Alopecia areata update: part II. Treatment

Current Protocols: Alopecia Areata Mouse Models for Drug Efficacy and Mechanism Studies

Alopecia areata is the second most common form of hair loss in humans after androgenetic alopecia. Although a variety of animal models for alopecia areata have been described, currently the C3H/HeJ mouse model is the most commonly used and accepted. Spontaneous hair loss occurs in 15%-25% of older mice in which the lesions wax and wane, similar to the human disease, with alopecia being more common and severe in female mice. Full-thickness skin grafts from mice with spontaneous alopecia areata to young, normal-haired, histocompatible mice provide a highly reproducible model with progressive lesions that makes it useful for drug efficacy and mechanism-based studies. As alopecia areata is a cell-mediated autoimmune disease, transfer of cultured lymph node cells from affected mice to unaffected, histocompatible recipients also promotes disease development and provides an alternative, nonsurgical protocol. Protocols are presented to produce these models such that they can be used to study alopecia areata and to develop novel drug therapies. © 2024 The Author(s). Current Protocols published by Wiley Periodicals LLC. Basic Protocol 1: Full-thickness skin grafts to reproducibly induce alopecia areata in C3H/HeJ mice Basic Protocol 2: Adoptive transfer of cultured lymphoid cells provides a nonsurgical method to induce alopecia areata in C3H/HeJ mice.

Nanostructured lipid carriers promote percutaneous absorption and hair follicle targeting of tofacitinib for treating alopecia areata

Alopecia areata affects over 140 million people worldwide and causes severe psychological distress. The Janus kinase (JAK) inhibitor, tofacitinib, shows significant potential in therapeutic applications for treating alopecia areata; however, the systemic adverse effects of oral administration and low absorption rate at the target site limit its application. Hence, to address this issue, we designed topical formulations of tofacitinib-loaded cationic lipid nanoparticles (TFB-cNLPs) with particle sizes of approximately 200 nm. TFB-cNLPs promoted percutaneous absorption and hair follicle targeting in an ex vivo pig ear model. TFB-cNLP decreased IFN-γ-induced alopecia areata symptoms in an in vitro follicle model by blocking the Janus kinase/signal transducers and activators of transcription (JAK/STAT) pathway. It also reduced the number of CD8+NKG2D+T cells in a C3H mouse model of alopecia areata in vivo, thereby inhibiting the progression of alopecia areata and reversing hair loss. These findings suggest that TFB-cNLP enhanced hair follicle targeting and has the potential for topical treatment or prevention of alopecia areata.

Disease burden, clinical management and unmet treatment need of patients with moderate to severe alopecia areata; consensus statements, insights, and practices from CERTAAE (Central/Eastern EU, Russia, Türkiye AA experts) Delphi panel

Objectives

This study aims to update the understanding of Alopecia Areata (AA) in Poland, Czechia, Russia, and Türkiye, focusing on the disease burden, clinical management, and patient journey. It seeks to establish a consensus on optimal management strategies for AA in these regions.

Methods

A modified 2-round Delphi panel was conveyed with 23 Dermatologists (Russia; 4, Türkiye; 7, Poland; 6, and Czechia; 6). The Delphi questionnaire consisted of 61 statements and 43 questions designed to obtain an overall understanding of the perception and acceptance of available information regarding the care of patients with alopecia areata.

Results

The study revealed that moderate-to-severe AA significantly impacts patients' and their families' QoL, consistent with previous studies. AA was found to cause more substantial impairment when additional lesions appeared in visible areas besides the scalp. Work and productivity impairment were notably higher in adults with moderate-to-severe AA. Diagnostic consensus highlighted the importance of skin biopsies and trichoscopy, while the need for more practical severity scoring systems was emphasized. Current treatments, including topical therapies, corticosteroids, and systemic immune modifiers, were deemed insufficient, highlighting the unmet medical need.

Conclusion

The Delphi study underscores a significant disease burden and unmet medical needs in patients with moderate-to-severe AA. It highlights the necessity of access to novel treatments and further research to develop more effective therapies with a tolerable safety profile. The findings align with global research, emphasizing the psychosocial impact of AA and the need for standardized, effective treatment protocols.

A case of alopecia areata after rabies vaccination: unreported adverse effect?

Alopecia areata (AA) is an autoimmune-related disorder characterized by non-scarring hair loss in children. We report the case of a child who had AA after the fifth dose of rabies vaccine and summarized various potential mechanisms of vaccination induced AA. This case indicates that rabies vaccine might be a predisposition of AA by causing immune dysregulation.

Platelet-Rich Plasma in Dermatology: New Insights on the Cellular Mechanism of Skin Repair and Regeneration

The skin's recognised functions may undergo physiological alterations due to ageing, manifesting as varying degrees of facial wrinkles, diminished tautness, density, and volume. Additionally, these functions can be disrupted (patho)physiologically through various physical and chemical injuries, including surgical trauma, accidents, or chronic conditions like ulcers associated with diabetes mellitus, venous insufficiency, or obesity. Advancements in therapeutic interventions that boost the skin's innate regenerative abilities could significantly enhance patient care protocols. The application of Platelet-Rich Plasma (PRP) is widely recognized for its aesthetic and functional benefits to the skin. Yet, the endorsement of PRP's advantages often borders on the dogmatic, with its efficacy commonly ascribed solely to the activation of fibroblasts by the factors contained within platelet granules. PRP therapy is a cornerstone of regenerative medicine which involves the autologous delivery of conditioned plasma enriched by platelets. This is achieved by centrifugation, removing erythrocytes while retaining platelets and their granules. Despite its widespread use, the precise sequences of cellular activation, the specific cellular players, and the molecular machinery that drive PRP-facilitated healing are still enigmatic. There is still a paucity of definitive and robust studies elucidating these mechanisms. In recent years, telocytes (TCs)-a unique dermal cell population-have shown promising potential for tissue regeneration in various organs, including the dermis. TCs' participation in neo-angiogenesis, akin to that attributed to PRP, and their role in tissue remodelling and repair processes within the interstitia of several organs (including the dermis), offer intriguing insights. Their potential to contribute to, or possibly orchestrate, the skin regeneration process following PRP treatment has elicited considerable interest. Therefore, pursuing a comprehensive understanding of the cellular and molecular mechanisms at work, particularly those involving TCs, their temporal involvement in structural recovery following injury, and the interconnected biological events in skin wound healing and regeneration represents a compelling field of study.

Alopecia Areata: Current Treatments and New Directions

Alopecia areata is an autoimmune hair loss disease that is non-scarring and is characterized by chronic inflammation at the hair follicle level. Clinically, patients' presentation varies from patchy, circumscribed scalp involvement to total body and scalp hair loss. Current management is guided by the degree of scalp and body involvement, with topical and intralesional steroid injections as primarily first-line for mild cases and broad immunosuppressants as the mainstay for more severe cases. Until recently, the limited number of blinded, randomized, placebo-controlled clinical trials for this disease had made establishing an evidence-based treatment paradigm challenging. However, growing insights into the pathogenesis of alopecia areata through blood and tissue analysis of human lesions have identified several promising targets for therapy. T-helper (Th) 1/interferon skewing has traditionally been described as the driver of disease; however, recent investigations suggest activation of additional immune mediators, including the Th2 pathway, interleukin (IL)-9, IL-23, and IL-32, as contributors to alopecia areata pathogenesis. The landscape of alopecia areata treatment has the potential to be transformed, as several novel targeted drugs are currently undergoing clinical trials. Given the recent US FDA approval of baricitinib and ritlecitinib, Janus kinase (JAK) inhibitors are a promising drug class for treating severe alopecia areata cases. This article will review the efficacy, safety, and tolerability of current treatments for alopecia areata, and will provide an overview of the emerging therapies that are leading the revolution in the management of this challenging disease.

Hair Loss Profiles and Ritlecitinib Efficacy in Patients with Alopecia Areata: Post Hoc Analysis of the ALLEGRO Phase 2b/3 Study

INTRODUCTION

Ritlecitinib demonstrated efficacy in patients with alopecia areata (AA) in the ALLEGRO phase 2b/3 study (NCT03732807). However, hair loss presentation may vary based on location (e.g., scalp, eyebrow/eyelash, body). Here, we sought to identify distinct hair loss profiles at baseline and evaluate whether they affected the efficacy of ritlecitinib.

METHODS

Patients with AA aged ≥ 12 years with ≥ 50% scalp hair loss were randomized to daily ritlecitinib 10 mg (assessed for dose ranging only), 30 or 50 mg (± 4-week, 200-mg loading dose), or placebo for 24 weeks. Latent class analysis (LCA) identified hair loss profiles based on four baseline measurements: clinician-reported extent of scalp (Severity of Alopecia Tool score), eyebrow hair loss, eyelash hair loss, and patient-reported body hair loss. Logistic regression evaluated ritlecitinib (50 and 30 mg) efficacy vs placebo using Patient Global Impression of Change (PGI-C) and Patient Satisfaction with Hair Growth (P-Sat; amount, quality, and overall satisfaction) responses at Week 24, adjusting for key covariates, including latent class membership.

RESULTS

LCA identified five latent classes: (1) primarily non-alopecia totalis (AT; complete loss of scalp hair); (2) non-AT with moderate non-scalp involvement; (3) extensive scalp, eyebrow, and eyelash involvement; (4) AT with moderate non-scalp involvement; and (5) primarily alopecia universalis (complete scalp, face, and body hair loss). Adjusting for latent class membership, patients receiving ritlecitinib 30 or 50 mg were significantly more likely to achieve PGI-C response (30 mg: odds ratio, 8.62 [95% confidence interval, 4.42-18.08]; 50 mg: 12.29 [6.29-25.85]) and P-Sat quality of hair regrowth (30 mg: 6.71 [3.53-13.51]; 50 mg: 8.17 [4.30-16.46]) vs placebo at Week 24. Results were similar for P-Sat overall satisfaction and amount of hair regrowth.

CONCLUSION

Distinct and clinically relevant hair loss profiles were identified in ALLEGRO-2b/3 participants. Ritlecitinib was efficacious compared with placebo, independent of hair loss profile at baseline.

TRIAL REGISTRATION

ClinicalTrials.gov identifier, NCT03732807.

Diphenylcyclopropenone and platelet-rich plasma in the management of severe or recalcitrant alopecia areata

BACKGROUND

Alopecia areata (AA) is a common disease characterized by hair loss with an autoimmune background. There are many lines of therapy, but no standard line for all cases. Consequently, treating severe forms of AA is challenging.

OBJECTIVE

This study aimed to compare the efficacy and safety of the combination of diphenylcyclopropenone (DPCP) and platelet-rich plasma (PRP) with DPCP alone in treating patients with severe or refractory AA.

PATIENTS AND METHODS

Our randomized clinical trial was conducted on patients with severe and recalcitrant AA. Group A included 13 patients who received only DPCP, while Group B included 11 patients who received both DPCP and PRP. After sensitization in both groups of patients, DPCP was applied to half the scalp weekly. In addition, PRP injection in all scalp was performed once a month in group B. The patients in both groups completed the study for six months.

RESULTS

The regrowth scale results were 53.85% and 54.5% for groups A and B, respectively. Although the response rate of group B was higher than that of group A, there is no statistically significant difference between the two groups.

CONCLUSION

From our clinical trial, it can be concluded that DPCP alone or combined with PRP is an effective and safe method for treating severe or recalcitrant AA.

Diagnosis and Management of Alopecia Areata: A Saudi Expert Consensus Statement (2023)

Alopecia areata (AA) is a complex autoimmune disease manifesting as a chronic inflammatory disease characterized by non-scarring patches of hair loss over the face, scalp, and body. Several treatments have been proposed for AA, but none are curative nor achieve a state of remission. The present consensus statement aims to present the evidence- and experience-based recommendations on the diagnosis and management of AA in Saudi Arabia. The Ministry of Health in Saudi Arabia has opted to initiate a meeting of a multidisciplinary group to discuss and concede on this topic. Eight dermatology experts and clinical pharmacists convened in eight consensus meetings. All content presented in this document was agreed upon by this working group, including diagnosis and severity assessment, prognostic indicators, and therapeutic options for AA. Special consideration was given to special patient populations including pediatric patients and patients with less frequent presentations of AA. Updates of the current recommendations will take place as new evidence evolves in the treatment of AA.

Beard Alopecia: An Updated and Comprehensive Review of Etiologies, Presentation and Treatment

Facial hair is an important social and psychologic aspect of clinical appearance for men. The purpose of this review is to provide a comprehensive overview of the causes of alopecia of the beard including the prevalence, pathophysiology, clinical presentation, and treatment. In this review, we highlight more common causes of beard alopecia including alopecia areata and pseudofolliculitis barbae, infectious causes such as tinea barbae and herpes simplex folliculitis, and rare causes including dermatopathia pigmentosa reticularis and frontal fibrosing alopecia. This review serves as an important resource for clinicians when faced with patients suffering from beard alopecia.

Differential impact of environmental factors on systemic and localized autoimmunity

The influence of environmental factors on the development of autoimmune disease is being broadly investigated to better understand the multifactorial nature of autoimmune pathogenesis and to identify potential areas of intervention. Areas of particular interest include the influence of lifestyle, nutrition, and vitamin deficiencies on autoimmunity and chronic inflammation. In this review, we discuss how particular lifestyles and dietary patterns may contribute to or modulate autoimmunity. We explored this concept through a spectrum of several autoimmune diseases including Multiple Sclerosis (MS), Systemic Lupus Erythematosus (SLE) and Alopecia Areata (AA) affecting the central nervous system, whole body, and the hair follicles, respectively. A clear commonality between the autoimmune conditions of interest here is low Vitamin D, a well-researched hormone in the context of autoimmunity with pleiotropic immunomodulatory and anti-inflammatory effects. While low levels are often correlated with disease activity and progression in MS and AA, the relationship is less clear in SLE. Despite strong associations with autoimmunity, we lack conclusive evidence which elucidates its role in contributing to pathogenesis or simply as a result of chronic inflammation. In a similar vein, other vitamins impacting the development and course of these diseases are explored in this review, and overall diet and lifestyle. Recent work exploring the effects of dietary interventions on MS showed that a balanced diet was linked to improvement in clinical parameters, comorbid conditions, and overall quality of life for patients. In patients with MS, SLE and AA, certain diets and supplements are linked to lower incidence and improved symptoms. Conversely, obesity during adolescence was linked with higher incidence of MS while in SLE it was associated with organ damage. Autoimmunity is thought to emerge from the complex interplay between environmental factors and genetic background. Although the scope of this review focuses on environmental factors, it is imperative to elaborate the interaction between genetic susceptibility and environment due to the multifactorial origin of these disease. Here, we offer a comprehensive review about the influence of recent environmental and lifestyle factors on these autoimmune diseases and potential translation into therapeutic interventions.

Impact and Management of Loss of Eyebrows and Eyelashes

Eyelashes and eyebrows have different functions, ranging from practical purposes such as protecting the eye apparatus from external hazards to the definition of our facial expression. For this reason, their loss could have both functional and psychological impact on patients' quality of life. Complete or partial loss can occur any time during life, and identifying the cause is mandatory to establish a correct and prompt treatment. The aim of this paper is to create a practical guide for the management of the most common causes of madarosis to the best of our knowledge.

Allergen desensitization reduces the severity of relapsed alopecia areata in dust-mite allergic patients

Atopy may be a facilitating factor in some alopecia areata (AA) patients with early disease onset and more severe/extensive AA. The underlying immune mechanisms are unknown, but allergen responses may support a pro-inflammatory environment that indirectly promotes AA. To investigate the long-term effect of allergen immunotherapy (AIT) against house dust mite (HDM) allergy on disease severity and prognosis for AA patients. An observational comparative effectiveness study was conducted on 69 AA patients with HDM allergy. 34 patients received conventional/traditional AA treatment (TrAA) plus AIT (AIT-TrAA), and 35 patients received TrAA alone. Serum total immunoglobulin E (tIgE), HDM specific IgE (sIgE), HDM specific IgG4 (sIgG4) and cytokines (IL-4, IL-5, IL-10, IL-12, IL-13, IL-33, IFNγ) were quantified in these patients, together with 58 non-allergic AA patients and 40 healthy controls. At the end of the 3-year desensitization course, the AIT-TrAA group presented with lower SALT scores than the TrAA group, especially in non-alopecia totalis/universalis (AT/U) patients and pre-adolescent AT/U patients (age ≤ 14). In patients with elevated tIgE levels before AIT, a decrease in tIgE was correlated to reduced extent of AA on completion of the AIT course. After desensitization, elevation of IL-5 and decrease of IL-33 were observed in HDM allergic-AA patients. Desensitization to HDM in allergic AA patients reduces the severity of relapse-related hair loss over the 3-year AIT treatment course, possibly via opposing Th2 dominance. This adjunctive treatment may help reduce disease severity and curtail the disease process in allergic patients with AA.

Janus Kinase Inhibitors in the Treatment of Alopecia Areata

Alopecia areata is a disease of autoimmune origin which causes non scarring hair loss. The extent of alopecia varies from a small patch to complete scalp and body hair loss, which can have huge psychosocial impact for those affected. Treatment modalities which have been used so far included nonspecific immunosuppressive medications, such as corticosteroids, cyclosporine, and methotrexate, or topical immunomodulators, such as diphencyprone, dithranol, and squaric acid dibutylester. The recognition of the importance of Janus kinase pathway in alopecia areata pathogenesis enabled more specific approaches in treatment. Positive outcomes of Janus kinase inhibitors in several trials granted approval for baricitinib which became the first on-label treatment for alopecia areata. The aim of this review is to summarize the role, efficacy and safety of several Janus kinase inhibitors in alopecia areata.

Comparative Efficacy and Safety of Janus Kinase Inhibitors Used in Alopecia Areata: A Systematic Review and Meta-analysis

The aim of this study was to compare the efficacy and safety of treatment with Janus kinase inhibitors for alopecia areata, measured by change in Severity of Alopecia Tool (SALT) score. A systematic review following Preferred Reporting Items for Systematic Reviews and Meta-analyses (PRISMA) guidelines was performed using Medline, EMBASE and Cochrane library. All studies investigating the efficacy of treatments for alopecia areata were included. Primary outcomes were the proportion of patients with alopecia areata achieving 30%, 50%, 75%, 90% and 100% improvement in SALT score after treatment with a Janus kinase inhibitor. A meta-analysis was performed including all randomized controlled trials investigating Janus kinase inhibitors. A total of 37 studies matched the inclusion criteria and were included. Meta-analysis was performed based on 5 randomized studies. Regarding patients with alopecia areata defined as ≥ 50% scalp hair loss, baricitinib 4 mg once daily demonstrated the highest efficacy. However, among patients with alopecia areata defined as a SALT score ≥ 50, oral deuruxolitinib 12 mg twice daily demonstrated the highest efficacy. Deuruxolitinib and baricitinib appear to be promising drugs for the treatment of alopecia areata. However, the response depends on the dosage of the drug. More randomized trials, with identical inclusion criteria and dose and duration of treatment, are required to confirm these findings.

Eyebrow and Eyelash Alopecia: A Clinical Review

Madarosis is characterized by either complete or partial loss of eyebrow or eyelash hair. Etiologies for madarosis are varied, and accurate diagnosis is the first step in clinical management. Many studies have described findings related to specific causes of madarosis, but few have summarized the collective literature. The purpose of this review is to provide an updated overview on the symptomatology, diagnosis, trichoscopy findings, and treatment of eyebrow and eyelash alopecia.

Induction of T cell exhaustion by JAK1/3 inhibition in the treatment of alopecia areata

Alopecia areata (AA) is an autoimmune disease caused by T cell-mediated destruction of the hair follicle (HF). Therefore, approaches that effectively disrupt pathogenic T cell responses are predicted to have therapeutic benefit for AA treatment. T cells rely on the duality of T cell receptor (TCR) and gamma chain (γc) cytokine signaling for their development, activation, and peripheral homeostasis. Ifidancitinib is a potent and selective next-generation JAK1/3 inhibitor predicted to disrupt γc cytokine signaling. We found that Ifidancitinib robustly induced hair regrowth in AA-affected C3H/HeJ mice when fed with Ifidancitinib in chow diets. Skin taken from Ifidancitinib-treated mice showed significantly decreased AA-associated inflammation. CD44⁺CD62L^- CD8⁺ T effector/memory cells, which are associated with the pathogenesis of AA, were significantly decreased in the peripheral lymphoid organs in Ifidancitinib-treated mice. We observed high expression of co-inhibitory receptors PD-1 on effector/memory CD8⁺ T cells, together with decreased IFN-γ production in Ifidancitinib-treated mice. Furthermore, we found that γc cytokines regulated T cell exhaustion. Taken together, our data indicate that selective induction of T cell exhaustion using a JAK inhibitor may offer a mechanistic explanation for the success of this treatment strategy in the reversal of autoimmune diseases such as AA.

Hair Follicle Melanocytes Initiate Autoimmunity in Alopecia Areata: a Trigger Point

Alopecia areata (AA) is characterized by common non-scarring alopecia due to autoimmune disorders. To date, the specific pathogenesis underlying AA remains unknown. Thus, AA treatment in the dermatological clinic is still a challenge. Numerous clinical observations and experimental studies have established that melanocytes may be the trigger point that causes hair follicles to be attacked by the immune system. A possible mechanism is that the impaired melanocytes, under oxidative stress, cannot be repaired in time and causes apoptosis. Melanocyte-associated autoantigens are released and presented, inducing CD8⁺ T cell attacks. Thereafter, amplification of the immune responses further spreads to the entire hair follicle (HF). The immune privilege of HF subsequently collapses, leading to AA. Herein, we present a narrative review on the roles of melanocytes in AA pathogenesis, aiming to provide a better understanding of this disease from the melanocyte's perspective.

A Comprehensive Review of Natural Alternatives for Treatment of Alopecia with an Overview of Market Products

Alopecia or hair loss is a widespread issue that has significant effects on personal well-being for both genders nationally and internationally. In addition, alopecia causes extreme emotional stress and negatively impacts the psychological health and self-esteem of cancer patients suffering from chemotherapy-induced alopecia. Unfortunately, available synthetic medications are costly, invasive, or have extreme adverse effects. On the contrary, natural and herbal hair loss products are widely available in the local and international markets in variable pharmaceutical forms with different mechanisms of action, namely, androgen antagonists, nutritional supplements, vasodilators, and 5α-reductase inhibitors or dihydrotestosterone blockers. Thus, it is of great importance to encourage researchers to investigate these natural alternatives that can act as potent therapeutic agents having diverse mechanisms of action as well as limited side effects. Currently, natural remedies are considered a fast-rising pharmaceutical segment with demand from a wide range of consumers. In this study, we present a review of reported herbal remedies and herb combinations recommended for hair loss and their mode of action, along with an overview of available market products and formulations, their composition, and declared effects. In addition, a general outline of the different forms of alopecia, its causes, and recommended treatments are mentioned as well. This was all done with the aim of assisting further studies with developing standardized natural formulations for alopecia as many were found to lack standardization of their bioactive ingredients and efficiency confirmation.

Oral Tofacitinib and Systemic Corticosteroids, Alone or in Combination, in Patients With Moderate-to-Severe Alopecia Areata: A Retrospective Study

Introduction

Alopecia areata (AA) is an autoimmune hair loss mediated by CD8 + T cells. Treatment for moderate-to-severe AA is still challenging. Janus kinase inhibitors, such as tofacitinib, have been recently investigated as a promising treatment option for AA. Evidence on the combination use of oral tofacitinib and systemic corticosteroids (SCs) for AA is still lacking.

Objective

To compare the efficacy and safety of monotherapy of oral tofacitinib and SCs, as well as their combination in patients with moderate-to-severe AA.

Methods

Patients with moderate-to-severe AA, who have been treated with at least 3 months of monotherapy of tofacitinib or SCs, or in their combination, were included in this study. The efficacy and adverse events of these treatments were retrospectively analyzed.

Results

Sixty-one patients with moderate-to-severe AA were included in this study. There were 12 (66.7%) of 18 patients in the SCs group, 12 (60.0%) of 20 patients in the tofacitinib group, and 18 (78.3%) of 23 patients achieved SALT50, with no significant difference among the three groups. The ratio of patients who achieved SALT50 was significantly higher in patients with a short duration of current hair loss episode (≤2 years) than in those with a duration of current hair loss episode (>2 years) in all the three groups. There were 66.7% patients in the SCs group, 35.0% patients in the tofacitinib group, and 56.5% patients in the combined group that showed adverse effects.

Conclusion

Tofacitinib was an effective treatment for patients with moderate-to-severe AA, and it was more tolerated than SCs. A combination of tofacitinib and SCs may have higher efficacy than SCs alone. Efficacy significantly decreased in patients with a current episode of disease for more than 2 years.

Nanomaterials in hair care and treatment

Hair care and treatment has evolved significantly through the years as new formulations are continuously being explored in an attempt to meet the demand in cosmetic and medicinal fields. While standard hair care procedures include hair washing, aimed at hair cleansing and maintenance, as well as hair dyeing and bleaching formulations for hair embellishment, modern hair treatments are mainly focused on circumventing hair loss conditions, strengthening hair follicle properties and treat hair infestations. In this regard, active compounds (ACs) included in hair cosmetic formulations include a vast array of hair cleansing and hair dye molecules, and typical hair treatments include anti-hair loss ACs (e.g. minoxidil and finasteride) and anti-lice ACs (e.g. permethrin). However, several challenges still persist, as conventional AC formulations exhibit sub-optimal performance and some may present toxicity issues, calling for an improved design of formulations regarding both efficacy and safety. More recently, nano-based strategies encompassing nanomaterials have emerged as promising tailored approaches to improve the performance of ACs incorporated into hair cosmetics and treatment formulations. The interest in using these nanomaterials is based on account of their ability to: (1) increase stability, safety and biocompatibility of ACs; (2) maximize hair affinity, contact and retention, acting as versatile biointerfaces; (3) enable the controlled release of ACs in both hair and scalp, serving as prolonged AC reservoirs; besides offering (4) hair follicle targeting features attending to the possibility of surface tunability. This review covers the breakthrough of nanomaterials for hair cosmetics and hair treatment, focusing on organic nanomaterials (polymer-based and lipid-based nanoparticles) and inorganic nanomaterials (nanosheets, nanotubes and inorganic nanoparticles), as well as their applications, highlighting their potential as innovative multifunctional nanomaterials towards maximized hair care and treatment. STATEMENT OF SIGNIFICANCE: This manuscript is focused on reviewing the nanotechnological strategies investigated for hair care and treatment so far. While conventional formulations exhibit sub-optimal performance and some may present toxicity issues, the selection of improved and suitable nanodelivery systems is of utmost relevance to ensure a proper active ingredient release in both hair and scalp, maximize hair affinity, contact and retention, and provide hair follicle targeting features, warranting stability, efficacy and safety. This innovative manuscript highlights the advantages of nanotechnology-based approaches, particularly as tunable and versatile biointerfaces, and their applications as innovative multifunctional nanomaterials towards maximized hair care and treatment.

Efficacy of a mixed preparation containing piperine, capsaicin and curcumin in the treatment of alopecia areata

Alopecia areata is a common non-scarring alopecia, mainly manifested as sudden localized patchy alopecia. It is currently believed to be related to autoimmune, genetic, emotional stress and endocrine factors. 60 patients were enrolled in this study and divided into 2 groups randomly: topical treated with the mixed preparation (case) twice daily and minoxidil (control) once daily for 3 months. The degree of hair loss was assessed by SALT and dermoscopy . Based on our findings, the mixed preparation of piperine, capsaicin and curcumin is effective in treating alopecia areata, but it has not been shown to be superior to minoxidil in short-term therapy.

The effect of latanoprost 0.005% solution in the management of scalp alopecia areata, a randomized double-blind placebo-controlled trial

BACKGROUND

Alopecia areata (AA) is a recurrent chronic disease that affects hair follicles and results in hair loss. Make an increase in the number, thickness, and length of eyelashes is an important side effect of latanoprost eye drop.

OBJECTIVE

This study aimed to evaluate the effect of hypertrichosis property of latanoprost in the treatment of scalp AA.

METHODS

In this randomized double-blind placebo-controlled trial, thirty participants with scalp AA assigned to receive either topical latanoprost 0.005% solution or placebo for 12 weeks. In both arms, patients also received clobetasol 0.05% cream in isopropyl alcohol (1:1). The hair loss area pictured at baseline and the end of the fourth, eighth, and twelfth weeks. According to the images, the dermatologist assessed the hair loss area, hair density, and the severity of alopecia.

RESULTS

Latanoprost significantly increased hair density (37.2± 26.1 vs. 14.6 ± 18.6) and regrowth (58.3 ± 39.3 vs. 21.6 ± 24.1) based on the Severity of Alopecia Tool (SALT) system compared to the control group (P=0.03 and 0.02, respectively). However, there were no significant differences between the two groups in reduction in the hair loss area and SALT, and the incidence of side effects (P=0.718, 0.262, and ≥0.99, respectively).

CONCLUSION

Results showed the acceptable safety and efficacy of latanoprost 0.005% solution to increase hair density and regrowth. So, it could be safely used for the management of scalp AA. This article is protected by copyright. All rights reserved.

Topical diphenylcyclopropenone plus topical 0.5% anthralin versus topical diphenylcyclopropenone alone for the treatment of chronic extensive alopecia areata: A split-scalp, double-blind, controlled study

Background:

The combination of diphenylcyclopropenone (DCP) and anthralin may demonstrate synergistic effects in the treatment of chronic extensive alopecia areata (AA).

Objective:

The objective of the study was to compare the efficacy of the combination therapy of topical DCP and topical 0.5% anthralin versus topical DCP alone for the treatment of chronic extensive AA.

Materials and Methods:

Ten patients were included in the study. Of these, 1, 2, and 7 patients were diagnosed with alopecia totalis, severe AA (>50% hair loss), and alopecia universalis, respectively. For each patient, one side of the scalp was treated with a DCP solution and 0.5% anthralin for 6 months, while the other side was treated with DCP and a cream base for the same duration. The clinical responses were assessed at baseline and then monthly until the end of the 6-month study period using the Severity of Alopecia Tool score. The side effects were evaluated at each follow-up visit.

Results:

The difference in the efficacies of the combination treatment and DCP alone was not statistically significant (P = 0.59). Regarding the side effects, DCP plus 0.5% anthralin caused significantly more excessive dermatitis than DCP alone (7 patients vs. 2 patients; P = 0.02). Eight patients reported temporary hyperpigmentation at the combination-treatment site, whereas no hyperpigmentation was reported at the DCP-alone site of any patient (P < 0.001).

Conclusions:

The combination of DCP and 0.5% anthralin was not superior to DCP alone for the treatment of chronic extensive AA. An increase in side effects – excessive dermatitis and hyperpigmentation – was observed in the combination-treatment group.

Immunopathology and Immunotherapy of Inflammatory Skin Diseases

Recently, there have been impressive advancements in understanding of the immune mechanisms underlying cutaneous inflammatory diseases. To understand these diseases on a deeper level and clarify the therapeutic targets more precisely, numerous studies including in vitro experiments, animal models, and clinical trials have been conducted. This has resulted in a paradigm shift from non-specific suppression of the immune system to selective, targeted immunotherapies. These approaches target the molecular pathways and cytokines responsible for generating inflammatory conditions and reinforcing feedback mechanisms to aggravate inflammation. Among the numerous types of skin inflammation, psoriasis and atopic dermatitis (AD) are common chronic cutaneous inflammatory diseases. Psoriasis is a IL-17–mediated disease driven by IL-23, while AD is predominantly mediated by Th2 immunity. Autoimmune bullous diseases are autoantibody-mediated blistering disorders, including pemphigus and bullous pemphigoid. Alopecia areata is an organ-specific autoimmune disease mediated by CD8⁺ T-cells that targets hair follicles. This review will give an updated, comprehensive summary of the pathophysiology and immune mechanisms of inflammatory skin diseases. Moreover, the therapeutic potential of current and upcoming immunotherapies will be discussed.

Intramuscular Corticosteroid Therapy in the Treatment of Alopecia Areata: A Time-to-Event Analysis

Introduction

Intramuscular corticosteroids (IMC) have gained popularity for the treatment of severe alopecia areata (AA) in recent years; however, evidence on their efficacy and safety is still limited.

Objective

To evaluate the efficacy, relapse rate, and tolerability of IMC in the treatment of AA, as well as factors associated with treatment outcomes.

Methods

Time-to-event analysis was performed on patients with severe, extensive, or rapidly progressive AA receiving IMC. The IMC regimen comprised triamcinolone acetonide 20–40 mg/mL injected every 4–6 weeks. The evaluated outcomes included initial (25% regrowth), significant (75% regrowth), and complete hair regrowth (100% regrowth). Relapse and adverse events were also noted. Factors associated with treatment outcomes and relapse were analyzed using the Cox proportional hazards model.

Results

A total of 101 patients were eligible for analysis. Significant hair regrowth was obtained in 80.2% of the patients (n = 81), in a median time of 3.4 months (95% confidence interval [CI] = 2.9–4.4). Complete hair regrowth was achieved in 48.5% of the subjects (n = 49), and relapse was observed in 47.5% (n = 48). Acneiform eruption was the most common adverse effect. Multivariable analysis revealed that nail involvement was a negative predictor of significant hair regrowth (adjusted hazard ratio [HR] = 0.04, 95% CI = 0.01–0.55; P = 0.015), whereas duration of AA longer than 6 months was associated with disease recurrence (adjusted HR = 4.02, 95% CI = 1.52–4.66; P = 0.005).

Conclusion

This study demonstrated the efficacy and safety of IMC in the treatment of severe or active AA; however, the relapse rate remained relatively high after discontinuation of the therapy. Nail involvement was a negative predictor of significant hair regrowth, while disease duration longer than 6 months predicted AA relapse.

Superficial cryotherapy versus intralesional corticosteroids injection in alopecia areata: A trichoscopic comparative study

Background:

Alopecia areata (AA) is an autoimmune disease leading to noncicatricial alopecia. Topical or intralesional corticosteroid (ILCS) is the accepted therapeutic option for mild cases; however, adverse effects are sometimes difficult to reverse. When the exposure to liquefied nitrogen is limited to a few seconds “superficial” cryotherapy, reactive vasodilation may improve microcirculation and nutritional status around hair follicles.

Objective:

This study aimed to evaluate and compare superficial cryotherapy and ILCS in the treatment of patchy AA.

Materials and Methods:

This prospective comparative study included 21 patients with patchy AA. Every patient received superficial cryotherapy on one patch, every 2 weeks for 3 months, and ILCS injection for another patch, once monthly for 3 months.

Results:

Clinical improvement was higher in cryotherapy group compared to ILCS group with a statistically significant difference (P = 0.002). On trichoscopic evaluation, terminal hair count was improved in lesions treated with cryotherapy more than lesions treated with ILCS but without statistical significance (P = 0.595) and vellus hair count was improved in lesions treated with cryotherapy more than lesions treated with ILCS with a statistical significance (P = 0.002).

Conclusions:

Cryotherapy is more effective and less painful than ILCS in the treatment of patchy AA.

Comparative study between the efficacies of azathioprine and mesalazine in the treatment of severe alopecia areata

BACKGROUND

Various systemic agents have been assessed for treatment of alopecia areata; however, there is a paucity of comparative studies.

AIM

To compare the efficacy of azathioprine versus mesalazine in the treatment of severe alopecia areata.

METHODS

Our study was carried out in 30 patients with severe alopecia areata divided into two groups, group A: fifteen patients were treated by azathioprine in an oral dose of 1-2 mg/kg/day and group B: fifteen patients were treated by mesalazine in an oral dose of 15-30 mg/kg/day in two divided doses. The treatment was considered effective if percentage regrowth of hair was determined by change in SALT score >50 from base line after 6 months of treatment. The treatment was continued for 3-6 months after complete remission to minimize the risk of relapse. The dose was gradually tapered during this time.

RESULTS

The study found that there is statistically significant difference between mean SALT scores before treatment and after 6 months of treatment in both groups. In group A, SALT score at base line was 84.42 ± 17.41, after 6 months it was 35.95 ± 35.79 (p value 0.04). In group B, SALT score at base line was 73.06 ± 22.10, after 6 months it was 23.04± 12.27 (p value 0.037). Changes in SALT score after 6 months were -27.74 ± 20.66 in group A and -60.42±38.41 in group B (p value 0.055).

CONCLUSION

Mesalazine may be considered as effective as azathioprine with lesser side effects. Azathioprine is also considered safe. However, a large group study should be performed to confirm these findings.

A prospective comparative study of two regimens of diphenylcyclopropenone (DPCP) in the treatment of alopecia areata

BACKGROUND

Alopecia areata (AA) is a chronic disorder and the best treatment regimen for it is unknown. Currently, one of the best documented treatment modalities for AA is topical immunotherapy.

AIM

To evaluate the safety and efficacy of a novel method (multi-concentration patch test) versus standard protocol for topical immunotherapy.

METHODS

A prospective randomized clinical trial was conducted on 30 patients with Alopecia areata, half of them received DPCP with a novel method using multi-concentration patch test to determine the optimal initiating concentration of DPCP (case group) and the other half experienced immunotherapy according to the standard protocol (control group). Percentage of hair regrowth after 6 months of treatment and the incidence of drug-related adverse effects were evaluated and compared between the two groups. (IRCT registration code: IRCT20141209020250N5).

RESULTS

Absolute and relative hair regrowth percentages were reported 25% and 41.49% in case group and 8.2% and 14.21% in control group respectively. Considerable response (more than 75% hair regrowth) was observed in 4 (26.6%) patients in case and 1 (6.6%) patient in control group. The clinical response was initiated about 7 weeks sooner in case compared to the control group (14 versus 7.38 weeks, P: 0.001). Overall, clinical response was higher in patients received new protocol, compared to control group. Moreover, patients who experienced new protocol had a higher level of treatment satisfaction in comparison with patients having standard protocol (P: 0.012).

CONCLUSION

This study revealed the effectiveness and safety of the novel multi-concentration patch test DPCP therapy for AA and its priority to conventional method, at least in terms of shortened duration of DPCP immunotherapy.

Characterizing the willingness to undergo treatment in patients with alopecia areata

Alopecia areata is an autoimmune disease that results in partial or total balding of the scalp and/or body. Treatments available are minimally effective, have severe side effects, and are often painful. Given these burdens, patients may not feel undergoing treatment is worthwhile. The purpose of this study is to characterize the willingness of patients with alopecia areata to undergo treatment. We found that few patients are willing to undergo treatment at the risk of severe health side effects. The most acceptable form of treatment administration was topical and the least acceptable was injection at the site of hair loss. A majority of patients would only undergo treatment for hair growth that is cosmetically acceptable and the most important site of hair regrowth was the scalp. The willingness to undergo treatment differed significantly by gender, age, time since disease onset, and disease severity. This study offers insight into the preferences of patients with alopecia areata and characteristics that would make treatment widely acceptable. Institutions conducting research on treatment for alopecia areata can use the results of this study to better understand the needs of their target population.

Clinical efficacy of adipocyte-derived stem cells conditioned media combined with micro-injury in refractory patch of alopecia areata

Management of alopecia areata (AA) is often challenging especially when patients have AA lesion refractory to conventional treatments such as corticosteroids, contact immunotherapy, and systemic therapy. Reports indicate adipocyte-derived stem cell conditioned media (ASC-CM) can activate hair growth and micro-injury using fractional laser or microneedling can also induce wound healing and hair regeneration, which suggests ASC-CM combined with fractional laser or microneedling might provide alternative therapeutic option for a refractory patch of AA. This study aimed to evaluate the clinical efficacy and safety of ASC-CM combined with 10,600 nm carbon dioxide fractional laser or microneedling for the treatment of refractory patch of AA. This retrospective study was based on evaluations of 14 patients with a refractory patch of AA treated with ASC-CM, combined with a 10,600 nm carbon dioxide fractional laser, or microneedling from March 2017 to August 2020. The efficacy of treatment was assessed by extents of hair regrowth percentages of involved areas. Of the 14 enrolled patients, 9 (64.3%) showed > 50% hair regrowth and 6 patients (42.9%) showed complete recovery. In the responder group (n = 9), mean period to achieve > 50% hair regrowth was 11.3 weeks (range 8-16 weeks). In the non-responder group (n = 5), 4 patients (28.6%) showed < 25% of hair regrowth and 1 patient show slight hair regrowth (7.1%) after 3 months of treatment. This study showed ASC-CM combined with 10,600 nm carbon dioxide fractional laser or microneedling may offer effective and safe treatment options for a refractory patch of AA.

Alopecia Areata: New Treatment Options Including Janus Kinase Inhibitors

Alopecia areata (AA) is a chronic, relapsing, autoimmune disorder characterized by patchy nonscaring hair loss. Although the pathogenesis of alopecia areata is not yet completely elucidated, loss of immune privilege in anagen stage hair follicles is widely accepted to play a key role. Several cytokines that depend on Janus kinase signaling have been identified to be involved in AA, including interleukin (IL)-2, IL-7, IL-15, IL-21, and interferon-γ, making Janus kinase inhibitors an attractive therapeutic target. Available information indicates that about 70% of patients with AA experience significant regrowth, but interruption of treatment is associated with disease recurrence.

Human papillomavirus symptomatic infection associated with increased risk of new-onset alopecia areata: A nationwide population-based cohort study

BACKGROUND

We investigated the correlation between a history of human papillomavirus (HPV) infection and alopecia areata risk.

METHODS

The study cohort comprised 30,001 patients with newly diagnosed HPV infection between 2000 and 2012; and with use of computer-generated randomly numbers, patients not had HPV infection were randomly selected as the comparison cohort. HPV infection cohort were matched to comparison individuals at a 1:1 ratio by age, gender and index year. All study individuals were followed up until they developed alopecia areata, withdraw from the insurance program, lost to follow-up, or until the end of 2013. Cox proportional hazards regression analysis was used to analyze the risk of alopecia areata with hazard ratios (HRs) and 95% confidence intervals (CIs) between the HPV and control cohort.

RESULTS

The adjusted hazard ratio (aHR) of alopecia areata for HPV patients relative to controls was 2.55 (95% C.I. = 1.88-3.47) after adjusting sex, age and comorbidities. Subgroup analysis indicated that patients with HPV infections had a significantly greater risk of alopecia areata for both genders, all age subgroups, and those with mental disorder diseases.

CONCLUSIONS

A history of HPV infection is associated with the development of subsequent alopecia areata in Taiwanese subjects.

Candida antigen immunotherapy versus steroid in the treatment of alopecia areata

Alopecia areata (AA) is an autoimmune hair follicle disorder that is challenging to treat. Although there are multiple topical immunotherapeutic agents, their side effects limit their use. Candida antigen can serve as another immunotherapeutic treatment, with an easier application and fewer side effects. To evaluate the efficacy of Candida antigen versus intralesional steroids for the treatment of AA. About 48 adult patients with AA were divided into two groups. The Candida group included 24 patients who were injected monthly with 0.1 mL of Candida albicans antigen in one patch of alopecia, and the intralesional corticosteroid group included 24 patients who were injected monthly with 0.1 mL of triamcinolone acetonide, as a control group, in all alopecia patches. After 5 months, there was a highly significant decrease in the severity of AA in both groups with no significant difference between them. In the Candida group, 8 patients showed complete hair regrowth and 9 patients showed partial regrowth. Side effects were mild and transient such as pain during injection, which was significantly lower in the Candida group than in the corticosteroid group. Intralesional Candida antigen is a promising effective treatment for AA with differing severities.

Systematic review of platelet-rich plasma in treating alopecia: Focusing on efficacy, safety, and therapeutic durability

Considering the different forms, alopecia could be a very common condition with particular therapeutic concerns; thus, recent therapies still require further assessments. Aim of this systematic review was to evaluate efficacy, safety, and therapeutic durability of platelet rich plasma (PRP) in treating various forms of alopecia. A total of 64 articles were found through a systematic search, and eight original articles were included in the study, based on inclusion/exclusion criteria. In most studies (62.5%) patients' conditions had improved by receiving PRP therapy; these cases experienced an increase in growth and thickness of hair. Simultaneous use of PRP and Minoxidil demonstrated the highest rate of improvement and satisfaction. The highest efficacy in patients with alopecia areata was 76% and the lowest efficacy was 31.7% and in patients with androgenetic alopecia the highest efficacy was 42.75% and the lowest reported efficacy was 25.55%. The main side effect was pain due to PRP injection, which disappeared after ending the treatment and only one article reported more serious side effects. Recurrence after treatment was also reported in only one article. PRP is a safe and easy method for treating hair loss and has limited adverse effects. Optimization of this method depends on dosage, number of sessions and their intervals, and injection techniques. According to the results, the use of PRP due to its relatively high efficiency, low and tolerable side effects, and low recurrence rate can be a good method for the treatment of alopecia and hair loss.

Assessment of treatment efficacy of diphenylcyclopropenone (DPCP) for alopecia areata

Background/aim

Alopecia areata (AA) is an inflammatory disease with a genetic and autoimmune basis. Herein, it was aimed to study the efficacy and safety of an immunomodulatory therapeutic agent, diphenylcyclopropenone, while manifesting its association with histopathological features, prognostic factors, and side effects.

Materials and methods

In this retrospective study, 98 patients (60 males, 38 females) with alopecia, who were referred to the Hair Disease Polyclinic at the Department of Dermatology, between 2011 and 2015, were included. Together with medical histories and dermatological examinations, a skin biopsy for histopathological examination was conducted for all of the patients prior to therapy. Therapeutic success was evaluated on the basis of the hair regrowth percentage.

Results

Regarding the overall treatment success, 33 (34%) patients had complete response, 16 (16%) had partial response (between 50% and 99%), 27 (28%) had minimal response (between 1% and 49%), and 22 (22%) were nonresponders. Both sexs were equally represented in the outcome.

Conclusions

There was a significant relation between the severity of alopecia and the treatment outcome (P = 0.038). Patients with AA had significantly better response when compared to those with alopecia totalis and universalis. There was no statistically significant relation with other parameters, such as disease duration, age, sex, atopy history, age of onset, and histopathological features.

Identification of novel step-up regimen of intralesional triamcinolone acetonide in scalp alopecia areata based on a double-blind randomized controlled trial

Although intralesional triamcinolone acetonide (TA) is the most commonly prescribed treatment for localized alopecia areata (AA), the literature regarding the optimal concentration for attaining better efficacy with the most acceptable side effects is scarce. To compare hair regrowth and local side effects of various concentrations of intralesional TA in scalp AA using clinical and dermoscopic parameters. A double-blind randomized control trial with four treatment groups (10, 5, 2.5 mg/ml TA and normal saline [NS]) was conducted between March 2018 and August 2019. After recruitment, each AA patch was divided into quadrants and randomized before first injection. Injections were given and outcome parameters were analyzed every 4-weekly till 12-weeks. Statistical analysis was done by the R software employing generalized estimation equation. P-value <.05 was considered significant. Out of 105-patients (168-AA patches), 75-patients (121-patches) completed the study. Hair regrowth scale of all TA concentrations was better than NS group (P < .001). Other parameters such as quadrants with poor clinical response and dermoscopic disease activity signs were also favorable in TA groups in comparison to NS. However the evidence of atrophy and telangiectasia was maximum in 10 mg/mL group. 10 mg/mL TA showed a comparatively better response at the cost of increased adverse effects. Based on the clinical benefit and adverse risk assessment from our study, it may be better to start with 2.5 mg/mL intralesional TA in limited scalp AA patients. It can be implied that the concentration of TA can be increased as a step-up regimen based on the serial clinical and dermoscopic response.

A Retrospective Comparative Study of Two Concentrations of Intralesional Triamcinolone Acetonide in the Treatment of Patchy Alopecia Areata on the Scalp

BACKGROUND

Alopecia areata (AA) usually manifests as patches of non-scarring hair loss due to immune dysregulation. Intradermal injection of steroids is considered a first-line treatment of patchy AA.

PURPOSE

To compare the efficacy and safety of two commonly used concentrations of intralesional triamcinolone acetonide (ILT) (5 mg/mL vs 10 mg/mL) in the treatment of patchy AA on the scalp.

PATIENTS AND METHODS

A retrospective comparative study that included 85 patients diagnosed with patchy AA on the scalp, who were treated with monthly injections of ILT. Patients were divided into Group 1 that received 5 mg/mL and Group 2 that received 10 mg/mL. The response rate (defined as the percentage of patients who achieved complete hair regrowth) and the side effects were compared between the two groups after completion of three treatment sessions, and recurrence was assessed after 1-3 years.

RESULTS

Demographic composition of the two groups was comparable. The difference in response rate and the side-effects between the two groups were not statistically significant. Complete hair regrowth was noted in 43.5% of patients in Group 1 and 53.8% of those in Group 2 (P=0.340). About 17% and 25% of patients in Group 1 and Group 2, respectively, developed minor local side-effects (P=0.354), and almost 45% of patients from both groups had recurrence after 1-3 years. Disease duration exceeding 6 months correlated with poor treatment response.

CONCLUSION

Intralesional injection of triamcinolone acetonide 5 mg/mL is equally effective and safe compared to 10 mg/mL in the treatment of patchy alopecia areata.

Therapeutic implications of psychological state in patients with alopecia areata: A qualitative study

Hair loss can significantly impact an individual's psychological state, self-image, and can lead to numerous personal, social, and occupational problems. Although these impairments are well documented in primary studies and reviews, and the need for appropriate psychological help is emphasized, there is still a lack of knowledge for a broader and specific picture. The patient's perspective is vital while seeking to understand the content of the variables like "impaired body image" or "low self-esteem." This article advocates the need for studies involving methodologies allowing to explore the complexity and depth of experience. A better understanding of patients' states, reactions, and needs might contribute to the practice of healthcare professionals seeking the best possible help. This study aimed to explore the lived experience of people with alopecia areata in Lithuania using a phenomenological approach. Experiences of six patients with varying degrees of alopecia areata, four women and two men (mean age 27 years), were explored. Data were obtained using an unstructured interview and were analyzed based on Colaizzi's phenomenological approach. This article explores findings related to patient's psychological state covering two superordinate themes: (a) devastating loss of perceived self and (b) grieving and the process of acceptance. The insights for the appropriate therapeutic intervention were formulated.

Immunology of alopecia areata

Alopecia areata is a condition that affects hair follicles and leads to hair loss ranging from small well-defined patches to complete loss of all body hair. Despite its high incidence, the pathobiology is not fully understood, and no single concept could be universally accepted.

Alopecia areata is mostly considered to be an autoimmune disease, in which the collapse of hair follicle immune privilege plays a key role. Higher incidence rate in the female population and increased overall risk of other autoimmune disorders militate in favor of autoimmune hypothesis. Antibodies against multiple components of hair follicles almost exclusively attack in anagen phase, where melanogenesis takes place. It suggests involvement of melanogenesis-associated autoantigens as a target epitope.

Some investigators believed that alopecia areata is not a truly autoimmune disease but is only ‘consistent with’ autoimmune mechanisms. High frequency of a positive family history up to 42% may reflects the contribution of heredity factors. In addition, no specific target autoantigen has been identified so far, and autoantibodies to hair follicle-associated antigens are detectable in normal individuals.

A randomized, placebo and active controlled, split scalp study to evaluate the efficacy of platelet-rich plasma in patchy alopecia areata of the scalp

Platelet-rich plasma (PRP) is a new modality of treatment in the field of dermatology. There are paucity of studies evaluating the effects of PRP in nonscarring alopecia especially alopecia areata (AA). To compare the efficacy and safety of PRP in patchy AA of the scalp in a placebo and active controlled trial. This was a randomized, placebo and active controlled, split scalp study. Fifty patients of patchy AA of the scalp were recruited and allocated to two treatment groups. Left side of the scalp received placebo (intralesional normal saline), right side of the scalp received intralesional PRP in one group and intralesional triamcinolone acetonide in second group. Three treatment sessions were given at 4-week interval and final follow-up was done at 8 weeks later. SALT scoring, dermoscopy were the parameters used to assess the efficacy. The SALT score showed statistically significant improvement from baseline in both the treatment groups (P value <.001). The maximum absolute regrowth was shown by the steroid group followed by PRP followed by placebo group (P value .016). Improvement in dermoscopic findings were similar in both the PRP and steroid groups followed by placebo (P value .448). PRP is a promising therapy in AA as an adjuvant in those with minimal response and those not tolerating steroids or have developed adverse effects to it.

Consensus on the treatment of alopecia areata - Brazilian Society of Dermatology

BACKGROUND

Alopecia areata is a highly frequent disease with an impact on quality of life and several treatment options with little clinical confirmatory evidence.

OBJECTIVE

To disseminate the recommendations of Brazilian dermatologists with expertise in the treatment of alopecia areata.

METHODS

Eight specialists with expertise in alopecia areata from different university centers were appointed by the Brazilian Society of Dermatology to reach a consensus on its treatment. Based on the adapted DELPHI methodology, the relevant elements were considered; then, an analysis of recent literature was carried out and the consensus was written down. Consensus on the management of alopecia areata was defined with the approval of at least 70% of the panel.

RESULTS/CONCLUSIONS

Intralesional injectable corticotherapy was considered the first option for localized disease in adults. In extensive cases with signs of activity, systemic corticosteroid therapy should be considered and can be used together with immunosuppressants (corticosteroid-sparing agents). The use of an immunosensitizer (diphencyprone) is an option for stable long-term cases. Evaluation of side effects is as important as the rate of hair regrowth.

Comparative Evaluation of Therapeutic Efficacy of Intralesional Injection of Triamcinolone Acetonide versus Intralesional Autologous Platelet-rich Plasma Injection in Alopecia Areata

Context:

Alopecia areata is a chronic non-scarring alopecia that involves scalp and/or body. Corticosteroids are the most popular drugs for its treatment.

Aim:

The aim of the study was to evaluate the therapeutic efficacy of intralesional injection of triamcinolone acetonide and platelet-rich plasma (PRP) in alopecia areata and to compare the efficacy of these modalities in alopecia areata.

Settings and Design:

This was a randomized controlled comparative study.

Subjects and Methods:

Forty patients were enrolled from the outpatient department and divided into two groups of 20 patients each. Group A and B randomly received intradermal triamcinolone acetonide suspension (10 mg/mL) and PRP, respectively, into the lesion using an insulin syringe in multiple 0.1 mL injections 1cm apart. The injections were repeated every 3 weeks till 12 weeks. The patients were evaluated by Severity of Alopecia Tool (SALT) score and photographically every 3 weeks till the end of 12 weeks and then at the end of 6 months. Statistical analysis used descriptive analysis along with Pearson chi-square test or Fisher exact test, paired samples, and independent samples t test or their nonparametric analogs for continuous variables.

Results:

The reduction in SALT score at each visit with respect to baseline was greater in the triamcinolone group as compared to PRP group. This signifies greater effect of triamcinolone in alopecia areata. Around 50% patients in triamcinolone group and 5% patients in PRP group showed grade V improvement. Pain during intralesional injection was higher in the PRP group.

Conclusion:

Both intralesional triamcinolone and PRP were found to be efficacious in alopecia areata but the latter produced lesser improvement.

Excimer laser/light treatment of alopecia areata: A systematic review and meta-analyses

BACKGROUND

The excimer laser/light (EL) has been reported to be effective for alopecia areata (AA), but its treatment response has not been systematically reviewed.

OBJECTIVE

To determine the treatment response and safety of EL treatment of AA.

METHODS

A comprehensive search of the Medline, EMBASE, Cochrane library, and Web of Science (from inception to December 31, 2018) was conducted to identify prospective clinical studies assessing the treatment response of EL for AA. The primary outcome was cosmetically acceptable hair regrowth (hair regrowth ≥75%); random-effects meta-analyses using generic inverse variance weighting were performed to estimate treatment responses. The study was registered with PROSPERO (CRD42019121092).

RESULTS

Of 52 records initially identified, 13 full-text articles were finally assessed in terms of eligibility. A total of 9 prospective clinical studies (129 AA patients) including 5 controlled clinical trials were identified. Cosmetically acceptable hair regrowth was achieved in 50.2% (95% confidence interval 31.5%-68.9%; 8 studies). EL treatment significantly improved hair regrowth compared with untreated controls (relative risk 7.83; 95% confidence interval 2.11-29.11; 5 controlled clinical trials). No serious adverse effect was noted.

CONCLUSIONS

EL treatment appeared to produce a favorable therapeutic response in AA patients. The use of EL should be encouraged for AA patients with the advantages of the non-invasiveness and no systemic effect.