November 2017
Dermatology
Peer Reviewed

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Ava, a 3.5-year-old, 9.1-lb (4.1-kg) spayed red Pomeranian, was presented to a dermatology service for a 19-month history of progressive, nonpruritic, diffuse alopecia affecting the trunk and caudal thighs. Alopecia was first noticed after surgical correction of right patellar luxation.  

Hair on the right pelvic limb that had been clipped for surgery failed to regrow. Alopecia progressed to the trunk, neck, abdomen, and caudal thighs. Ava’s skin in the affected areas became hyperpigmented. Results of a previous low-dose dexamethasone suppression test and thyroid panel were within normal limits; reproductive hormone testing was not performed, and because of Ava’s plush coat before onset of alopecia, investigation into the owner’s use of topical hormone creams was not pursued. Empiric treatment with thyroxine and melatonin (of unknown dose and duration) did not result in hair regrowth, nor did treatment with trilostane (2.4 mg/kg PO q24h for 30 days). Ava was up to date on monthly oral heartworm and flea preventives, was fed a commercial adult canned diet supplemented with treats, and had no other health issues.

Physical Examination & Diagnostics

On physical examination, large areas of hypotrichosis with loss of guard hairs and complete alopecia were noted on the neck, chest, abdomen, caudal thighs, and flanks (Figure 1). The skin in the affected areas was hyperpigmented with a mild, dry, adherent scale. The distal extremities, tail, and face were unaffected. In addition to generalized scaling, multiple epidermal collarettes were present on the dorsum, neck, and caudal abdomen.

FIGURE 1 Ava’s skin showing alopecia, hypotrichosis, and hyperpigmentation

Initial diagnostics included skin scrapings and skin cytology to screen for infectious agents. CBC, serum chemistry profile, and urinalysis were also performed to screen for underlying disease processes. CBC and serum chemistry profile were unremarkable with the exception of a mild increase in glucose, which was attributed to stress. Urinalysis was within normal limits. Skin scrapings were negative for mites. Skin cytology revealing many neutrophils with intracellular cocci was compatible with superficial pyoderma. 

Diagnosis

Based on breed, age at alopecia onset, and the lack of other clinical signs or laboratory abnormalities, diagnoses of alopecia X and secondary pyoderma were made. Although a biopsy can help confirm noninflammatory alopecia, histopathology cannot differentiate alopecia X from other noninflammatory diseases; therefore, biopsy was not performed in this patient.

Alopecia X is a noninflammatory form of alopecia that affects canine breeds with thick undercoats (eg, Pomeranian, Alaskan malamute, chow chow, keeshond).1 The disease is recognized in both intact and neutered dogs and affects males and females equally, with onset between 1 and 10 years of age. Affected dogs develop bilaterally symmetrical alopecia that spares the head and distal extremities and is usually accompanied by hyperpigmentation of the skin.1 Alopecia X is a diagnosis of exclusion, as the pathophysiologic mechanism is unknown (see Take-Home Messages).

Treatment & Outcome

Pyoderma was treated with cefpodoxime (12 mg/kg PO q24h), which was administered slightly above the label dose (5-10 mg/kg q24h) to accommodate pill size, for 30 days. The patient was also bathed twice weekly with a 3% chlorhexidine-based shampoo. Cefpodoxime was chosen for its q24h dosing to accommodate the dog’s small size and the owner’s difficulty in administering oral medications. Cefpodoxime has been shown to be effective in the treatment of staphylococcal infections.2 Although some dermatologists will use cefpodoxime as a first-line agent,3 others recommend third-generation cephalosporins be used as first-line agents only if there is a problem with owner compliance, as in this case.4

Alopecia X treatment options presented to the owner included retrying melatonin (3 mg PO q12h for a minimum of 3 months) or monthly medroxyprogesterone acetate injections (5 mg/kg SC), although, at the time of recommendation, success rates were unknown and treatment was novel. Medroxyprogesterone acetate injections were considered because synthetic progestins can induce endogenous growth hormone secretion, and growth hormone has historically been used to treat alopecia X.5 Possible adverse effects include development of mammary nodules and cystic endometrial hyperplasia; however, these effects are not of concern in dogs that have undergone ovariohysterectomy. Diabetes mellitus is a possible sequela but has been reported only in a small number of dogs in one study.6

Because of melatonin’s previous lack of efficacy in this patient and the owner’s difficulty administering medications, the owner elected therapy with medroxyprogesterone acetate injections. The patient’s monitoring plan also entailed monthly serum chemistry profiles and urinalyses to monitor for adverse effects (see Treatment at a Glance).

FIGURE 2 Ava after 4 monthly injections of medroxyprogesterone acetate (5 mg/kg SC). Decreased areas of alopecia, scaling, and hyperpigmentation of the skin can be noted.

No hair regrowth was noted during the first 3 monthly rechecks. By the fourth recheck, after 4 monthly injections, there was evidence of incomplete hair regrowth (Figure 2). The skin was no longer scaly, and the degree of hyperpigmentation had decreased. No abnormalities were detected on blood work throughout the treatment, and no adverse effects were reported. Because the patient had begun to show signs of improvement, an additional 2 monthly injections (total of 6) were administered, after which hair regrowth improved minimally.

TREATMENT AT A GLANCE

  • Intact dogs with alopecia X should be spayed or neutered, as hair regrowth may occur after surgery.9
  • Treatment with deslorelin has been successful in some intact male dogs.10 Follicular cysts and prolonged estrus have been described in a female dog.11 
  • Melatonin (3-9 mg [≈1 mg/kg for small dogs] q12h) has resulted in hair regrowth in 40% to 60% of dogs with alopecia X.12 Exceeding a total dose of 9 mg often results in profound sedation and therefore is usually not prescribed. Treatment should be continued for a minimum of 3 months, but treatment for 6 to 9 months may increase positive results.12 Adverse effects include sedation and, possibly, insulin resistance.12
  • Monthly medroxyprogesterone acetate injections (5-10 mg/kg SC for 4-6 months) may result in hair regrowth in a portion of dogs with alopecia X.5 
  • Trilostane and Lysodren have been reported to result in partial-to-complete hair regrowth in more than 90% and 67%, respectively, of dogs with alopecia X.12,13 Close monitoring is advised.
  • A microneedling procedure, as used in human cosmetic dermatology, reportedly resulted in hair regrowth in 2 female Pomeranian siblings.14 The procedure was performed with the patients under general anesthesia using a human microneedling device.
  • As reported and in the author’s experience, the new hair is rarely permanent and will often fall out in months to years15; therefore, discontinuation of any treatment once hair regrowth has occurred is recommended. When hair loss resumes, reinstitution of the previous treatment or beginning another treatment should be considered. 

Prognosis

The prognosis for alopecia X is guarded for complete hair regrowth, and any new growth following treatment may not be permanent.1 Hair might remain for a period of months to years, at which point alopecia may recur1; in these cases, medroxyprogesterone acetate injections or another therapy could be attempted.

TAKE-HOME MESSAGES

  • Alopecia X affects plush-coated breeds and is recognized in Pomeranians and other breeds.1
  • Alopecia X is a diagnosis of exclusion, as the pathophysiologic mechanism is unknown; other causes of hair cycle arrest (eg, hypothyroidism, hyperadrenocorticism, reproductive hormone disorders of intact animals) should be ruled out.7
  • Biopsy and histopathology should be performed to rule out inflammatory causes of alopecia (eg, sebaceous adenitis). Histopathology will not differentiate alopecia X from endocrine causes of alopecia.8 
  • Alopecia X can be associated with secondary skin changes and pyoderma.
  • No treatment is guaranteed to be successful. Potential adverse effects of treatment must be weighed with the clinical presentation of a cosmetic condition.
References and author information Show
References
  1. Frank LA. Endocrine and metabolic diseases. In: Miller WH, Griffin CE, Campbell KL, eds. Muller and Kirk’s Small Animal Dermatology. 7th ed. St. Louis, MO: Elsevier; 2013:501-553.
  2. Cherni JA, Boucher JF, Skogerboe TL, Tarnacki S, Gajewski KD, Lindeman CJ. Comparison of the efficacy of cefpodoxime proxetil and cephalexin in treating bacterial pyoderma in dogs. Intern J Appl Res Vet Med. 2006;49:384-391.
  3. Hillier A, Lloyd DH, Weese JS, et al. Guidelines for the diagnosis and antimicrobial therapy of canine superficial bacterial folliculitis (Antimicrobial Guidelines Working Group of the International Society for Companion Animal Infectious Diseases). Vet Dermatol. 2014;25(3):163-175, e142-163.
  4. Guardabassi L, Houser GA, Frank LA, Papich MG. Guidelines for antimicrobial use in dogs and cats. In: Guardabassi L, Jensen LB, Kruse H, eds. Guide to Antimicrobial Use in Animals. Oxford, UK: Wily-Blackwell; 2008:183-206.
  5. Frank LA, Watson JB. Treatment of alopecia X with medroxyprogesterone acetate. Vet Dermatol. 2013;24(6): 624-627.
  6. Beijerink NJ, Bhatti SF, Okkens AC, et al. Adenohypophyseal function in bitches treated with medroxyprogesterone acetate. Domes Anim Endocrinol. 2007;32(2):63-78.
  7. Frank LA. Growth hormone-responsive alopecia in dogs. J Am Vet Med Assoc. 2005;226(9):1494-1497.
  8. Müntener T, Schuepbach-Regula G, Frank L, Rüfenacht S, Welle MM. Canine noninflammatory alopecia: a comprehensive evaluation of common and distinguishing histological characteristics. Vet Dermatol. 2012;23(3):206-221.
  9. Rosser EJ. Castration responsive dermatosis in the dog. In: von Tscharner C, Halliwell REW, eds. Advances in Veterinary Dermatology. Volume 1. Philadelphia, PA: Baillière Tindall; 1990:34-42.
  10. Albanese F, Malerba E, Abramo F, Miragliotta V, Fracassi F. Deslorelin for the treatment of hair cycle arrest in intact male dogs. Vet Dermatol. 2014;25(6):519-522.
  11. Arlt SP, Spankowshy S, Heuwieser W. Follicular cysts and prolonged oestrus in a female dog after administration of a deslorelin implant. N Z Vet J. 2011;59(2):87-91.
  12. Frank LA, Hnilica KA, Oliver JW. Adrenal steroid hormone concentrations in dogs with hair cycle arrest (alopecia X) before and during treatment with melatonin and mitotane. Vet Dermatol. 2004;15(2):278-284.
  13. Cerundolo R, Lloyd DH, Persechino A, Evans H, Cauvin A. Treatment of alopecia X with trilostane. Vet Dermatol. 2004;15(5):285-293.
  14. Stoll S, Dietlin C, Nett-Mettler CS. Microneedling as a successful treatment for alopecia X in Pomeranian siblings. Vet Dermatol. 2015;26(5):387-390.
  15. Scott DW, Walton DK. Hyposomatotropism in the mature dog: a discussion of 22 cases. J Am Anim Hosp Assoc. 1986;22:467-473.
Author

Linda A. Frank

MS, DVM, DACVD University of Tennessee

Linda A. Frank, MS, DVM, DACVD, is a professor of dermatology at University of Tennessee. She has been a practicing dermatologist for more than 25 years. Her research focuses on the investigation of the cause and treatment of alopecia X and on improved tests for the diagnosis of atypical Cushing’s disease in dogs. She has spoken and published numerous research and review articles on these subjects.

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