyroid-stimulatinghormone (1.05 �IU/mL; normal range, 0.40-4.00�IU/mL) were normal. Consistent with telogeneffluvium, 9 of 24 terminal hair follicles presentin a horizontally sectioned 4-mm punch biopsyspecimen of the scalp were in telogen (Fig 2).Pramipexole was discontinued. Hair regrowth wasnoted within 4 months (Fig 1, B).

From July 1997, when the Food and DrugAdministration approved pramipexole for treatmentof Parkinson’s disease, through September 2004, thedrug’smanufacturer received 36 reports of alopecia inpatients taking pramipexole (Boehringer Ingelheim,written communication, Oct 19, 2004). In the onepublished case of hair loss associated with pramipex-ole, hair loss began within 2 months of pramipexoletaken at a maximum dose of 1.5 mg daily.1 No scalpbiopsy results were reported. Hair regrowth beganwithin a month of switching from pramipexole toropinirole.1 Other dopamine agonists, including,ropinirole,1 bromocriptine,2 pergolide,3 and carber-goline,4 aswell as thedopamineprecursor levodopa,5

have also been associated with telogen effluvium.Telogen effluvium pathophysiology is not well

understood, but results from hair follicles’ synchro-nous entry into exogen, the shedding phase of thehair follicle cycle.6-8 Dopamine agonists’ effects onthis cycle may be mediated by decreased serumprolactin levels. In healthy volunteers, a 0.3-mg doseof pramipexole decreased prolactin levels nearly

50%; levels remained lower than those in controlpatients 8 hours later.9 Multiple observations provideevidence for prolactin’s role in hair follicle cycling.Clinically, hyperprolactinemia causes hirsutism; treat-ment of hyperprolactinemia with bromocriptine, adopamine agonist that inhibits prolactin, can result inalopecia.10 Experimentally, prolactin and prolactinreceptor are present in human hair follicle epitheliumin hair-cycle-dependent levels.10,11 Prolactin receptorknockout mice molt and replace hair earlier and growlonger, coarser hair than wild-type mice.11 Further-more, in vitro experiments have demonstrated that

Fig 1. A, Diffuse nonciatricial alopecia of the scalp in a55-year-old woman with Parkinson’s disease treated withpramipexole for 8 months. B, Same patient 8 months afterdiscontinuing pramipexole.

Eccrine angiokeratomatous hamartoma:A new variant of eccrine hamartomawith angiokeratoma

To the Editor: Eccrine angiomatous hamartoma (ornevus-EAH) is a rare hamartomatous tumor combin-ing a dermal proliferation of eccrine sweat glandsand capillary blood vessels. Up to 2002, fewer than80 EAH cases had been published.1-3 We recentlyobserved a lesion that met the clinicopathologicalcriteria of EAH, the surface of which showed featuresof angiokeratoma. This seems to be a new variantof EAH, for which we suggest the term ‘‘eccrineangiokeratomatous hamartoma.’’

A 27-year-old Caucasian man in good health andwith an unremarkable personal and family historyhad presented since childhood with a red to viola-ceous keratotic nodule, measuring 2 3 1 cm, over hisright outer malleolus (Fig 1, A ) that was tender onpalpation. The lesion was excised with the patientunder local anesthesia.

Microscopic examination showed a tumor withan overlying hyperplastic, papillomatous, and ver-rucous epidermis (Fig 1, B ). The horny layershowed compact orthohyperkeratosis and containedhemosiderin pigment. Thedermal papillae containeda proliferation of ectatic blood vessels containingerythrocytes, coming very close to the dermoepider-mal junction (Fig 2, A ). The mid dermis containeda proliferation of eccrine sweat glands and bloodvessels. The sweat glands consisted of excretoryducts and secretory coils, many of which had dilatedlumina. The blood vessels consisted of small roundor elongated capillaries with a thin wall lined by flatendothelial cells (Fig 2, B ). This mixed glandular/vascular proliferation was surrounded by a mucinousconnective tissue that stained with alcian blueand (metachromatically) with toluidine blue and

J AM ACAD DERMATOL

NOVEMBER 2006

S104 Letters

supraphysiologic doses of prolactin accelerate catagendevelopment in murine hair follicles.10

Further research into neurohormonal regulationof the hair follicle cycle may help elucidate thepathophysiology of dopamine agonisteassociatedtelogen effluvium. In the meantime, dermatologistsshould consider the potential link between dopa-mine agonists and telogen effluvium when evaluat-ing hair loss in patients with Parkinson’s disease.

Kenneth A. Katz, MD, MSc,a,b George Cotsarelis,MD,a,b Rajat Gupta, BS,b and John T. Seykora,MD, PhDa,b

Department of Dermatology,a University of Penn-sylvania School of Medicine,b Philadelphia,Pennsylvania

Funding source: Fellowship for Dr Katz funded bya Kirschstein National Research Service Awardfrom the National Institutes of Arthritis andMusculoskeletal and Skin Diseases

Correspondence to: George Cotsarelis, MD, Depart-ment of Dermatology, University of PennsylvaniaSchool of Medicine, M8C Stellar Chance Labora-tories, 422 Curie Blvd, Philadelphia, PA 19104

E-mail: cotsarel@mail.med.upenn.edu

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4. Miwa H, Kondo T. Hair loss induced by dopamine agonist: case

report and review of the literature. Parkinsonism Relat Disord

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Fig 2. Horizontal sections of scalp biopsy specimendemonstrate increased numbers of telogen germinal units(arrows) relative to terminal hairs. (Hematoxylin-eosinstain; original magnification: 3100.)

6. Headington JT. Telogen effluvium. New concepts and review.

Arch Dermatol 1993;129:356-63.

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doi:10.1016/j.jaad.2005.09.039