Hair regrowth in 2 patients with recalcitrant central centrifugal cicatricial alopecia after use of topical metformin

Proteomic Profiling of Central Centrifugal Cicatricial Alopecia Reveals Role of Humoral Immune Response Pathway and Metabolic Dysregulation

Proteomic profiling on other primary cicatricial alopecias, such as frontal fibrosing alopecia and lichen planopilaris, have suggested a T helper 1-mediated inflammatory pathway, but in central centrifugal cicatricial alopecia (CCCA), the protein expression patterns are unknown. In this study, we sought to characterize protein expression patterns in CCCA to identify biomarkers of disease activity that will identify potential therapeutic avenues for treatment. Scalp protein quantification was performed to understand protein expression patterns in affected versus unaffected scalps in CCCA. A total of 5444 proteins were identified, of which 148 proteins were found to be differentially expressed in CCCA-affected scalp, with upregulation of adaptive immune pathways (IGHG3, P = .034; IGHG4, P = .01; IGG1, P = .026) and markers of fibrosis (ITGA1, P = .016; SFRP2, P = .045; TPM2, P = .029; SLMAP, P = .016) and downregulation of metabolic proteins (ALOX15B, P = .003; FADS2, P = .006; ELOVL5, P = .007; FA2H, P = .017; FAR2, P = .011; SC5D, P < .001). Our analysis revealed, to our knowledge, previously unknown humoral immune canonical pathways, notably IgG, implicated in CCCA and additionally confirmed aberrant lipid metabolism pathways implicated in diabetes mellitus, suggesting unique mechanisms of disease in patients with CCCA.

Updates on disorders in curly hair

Hair disorders, including central centrifugal cicatricial alopecia (CCCA), traction alopecia (TA), and acquired trichorrhexis nodosa (ATN), commonly occur in individuals with curly textured hair. Curly textured hair in individuals of African descent has unique properties and can present diagnostic and therapeutic challenges. CCCA has been linked to uterine leiomyoma and type 2 diabetes mellitus, as well as fibroproliferation. TA often presents with a fringe sign and can arise from high-tension hairstyles presumed to be protective. Trichoscopy is useful in establishing a diagnosis; perifollicular halos are more commonly seen than perifollicular erythema or scale in CCCA. In TA, miniaturized follicles, hair casts, and "flambeau sign" can be seen. Hairstyling practices likely contribute to TA and ATN; however, the data are mixed on the role of chemical relaxers and heat styling in CCCA. Unique considerations in the presentation of frontal fibrosing alopecia in curly textured hair have also been published recently. This review provides a comprehensive, up-to-date summary of these disorders with an emphasis on their unique properties, as well as considerations in hair care for curly textured hair.

Central centrifugal cicatricial alopecia: a deeper insight into the disease

Central centrifugal cicatricial alopecia (CCCA) is a scarring alopecia of multifactorial etiology that presents on the vertex as patchy areas of hair loss, spreading centrifugally over the scalp. It most commonly affects women of African descent, but cases among other ethnicities have also been reported. CCCA typically starts with thinning and breaking of the hair as the first sign of presentation, which eventually progresses to hair loss over the central part of the scalp, spreading symmetrically outwards to involve a larger area. Currently, there is no definitive cure for the disease; however, multiple management options are available, which should aim to be tailored to the individual patient. Owing to its cosmetic outcomes, the quality of life (QoL) of patients with central centrifugal cicatricial alopecia is also disturbed, as patients may face psychological and social stress due to their permanent hair loss. This article focuses on various aspects of the pathogenesis, clinical trials, quality of life, barriers faced by patients, and treatment of central centrifugal cicatricial alopecia.

Treatment for central centrifugal cicatricial alopecia-Delphi consensus recommendations

BACKGROUND

There is no established standard of care for treating central centrifugal cicatricial alopecia (CCCA), and treatment approaches vary widely.

OBJECTIVE

To develop consensus statements regarding the use of various pharmacological therapies in treating adults with CCCA.

METHODS

We invited 27 dermatologists with expertise in hair and scalp disorders to participate in a 3-round modified Delphi study between January and March 2023. Statements met strong consensus if 75% of respondents agreed or disagreed. Statements met moderate consensus if 55% or more but less than 75% agreed or disagreed.

RESULTS

In round 1, 5 of 33 (15.2%) statements met strong consensus, followed by 9 of 28 (32.1%) in round 2. After the final round 3 meeting, strong consensus was reached for 20 of 70 (28.6%) overall statements. Two statements achieved moderate consensus.

LIMITATIONS

This study included only English-speaking, US-based dermatologists and did not consider nonpharmacological therapies.

CONCLUSION

Despite varying opinions among dermatologists, consensus was reached for several statements to help clinicians manage CCCA. We also highlight areas that lack expert consensus with the goal of advancing research and therapeutic options for CCCA.

Topical metformin 30% gel in the treatment of acne vulgaris in women, a split face, placebo-controlled study

Acne vulgaris (AV), a widely common disorder, that negatively affects the quality of life. Metformin is a relatively safe, cheap and well tolerated drug that is widely used in the treatment of Diabetes. Systemic metformin has demonstrated promising results in treating acne, while topically it was studied for melasma and recalcitrant central centrifugal cicatricial alopecia. To study the safety and efficacy of topical metformin 30% in the treatment of AV. Twenty-seven female AV patients were asked to blindly apply metformin and placebo gels to either side of the face for 12 weeks. AV lesion count was performed at baseline, at each visit and 4 weeks after end of treatment. At the end of the treatment period, the treated side showed significant improvement of comedones, papules and nodules but not pustules. Although, lesions count increased 1 month after stopping treatment, comedones and papules numbers were still significantly less on the metformin side compared to placebo. No side effects were reported. The limited number of patients studied and the limited follow-up period. The metformin effect was not studied on cellular and molecular levels. Topical metformin nanoemulsion gel can be a promising safe and effective treatment of AV.

Clinical factors and hair care practices influencing outcomes in central centrifugal cicatricial alopecia

Central centrifugal cicatricial alopecia (CCCA) is the most common form of primary scarring alopecia in women of African descent, negatively impacting their quality of life. Treatment is often challenging, and we usually direct therapy to suppress and prevent the inflammation. However, factors affecting clinical outcomes are still unknown. To characterize medical features, concurrent medical conditions, hair care practices, and treatments used for patients with CCCA and assess their relationship with treatment outcomes. We analyzed data from a retrospective chart review of 100 patients diagnosed with CCCA who received treatment for at least one year. Treatment outcomes were compared with patient characteristics to determine any relationships. P-values were calculated using logistic regression and univariate analysis with 95% CI P < 0.05 was considered significant. After one year of treatment, 50% of patients were stable, 36% improved, and 14% worsened. Patients without a history of thyroid disease (P = 0.0422), using metformin for diabetes control (P = 0.0255), using hooded dryers (P = 0.0062), wearing natural hairstyles (P = 0.0103), and having no other physical signs besides cicatricial alopecia (P = 0.0228), had higher odds of improvement after treatment. Patients with scaling (P = 0.0095) or pustules (P = 0.0325) had higher odds of worsening. Patients with a history of thyroid disease (P = 0.0188), not using hooded dryers (0.0438), or not wearing natural hairstyles (P = 0.0098) had higher odds of remaining stable. Clinical characteristics, concurrent medical conditions, and hair care practices may affect clinical outcomes after treatment. With this information, providers can adjust proper therapies and evaluations for patients with Central centrifugal cicatricial alopecia.

Unveiling a Shared Precursor Condition for Acne Keloidalis Nuchae and Primary Cicatricial Alopecias

Purpose

Small observational studies suggest subclinical disease occurrence in the normal-appearing scalp zones of several primary cicatricial alopecias. To aid patient management, we began routinely evaluating the entire scalp of patients with acne keloidalis nuchae (AKN), including trichoscopy-guided biopsies.

Patients and Methods

This retrospective study evaluated 41 patients sequentially presenting with AKN at a single clinic between June and December 2022. Primary lesions and normal-appearing scalp in the superior parietal scalp at least 5 cm away from AKN-affected zones were clinically evaluated, and areas showing perifollicular erythema or scales/casts on trichoscopy were biopsied and histologically analyzed.

Results

Forty-one men with AKN, including 20 men of African descent, 17 Hispanic, and 4 European-descended Whites, were evaluated. All patients, including 22% with associated folliculitis decalvans, showed scalp-wide trichoscopy signs of perifollicular erythema or scaling in normal-appearing scalp areas. All patients showed histologic evidence of perifollicular infundibulo-isthmic lymphocytoplasmic infiltrates and fibrosis (PIILIF), with 96% showing Vellus or miniaturized hair absence. PIILIF was often clinically mistaken for seborrheic dermatitis (44-51%). All White patients had mild papular acne keloidalis nuchae lesions mistaken for seborrheic dermatitis.

Conclusion

PIILIF may be a precursor to a wide spectrum of primary cicatricial alopecias, including AKN and folliculitis decalvans. This finding carries implications for the early diagnosis and management of AKN and other primary cicatricial alopecias.

Treatment modalities for lymphocytic and neutrophilic scarring alopecia

Primary cicatricial alopecia can result in permanent hair loss from the destruction of hair follicles. Early intervention is key in controlling disease progression, reducing symptoms, and optimizing hair density. Treatment modalities range from topical and intralesional therapies to oral medications and light therapy.

Τhe Endless Beauty of Metformin: Does It Also Protect from Skin Aging? A Narrative Review

Metformin has shown multiple effects beyond its widely known antidiabetic effect. Impressively, it has already been proposed as an anti-aging factor. However, the potentially protective role of metformin in skin aging, the most common manifestation of aging, is not well examined. Existing evidence based on experimental studies suggests a potential anti-aging effect on skin. Proposed molecular skin anti-aging mechanisms of metformin include mainly reduction of nuclear factor kappa B (NF-κB) (p65) activity. Moreover, metformin appears to inhibit ultraviolet B (UVB)-induced secretion of pro-inflammatory cytokines. Nonetheless, data is still limited, and so more studies are needed. Importantly, we need more studies conducted in humans to further examine this interesting potential. Until then, whether oral administration of metformin or local use of the agent could be used to delay skin aging remains to be answered.

The function, mechanisms, and clinical applications of metformin: potential drug, unlimited potentials

Metformin has been used clinically for more than 60 years. As time goes by, more and more miraculous effects of metformin beyond the clinic have been discovered and discussed. In addition to the clinically approved hypoglycemic effect, it also has a positive metabolic regulation effect on the human body that cannot be ignored. Such as anti-cancer, anti-aging, brain repair, cardiovascular protection, gastrointestinal regulation, hair growth and inhibition of thyroid nodules, and other nonclinical effects. Metformin affects almost the entire body in the situation taking it over a long period, and the preventive effects of metformin in addition to treating diabetes are also beginning to be recommended in some guidelines. This review is mainly composed of four parts: the development history of metformin, the progress of clinical efficacy, the nonclinical efficacy of metformin, and the consideration and prospect of its application.

Beyond the Hot Comb: Updates in Epidemiology, Pathogenesis, and Treatment of Central Centrifugal Cicatricial Alopecia from 2011 to 2021

Central centrifugal cicatricial alopecia (CCCA) is a form of scarring alopecia that predominantly affects middle-aged women of African descent. Recent data suggest a multifactorial etiology of CCCA that is influenced by environmental and genetic factors. Emerging evidence regarding the genetic basis of the condition may elucidate new therapies. While topical and intralesional steroids and tetracycline antibiotics are the mainstay of treatment, refractory cases may be considered for hair transplantation. Emerging therapies using platelet-rich plasma, botanical formulas, and cosmetic procedures have shown promising results for the future management of CCA. As recent notable advances in CCCA have been achieved, this review provides an update on the epidemiology, pathophysiology, and management of CCCA.

Modulation of autophagy, apoptosis and oxidative stress: a clue for repurposing metformin in photoaging

Long-term sun exposure is the commonest cause of photoaging, where mutual interplay between autophagy, oxidative stress, and apoptosis is incriminated. In combating photoaging, pharmacological approaches targeted to modulate autophagy are currently gaining more ground. This study aimed to examine repurposing metformin use in such context with or without the antioxidant coenzyme Q10 (coQ10) in ultraviolet A (UVA) irradiation-induced skin damage. The study was conducted on 70 female CD1 mice that were randomly assigned into seven groups (10/group): normal control, vehicle-treated-UVA-exposed mice, three metformin UVA-exposed groups (Topical 1 and 10%, and oral 300 mg/kg), topical coQ10 (1%)-treated mice, and combined oral metformin with topical coQ10-treated UVA-exposed mice. After UVA-exposure for 10 weeks (3 times/week), macroscopic signs of photoaging were evaluated. Mice were then euthanized, and the skin was harvested for biochemical estimation of markers for oxidative stress, inflammation, matrix breakdown, and lysosomal function. Histopathological signs of photoaging were also evaluated with immunohistochemical detection of associated changes in autophagic and apoptotic markers. Metformin, mainly by topical application, improved clinical and histologic signs of photoaging. This was associated with suppression of the elevated oxidative stress, IL-6, matrix metalloproteinase 1, and caspase, with induction of cathepsin D and subsequent change in anti-LC3 and P62 staining in skin tissue. In addition to metformin antioxidant, anti-inflammatory, and antiapoptotic activities, its anti-photoaging effect is mainly attributed to enhancing autophagic flux by inducing cathepsin D. Its protective effect is boosted by coQ10, which supports their potential use in photoaging.

Treatment-Refractory Central Centrifugal Cicatricial Alopecia Responsive to a Novel Botanical Treatment

Purpose

Central centrifugal cicatricial alopecia (CCCA) is the most common cause of scarring alopecia in women of African descent. However, current treatments for CCCA, such as immunosuppressants and immunomodulatory pharmaceutical agents, have suboptimal efficacy and undesirable side effects. This case series reports the therapeutic effect of a new botanical formulation (Dr. UGro Gashee) in four patients with histologically supported diagnoses of CCCA. The formulations contain at least three phytoactive ingredients that affect multiple targets in the cascade of pathophysiologic events contributing to CCCA. Possible mechanisms of action include anti-inflammatory effects, inhibiting proinflammatory cytokines, and the net antifibrotic effect of inhibiting transforming growth factor-beta while upregulating AMP-activated protein kinase and peroxisome proliferator-associated receptor-gamma activity.

Patients and Methods

Four African American women with treatment-refractory CCCA were treated with a new topical botanical formula (cosmeceutical) alone or in combination with its oral formulation (nutraceutical) for 8 weeks to 1 year. The cosmeceutical and nutraceutical treatments contain similar phytoactive ingredient profiles. Treatment outcomes were collected using documented patient reports and images and by direct observation.

Results

In all patients, scalp pruritus cessation occurred within 2 weeks of treatment, and significant hair regrowth was observed within 2 months. All patients reported a high satisfaction level without adverse effects.

Conclusion

Patients with treatment-refractory CCCA responded to the novel botanical treatment reported in this study. Further evaluations in a controlled trial with more patients are warranted.

Metformin Promotes the Hair-Inductive Activity of Three-Dimensional Aggregates of Epidermal and Dermal Cells Self-Assembled In Vitro

INTRODUCTION

Although it has been reported that the anti-diabetic drug metformin has multiple extra-hypoglycemic activities, such as anti-oxidation, anti-aging and even anti-tumor, topical metformin also can induce hair regeneration, but the precise mechanism involved in that process is still unclear.

OBJECTIVES

To assess the effect of metformin on hair growth in a mouse hair follicle reconstitution model generated by in vitro self-assembled three-dimensional aggregates of epidermal and dermal cells (3D aggregates).

METHODS

Epidermal cells and dermal cells were isolated and cultured from the mouse skin of fifty C57BL/6 mouse pups (1-day-old). For tracing the distribution of dermal cells during the self-assembly process of 3D aggregates, the dermal cells were labeled with Vybrant Dil cell-labelling solution and mixed with epidermal cells at 1:1 ratio. Formed 3D aggregates were treated with 10 mM metformin and then were grafted into recipient BALB/c nude mice. The biomarkers (HGF, CD133, ALP, β-catenin and SOX2) associated with the hair-inductive activity of dermal cells were detected in the grafted skin tissues and in cultured 3D aggregates treated with metformin using immunofluorescent staining, quantitative real-time RT-PCR (qRT-PCR), and western blotting. Furthermore, the expression levels of CD133 were also examined in dermal cells with different passage numbers using qRT-PCR and western blotting.

RESULTS

Metformin directly stimulates the activity of alkaline phosphatase (ALP) of cultured 3D aggregates, upregulates both the protein and mRNA expression levels of molecular markers (HGF, CD133, ALP, β-catenin and SOX2) and improves the survival rate of reconstituted hair follicles. Moreover, we also found that metformin increases the expression of CD133 in dermal cells thus maintaining their trichogenic capacity that would normally be lost by serial subculture.

CONCLUSIONS

These results suggest that metformin can promote hair follicle regeneration in vitro through up-regulation of the hair inductive capability of dermal cells, warranting further evaluation in the clinical treatment of male or female pattern hair loss.

Compatibility of Different Formulations in Pentravan® and Pentravan® Plus for Transdermal Drug Delivery

The potential therapeutic benefit of transdermal delivery systems for some active pharmaceutical ingredients (APIs) has been well-established for decades within the scientific community. However, together with the clinical efficacy, there is the need for an evaluation of the stability of such APIs in bases with known transdermal capabilities, which is necessary to provide the compounding pharmacist with confidence when providing transdermal products. In this study, the stability of danazol, metformin HCl, and resveratrol as individual ingredients, as well as metformin HCl, resveratrol, and Vitamin D3 in combinations at bracketed high and low concentrations, were evaluated over a period of 6 months, using a ready-to-use transdermal vehicle for compounding pharmacies (Pentravan® or Pentravan® Plus). The five formulations tested (F1: Danazol 50 mg/g + MiodesinTM 85 mg/g in Pentravan®, F2: Metformin HCl 200 mg/g in Pentravan®, F3: Resveratrol 200 mg/g in Pentravan®, F4: Metformin HCl 100 mg/g + Resveratrol 100 mg/g + Vitamin D3 5000 IU in Pentravan®, and F5: Metformin HCl 200 mg/g + Resveratrol 200 mg/g + Vitamin D3 5000 IU in Pentravan® Plus) presented a beyond-use date of at least 6 months, presenting high convenience for the compounding pharmacies.

An Approach to Patients with Alopecia

Alopecia is a dermatologic condition in which sudden or gradual loss of hair occurs on 1 or more areas of the body, most commonly the scalp. Hair loss can be acute or chronic in nature as a result of underlying inflammation, autoimmune processes, stressors, chemotherapy, or hairstyling practices. Alopecia can have substantial psychological consequences, having a negative impact on the quality of life in affected patients. The ability to both recognize and distinguish these condition holds great significance not only in providing adequate and timely treatment to improve outcomes but also meeting patient needs.

Central Centrifugal Cicatricial Alopecia: Challenges and Treatments

Central centrifugal cicatricial alopecia (CCCA) is the most common form of primary scarring alopecia diagnosed in women of African descent. Although the etiology was originally attributed exclusively to hairstyling practices common among women of African descent, more recent research on CCCA supports the concept that there are several contributing factors, including variants in gene expression, hair grooming practices that increase fragility on the hair follicle, and associations with other systemic conditions. Treatment of CCCA involves a combination of patient counseling and education on alternative hairstyles, medical therapies, and procedural methods when necessary.

Hair regrowth in cicatricial alopecia: A literature review

Cicatricial alopecias (CA) describes multiple subtypes of hair loss in which the hair follicle is destroyed by an unknown inflammatory mechanism. The main goal of treatment is to stop this inflammatory process and prevent further hair loss; however, there have been occasional reports of hair regrowth following treatment in some subtypes of CA. This review aims to highlight these reports. A total of 71 cases of hair regrowth were found documented in the literature. The treatments used varied widely both between and within each subtype of alopecia. This review highlights that regrowth is possible in at least a subset of patients with cicatricial alopecia; however, the mechanism by which this occurs has yet to be elucidated.