Alopecia in Association with Malignancy: A Review

Dosimetric comparison of advanced radiation techniques for scalp-sparing in low-grade gliomas

BACKGROUND

Alopecia causes significant distress for patients and negatively impacts quality of life for low-grade glioma (LGG) patients. We aimed to compare and evaluate variations in dose distribution for scalp-sparing in LGG patients with proton therapy and photon therapy, namely intensity-modulated proton therapy (IMPT), intensity-modulated radiotherapy (IMRT), volumetric modulated arc therapy (VMAT), and helical tomotherapy (HT).

METHODS

This retrospective study utilized a dataset comprising imaging data from 22 patients with LGG who underwent postoperative radiotherapy. Treatment plans were generated for each patient with scalp-optimized (SO) approaches and scalp-non-optimized (SNO) approaches using proton techniques and photons techniques; all plans adhered to the same dose constraint of delivering a total radiation dose of 54.04 Gy to the target volume. All treatment plans were subsequently analyzed.

RESULTS

All the plans generated in this study met the dose constraints for the target volume and OARs. The SO plans resulted in reduced maximum scalp dose (Dmax), mean scalp dose (Dmean), and volume of the scalp receiving 30 Gy (V30) and 40 Gy (V40) compared with SNO plans in all radiation techniques. Among all radiation techniques, the IMPT plans exhibited superior performance compared to other plans for dose homogeneity as for SO plans. Also, IMPT showed lower values for Dmean and Dmax than all photon radiation techniques.

CONCLUSION

Our study provides evidence that the SO approach is a feasible technique for reducing scalp radiation dose. However, it is imperative to conduct prospective trials to assess the benefits associated with this approach.

The Constellation of Risk Factors and Paraneoplastic Syndromes in Cholangiocarcinoma: Integrating the Endocrine Panel Amid Tumour-Related Biology (A Narrative Review)

Cholangiocarcinomas (CCAs), a heterogeneous group of challenging malignant tumours which originate from the biliary epithelium, are associated with an alarming increasing incidence during recent decades that varies between different regions of the globe. Thus, awareness represents the key operating factor. Our purpose was to overview the field of CCAs following a double perspective: the constellation of the risk factors, and the presence of the paraneoplastic syndromes, emphasizing the endocrine features amid the entire multidisciplinary panel. This is a narrative review. A PubMed-based search of English-language original articles offered the basis of this comprehensive approach. Multiple risk factors underlying different levels of statistical evidence have been listed such as chronic biliary diseases and liver conditions, inflammatory bowel disease, parasitic infections (e.g., Opisthorchis viverrini, Clonorchis sinensis), lifestyle influence (e.g., alcohol, smoking), environmental exposure (e.g., thorotrast, asbestos), and certain genetic and epigenetic interplays. With regard to the endocrine panel, a heterogeneous spectrum should be taken into consideration: non-alcoholic fatty liver disease, obesity, type 2 diabetes mellitus, and potential connections with vitamin D status, glucagon-like peptide 1 receptor, or the galanin system, respectively, with exposure to sex hormone therapy. Amid the numerous dermatologic, hematologic, renal, and neurologic paraneoplastic manifestations in CCAs, the endocrine panel is less described. Humoral hypercalcaemia of malignancy stands as the most frequent humoral paraneoplastic syndrome in CCAs, despite being exceptional when compared to other paraneoplastic (non-endocrine) manifestations and to its reported frequency in other (non-CCAs) cancers (it accompanies 20-30% of all cancers). It represents a poor prognosis marker in CCA; it may be episodic once the tumour relapses. In addition to the therapy that targets the originating malignancy, hypercalcaemia requires the administration of bisphosphonates (e.g., intravenous zoledronic acid) or denosumab. Early detection firstly helps the general wellbeing of a patient due to a prompt medical control of high serum calcium and it also provides a fine biomarker of disease status in selected cases that harbour the capacity of PTHrP secretion. The exact molecular biology and genetic configuration of CCAs that display such endocrine traits is still an open matter, but humoral hypercalcaemia adds to the overall disease burden.

Trichoscopic Features of Syphilitic Alopecia and Alopecia Areata: A Comparative Study

Background

Syphilitic alopecia (SA) and alopecia areata (AA) are two distinct conditions that frequently present diagnostic difficulties, especially when differentiating between them due to their similar clinical presentations. Trichoscopy may help in differential diagnosis, but a comparison between trichoscopic features of SA and AA is yet to be researched.

Objective

To compare trichoscopic features between SA and AA and determine their discriminative values.

Methods

Electronic medical records and trichoscopic images of patients diagnosed with SA or AA between January 2000 and February 2022 were retrieved. Trichoscopic features were statistically compared, and their discriminative values were demonstrated as sensitivity, specificity, predictive value, likelihood ratio, and area under the receiver operating characteristic curve (AUC).

Results

A total of 69 patients were included: 23 SA and 46 AA cases were matched with a 1:2 ratio. Black dots, broken hairs, pigtail hairs, exclamation mark hairs, tapered hairs, angulated hairs, and non-pigmented regrowing hairs were significantly more prevalent in AA than in SA (all P<0.05), whereas erythematous background was more prevalent in SA than in AA patients (P=0.008). Among the aforementioned trichoscopic features, exclamation mark hairs and non-pigmented regrowing hairs had a high positive likelihood ratio for AA (16.17 and 8.34, respectively); however, only exclamation mark hairs revealed high AUC (AUC=0.816).

Conclusion

Despite the presence of several similar trichoscopic features between SA and AA, trichoscopy can aid in distinguishing between the two diseases. Exclamation mark hairs are the only trichoscopic feature that can be used to differentiate patients with clinically suspicious SA from those with AA.

Differences in Demographic and Clinical Characteristics Among Subtypes of Female Pattern Hair Loss

Background

Female pattern hair loss (FPHL) is the most common hair loss disorder in women that can be classified into three patterns, including Ludwig, Olsen, and Hamilton-Norwood subtypes. Information regarding the comparison of demographics, clinical characteristics, and associated comorbidities among subtypes of FPHL is scarce and contradictory.

Objective

To evaluate and compare the epidemiology, clinical manifestations, and comorbid conditions of FPHL subtypes and determine their associated factors.

Methods

This retrospective study included patients who were diagnosed with FPHL between January 2000 and November 2021. Participants were classified into three subtypes, namely Ludwig, Olsen, and Hamilton-Norwood, and were statistically compared. Variables significantly associated with each FPHL subtype were identified using multivariable multinomial logistic regression analysis.

Results

Among the 519 patients with FPHL, the Ludwig subtype was the most prevalent (51.1%), followed by the Olsen (32.9%) and Hamilton-Norwood (16%) subtypes. The Hamilton-Norwood subtype revealed significantly higher frequencies of early disease onset (61.4%), menstrual irregularity (22.9%), polycystic ovary syndrome (PCOS, 18.1%), and seborrhea (30.1%) but lower frequencies of overweight (24.1%) and type 2 diabetes mellitus (DM, 2.4%). Multivariable multinomial regression analysis demonstrated that the Hamilton-Norwood subtype was a predictor for early disease onset and PCOS compared to Ludwig (early onset: odds ratio (OR) = 2.14, 95% confidence interval (CI) = 1.39-4.22, P = 0.02; PCOS: OR = 2.02, 95% CI = 1.55-4.84, P = 0.03), and Olsen (early onset: OR = 1.89, 95% CI = 1.03-3.92, P = 0.04; PCOS: OR = 2.24, 95% CI = 1.89-5.31, P = 0.01). In contrast, the Hamilton-Norwood pattern was at decreased risk for type 2 DM compared to Ludwig (OR = 0.51, 95% CI = 0.03-0.82, P = 0.02), and Olsen (OR = 0.68, 95% CI = 0.04-0.79, P = 0.03).

Conclusion

The Ludwig pattern was found to be the most prevalent FPHL subtype among Thai patients. Moreover, the Hamilton-Norwood subtype was associated with early disease onset and PCOS, whereas the Ludwig and Olsen subtypes were associated with type 2 DM.

Plica Neuropathica as a Presenting Rare Dermatologic Symptom of Schizophrenia

Plica neuropathica (PN), also known as plica polonica, trichoma, matting, felting, or bird's nest hair, is a common but rarely reported hair disorder. It is characterized by the abrupt onset of irreversible hair entanglement, forming a densely matted hair mass. PN has been associated with the use of ionic or herbal shampoos, vigorous hair care practice, self-neglect, systemic infection, parasitic infestation, immunosuppressive drugs, and psychiatric conditions. However, literature supporting the coexistence of PN in psychiatric disorders is scarce. PN may be one of the presenting symptoms observed by physicians. In some cases of psychiatric illness, patients consult more readily with non-mental health professionals than psychologists or psychiatrists. To highlight this issue, we herein report a case of PN in a 32-year-old woman with a 1-month history of being unable to detangle her hair. The patient initially visited the dermatology department and was subsequently diagnosed with schizophrenia following psychiatric consultation. After establishing the fundamental diagnosis apparently underlying the PN, psychiatric treatment with antipsychotic medication and dermatological treatment of the hair condition were instituted. There was an improvement in both at the four-week follow-up. This case history highlights a rare presentation of schizophrenia.

Granular Parakeratosis of the Eccrine Ostium: A Case Report

Granular parakeratosis (GP) is a unique keratotic disorder that often affects the intertriginous areas. GP usually presents as erythematous or brownish hyperkeratotic papules or plaques and can be further classified into five types. GP of the eccrine ostium is a rare subtype; its pathological defects are mainly localized to the stratum corneum of the eccrine ostia. Due to its rarity, there is usually a delay in diagnosing GP, and these patients are often misdiagnosed with other dermatological conditions. In this report, we present the case of a 64-year-old Thai female who presented with recurrent pruritic erythematous rashes on her neck since approximately 40 years. She was previously diagnosed with eczema or folliculitis. Histopathological examination confirmed a final diagnosis of GP of the eccrine ostium. She was advised to avoid excessive heat and keep her intertriginous areas dry. Her condition improved significantly during the follow-up visit.

Familial Dyskeratotic Comedones: A Case Report and Literature Review

Familial dyskeratotic comedones (FDC) is an autosomal dominant inherited skin disorder characterized by generalized multiple discrete comedone-like hyperkeratotic papules. The disease demonstrates a distinct histopathologic feature of dyskeratosis of the crater-like invaginated epidermis or follicle-like structures with or without acantholysis. Despite its asymptomatic and benign course, the condition is refractory to treatment. Herein, we report a case of a 54-year-old female presenting with progressively developed generalized multiple hyperkeratotic papules with central keratin plugs on the trunk and extremities for 20 years. A definite diagnosis was made by clinical manifestations and histopathological examination. The lesions were slightly improved after 3 months of topical retinoids and urea cream treatments. Besides, we first describe dermoscopic findings of FDC and reviewed 21 previously reported FDC cases from 11 families in the literature.

Pretibial Pruritic Papular Dermatitis: A Case Report and Emphasis on Effective Treatment with Pentoxifylline

Pretibial pruritic papular dermatitis (PPPD) is a distinctive skin disorder in response to persistent pretibial manipulation. Clinically, it manifests as multiple discrete, pruritic, flesh-colored-to-erythematous papules and plaques confined to the pretibial area. The histological hallmark of PPPD comprises irregular epidermal psoriasiform hyperplasia with parakeratosis and spongiosis, dermal fibrosis, and lymphohistiocytic infiltration. Due to its rarity and underrecognition, the prevalence and standard treatment of the disease have yet to be well elucidated. Here, we present a case of PPPD in a 60-year-old female presenting with numerous pruritic, erythematous-to-brownish papules and plaques on bilateral pretibial areas for 1.5 years. The lesions were significantly improved after 1 month of additional treatment with oral pentoxifylline. In this report, we aim to raise awareness in recognizing PPPD since it manifests unique clinical, dermoscopic, and histological features, representing pretibial skin's response to chronic rubbing. In addition, we proposed a novel effective therapy for the disease using pentoxifylline.

Case report: Dermatosis neglecta mimicking pemphigus foliaceus in association with obsessive-compulsive disorder

Dermatosis neglecta (DN) is a frequently underrecognized skin disorder that occurs due to unconscious or conscious neglect of self-cleaning, causing the accumulation of keratin, sweat, sebum, and impurities. It is characterized by asymptomatic yellowish-to-brownish, waxy, adherent papules or plaques with cornflake-like scales that mimic several dermatological conditions. DN awareness is crucial for avoiding unnecessary invasive diagnostic procedures. Its lesions can be removed with some difficulty by ordinary cleansing and efficiently cleared with ethyl or isopropyl alcohol. Individuals with underlying physical or mental disabilities or psychiatric conditions are highly associated with DN. Nevertheless, supportive evidence for the coexistence of DN and psychological conditions is sparse, and most individuals with mental problems usually deny having psychiatric issues. Here, we present a case of DN resembling pemphigus foliaceus on the face with obsessive-compulsive disorder in a 16-years old male. The definitive diagnosis of DN in this patient was confirmed via histopathological examination. The lesions completely disappeared after appropriate facial cleansing and psychiatric management. DN may reveal underlying psychiatric disorders in patients.

Liver fibrosis prevalence and risk factors in patients with psoriasis: A systematic review and meta-analysis

Background

Patients with psoriasis are more likely than matched controls in the general population to have advanced liver fibrosis; however, our understanding of these patients is limited. There is currently no systematic evaluation of the prevalence and risk factors of liver fibrosis in psoriasis patients.

Objective

To evaluate the prevalence of psoriasis patients who are at high or low risk for advanced liver fibrosis and determine the risk factors for developing liver fibrosis.

Methods

Electronic searches were conducted using the PubMed, Embase, Scopus, and Cochrane Library databases from the dates of their inception till May 2022, using the PubMed, Embase, Scopus, and Cochrane Library databases. Any observational study describing the prevalence and/or risk factors for liver fibrosis in patients with psoriasis was included.

Results

Patients with psoriasis at high risk for advanced liver fibrosis had a pooled prevalence of 9.66% [95% confidence interval (CI): 6.92-12.75%, I ² = 76.34%], whereas patients at low risk for advanced liver fibrosis had a pooled prevalence of 77.79% (95% CI: 73.23-82.05%, I ² = 85.72%). Studies that recruited methotrexate (MTX)-naïve patients found a lower prevalence of advanced liver fibrosis (4.44, 95% CI: 1.17-9.22%, I ² = 59.34%) than those that recruited MTX-user cohorts (12.25, 95% CI: 6.02-20.08%, I ² = 82.34%). Age, sex, BMI, PASI score, psoriasis duration, MTX cumulative dose, and the prevalence of obesity, MTX users, diabetes mellitus, hypertension, dyslipidemia, and metabolic syndrome were not identified as sources of heterogeneity by meta-regression analysis. The pooled odds ratios for age >50 years, BMI > 30, diabetes mellitus, hypertension, dyslipidemia, and metabolic syndrome were 2.20 (95% CI: 1.42-3.40, I ² = 0%), 3.67 (95% CI: 2.37-5.68, I ² = 48.8%), 6.23 (95% CI: 4.39-8.84, I ² = 42.4%), 2.82 (95% CI: 1.68-4.74, I ² = 0%), 3.08 (95% CI: 1.90-4.98, I ² = 0%), and 5.98 (95% CI: 3.63-9.83, I ² = 17%), respectively.

Conclusion

Approximately 10% of the population with psoriasis is at high risk for advanced liver fibrosis, while 78% are at low risk. Patients over the age of 50 with obesity, diabetes, hypertension, dyslipidemia, and/or metabolic syndrome have an increased risk of developing liver fibrosis, necessitating monitoring.

Systematic review registration

[https://www.crd.york.ac.uk/prospero/display_record.php?ID=CRD42022303886], identifier [CRD42022303886].

Platelet-rich plasma in alopecia areata and primary cicatricial alopecias: A systematic review

Background

Immune-mediated alopecias (IMAs), a group of hair disorders associated with immunological reactions, remain a therapeutic challenge since available treatments are generally unfavorable with potential side effects. Platelet-rich plasma (PRP) has been recently proposed as a treatment option based on several limited-quality studies; however, there is no systematic evaluation of PRP efficacy on IMAs in the literature.

Objective

To assess PRP's effects in treating IMAs using a systematic review.

Methods

Electronic searches were conducted using PubMed, Embase, Scopus, and Cochrane Library databases. A search strategy was designed to retrieve all studies exploring PRP in treating IMAs, including alopecia areata (AA) and primary cicatricial alopecias (PCAs). In addition, all randomized and non-randomized studies reporting subjective and/or objective outcomes of alopecia treatment with PRP were included.

Results

Thirty-two studies were included, comprising 621 patients with AA and 19 patients with PCAs. PRP had superior efficacy as monotherapy in five studies, comparable to intralesional corticosteroids in six studies in AA treatment. In addition, in the analysis of PCAs, including lymphocytic and neutrophilic subtypes, PRP was efficacious in alleviating disease progression in nine studies.

Conclusion

PRP is considered a promising treatment for AA and PCAs in patients who experienced unfavorable outcomes from conventional treatment. However, its clinical application remains to be standardized, and its recommendation as a treatment for IMAs could not be ascertained due to a lack of high-quality evidence.

Systematic review registration

[https://www.crd.york.ac.uk/prospero/display_record.php?RecordID=353859], identifier [CRD42022353859].

Rumpel-Leede Phenomenon Associated with Pneumatic Compression: A Case Report

Rumpel-Leede phenomenon is a rarely reported condition with an unknown prevalence. It is characterized by the acute development of non-blanchable purpuric macules resulting from dermal capillary rupture caused by compressive forces. We report a case of Rumpel-Leede phenomenon in both feet following the application of pneumatic compression in a 49-year-old woman who underwent en bloc spondylectomy for a giant cell tumor of the spine. The condition appeared after the application of pneumatic compression on both legs for venous thromboembolism prophylaxis, and the lesions spontaneously resolved after discontinuation of compression. Currently, most cases are reported in patients with a history of diabetes mellitus, hypertension, or thrombocytopenia. We report a case of Rumpel-Leede phenomenon in a patient without underlying medical conditions. In our patient, capillary fragility combined with increased intracapillary pressure was hypothesized as the underlying mechanism.

Epidemiological, Clinical, and Trichoscopic Features of Syphilitic Alopecia: A Retrospective Analysis and Systematic Review

Background

Syphilitic alopecia (SA), which mimics other types of alopecia, is an uncommon manifestation of secondary syphilis. Trichoscopic features may facilitate its diagnosis. However, studies on SA and its trichoscopic characteristics remain limited.

Objective

To investigate the epidemiological, clinical, and trichoscopic findings and laboratory results, treatment, and outcomes of SA in Thai patients as well as to comprehensively summarize all trichoscopic features of SA through a systematic review.

Methods

Data on patients diagnosed with SA between December 2010 and December 2021 were obtained from their medical records and analyzed retrospectively. A systematic review of trichoscopic data, both from our institution and from studies registered in the PubMed, MEDLINE, and Embase databases, was conducted. A descriptive summarization was performed to comprehensively study the trichoscopic features of SA.

Results

Of the 205 patients with secondary syphilis, 23 patients with SA (symptomatic SA: 20, essential SA: 3) were included. The mean age was 27.6 ± 8.8 years, and male predominance was noted. The moth-eaten pattern was the most common SA presentation, and the parieto-occipital scalp was the most commonly affected area. All patients with SA achieved significant hair regrowth within 3 months of antibiotic therapy. Trichoscopic images were available for 20 patients with SA from our institute and were included in the systematic review. Fourteen articles provided information on 21 patients. Overall (N = 41), 26 (63.4%), 8 (19.5%), and 7 (17.1%) patients had moth-eaten alopecia, diffuse alopecia, and mixed alopecia, respectively. The most frequent trichoscopic finding was short regrowing hairs (78%), followed by decreased hair per follicular unit (75.6%), and empty follicles (51.2%). Unique features included flame hairs, bent tapering hairs, reddish-brown background, and brown rings around the perifollicular areas, each described in one case. However, the results were based only on case reports and small case series.

Conclusions

Given the progressively increasing frequency of SA, trichoscopic examination may be valuable when SA is suspected in patients with idiopathic alopecia; however, our findings are quite non-specific. The absence of exclamation mark hairs may help in the diagnosis of SA. Further comparative studies on other types of alopecia are required to determine the most useful diagnostic features.

Alopecia in children undergoing chemotherapy, radiation, and hematopoietic stem cell transplantation: Scoping review and approach to management

Alopecia is a common sequela in children undergoing chemotherapy, radiation, and hematopoietic stem cell transplantation. In most cases, this is a transient state in which full hair regrowth eventually occurs, but permanent or persistent alopecia, defined as the presence of incomplete hair regrowth more than 6 months after cessation of treatment, is possible and can be psychologically distressing. We sought to characterize the risk factors that can lead to permanent alopecia following the aforementioned treatments in pediatric populations, as well as diagnostic and treatment options that may be considered, as part of a scoping review of the literature. A general algorithm for approaching these patients was developed based on our findings.

Pre-treatment visualization of predicted radiation-induced acute alopecia in brain tumour patients

•

Alopecia as a side effect of radiotherapy beholds a significant psychological burden for brain tumor patients. Prediction of occurrence and location of alopecia can prepare patients both mentally and practically.

•

We demonstrate a model within our treatment planning system to visualize expected alopecia 4 weeks after radiation treatment for brain tumors.

•

The validation cohort consisted of 147 brain tumor patients and showed a 100% accuracy of expected alopecia in 90% of all cases treated with photon beam radiotherapy.

Background and purpose

Temporary alopecia is a common side-effect in brain tumour patients receiving cranial radiotherapy with a significant psychological burden for the affected patient. The purpose of this study was to generate a method in our treatment planning system (TPS) to visualize the expected radiation-induced alopecia 4 weeks after treatment, in order to inform the patients thereupon before the start of radiotherapy.

Material and methods

A pilot study was conducted in ten patients receiving hypo- (HF) or conventionally fractionated (CF) photon beam Volumetric Modulated Arc Therapy (VMAT) for an intracranial lesion. Dose calculations were correlated to visible alopecia four weeks after the end of treatment to create a structure predictive of alopecia in our TPS. These alopecia structures for both fractionation schedules were validated in two cohorts of 69 HF and 78 CF patients undergoing radiotherapy between 2016 and 2019.

Results

In the pilot cohort, a total physical dose of 4 Gy for HF and 12.6 Gy for CF radiotherapy were found to be predictive of alopecia 4 weeks after treatment. Applying these doses to our validation cohort, we found an accurate prediction of alopecia in 59/69 (86%) HF and 73/78 (96%) CF patients. For the total patient group of 147 patients, the predicted amount of alopecia was accurate in 90% of the cases. All inaccurate predictions overestimated the expected extent of alopecia.

Conclusion

The presented straightforward method to visualize predicted alopecia 4 weeks after treatment has proven to predict the extent alopecia highly accurate in the vast majority of patients. Sharing these results with the patients pre-treatment may result in stress reduction before cranial irradiation.

Variation of Hair Follicle Counts among Different Scalp Areas: A Quantitative Histopathological Study

INTRODUCTION

Scalp biopsy is a standard method for the definitive diagnosis of alopecia. The hair count parameters of each scalp area remain unclear. This study aimed to determine hair count values at different scalp locations from histopathology and to establish reference values for each part of the scalp.

METHODS

We obtained biopsy specimens from the frontal, vertex, temporoparietal, and occipital areas of the scalps of normal deceased subjects. All specimens were evaluated for the number of follicular units, hair counts, hair types, and stages of the hair cycle.

RESULTS

In total, 240 specimens were collected from 60 cadavers. Across all scalp sites, the temporoparietal area showed the lowest mean hair count, number of follicular units, terminal and vellus hairs, and terminal-to-vellus hair ratio. The average anagen-to-telogen hair ratio was comparable across all scalp sites. This study did not observe a significant association of hair parameters with gender differences or increasing age in all scalp areas.

CONCLUSIONS

The present study revealed the diversity of the hair index among different scalp areas and suggested that normal hair count values should be separately standardized on each scalp region. Our findings may provide useful reference values for the histopathological evaluation of hair disorders in Asians.

Circle Hairs in a Patient with Multiple Myeloma

Circle hair is a rare body-hair disorder of unknown etiology, typically characterized by perfectly or nearly perfectly coiled hair located below the cornified layer of the skin. Its main histopathological features are dilated hair-follicle infundibula and entrapped hair shafts. After its first description in 1963, there have only been a small number of reported cases, and its pathophysiology remains unclear. Herein, we report a case of an 80-year-old woman with skin lesions and abnormal hairs on both legs. We also propose a possible mechanism of her circle hairs: it may have occurred as an effect of her acquired ichthyosis secondary to her underlying multiple myeloma. There is no specific treatment for circle hairs, and reassurance that it is a harmless condition is sufficient. We prescribed a topical humectant and keratolytic agent to moisten the skin and lessen the hair entrapment, which resulted in clinical improvement. As the pathogenesis of the disease is unknown, further studies are warranted.

Histopathological Evidence of Occipital Involvement in Male Androgenetic Alopecia

Background: The occipital region of the scalp is generally accepted as an unaffected area of androgenetic alopecia (AGA) for both genders. However, evidence of AGA involving the occipital scalp has been demonstrated in women; meanwhile, it is unclear whether occipital involvement also occurs in men. Objective: We aimed to determine if there is occipital involvement in men with AGA. Methods: This case-control study compared hair counts of scalp biopsy specimens from the occipital region of 82 men with Hamilton-Norwood III-VII and 82 unaffected men. Results: The mean ages of men with AGA and controls were 40.1 ± 8.9 and 38.6 ± 10.5 years, respectively (P = 0.291). A significant decrease in total hair follicles, terminal hair follicles, follicular units and terminal to vellus (T:V) ratio, along with a significant increase in follicular stelae was indicated in the AGA group compared to controls (all P < 0.05). Subgroup analyses revealed that average counts of total hair follicles, terminal hair follicles and T:V ratios were also significantly lower in males with Hamilton-Norwood VI and VII than in controls (all P < 0.05). There were no correlations between increasing age and hair count parameters, but a significant negative association was found between total follicle numbers and disease duration (r = -0.23, P = 0.02). Conclusions: AGA can involve the occipital area of male patients with advanced disease. Therefore, the occiput of particular cases should not be used to determine reference data for normal scalp hair, and preoperative measurements of miniaturized hairs in the donor site are strongly recommended in all persons undergoing hair transplantation.

Prevalence and Risk Factors Associated with the Occurrence of Autoimmune Diseases in Patients with Alopecia Areata

BACKGROUND

Increased rates of autoimmune diseases (ADs) have been reported in association with alopecia areata (AA); however, the risk factors for coexisting ADs in AA patients have been poorly investigated.

OBJECTIVE

To evaluate the prevalence and factors associated with AD comorbidities in patients with AA.

METHODS

This case-control study included patients diagnosed with AA between January 2000 and March 2020. Individuals with AA, both with and without concomitant ADs, were statistically compared. Variables significantly associated with coexisting ADs were identified using univariate and multivariate logistic regression analyses. Multinomial logistic regression analysis was performed to identify the specific risk factors for each concomitant AD.

RESULTS

Among the 615 patients with AA, comorbid ADs were found in 76 (12.4%). Autoimmune thyroid disease (AITD) exhibited the highest frequency (n = 42, 6.8%), followed by vitiligo (n = 15, 2.4%), and systemic lupus erythematosus (SLE) (n = 12, 2.0%). Logistic regression analyses revealed that female sex (odds ratio [OR] = 2.45, 95% confidence interval [CI] = 1.24-4.82; P = 0.011), nail abnormalities (OR = 2.49, 95% CI = 1.14-5.46; P = 0.023), and atopic diseases (OR = 1.98, 95% CI = 1.09-2.43; P < 0.001) were significantly associated with coexisting ADs. Regarding each concomitant AD, nail abnormalities were an associated factor for AITD (OR = 4.65, 95% CI = 1.96-7.24; P = 0.01), whereas coexisting atopic diseases were demonstrated as a predictor of vitiligo (OR = 2.48, 95% CI = 1.43-4.58; P = 0.02). Female sex (OR = 1.61, 95% CI = 1.18-4.27; P = 0.04) and family history of AD (OR = 1.85, 95% CI = 1.26-4.19; P = 0.03) were predictors of SLE.

CONCLUSION

This study suggests that female AA patients with nail abnormalities and atopic diseases have increased rates of AD comorbidities. A thorough review of systems for associated factors can help physicians screen for concomitant ADs.

Alopecia Areata: An Autoimmune Disease of Multiple Players

Alopecia areata (AA) is an autoimmune disease of the hair follicles. It is characterized by a well-defined non-scarring alopecic patch or patches that may extend to the entire scalp or lead to total body hair loss. Due to its unpredictable clinical course, AA causes substantial psychological harm. Despite the high prevalence of this disease and extensive research, its exact pathomechanism is unclear, and current treatments have a high relapse rate that has deemed AA incurable. Over the past few decades, researchers have investigated multiple potential factors that may help alleviate its pathogenesis and provide effective treatment. Given its complex immunopathogenesis, AA is considered an autoimmune disease with multiple factors. This review gathers current evidence that emphasizes molecular mechanisms, possible causative etiologies, and targeted immunotherapies for AA. Understanding its underlying mechanisms may shed light on new strategies to effectively manage AA in the future.

Flame Hair: Auxiliary Trichoscopic Finding in Radiotherapy-Induced Alopecia

Radiotherapy-induced alopecia is characterized by an anagen effluvium (AE). It may be temporary or permanent, depending on the radiation dose. The diagnosis is based on clinical history and dermatologic exam with trichoscopy being auxiliary the presence of flame hair. We describe a case of an AE induced by radiotherapy, emphasizing the trichoscopic findings.

Application of Topical Immunotherapy in the Treatment of Alopecia Areata: A Review and Update

Treatment of extensive or recalcitrant alopecia areata (AA) is a major clinical challenge. Even after thorough investigation of several medications, its treatment outcomes have remained unsatisfactory. While there is no US Food and Drug Administration-approved medication for AA yet, topical immunotherapy has been a well-documented treatment option. Dinitrochlorobenzene, squaric acid dibutylester, and diphenylcyclopropenone are three substances that have demonstrated efficacy in the treatment of extensive or recalcitrant AA. Despite being commonly used, the mechanism underlying topical immunotherapy is not well-elucidated and a wide range of clinical efficacies have been reported in the literature. The aim of this review was to summarize and update the pharmacology, mechanism of action, therapeutic efficacy, and tolerability of topical immunotherapy in the treatment of AA.

Assessment and Treatment Outcomes of Persistent Radiation-Induced Alopecia in Patients With Cancer

Importance

Persistent radiation-induced alopecia (pRIA) and its management have not been systematically described.

Objective

To characterize pRIA in patients with primary central nervous system (CNS) tumors or head and neck sarcoma.

Design, Setting, and Participants

A retrospective cohort study of patients from January 1, 2011, to January 30, 2019, was conducted at 2 large tertiary care hospitals and comprehensive cancer centers. Seventy-one children and adults diagnosed with primary CNS tumors or head and neck sarcomas were evaluated for pRIA.

Main Outcomes and Measures

The clinical and trichoscopic features, scalp radiation dose-response relationship, and response to topical minoxidil were assessed using standardized clinical photographs of the scalp, trichoscopic images, and radiotherapy treatment plans.

Results

Of the 71 patients included (median [range] age, 27 [4-75] years; 51 female [72%]), 64 (90%) had a CNS tumor and 7 (10%) had head and neck sarcoma. Alopecia severity was grade 1 in 40 of 70 patients (56%), with localized (29 of 54 [54%]), diffuse (13 of 54 [24%]), or mixed (12 of 54 [22%]) patterns. The median (range) estimated scalp radiation dose was 39.6 (15.1-50.0) Gy; higher dose (odds ratio [OR], 1.15; 95% CI, 1.04-1.28) and proton irradiation (OR, 5.7; 95% CI, 1.05-30.8) were associated with greater alopecia severity (P < .001), and the dose at which 50% of patients were estimated to have severe (grade 2) alopecia was 36.1 Gy (95% CI, 33.7-39.6 Gy). Predominant trichoscopic features included white patches (16 of 28 [57%]); in 15 patients, hair-shaft caliber negatively correlated with scalp dose (correlation coefficient, -0.624; P = .01). The association between hair density and scalp radiation dose was not statistically significant (-0.381; P = .16). Twenty-eight of 34 patients (82%) responded to topical minoxidil, 5% (median follow-up, 61 [interquartile range, 21-105] weeks); 4 of 25 (16%) topical minoxidil recipients with clinical images improved in severity grade. Two patients responded to hair transplantation and 1 patient responded to plastic surgical reconstruction.

Conclusions and Relevance

Persistent radiation-induced alopecia among patients with primary CNS tumors or head and neck sarcomas represents a dose-dependent phenomenon that has distinctive clinical and trichoscopic features. The findings of this study suggest that topical minoxidil and procedural interventions may have benefit in the treatment of pRIA.

Paraneoplastic syndromes in cholangiocarcinoma

Paraneoplastic syndromes are the symptoms or signs which result from damage to tissues that are distant from the site of malignancy, due to complex interactions between the body’s immune system and malignant neoplasm. Cholangiocarcinoma (CCA) is an aggressive epithelial malignancy of hepatobiliary tree and it is found to be associated with various paraneoplastic syndromes. These syndromes can present as dermatological, neurological, renal, hematological, or multi-systemic manifestations. Clinical suspicion and timely recognition of these syndromes can lead to early diagnosis of covert malignancies like CCA. The management plan remains the removal of the underlying cause which in this case is CCA.

Minoxidil and its use in hair disorders: a review

Minoxidil was first introduced as an antihypertensive medication and the discovery of its common adverse event, hypertrichosis, led to the development of a topical formulation for promoting hair growth. To date, topical minoxidil is the mainstay treatment for androgenetic alopecia and is used as an off-label treatment for other hair loss conditions. Despite its widespread application, the exact mechanism of action of minoxidil is still not fully understood. In this article, we aim to review and update current information on the pharmacology, mechanism of action, clinical efficacy, and adverse events of topical minoxidil.