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Tekin B, Xie F, Lehman JS. Lichen Planus: What is New in Diagnosis and Treatment? Am J Clin Dermatol 2024:10.1007/s40257-024-00878-9. [PMID: 38982032 DOI: 10.1007/s40257-024-00878-9] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 06/16/2024] [Indexed: 07/11/2024]
Abstract
Lichen planus (LP), an idiopathic, multifaceted chronic inflammatory disease with a heterogeneous clinical presentation, affects approximately 0.5-1% of the population. The various clinical manifestations of LP fall into three broad categories, namely cutaneous, appendageal, and mucosal, with further subclassification depending on the morphology and distribution patterns of individual lesions. There is mounting evidence that LP has systemic associations, including autoimmune conditions, glucose intolerance, dyslipidemia, and cardiovascular disorders. Cutaneous hypertrophic and mucosal forms of LP are at a heightened risk for malignant transformation. Familiarity with these potential associations in conjunction with long-term follow-up and regular screening could lead to a timely diagnosis and management of concomitant conditions. In addition, the frequent quality of life (QoL) impairment in LP underscores the need for a comprehensive approach including psychological evaluation and support. Several treatment strategies have been attempted, though most of them have not been adopted in clinical practice because of suboptimal benefit-to-risk ratios or lack of evidence. More recent studies toward pathogenesis-driven treatments have identified Janus kinase inhibitors such as tofacitinib, phosphodiesterase-4 inhibitors such as apremilast, and biologics targeting the interleukin-23/interleukin-17 pathway as novel therapeutic options, resulting in a dramatic change of the treatment landscape of LP. This contemporary review focuses on the diagnosis and management of LP, and places emphasis on more recently described targeted treatment options.
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Affiliation(s)
- Burak Tekin
- Department of Laboratory Medicine and Pathology, Mayo Clinic, 200 First St SW, Rochester, MN, 55905, USA
- Department of Dermatology, Mayo Clinic, Rochester, MN, USA
| | - Fangyi Xie
- Department of Dermatology, Mayo Clinic, Rochester, MN, USA
- Department of Dermatology, Royal Devon and Exeter NHS Foundation Trust, Exeter, UK
| | - Julia S Lehman
- Department of Laboratory Medicine and Pathology, Mayo Clinic, 200 First St SW, Rochester, MN, 55905, USA.
- Department of Dermatology, Mayo Clinic, Rochester, MN, USA.
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Méchin MC, Simon M. Deimination in epidermal barrier and hair formation. Philos Trans R Soc Lond B Biol Sci 2023; 378:20220245. [PMID: 37778378 PMCID: PMC10542453 DOI: 10.1098/rstb.2022.0245] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/27/2023] [Accepted: 04/13/2023] [Indexed: 10/03/2023] Open
Abstract
Peptidylarginine deiminases (PADs) transform a protein arginine residue into the non-standard amino acid citrulline. This calcium-dependent post-translational modification of proteins is called citrullination or deimination. As described in this special issue, PADs play a role in various physiological processes, and PAD deregulations are involved in many human diseases. Three PADs are expressed in the epidermis, where their roles begin to be deciphered. PAD1 and PAD3 are involved in keratinocyte differentiation, particularly in the epidermal barrier function, keratins, filaggrin and filaggrin-related proteins being the most abundant deiminated epidermal proteins. Reduced amounts of deiminated proteins and PAD1 expression may be involved in the pathogenesis of psoriasis and atopic dermatitis, two very frequent and chronic skin inflammatory diseases. The trichohyalin/PAD3/transglutaminase three pathway is important for hair shaft formation. Mutations of the PADI3 gene, leading to a decreased activity or abnormal localization of the corresponding isotype, are the cause of a rare hair disorder called uncombable hair syndrome, and are associated with the central centrifugal cicatricial alopecia, a frequent alopecia mainly affecting women of African ancestry. This article is part of the Theo Murphy meeting issue 'The virtues and vices of protein citrullination'.
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Affiliation(s)
- Marie-Claire Méchin
- Toulouse Institute for Infectious and Inflammatory Diseases (Infinity), University of Toulouse, CNRS, INSERM, University Paul Sabatier, 31024 Toulouse, France
| | - Michel Simon
- Toulouse Institute for Infectious and Inflammatory Diseases (Infinity), University of Toulouse, CNRS, INSERM, University Paul Sabatier, 31024 Toulouse, France
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Umar S, Ton D, Carter MJ, Shitabata P. Unveiling a Shared Precursor Condition for Acne Keloidalis Nuchae and Primary Cicatricial Alopecias. Clin Cosmet Investig Dermatol 2023; 16:2315-2327. [PMID: 37649568 PMCID: PMC10464825 DOI: 10.2147/ccid.s422310] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/12/2023] [Accepted: 08/18/2023] [Indexed: 09/01/2023]
Abstract
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.
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Affiliation(s)
- Sanusi Umar
- Department of Medicine, University of California at Los Angeles, Los Angeles, CA, USA
- Division of Dermatology, Department of Medicine, Harbor-UCLA Medical Center, Torrance, CA, USA
- Dr. U Hair and Skin Clinic, Manhattan Beach, CA, USA
| | - Donna Ton
- Dr. U Hair and Skin Clinic, Manhattan Beach, CA, USA
| | | | - Paul Shitabata
- Department of Medicine, University of California at Los Angeles, Los Angeles, CA, USA
- Division of Dermatology, Department of Medicine, Harbor-UCLA Medical Center, Torrance, CA, USA
- Dermatopathology Institute, Torrance, CA, USA
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Larrondo J, McMichael AJ. Scarring Alopecia. Dermatol Clin 2023; 41:519-537. [PMID: 37236719 DOI: 10.1016/j.det.2023.02.007] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 05/28/2023]
Abstract
African hair shaft and pigmented scalp have unique features that challenge diagnosis in scarring alopecia. In addition, Black patients may associate 2 or more types of hair disorders. Therefore, it is imperative to understand their findings thoroughly to establish a good diagnosis. Differential diagnosis on the frontal scalp includes traction alopecia and frontal fibrosing alopecia. Disorders such as central centrifugal cicatricial alopecia, fibrosing alopecia in a pattern distribution, discoid lupus erythematosus, and lichen planopilaris usually affect the middle scalp. Folliculitis decalvans, dissecting cellulitis, and acne keloidalis nuchae are the main differential diagnosis of the posterior scalp.
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Affiliation(s)
- Jorge Larrondo
- Department of Dermatology, Wake Forest Baptist Health, 4618 Country Club Road, Winston-Salem, NC 27104, USA; Department of Dermatology, Clínica Alemana-Universidad del Desarrollo, Av. Vitacura 5951, Santiago, 7650568, Chile
| | - Amy J McMichael
- Department of Dermatology, Wake Forest Baptist Health, 4618 Country Club Road, Winston-Salem, NC 27104, USA.
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Smith SDB, Woddor N, Cassarino DS, Chen W, Clemetson N, Nava VE. Central Centrifugal Cicatricial Alopecia Associated With PDL1 Loss and Increased Expression of Caspase 3: A Case Series. Am J Dermatopathol 2023; 45:418-422. [PMID: 37074004 DOI: 10.1097/dad.0000000000002428] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 04/20/2023]
Abstract
ABSTRACT Central centrifugal cicatricial alopecia (CCCA) is a scarring alopecia that disproportionately affects patients with skin of color. Genetic studies have revealed that approximately 30% of CCCAs are associated with peptidyl arginine deiminase 3 misfolding mutations. Patients with CCCA usually have a poor prognosis with progressive and permanent hair loss. To further characterize CCCA, we evaluated the inflammatory milieu, PDL1, and caspase 3 expression. The data support the idea of CCCA being a CD4-predominant T-cell process. The loss of PDL1 and increase in caspase 3 expression raises the possibility of involvement of the PD1/PDL1 pathway in CCCA.
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Affiliation(s)
- Shane D B Smith
- Department of Pathology, The George Washington University, Washington, DC
| | - Navitha Woddor
- Department of Pathology, The George Washington University, Washington, DC
| | - David S Cassarino
- Department of Pathology, Southern California Permanente Medical Group, Los Angeles, CA
| | - Wen Chen
- Department of Pathology, The George Washington University, Washington, DC
- Department of Pathology, Veterans Affairs Medical Center, Washington, DC; and
| | - Nashay Clemetson
- Department of Medicine, Dermatology, Veterans Affairs Medical Center, West Palm Beach, FL
| | - Victor E Nava
- Department of Pathology, The George Washington University, Washington, DC
- Department of Pathology, Veterans Affairs Medical Center, Washington, DC; and
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Beyond the Hot Comb: Updates in Epidemiology, Pathogenesis, and Treatment of Central Centrifugal Cicatricial Alopecia from 2011 to 2021. Am J Clin Dermatol 2023; 24:81-88. [PMID: 36399228 DOI: 10.1007/s40257-022-00740-w] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 10/17/2022] [Indexed: 11/19/2022]
Abstract
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.
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Umar S, Kan P, Carter MJ, Shitabata P, Novosilska M. Lichen Planopilaris Responsive to a Novel Phytoactive Botanical Treatment: A Case Series. Dermatol Ther (Heidelb) 2022; 12:1697-1710. [PMID: 35674981 PMCID: PMC9276860 DOI: 10.1007/s13555-022-00749-3] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/06/2022] [Accepted: 05/17/2022] [Indexed: 11/28/2022] Open
Abstract
INTRODUCTION Lichen planopilaris (LPP) is characterized by chronic scarring alopecia that is progressive and typically refractory to therapy. Current drug treatments are suboptimal and not applicable for long-term use because of the high potential for adverse effects, warranting safer and more effective treatment alternatives. METHODS Based on our previous success in treating a patient with central centrifugal cicatricial alopecia using a topical botanical formulation (Gashee), we reviewed records of four patients with biopsy-proven LPP treated with the topical formulation alone or in combination with its oral preparation. Three patients had failed previous treatment with intralesional steroid injections, topical minoxidil, tacrolimus, and clobetasol. Physical examination and photographic documentation were also used as outcome measures. Treatment duration with the botanical formulations ranged from 6 weeks to 9.5 months. RESULTS All patients showed overall improvement in surrogate indicators of LPP activity as evidenced by the disappearance of symptoms (pruritus, tenderness, scalp irritation, and hair shedding), improvement in hair growth, and reduction in redness. All reported a high satisfaction level and no adverse effects. CONCLUSIONS Patients with treatment-refractory LPP responded to a novel botanical treatment. To the best of our knowledge, this is the first published report of LPP responding to a plant-based natural treatment. Further evaluation of this treatment in a controlled trial with a larger number of patients is warranted.
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Affiliation(s)
- Sanusi Umar
- Department of Medicine, University of California at Los Angeles, Los Angeles, CA, USA. .,Division of Dermatology, Department of Medicine, Harbor-UCLA Medical Center, Torrance, CA, USA. .,Dr. U Hair and Skin Clinic, 2121 N. Sepulveda Avenue, Suite 200, Manhattan Beach, CA, 90266, USA.
| | - Petrina Kan
- Department of Molecular Biology, University of California at Los Angeles, Los Angeles, CA, USA
| | | | - Paul Shitabata
- Department of Medicine, University of California at Los Angeles, Los Angeles, CA, USA.,Division of Dermatology, Department of Medicine, Harbor-UCLA Medical Center, Torrance, CA, USA.,Dermatopathology Institute, Torrance, CA, USA
| | - Myroslava Novosilska
- Department of Dermatology and Oncology, Aesthetic Medical Clinic Myroslava Novosilska, Lviv, Ukraine
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Watson VE, Faniel ML, Kamili NA, Krueger LD, Zhu C. Immune-mediated alopecias and their mechanobiological aspects. Cells Dev 2022; 170:203793. [PMID: 35649504 PMCID: PMC10681075 DOI: 10.1016/j.cdev.2022.203793] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/01/2022] [Accepted: 05/24/2022] [Indexed: 02/06/2023]
Abstract
Alopecia is a non-specific term for hair loss clinically diagnosed by the hair loss pattern and histological analysis of patient scalp biopsies. The immune-mediated alopecia subtypes, including alopecia areata, lichen planopilaris, frontal fibrosing alopecia, and central centrifugal cicatricial alopecia, are common, significant forms of alopecia subtypes. For example, alopecia areata is the most common autoimmune disease with a lifetime incidence of approximately 2% of the world's population. In this perspective, we discuss major results from studies of immune-mediated alopecia subtypes. These studies suggest the key event in disease onset as the collapse in immune privilege, which alters the hair follicle microenvironment, e.g., upregulation of major histocompatibility complex molecules and increase of cytokine production, and results in immune cell infiltration, inflammatory responses, and damage of hair follicles. We note that previous studies have established that the hair follicle has a complex mechanical microenvironment, which may regulate the function of not only tissue cells but also immune cell infiltrates. This suggests a potential for mechanobiology to contribute to alopecia research by adding new methods, new approaches, and new ways of thinking, which is missing in the existing literature. To fill this a gap in the alopecia research space, we develop a mechanobiological hypothesis that alterations in the hair follicle microenvironment, specifically in the mechanically responsive tissues and cells, partially due to loss of immune privilege, may be contributors to disease pathology. We further focus our discussion on the potential for applying mechanoimmunology to the study of T cell infiltrates in the hair follicle, as they are considered primary contributors to alopecia pathology. To establish the connection between the mechanoimmunological hypothesis and immune-mediated alopecia subtypes, we discuss what is known about the role of T cells in immune-mediated alopecia subtypes, using the most extensively studied AA as our model.
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Affiliation(s)
- Valencia E Watson
- Wallace H. Coulter Department of Biomedical Engineering, USA; Bioengineering PhD Program, USA; Parker H. Petit Institute for Bioengineering and Biosciences, Georgia Institute of Technology, Atlanta, GA, USA
| | - Makala L Faniel
- Wallace H. Coulter Department of Biomedical Engineering, USA; Bioengineering PhD Program, USA; Parker H. Petit Institute for Bioengineering and Biosciences, Georgia Institute of Technology, Atlanta, GA, USA
| | | | - Loren D Krueger
- Department of Dermatology, Emory University School of Medicine, Atlanta, GA, USA.
| | - Cheng Zhu
- Wallace H. Coulter Department of Biomedical Engineering, USA; Bioengineering PhD Program, USA; Parker H. Petit Institute for Bioengineering and Biosciences, Georgia Institute of Technology, Atlanta, GA, USA.
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Uchiyama M. Primary cicatricial alopecia: Recent advances in evaluation and diagnosis based on trichoscopic and histopathological observation, including overlapping and specific features. J Dermatol 2021; 49:37-54. [PMID: 34866229 DOI: 10.1111/1346-8138.16252] [Citation(s) in RCA: 8] [Impact Index Per Article: 2.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/31/2021] [Revised: 11/04/2021] [Accepted: 11/09/2021] [Indexed: 12/27/2022]
Abstract
Primary cicatricial alopecia (PCA) is a form of alopecia in which inflammatory cells target follicles, including the bulge region containing follicular stem cells, leading to permanent alopecia. New classifications of PCA subtypes have recently been proposed, including those that account for novel trichoscopic and histopathological features of PCA, enabling greater precision in the evaluation and diagnosis of this condition. Nonetheless, diagnosis remains challenging clinically and histopathologically because the etiology of PCA is multifactorial. Inconsistent use of terminology, overlapping disease concepts, and changes in the clinical or histopathological severity of inflammation in the disease course in the same patient also make diagnosis quite challenging. The present study comprehensively reviews recent progress in diagnostic techniques, including the use of clinical, trichoscopic, and histopathological features, in evaluating each PCA subtype, containing overlapping and specific features. Elucidating the features of PCA, including those that are common to multiple subtypes as well as specific to each in both early and advanced-stage lesions, is important for accurate diagnosis. Improving the evaluation and treatment of this disease depends on having a broader clinical understanding that takes into account not only the features of the disease at a given point in time, but also the changes that occur during the entire disease course.
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Affiliation(s)
- Masaki Uchiyama
- Department of Dermatology, Tokyo Medical University, Tokyo, Japan
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Saggini A, Kempf W, Kutzner H. Lichen planus follicularis tumidus: Immunotyping of the inflammatory infiltrate with focus on plasmacytoid dendritic cells. J Cutan Pathol 2020; 47:923-928. [PMID: 32458476 DOI: 10.1111/cup.13724] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/03/2020] [Revised: 04/09/2020] [Accepted: 04/20/2020] [Indexed: 12/13/2022]
Abstract
Lichen planus follicularis tumidus (LPFT) is a rare clinicopathological variant of lichen planus (LP), clinically presenting with red-to-violaceous plaques studded with comedo-like lesions and keratin-filled milia-like cysts. Histopathologically, LPFT is characterized by cystically dilated follicular infundibula in the dermis, surrounded by a dense lichenoid lymphoid infiltrate with an associated interface reaction. We describe the clinicopathological features of an additional case of LPFT, focusing on the number and distribution of CD123(+) TCF4(+) plasmacytoid dendritic cells (pDCs). In our case, pDCs represented approximately 5% of the total inflammatory infiltrate, predominantly exhibiting a lichenoid distribution around the infundibula with no evidence of cluster formation, thus ruling out cutaneous lupus erythematosus. Our report is the first to describe the number and distribution of pDCs in LPFT. The results of our immunohistochemical analysis corroborate the notion that LPFT should be regarded as a rare variant of LP.
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Affiliation(s)
| | - Werner Kempf
- Kempf und Pfaltz Histologische Diagnostik, Zürich, Switzerland
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Méchin MC, Takahara H, Simon M. Deimination and Peptidylarginine Deiminases in Skin Physiology and Diseases. Int J Mol Sci 2020; 21:ijms21020566. [PMID: 31952341 PMCID: PMC7014782 DOI: 10.3390/ijms21020566] [Citation(s) in RCA: 43] [Impact Index Per Article: 10.8] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/19/2019] [Revised: 01/10/2020] [Accepted: 01/12/2020] [Indexed: 01/06/2023] Open
Abstract
Deimination, also known as citrullination, corresponds to the conversion of the amino acid arginine, within a peptide sequence, into the non-standard amino acid citrulline. This post-translational modification is catalyzed by a family of calcium-dependent enzymes called peptidylarginine deiminases (PADs). Deimination is implicated in a growing number of physiological processes (innate and adaptive immunity, gene regulation, embryonic development, etc.) and concerns several human diseases (rheumatoid arthritis, neurodegenerative diseases, female infertility, cancer, etc.). Here, we update the involvement of PADs in both the homeostasis of skin and skin diseases. We particularly focus on keratinocyte differentiation and the epidermal barrier function, and on hair follicles. Indeed, alteration of PAD activity in the hair shaft is responsible for two hair disorders, the uncombable hair syndrome and a particular form of inflammatory scarring alopecia, mainly affecting women of African ancestry.
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Affiliation(s)
- Marie-Claire Méchin
- UDEAR, Institut National de la Santé Et de la Recherche Médicale, Université Paul Sabatier, Université de Toulouse Midi-Pyrénées, U1056, 31059 Toulouse, France;
| | - Hidenari Takahara
- University of Ibaraki, School of Agriculture, Ibaraki 300-0393, Japan;
| | - Michel Simon
- UDEAR, Institut National de la Santé Et de la Recherche Médicale, Université Paul Sabatier, Université de Toulouse Midi-Pyrénées, U1056, 31059 Toulouse, France;
- Correspondence: ; Tel.: +33-5-6115-8427
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