[Extracted from the American Journal of the Medical Sciences for July, 1878 J 
CASE OF AN UNDESCRIBEIJTFORM OF ATROPHY 
OF THE HAIR OF THE BEARD.! 
LOUIS A. DUBBING, M.D., 
PROFESSOR OF SKIN DISEASES IN THE UNIVERSITY OF PENNSYLVANIA, DERMATOLOGIST 
TO THE PHILADELPHIA HOSPITAL, ETC. 
The case that I am about to describe au interesting and, I 
think, new form of disease of the hair. It onic, disease 
of the hair of the beard, characterized by atrophy oTrhe nftii^WTfb, and by 
splitting of the hair-substance, producing irritation of the follicles, and 
giving rise to disfigurement. 
The subject is a physician, thirty-three years of age, of average height 
and proportions, with dark complexion and blackish hair. I first saw 
him one year ago. He stated that he was suffering with a singular dis- 
ease of the beard, which gave him great mental worriment and considera- 
ble discomfort. He had had it for some years, and although it had been 
vigourously treated, no benefit had resulted. He added that neither he 
nor the several physicians whom he had consulted had been able to arrive 
at a conclusion regarding the nature of the disease, but that by some it 
had been considered to be parasitic. 
I found him of a highly nervous temperament, and exceedingly dis- 
turbed in mind about his condition. His general health was below the 
average. He was dyspeptic, and suffered with an irritable prostate gland. 
The hair of the scalp was cut quite close, and presented no peculiarities. 
Upon the upper lip he carried a long, narrow, brownish moustache, which, 
except that it was noticeably narrow, and had an irregular, broken upper 
border, appeared to be healthy. The rest of the face possessed about a 
week’s growth of dark-brown, manifestly more or less diseased hair, which 
was nowhere abundant, and moreover inclined to grow in patches. The 
hair upon other regions of the body was normal. He gave the following- 
account of the affection : It first manifested itself about seven years ago, 
upon either side of the chin, in the form of small irregular areas about the 
size of a dime. He was not at that time in the habit of shaving, but wore 
a full beard, which was thick, luxuriant, and perfect as regards the hair. 
He noticed that the hairs of the patches referred to became dry, brittle, 
and split up, and that they broke off here and there, leaving ragged ex- 
tremities. Shaving of the whole face was now instituted, and kept up for 
a period, but it was noted that the disease still continued, and that it was 
very gradually encroaching on new territory. Three years ago it made 
1 Read before the American Dermatological Association, at its first annual meeting, 
at Niagara Falls, Sept. 1877. 2 
its appearance around the upper border of the moustache on either side, 
where it has persisted, creeping downwards very slowly to its present line. 
Pie states that he has observed that the etfect of shaving is, upon the 
whole, beneficial. If daily shaving be practised, the skin and the hairs in 
time assume a healthier appearance. As soon, however, as the hairs are 
permitted to grow, the abnormal condition reappears. More or less irri- 
tation of the skin and slight scaliness of the affected regions are at all times 
present, but in a marked degree only after the beard has existed for some 
days. Occasionally the disturbance of the follicles is so great that small fol- 
licular papules and pustules form here and there. If the beard be allowed 
to glow for a fortnight, the hairs assume a stiff, brittle, split-up condition, 
the free ends showing brush-like extremities, while the skin becomes 
hyperamic or inflamed and scaly. Sooner or later the hairs loosen, and 
may be easily pulled out, or in time drop out. Repeatedly of late the 
patient has resolved to permit the beard to grow indefinitely, for the pur- 
pose of further studying the course of the disease; but at the end of a 
fortnight the irritation and disfigurement have been so great that he has 
been compelled to abandon his determination. The disease, he states, is 
in a much more active condition now than it was a year or two since. 
The subjective symptoms he describes as being very annoying, consist- 
ing of more or less itching and general irritation of the affected parts. 
They are decidedly worse when the beard is growing. 
The present appearance of the disease may be described as follows : It 
will be remembered, as stated, that a week’s growth of hair exists upon 
the chin, and that the moustache is of full length. The regions invaded 
are two indistinctly defined, irregularly ovalish areas, about as large as 
olives, on either side of the chin between the median line and the angle of 
the lower jaw. They come down over the chin quite symmetrically, almost 
joining at the median line. The upper lip is attacked in the form of two 
irregularly shaped, elongate patches, extending on either side from the 
lower border of the nares to the angles of the mouth; in other words, 
completely around the upper border of the moustache, which is in part 
destroyed. The remainder of the moustache is normal. The side whis- 
kers as well as the hair of the neck are likewise unaffected. Around the 
outer border of the moustache the hairs are entirely wanting, the diseased 
areas having been recently depilated. The skin is slightly reddened and 
scaly, and has the appearance of being the seat of seborrhoea. As already 
stated, the moustache is unusually narrow and presents a broken, irregular 
upper outline. The patches upon the sides of the chin have a hypenemic, 
scaly surface, and are partially bald, the hairs that remain being plainly 
diseased. Here and there are minute follicular papules and pustules. 
The free extremities of the hairs are split up into two or more parts, giv- 
ing the hairs a ragged look. They are of irregular length and calibre; 
some are uncommonly thick, while others are remarkably thin and atro- 
phied. One hair only is noted to proceed from a follicle. There is no 
swelling of the skin, but the surface is hyperamic and slightly scaly, and, 
as upon the upper lip, resembles seboirhoea. The condition also bears 
some likeness to tinea circinata of this region, but not to tinea sycosis, for, 
as stated, there is no swelling of the tissues. 
The hairs when seized with the forceps are found in some instances to 
be firmly seated in their follicles, and in other cases to be so loose that they 
may be readily extracted. Depilation is in no instance painful. Even 
the hairs which are securely lodged may be pulled out without causing the 3 
least pain. This has always been the case, and has been noted by the 
patient as being a singular feature of the disease. With some hairs depila- 
tion is difficult, the hairs breaking off leaving the roots within the follicles. 
To the naked eye the extracted hairs are seen to vary greatly in appear- 
ance. They are from one to several lines in length. Some have a uniform 
diameter, several times greater than normal, while others throughout their 
length are unusually slender. They also vary in form, some being straight, 
others crooked. The bulbs are in almost all instances smaller than nor- 
mal, and have a markedly contracted look. Not unfrequently the diameter 
of the bulb and root is considerably less than that of the shaft. The shafts 
are either diminutive, in which case they are generally free of root-sheath; 
or, they are of large calibre and surrounded with adherent root-sheath. 
The majority of the hairs show splitting into two, three, or more parts 
throughout their entire length. The extent of the splitting varies; in 
some hairs the substance is split up into a number of parts, or stalks, widely 
separated, while in other specimens the stalks hold together, so that the 
form of the hair is still preserved, although larger than normal. Many of 
the hairs look as though they might have been cleft with a delicate knife. 
In other cases the disintegration is in a less advanced stage, the hairs 
showing merely indications of splitting. 
Specimens of hair showing the several varieties of disease. 20 diameters. 
Aymun Yan'JlariJ\/sfmJ)ei 
Under the microscope the hairs exhibit still greater diversity of struc- 
ture, as may be seen in the accompanying drawing. They are, in the first 
place, notable for their irregularity of form, scarcely two of them being 
alike. Atrophy of the bulbs and fission of the hair substance are the con- 4 
spicuous features. In the majority of the specimens the bulbs are distinctly 
shrunken and atrophied, appearing as small contracted points or knobs. 
The hairs, as a rule, begin to fissure within the bulb, the separation of the 
parts taking place either at the bulb or at a variable distance beyond it. 
The hair structure is noted to divide very irregularly into two, three, four 
or more parts, which either adhere throughout the length of the hair, or 
diverge at once, and, in some cases, split again into other stalks. The 
splitting and branching may, I think, be quite appropriately compared to 
this process as it takes place in many elm trees, where the limbs are often 
thrown off at no great distance from the roots. No uniformity is observed 
in the fission; some stalks spring directly from the bulb, others are formed by 
the division of a stalk. They vary as to number and size. The majority 
of hairs show from three to five stalks. Some are short and thick; others 
are long and slender. As a rule, they incline to diverge widely as 
the free extremity is approached, giving the hair somewhat the form 
and appearance of a feather brush. They either retain their original 
calibre throughout their length, or they gradually enlarge towards their 
free ends, in some instances to fully double the size they possess at 
their point of departure from the main structure. This is a striking and, 
at the same time, a curious feature of the disease, and is well shown in one 
of the drawings. 
The cortical substance has either a dry, brittle look, as occurs in the 
atrophied, slender stalks, or it possesses a spongy, luxuriant appearance, as 
is seen in the thick, hypertrophied parts. The medulla is nowhere normal. 
It is present here and there, but in broken tracts. In many specimens 
nothing further than an irregular streak of pigment can be found, either 
at the bulb or in the shaft. The distribution of pigment is variable as to 
quantity and localization. In some hairs it is concentrated, as about the 
bulbs; in others it is noticeably wanting. The hairs vary in colour from 
yellowish to blackish. 
The exterior surface of the hairs varies; in some cases it is smooth, in 
others dry, rough, broken, and ragged. Here and there are noticed jagged 
processes and spicules of partially detached filaments. 
Concerning the treatment to which the disease has been subjected, it 
may be stated that various methods have been instituted and carried out 
more or less faithfully, including both internal and local remedies. Among 
the former, arsenic, strychnia, iron, iodide of potassium, and Donovan’s 
solution may be mentioned, none of which exerted any influence on the 
affection. Locally, close shaving and depilation have been practised on 
several occasions, but never for a long period. During the time when the 
disease was regarded as being probably due to a vegetable parasite, para- 
siticides were freely employed, without benefit. The only remedies likely 
to prove of value, in my opinion, are long-continued shaving and depila- 
tion. 
The disease is one of interest on account of its rarity and for the pecu- 
liar pathological changes. The symptoms, moreover, combine to render 
it both an annoying and a disfiguring affection. Regarding its pathology 
we learn from microscopic study that the morbid process takes its origin 
at the base of the bulb, and consequently manifests itself as soon as the 
hair commences to grow. The changes take place within the follicle. 
With the development of the hair occurs atrophy of the bulbs, followed by fission, and subsequently irregular growth of the hair-substance. The 
increase in the bulk of the hair, caused by the separation of its parts, ren- 
ders it too large for the follicle, which becomes distended and more or less 
inflamed. The clinical symptoms are by this explanation satisfactorily 
accounted for. The most striking feature of the disease is found in the 
fact that while the bulbs are in a state of marked atrophy, the root and 
shaft show apparent hypertrophy, and in some cases this in a remarkable 
degree. The phenomenon admits of no explanation. 
The theory of the parasitic nature of the affection need be mentioned 
merely to be disposed of as being entirely out of the question. No sign of any 
vegetable organism was found within the hair or in any of the epithelial 
cells of the epidermis or follicle. The microscopic examinations were 
conducted with much care, a large number of hairs, together with epithe- 
lial matter taken from the follicles and epidermis, having been viewed 
under both low and high powers. The specimens were obtained and ex- 
amined on several occasions, and at intervals of months, Avith invariably 
the same result. 
Splitting of the hair taking place without the follicle is by no means a 
rare condition, and may exist in all degrees of severity. It occurs in the 
long fine hairs of the scalp, and also less frequently in the shorter hairs of 
the beard. A case of simple splitting of the hair of the beard occurring 
in a gentleman of thirty with reddish hair, is at the present time under 
my observation. The hairs, upon being allowed to grow to any length, 
become dry and brittle, and split up at their free extremities into two or 
more parts, giving the beard a somewhat curly, bushy appearance. 
In conclusion, it may be remarked that the disease which is the subject 
of this communication must be regarded as one of atrophy of the hair, and 
may be grouped Avith that singular and rare disease which Avas first de- 
scribed by Beigel under the name of “ swelling and bursting of the hairs” 
(Sitzb. d. k, Akad. d. W. bd. xvii. p. 612, 1855). Kaposi, who has also met 
with the disease of Beigel, just referred to, proposes for it the name “ tricho- 
rexis nodosa” (Hebra and Kaposi, Diseases of the Skin, New Syd. Soc. 
Trans., vol. iii. p. 244). The affection described by Devergie, and called by 
him “ tricoptilosis” (Annales de Derm, et de Syph. No. i. 1871, 1872), is 
doubtless the same disease as the “ swelling and bursting of the hairs” of 
Beigel. .It differs in many particulars from the disease under considera- 
tion.