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

The value of immunohistochemical expression of SOX9 and CD34 in alopecia areata

BACKGROUND

Alopecia areata (AA), an immune-mediated disorder, is marked by temporary, nonscarring hair loss. The bulge area is protected from immune attacks by immune privilege; however, recent studies demonstrated immune cells infiltrating the bulge area.

OBJECTIVE

This study aims to investigate the immunohistochemical expression of the sex-determining region Y-box 9 (SOX9) and cluster of differentiation 34 (CD34) in AA patients as markers of hair follicle stem cells (HFSCs) and progenitor cells, respectively.

METHODS

Immunohistochemical staining of SOX9 and CD34 was applied on skin samples of 20 AA patients and 20 healthy controls.

RESULTS

SOX9 and CD34 were significantly lower in lesional samples of cases compared to perilesional and control skin biopsies. Furthermore, SOX9 level was negatively correlated with the severity of alopecia tool score (SALT score) among the studied AA patients. Moreover, lowered SOX9 expression was present in patients with recurrent attacks.

CONCLUSIONS

The significant reduction of stem cell markers (SOX9 and CD34) in our studied AA cases signifies the pathological affection of HFSCs and their progeny in AA. This is thought to cause a loss of competence in generating new hair in some AA cases, which needs to be validated in further research.

LIMITATIONS OF THE STUDY

This study has a small sample size.

M1 polarization of macrophages promotes stress-induced hair loss via interleukin-18 and interleukin-1β

Stress-induced hair loss is a prevalent health concern, with mechanisms that remain unclear, and effective treatment options are not yet available. In this study, we investigated whether stress-induced hair loss was related to an imbalanced immune microenvironment. Screening the skin-infiltrated immune cells in a stressed mouse model, we discovered a significant increase in macrophages upon stress induction. Clearance of macrophages rescues mice from stress-induced hair shedding and depletion of hair follicle stem cells (HFSCs) in the skin, demonstrating the role of macrophages in triggering hair loss in response to stress. Further flow cytometry analysis revealed a significant increase in M1 phenotype macrophages in mice under stressed conditions. In searching for humoral factors mediating stress-induced macrophage polarization, we found that the hormone Norepinephrine (NE) was elevated in the blood of stressed mice. In addition, in-vivo and in-vitro studies confirm that NE can induce macrophage polarization toward M1 through the β-adrenergic receptor, Adrb2. Transcriptome, enzyme-linked immunosorbent assay (ELISA), and western blot analyses reveal that the NLRP3/caspase-1 inflammasome signaling and its downstream effector interleukin 18 (IL-18) and interleukin 1 beta (IL-1β) were significantly upregulated in the NE-treated macrophages. However, inhibition of the NE receptor Adrb2 with ICI118551 reversed the upregulation of NLRP3/caspase-1, IL-18, and IL-1β. Indeed, IL-18 and IL-1β treatments lead to apoptosis of HFSCs. More importantly, blocking IL-18 and IL-1β signals reversed HFSCs depletion in skin organoid models and attenuated stress-induced hair shedding in mice. Taken together, this study demonstrates the role of the neural (stress)-endocrine (NE)-immune (M1 macrophages) axis in stress-induced hair shedding and suggestes that IL-18 or IL-1β may be promising therapeutic targets.

Neurotensin counteracts hair growth inhibition induced by chronic restraint stress

Stress has been considered as a potential trigger for hair loss through the neuroendocrine-hair follicle (HF) axis. Neurotensin (NTS), a neuropeptide, is known to be dysregulated in the inflammatory-associated skin diseases. However, the precise role of NTS in stress-induced hair loss is unclear. To investigate the function and potential mechanisms of NTS in stress-induced hair growth inhibition, we initially detected the expression of neurotensin receptor (Ntsr) and NTS in the skin tissues of stressed mice by RNA-sequencing and ELISA. We found chronic restraint stress (CRS) significantly decreased the expression of both NTS and Ntsr in the skin tissues of mice. Intracutaneous injection of NTS effectively counteracted CRS-induced inhibition of hair growth in mice. Furthermore, NTS regulated a total of 1093 genes expression in human dermal papilla cells (HDPC), with 591 genes being up-regulated and 502 genes being down-regulated. GO analysis showed DNA replication, cell cycle, integral component of plasma membrane and angiogenesis-associated genes were significantly regulated by NTS. KEGG enrichment demonstrated that NTS also regulated genes related to the Hippo signalling pathway, axon guidance, cytokine-cytokine receptor interaction and Wnt signalling pathway in HDPC. Our results not only uncovered the potential effects of NTS on stress-induced hair growth inhibition but also provided an understanding of the mechanisms at the gene transcriptional level.

Effect of topical naringenin and its combination with minoxidil on enhancing hair growth in a mouse model

This study aimed to investigate the efficacy of naringenin (NAR) in reducing hair loss. Twenty-four adult Wistar Albino mice, weighing between 25-35 g and aged 6-7 weeks, were used in this research. The dorsal hair of these mice was meticulously clipped and stained subsequently. The mice were randomly divided into four groups (n=6 for each group): (1) negative control group, treated with absolute ethanol alcohol as the vehicle (2) minoxidil (5%) treated group; (3) 0.5% naringenin treated group, and (4) naringenin plus minoxidil treated group. The treatment groups had significantly higher total antioxidant capacity in tissue levels and increased serum levels of vascular endothelial growth factor compared to the control group. No significant differences were observed in keratinocyte growth factor tissue levels between the treatment and control groups. However, the medication significantly increased hair growth, hair follicle diameter expansion, and hair follicle quantity compared to the control group. The finding suggests that the antioxidant and anti-inflammatory properties of NAR significantly reduced hair loss in adult male mice.

Approach to the patient with hair loss

Hair loss is a common complaint among both men and women and is associated with significant psychologic distress. Due to the varied causes, it is important to correctly diagnose the type of alopecia a patient is experiencing to ensure tailoring of treatment. This continuing medical education article describes the approach to diagnose alopecia based on current clinical practice and standards.

EVALUATION OF THE EFFECT OF TOPICALLY APPLIED METHYLSULFONYLMETHANE AND THEIR COMBINATION WITH MINOXIDIL SOLUTION FOR IMPROVEMENT OF HAIR GROWTH IN MALE MICE

OBJECTIVE

The aim: The purpose of this research was to find out the effect of Methylsulfonylmethane in minimizing hair loss.

PATIENTS AND METHODS

Materials and methods: Twenty adult Wister Albino mice weighing 25-35g and aged 6-7 weeks were employed. Male mice's coat hairs on the dorsal skin were carefully clipped and then colored. Mice were randomly assigned into four groups, each with five animals: (1) Control group: Treated with D.W. (2), Minoxidil (5%) treated group (3), Methylsulfonylmethane (10%) treated group (4), Methylsulfonylmethane plus Minoxidil treated group.

RESULTS

Results: We found that the tissue level of 8-isoprastanein the groups receiving medication are considerably lower than in the control (D.W.). We also discovered that the serum tissue vascular endothelial growth factor levels in the groups receiving medication are considerably greater than those in the control (D.W.) groups. On the other hand, we discovered that hair growth, hair follicle expansion and hair follicle number are much higher in the groups receiving medication than in the control groups.

CONCLUSION

Conclusions: We concluded that MSM, through its antioxidant and anti-inflammatory properties, dramatically reduces hair loss in male mice.

[Psychodermatology: Foundations for new developments in integrated care]

The burden of a skin disease is easily understood by any observer due to its visibility: psychosocial issues are therefore ubiquitous in dermatology. Current evidence now shows that this relationship is two-way, as psychosocial stress can cause skin disease and its worsening. This interrelationship poses a major challenge.

Hair Shedding Evaluation for Alopecia: A Refined Wash Test

PURPOSE

The aim of this study is to establish a refined wash test (RWT) and explore the characteristics of daily shedding hair parameters in normal individuals and patients with androgenetic alopecia (AGA) or telogen effluvium (TE).

MATERIALS AND METHODS

Chinese subjects diagnosed as normal, AGA or TE were enrolled. For the RWT procedure, the subjects were asked to pre-wash their hair 24 hours before the first collection, then to wash and rinse their hair with flowing water above a sink covered with a piece of filtering cloth. All hairs entrapped in the filtering cloth were air dried and collected. This "wash-and-collect" process was repeated for 3 consecutive days with a 24 ± 2 hour interval. Collected hairs were counted manually, and hair diameter was measured by videodermoscope. Number and diameter of daily shedding hairs and percentage of vellus and terminal hairs were analyzed.

RESULTS

A total of 176 subjects participated in and completed the study. Shedding hair number during daily shampooing was 27.9 ± 12.2, 52.2 ± 28.5 and 125.5 ± 62.7 hairs in normal, AGA and TE participants, respectively, and the differences between each two of the three groups were all statistically significant. Diameter of shedding hairs was 76.9 ± 9.0 μm, 60.0 ± 9.5 μm and 82.7 ± 9.2 μm in normal, AGA and TE, respectively. Along with advancement of AGA severity, shedding hair number was generally increased, while hair diameter decreased. The percentage of vellus hairs in AGA was significantly higher than in the normal and TE groups (8.3 ± 6.6% vs 1.0 ± 1.6% and 1.0 ± 1.0%). The combination of shedding hair number and percentage of vellus hairs had a high diagnostic confidence (AUC = 0.957) to diagnose AGA from normal. Shedding hair number alone showed high confidence to diagnose TE from normal (AUC = 0.999).

CONCLUSION

The non-invasive, easy-to-use RWT established in this study is a valuable tool to evaluate daily shedding hairs, which may be useful in diagnosis, dynamic monitoring of disease progression and treatment efficacy.

Practical Approach to Hair Loss Diagnosis

Hair loss is one of the common complaints encountered in a cosmetic practice. Evaluating a patient with hair loss requires a thorough understanding of the various causes of hair loss and practical knowledge in hair cosmetics and hair styling procedures. A systematic approach in hair loss evaluation helps the treating physician in arriving at a diagnosis. Various bedside tests and advent of trichoscopy has empowered the physician in arriving at a diagnosis. This article aims to provide the physician a systematic approach in evaluating a patient with hair loss.

The Roles of Non-coding RNA in the Development and Regeneration of Hair Follicles: Current Status and Further Perspectives

Alopecia is a common problem that affects almost every age group and is considered to be an issue for cosmetic or psychiatric reasons. The loss of hair follicles (HFs) and hair caused by alopecia impairs self-esteem, thermoregulation, tactile sensation and protection from ultraviolet light. One strategy to solve this problem is HF regeneration. Many signalling pathways and molecules participate in the morphology and regeneration of HF, such as Wnt/β-catenin, Sonic hedgehog, bone morphogenetic protein and Notch. Non-coding RNAs (ncRNAs), especially microRNAs and long ncRNAs, have significant modulatory roles in HF development and regeneration via regulation of these signalling pathways. This review provides a comprehensive overview of the status and future prospects of ncRNAs in HF regeneration and could prompt novel ncRNA-based therapeutic strategies.

Alopecia areata: Current understanding of the pathophysiology and update on therapeutic approaches, featuring the Japanese Dermatological Association guidelines

Alopecia areata (AA) is a relatively common nonscarring hairloss disease characterized by an autoimmune response to anagen hair follicles (HFs). Accumulated evidence suggests that collapse of the HF immune privilege subsequent to triggering events, represented by viral infection, leads to autoimmune response in which autoreactive cytotoxic CD8+NKG2D+ T cells mainly target exposed HF autoantigens. AA had been recognized as type 1 inflammatory disease, but recent investigations have suggested some roles of type 2- and Th17-associated mediators in AA pathogenesis. The significance of psychological stress in AA pathogenesis is less emphasized nowadays, but psychological comorbidities, such as depression and anxiety, attract greater interest in AA management. In this regard, the disease severity may not solely be evaluated by the extent of hair loss. Use of trichoscopy markedly improved the resolution of the diagnosis and evaluation of the phase of AA, which is indispensable for the optimization of treatment. For the standardization of AA management, the establishment of guidelines/expert consensus is pivotal. Indeed, the Japanese Dermatological Association (JDA) and other societies and expert groups have published guidelines/expert consensus reports, which mostly recommend intralesional/topical corticosteroid administration and contact immunotherapy as first-line treatments, depending on the age, disease severity, and activity of AA. The uniqueness of the JDA guidelines can be found in their descriptions of intravenous corticosteroid pulse therapy, antihistamines, and other miscellaneous domestically conducted treatments. Considering the relatively high incidence of spontaneous regression in mild AA and its intractability in severe subsets, the importance of course observation is also noted. Evidenced-based medicine for AA is currently limited, however, novel therapeutic approaches, represented by JAK inhibitors, are on their way for clinical application. In this review, the latest understanding of the etiopathogenesis and pathophysiology, and update on therapeutic approaches with future perspectives are summarized for AA, following the current version of the JDA AA management guidelines.

The hair follicle-psoriasis axis: Shared regulatory mechanisms and therapeutic targets

It has long been known that there is a special affinity of psoriasis for the scalp: Here, it occurs most frequently, lesions terminate sharply in frontal skin beyond the hair line and are difficult to treat. Yet, surprisingly, scalp psoriasis only rarely causes alopecia, even though the pilosebaceous unit clearly is affected. Here, we systematically explore the peculiar, insufficiently investigated connection between psoriasis and growing (anagen) terminal scalp hair follicles (HFs), with emphasis on shared regulatory mechanism and therapeutic targets. Interestingly, several drugs and stressors that can trigger/aggravate psoriasis can inhibit hair growth (e.g. beta-blockers, chloroquine, carbamazepine, interferon-alpha, perceived stress). Instead, several anti-psoriatic agents can stimulate hair growth (e.g. cyclosporine, glucocorticoids, dithranol, UV irradiation), while skin/HF trauma (Köbner phenomenon/depilation) favours the development of psoriatic lesions and induces anagen in "quiescent" (telogen) HFs. On this basis, we propose two interconnected working models: (a) the existence of a bidirectional "hair follicle-psoriasis axis," along which keratinocytes of anagen scalp HFs secrete signals that favour the development and maintenance of psoriatic scalp lesions and respond to signals from these lesions, and (b) that anagen induction and psoriatic lesions share molecular "switch-on" mechanisms, which invite pharmacological targeting, once identified. Therefore, we advocate a novel, cross-fertilizing and integrative approach to psoriasis and hair research that systematically characterizes the "HF-psoriasis axis," focused on identification and therapeutic targeting of selected, shared signalling pathways in the future management of both, psoriasis and hair growth disorders.

Acute telogen effluvium triad after resolution

Five cases of telogen effluvium undergoing resolution are shown, with the presence of frontal, bitemporal, and occipital hair regrowth. Diagnosing acute telogen effluvium after the end of the active phase can be challenging, especially when the pull test is negative. The differential diagnosis includes alopecia areata and traction alopecia. Clinical signs of hair regrowth after telogen effluvium can help in the diagnosis. The frontal and temporal areas have more telogen hairs and are more affected. On the occipital area, hairs seem to have the same behavior. The acute telogen effluvium triad during resolution is proposed: frontal fringe, temporal recess and occipital fringe.

Scarring Alopecia: Diagnosis and New Treatment Options

This article focuses on the assessment and treatment of patients with primary cicatricial alopecia and provides new information regarding the genetics and pathophysiology of this group of diseases.

New Diagnostic Tools to Evaluate Hair Loss

The precise and reliable diagnosis of hair loss disorders is essential for developing a successful management plan. It is, thus, the responsibility of the dermatologist to select the appropriate diagnostic tools to effectively evaluate patients presenting with hair loss concerns. Fortunately, there is a growing body of noninvasive and invasive diagnostic resources, each with advantages and disadvantages. For the practicing dermatologist, tactile assessments and direct visualization are enhanced with scoring instruments, questionnaires, handheld trichoscopy, and scalp biopsy. For research and clinical study purposes, the more precise, high-resolution tools such as videodermoscopy, optical coherence tomography, and phototrichograms, may be useful.

Recent Insight on the Management of Lupus Erythematosus Alopecia

Lupus erythematosus (LE) is a chronic autoimmune condition with a wide spectrum of clinical presentations. Alopecias, both non-scarring and scarring, frequently occur in the context of LE and can assume several different patterns. Furthermore, alopecia occurring with LE may be considered LE-specific if LE-specific features are present on histology; otherwise, alopecia is considered non-LE-specific. Non-scarring alopecia is highly specific to systemic LE (SLE), and therefore has been regarded as a criterion for the diagnosis of SLE. Variants of cutaneous LE (CLE), including acute, subacute, and chronic forms, are also capable of causing hair loss, and chronic CLE is an important cause of primary cicatricial alopecia. Other types of hair loss not specific to LE, including telogen effluvium, alopecia areata, and anagen effluvium, may also occur in a patient with lupus. Lupus alopecia may be difficult to treat, particularly in cases that have progressed to scarring. The article summarizes the types of lupus alopecia and recent insight regarding their management. Data regarding the management of lupus alopecia are sparse and limited to case reports, and therefore, many studies including in this review report the efficacy of treatments on CLE as a broader entity. In general, for patients with non-scarring alopecia in SLE, management is aimed at controlling SLE activity with subsequent hair regrowth. Topical medications can be used to expedite recovery. Prompt treatment is crucial in the case of chronic CLE due to potential for scarring and irreversible damage. First-line therapies for CLE include topical corticosteroids and oral antimalarials, with or without oral corticosteroids as bridging therapy. Second and third-line systemic treatments for CLE include methotrexate, retinoids, dapsone, mycophenolate mofetil, and mycophenolate acid. Additional topical and systemic medications as well as physical modalities used for the treatment of lupus alopecia and CLE are discussed herein.

Investigating the Safety and Efficacy of Platelet-Rich Plasma (PRP) Treatment for Female Androgenetic Alopecia: Review of the Literature

Background: female androgenetic alopecia (FAGA) is a common cause of non-scarring alopecia in women, affecting approximately 40% of women by age 50, bearing a significant psychosocial burden on affected patients. Platelet-rich plasma (PRP) has been widely investigated as a potential effective treatment for several dermatological conditions, including male androgenetic alopecia (MAGA). However, few studies have been conducted focusing on the use of PRP in FAGA. The aim of this review was to identify reports that investigated the use of PRP for the treatment of FAGA. Methods: Electronic databases of MEDLINE, EMBASE, and Cochrane Central Register of Controlled Trials (CENTRAL) from inception to September 2020 have been searched using different combinations of the following terms: “androgenetic alopecia,” “FAGA,” “female pattern hair loss,” “platelet-rich fibrin,” “platelet-rich plasma,” and “PRP”. Results and conclusions: Eight (n = 8) clinical studies consistent with our research were identified. A total of 197 subjects has been enrolled in the included studies. All of them were adult female patients (mean age: 38.9) affected by female pattern hair loss. PRP is a well-tolerated procedure which showed promising results in males-only and mixed populations of AGA patients. PRP showed to produce high levels of satisfaction and improvement in the quality of life in patients affected by FAGA. In the light of this evidence, PRP may be proposed in patients who did not respond or did not tolerate topical minoxidil, as well as in combination with topical and oral treatments.

The role of sleep in telogen effluvium and trichodynia: A commentary in the context of the current pandemic

Telogen effluvium (TE), a common hair disease, is supposed to be related to stress, which could be secondary to poor sleep. We call attention to the current COVID-19 pandemic, that is leading to an increase in the prevalence of sleep disturbances, and as a consequence, higher states of stress and anxiety, which are possible triggers for TE. In parallel, trichodynia is a sensorial symptom that is commonly related with hair diseases, including TE. We argue that substance P, a neuropeptide that has participation in the neuroinflammation and in the sleep regulation, may play a possible role in this scalp paresthesia. We suggest that there may be an association between this substrate and sleep, which can aggravate trichodynia and TE. Further studies on this subject could provide more evidence on these relationships, and help to improve the patients' quality of life and management of the condition.

Accuracy of clinical diagnosis and videodermoscopy in female pattern hair loss

BACKGROUND

Female pattern hair loss (FPHL) is a non-scarring hair disease characterized by progressive hair diminishment and decrease of its density. Although typical cases of FPHL are usually straightforward to diagnose, its initial forms can be unrecognized and often need the use of other diagnostic methods.

OBJECTIVE

To describe the accuracy of a diagnosis of FPHL based on clinical grounds and videodermoscopy compared with scalp biopsy.

METHODS

An observational diagnostic test study was performed. Scalp biopsies were read by the same dermatopathologist and processed horizontally to allow follicle's number and size evaluation. Digital videodermoscopy was also performed.

RESULTS

A total of 202 patients were enrolled, but only 35 women were assessed with digital videodermoscopy. When clinical diagnosis was compared to scalp biopsy, a sensitivity, specificity, positive predictive value (PPV), and a negative predictive value (NPV), of 77% %, 72.4%, 82.2%; and 65.5%, were respectively obtained. Videodermoscopy showed a sensitivity, specificity, PPV and NPV of 88.9%, 100%, 100%, and 72.7%, respectively.

CONCLUSIONS

This study provided valuable information on the accuracy of clinical examination of FPHL, showed the usefulness of videodermoscopy as a method that in the future may replace scalp biopsy for its diagnosis, or also could aid patient´s follow-up.

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.

High-frequency ultrasonography of the scalp - Comparison of ultrasound and trichoscopic images in healthy individuals

BACKGROUND

Hair loss is a common problem in dermatological patients. Its diagnosis is based on selected non-invasive and invasive tests. Searching for new diagnostic methods, especially non-invasive ones, aims to accelerate the correct diagnosis in the least invasive way possible. The aim of our study was to establish the characteristics of ultrasound images in healthy individuals and to compare them to selected trichoscopic parameters.

MATERIALS AND METHODS

Eighteen healthy adults (10 women and 8 men) underwent trichoscopy and high-frequency ultrasound (HF-USG) with 20 MHz DermaScan transducer on the parietal region of the scalp. Selected parameters were compared in relation to sex and the research method used.

RESULTS

HF-USG of the parietal area in all examined patients revealed hyperechogenic entrance echo and less echogenic layer corresponding to the dermis with well-defined hypoechoic follicular structures (FS). The number of hair units in trichoscopy and the number of FS in HF-USG did not differ significantly, while the differences in the studied distances between structures were statistically significant. The width of FS in HF-USG was significantly higher than hair shafts thickness in trichoscopy.

CONCLUSIONS

HF-USG (20MHz) due to the possibility of visualization of FS can be a valuable complement to the range of non-invasive diagnostic procedures used in evaluation of the scalp.

Trichoscopy of Alopecia Areata: Hair Loss Feature Extraction and Computation Using Grid Line Selection and Eigenvalue

Recently, the hair loss population, alopecia areata patients, is increasing due to various unconfirmed reasons such as environmental pollution and irregular eating habits. In this paper, we introduce an algorithm for preventing hair loss and scalp self-diagnosis by extracting HLF (hair loss feature) based on the scalp image using a microscope that can be mounted on a smart device. We extract the HLF by combining a scalp image taken from the microscope using grid line selection and eigenvalue. First, we preprocess the photographed scalp images using image processing to adjust the contrast of microscopy input and minimize the light reflection. Second, HLF is extracted through each distinct algorithm to determine the progress degree of hair loss based on the preprocessed scalp image. We define HLF as the number of hair, hair follicles, and thickness of hair that integrate broken hairs, short vellus hairs, and tapering hairs.

Favorable effects of microneedling on long-standing androgenetic alopecia in an elderly man: A case report

BACKGROUND

Androgenetic alopecia (AGA) is the most common type of alopecia. Currently, various methods have been tried to treat male AGA, but the outcomes are often unsatisfactory, especially for elderly persons.

AIMS

We report a case of an elderly man with a severe long-standing AGA, which was successfully managed with microneedling and minoxidil.

PATIENTS/METHODS

The patient was a 70-year-old Japanese man with family history of AGA, showed no abnormality in physical and laboratory examinations, and had received no treatment. We did monotherapy with 5% minoxidil twice daily to the right half of the scalp, while on the left half topical minoxidil was combined with weekly microneedling using an automated microneedling pen.

RESULTS

After 14 weeks of treatment, negligible hair growth was observed on the monotherapy side. On the combined-therapy side, however, hair growth was obvious and the density of hairs determined under trichoscope was significantly increased compared with the monotherapy side (P < .001). Only transient pain, erythema, and pinpoint bleeding were observed as adverse effects.

CONCLUSION

Although we need further clinical trials to assess the efficacy and safety and to standardize the method, microneedling combined with topical minoxidil could be a treatment option for severe AGA in elderly patients.

Trichoscopic Patterns of Nonscarring Alopecia's

BACKGROUND

Hair loss (alopecia) is a common problem and is a major cause of psychological stress and anxiety among affected individuals. It is of utmost importance to diagnose these cases at the earliest and treat them accordingly. Trichoscopy provides a noninvasive option that can be used for early diagnosis and monitoring the progression of the hair disorders.

AIMS AND OBJECTIVES

To perform trichoscopy and document the findings in patients with nonscarring alopecia's.

MATERIALS AND METHODS

A total of 100 cases satisfying the inclusion criteria were screened for general physical examination and scalp examination including hair shaft and root, and tests for hair anchorage and fragility were also done. The lesions were examined through dermoscope, photographs were taken, and findings were documented.

RESULTS

Among the total of 100 cases screened, 57 were female and 43 were male. The mean age of the study group was 26 ± 14.8 years. Females were affected by alopecia areata (AA) and female pattern hair loss (29.8%) equally, whereas males were most commonly affected by AA (41.8%). The common trichoscopic follicular features noted were broken hair (48%), black dots (48%), single hair follicle unit (45%), short vellus hair (44%), upright hair (41%), and yellow dots (40%). The common interfollicular features seen were honeycomb pigmentation (26%) and arborizing red lines (12%).

CONCLUSION

The emergence of newer hair signs on trichoscopic studies aids in identification and has a definitive role in the diagnosis of clinically difficult cases, so it is recommended to use trichoscopy in the routine examination of nonscarring alopecia's.

Analysis of Microscopic Examination of Pulled Out Hair in Telogen Effluvium Patients

Background

Telogen effluvium (TE) is characterized by massive hair shedding and results from an abrupt conversion of anagen to telogen. Differentiation of TE with other hair disorders showing massive hair shedding is difficult.

Objective

To evaluate the morphologic characteristics of pulled out hair of TE.

Methods

We analyzed microscopic examination of pulled out hairs by hair pull test in TE patients, and compared these hairs with pulled out hairs in diffuse alopecia areata (AA) patients and healthy volunteers.

Results

Hair microscopic examination in 44 TE patients (370 hairs) and 30 healthy volunteers (295 hairs) were as follows: typical club hair, 32.7%, 62.7%; club hair with tail, 23.5%, 23.7%; club hair with remnant sheath, 23.0%, 6.8%; club hair with both tail and remnant sheath, 18.9%, 5.4%; and unclassified hair, 1.9%, 1.4%. The examination in 7 diffuse AA patients (63 hairs) was as follows: typical club hair, 23.9%; atypical club hair, 47.7%; and distinctive AA hair, 28.4%. There was statistical difference between TE patients and healthy volunteers group (p=0.000).

Conclusion

Increased atypical club hair in microscopic hair examination might be characteristics of TE.

Accelerated hair growth by combining thread monofilament and minoxidil in female androgenetic alopecia

BACKGROUND

Monofilament thread therapy (PLLA) and minoxidil have been used as alternative treatments for female androgenetic alopecia.

AIM

The aim was to determine the efficacy and safety of thread therapy combined with minoxidil in female androgenetic alopecia.

PATIENT AND METHODS

Twenty-seven women were enrolled in this randomized half-split study based on a left-head to the right-head pattern. Thread therapy (PLLA) treatment was unilaterally performed (once); minoxidil was bilaterally applied for 6 months. Global photographs and dermoscopy assessments were performed in the baseline and every 2 months till the end of treatment. Global photographs underwent blinded review by three independent dermatologists.

RESULTS

Mean hair density increased from 114 ± 27 to 143 ± 25/cm² (P < .001) in the combined group and from 113 ± 24 to 123 ± 19/cm² in the minoxidil group (P < .001). The mean change from baseline between the two groups was also compared (P = .003). Global photographs showed improvement in 93% (25/27) patients in the combined group and 52% (14/27) patients in the minoxidil group.

CONCLUSION

Poly-l-lactic acid microthread therapy combined with minoxidil may improve hair density, hair thickness, and hair appearance better than minoxidil alone.

Overall clinical and trichoscopic analysis performed in patients who underwent pressurized intraperitoneal aerosol chemotherapy (PIPAC) treatment for peritoneal carcinomatosis - initial trial preliminary report

Introduction

Cutaneous adverse events are among the remaining problematic issues of current oncology. The term peritoneal carcinomatosis (PC) refers to the advanced cancer stage. The innovative treatment of PC includes the use of pressurized intraperitoneal aerosol chemotherapy (PIPAC).

Aim

To present a preliminary report from an initial trial aimed at an overall clinical and trichoscopic analysis performed in patients who underwent PIPAC treatment due to PC.

Material and methods

For all steps of this study we obtained the consent of the local bioethics commission #KB 196/2018. Three different hair assessment methods were used in our study: 1) general clinical and patient self-feeling assessment; 2) hair pull test; 3) and trichoscopic analysis.

Results

No hair or scalp disorders were noted in the observation period. In the self-feeling test assessment the vast majority recognized their hair as being of comparable quality or even better in quality compared to previous forms of chemotherapy they had undergone. In all patients we observed a reduction of hair loss in the pull test in the hospitalization period. In trichoscopic analysis we found all determinants and signs of hair disorders in the assessed group.

Conclusions

The PIPAC is safe and is not a burdensome or aggressive form of therapy, especially according to the very important factors influencing the potential quality of hair and hair loss. The authors, however, realize that to obtain comprehensive results and evaluate this novel and promising method we need to perform more research without any limitations like those in our study.

The psychological and aesthetic impact of age-related hair changes in females

BACKGROUND

While dermatologists focus on practices to promote anti-aging, thinning hair that frames a more rejuvenated face can affect age perception and cosmesis.

OBJECTIVES

To characterize the effects of age-related hair changes on age determination and perceived attractiveness.

METHODS

A search was conducted for articles on intrinsic and extrinsic aging as it relates to hair. Key studies on the hair aging process and its effects on self-perception, confidence, and anti-aging were reviewed.

RESULTS

According to several studies, hair density peaks about 27 years of age or earlier and then decreases from the mid-thirties onward. This serves as an opportunity to prevent or treat hair loss in a similar way we treat aging skin. Without optimizing appearance of hair, overall cosmesis to foster self-perception can be curtailed despite multiple efforts to rejuvenate and restore the aging face.

CONCLUSION

The discrepancy between rejuvenated faces and thinner appearing hair that frames the face highlights the importance of a holistic approach to the anti-aging consultation. To more comprehensively address the aesthetic patient, we need to promote awareness of the onset of these hair changes in order to incorporate prevention and therapeutic strategies to preserve hair to complement overall appearance.

Assessing the correlation between trichoscopic features in lichen planopilaris and lichen planopilaris activity index

BACKGROUND/OBJECTIVES

Videodermoscopy is a valuable tool for the diagnosis of cicatricial alopecias such as lichen planopilaris. Lichen planopilaris activity index is used for evaluating lichen planopilaris severity. Our aim was to examine the utility of videodermoscopy in the assessment of lichen planopilaris severity.

METHODS

One hundred and seventeen histopathologically confirmed lichen planopilaris patients under went videodermoscopy. Lichen planopilaris activity index was calculated according to cicatricial alopecia standardised flowchart. Differences and correlations between trichoscopic features, clinical findings and lichen planopilaris activity index were calculated.

RESULTS

Most trichoscopic features had statistically significant higher prevalence than similar clinical findings. Targetoid pigment pattern, perifollicular scale and milky-red areas were significantly correlated with lichen planopilaris activity index (P-value < 0.05). There was statistically significant correlation between targetoid pigment pattern and positive anagen pull test (P-value < 0.001).

CONCLUSION

Using trichoscopic features in calculating lichen planopilaris activity index with videodermoscope can help in early lichen planopilaris diagnosis and improve post-treatment follow-up.

Current and emerging treatment strategies for hair loss in women of color

Hair loss is common in women of color, and is associated with significant psychosocial complaints. Early clinical recognition and prompt initiation of intervention with medical treatment is critical to halt the disease process. In this article, we review the clinical presentations of nonscarring and scarring alopecias in women of color, use of dermoscopy for early recognition of the disease process, and medical, procedural, and surgical interventions. In conditions that result in scarring alopecia, such as late-stage traction, frontal fibrosing, or central centrifugal cicatricial alopecia, patients may benefit from procedural interventions, such as hair transplantation, platelet rich plasma injections, low-level laser therapy, or scalp therapy.

A semiquantitative grading scale for frontal and vertex of androgenetic alopecia

BACKGROUND

Depending on the severity and region of baldness, numerous researchers proposed different classifications of alopecia. However, these previous classifications have some limitations. The study aimed to establish a semiquantitative grading scale for frontal and vertex androgenetic alopecia (AGA) in both males and females.

METHODS

Standardized pictures from 1,602 AGA cases were obtained. Three sets of reference photographs with different alopecia extents from scale 0 to 5 were developed with detailed description. The photographs covered the vertex, frontal of men, and vertex + frontal (V+F) area of the scalp of women. Hair density and the ratio of vellus and terminal hairs in the alopecia area were quantitatively measured by DermDOC^® dermoscopy. Hair coverage rate of alopecia area was calculated by Photoshop software. Multirater consensus method was used to test the reliability and validity of the alopecia scale.

RESULTS

Fleiss-Kappa coefficients of the three sets of reference photographs for interobserver analysis reached 0.81-0.89. The overall Kendall's coefficients for intraobserver assessment totaled 0.934-0.963.

CONCLUSION

This new grading scale is a more sensitive and objective quantitative grading scale for alopecia and treatment response compared with the existing classification.

Alopecias in lupus erythematosus

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

Severe hair loss associated with psychotropic drugs in psychiatric inpatients-Data from an observational pharmacovigilance program in German-speaking countries

BACKGROUND

The study aimed to investigate severe hair loss related to psychotropic drugs (PDs) by using data from the drug safety programme Arzneimittelsicherheit in der Psychiatrie (AMSP).

METHODS

Data on PD utilization and reports of severe PD-related hair loss were collected in 83 psychiatric hospitals in Austria, Germany and Switzerland during the period 1993-2013.

RESULTS

Out of 432,215 patients under surveillance, 404,009 patients were treated with PDs for the main indications of depression, schizophrenic disorder, neurosis, mania, and organic psychosis. Severe hair loss related to PD treatment was reported in 43 cases (0.01%). The rates of hair loss under antipsychotic drugs were slightly lower than the mean rates of all PDs and antidepressant drugs. Valproic acid was related to the highest risk. In 6 of the 43 cases, hair loss was imputed to multiple drugs, with 4 cases imputed to double drug combinations and 2 cases to triple combinations. Rates of severe hair loss under valproic acid (VPA) and lithium salts were distinctly lower as compared with the overall rates reported in literature. Severe hair loss under PD treatment was reported significantly more often in female patients than in male patients (p < 0.01).

CONCLUSION

The rate of severe PD-related hair loss was very low in the present survey. The large number of patients included in this multicentre study allows for assessment and comparison of hair loss rates related to different PDs and groups of PDs and provides new and supplementary information on PD-related hair loss.

Correlation of clinical and pathologic evaluation of scarring alopecia

BACKGROUND

Differentiating scarring and nonscarring alopecia poses a diagnostic dilemma for clinicians, with histopathology used to distinguish. The extent to which dermatologists are able to clinically classify alopecia has not been evaluated.

METHODS

A retrospective study of pathology reports on 458 patients was used to calculate a kappa coefficient to correlate clinical presence of scarring or nonscarring alopecia to histopathologic presence of scarring or nonscarring. A multivariate analysis was performed to assess for associations with scarring.

RESULTS

The kappa correlation coefficient was 0.59 (P < 0.0001), indicating moderate agreement and varied by race and sex. There were 15 times higher odds of making the clinical diagnosis of scarring alopecia (OR 14.64 95% CI [8.64-24.18]; P < 0.001), and this increased with age.

CONCLUSIONS

These results suggest that clinical exam is moderately reliable in distinguishing between scarring and nonscarring alopecia. Our results highlight the need for education and diagnostic schemata for evaluation of alopecia based on gender and in skin of color.

Hair disorders in patients with cancer

Cytotoxic chemotherapies, molecularly targeted therapies, immunotherapies, radiotherapy, stem cell transplants, and endocrine therapies may lead to hair disorders, including alopecia, hirsutism, hypertrichosis, and pigmentary and textural hair changes. The mechanisms underlying these changes are varied and remain incompletely understood, hampering the development of preventive or therapeutic guidelines. The psychosocial impact of chemotherapy-induced alopecia has been well documented primarily in the oncology literature; however, the effect of other alterations, such as radiation-induced alopecia, hirsutism, and changes in hair color or texture on quality of life have not been described. This article reviews clinically significant therapy-related hair disorders in oncology patients, including the underlying pathophysiological mechanisms, severity grading scales, patient-reported quality of life questionnaires, management strategies, and future translational research opportunities.

Alopecia Areata: Review of Epidemiology, Clinical Features, Pathogenesis, and New Treatment Options

Alopecia areata (AA) is a complex autoimmune condition that causes nonscarring hair loss. It typically presents with sharply demarcated round patches of hair loss and may present at any age. In this article, we review the epidemiology, clinical features, pathogenesis, and new treatment options of AA, with a focus on the immunologic mechanism underlying the treatment. While traditional treatment options such as corticosteroids are moderately effective, a better understanding of the disease pathogenesis may lead to the development of new treatments that are more directed and effective against AA. Sources were gathered from PubMed, Embase, and the Cochrane database using the keywords: alopecia, alopecia areata, hair loss, trichoscopy, treatments, pathogenesis, and epidemiology.

Lichen planopilaris in a Latin American (Chilean) population: demographics, clinical profile and treatment experience

BACKGROUND

Lichen planopilaris (LPP) is characterized by lymphocytic infiltrate, fibrosis and potential destruction of the hair follicle. Demographic and clinical studies in LPP are limited, and racial differences have not been thoroughly investigated.

AIM

To analyse epidemiological data and clinical profiles of Chilean adults with LPP, and report on the treatments used.

METHODS

This was a retrospective review of medical records and clinical follow-up of Chilean adults with a clinical and histopathological diagnosis of LPP. Treatment response was categorized clinically as none (with progression of condition), mild or satisfactory.

RESULTS

The study assessed 103 patients with LPP [67 women (mean age 54.1 years) and 36 men (mean age 39.1 years)]. Of the 103 patients, 41 women and 34 men were diagnosed with classic LPP (CLPP) and 26 women and 1 man with frontal fibrosing alopecia (FFA), while Graham-Little-Piccardi-Lassueur syndrome (GLPLS) was identified in 1 man. Men with CLPP had a significantly (P < 0.001) earlier age of onset than women. Scalp dysaesthesia, erythema and peripilar hyperkeratosis were common findings, and 51 (66%) of patients with CLPP had cicatricial patches, most of which were circumscribed in the vertex area. All patients with FFA had band-like scarring in the frontal and temporal hairlines. Morbidities associated with LPP were hypothyroidism, dyslipidaemia, hypertension and depression. For most patients, treatment halted or improved their inflammatory/scarring condition. A sustained combination of at least one topical (clobetasol, minoxidil and salicylic acid) and one systemic (cetirizine, hydroxychloroquine, finasteride, methotrexate and isotretinoin) medication was necessary in all of our patients with LPP.

CONCLUSION

This investigation is one of the first to describe the demographic, clinical and therapeutic features of LPP in a Latin American population. Similar profiles to previous reports may encourage research in larger multicentre international studies.

Phage Therapy in a 16-Year-Old Boy with Netherton Syndrome

Netherton syndrome (NS) is a rare autosomal recessive disorder, characterized by a classical triad of clinical features, including congenital ichthyosiform erythroderma, trichorrhexis invaginata, and atopic diathesis coupled with frequent bacterial infections (1). The genetic basis for the disease has been recently identified with mutations in gene SPINK5, which is involved in the regulation of formation of skin barriers. We report on a 16-year-old male with all the typical manifestations of NS, including atopic diathesis and ongoing serious staphylococcal infections and allergy to multiple antibiotics whose family sought help at the Eliava Phage Therapy Center when all other treatment options were failing. Treatment with several antistaphylococcal bacteriophage preparations led to significant improvement within 7 days and very substantial changes in his symptoms and quality of life after treatment for 6 months, including return visits to the Eliava Phage Therapy Center after 3 and 6 months of ongoing use of phage at home.

A Holistic Approach to Antiaging as an Adjunct to Antiaging Procedures: A Review of the Literature

BACKGROUND

Aging is a multifactorial process and depends on both intrinsic and extrinsic factors. Procedural options for diminishing signs of intrinsic aging and cosmetic rejuvenation have expanded dramatically. However, less attention is paid to counseling patients on options for mitigating extrinsic factors related to aging.

OBJECTIVE

The objective of this study was to review changes that occur with intrinsic and extrinsic aging, and provide evidence-based holistic counseling recommendations that can be used synergistically with aesthetic procedures to maximize antiaging interventions.

MATERIALS AND METHODS

A PubMed search was conducted for articles on intrinsic and extrinsic aging as it relates to skin, fat, muscle, and bone. Key clinical trials and studies on the effect of diet, hormones, exercise, sleep, stress, dental hygiene, smoking, pollution, and oxidative stress on the aging process are reviewed, and treatment recommendations are summarized based on available evidence.

RESULTS

Conventional cosmetic procedures and cosmeceuticals work together with nutritious diet, exercise, dental hygiene, hormonal balance, stress reduction, smoking and pollution avoidance, and healthy sleep patterns for a better effect on antiaging.

CONCLUSION

A combination approach of multiple nonsurgical modalities along with healthy lifestyle recommendations to minimize intrinsic and extrinsic aging factors allows cosmetic practitioners to target multiple facets of aging concurrently and maximize the aesthetic interventions cosmetic dermatologists/practitioners provide.