Drug Reactions Affecting Hair: Diagnosis

Changing human hair fibre colour and shape from the follicle

INTRODUCTION

Natural hair curvature and colour are genetically determined human traits, that we intentionally change by applying thermal and chemical treatments to the fibre. Presently, those cosmetic methodologies act externally and their recurrent use is quite detrimental to hair fibre quality and even to our health.

OBJECTIVES

This work represents a disruptive concept to modify natural hair colour and curvature. We aim to model the fibre phenotype as it is actively produced in the follicle through the topical delivery of specific bioactive molecules to the scalp.

METHODS

Transcriptome differences between curly and straight hairs were identified by microarray. In scalp samples, the most variable transcripts were mapped by in situ hybridization. Then, by using appropriate cellular models, we screened a chemical library of 1200 generic drugs, searching for molecules that could lead to changes in either fibre colour or curvature. A pilot-scale, single-centre, investigator-initiated, prospective, blind, bilateral (split-scalp) placebo-controlled clinical study with the intervention of cosmetics was conducted to obtain a proof of concept (RNEC n.92938).

RESULTS

We found 85 genes transcribed significantly different between curly and straight hair, not previously associated with this human trait. Next, we mapped some of the most variable genes to the inner root sheath of follicles, reinforcing the role of this cell layer in fibre shape moulding. From the drug library screening, we selected 3 and 4 hits as modulators of melanin synthesis and gene transcription, respectively, to be further tested in 33 volunteers. The intentional specific hair change occurred: 8 of 14 volunteers exhibited colour changes, and 16 of 19 volunteers presented curvature modifications, by the end of the study.

CONCLUSION

The promising results obtained are the first step towards future cosmetics, complementary or alternative to current methodologies, taking hair styling to a new level: changing hair from the inside out.

Cyclosporine-induced alopecia:a case report, FDA adverse event reporting system analysis and literature assessment

Cyclosporine is a potent immunosuppressive drug for various immune-mediated diseases in children. Cyclosporine's expected therapeutic effect also carries a wide range of side effects. One of the most common and intriguing dermatological side effects is hypertrichosis. However, recent reports have recognized alopecia as a potential adverse effect of cyclosporine. Here, we report a case of a 29-month-old boy diagnosed with aplastic anemia. During cyclosporine therapy, the patient presented with hair loss on the scalp, which and subsequently spread to the eyebrows and eyelashes. The alopecic symptoms were not relieved following topical minoxidil liniment interventions. When the cyclosporine was discontinued, a remarkable improvement was observed in the scalp, with complete hair regrowth. Data concerning cyclosporine from the FDA Adverse Event Reporting System (FAERS) database were extracted from January 2004 to January 2023. Within FAERS, our post-marketing pharmacovigilance analysis detected the reporting association of cyclosporine and alopecia. In monotherapy, cyclosporine-induced alopecia was observed in 118 cases, and tacrolimus-induced alopecia signals were detected in 197 cases. Although the potential mechanism of medication-induced hair loss is unclear, we identified a potential correlation between alopecia and cyclosporine, and it is still necessary to adequately recognize and clinically monitor this paradoxical reaction.

Telogen effluvium: a 360 degree review

Telogen effluvium (TE) is one of the most common presentations of diffuse non-cicatricial alopecia and is generally self-limited. Multiple causes are associated with TE onset and its maintenance, with stress being felt the most common factor. The multifactorial etiologies involved in TE makes it a complex disorder to diagnose and treat often placing this entity into a "waste basket" diagnosis. By critically assessing the available scientific literature we aimed to review the multifaceted aspects of TE. Our objectives were to review the pathogenesis with the role of stress (including Coronavirus 19-associated TE), as well as to describe the main clinical findings, its differential diagnosis and the current knowledge on TE treatments along with the future treatment's insights.

Stress-Related Hair Loss Among the General Population in Al Majma'ah, Saudi Arabia: A Cross-Sectional Study

Background Hair loss is a prevalent concern affecting individuals worldwide, often attributed to various factors including genetics, hormonal changes, and stress. This study aims to investigate the prevalence of stress-related hair loss among the general population in Al Majma'ah, Saudi Arabia, and hair loss association with sociodemographic characteristics and risk factors. Methods A cross-sectional study was conducted involving 1080 participants. Data were collected through a structured questionnaire that encompassed sociodemographic factors, stress levels, psychosocial factors, and habits related to hair care and lifestyle. The data were analyzed using descriptive statistics, chi-square tests, and logistic regression analysis. Results The study revealed that 770 (71.3%) of participants reported experiencing hair loss, with females showing a higher prevalence compared to males 622 vs. 148 (78.2% vs. 51.9%). A significant relationship between age and hair loss was observed (Chi-x2 = 8.264, p-value = 0.016), with individuals aged 31 to 40 years experiencing hair loss more frequently 108 (80.6%). Stress was found to be a significant contributing factor to hair loss (χ^2 = 37.533, p < 0.001), with 674 (73.8%) of participants reporting stress. Moreover, stress levels exhibited a dose-response relationship with the severity of hair loss. Psychosocial factors, including personal relationship problems and financial difficulties, also demonstrated significant associations with hair loss (p-value = 0.005, 0.003, respectively). Conclusion The study underscores the considerable prevalence of stress-related hair loss among the general population in Al Majma'ah, Saudi Arabia. Stress, along with various sociodemographic and psychosocial factors, emerged as significant contributors to hair loss. These findings emphasize the need for holistic approaches that address both physiological and psychological aspects to mitigate the burden of hair loss in the community. Further research is warranted to explore the underlying mechanisms and develop targeted interventions for individuals at risk of stress-induced hair loss.

Medication-induced hair loss: An update

This article discusses drug-induced hair loss, which can occur with many drugs including cytotoxic agents, biologics, and immunomodulating agents, among others. It outlines the diagnosis and management of drug-induced alopecia, with a focus on recently implicated drugs.

Commonly prescribed medications associated with alopecia

BACKGROUND

The diagnosis and treatment of medication-associated alopecia often challenges patients and physicians. While numerous studies on the topic exist, limited information on the strength and magnitude of these studies exists.

OBJECTIVES

We investigated the most commonly prescribed medications with high levels of evidence to support associations with alopecia.

METHODS

A list of most commonly prescribed medications was compiled using the "Top 100 Prescriptions, Sales" (Intercontinental Marketing Services) and "Top 200 Names Searched" (RxList.com). PubMed, Embase, and Web of Science were searched for "generic drug name" AND "alopecia" and "generic drug name" AND "hair loss." Two reviewers independently reviewed articles for drug, study type and level of evidence, and number of alopecia cases.

RESULTS

A total of 192 unique drugs were investigated, with 110 yielding positive search results. Of these, 13 were associated with alopecia in studies with strong levels of evidence (adalimumab, infliximab, budesonide, interferon β-1α, tacrolimus, enoxaparin, zoster vaccine, lamotrigine, docetaxel, capecitabine, erlotinib, imatinib, and bortezomib).

LIMITATIONS

Only full-length articles available in the English language were included. The methodology used relied on lists of drugs based on their sales rather than number of prescriptions, which likely overrepresented expensive drugs.

CONCLUSIONS

Few studies with high levels of evidence have been conducted on the topic of medication-associated alopecia. The mechanisms of hair loss must be further identified to provide effective management.

Regulation of epidermal proliferation and hair follicle cycling by synthetic photostable retinoid EC23

BACKGROUND

Retinoid signaling is an important regulator of the epidermis and skin appendages. Therefore, synthetic retinoids have been developed for therapeutic use for skin disorders such as psoriasis and acne.

AIMS

In previous studies, we showed how the photostable retinoid EC23 induces neuronal differentiation in stem cell-like cell populations, and here, we aim to investigate its ability to influence epidermal and hair follicle growth.

METHODS

EC23 influence on skin biology was investigated initially in cultures of monolayer keratinocytes and three-dimentional in vitro models of skin, and finally in in vivo studies of mice back skin.

RESULTS

EC23 induces keratinocyte hyperproliferation in vitro and in vivo, and when applied to mouse skin increases the number of involucrin-positive suprabasal cell layers. These phenotypic changes are similar in skin treated with the natural retinoid all-trans retinoic acid (ATRA); however, EC23 is more potent; a tenfold lower dose of EC23 is sufficient to induce epidermal thickening, and resulting hyperproliferation is sustained for a longer time period after first dose. EC23 treatment resulted in a disorganized stratum corneum, reduced cell surface lipids and compromised barrier, similar to ATRA treatment. However, EC23 induces a rapid telogen to anagen transition and hair re-growth in 6-week-old mice with synchronously resting back skin follicles. The impact of EC23 on the hair cycle was surprising as similar results have not been seen with ATRA.

CONCLUSIONS

These data suggest that synthetic retinoid EC23 is a useful tool in exploring the turnover and differentiation of cells and has a potent effect on skin physiology.

Hair Aging and Hair Disorders in Elderly Patients

Hair loss in elderly patients is a common complaint. It can be related to different conditions that affect patients' quality of life and represents a challenge for dermatologists. It affects both men and women during the aging process with an estimated percentage of balding after 65 years of age of 53% and 37%, respectively. Androgenetic alopecia, frontal fibrosing alopecia, senile alopecia, and erosive pustular dermatosis of the scalp are the hair diseases most frequently described in this age group. The objective of this review is to summarize the current knowledge about alopecia affecting elderly patients, differentiating between chronological hair aging signs and pathological changes, to help clinicians, offer an adequate management of these disorders to their patients.

Comparing the frequency of isotretinoin-induced hair loss at <0.5-mg/kg/d versus ≥0.5-mg/kg/d dosing in acne patients: A systematic review

Over 1 million isotretinoin prescriptions are authorized in the United States per year. An insight into the frequency, dose dependency, timing, and reversibility of hair loss associated with isotretinoin treatment for acne vulgaris could help guide dosing regimens and patient counseling. The objective of this systematic review was to assess the frequency of hair loss in patients with acne vulgaris on <0.5 mg/kg/d daily doses of isotretinoin versus the frequency of hair loss in patients with acne vulgaris on ≥0.5 mg/kg/d daily doses of isotretinoin.

An Embase and MEDLINE search was conducted on July 15, 2020, in accordance with the Preferred Reporting Items for Systematic Reviews and Meta-Analyses guidelines. The review focused on acne vulgaris patients. The treatment of acne vulgaris is the most common use of isotretinoin, and the population is typically younger and with fewer comorbidities.

Twenty-two studies reported hair loss with oral isotretinoin treatment. A frequency analysis suggested that patients with acne vulgaris on <0.5 mg/kg/d of isotretinoin experienced hair loss at a frequency of 3.2% (n = 18/565) compared with those on ≥0.5 mg/kg/d, who experienced hair loss at a frequency of 5.7% (n = 192/3375). Inferential statistics were not possible.

Physicians should consider counseling patients about the risk of telogen effluvium prior to drug initiation, as is commonly done for other side effects. The potential trend of increased hair loss frequency at a higher daily dosing warrants further investigation using higher-quality research.

Post-SARS-CoV-2 Acute Telogen Effluvium: An Expected Complication

Post-SARS-CoV-2 telogen effluvium has been described in case reports of COVID-19 patients. We evaluated the prevalence of post-SARS-CoV-2 telogen effluvium in patients from a single medical center, exploring any causal links with the infection. Our hospital-based, cross-sectional study was conducted with patient participants discharged with a diagnosis of SARS-CoV-2 pneumonia from 1 March to 4 April 2020. All patients were evaluated by the same senior dermatologist; a clinical/dermatoscopic evaluation was performed. Alopecia was assessed in 31.3% of patients, with a significant difference in sex (females 73%, males 26.7%). The average time detected from the onset of the first symptoms to alopecia was 68.43 days. Overall, there were no significant associations between alopecia and COVID-19-related features (length of hospitalization, virologic positivity, or duration of fever), treatment characteristics, or laboratory findings. In this paper, we report that post-infection acute telogen effluvium occurs in a significant number of COVID-19 patients. The burden of this condition may impair the quality of life, with a significant impact on individuals.

Characteristics of patients with hair loss after isotretinoin treatment: A retrospective review study

Background:

Oral isotretinoin has been used to treat acne for decades. Although the side effects of isotretinoin are mostly predictable, one less common side effect of isotretinoin use is hair loss, typically telogen effluvium.

Objective:

This study is a retrospective report on the development of alopecia in patients on isotretinoin therapy.

Methods:

To characterize these patients, they were further compared to other patients in the same time period who were prescribed isotretinoin and did not experience hair loss.

Results:

Of 6330 patients with hair loss, 48 had been prescribed isotretinoin at some time between 2013 and 2018. Of these 48 patients, hair loss occurred concurrently or within two years after taking isotretinoin in 19 patients. When compared to controls, patients who experienced hair loss from isotretinoin were older, had greater cumulative isotretinoin doses, and had longer durations of treatment.

Conclusion:

Although the exact mechanism of how retinoids affect hair loss is still unclear, our findings suggest dosage or duration of usage may be associated. This information may be useful in counseling patients who may be concerned about hair loss when considering isotretinoin treatment.

Characteristics of telogen effluvium in COVID-19 in western Iran (2020)

BACKGROUND

Although COVID-19 pandemic significantly induces mortality, many of the patients who recovered present other medical problems such as alopecias. Telogen effluvium is a common alopecia that is usually related to previous events such as acute febrile diseases, including COVID-19.

OBJECTIVE

To evaluate the characteristics of telogen effluvium in COVID-19.

METHOD

This cross-sectional study was carried out on 526 patients with documented telogen effluvium that recovered from COVID-19. Demographic data, concurrent alopecia, associated diseases, and COVID-19 severity were recorded. Data were analyzed by appropriate statistical methods.

RESULTS

The mean age of the 526 patients (410 females, 116 males) was 30.97 ± 9.592 years, with 7.65 ± 1.739 weeks of mean time of alopecia onset. Vitamin D deficiency (24.3%), androgenetic alopecia (78.2%), and grade III COVID-19 severity were the most common findings. Alopecia onset was significantly earlier in the younger age group, females, in hypothyroidism, and more severe coronavirus infection. Higher grade coronavirus infection was significantly seen in males, higher ages, earlier onset, and androgenic alopecia.

STUDY LIMITATIONS

Performing a single-center study and considering limited variables.

CONCLUSION

Although Coronavirus 2 infection can be an important factor in telogen effluvium induction, other factors such as associated diseases, drug intake and emotional stress may also be involved. In the cases of early onset of alopecia, concomitant diseases such as hypothyroidism and severe coronavirus infection can occur, thus, the presence of various factors in telogen effluvium induction should be considered.

Premature graying of hair: Risk factors, co-morbid conditions, pharmacotherapy and reversal-A systematic review and meta-analysis

Premature graying of hair (PGH) being a very common entity for which pharmacotherapy and reversibility are not properly addressed. Therefore, this systematic review was conducted to address these issues. For this relevant study were selected from various databases including PubMed, EMBASE, OVID, Web of science, Scopus, and Google Scholar till January 20, 2019. Studies which reported risk factors, co-morbid conditions associated with PGH, its pharmacotherapy and reversal were included in the study. Although many risk factors are reported in literature, smoking, vitamin deficiency (B12, folic acid, and B7), mineral deficiency (low serum calcium and serum ferritin) are found to be associated with PGH. Other important risk factors are family history of PGH, obesity, high B.P, lack of exercise, drugs, genetic syndromes, dyslipidemia, thyroid disorders, hyperuricemia, and alteration in liver function. PGH is found to be an important marker of CAD, more so in case of smoker. Among different pharmacotherapeutic management options, low grade recommendation (2A) is given to calcium pantothenate, PABA, calcium pantothenate + PABA combination. Anu-tailam is the only herbal agent evaluated in clinical research settings. Finally, treating the accompanying pathologies led to the reversal of the disease in many cases.

Telogen Effluvium: A Review of the Literature

Telogen effluvium is one of the most common causes of alopecia. It is a scalp disorder characterized by excessive shedding of hair. Several factors such as drugs, trauma, and emotional and physiological stress can lead to the development of telogen effluvium. Multiple alterations in the hair cycle have been proposed as the underlying mechanism. Telogen effluvium can present as acute or chronic hair fall with symptoms such as trichodynia. Diagnostic tests that can be used include hair wash test, trichogram, phototrichogram, and scalp biopsy. In the treatment of telogen effluvium, it is essential to identify and remove the causative factors and to use drugs such as corticosteroids, minoxidil, and novel treatments such as CNPDA (caffeine, niacinamide, panthenol, dimethicone, and an acrylate polymer). Herein, we discuss the presentation, diagnostic approaches, and effective treatment options available for telogen effluvium.

Alopecia in Association with Malignancy: A Review

The interaction between hair and malignancy is complicated. Various hair abnormalities can manifest in oncology patients as a clinical manifestation, the result of cancer therapy, or due to a paraneoplastic condition. The mechanisms of these changes remain unclear. Alopecia is one of the common clinical presentations occurring in oncology patients that affects their quality of life. The condition can concomitantly develop during the course of malignancy or when patients undergo cancer treatment. It is important for physicians to understand alopecia in association with malignancy as it may be an important associated finding or provide the clues to aid diagnosis. The aim of this review is to summarize the clinical characteristics of alopecia that occur in cancer patients and their relationship with the type of malignancy and its treatment.

Curling of Hair in Two Female Patients Taking Alitretinoin

Two female patients aged 45 and 51 years experienced curling of hair during treatment with alitretinoin (Toctino^®). For one patient, the indication for use was severe chronic hand eczema, but for the second patient the indication was not reported. After 5 and 9 months, respectively, the patients developed hair texture changes and their straight hair began to curl. The dose of alitretinoin was reduced in both cases, but the patients’ hair had not straightened at the time of reporting (9 months and 2 years after onset of the event). Based on the described reports received by the Netherlands Pharmacovigilance Centre Lareb, the case reports in the literature, and the possible mechanisms, we suggest a causal relationship between curling of the hair and the use of alitretinoin. Using the World Health Organization Uppsala Monitoring Centre (WHO-UMC) system for standardized case causality assessment, the association in our cases can be assessed as likely.

Alopecia due to high androgen index contraceptives

Adverse reactions to hormonal contraceptives are a common patient concern. Alopecia, an adverse reaction to androgen activity caused by the progestin component of hormonal contraceptives, can cause considerable psychosocial distress for women. This article discusses how to identify the level of androgen activity in certain progestins, how increased androgen activity can lead to hair loss, and alternatives for patients experiencing androgenic alopecia due to high androgen index contraceptives.

Dermatologic Manifestations of Colchicine Intoxication

Colchicine is an anti-inflammatory drug that has a narrow therapeutic index. Poisoning typically shows 3 phases with systemic symptoms. Gastrointestinal symptoms dominate in the first phase. Dermatologic manifestations usually appear, with skin eruptions in the second phase where multiorgan failure occurs and alopecia in the third phase where organ derangements resolve. Alopecia is a cardinal feature of the third phase, but there is no specifically defined eruption for toxication. Here, we report a case of colchicine intoxication in a 16-year-old girl with maculopapular/purpuric rash and alopecia.

Unusual and Interesting Adverse Cutaneous Drug Reactions

Any drug can cause any rash! Cutaneous adverse drug reactions (CADRs) are great mimickers and can be included in the differential diagnosis of any inflammatory dermatoses. Several drugs can cause rash of similar morphology and the same drug can cause rash of different morphology. While some common and specific drug reaction patterns are recognized easily by the clinicians, many a times unusual and interesting patterns can be induced by drug(s), thus leading to erroneous diagnosis and mistreatment. This review aims to familiarize clinicians with some rare, yet interesting patterns of CADR.

Autophagy is essential for maintaining the growth of a human (mini-)organ: Evidence from scalp hair follicle organ culture

Autophagy plays a crucial role in health and disease, regulating central cellular processes such as adaptive stress responses, differentiation, tissue development, and homeostasis. However, the role of autophagy in human physiology is poorly understood, highlighting a need for a model human organ system to assess the efficacy and safety of strategies to therapeutically modulate autophagy. As a complete, cyclically remodelled (mini-)organ, the organ culture of human scalp hair follicles (HFs), which, after massive growth (anagen), spontaneously enter into an apoptosis-driven organ involution (catagen) process, may provide such a model. Here, we reveal that in anagen, hair matrix keratinocytes (MKs) of organ-cultured HFs exhibit an active autophagic flux, as documented by evaluation of endogenous lipidated Light Chain 3B (LC3B) and sequestosome 1 (SQSTM1/p62) proteins and the ultrastructural visualization of autophagosomes at all stages of the autophagy process. This autophagic flux is altered during catagen, and genetic inhibition of autophagy promotes catagen development. Conversely, an anti-hair loss product markedly enhances intrafollicular autophagy, leading to anagen prolongation. Collectively, our data reveal a novel role of autophagy in human hair growth. Moreover, we show that organ-cultured scalp HFs are an excellent preclinical research model for exploring the role of autophagy in human tissue physiology and for evaluating the efficacy and tissue toxicity of candidate autophagy-modulatory agents in a living human (mini-)organ.

Large-scale detection of drug off-targets: hypotheses for drug repurposing and understanding side-effects

Background

Promiscuity in molecular interactions between small-molecules, including drugs, and proteins is widespread. Such unintended interactions can be exploited to suggest drug repurposing possibilities as well as to identify potential molecular mechanisms responsible for observed side-effects.

Methods

We perform a large-scale analysis to detect binding-site molecular interaction field similarities between the binding-sites of the primary target of 400 drugs against a dataset of 14082 cavities within 7895 different proteins representing a non-redundant dataset of all proteins with known structure. Statistically-significant cases with high levels of similarities represent potential cases where the drugs that bind the original target may in principle bind the suggested off-target. Such cases are further analysed with docking simulations to verify if indeed the drug could, in principle, bind the off-target. Diverse sources of data are integrated to associated potential cross-reactivity targets with side-effects.

Results

We observe that promiscuous binding-sites tend to display higher levels of hydrophobic and aromatic similarities. Focusing on the most statistically significant similarities (Z-score ≥ 3.0) and corroborating docking results (RMSD < 2.0 Å), we find 2923 cases involving 140 unique drugs and 1216 unique potential cross-reactivity protein targets. We highlight a few cases with a potential for drug repurposing (acetazolamide as a chorismate pyruvate lyase inhibitor, raloxifene as a bacterial quorum sensing inhibitor) as well as to explain the side-effects of zanamivir and captopril. A web-interface permits to explore the detected similarities for each of the 400 binding-sites of the primary drug targets and visualise them for the most statistically significant cases.

Conclusions

The detection of molecular interaction field similarities provide the opportunity to suggest drug repurposing opportunities as well as to identify potential molecular mechanisms responsible for side-effects. All methods utilized are freely available and can be readily applied to new query binding-sites. All data is freely available and represents an invaluable source to identify further candidates for repurposing and suggest potential mechanisms responsible for side-effects.

Electronic supplementary material

The online version of this article (doi:10.1186/s40360-017-0128-7) contains supplementary material, which is available to authorized users.

Systemic causes of hair loss

Hair loss is both a common chief complaint by patients and a clinical challenge for physicians, especially general practitioners, yet few dermatological problems yield as much patient satisfaction when resolved as hair loss. The diagnosis is often attributed to androgen-related hair loss, while other causes, some of which are life-threatening but treatable, are overlooked. We searched for relevant literature on hair loss and supported these findings with our clinical experience to identify seven major systemic etiologies of hair loss, ranging from infectious agents to consumption of unsafe supplements. Many causes are only described in the literature through case studies, though some original articles and meta-analyses are available. Careful history taking, proper examination techniques, and judicious use of laboratory tests are essential to reach at the correct diagnosis in a cost-effective manner when performing patient work-up. Such methodical evaluation of hair loss can result in the appropriate treatment plan and provide significant patient satisfaction. Key messages Hair loss is a common chief complaint and a difficult challenge for both general practitioners and dermatology consultants. We identified seven major categories of systemic hair loss etiology and present a framework for their clinical evaluation. A methodical approach to hair loss can result in the appropriate treatment plan and provide significant patient satisfaction.

5-Bromo-2'-deoxyuridine induced effluvium via p53-mediated CD326-positive keratinocyte apoptosis in C57BL/6 mice

Anagen effluvium develops because of disturbances in the hair follicle cycle, leading to acute and severe hair loss in humans. The objective of this study was to establish a mouse model of anagen effluvium by 5-bromo-2'-deoxyuridine (BrdU) treatment, and evaluate the pathological changes and underlying mechanisms. We treated 9-10-day-old pups and 3-7-week-old C57BL/6 mice with BrdU. After successfully inducing hair loss in the neonatal pups, microscopic, immunohistochemical and flow cytometry analyses were conducted. BrdU induced early onset alopecia in neonates and caused epidermal thickening and hair shaft breakage. BrdU appeared to incorporate the CD326-positive keratinocyte layer and induced p53-related apoptosis. Keratinocyte apoptosis caused immune cell infiltration in the dermal region; M2 macrophages and neutrophils were dominant. The BrdU-induced hair loss was dose-dependent, and alopecia was visible at a dose range of 25-200 μg/g bodyweight. The BrdU-induced anagen effluvium mouse model is novel and easily established by administrating four simple BrdU injections to pups; these mice showed synchronized onset of alopecia symptoms with little individual variation. Moreover, this model showed an alopecia phenotype similar to that of human anagen effluvium with acute, severe and widespread hair loss.

Evidence-based approach to cutaneous hyperandrogenism in women

Hirsutism, acne, and androgenetic alopecia are classically considered signs of cutaneous hyperandrogenism (CHA). These common skin findings have significant impacts on the quality of patients' lives and pose the diagnostic challenge of excluding underlying disorders. Many with CHA have normal serum androgen levels. Hirsutism is more strongly associated with hyperandrogenism than are acne or androgenetic alopecia. Variable association of CHA with hyperandrogenemia results from the complexity of the underlying pathophysiology, including factors local to the pilosebaceous unit. CHA often occurs in the setting of polycystic ovary syndrome, the most common disorder of hyperandrogenism, but can also present in uncommon conditions, including nonclassic adrenal hyperplasia and androgen-producing tumors. A thorough history and full skin examination are important to guide appropriate diagnostic evaluation. Oral contraceptive pills with or without antiandrogens can provide therapeutic benefit for hirsutism and acne. Medical options for androgenetic alopecia remain limited. Multidisciplinary approaches may be needed given endocrine, metabolic, reproductive, and psychiatric disorders associated with CHA. More high-quality studies into the mechanisms of CHA and the benefits of antiandrogenic therapies are needed. We provide an evidence-based review of key diagnostic and therapeutic considerations in the treatment of women with CHA.

Recovery of Transplanted Eyebrow From Radiation-Induced Anagen Effluvium

Ablative surgery for skin cancer of the face can often leave patients with significant deformities. These disfigurements can include loss of hair in conspicuous areas such as the eyebrows, leaving the patients with unsightly facial asymmetry. Eyebrow transplantation serves to address this issue; however, it has often been discouraged in patients who are destined to receive radiotherapy to the cutaneous area in question. This is due to the anagen effluvium effect of radiation therapy on hair follicles. We present a case in which the transplanted eyebrow hair follicles survived the deleterious effects of radiotherapy, leaving the patient with a symmetrical and aesthetically satisfactory eyebrow appearance.

Body image dissatisfaction in patients with inflammatory bowel disease

BACKGROUND

Despite the fact that the inflammatory bowel diseases (IBD) and their treatments may affect physical appearance, the effect of IBD on body image is poorly understood. The aims of this study were to determine whether body image dissatisfaction (BID) changes over time in patients with IBD and to examine the demographic and disease-related variables associated with decreased body image.

METHODS

Adults aged 18 and above in the Ocean State Crohn's and Colitis Area Registry with at least 2 years of follow-up were eligible for this study. All patients were enrolled within 6 months of IBD diagnosis and followed prospectively. BID was assessed using a modified version of the Adapted Satisfaction With Appearance questionnaire. Total Adapted Satisfaction With Appearance scores and 2 subscores were calculated. To assess for changes over time, general linear models for correlated data were used for continuous outcomes, and generalized estimating equations were used for discrete outcomes.

RESULTS

Two hundred seventy-four patients were studied. BID was found to be stable over time among men and women with IBD despite overall improvements in disease activity. No differences were found in BID according to IBD subtype. Female gender, greater disease activity, higher symptom burden, longer duration of steroid use, dermatologic and musculoskeletal manifestations of IBD, and ileocolonic disease location among patients with Crohn's disease were associated with greater BID. Greater BID was associated with lower health-related quality of life.

CONCLUSIONS

BID remains stable in an incident cohort of IBD despite improved disease activity and is associated with lower health-related quality of life.

[Development of curly hair under systemic therapy with alitretinoin]

BACKGROUND

The retinoid alitretinoin is a therapeutic option for chronic refractory hand eczema. Dryness of skin and mucosa, erythema, pruritus and alopecia are typical cutaneous side effects.

CASE REPORT

We report the case of a 44-year-old man whose head hair became curly while taking alitretinoin. Other causes could not be elicited as the patient was otherwise healthy, did not take any other drugs, and denied any specific physical or mental stress.

RESULTS

Until now there has been no report about hair curling under alitretinoin. Case reports exist for the retinoids acitretin, isotretinoin and etretinate and for other drugs such as valproat or EGFR tyrosine-kinase inhibitors. The underlying pathogenetic mechanisms are still unclear. With regard to retinoids, an influence on the keratinisation of the inner root sheath has been speculated; however further investigation will be needed to better understand the processes.

Evaluation and diagnosis of the hair loss patient: part I. History and clinical examination

Hair loss (alopecia) is a common problem and is often a major source of distress for patients. The differential diagnosis of alopecia includes both scarring and nonscarring alopecias. In addition, many hair shaft disorders can produce hair shaft fragility, resulting in different patterns of alopecia. Therefore, an organized and systematic approach is needed to accurately address patients' complaints to achieve the correct diagnosis. Part 1 of this 2-part continuing medical education article on alopecia describes history taking and the clinical examination of different hair loss disorders. It also provides an algorithmic diagnostic approach based on the most recent knowledge about different types of alopecia.

Pattern Alopecia during Hormonal Anticancer Therapy in Patients with Breast Cancer

We report five cases of pattern alopecia in female patients who are undergoing hormonal anticancer therapy for the prevention of recurrence of breast cancer after surgery. Three patients demonstrated male pattern alopecia with receding frontal hairlines, and two patients demonstrated female pattern alopecia without receding hairlines. The detailed clinical history showed that the pattern alopecia of the patients developed after the full recovery of global hair loss of the entire scalp due to previous cytotoxic chemotherapy. All of the adjuvant hormonal anticancer drugs that were used in the patients are antiestrogenic agents, either aromatase inhibitors or selective estrogen receptor modulators. Considering androgen effect on the hair follicles of the fronto-parietal scalp, the androgen-estrogen imbalance caused by the drugs was thought to be the reason for the onset of pattern alopecia in the patients. In general, alopecia that develops during cytotoxic chemotherapy is well known to both physicians and patients; however, the diagnosis of pattern alopecia during hormonal anticancer therapy in breast cancer patients seems to be overlooked.

Antiretroviral-Related Alopecia in HIV-Infected Patients

Objective: To review the literature evaluating antiretroviral-related alopecia and to provide guidance on the differential diagnosis and management of this condition.

DATA SOURCES

A literature search was performed using PubMed, MEDLINE, Embase, International Pharmaceutical Abstracts (IPA), Cumulative Index to Nursing and Allied Health (CINAHL), and the Cochrane database (through May 2014). Relevant conference abstracts and product monographs were reviewed. Search terms included antiretroviral, individual antiretroviral classes and names, highly active antiretroviral therapy, HIV, AIDS, alopecia, hair, hair loss and drug.

STUDY SELECTION AND DATA EXTRACTION

English-language studies and case reports were included. A total of 16 articles and 1 conference abstract were retrieved, with a total of 46 patients with hair loss.

DATA SYNTHESIS

The protease inhibitor class, in particular indinavir, was most commonly reported to cause hair loss, followed by the NRTI, lamivudine. The majority of cases presented with alopecia of the scalp alone, with a median time of onset of 2.5 months. Management involved discontinuing the drug in most cases, with at least partial reversal in half the cases.

CONCLUSIONS

In antiretroviral-induced alopecia, discontinuation of the suspected agent is the optimal management, and hair regrowth should occur within 1 to 3 months. Management may also include replacing the offending medication with an antiretroviral less likely to cause hair loss. It is essential to rule out other causes of alopecia with a complete patient history, including characterization of the hair loss and assessment of the patient's medical history, medication use, and family history of alopecia.

Anidulafungin-Induced Alopecia

Objetive: To report a case of a woman in whom alopecia appeared after several months of treatment with anidulafungin. Case Summary: A 34-year-old woman with chronic femoral osteomyelitis with the presence of persistent suppuration, developed a Candida albicans infection, isolated in the fistula exudate cultures. After initial failures of single therapy with azoles, it was decided to administer fluconazole and anidulafungin 100 mg/d. One month after starting the treatment, the patient mentioned a greater hair loss than usual. At 3 months, the patient stopped taking the drug on noting the loss and easy falling out of her hair, with alopecia plaques 1 to 2 cm in size. At 2 months after stopping the anidulafungin, it was decided to restart combined antifungal treatment using micafungin and fluconazole; there was no mention of new or greater loss of hair. It was decided to change micafungin to anidulafungin again 90 days after starting treatment. In the first month of treatment, there appeared to be a reactivation in hair loss that later stabilized and improved. Discussion: Drug-induced hair loss is an adverse reaction that has been identified during different hair growth phases. It has been described for the azoles group and has not been associated with candins until now. Results of the causality analysis, using the probability scale established by Naranjo, found the relationship as probable. Conclusions: Anidulafungin could be associated with hair loss. Physicians must be aware of this adverse effect in order to approach it properly and to detect possible nonadherence to treatment.

The changes in the hair cycle during gestation and the post-partum period

BACKGROUND

In pregnancy, increased numbers of hair follicles remain in the anagen phase for longer periods due to hormonal changes and return to the telogen phase within 3-6 months of delivery with a sudden drop in hormone levels. This results in excessive shedding of hair known as post-partum telogen effluvium.

OBJECTIVE

To determine the changes in the hair cycle during gestation and the post-partum period.

METHODS

We included 116 women in this study; 28 women at the 24th week of pregnancy, 30 pregnant women at term gestation, 29 women in the 4th post-partum month, and 29 in the first post-partum year. The number of breastfeeding mothers in the post-partum period and the month in which they were examined were also recorded. The ratios of anagen and telogen were measured using Trichoscan.

RESULTS

A statistically significant difference was observed between the groups in terms of the anagen and telogen ratios (P = 0.042, P = 0.042). In the inter-group comparisons, the mean anagen rate in the 4th post-partum month was significantly lower than that in the 6th and 9th month of pregnancy (P = 0.045, P = 0.038), while the average telogen rate was significantly higher (P = 0.045, P = 0.038). The mean anagen rate in the 4th post-partum month in the breastfeeding group was significantly higher than that in the non- breastfeeding group (P = 0.014), while the mean telogen rate was significantly lower (P = 0.014). There was no statistically significant difference between the two groups (the breastfeeding and non-breastfeeding groups) in terms of the mean anagen and mean telogen ratios in the first post-partum year (P = 0.385).

CONCLUSION

The anagen rate increases during pregnancy and the telogen rate rises after delivery, however, there is no exaggeration in these changes in most women.

Hot flashes in a young girl: a wake-up call concerning Serenoa repens use in children

Extracts of the plant Serenoa repens are widely used in male adults for the treatment of benign prostatic hyperplasia. Recently, therapy with S repens has been proposed as a "natural" alternative to conventional treatments for male androgenetic alopecia as well as for other hair disorders. Telogen effluvium is a form of alopecia characterized by abnormality of hair cycling, resulting in excessive loss of telogen hair. We report the case of an 11-year-old girl presenting hot flashes that appeared after treatment of telogen effluvium with a food supplement containing S repens that lasted for ~2 months. When use of the product was discontinued, the hot flashes no longer occurred. Four months after the start of S repens intake and 45 days from the cessation of therapy, the girl experienced menarche at the age of 11 years. The Naranjo adverse drug reaction probability scale indicated a probable relationship (score of 6) between the appearance of hot flashes and the intake of S repens. A correlation between exposure to S repens and the onset of menarche is not certain, but it cannot be excluded. Medicinal products or food supplements containing S repens are generally well tolerated in male adults, but we believe that their use in pediatric patients should be better evaluated.

Madarosis: a marker of many maladies

Madarosis is a terminology that refers to loss of eyebrows or eyelashes. This clinical sign occurs in various diseases ranging from local dermatological disorders to complex systemic diseases. Madarosis can be scarring or non-scarring depending upon the etiology. Appropriate diagnosis is essential for management. Follicular unit transplantation has been found to be a useful method of treating scarring madarosis and the procedure relevant to eyebrow and eyelash reconstruction has been discussed. A useful clinical approach to madarosis has also been included for bedside diagnosis. The literature search was conducted with Pubmed, Medline, and Google scholar using the keywords madarosis, eyebrow loss, and eyelash loss for articles from 1960 to September 2011. Relevant material was also searched in textbooks and used wherever appropriate.

Drugs and hair loss

Hair loss is a common complaint, both in men and women, and use of prescription medications is widespread. When there is a temporal association between the onset of hair loss and commencement of a medication, the medication is commonly thought to have caused the hair loss. However, hair loss and in particular telogen effluvium may occur in response to a number of triggers including fever, hemorrhage, severe illness, stress, and childbirth, and a thorough exclusion of these potential confounders is necessary before the hair loss can be blamed on the medication. Certain medications are known to cause hair loss by a variety of mechanisms including anagen arrest, telogen effluvium, or accentuation of androgenetic alopecia by androgens.

Skin manifestations associated with chemotherapy in children with hematologic malignancies

Chemotherapy used in the treatment of malignancies produces multiple mucocutaneous adverse reactions that may be clinically challenging. These mucocutaneous reactions are common and sometimes not diagnosed. The objective of this study was to determine the clinical patterns of the mucocutaneous manifestations during and after chemotherapy in children with a hematologic malignancy and to determine whether nutritional status influences the clinical presentation. We recruited patients aged 6 months to 16 years diagnosed with leukemia and lymphoma from a pediatric hematology outpatient clinic between November 2008 and May 2010. The patients were divided into two groups: Group 1, recently diagnosed patients, included in the study before receiving chemotherapy, and Group 2, patients in surveillance who had not had chemotherapy for at least 3 months. A dermatologic examination was performed, and biopsy and mycological and bacteriological tests were conducted if necessary, with 6 months of follow-up. We evaluated 89 patients and included 65 in the study: 40 boys and 25 girls with an average age of 8.3 years. All patients had skin lesions at some time during their baseline assessment or follow-up. The manifestations found were anagen effluvium, xerosis, and acral hyperpigmentation. To our knowledge, this is the first comparative study of skin manifestations associated with chemotherapy in a Mexican pediatric population. The mucocutaneous manifestations associated with chemotherapy are important causes of morbidity. All of the children in our study had skin lesions on assessment. We did not find an association between skin manifestations and nutritional status.

Central centrifugal cicatricial alopecia - an approach to diagnosis and management

Central centrifugal cicatricial alopecia (CCCA) occurs primarily in African-American women and is the most common cause of scarring hair loss in this population. Since the mid 20th century, hair care practices of African-American women have been associated with CCCA, although there is developing evidence that the etiology of CCCA may be multifactorial. Clinically diagnosing CCCA may be challenging because it can resemble female pattern hair loss, alopecia areata, lichen planopilaris, or telogen effluvium. Therapeutic options are limited, thus the goal of treatment is to prevent progression of disease because once scar formation occurs, it is irreversible.

Antipsychotics and physical attractiveness

BACKGROUND

Antipsychotics are effective in treating the symptoms of schizophrenia, but they may induce adverse effects, some of which-those that impact negatively on physical appearance-have not been sufficiently discussed in the psychiatric literature.

AIM

Through a narrative review, to catalog antipsychotic side effects that interfere with physical attractiveness and to suggest ways of addressing them.

METHOD

PubMed databases were searched for information on the association between "antipsychotic side effects" and "attractiveness" using those two search phrases plus the following terms: "weight," "teeth," "skin," "hair," "eyes," "gait," "voice," "odor." Data from relevant qualitative and quantitative articles were considered, contextualized, and summarized.

RESULTS

Antipsychotics, as a group, increase weight and may lead to dry mouth and bad breath, cataracts, hirsutism, acne, and voice changes; they may disturb symmetry of gait and heighten the risk for tics and spasms and incontinence, potentially undermining a person's attractiveness.

CONCLUSIONS

Clinicians need to be aware of the impact of therapeutic drugs on appearance and how important this issue is to patients. Early in treatment, they need to plan preventive and therapeutic strategies.

Diseases of the hair and nails

The hair and nails are rapidly growing structures and as such their cell division can be interrupted by disease states and iatrogenic treatments. Other internal diseases can alter the structure and color of the hair and nails. These alterations in the hair and nails supply important information to the physician regarding the underlying diagnosis.