Cytokines and other mediators in alopecia areata

Alopecia areata profiling shows TH1, TH2, and IL-23 cytokine activation without parallel TH17/TH22 skewing

BACKGROUND

Alopecia areata (AA) is a common T cell-mediated disorder with limited therapeutics. A molecular profile of cytokine pathways in AA tissues is lacking. Although studies have focused on TH1/IFN-γ responses, several observations support a shared genetic background between AA and atopy.

OBJECTIVE

We sought to define the AA scalp transcriptome and associated biomarkers with comparisons with atopic dermatitis (AD) and psoriasis.

METHODS

We performed microarray and RT-PCR profiling of 27 lesional and 17 nonlesional scalp samples from patients with AA for comparison with normal scalp samples (n = 6). AA gene expression was also compared with samples from patients with lesional or nonlesional AD and those with psoriasis. A fold change of greater than 1.5 and a false discovery rate of less than 0.05 were used for differentially expressed genes (DEGs).

RESULTS

We established the AA transcriptomes (lesional vs nonlesional: 734 DEGs [297 upregulated and 437 downregulated]; lesional vs normal: 4230 DEGs [1980 upregulated and 2250 downregulated]), including many upregulated immune and downregulated hair keratin genes. Equally impressive as upregulation in TH1/interferon markers (IFNG and CXCL10/CXCL9) were those noted in TH2 (IL13, CCL18, CCL26, thymic stromal lymphopoietin, and periostin), TH9/IL-9, IL-23 (p40 and p19), and IL-16 mediators (all P < .05). There were no increases in TH17/TH22 markers. Hair keratin (KRT) expressions (ie, KRT86 and KRT85) were significantly suppressed in lesional skin. Greater scalp involvement (>25%) was associated with greater immune and keratin dysregulation and larger abnormalities in nonlesional scalp samples (ie, CXCL10 and KRT85).

CONCLUSIONS

Our data associate the AA signature with TH2, TH1, IL-23, and IL-9/TH9 cytokine activation, suggesting consideration of anti-TH2, anti-TH1, and anti-IL-23 targeting strategies. Similar to psoriasis and AD, clinical trials with selective antagonists are required to dissect key pathogenic pathways.

Efficacy and safety of methotrexate in alopecia areata

BACKGROUND

Alopecia areata is a chronic disorder of the hair follicles and nails, of unknown etiology, with clear autoimmune components and genetic factors. Several therapeutic options have been suggested; however, no treatment is able to modify the disease course. Methotrexate is an immunosuppressant used in various dermatoses and recently introduced as a therapeutic option for alopecia areata.

OBJECTIVES

To evaluate the efficacy and safety of methotrexate in alopecia areata.

METHODS

In a retrospective, non-controlled study, we evaluated 31 patients with alopecia areata in current or prior treatment with methotrexate to assess the therapeutic response according to sex, age, pattern of alopecia areata, disease duration, cumulative dose of methotrexate, use of systemic corticosteroids or other treatments, and drug safety.

RESULTS

Regrowth greater than 50% was observed in 67.7% of patients, with the best responses observed in those with <5 years of disease progression (79%), age over 40 years (73.3%), male patients (72.8%), cumulative dose of methotrexate 1000-1500 mg, and multifocal alopecia areata (93%). Among patients receiving systemic corticosteroids in combination with methotrexate, 77.3% had greater than 50% regrowth, compared with 44.4% in those who used methotrexate alone. The therapeutic dose ranged from 10-25 mg/week. No patient had serious adverse effects. Relapse was observed in 33.3% of patients with more than 50% regrowth.

CONCLUSION

Methotrexate appears to be a promising and safe medication for the treatment of severe alopecia areata when used alone or in combination with corticosteroids.

Drug discovery for alopecia: gone today, hair tomorrow

INTRODUCTION

Hair loss or alopecia affects the majority of the population at some time in their life, and increasingly, sufferers are demanding treatment. Three main types of alopecia (androgenic [AGA], areata [AA] and chemotherapy-induced [CIA]) are very different, and have their own laboratory models and separate drug-discovery efforts.

AREAS COVERED

In this article, the authors review the biology of hair, hair follicle (HF) cycling, stem cells and signaling pathways. AGA, due to dihydrotesterone, is treated by 5-α reductase inhibitors, androgen receptor blockers and ATP-sensitive potassium channel-openers. AA, which involves attack by CD8(+)NK group 2D-positive (NKG2D(+)) T cells, is treated with immunosuppressives, biologics and JAK inhibitors. Meanwhile, CIA is treated by apoptosis inhibitors, cytokines and topical immunotherapy.

EXPERT OPINION

The desire to treat alopecia with an easy topical preparation is expected to grow with time, particularly with an increasing aging population. The discovery of epidermal stem cells in the HF has given new life to the search for a cure for baldness. Drug discovery efforts are being increasingly centered on these stem cells, boosting the hair cycle and reversing miniaturization of HF. Better understanding of the molecular mechanisms underlying the immune attack in AA will yield new drugs. New discoveries in HF neogenesis and low-level light therapy will undoubtedly have a role to play.

Fibroblast growth factors stimulate hair growth through β-catenin and Shh expression in C57BL/6 mice

Growth factors are involved in the regulation of hair morphogenesis and cycle hair growth. The present study sought to investigate the hair growth promoting activities of three approved growth factor drugs, fibroblast growth factor 10 (FGF-10), acidic fibroblast growth factor (FGF-1), and basic fibroblast growth factor (FGF-2), and the mechanism of action. We observed that FGFs promoted hair growth by inducing the anagen phase in telogenic C57BL/6 mice. Specifically, the histomorphometric analysis data indicates that topical application of FGFs induced an earlier anagen phase and prolonged the mature anagen phase, in contrast to the control group. Moreover, the immunohistochemical analysis reveals earlier induction of β-catenin and Sonic hedgehog (Shh) in hair follicles of the FGFs-treated group. These results suggest that FGFs promote hair growth by inducing the anagen phase in resting hair follicles and might be a potential hair growth-promoting agent.

Evaluation of Serum Homocysteine, High-Sensitivity CRP, and RBC Folate in Patients with Alopecia Areata

Introduction:

Alopecia areata (AA) is a common type of hair loss with an autoimmune basis. As the role of homocysteine (Hcys), folate, and CRP has been considered in some autoimmune diseases.

Objectives:

To evaluate homocysteine, folate and CRP level in AA.

Methods:

This study was performed on 29 patients who had AA for at least 6 months affecting more than 20% of scalp, and 32 healthy controls. Levels of serum Hcys, blood high-sensitivity CRP, and RBC folate were measured in all subjects.

Results:

The mean level of RBC folate was significantly lower in the patient group than that in controls (P < 0.001). Also, the level of RBC folate was significantly lower in patients with extensive forms of disease (alopecia totalis/alopecia universalis) in comparison with more localized form (patchy hair loss) (P < 0.05). Patients with higher “Severity of Alopecia Total” (SALT) score had lower RBC folate, as well. Serum Hcys and blood high-sensitivity CRP levels did not show a significant difference in two groups.

Conclusion:

Patients with alopecia areata have lower level of RBC folate which is in negative correlation with both severity and extension of AA.

Total serum immunoglobulin E in patients with alopecia areata

Context:

Alopecia areata (AA) is a common form of localized, non-scarring hair loss. The pathogenesis of the disease is unknown. Previous evidence suggested the involvement of Th2 cytokines in disease pathogenesis.

Aim:

To determine serum level of total IgE, this is mainly influenced by Th2 cytokines, in Egyptian patients with AA.

Materials and Methods:

Fifty subjects with AA (28 males and 22 females) were selected from Dermatology Outpatient Clinic, Menoufiya University Hospital from February 2012 to December 2012. Subjects with other conditions that might elevate serum IgE were excluded from the study. Fifty age- and sex-matched healthy subjects were selected as a control group. Venous blood samples were taken from cases and controls for measurement of total serum IgE by enzyme-linked immunosorbent assay. Skin biopsy was taken from every case from an active area of hair loss.

Results:

Total serum IgE was elevated in 27 (54%) cases. Its values among patients ranged from 13.5 IU/ml to 780 IU/ml. There was a statistically significant difference between cases and controls with regard to mean value of serum IgE (P < 0.05). Mean value of IgE did not vary significantly with disease severity, patients’ age, patients’ gender, disease duration, site of lesions, and positive family history of AA. No correlation was found between serum IgE levels and histopathological changes detected in examined cases.

Conclusions:

Total serum IgE is elevated in AA. This elevation is not related to age, gender, disease duration, disease severity, site of affection or family history of AA.

A functional polymorphism in interleukin-1α (IL1A) gene is associated with risk of alopecia areata in Chinese populations

Alopecia areata (AA) is an inflammatory hair loss disorder with a major genetic component, which may cause great psychosocial distress for those affected. Studies have shown that interleukin-1 (IL-1) is a very potent inducer of hair loss and a significant human hair growth inhibitor. The 4-bp insertion/deletion (Indel) polymorphism (rs3783553) within the 3' untranslated regions of IL1A gene has been suggested to be associated with risk of various types of cancers, possibly through regulating expression of IL-1α levels. In the current study, we estimated the susceptibility to AA associated with rs3783553 in two independent case-control panels of Eastern and Southern Chinese populations, totally containing 313 AA cases and 626 healthy controls. Logistic regression analysis showed that the heterozygote and the homozygote 4-bp ins/ins confer a significantly lower risk of AA in both panels and total subjects [odds ratio (OR)=0.55, 95% confidence interval (C.I.)=0.41-0.75, P=6.24×10(-5); OR=0.47, 95% C.I.=0.28-0.76, P=0.001, respectively]. Stratification analysis based on age onset showed that the protective roles of ins/del and ins/ins genotype against developing AA was more obvious in AA patients with early age onset (<30years) under dominant model (OR=0.48, 95% C.I.=0.29-0.77, P=0.001). The results of luciferase assay showed that rs3783553 could influence expression of IL-1α in a miR-122 dependant manner. Taken together, our results suggested that the IL1A 4-bp indel polymorphism may be a marker for genetic susceptibility to patchy (mild) AA in Chinese populations, likely through miR-122 mediated regulation.

Hair growth-promoting activity of hot water extract of Thuja orientalis

BACKGROUND

Thuja orientalis has been traditionally used to treat patients who suffer from baldness and hair loss in East Asia. The present study sought to investigate the hair growth-promoting activity of T. orientalis hot water extract and the underlying mechanism of action.

METHODS

After T. orientalis extract was topically applied to the shaved dorsal skin of telogenic C57BL/6 N mice, the histomorphometric analysis was employed to study induction of the hair follicle cycle. To determine the effect of T. orientalis extract on the telogen to anagen transition, the protein expression levels of β-catenin and Sonic hedgehog (Shh) in hair follicles were determined by immunohistochemistry.

RESULTS

We observed that T. orientalis extract promoted hair growth by inducing the anagen phase in telogenic C57BL/6 N mice. Specifically, the histomorphometric analysis data indicates that topical application of T. orientalis extract induced an earlier anagen phase and prolonged the mature anagen phase, in contrast to either the control or 1% minoxidil-treated group. We also observed increases in both the number and size of hair follicles of the T. orientalis extract-treated group. Moreover, the immunohistochemical analysis reveals earlier induction of β-catenin and Shh proteins in hair follicles of the T. orientalis extract-treated group, compared to the control or 1% minoxidil-treated group.

CONCLUSION

These results suggest that T. orientalis extract promotes hair growth by inducing the anagen phase in resting hair follicles and might therefore be a potential hair growth-promoting agent.

Genetic basis of alopecia areata: a roadmap for translational research

Alopecia areata (AA) is a recurrent autoimmune type of hair loss that affects about 5.3 million people in the United States alone. Despite being the most prevalent autoimmune disease, the molecular and cellular mechanisms underlying this complex disease are still poorly understood, and rational treatments are lacking. Further efforts are necessary to clearly pinpoint the causes and molecular pathways leading to this disease and to find evidence-based treatments for AA. The authors focus on the central role of genetics for gaining insight into disease pathogenesis and setting the stage for the rational development of novel effective therapeutic approaches.

Insulin resistance is increased in alopecia areata patients

Increased insulin resistance (IR) has been found in androgenetic alopecia in several studies. However, IR has not been investigated in alopecia areata (AA). We aimed to investigate IR in AA patients and the controls. Anthropometric and demographic data were obtained from 51 AA patients and 36 controls. We measured insulin, c-peptide and blood glucose and HOMA-IR. Demographic characteristics of the two groups were similar. AA group had higher insulin [12.5 ± 7.01 vs. 8.3 ± 3.9 µIU/mL, p = 0.001], c-peptide [2.7 ± 1.07 vs. 2. ± 0.6 ng/mL, p = 0.007] and HOMA-IR levels [2.8 ± 1.6 vs. 1.9 ± 0.9, p = .004] than the controls. Patient and control groups were also similar regarding lipid profiles. In this study, we found increased IR in AA patients for the first time in literature. Increased inflammatory cytokines and hypothalamic-pituitary-adrenal axis activation may be responsible for this finding. Further studies with larger sample sizes may give additional information for IR in AA.

Serum Concentrations and IL-2, IL-6, IL-12 and TNF-α in Patients with Alopecia Areata

Alopecia areata (AA) has been represented as a restricted T cell-mediated autoimmune disease. Several studies have shown that cytokines may play an important role in its pathogenesis although many pathways exist. We investigated cytokine (IL-2, IL-6, IL-12 and TNFα) levels in peripheral blood mononuclear cell (PBMC) of 105 patients with different grade and duration of alopecia areata, to confirm that T-cell responses in AA is regulated via mechanisms of peripheral T-cell tolerance. We observed that IL-12 levels are higher for patients with bigger extensions and tend to increase according to the duration of the AA; TNFα, instead, is more related to the gender of the patients and to the duration. Therefore abnormalities in cytokines production, showed by our results, may suggest that T-cell responses in AA scalp are closely regulated via mechanisms of peripheral T-cell tolerance and therefore confirm that this disease has an immuno-pathogenesis. Our aim is to shed light upon the complexity of AA underlying mechanisms and indicate pathways that may suggest future treatments.

Prevention and treatment of alopecia areata with quercetin in the C3H/HeJ mouse model

Alopecia areata (AA) is an autoimmune non-scarring hair loss disorder. AA can be acute, recurrent, or chronic. Current therapeutic options for AA are limited, and there is no effective prevention for recurrent AA. We have previously shown a correlation between the expression of HSP70 (HSPA1A/B), a heat shock protein involved in the inflammatory response, and the onset of AA in the C3H/HeJ mouse model. In this study, we tested the effects of quercetin, a bioflavonoid with anti-inflammatory properties, on AA development and HSP70 expression in the C3H/HeJ model. Mice with spontaneous AA were treated with subcutaneous quercetin or sham injections. Hair regrowth was observed in lesional areas in all the quercetin-treated mice, but in none of the sham-treated mice. In addition, non-alopecic C3H/HeJ mice were heat-treated to induce alopecia, along with quercetin or sham injections. Whereas 24% of the heat-treated mice with sham injections developed alopecia, none of the mice receiving quercetin injections did. As expected, the level of HSP70 expression in quercetin-treated areas was comparable to control. Furthermore, we showed that systemic delivery of quercetin by intraperitoneal injections prevented/reduced spontaneous onset of AA. Our results demonstrated that quercetin provided effective treatment for AA as well as prevention of onset of AA in the C3H/HeJ model, and warrant further clinical studies to determine whether quercetin may provide both treatment for preexisting AA and prevention of recurrent AA. The ready availability of quercetin as a dietary supplement may lead to increased patient compliance and positive outcomes for AA.

Intermediate uveitis and alopecia areata: is there a relationship? Report of 3 pediatric cases

Three previously healthy children, aged 5, 8, and 15 years, with idiopathic intermediate uveitis (IU) and alopecia areata (AA) are described. These are the first 3 cases of which we are aware with this coexistence. The results of extensive diagnostic evaluations were negative in all 3 cases. AA preceded the diagnosis of bilateral IU in 1 child and followed within several months after IU diagnosis in 2 children. The severity of uveitis ranged from mild to sight-threatening, and hair loss ranged from local lesions in 2 cases to total alopecia in 1 case. Pathogenesis of both diseases is discussed. Theoretically, the coexistence of IU and AA might be based on the similarities in their complex pathogenesis. However, more research is needed to evaluate if the coexistence is based on an association between 2 autoimmune disorders or is a coincidence.

Topical application of Polygonum multiflorum extract induces hair growth of resting hair follicles through upregulating Shh and β-catenin expression in C57BL/6 mice

ETHNOPHARMACOLOGICAL RELEVANCE

Polygonum multiflorum has traditionally been used for treating patients suffering from baldness and hair loss in East Asia.

AIM OF THE STUDY

The present study sought to investigate the hair growth promoting activities of Polygonum multiflorum and its mechanism of action.

MATERIALS AND METHODS

The Polygonum multiflorum extract was topically applied to the shaved dorsal skin of telogenic C57BL6/N mice. To determine the effect of Polygonum multiflorum extract in telogen to anagen transition, the expression of β-catenin and Sonic hedgehog (Shh) was determined by immunohistochemistry analysis.

RESULTS

Polygonum multiflorum extract promoted hair growth by inducing anagen phase in telogenic C57BL6/N mice. In Polygonum multiflorum extract treated group, we observed increase in the number and the size of hair follicles that are considered as evidence for anagen phase induction. Immunohistochemical analysis revealed that earlier induction of β-catenin and Shh were observed in Polygonum multiflorum extract treated group compared to that in control group.

CONCLUSION

These results suggest that Polygonum multiflorum extract promotes hair growth by inducing anagen phase in resting hair follicles.

The α-lipoic acid derivative sodium zinc dihydrolipoylhistidinate reduces chemotherapy-induced alopecia in a rat model: a pilot study

PURPOSE

Alopecia is one of the most common side effects of chemotherapy for which treatments have not been developed. In the present study, we evaluated the effects of sodium zinc dihydrolipoylhistidinate (DHLHZn), a new derivative of the multifunctional antioxidant α-lipoic acid, to treat chemotherapy-induced alopecia.

METHODS

Wistar rats (8 days old) were treated with cytosine arabinoside (AraC; 20 mg/kg by daily intraperitoneal injection; days 0-6) and DHLHZn (0%, 0.5%, or 1% topically applied in a white petrolatum base; days 0-12). A control group received daily saline injections (days 0-6) and topical application of white petrolatum (days 0-12). On day 12, we evaluated hair loss and histologic changes to scalp tissue for each group (n = 10).

RESULTS

Rats treated with AraC and 0% DHLHZn cream exhibited complete hair loss; however, treatment with 0.5% or 1% DHLHZn significantly reduced chemotherapy-induced hair loss. Histological analysis revealed that AraC treatment promoted inflammatory cell infiltration of the hair follicles, but this inflammatory response was attenuated by DHLHZn.

CONCLUSIONS

Our findings demonstrate that DHLHZn attenuates chemotherapy-induced alopecia, indicating the potential use of this α-lipoic acid derivative as a therapeutic agent against this common side effect of chemotherapy.

[Alopecia areata during anti-TNF alpha therapy: Nine cases]

BACKGROUND

In recent years, a growing number of biological agents have been introduced for the treatment of various diseases, and their principal adverse events are known. We present nine cases of alopecia areata (AA) developed in patients treated with TNF-α blocking agents.

PATIENTS AND METHODS

Nine cases are described: five men and four women of mean age 39.2 years (range: 29-54 years). Two patients had a past history of alopecia areata. The anti-TNF given was adalimumab (Humira(®)) in eight cases and etanercept (Enbrel(®)) in one case. The time lapse to development of AA following introduction of the anti-TNF alpha agent was between six weeks and eight months (mean: 4.2 months). There were five cases of patchy AA and four of AA universalis. Anti-TNF alpha treatment was stopped in all patients. Complete regrowth was seen in five patients. Two patients showed no improvement. In two patients, partial hair regrowth (<50%) was seen after systemic corticosteroid therapy and methotrexate.

DISCUSSION

Our nine cases of alopecia areata developed in patients treated with TNF-α blockers constitute the largest series reported to our knowledge. 17 cases of AA during anti-TNF-alpha therapy have previously been described in the literature. AA may be a side effect of anti-TNF-alpha drugs. In our patients, no conclusive triggers could be associated with the development of AA, except a context of stress in four patients. Complete regrowth in three patients after discontinuation of the anti-TNF-alpha (without other therapy) is an additional argument in favour of the implication of biotherapies. However, a random coincidence of AA with anti-TNF-alpha cannot be completely ruled out. The role of anti-TNF-alpha therapy in the pathogenesis of AA is poorly understood. Activation of self-reactive T cells by anti-TNF-alpha could lead to the development of AA.