Hair loss as a result of cutaneous autoimmunity: Frontiers in the immunopathogenesis of primary cicatricial alopecia

Destruction of the stem cell Niche, Pathogenesis and Promising Treatment Targets for Primary Scarring Alopecias

The Primary Scarring Alopecias are characterised by the irreversible destruction and fibrosis of hair follicles, leading to permanent and often disfiguring loss of hair. The pathophysiology of these diseases is not well understood. However, follicular-fibrosis and loss of the stem-cell niche appears to be a common theme. This review explores the pathogenesis of primary scarring alopecias, asking what happens to the stem cells of the hair follicle and how they may contribute to the progression of these diseases. Bulge-resident cells are lost (leading to loss of capacity for hair growth) from the follicle either by inflammatory-mediate apoptosis or through epigenetic reprogramming to assume a mesenchymal-like identity. What proportion of bulge cells is lost to which process is unknown and probably differs depending on the individual PCA and its specific inflammatory cell infiltrate. The formation of fibroblast-like cells from follicular stem cells may also mean that the cells of the bulge have a direct role in the pathogenesis. The identification of specific cells involved in the pathogenesis of these diseases could provide unique diagnostic and therapeutic opportunities to prevent disease progression by preventing EMT and specific pro-fibrotic signals.

Alopecias in lupus erythematosus

Several patterns of hair loss can occur in lupus erythematosus (LE). Alopecias which show histological characteristics of LE are LE-specific, and include discoid LE (DLE), diffuse or patchy hair loss in acute LE, subacute cutaneous LE, and rarely tumid LE. Lupus hair in SLE is a poorly characterised entity and may be a form of telogen effluvium. Alopecia areata can coexist with LE and may mimic DLE. Non-lupus alopecias such as telogen effluvium and anagen effluvium have a myriad of causes which include disease flares, drugs and stress in the setting of LE. The latest validated Systemic Lupus International Collaborating Clinics classification criteria for SLE includes non-scarring alopecia as a criterion; therefore, recognising the aetiology of hair loss in the setting of LE is crucial in classifying a patient to have systemic disease.

Effect of sinapic acid on hair growth promoting in human hair follicle dermal papilla cells via Akt activation

Hair loss known as alopecia is caused by abnormal hair follicle cycling including shortening of the anagen (growth) phase and changing of hair follicle morphology with miniaturization. In accordance with the life extension, the quality of life is considered to be a most important thing. The yearning for healthy and beautiful hair and low self esteem due to hair loss had negative influence on the quality of life with psychosocial maladjustment. The objective of this research was to identify new compound that can be used as a drug to promote hair growth. We investigated whether the function of sinapic acid (SA) is able to promote hair growth in human hair follicle dermal papilla cells (hHFDPC). We showed that treatment of SA in hHFDPC could induce proliferation and the activation of Akt signaling in HFDPC. In addition, SA could stimulate the expressions of the several growth factors, insulin-like growth factor 1, and vascular endothelial growth factor for hair growth. We showed that SA led to an increased level of phospho-GSK-3β and β-catenin accumulation in HFDPC. Finally, the promoting effect of SA in hHFDPC cell growth occurred by the induction of cell cycle progression. These results suggest that SA could be one of the potential candidate compounds for the treatment of alopecia by inducing hair growth through triggering the expressions of growth factors via activation of Akt and subsequent inactivation of GSK-3β /β-catenin pathway.

Regeneration of hair and other skin appendages: A microenvironment-centric view

Advances in skin regeneration have resulted in techniques and products that have allowed regeneration of both the dermis and epidermis. Yet complete skin regeneration requires the adnexal skin structures. Thus it is crucial to understand the regenerative potential of hair follicles where genetic, nutritional, and hormonal influences have important effects and are critical for skin regeneration. The follicular stem cell niche serves as an anatomical compartment, a structural unit, a functional integrator, and a dynamic regulator necessary to sustain internal homeostasis and respond to outside stimuli. In particular, mechanics such as pressure, compression, friction, traction, stretch, shear, and mechanical wounding can influence hair loss or growth. Relevant niche signaling pathways such as Wnt, bone morphogenetic protein, fibroblast growth factor, Shh, and Notch may yield potential targets for therapeutic interventions.

Cicatricial alopecia: What’s new in etiology?

Cicatricial alopecia is a rare, clinically diversified set of disorders causing permanent and irreversible hair loss, which often results in serious discomfort and patient’s mental problems.

Clinically, this form of irreversible hair loss is characterized by visible loss of hair follicle openings in the bald spots. Histologically, it consists in destroying a hair follicle and replacing it with fibrocartilage. Such disorders are perceived as primary if a hair follicle itself is the target of the disease process and secondary if hair follicles are damaged incidentally in the context of more general tissue damage (e.g. deep skin infections, thermal burns, trauma or ionizing radiation).

In this article we tried to summarize the knowledge on possible pathogenic mechanisms of cicatricial alopecia. The presented factors usually overlap and affect prognosis of particular patients. Their profound understanding may enable further research on the treatment methods of this challenging disease unit.

Retinoid metabolism is altered in human and mouse cicatricial alopecia

C57BL/6 mice develop dermatitis and scarring alopecia resembling human cicatricial alopecias (CA), particularly the central centrifugal cicatricial alopecia (CCCA) type. To evaluate the role of retinoids in CA, expression of retinoid metabolism components were examined in these mice with mild, moderate, or severe CA compared to hair cycle matched mice with no disease. Two feeding studies were performed with dams fed either NIH 31 diet (study 1) or AIN93G diet (study 2). Adult mice were fed AIN93M diet with 4 (recommended), 28, or 56 IU vitamin A/g diet. Feeding the AIN93M diet to adults increased CA frequency over NIH 31 fed mice. Increased follicular dystrophy was seen in study 1 and increased dermal scars in study 2 in mice fed the 28 IU diet. These results indicate that retinoid metabolism is altered in CA in C57BL/6J mice that require precise levels of dietary vitamin A. Human patients with CCCA, pseudopelade (end stage scarring), and controls with no alopecia were also studied. Many retinoid metabolism proteins were increased in mild CCCA, but were undetectable in pseudopelade. Studies to determine if these dietary alterations in retinoid metabolism seen in C57BL/6J mice are also involved in different types of human CA are needed.

Damage of hair follicle stem cells and alteration of keratin expression in external radiation-induced acute alopecia

Alopecia is known as a symptom of acute radiation, yet little is known concerning the mechanism of this phenomenon and the alteration of hair protein profiles. To examine this, 6-week-old male C57/BL6 mice were exposed to 6 Gy of X-ray irradiation, which caused acute alopecia. Their hair and skin were collected, and hair proteins were analyzed with liquid chromatography/electrospray-ionization mass spectrometry and immunohistochemistry. No change was observed in the composition of major hair keratins, such as Krt81, Krt83 and Krt86. However, cytokeratin Krt15 and CD34, which are known as hair follicle stem cell markers, were decreased in alopecic mice. Cytokeratin Krt5, which is known as a marker for basal and undifferentiated keratinocytes, was increased in the epidermis of alopecic mice. These findings suggest that radiation damages hair stem cells and the differentiation of keratinocytes in the epidermis. For the evaluation of radiation exposure, chromosomal aberration is considered to be the gold standard, yet our results suggest that Krt5 may be a novel biological marker for acute radiation symptoms.

Endogenous retinoids in the hair follicle and sebaceous gland

Vitamin A and its derivatives (retinoids) are critically important in the development and maintenance of multiple epithelial tissues, including skin, hair, and sebaceous glands, as shown by the detrimental effects of either vitamin A deficiency or toxicity. Thus, precise levels of retinoic acid (RA, active metabolite) are needed. These precise levels of RA are achieved by regulating several steps in the conversion of dietary vitamin A (retinol) to RA and RA catabolism. This review discusses the localization of RA synthesis to specific sites within the hair follicle and sebaceous gland, including their stem cells, during both homeostasis and disease states. It also discusses what is known about the specific roles of RA within the hair follicle and sebaceous gland. This article is part of a Special Issue entitled: Retinoid and Lipid Metabolism.

Gsdma3 mutation causes bulge stem cell depletion and alopecia mediated by skin inflammation

Primary cicatricial alopecias (PCAs) are a group of permanent hair loss disorders, of which the pathogenesis is still poorly understood. The alopecia and excoriation (AE) mouse strain is a dominant mutant generated from ethyl nitrosourea mutagenesis. AE mice exhibit a progressive alopecia phenotype similar to that seen in PCAs, resulting from a point mutation in the gasdermin A3 gene. Mutant mice begin to show alopecia on the head from postnatal day 22 and experience complete hair loss by the age of 6 months, along with hyperkeratosis and catagen delay. The results of a histological examination showed that bulge stem cells in AE skin are gradually depleted, as indicated by decreased keratin 15 and CD34 expression, and reduced bromodeoxyuridine label-retaining cells in the AE bulge. In addition, AE mice display an inflammatory condition in the skin from postnatal day 7, including elevated tumor necrosis factor-α and monocyte chemotactic protein-1 mRNA levels and significantly increased macrophages and dendritic cell number. Immune privilege in the bulge was also compromised in AE skin. Consistently, after treatment with the immunosuppressive agent, cyclosporine A, immune privilege collapse, stem cell destruction, and alopecia phenotype of AE mice were all rescued. Collectively, our data demonstrate that immune-mediated destruction of bulge stem cells plays a crucial role in the pathogenesis of alopecia in AE mice, and this strain might be an interesting model for PCAs, especially for lichen planopilaris.

Primary cicatricial alopecia: recent advances in understanding and management

Primary cicatricial alopecias (PCA) are a rare group of disorders, in which the hair follicle is the main target of destructive inflammation resulting in irreversible hair loss with scarring of affected lesions. The most typical clinical manifestation of PCA is the loss of visible follicular ostia. The histopathological hallmark of a fully developed lesion is the replacement of the hair follicle structure by fibrous tissue. PCA could share similar clinical manifestations and eventually lead to "burn-out" alopecia. Some subsets are hardly distinguishable histopathologically and the mechanisms that elicit such a destructive reaction have not been fully elucidated. Thus, the management of PCA represents one of the most challenging clinical problems for dermatologists. The aim of this review is to provide a concise and comprehensive summary of recent advances in PCA management, especially focusing on novel methodologies to aid diagnosis, and updates on our understanding of the etiopathogenesis. Dermoscopy, a new pathological preparation technique and direct immunofluorescence analysis enable more accurate clinicopathological diagnosis of PCA. Microarray analysis may be beneficial to distinguish PCA subtypes. Currently suggested mechanisms underlying PCA include loss of immune protection of stem cells, impaired stem cell self-maintenance, enhanced autoimmunity by pro-inflammatory cytokines and environmental/genetic predispositions. Interestingly, recent data indicates the association between lipid metabolism dysregulation and PCA development, implying an important role of the sebaceous gland dysfunction in the etiopathogenesis. Based on that hypothesis and observations, novel therapeutic approaches have been proposed, including the use of peroxisome proliferator-activated receptor-γ agonist for lichen planopilaris.

The pathogenesis of primary cicatricial alopecias

Cicatricial (scarring) alopecia results from irreversible damage to epithelial stem cells located in the bulge region of the hair follicle, generally as a result of inflammatory mechanisms (eg, in the context of autoimmune disease). In primary cicactricial alopecia (PCA), the hair follicle itself is the key target of autoaggressive immunity. This group of permanent hair loss disorders can be classified into distinct subgroups, characterized by the predominant peri-follicular inflammatory cell type. In none of these PCA forms do we know exactly why hair follicles begin to attract such an infiltrate. Thus, it is not surprising that halting or even reversing this inflammation in PCA is often extremely difficult. However, increasing evidence suggests that healthy hair follicle epithelial stem cells enjoy relative protection from inflammatory assault by being located in an immunologically "privileged" niche. Because this protection may collapse in PCA, one key challenge in PCA research is to identify the specific signaling pathways that endanger, or restore, the relative immunoprotection of these stem cells. After a summary of pathobiological principles that underlie the development and clinical phenotype of PCA, we close by defining key open questions that need to be answered if more effective treatment modalities for this therapeutically very frustrating, but biologically fascinating, group of diseases are to be developed.

[Pathogenesis of cutaneous lupus erythematosus from LE-prone mice]

Mouse models are similar but not identical to human diseases. However, they are important for research into the pathogenesis underlying autoimmune diseases because they allow us to evaluate similarities and differences between human diseases and mouse models. There are many inbred strains of systemic lupus erythematosus (SLE)-prone mice including New Zealand Black (NZB), F1 hybrids of NZB x New Zealand White (NZW) (B/W F1), MRL/Mp-lpr/lpr (MRL/lpr), and BXSB mice. The postulated etiology of these murine diseases includes many genetic and extrinsic factors such as retroviruses, an impaired balance of T cell interaction, ultraviolet irradiation, etc. For examples, genetic studies of MRL/lpr mice revealed that the appearance of macroscopic LE-like skin lesions needs the lpr mutation plus an additional factor in an autosomal dominant fashion. The candidate is ultraviolet (UV) B light, the susceptibility to which is regulated by the genetic background. Such abnormalities described in SLE now span the spectrum from innate immunity to acquired immunity. In this review, based on historical review, we focus on skin lesions from the well-studied MRL/lpr and B/W F1 mouse and discuss how SLE-prone mice can contribute to a better understanding of cutaneous LE pathogenesis.

Endocrine controls of primary adult human stem cell biology: thyroid hormones stimulate keratin 15 expression, apoptosis, and differentiation in human hair follicle epithelial stem cells in situ and in vitro

Here we demonstrate that physiological concentrations of the thyroid hormones T3 and T4 enhance the KERATIN 15 promoter activity and expression in epithelial stem cells of adult human scalp hair follicles in situ and in vitro. Additionally, T3 and T4 stimulate expression of the immuno-inhibitory surface molecule CD200. Subsequently, T3 and T4 induce apoptosis and differentiation and inhibit clonal growth of these progenitor cells in vitro. These data suggest that human hair follicle bulge-derived epithelial stem cells underlie profound, previously unknown hormonal regulation by thyroid hormones, and show that primary human keratin 15-GFP+ progenitor cells can be exploited to further elucidate fundamental endocrine controls of human epithelial stem cells.