Alopecia areata: diagnosis and management

Real-World Treatment Patterns among Patients with Alopecia Areata in the USA: A Retrospective Claims Analysis

Alopecia areata is an autoimmune disorder characterized by hair loss, for which there are few treatment options. This claims-based study characterized recent real-world treatment patterns among patients in the USA with alopecia areata, including the subtypes alopecia totalis and alopecia universalis, in the first year after diagnosis of an episode of alopecia areata. Approximately 5% of all patients (adults (age ≥ 18 years), n = 7,703; adolescents (age 12-17 years), n = 595) had alopecia totalis or alopecia universalis. Corticosteroids were the most common first-line (1L) and second-line (2L) treatments. The mean time from diagnosis of alopecia areata to initiation of 1L treatment was 2.2 days for adults and 2.6 days for adolescents; mean 1L duration was 76.9 and 64.3 days, respectively. For adults (57.5%) and adolescents (59.7%) with 2L therapy, the mean time from 1L discontinuation to 2L initiation was 57.2 and 53.6 days, respectively; the mean duration of 2L treatment was 55.5 and 50.1 days, respectively. More patients with vs without alopecia totalis or alopecia universalis initiated 2L therapy (adults: 71.9% vs 56.8%; adolescents: 71.4% vs 58.9%). The proportion of days covered during the first year post-diagnosis was 36.7% (adults) and 34.1% (adolescents). These results highlight the substantial disease burden of alopecia areata and a need for more effective treatments.

Alopecias in humans: biology, pathomechanisms and emerging therapies

BACKGROUND

The hair follicle is a complete mini-organ with a complex biology. Recent discoveries have shed light on the pathogenesis and genetic basis of a number of hair loss conditions, offering novel treatment alternatives.

OBJECTIVE

To explore the biology and physiology of hair growth, the pathomechanism behind alopecias and emerging therapies.

CONCLUSION AND CLINICAL IMPORTANCE

Hair growth is influenced by numerous physiological moderators. Greater understanding of the biology and physiology of the hair follicle and the pathomechanisms of hair disease facilitates development of targeted treatments. Sublingual minoxidil is a promising therapy in humans where optimised drug delivery enhances efficacy and reduces systemic adverse effects. Janice kinase inhibitors, which disrupt the inflammatory cascade, help maintain the hair follicle, preserve immune privilege, and regrow hair in alopecia areata. As the pathomechanisms of other forms of alopecia become better understood, new targeted therapies with greater efficacy will emerge.

Childhood Alopecia Areata: An Overview of Treatment and Recent Patents

BACKGROUND

Alopecia Areata (AA) is a systemic autoimmune condition that usually starts in childhood.

OBJECTIVE

This article aims to review genetics, therapy, prognosis, and recent patents for AA.

METHODS

We used clinical queries and keywords "alopecia areata" AND "childhood" as a search engine. Patents were searched using the key term "alopecia areata" in Patents.google.com and freepatentsonline. com.

RESULTS

Due to an immune-mediated damage to the hair follicles, hair is lost from the scalp and other areas of the body temporarily or even permanently. Children with AA are generally healthy. Evidence of genetic association and increased predisposition for AA was found by studying families with affected members. Pathophysiologically, T- lymphocytes attack hair follicles and cause inflammation and destruction of the hair follicles and hair loss. In mild cases, there would be well-demarcated round patchy scalp hair loss. The pathognomonic "exclamation mark hairs" may be seen at the lesion periphery. In more severe cases, the hair loss may affect the whole scalp and even the whole body. The clinical course is also variable, which may range from transient episodes of recurrent patchy hair loss to an indolent gradually deteriorating severe hair loss. The treatment of AA depends on factors including patients' age, the extent of the hair loss, duration of disease, psychological impact, availability and side effect profile of the treatments. For localized patchy alopecia, topical application of corticosteroids and/or intralesional corticosteroids are the treatment of choice. Other topical treatments include minoxidil, anthralin, coal tar and immunotherapy. In severe resistant cases, systemic immunosuppressants may be considered. Although herbal medicine, acupuncture, complementary and alternative medicine may be tried on children in some Asian communities, the evidence to support these practices is lacking. To date, only a few recent patents exist in topical treatments, including Il-31, laser and herbal medications. Clinical efficacy is pending for these treatment modalities.

CONCLUSION

None of the established therapeutic options are curative. However, newer treatment modalities, including excimer laser, interleukin-31 antibodies and biologics, are evolving so that there may be significant advances in treatment in the near future. AA can be psychosocially devastating. It is important to assess the quality of life, degree of anxiety, social phobia and mood of the patients and their families. Psychological support is imperative for those who are adversely affected psychosocially.

Topographic Phenotypes of Alopecia Areata and Development of a Prognostic Prediction Model and Grading System: A Cluster Analysis

Importance

Diverse assessment tools and classification have been used for alopecia areata; however, their prognostic values are limited.

Objective

To identify the topographic phenotypes of alopecia areata using cluster analysis and to establish a prediction model and grading system for stratifying prognoses.

Design, Setting, and Participants

A retrospective cohort study of 321 patients with alopecia areata who visited a single tertiary referral center between October 2012 and February 2017 and underwent 4-view photographic assessment.

Exposures

Clinical photographs were reviewed to evaluate hair loss using the Severity of Alopecia Tool 2. Topographic phenotypes of alopecia areata were identified using hierarchical clustering with Ward's method. Differences in clinical characteristics and prognosis were compared across the clusters. The model was evaluated for its performance, accuracy, and interobserver reliability by comparison to conventional methods.

Main Outcomes and Measures

Topographic phenotypes of alopecia areata and their major (60%-89%) and complete regrowth probabilities (90%-100%) within 12 months.

Results

A total of 321 patients were clustered into 5 subgroups. Grade 1 (n = 200; major regrowth, 93.4%; complete regrowth, 65.2%) indicated limited hair loss, whereas grades 2A (n = 66; major regrowth, 87.8%; complete regrowth, 64.2%) and 2B (n = 20; major regrowth, 73.3%; complete regrowth, 45.5%) exhibited greater hair loss than grade 1. The temporal area was predominantly involved in grade 2B, but not in grade 2A, despite being comparable in total extent of hair loss. Grade 3 (n = 20; major regrowth, 45.5%; complete regrowth, 25.5%) included diffuse or extensive alopecia areata, and grade 4 (n = 15; major regrowth, 28.2%; complete regrowth, 16.7%) corresponded to alopecia (sub)totalis. No significant differences in prognosis (hazard ratio [HR] for major regrowth, 0.79; 95% CI, 0.56-1.12) were found between grades 2A and 1, whereas grades 2B (HR, 0.41; 95% CI, 0.21-0.81), 3 (HR, 0.24; 95% CI, 0.12-0.50), and 4 (HR, 0.16; 95% CI, 0.06-0.39) had significantly poorer response. Among multiple models, the cluster solution had the greatest prognostic performance and accuracy. The tree model of the cluster solution was converted into the Topography-based Alopecia Areata Severity Tool (TOAST), which revealed an excellent interobserver reliability among 4 dermatologists (median quadratic-weighted κ, 0.89).

Conclusions and Relevance

Temporal area involvement should be independently measured for better prognostic stratification. The TOAST is an effective tool for describing the topographical characteristics and prognosis of hair loss and may enable clinicians to establish better treatment plans.

Human umbilical cord blood mesenchymal stem cells engineered to overexpress growth factors accelerate outcomes in hair growth

Human umbilical cord blood mesenchymal stem cells (hUCB-MSCs) are used in tissue repair and regeneration; however, the mechanisms involved are not well understood. We investigated the hair growth-promoting effects of hUCB-MSCs treatment to determine whether hUCB-MSCs enhance the promotion of hair growth. Furthermore, we attempted to identify the factors responsible for hair growth. The effects of hUCB-MSCs on hair growth were investigated in vivo, and hUCB-MSCs advanced anagen onset and hair follicle neogeneration. We found that hUCB-MSCs co-culture increased the viability and up-regulated hair induction-related proteins of human dermal papilla cells (hDPCs) in vitro. A growth factor antibody array revealed that secretory factors from hUCB-MSCs are related to hair growth. Insulin-like growth factor binding protein-1 (IGFBP-1) and vascular endothelial growth factor (VEGF) were increased in co-culture medium. Finally, we found that IGFBP-1, through the co-localization of an IGF-1 and IGFBP-1, had positive effects on cell viability; VEGF secretion; expression of alkaline phosphatase (ALP), CD133, and β-catenin; and formation of hDPCs 3D spheroids. Taken together, these data suggest that hUCB-MSCs promote hair growth via a paracrine mechanism.

Molecular functional analyses revealed essential roles of HSP90 and lamin A/C in growth, migration, and self-aggregation of dermal papilla cells

Previous expression study using quantitative proteomics has shown that immune-mediated pathway may not be the main mechanism inducing alopecia areata (AA). Nevertheless, functional impact of such expression data set remained unknown and unexplored. This study thus aimed to define potentially novel mechanisms of the AA pathogenesis by functional investigations of the differentially expressed proteins previously identified from lesional biopsies. From 122 altered proteins, protein–protein interactions network analysis revealed that downregulated heat shock protein 90 (HSP90) and lamin A/C served as the central nodes of protein–protein interactions involving in several crucial biological functions, including cytoskeleton organization, extracellular matrix organization, and tissue development. Interaction between HSP90 and lamin A/C in dermal papilla cells (DPCs) was confirmed by reciprocal immunoprecipitation and immunofluorescence co-staining. Small-interfering RNA (siRNA) targeting to HSP90 (siHSP90) and lamin A/C (siLamin A/C) effectively reduced levels of HSP90 and lamin A/C, respectively and vice versa, comparing to non-transfected and siControl-transfected cells, strengthening their interactive roles in DPCs. Functional investigations revealed that DPCs transfected with siHSP90 and siLamin A/C had defective cell proliferation and growth, prolonged doubling time, cell cycle arrest at G0/G1 phase, and defective self-aggregation formation. Moreover, siHSP90-transfected cells had less spindle index, reduced levels of vimentin (mesenchymal marker) and fibronectin (extracellular matrix), and defective migratory activity. Our data have demonstrated for the first time that HSP90 and lamin A/C physically interact with each other. Moreover, both of them are essential for growth, migration, and self-aggregation of DPCs and can be linked to the disease mechanisms of AA.

Differential proteomics of lesional vs. non-lesional biopsies revealed non-immune mechanisms of alopecia areata

Alopecia areata (AA) is one of the common hair disorders for which treatment is frequently ineffective and associated with relapsing episodes. Better understanding of disease mechanisms and novel therapeutic targets are thus required. From 10 AA patients, quantitative proteomics using LTQ-Orbitrap-XL mass spectrometer revealed 104 down-regulated, 4 absent, 3 up-regulated and 11 newly present proteins in lesional vs. non-lesional biopsies. Among these, the decreased levels of α-tubulin, vimentin, heat shock protein 70 (HSP70), HSP90, annexin A2 and α-enolase were successfully confirmed by Western blotting. Protein-protein interactions network analysis using STRING tool revealed that the most frequent biological processes/networks of the down-regulated proteins included tissue development, cell differentiation, response to wounding and catabolic process, whereas those for the up-regulated proteins included biological process, metabolic process, cellular transport, cellular component organization and response to stimulus. Interestingly, only 5 increased/newly present proteins were associated with the regulation of immune system, which may not be the predominant pathway in AA pathogenic mechanisms as previously assumed. In summary, we report herein the first proteome dataset of AA demonstrating a number of novel pathways, which can be linked to the disease mechanisms and may lead to discovery of new therapeutic targets for AA.

Different trichoscopic features of tinea capitis and alopecia areata in pediatric patients

Background. Diagnosis of patchy hair loss in pediatric patients is often a matter of considerable debate among dermatologists. Trichoscopy is a rapid and noninvasive tool to detect more details of patchy hair loss. Like clinical dermatology, trichoscopy works parallel to the skin surface and perpendicular to the histological plane; like the histopathology, it thus allows the viewing of structures not discovered by the naked eye. Objective. Aiming to compare the different trichoscopic features of tinea capitis and alopecia areata in pediatric patients. Patients and Methods. This study included 40 patients, 20 patients with tinea capitis and 20 patients with alopecia areata. They were exposed toclinical examination, laboratory investigations (10% KOH and fungal culture), and trichoscope examination. Results. Our obtained results reported that, in tinea capitis patients, comma shaped hairs, corkscrew hairs, and zigzag shaped hairs are the diagnostic trichoscopic features of tinea capitis. While in alopecia areata patients, the most trichoscopic specific features were yellow dots, exclamation mark, and short vellus hairs. Conclusion. Trichoscopy can be used as a noninvasive tool for rapid diagnosis of tinea capitis and alopecia areata in pediatric patients.

Efficacy of korean red ginseng in the treatment of alopecia areata

Alopecia areata (AA) is an autoimmune disease that can affect any hair-bearing area. AA is known to be caused by immunological disorder but still, the pathogenesis is not fully understood. Many therapeutic modalities have been used to treat alopecia areata, with variable efficacy and safety profiles. Unfortunately, none of these agents is definitely curative or preventive alone. We studied hair growth efficacy and safety of Korean red ginseng (KRG) in AA comparing corticosteroid intra-lesional injection (ILI) alone patient group with ILI with KRG taking patient group using Folliscope 2.5 for 12 wk. Herein, we would like to report the efficacy of KRG in the treatment of AA and recommend KRG as a useful complimentary food for gaining efficacy of treatment for AA.

Exomic sequencing of immune-related genes reveals novel candidate variants associated with alopecia universalis

Alopecia areata (AA) is a common autoimmune disorder mostly presented as round patches of hair loss and subclassified into alopecia totalis/alopecia universalis (AT/AU) based on the area of alopecia. Although AA is relatively common, only 5% of AA patients progress to AT/AU, which affect the whole scalp and whole body respectively. To determine genetic determinants of this orphan disease, we undertook whole-exome sequencing of 6 samples from AU patients, and 26 variants in immune-related genes were selected as candidates. When an additional 14 AU samples were genotyped for these candidates, 6 of them remained at the level of significance in comparison with 155 Asian controls (p<1.92×10(-3)). Linkage disequilibrium was observed between some of the most significant SNPs, including rs41559420 of HLA-DRB5 (p<0.001, OR 44.57) and rs28362679 of BTNL2 (p<0.001, OR 30.21). While BTNL2 was reported as a general susceptibility gene of AA previously, HLA-DRB5 has not been implicated in AA. In addition, we found several genetic variants in novel genes (HLA-DMB, TLR1, and PMS2) and discovered an additional locus on HLA-A, a known susceptibility gene of AA. This study provides further evidence for the association of previously reported genes with AA and novel findings such as HLA-DRB5, which might represent a hidden culprit gene for AU.

Diphencyprone induced vitiligo: a case report

Diphencyprone (DCP) is a contact sensitizer which is used to treat dermatological disorders with an immunological origin, such as extensive alopecia areata (AA). Vitiligo is a rare but known side effect of DPCP therapy which is formed in the treatment site or remote areas. In this paper a 37-year-old man developed alopecia totalis with loss of eyebrows and eyelashes who presented some vitiligo patches on his scalp and arm distant from the location of DPCP application and a 42-year-old woman with 25 years history of hair loss and 3 months DPCP application who revealed some vitiligo patches on the scalp with distant to the site of application at the 6th week are reported. Considering the absence of personal and family history of Vitiligo in our two cases, the hypothesis of latent Vitiligo is not proved. The positive patch test in left arm of one of the patients also suggests the direct role of DPCP as the cause of Vitiligo occurrence. As the development of vitiligo by DCP is unpredictable and the depigmentation may persist indefinitely, it is important to inform all patients about this potential adverse effect before starting the treatment.

Alopecia areata update: part I. Clinical picture, histopathology, and pathogenesis

Alopecia areata (AA) is an autoimmune disease that presents as nonscarring hair loss, although the exact pathogenesis of the disease remains to be clarified. Disease prevalence rates from 0.1% to 0.2% have been estimated for the United States. AA can affect any hair-bearing area. It often presents as well demarcated patches of nonscarring alopecia on skin of overtly normal appearance. Recently, newer clinical variants have been described. The presence of AA is associated with a higher frequency of other autoimmune diseases. Controversially, there may also be increased psychiatric morbidity in patients with AA. Although some AA features are known poor prognostic signs, the course of the disease is unpredictable and the response to treatment can be variable. Part one of this two-part series on AA describes the clinical presentation and the associated histopathologic picture. It also proposes a hypothesis for AA development based on the most recent knowledge of disease pathogenesis.

LEARNING OBJECTIVES

After completing this learning activity, participants should be familiar with the most recent advances in AA pathogenesis, recognize the rare and recently described variants of AA, and be able to distinguish between different histopathologic stages of AA.

Substance P as an Immunomodulatory Neuropeptide in a Mouse Model for Autoimmune Hair Loss (Alopecia Areata)

Alopecia areata (AA) is an autoimmune disorder of the hair follicle characterized by inflammatory cell infiltrates around actively growing (anagen) hair follicles. Substance P (SP) plays a critical role in the cutaneous neuroimmune network and influences immune cell functions through the neurokinin-1 receptor (NK-1R). To better understand the role of SP as an immunomodulatory neuropeptide in AA, we studied its expression and effects on immune cells in a C3H/HeJ mouse model for AA. During early stages of AA development, the number of SP-immunoreactive nerve fibers in skin is increased, compared to non-affected mice. However, during advanced stages of AA, the number of SP-immunoreactive nerves and SP protein levels in skin are decreased, whereas the expression of the SP-degrading enzyme neutral endopeptidase (NEP) is increased, compared to control skin. In AA, NK-1R is expressed on CD8+ lymphocytes and macrophages accumulating around affected hair follicles. Additional SP supply to the skin of AA-affected mice leads to a significant increase of mast cell degranulation and to accelerated hair follicle regression (catagen), accompanied by an increase of CD8+ cells-expressing granzyme B. These data suggest that SP, NEP, and NK-1R serve as important regulators in the molecular signaling network modulating inflammatory response in autoimmune hair loss.

Alopecia areata masquerading as frontal fibrosing alopecia

SUMMARY Postmenopausal women with frontal recession may represent a diagnostic challenge, as frontal fibrosing alopecia and alopecia areata may be clinically difficult to distinguish. A 53-year-old postmenopausal woman presented with a progressive fronto-temporal marginal alopecia with sparing of her eyebrows. Scalp biopsy of the affected frontal hairline revealed peribulbar lymphocytic inflammation, but no evidence of lichenoid inflammation, perifollicular fibrosis or scarring. Whereas the pathology strongly favoured alopecia areata, the clinical features overlapped with frontal fibrosing alopecia, a variant of lichen planopilaris targeting the frontal scalp. This paper presents an atypical clinical presentation of alopecia areata, which may be mistaken for frontal fibrosing alopecia.

Alopecia areata: revisão e atualização

Trata-se de artigo de revisão em que são analisados os aspectos clínicos, histopatológicos, etiopatogênicos e a terapêutica atual da alopecia areata. Enfatiza-se a posição nosológica atual da alopecia areata como doença auto-imune que se desenvolve em substrato genético e discutem-se os possíveis mecanismos fisiopatológicos da enfermidade, bem como os tratamentos atuais, particularmente para as formas mais graves da doença, compreendendo terapêuticas imunomoduladoras tópicas com dibutilester do ácido esquárico e difenciprona e seus possíveis mecanismos de ação.

Efficacy of betamethasone valerate foam formulation in comparison with betamethasone dipropionate lotion in the treatment of mild-to-moderate alopecia areata: a multicenter, prospective, randomized, controlled, investigator-blinded trial

BACKGROUND

Betamethasone valerate foam (BVF) is a new topical corticosteroid formulation. In scalp psoriasis patients BVF has induced a significantly greater clinical improvement in comparison with corticosteroid lotions. No data are available to date regarding the efficacy and safety of BVF in mild-to-moderate alopecia areata (AA).

STUDY AIM

To evaluate the efficacy, tolerability and safety of BVF treatment in patients with mild-to-moderate AA.

SUBJECTS AND METHODS

Sixty-one patients (26 men and 35 women; mean age 41 +/- 13 years) with mild-to-moderate AA (hair loss < 26%) were enrolled in a parallel-group, investigator-blinded trial. Subjects were assigned randomly to BVF (31 patients) or to betamethasone dipropionate lotion (BDL) (30 subjects). Both treatments were applied to the affected areas twice a day for 12 consecutive weeks.

OUTCOMES

The primary study outcome was to compare the hair regrowth rate. Efficacy was evaluated at weeks 8 and 12 and at follow up (week 20), using a hair regrowth score (RGS) with a scale ranging from 0 (regrowth < 10%) to 4 (regrowth > 75%).

RESULTS

Fifty-seven subjects (93%) completed the trial. At week 20, the RGS was 3.1 +/- 1.5 and 1.8 +/- 1.6 in the BVF and BDL groups, respectively (P < 0.01). A RGS > 3 was observed in 61% of patients in the BVF group (19/31) in comparison with 27% (8/30) in the BDL group (P < 0.03). No serious adverse events were observed in both groups during the study.

CONCLUSION

Betamethasone valerate foam has shown to be an effective and well-tolerated treatment of mild-to-moderate AA. Further trials are warranted to evaluate the role of this new formulation in comparison or in combination with intralesional corticosterioids in AA treatment.

Alopecia areata update

Alopecia areata (AA) is a nonscarring hair loss condition. Among the many factors under investigation in the pathogenesis of AA, the main areas of concentration have been genetic constitution as well as nonspecific immune and organ-specific autoimmune reactions. Treatment with intralesional corticosteroid injections for localized patchy AA and topical immunotherapy for extensive AA have proven successful in the majority of patients, although all treatments are palliative and do not change the prognosis of the disease.