Measuring reversal of hair miniaturization in androgenetic alopecia by follicular counts in horizontal sections of serial scalp biopsies: results of finasteride 1 mg treatment of men and postmenopausal women

Vellus-to-terminal Hair Follicle Reconversion Occurs in Male Pattern Balding and is Promoted by Minoxidil and Platelet-rich Plasma: In Vivo Evidence from a New Humanized Mouse Model of Androgenetic Alopecia

Abstract is missing (Short communication)

Noninvasive Hair Rejuvenation

Both nonsurgical and surgical modalities for the treatment of hair loss are being used by providers at an increasing rate worldwide. Men and woman are affected by hair loss, but the pathophysiology of the hair loss is thought to be different between sexes; therefore, gender must play a role in treatment decisions. Currently, there are 3 Food and Drug Administration-approved nonsurgical androgenetic alopecia treatments: minoxidil, finasteride, and low-light laser therapy. Platelet-rich plasma injections are showing promise as a single modality and as an adjunct to other nonsurgical and surgical treatments of androgenetic alopecia.

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.

Following historical "tracks" of hair follicle miniaturisation in patterned hair loss: Are elastin bodies the forgotten aetiology?

Pattern hair loss (PHL) is a chronic regressive condition of the scalp, where follicular miniaturisation and decreased scalp hair coverage occurs in affected areas. In all PHL cases, there is a measurable progressive shortening of the terminal hair growth duration, along with reduced linear growth rates. In both genders, PHL initially shows an increase in short telogen hairs ≤30 mm in length, reflecting a cycle completion of under 6 months in affected terminal hair follicles. To understand the miniaturisation process, we re-examine the dynamics of miniaturisation and ask the question, "why do miniaturised hair follicles resist treatment?" In the light of recent developments in relation to hair regeneration, we looked back in the older literature for helpful clues "lost to time" and reprise a 1978 Hermann Pinkus observation of an array of elastin deposits beneath the dermal papilla following subsequent anagen/telogen transitions in male balding, originally described by Arao and Perkins who concluded that these changes provide a "morphologic marker of the entire biologic process in the balding scalp." Thus, we have reviewed the role of the elastin-like bodies in hair pathology and we propose that alterations in elastin architecture may contribute to the failure of vellus-like hair reverting back to their terminal status and may indicate a new area for therapeutic intervention.

Combining Deep Learning With Optical Coherence Tomography Imaging to Determine Scalp Hair and Follicle Counts

BACKGROUND AND OBJECTIVES

One of the challenges in developing effective hair loss therapies is the lack of reliable methods to monitor treatment response or alopecia progression. In this study, we propose the use of optical coherence tomography (OCT) and automated deep learning to non-invasively evaluate hair and follicle counts that may be used to monitor the success of hair growth therapy more accurately and efficiently.

STUDY DESIGN/MATERIALS AND METHODS

We collected 70 OCT scans from 14 patients with alopecia and trained a convolutional neural network (CNN) to automatically count all follicles present in the scans. The model is based on a dual approach of both detecting hair follicles and estimating the local hair density in order to give accurate counts even for cases where two or more adjacent hairs are in close proximity to each other.

RESULTS

We evaluate our system on 70 OCT manually labeled scans taken at different scalp locations from 14 patients, with 20 of those redundantly labeled by two human expert OCT operators. When comparing the individual human predictions and considering the exact locations of hair and follicle predictions, we find that the two human raters disagree with each other on approximately 22% of hairs and follicles. Overall, the deep learning (DL) system predicts the number of follicles with an error rate of 11.8% and the number of hairs with an error rate of 18.7% on average on the 70 scans. The OCT system can capture one scalp location in three seconds, and the DL model can make all predictions in less than a second after processing the scan, which takes half a minute using an unoptimized implementation.

CONCLUSION

This approach is well-positioned to become the standard for non-invasive evaluation of hair growth treatment progress in patients, saving significant amounts of time and effort compared with manual evaluation. Lasers Surg. Med. © 2020 Wiley Periodicals, Inc.

The study of hair follicle counts from scalp histopathology in the Thai population

BACKGROUND

The horizontal section of a scalp specimen offers an advantage over a vertical section by providing quantitative information. The reference data for hair counts in Asians, including Thais, are inconclusive. We aimed to determine the normal values of hair counts in scalp biopsy specimens in the Thai population.

METHODS

A 4-mm punch biopsy was performed at the occipital area of the scalp from subjects presenting with clinically normal hair and scalp appearance. All specimens were horizontally sectioned and observed to assess the number of follicular units and hair follicles, type of hairs, and phase of the hair cycle. The results were further compared between sexes and with the pre-existing data from previous studies.

RESULTS

Ninety specimens were collected from 90 subjects. The average number of total hairs, terminal hairs, vellus hairs, and follicular units per 4-mm punch scalp skin were 20.5 ± 5.2, 18.2 ± 4.1, 2 (range 0-7), and 9.1 ± 1.6, respectively. The mean ratio of terminal to vellus hair was 8.9:1 and of anagen to telogen hair was 91.9:7.9. There were no gender differences in any of the parameters and no correlations with changing age. Compared to other Asian populations, Thais and Taiwanese showed intermediate values between Iranians and Koreans; when compared to other ethnic groups, hair density in Asians showed lower than Caucasians and Hispanics but was comparable to Africans.

CONCLUSION

This study established reference values of scalp horizontal sections in the Thai population; this will be helpful for clinicians and researchers to evaluate hair disorders.

Physiology and Medical Treatments for Alopecia

Androgenetic alopecia (AGA) is the most common hair loss disorder in men and women. The characteristic and reproducible balding pattern in AGA negatively affects self-image and the external perceptions of the balding patient. The phenotypical changes are driven by dihydrotestosterone (DHT) and its precursor testosterone. DHT induces follicle miniaturization and hair cycle changes until resulting hairs no longer extrude through the skin surface. AGA is inherited in a polygenetic pattern and is susceptible to epigenetic and environmental factors. Currently, minoxidil, finasteride, and photolaser therapy are the only Food and Drug Administration-approved medical treatments for AGA.

Finasteride and Its Potential for the Treatment of Female Pattern Hair Loss: Evidence to Date

The currently approved treatment for female pattern hair loss (FPHL) includes topical minoxidil administration; however, this treatment fails to achieve hair regrowth in some patients. Finasteride, a selective 5α-reductase inhibitor (5-ARI), may be considered as an alternative treatment. However, because of its potential teratogenic effects, clinical studies and use of finasteride for FPHL are limited. In this review, we aim to summarize the literature regarding the pharmacology, clinical efficacy, and adverse effects of oral finasteride for the treatment of FPHL and to provide novel therapeutic options including topical finasteride and dutasteride, a new generation 5-ARI, for the treatment of FPHL.

Topical ketoconazole for the treatment of androgenetic alopecia: A systematic review

Androgenetic alopecia (AGA) is common and associated with significant psychosocial distress. Treatment options are needed for patients that do not adequately respond to first line treatments of finasteride or minoxidil. Topical ketoconazole has been proposed as a promising treatment. The goal of this systematic review was to evaluate the efficacy of topical ketoconazole in the treatment of AGA. A systematic literature search was conducted within the MEDLINE database using the key terms "ketoconazole" and "alopecia." Forty-seven papers were screened for inclusion, of which nine were assessed for eligibility. Seven articles were included in the qualitative synthesis, including two animal studies (total of 40 participants) and five human studies (total of 318 participants). Murine studies demonstrated a significant increase in mean ratio of hair regrowth to denuded area in the ketoconazole treatment groups compared to controls. Human studies reported increased hair shaft diameter following ketoconazole use. One study reported a significant increase in pilary index (percent anagen phase × diameter) following treatment. Studies also demonstrated clinical improvement of AGA based on photographic assessment and subjective evaluation. Topical ketoconazole is a promising adjunctive or alternative therapy in the treatment of AGA. Randomized controlled trials are needed.

Androgenetic alopecia: combing the hair follicle signaling pathways for new therapeutic targets and more effective treatment options

Introduction: In the past 30 years, only two drugs have received FDA approval for the treatment of androgenetic alopecia reflecting a lack of success in unraveling novel targets for pharmacological intervention. However, as our knowledge of hair biology improves, new signaling pathways and organogenesis processes are being uncovered which have the potential to yield more effective therapeutic modalities. Areas covered: This review focuses on potential targets for drug development to treat hair loss. The physiological processes underlying the promise of regenerative medicine to recreate new functional hair follicles in bald scalp are also examined. Expert opinion: The discovery of promising new targets may soon enable treatment options that modulate the hair cycle to preserve or extend the growth phase of the hair follicle. These new targets could also be leveraged to stimulate progenitor cells and morphogenic pathways to reactivate miniaturized follicles in bald scalp or to harness the potential of wound healing and embryogenic development as an emerging paradigm to generate new hair follicles in barren skin.

Post-Finasteride Syndrome: An Induced Delusional Disorder with the Potential of a Mass Psychogenic Illness?

Post-finasteride syndrome (PFS) has been claimed to occur in men who have taken oral finasteride to treat either hair loss or benign prostatic hyperplasia, independent of age, dosage, or indication. By definition, the condition is characterized by sexual dysfunction, somatic symptoms, and psychological disorders that persist after cessation of finasteride treatment. As yet, the condition is not recognized by the medical community, although individuals who suffer from PFS present with relatively homogenous symptoms. The concept of PFS has emerged from reports of non-dermatologists, neuroendocrinological research and reflections, and uncontrolled studies of low quality and with a strong bias selection, while a significant nocebo effect among patients informed about possible side effects of finasteride is recognized. There are no predictive factors for the risk of development of PFS. Nevertheless, it has been suggested that a patient history of preexisting mental health disorder, particularly depression, may put patients at an increased risk. We report the first case of PFS in a long-standing (over 20 years) dermatotrichological practice with frequent finasteride prescription observed in a 25-year-old male following dutasteride treatment for male androgenetic alopecia. There was circumstantial evidence that PFS may represent a delusional disorder of the somatic type, possibly on a background of a histrionic personality disorder, which would explain the refractoriness of the condition and a high degree of suggestibility.

Female Pattern Hair Loss and Androgen Excess: A Report From the Multidisciplinary Androgen Excess and PCOS Committee

OBJECTIVE

To determine the current state of knowledge and provide evidence-based recommendations that could be valid for all specialists taking care of female pattern hair loss (FPHL), a common form of hair loss in women that is characterized by the reduction of hair density in the central area of the scalp, whereas the frontal hairline is generally well conserved.

PARTICIPANTS

An expert task force appointed by the Androgen Excess and PCOS Society, which included specialists from dermatology, endocrinology, and reproductive endocrinology.

DESIGN

Levels of evidence were assessed and graded from A to D. Peer-reviewed studies evaluating FPHL published through December 2017 were reviewed. Criteria for inclusion/exclusion of the published papers were agreed on by at least two reviewers in each area and arbitrated by a third when necessary.

CONCLUSIONS

(i) The term "female pattern hair loss" should be used, avoiding the previous terms of alopecia or androgenetic alopecia. (ii) The two typical patterns of hair loss in FPHL are centrifugal expansion in the mid scalp, and a frontal accentuation or Christmas tree pattern. (iii) Isolated FPHL should not be considered a sign of hyperandrogenism when androgen levels are normal. (iv) The assessment of patients with FPHL is primarily clinical. (v) In all patients with FPHL, assessment of a possible androgen excess is mandatory. Measurement of vitamin D, iron, zinc, thyroid hormones, and prolactin are optional but recommended. (vi) Treatment of FPHL should start with minoxidil (5%), adding 5α-reductase inhibitors or antiandrogens when there is severe hair loss or hyperandrogenism.

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.

Review of Human Hair Follicle Biology: Dynamics of Niches and Stem Cell Regulation for Possible Therapeutic Hair Stimulation for Plastic Surgeons

Plastic surgeons are frequently asked to manage male- and female-pattern hair loss in their practice. This article discusses the epidemiology, pathophysiology, and current management of androgenetic alopecia and emphasizes more recent knowledge of stem cell niches in hair follicles that drive hair cycling, alopecia, and its treatment. The many treatment programs available for hair loss include newer strategies that involve the usage of growth factors, platelet-rich plasma, and fat to stimulate follicle growth. Future research may clarify novel biomolecular mechanisms that target specific cells that promote hair regeneration.Level of Evidence V This journal requires that authors assign a level of evidence to each article. For a full description of these Evidence-Based Medicine ratings, please refer to the Table of Contents or the online Instructions to Authors www.springer.com/00266 .

A Study of the Histopathological Features of Alopecias on Transverse Sections of Scalp Biopsies

Background:

Transverse sections of scalp biopsies are performed for the assessment of alopecias and are considered advantageous over vertical sections.

Aim:

The aim was to study the histopathological features of alopecias on transverse sections of scalp biopsies.

Methods:

It was a descriptive study. Clinically confirmed cases of noncicatricial and cicatricial alopecias were subjected to 4 mm scalp biopsies, which were sectioned transversely and analyzed. Biopsies obtained from occipital region of androgenetic alopecia (AGA) cases were taken as controls.

Results:

Biopsies from 41 cases were assessed, including male and female AGA, alopecia areata (AA), trichotillomania, lichen planopilaris (LPP), discoid lupus erythematosus (DLE), and folliculitis decalvans (FD). Normal scalp (control) biopsies showed the median total number of hair follicles of 35 (32–37), anagen:telogen/catagen ratio of 17.5 (16.5–31), and terminal:vellus ratio of 15 (10.7–17.5). In AGA and AA, miniaturization and shift toward telogen and catagen hair were consistently observed. Peribulbar inflammation was seen in two-third of AA. Trichotillomania showed increased catagen hair and numerous pigment casts. In DLE, besides perifollicular inflammation, prominent peri-arrector pili and peri-eccrine inflammation were observed. Type of inflammatory infiltrate was similar in DLE and LPP (lymphocytic), whereas FD showed neutrophilic and plasma cell infiltrate, both around follicles and interstitially. Basal cell damage in the follicles and pigment incontinence were seen in majority of DLE and LPP patients. DLE also showed basement membrane thickening, mucin deposition, and telangiectasia. Reduction/absence of sebaceous glands and perifollicular fibrosis were observed in almost all cicatricial alopecias.

Conclusion:

Transverse sectioning may be a useful tool in the diagnosis of alopecias.

Androgens in women: Hormone-modulating therapies for skin disease

Androgen-mediated cutaneous disorders (AMCDs) in women, including acne, hirsutism, and female pattern hair loss, can be treated with hormone-modulating therapies. In the second article in this Continuing Medical Education series, we discuss the hormone-modulating therapies available to dermatologists for the treatment of AMCDs, including combined oral contraceptives, spironolactone, finasteride, dutasteride, and flutamide. Available hormone-modulating treatments used for each AMCDs are reviewed, along with mechanisms of androgen modulation, safety profile, contraindications, monitoring parameters, and evidence of efficacy. Medications discussed include those that are approved by the US Food and Drug Administration for certain AMCDs and some that are used off-label. Despite the ubiquity of hormone-modulating therapies used for AMCDs, this review highlights the need for more rigorous studies to evaluate these therapies for acne, hirsutism, and female pattern hair loss.

Efficacy of non-surgical treatments for androgenetic alopecia: a systematic review and network meta-analysis

Androgenetic alopecia, or male/female pattern baldness, is the most common type of progressive hair loss disorder. The aim of this study was to review recent advances in non-surgical treatments for androgenetic alopecia and identify the most effective treatments. A network meta-analysis (NMA) was conducted of the available literature of the six most common non-surgical treatment options for treating androgenetic alopecia in both men and women; dutasteride 0.5 mg, finasteride 1 mg, low-level laser therapy (LLLT), minoxidil 2%, minoxidil 5% and platelet-rich plasma (PRP). Seventy-eight studies met the inclusion criteria, and 22 studies had the data necessary for a network meta-analysis. Relative effects show LLLT as the superior treatment. Relative effects show PRP, finasteride 1 mg (male), finasteride 1 mg (female), minoxidil 5%, minoxidil 2% and dutasteride (male) are approximately equivalent in mean change hair count following treatment. Minoxidil 5% and minoxidil 2% reported the most drug-related adverse events (n = 45 and n = 23, respectively). The quality of evidence of minoxidil 2% vs. minoxidil 5% was high; minoxidil 5% vs. placebo was moderate; dutasteride (male) vs. placebo, finasteride (female) vs. placebo, minoxidil 2% vs. placebo and minoxidil 5% vs. LLLT was low; and finasteride (male) vs. placebo, LLLT vs. sham, PRP vs. placebo and finasteride vs. minoxidil 2% was very low. Results of this NMA indicate the emergence of novel, non-hormonal therapies as effective treatments for hair loss; however, the quality of evidence is generally low. High-quality randomized controlled trials and head-to-head trials are required to support these findings and aid in the development of more standardized protocols, particularly for PRP. Regardless, this analysis may aid physicians in clinical decision-making and highlight the variety of non-surgical hair restoration options for patients.

Clinical efficacy of oral administration of finasteride at a dose of 2.5 mg/day in women with female pattern hair loss

Female pattern hair loss (FPHL) presents with diffuse thinning over the mid-frontal scalp, for which various treatment modalities have been tried. Although currently, oral 5 α-reductase inhibitors such as finasteride are being used, their clinical efficacy remains controversial. We retrospectively investigated 544 premenopausal or postmenopausal patients with FPHL who were prescribed finasteride at a dose of 2.5 mg/day. Our study excluded patients with a follow-up period of < 3 months and patients who were prescribed other FPHL treatment modalities including topical minoxidil. Finally, 112 patients were evaluated based on their medical records and clinical photographs. Based on assessment using the Ludwig scale at the time of their initial visit, among 112 patients studied, 59 patients were classified as belonging to grade I, 47 were grade II, and 6 were grade III. Using global photographs, we found that 33 (29.5%) of the 112 patients studied showed slight improvement, 73 (65.2%) showed significant improvement, whereas no change was recorded in 6 (5.4%). We could demonstrate efficacy of administration of finasteride at a dose of 2.5 mg/day for patients with FPHL and also found that finasteride has a better effect on hair growth when patients had a lower Ludwig score and an older age at onset.

A Comment on the Post-Finasteride Syndrome

The post-Finasteride syndrome (PFS) has been claimed to occur in men who have taken oral finasteride to treat hair loss or benign prostatic hyperplasia. While the incidence of persistent sexual, mental, and physical side effects despite quitting finasteride is unknown, and the condition is not recognized by the scientific community, individuals who suffer from PFS do present with very distinctive and homogenous symptoms. The concept has emerged from reports of nondermatologists, neuroendocrinological research, case reports, and uncontrolled studies. These have been scrutinized by hair experts who found that persistent sexual side effects were only documented in low-quality studies with a strong bias selection and a significant nocebo effect. Others totally dispute the credibility of the PFS. In any case, the PFS is a problem that has to be dealt with. Low-quality studies neither confirm nor refute the condition as a valid nosologic entity. Therefore, it is as inappropriate to dismiss the condition, as it would be to demonize finasteride for the treatment of male pattern hair loss. Whether the PFS represents a nocebo reaction or a real drug adverse event is irrelevant, while the best way to alleviate the emotional distress related to hair loss is to effectively treat the condition causing the problem. It is not sufficient to only discuss the plausibility of the PFS. There is a need for practical recommendations to include such important issues as patient selection and risk assessment, appropriate patient information, how to react in case of drug-related adverse events, issues of fertility and malignancy, management of the PFS, and alternatives, specifically the use of topical finasteride. It is the aim of this commentary to provide the respective information.

Evidence-based (S3) guideline for the treatment of androgenetic alopecia in women and in men - short version

Androgenetic alopecia is the most common hair loss disorder, affecting both men and women. Initial signs of androgenetic alopecia usually develop during teenage years leading to progressive hair loss with a pattern distribution. Moreover, its frequency increases with age and affects up to 80% Caucasian men and 42% of women. Patients afflicted with androgenetic alopecia may undergo significant impairment of quality of life. The European Dermatology Forum (EDF) initiated a project to develop evidence-based guidelines for the treatment of androgenetic alopecia. Based on a systematic literature research the efficacy of the currently available therapeutic options was assessed and therapeutic recommendations were passed in a consensus conference. The purpose of the guideline is to provide dermatologists with an evidence-based tool for choosing an efficacious and safe therapy for patients with androgenetic alopecia.

The effectiveness of treatments for androgenetic alopecia: A systematic review and meta-analysis

BACKGROUND

Androgenetic alopecia, or male pattern hair loss, is a hair loss disorder mediated by dihydrotestosterone, the potent form of testosterone. Currently, minoxidil and finasteride are Food and Drug Administration (FDA)-approved, and HairMax LaserComb, which is FDA-cleared, are the only treatments recognized by the FDA as treatments of androgenetic alopecia.

OBJECTIVE

This systematic review and meta-analysis assesses the efficacy of nonsurgical treatments of androgenetic alopecia in comparison to placebo for improving hair density, thickness, growth (defined by an increased anagen:telogen ratio), or subjective global assessments done by patients and investigators.

METHODS

A systematic review of randomized controlled trials was conducted. PubMed, Embase, and Cochrane were searched up to December 2016, with no lower limit on the year. We included only randomized controlled trials of good or fair quality based on the US Preventive Services Task Force quality assessment process.

RESULTS

A meta-analysis was conducted separately for 5 groups of studies that tested the following hair loss treatments: low-level laser light therapy in men, 5% minoxidil in men, 2% minoxidil in men, 1 mg finasteride in men, and 2% minoxidil in women. All treatments were superior to placebo (P < .00001) in the 5 meta-analyses. Other treatments were not included because the appropriate data were lacking.

LIMITATIONS

High heterogeneity in most studies.

CONCLUSIONS

This meta-analysis strongly suggests that minoxidil, finasteride, and low-level laser light therapy are effective for promoting hair growth in men with androgenetic alopecia and that minoxidil is effective in women with androgenetic alopecia.

Androgenetic Alopecia: An Update of Treatment Options

Androgenetic alopecia (AGA) is characterized by a non-scarring progressive miniaturization of the hair follicle in predisposed men and women with a pattern distribution. Although AGA is a very prevalent condition, approved therapeutic options are limited. This article discusses the current treatment alternatives including their efficacy, safety profile, and quality of evidence. Finasteride and minoxidil for male androgenetic alopecia and minoxidil for female androgenetic alopecia still are the therapeutic options with the highest level evidence. The role of antiandrogens for female patients, the importance of adjuvant therapies, as well as new drugs and procedures are also addressed.

Hair loss and regeneration performed on animal models

Research in the field of reversal hair loss remains a challenging subject. As Minoxidil 2% or 5% and Finasteride are so far the only FDA approved topical treatments for inducing hair regrowth, research is necessary in order to improve therapeutical approach in alopecia. In vitro studies have focused on cultures of a cell type - dermal papilla or organ culture of isolated cell follicles. In vivo research on this topic was performed on mice, rats, hamsters, rabbits, sheep and monkeys, taking into consideration the advantages and disadvantages of each animal model and the depilation options. Further studies are required not only to compare the efficiency of different therapies but more importantly to establish their long term safety.

Polymorphic CAG Repeat Numbers in the Androgen Receptor Gene of Female Pattern Hair Loss in a Han Chinese Population

OBJECTIVE

To investigate the association of CAG repeat numbers in the androgen receptor (AR) gene with female pattern hair loss (FPHL) in a Chinese population.

METHODS

A total of 200 Han Chinese patients with FPHL (142 Ludwig II and 58 Ludwig III cases) and 200 healthy controls were enrolled in this study. The polymorphism of CAG repeat numbers was analyzed by the fluorescent amplified fragment length polymorphism technique.

RESULTS

The CAG biallelic mean length was 23.73 ± 2.04 repeats in Han Chinese FPHL patients and 23.90 ± 2.13 repeats in healthy controls, without any significant difference between the two groups (p = 0.481). In addition, neither the shorter nor the longer CAG repeat numbers were significantly different between FPHL and control subjects (p = 0.726, p = 0.383).

CONCLUSION

The polymorphism of CAG repeat numbers of the AR gene may not be the genetic marker of FPHL in a Chinese population.

Interventions for female pattern hair loss

BACKGROUND

Female pattern hair loss (FPHL), or androgenic alopecia, is the most common type of hair loss affecting women. It is characterised by progressive shortening of the duration of the growth phase of the hair with successive hair cycles, and progressive follicular miniaturisation with conversion of terminal to vellus hair follicles (terminal hairs are thicker and longer, while vellus hairs are soft, fine, and short). The frontal hair line may or may not be preserved. Hair loss can have a serious psychological impact on women.

OBJECTIVES

To determine the efficacy and safety of the available options for the treatment of female pattern hair loss in women.

SEARCH METHODS

We updated our searches of the following databases to July 2015: the Cochrane Skin Group Specialised Register, CENTRAL in the Cochrane Library (2015, Issue 6), MEDLINE (from 1946), EMBASE (from 1974), PsycINFO (from 1872), AMED (from 1985), LILACS (from 1982), PubMed (from 1947), and Web of Science (from 1945). We also searched five trial registries and checked the reference lists of included and excluded studies.

SELECTION CRITERIA

We included randomised controlled trials that assessed the efficacy of interventions for FPHL in women.

DATA COLLECTION AND ANALYSIS

Two review authors independently assessed trial quality, extracted data and carried out analyses.

MAIN RESULTS

We included 47 trials, with 5290 participants, of which 25 trials were new to this update. Only five trials were at 'low risk of bias', 26 were at 'unclear risk', and 16 were at 'high risk of bias'.The included trials evaluated a wide range of interventions, and 17 studies evaluated minoxidil. Pooled data from six studies indicated that a greater proportion of participants (157/593) treated with minoxidil (2% and one study with 1%) reported a moderate to marked increase in their hair regrowth when compared with placebo (77/555) (risk ratio (RR) = 1.93, 95% confidence interval (CI) 1.51 to 2.47; moderate quality evidence). These results were confirmed by the investigator-rated assessments in seven studies with 1181 participants (RR 2.35, 95% CI 1.68 to 3.28; moderate quality evidence). Only one study reported on quality of life (QoL) (260 participants), albeit inadequately (low quality evidence). There was an important increase of 13.18 in total hair count per cm² in the minoxidil group compared to the placebo group (95% CI 10.92 to 15.44; low quality evidence) in eight studies (1242 participants). There were 40/407 adverse events in the twice daily minoxidil 2% group versus 28/320 in the placebo group (RR 1.24, 95% CI 0.82 to 1.87; low quality evidence). There was also no statistically significant difference in adverse events between any of the individual concentrations against placebo.Four studies (1006 participants) evaluated minoxidil 2% versus 5%. In one study, 25/57 participants in the minoxidil 2% group experienced moderate to greatly increased hair regrowth versus 22/56 in the 5% group (RR 1.12, 95% CI 0.72 to 1.73). In another study, 209 participants experienced no difference based on a visual analogue scale (P = 0.062; low quality evidence). The assessments of the investigators based on three studies (586 participants) were in agreement with these findings (moderate quality evidence). One study assessed QoL (209 participants) and reported limited data (low quality evidence). Four trials (1006 participants) did not show a difference in number of adverse events between the two concentrations (RR 1.02, 95% CI 0.91 to 1.20; low quality evidence). Both concentrations did not show a difference in increase in total hair count at end of study in three trials with 631 participants (mean difference (MD) -2.12, 95% CI -5.47 to 1.23; low quality evidence).Three studies investigated finasteride 1 mg compared to placebo. In the finasteride group 30/67 participants experienced improvement compared to 33/70 in the placebo group (RR 0.95, 95% CI 0.66 to 1.37; low quality evidence). This was consistent with the investigators' assessments (RR 0.77, 95% CI 0.31 to 1.90; low quality evidence). QoL was not assessed. Only one study addressed adverse events (137 participants) (RR 1.03, 95% CI 0.45 to 2.34; low quality evidence). In two studies (219 participants) there was no clinically meaningful difference in change of hair count, whilst one study (12 participants) favoured finasteride (low quality evidence).Two studies (141 participants) evaluated low-level laser comb therapy compared to a sham device. According to the participants, the low-level laser comb was not more effective than the sham device (RR 1.54, 95% CI 0.96 to 2.49; and RR 1.18, 95% CI 0.74 to 1.89; moderate quality evidence). However, there was a difference in favour of low-level laser comb for change from baseline in hair count (MD 17.40, 95% CI 9.74 to 25.06; and MD 17.60, 95% CI 11.97 to 23.23; low quality evidence). These studies did not assess QoL and did not report adverse events per treatment arm and only in a generic way (low quality evidence). Low-level laser therapy against sham comparisons in two separate studies also showed an increase in total hair count but with limited further data.Single studies addressed the other comparisons and provided limited evidence of either the efficacy or safety of these interventions, or were unlikely to be examined in future trials.

AUTHORS' CONCLUSIONS

Although there was a predominance of included studies at unclear to high risk of bias, there was evidence to support the efficacy and safety of topical minoxidil in the treatment of FPHL (mainly moderate to low quality evidence). Furthermore, there was no difference in effect between the minoxidil 2% and 5% with the quality of evidence rated moderate to low for most outcomes. Finasteride was no more effective than placebo (low quality evidence). There were inconsistent results in the studies that evaluated laser devices (moderate to low quality evidence), but there was an improvement in total hair count measured from baseline.Further randomised controlled trials of other widely-used treatments, such as spironolactone, finasteride (different dosages), dutasteride, cyproterone acetate, and laser-based therapy are needed.

Evidence-based approach to cutaneous hyperandrogenism in women

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

Histologic features of alopecias-part I: nonscarring alopecias

The diagnosis of disorders of the hair and scalp can generally be made on clinical grounds, but clinical signs are not always diagnostic and in some cases more invasive techniques, such as a biopsy, may be necessary. This 2-part article is a detailed review of the histologic features of the main types of alopecia based on the traditional classification of these disorders into 2 major groups: scarring and nonscarring alopecias. Scarring alopecias are disorders in which the hair follicle is replaced by fibrous scar tissue, a process that leads to permanent hair loss. In nonscarring alopecias, the follicles are preserved and hair growth can resume when the cause of the problem is eliminated. In the first part of this review, we describe the histologic features of the main forms of nonscarring alopecia. Since a close clinical-pathological correlation is essential for making a correct histologic diagnosis of alopecia, we also include a brief description of the clinical features of the principal forms of this disorder.

Follicular density and ratios in scarring and nonscarring alopecia

Follicular counts from transverse sectioning of scalp biopsies have not been statistically scrutinized across disease entities in a standardized fashion. We applied uniform histological criteria and strict statistical measures to compare nonscarring and scarring alopecia. We studied 700 consecutive cases including 355 nonscarring alopecia [136 telogen effluvium, 115 alopecia areata (AA), 95 androgenetic alopecia, and 9 trichotillosis] and 345 scarring alopecia [238 central centrifugal cicatricial alopecia, 29 traction alopecia, 26 lichen planopilaris, 21 end-stage alopecia, 20 lupus erythematosus, 11 folliculitis decalvans]. We counted follicular units, anagen, catagen/telogen, and vellus-like follicles at the central follicular unit level. We calculated follicular density per square centimeter, anagen percentage, telogen percentage, anagen to telogen ratio, and terminal to vellus ratio (TVR). The following achieved statistical significance (P < 0.05): follicular density was 249.4 ± 4.6 in nonscarring alopecia versus 120.1 ± 3.8 in scarring alopecia, follicular density of telogen effluvium was 273.5 ± 7.0 (36.5 ± 12.5 above nonscarring alopecia mean), TVR of androgenetic alopecia was 1.6 ± 0.1 (3.6 ± 0.5 below nonscarring alopecia mean), TVR of AA was 3.2 ± 0.4 (1.5 ± 0.6 below nonscarring alopecia mean), anagen percentage of AA was 26.8 ± 1.8 (26.3 ± 3.0 below nonscarring alopecia mean), anagen to telogen ratio of AA was 1.6 ± 0.4 (3.9 ± 0.7 below nonscarring alopecia mean), and telogen percentage of AA was 59.0 ± 2.3 (31.0 ± 3.5 above nonscarring alopecia mean). There exists a great overlap of densities and ratios across the various disorders due to the limited nature of the punch biopsy sample, variations in scalp anatomy, disease biology and duration, patient gender, and age, etc. Our data provide a bell curve distribution that helps analyze hair counts in the clinicopathologic context.

Bleaching Phototrichogram: An Improved Method for Hair Growth Assessment

The phototrichogram (PT) is a non-invasive tool for monitoring hair growth in vivo. However, the majority of PT techniques are of little use to clinicians bacause they are time-consuming and/or difficult to perform. Consequently, there is a need for an easy and time-saving PT technique. This study was performed to evaluate the accuracy and availability of a modified PT, bleaching phototrichogram (BPT), by comparing it with the conventional phototrichogram (CPT). Ten healthy male volunteers (age range 26-33 years) comprised the study subjects. Hairs were clipped from two adjacent circular areas in the occipital region of each subject. The clipped hairs in the first area were bleached and photographed two days later. The second area was photographed just after clipping and two days later. In each area, the following biological parameters of hair growth were analyzed; 1: hair density (number/cm2), 2: anagen hair ratio (%), 3: linear hair growth rate (mm/day), 4: non-vellus hair ratio (%) and 5: anagen hair thickness (microm). The hair density, anagen hair ratio, linear hair growth rate, and anagen hair thickness by BPT were similar to the CPT values with no significant differences, although the non-vellus hair ratio by BPT was higher than the CPT value. The BPT has a higher clinical usefulness than the CPT because it saves much time with satisfactory accuracy.

Androgenetic alopecia: an evidence-based treatment update

BACKGROUND

Androgenetic alopecia (AGA) is one of the most common chronic problems seen by dermatologists worldwide. It is characterized by progressive hair loss, especially of scalp hair, and has distinctive patterns of loss in women versus men, but in both genders the central scalp is most severely affected. It often begins around puberty and is known to effect self-esteem and the individual's quality of life. In contrast to the high prevalence of AGA, approved therapeutic options are limited. In addition to the scarce pharmacologic treatments, there are numerous nonprescription products claimed to be effective in restoring hair in androgenetic alopecia.

OBJECTIVES

The purpose of this paper is to review published medical and non-medical treatments for male and female AGA using the American College of Physicians evidence assessment methods. MEDLINE, EMBASE and Cochrane Library were searched for systematic reviews, randomized controlled trials, open studies, case reports and relevant studies of the treatment of male and female AGA. The relevant articles were classified according to grade and level of evidence.

RESULTS

The medical treatments with the best level of evidence classification for efficacy and safety for male AGA are oral finasteride and topical minoxidil solution. For female AGA, topical minoxidil solution appears to be the most effective and safe treatment. The medical treatments corresponding to the next level of evidence quality are some commonly used therapeutic non-FDA-approved options including oral and topical anti-hormonal treatments. Surgical treatment of follicular unit hair transplantation is an option in cases that have failed medical treatment although there is high variation in outcomes.

LIMITATIONS

Some articles, especially those concerning traditional herbs claimed to promote hair regrowth, were published in non-English, local journals.

CONCLUSIONS

An assessment of the evidence quality of current publications indicates that oral finasteride (for men only) and topical minoxidil (for men and women) are the best treatments of AGA.

Hair-Loss Preventing Effect of Grateloupia elliptica

This study was conducted to evaluate the effect of Grateloupia elliptica, a seaweed native to Jeju Island, Korea, on the prevention of hair loss. When immortalized rat vibrissa dermal papilla cells were treated with extract of G. elliptica, the proliferation of dermal papilla cells significantly increased. In addition, the G. elliptica extract significantly inhibited the activity of 5α-reductase, which converts testosterone to dihydrotestosterone (DHT), a main cause of androgenetic alopecia. On the other hand, the G. elliptica extract promoted PGE2 production in HaCaT cells in a dose-dependent manner. The G. elliptica extract exhibited particularly high inhibitory effect on LPS-stimulated IL-12, IL-6, and TNF-α production in lipopolysaccharide (LPS)-stimulated bone marrow-derived dendritic cells. The G. elliptica extract also showed inhibitory activity against Pityrosporum ovale, a main cause of dandruff. These results suggest that G. elliptica extract has the potential to treat alopecia via the proliferation of dermal papilla, 5α-reductase inhibition, increase of PGE2 production, decrease of LPS-stimulated pro-inflammatory cytokines and inhibitory activity against Pityrosporum ovale.

Female pattern alopecia: current perspectives

Hair loss is a commonly encountered problem in clinical practice, with men presenting with a distinctive pattern involving hairline recession and vertex balding (Norwood-Hamilton classification) and women exhibiting diffuse hair thinning over the crown (increased part width) and sparing of the frontal hairline (Ludwig classification). Female pattern hair loss has a strikingly overwhelming psychological effect; thus, successful treatments are necessary. Difficulty lies in successful treatment interventions, as only two medications - minoxidil and finasteride - are approved for the treatment of androgenetic alopecia, and these medications offer mediocre results, lack of a permanent cure, and potential complications. Hair transplantation is the only current successful permanent option, and it requires surgical procedures. Several other medical options, such as antiandrogens (eg, spironolactone, oral contraceptives, cyproterone, flutamide, dutasteride), prostaglandin analogs (eg, bimatoprost, latanoprost), and ketoconazole are reported to be beneficial. Laser and light therapies have also become popular despite the lack of a profound benefit. Management of expectations is crucial, and the aim of therapy, given the current therapeutic options, is to slow or stop disease progression with contentment despite patient expectations of permanent hair regrowth. This article reviews current perspectives on therapeutic options for female pattern hair loss.

Factors associated with female pattern hair loss and its prevalence in Taiwanese women: a community-based survey

BACKGROUND

Although female pattern hair loss (FPHL) has been considered simply the female counterpart of male pattern hair loss in men, the risk factors may differ.

OBJECTIVE

We sought to evaluate factors associated with FPHL and to estimate its prevalence in women.

METHOD

In total, 26,226 subjects aged 30 years and older participated in a cross-sectional survey. Ludwig and Norwood classifications were used to assess the degree of hair loss. Information on possible risk factors for FPHL was collected using a questionnaire interview.

RESULTS

The prevalence of FPHL (Ludwig grade >I) for all ages was 11.8% (95% CI 11.5%-12.2%), increasing with advancing age. After controlling for age and family history, statistically significant associations were noted between FPHL and high fasting glucose (odds ratio [OR] 1.15, 95% confidence interval [CI] 1.04-1.28), fewer childbirths (OR 1.24, 95% CI 1.12-1.38), breast-feeding (OR 0.88, 95% CI 0.78-0.98), oral contraceptive use (OR 1.21, 95% CI 1.01-1.45), and ultraviolet exposure more than 16 hours per week (OR 1.12, 95% CI 1.02-1.22).

LIMITATIONS

The validity and reliability of FPHL classification may be not perfect in this survey and may need to be verified. Information on family history may be still subject to recall bias.

CONCLUSIONS

Risk factors for FPHL and male androgenic alopecia may differ.

Hair counts from normal scalp biopsy in Taiwan

BACKGROUND

Horizontal scalp biopsy is a better method to use when evaluating hair disorders, but an accurate diagnosis requires quantitative data regarding normal hair counts to be used as a control, which are currently available only for Caucasians, African Americans, Koreans, and Iranians.

OBJECTIVES

To evaluate scalp hair counts in the Taiwanese population.

METHODS

Two 4-mm punch biopsies were taken from clinically normal-looking scalp skin of 31 patients who underwent scalp surgery for non-hair-loss disorders. Punch biopsy specimens were sectioned horizontally at the sebaceous gland level and the number of follicular units, terminal hairs including anagen and telogen hairs, and vellus hairs were counted and compared with other published data. The numbers of hairs were also compared between the sexes, different age groups, and different anatomical locations of the scalp.

RESULTS

The average counts of total hairs, terminal hairs, vellus hairs, and follicular units per 4-mm punch scalp skin were 21.3, 20.5, 0.8, and 9.4, respectively. The mean ratio of anagen hair to telogen hair was 91.6:8.4 and of terminal hair to vellus hair was 25.3:1. The average density of hair follicles was 1.69 mm(2). The mean counts of terminal hairs, total hairs, follicular units, and hair follicles/mm(2) were significantly different between different age groups.

CONCLUSION

Differences in hair count parameters were recognized between different ethnic groups. Parameters of hair density established in the Taiwanese population will provide clinicians with useful reference data for the evaluation of hair disorders in Asians.

Treatment options for alopecia: an update, looking to the future

INTRODUCTION

Hair loss is a very common complaint. The diagnosis is based on clinical, dermoscopic and pathological examination. The treatment is usually continuous and requires strong compliance.

AREAS COVERED

This article aims to i) summarize current treatment options for the most common forms of hair loss; ii) update the literature on treatment options to emerge over the 3 years since the release of the first edition of this article in 2009; and iii) outline future strategies for treating alopecia.

EXPERT OPINION

There is good evidence-based information for the treatment of androgenetic alopecia. There are very few good-quality randomized studies, and no information about long-term results for most of the available treatments for alopecia areata and cicatricial alopecias. Significant research success has been achieved over the past few years through i) discovering the genetic profile of alopecia areata; ii) working on follicular neogenesis in androgenetic alopecia; and iii) discovering the PPAR-γ pathway in scarring alopecia.