Letter - Clinical
Case for diagnosis. Hair analysis in a child with delayed psychomotor development and fragile and brittle hair: Trichothiodystrophy
Irene López Riquelme
, Alberto Andamoyo Castañeda, Elisabeth Gómez Moyano, Ángel Vera Casaño
Corresponding author
Department of Dermatology, Hospital Regional Universitario de Málaga, Málaga, Spain
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Hair analysis in a child with delayed psychomotor development and fragile and brittle hair: Trichothiodystrophy" "tieneTextoCompleto" => true "saludo" => "Dear Editor," "paginas" => array:1 [ 0 => array:2 [ "paginaInicial" => "250" "paginaFinal" => "252" ] ] "autores" => array:1 [ 0 => array:4 [ "autoresLista" => "Irene López Riquelme, Alberto Andamoyo Castañeda, Elisabeth Gómez Moyano, Ángel Vera Casaño" "autores" => array:4 [ 0 => array:4 [ "nombre" => "Irene" "apellidos" => "López Riquelme" "email" => array:1 [ 0 => "lopezriquelmeirene@uma.es" ] "referencia" => array:1 [ 0 => array:2 [ "etiqueta" => "<span class="elsevierStyleSup">*</span>" "identificador" => "cor0005" ] ] ] 1 => array:2 [ "nombre" => "Alberto" "apellidos" => "Andamoyo Castañeda" ] 2 => array:2 [ "nombre" => "Elisabeth" "apellidos" => "Gómez Moyano" ] 3 => array:2 [ "nombre" => "Ángel" "apellidos" => "Vera Casaño" ] ] "afiliaciones" => array:1 [ 0 => array:2 [ "entidad" => "Department of Dermatology, Hospital Regional Universitario de Málaga, Málaga, Spain" "identificador" => "aff0005" ] ] "correspondencia" => array:1 [ 0 => array:3 [ "identificador" => "cor0005" "etiqueta" => "⁎" "correspondencia" => "Corresponding author." ] ] ] ] "resumenGrafico" => array:2 [ "original" => 0 "multimedia" => array:8 [ "identificador" => "fig0010" "etiqueta" => "Figure 2" "tipo" => "MULTIMEDIAFIGURA" "mostrarFloat" => true "mostrarDisplay" => false "figura" => array:1 [ 0 => array:4 [ "imagen" => "gr2.jpeg" "Alto" => 1366 "Ancho" => 1675 "Tamanyo" => 121792 ] ] "detalles" => array:1 [ 0 => array:3 [ "identificador" => "at0030" "detalle" => "Figure " "rol" => "short" ] ] "descripcion" => array:1 [ "en" => "<p id="spar0010" class="elsevierStyleSimplePara elsevierViewall">Examination of the hair under a polarized microscope: trichoscisis with typical “tiger-tail pattern”. Note the alternating dark and light transverse banding.</p>" ] ] ] "textoCompleto" => "<span class="elsevierStyleSections"><p id="par0005" class="elsevierStylePara elsevierViewall">A 4-year-old female child presented to the Dermatology Department with short, thin, and fragile hair since birth (<a class="elsevierStyleCrossRef" href="#fig0005">Fig. 1</a>). She also presented important xerosis and eczematous plaques in her back, trunk, and scalp and photosensitivity. The patient also had short stature, severe myopia, delayed psychomotor development, and recurrent respiratory infections.</p><elsevierMultimedia ident="fig0005"></elsevierMultimedia><p id="par0010" class="elsevierStylePara elsevierViewall">Examination of the hair under a polarized light microscope showed fine hair and trichoscisis with typical alternating dark and light transverse banding, called “tiger-tail pattern” (<a class="elsevierStyleCrossRef" href="#fig0010">Fig. 2</a>) and an irregular surface (<a class="elsevierStyleCrossRef" href="#fig0015">Fig. 3</a>).</p><elsevierMultimedia ident="fig0010"></elsevierMultimedia><elsevierMultimedia ident="fig0015"></elsevierMultimedia><p id="par0015" class="elsevierStylePara elsevierViewall">A genetic study revealed a mutation in the ERCC2 gene.</p><span id="sec0005" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0005">What is your diagnosis?</span><p id="par0095" class="elsevierStylePara elsevierViewall"><ul class="elsevierStyleList" id="lis0005"><li class="elsevierStyleListItem" id="lsti0005"><span class="elsevierStyleLabel">a)</span><p id="par0020" class="elsevierStylePara elsevierViewall">Xeroderma Pigmentosum</p></li><li class="elsevierStyleListItem" id="lsti0010"><span class="elsevierStyleLabel">b)</span><p id="par0025" class="elsevierStylePara elsevierViewall">Trichothiodystrophy</p></li><li class="elsevierStyleListItem" id="lsti0015"><span class="elsevierStyleLabel">c)</span><p id="par0030" class="elsevierStylePara elsevierViewall">Menkes disease</p></li><li class="elsevierStyleListItem" id="lsti0020"><span class="elsevierStyleLabel">d)</span><p id="par0035" class="elsevierStylePara elsevierViewall">Cockayne syndrome</p></li></ul></p></span><span id="sec0010" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0010">Discussion</span><p id="par0040" class="elsevierStylePara elsevierViewall">Based on clinical presentation, trichological and genetic examination, the diagnosis of trichothiodystrophy was established.</p><p id="par0045" class="elsevierStylePara elsevierViewall">Trichothiodystrophy (TTD) is a heterogeneous group of neuroectodermal disorders with an autosomal recessive inheritance, although a few cases with possible X-linked transmission have been reported. The photosensitive form of TTD is caused by mutations in XPB, XPD, or p8/TTDA genes, which encode subunits of TFIIH transcription/repair factor. Non-photosensitive form of TTD is genetically heterogeneous, being TTDN1 gene the one described in a small proportion of patients.<a class="elsevierStyleCrossRef" href="#bib0005"><span class="elsevierStyleSup">1</span></a> In photosensitive TTD, the most frequently described is XPD (ERCC2) mutation,<a class="elsevierStyleCrossRef" href="#bib0010"><span class="elsevierStyleSup">2</span></a> which is also involved in the pathogenesis of xeroderma pigmentosum (XP) and Cockayne syndrome, although, unlike XP, there is no predisposition to cutaneous malignancies. XP, Cockayne syndrome, and TTD are an example of the phenomenon called clinical heterogeneity, in which mutations in one gene (in this case XPD) may result in distinct diseases or variants.<a class="elsevierStyleCrossRef" href="#bib0015"><span class="elsevierStyleSup">3</span></a></p><p id="par0050" class="elsevierStylePara elsevierViewall">Clinical features of patients with TTD vary widely in nature and severity, and the single common feature in all patients is fragile hair (short, unruly, fragile hair of the scalp, eyebrows, and eyelashes) due to abnormally low sulfur content. In addition, a wide spectrum of other clinical symptoms that usually affect organs of ectodermal and neuroectodermal origin may be present, such as intellectual and growth retardation, ichthyosis, short stature, decreased fertility, neurologic and ocular abnormalities and, in some cases, recurrent infections,<a class="elsevierStyleCrossRef" href="#bib0020"><span class="elsevierStyleSup">4</span></a> as in the case of our patient. Approximately half of the patients present photosensitivity.<a class="elsevierStyleCrossRefs" href="#bib0005"><span class="elsevierStyleSup">1,4</span></a></p><p id="par0055" class="elsevierStylePara elsevierViewall">When examined under a polarized microscope, hair samples constantly show striking bright and dark transverse banding or “tiger tail pattern”, and they often exhibit an undulating, irregular contour in all hairs (differently from pseudo-tiger tail banding).<a class="elsevierStyleCrossRefs" href="#bib0025"><span class="elsevierStyleSup">5,6</span></a> Trichoschisis and trichorrhexis nodosa-like defects are also distinctive hair shaft abnormalities in TTD though not always present. In contrast to TTD, other patients with similar defects in DNA repair and mutations in the XPD gene do not show true “tiger tail banding”. A “pseudo-tiger tail banding” can be observed in segments of normal shafts, but the banding pattern is usually less pronounced and less regular than the bright and dark banding observed in TTD patients.<a class="elsevierStyleCrossRef" href="#bib0025"><span class="elsevierStyleSup">5</span></a> In fact, characteristic microscopic hair findings distinguish trichothiodystrophy from other conditions with congenital alopecia or hypotrichosis. For example, patients with Menkes disease typically present “kinky hairs” with twists around their long axis at irregular intervals in the shaft when observed under a light microscope, also known as pili torti.<a class="elsevierStyleCrossRef" href="#bib0035"><span class="elsevierStyleSup">7</span></a></p><p id="par0060" class="elsevierStylePara elsevierViewall">In conclusion, analysis of the hair under a polarized microscope is considered a very useful diagnostic marker in trichothiodystrophy since it shares clinical and genetic characteristics with other neuroectodermal syndromes. Diagnosis can be made on the basis of clinical and trichological examination with a polarizing and light microscope, although a genetic study may be helpful.</p></span><span id="sec0015" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0015">Financial support</span><p id="par0065" class="elsevierStylePara elsevierViewall">None declared.</p></span><span id="sec0020" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0020">Authors' contributions</span><p id="par0070" class="elsevierStylePara elsevierViewall">Irene López Riquelme: Critical review of the literature; writing of the manuscript; final approval of the final version of the manuscript.</p><p id="par0075" class="elsevierStylePara elsevierViewall">Alberto Andamoyo Castañeda: Critical review of the literature; writing of the manuscript; final approval of the final version of the manuscript.</p><p id="par0080" class="elsevierStylePara elsevierViewall">Elisabeth Gómez Moyano: Intellectual participation in the propaedeutic conduct of the case; final approval of the final version of the manuscript.</p><p id="par0085" class="elsevierStylePara elsevierViewall">Ángel Vera Casaño: Intellectual participation in the propaedeutic conduct of the case; final approval of the final version of the manuscript.</p></span><span id="sec0025" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0025">Conflicts of interest</span><p id="par0090" class="elsevierStylePara elsevierViewall">None declared.</p></span></span>" "textoCompletoSecciones" => array:1 [ "secciones" => array:6 [ 0 => array:2 [ "identificador" => "sec0005" "titulo" => "What is your diagnosis?" ] 1 => array:2 [ "identificador" => "sec0010" "titulo" => "Discussion" ] 2 => array:2 [ "identificador" => "sec0015" "titulo" => "Financial support" ] 3 => array:2 [ "identificador" => "sec0020" "titulo" => "Authors' contributions" ] 4 => array:2 [ "identificador" => "sec0025" "titulo" => "Conflicts of interest" ] 5 => array:1 [ "titulo" => "References" ] ] ] "pdfFichero" => "main.pdf" "tienePdf" => true "fechaRecibido" => "2021-08-23" "fechaAceptado" => "2021-10-19" "NotaPie" => array:1 [ 0 => array:2 [ "etiqueta" => "☆" "nota" => "<p class="elsevierStyleNotepara" id="npar0005">Study conducted at the Hospital Regional Universitario de Málaga, Málaga, Spain.</p>" ] ] "multimedia" => array:3 [ 0 => array:8 [ "identificador" => "fig0005" "etiqueta" => "Figure 1" "tipo" => "MULTIMEDIAFIGURA" "mostrarFloat" => true "mostrarDisplay" => false "figura" => array:1 [ 0 => array:4 [ "imagen" => "gr1.jpeg" "Alto" => 2173 "Ancho" => 2508 "Tamanyo" => 1146112 ] ] "detalles" => array:1 [ 0 => array:3 [ "identificador" => "at0025" "detalle" => "Figure " "rol" => "short" ] ] "descripcion" => array:1 [ "en" => "<p id="spar0005" class="elsevierStyleSimplePara elsevierViewall">Short brittle hair easily broken at different lengths.</p>" ] ] 1 => array:8 [ "identificador" => "fig0010" "etiqueta" => "Figure 2" "tipo" => "MULTIMEDIAFIGURA" "mostrarFloat" => true "mostrarDisplay" => false "figura" => array:1 [ 0 => array:4 [ "imagen" => "gr2.jpeg" "Alto" => 1366 "Ancho" => 1675 "Tamanyo" => 121792 ] ] "detalles" => array:1 [ 0 => array:3 [ "identificador" => "at0030" "detalle" => "Figure " "rol" => "short" ] ] "descripcion" => array:1 [ "en" => "<p id="spar0010" class="elsevierStyleSimplePara elsevierViewall">Examination of the hair under a polarized microscope: trichoscisis with typical “tiger-tail pattern”. Note the alternating dark and light transverse banding.</p>" ] ] 2 => array:8 [ "identificador" => "fig0015" "etiqueta" => "Figure 3" "tipo" => "MULTIMEDIAFIGURA" "mostrarFloat" => true "mostrarDisplay" => false "figura" => array:1 [ 0 => array:4 [ "imagen" => "gr3.jpeg" "Alto" => 1322 "Ancho" => 1675 "Tamanyo" => 121262 ] ] "detalles" => array:1 [ 0 => array:3 [ "identificador" => "at0035" "detalle" => "Figure " "rol" => "short" ] ] "descripcion" => array:1 [ "en" => "<p id="spar0015" class="elsevierStyleSimplePara elsevierViewall">Irregular, undulating hair shaft when examined under light microscopy.</p>" ] ] ] "bibliografia" => array:2 [ "titulo" => "References" "seccion" => array:1 [ 0 => array:2 [ "identificador" => "bibs0005" "bibliografiaReferencia" => array:7 [ 0 => array:3 [ "identificador" => "bib0005" "etiqueta" => "1" "referencia" => array:1 [ 0 => array:2 [ "contribucion" => array:1 [ 0 => array:2 [ "titulo" => "Trichothiodystrophy: from basic mechanisms to clinical implications" "autores" => array:1 [ 0 => array:2 [ "etal" => false "autores" => array:4 [ 0 => "M. 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| Year/Month | Html | Total | |
|---|---|---|---|
| 2024 November | 38 | 5 | 43 |
| 2024 October | 182 | 67 | 249 |
| 2024 September | 221 | 100 | 321 |
| 2024 August | 237 | 128 | 365 |
| 2024 July | 233 | 106 | 339 |
| 2024 June | 159 | 75 | 234 |
| 2024 May | 130 | 58 | 188 |
| 2024 April | 263 | 81 | 344 |
| 2024 March | 166 | 62 | 228 |
| 2024 February | 183 | 68 | 251 |
| 2024 January | 125 | 59 | 184 |
| 2023 December | 102 | 64 | 166 |
| 2023 November | 100 | 88 | 188 |
| 2023 October | 71 | 98 | 169 |
| 2023 September | 102 | 75 | 177 |
| 2023 August | 72 | 33 | 105 |
| 2023 July | 86 | 36 | 122 |
| 2023 June | 80 | 47 | 127 |
| 2023 May | 80 | 19 | 99 |
| 2023 April | 96 | 28 | 124 |
| 2023 March | 116 | 63 | 179 |
| 2023 February | 77 | 43 | 120 |
| 2023 January | 43 | 61 | 104 |
| 2022 December | 35 | 35 | 70 |
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