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Genedy RM, Badran FK, Tayae EM, Sabra HN. Lesson to Learn From Cellular infiltrate in Scalp Biopsy of Alopecia Areata. Am J Dermatopathol 2021; 43:e158-e164. [PMID: 33606369 DOI: 10.1097/dad.0000000000001929] [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: 11/26/2022]
Abstract
BACKGROUND Alopecia areata (AA) is a common cause of hair loss. It is mediated by T lymphocytes. Scalp biopsy findings in AA differ according to the disease phase and activity. OBJECTIVES To study the cellular infiltrate in the transverse section of scalp biopsy of AA at different disease stages and in relation to disease activity. METHODS The study was performed on 40 subjects with AA. A 4-mm punch biopsy was obtained from an AA scalp lesion. Biopsies were sectioned horizontally; 2 anatomical levels were studied (mid dermal and deep dermal levels). RESULTS Ninety-five percent of AA showed noncicatrical alopecia. A significant relation was found between the course of AA and the terminal:vellus ratio. Peribulbar lymphocytic infiltration was seen in 70% of cases. Mast cells were observed in 87.5% of cases, including fibrous tract and around the arrector pili muscles. Eosinophils were detected in the scalp biopsy of 22.5% of cases. Course and activity of AA were significantly related to the peribulbar lymphocytic cell infiltration but not to mast cells and eosinophils. CONCLUSION Although a peribulbar lymphocytic infiltrate is the classical finding of AA, it is absent in the chronic phase. Mast cells are commonly found in the scalp biopsy of AA and could explain the potential therapeutic effect of antihistamines.
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Affiliation(s)
- Rasha Mahmoud Genedy
- Department of Dermatology and Venereology, Faculty of Medicine, Alexandria University, Alexandria, Egypt
| | - Fairouz Khalil Badran
- Department of Dermatology and Venereology, Faculty of Medicine, Alexandria University, Alexandria, Egypt
| | - Eman Mohamed Tayae
- Department of Clinical and Chemical Pathology, Faculty of Medicine, Alexandria University Egypt, Alexandria, Egypt; and
| | - Heba Nasrallah Sabra
- Department of Dermatology and Venereology, Ministry of Health Hospitals, Alexandria, Egypt
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Zhou C, Li X, Wang C, Zhang J. Alopecia Areata: an Update on Etiopathogenesis, Diagnosis, and Management. Clin Rev Allergy Immunol 2021; 61:403-423. [PMID: 34403083 DOI: 10.1007/s12016-021-08883-0] [Citation(s) in RCA: 97] [Impact Index Per Article: 32.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 07/24/2021] [Indexed: 12/11/2022]
Abstract
Alopecia areata (AA) is a common chronic tissue-specific autoimmune disease, resulting in hair loss, that affects up to 2% of the general population. The exact pathobiology of AA has still remained elusive, while the common theory is the collapse of the immune privilege of the hair follicle caused by immunological mechanism. Multiple genetic and environment factors contribute to the pathogenesis of AA. There are several clinical treatments for AA, varying from one or multiple well-defined patches to more diffuse or total hair loss of the scalp (alopecia totalis) or hair loss of the entire body (alopecia universalis). The available treatments for AA, such as corticosteroids and other immunomodulators, minoxidil, and contact immunotherapy, are of limited efficacy with a high risk of adverse effects and high recurrence rates, especially for patients with severe AA. Recent insights into the pathogenesis of AA have led to the development of new treatment strategies, such as Janus kinase (JAK) inhibitors, biologics, and several small molecular agents. In addition, modern therapies for AA, including antihistamines, platelet-rich plasma (PRP) injection, and other novel therapies have been well explored. In this review, we discussed the recent advances in the pathogenesis, diagnosis, and treatment of AA.
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Affiliation(s)
- Cheng Zhou
- Department of Dermatology, Peking University People's Hospital, No. 11 Xizhimen South Street, Xicheng District, Beijing, China
| | - Xiangqian Li
- Department of Dermatology, Peking University People's Hospital, No. 11 Xizhimen South Street, Xicheng District, Beijing, China
| | - Chen Wang
- Department of Dermatology, Peking University People's Hospital, No. 11 Xizhimen South Street, Xicheng District, Beijing, China
| | - Jianzhong Zhang
- Department of Dermatology, Peking University People's Hospital, No. 11 Xizhimen South Street, Xicheng District, Beijing, China.
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Abstract
Alopecia areata (AA) is an autoimmune condition that affects up to 2% of the general population. Currently available treatment options for AA are of limited efficacy and can be associated with adverse effects. The advancement in understanding of the genetic and molecular mechanisms of AA has led to the development of novel treatment options, with the Janus kinase (JAK) inhibitor class of drugs at the forefront of ongoing clinical trials. Platelet-rich plasma, fecal transplants, and cytokine-targeted therapy with ustekinumab and dupilumab have also been shown to regrow hair in patients with AA in individual case reports or small studies. Several other novel therapies have preliminary data or are being tested in clinical trials.
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Zhang X, McElwee KJ. Allergy promotes alopecia areata in a subset of patients. Exp Dermatol 2019; 29:239-242. [PMID: 31479542 DOI: 10.1111/exd.14027] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [Key Words] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/24/2018] [Revised: 08/02/2019] [Accepted: 08/15/2019] [Indexed: 11/28/2022]
Abstract
In this commentary, we focus on allergy as a facilitating factor in the pathogenesis of alopecia areata (AA). From previous studies on AA, it is well known that subsets of patients can have one or more of; seasonal relapse, comorbid atopic rhinitis, asthma and dermatitis, lesion infiltrating eosinophils and plasma cells, high levels of total IgE, specific IgE for house dust mites (HDMs), and/or disrupted skin barrier function by the evaluation of filaggrin. Allergy and AA share a similar genetic background; both contributing to an immune reaction imbalance. Furthermore, adjunctive treatment with antihistamines, or desensitization for HDM, can reduce the severity of alopecia in atopic AA patients. Therefore, allergies may contribute to the onset and relapse of AA. Identification of an allergic or atopic immune component in AA patient subsets may indicate adjunctive treatment intervention measures against allergies should be taken which may improve the success of conventional AA treatment.
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Affiliation(s)
- Xingqi Zhang
- Department of Dermatology, The First Affiliated Hospital, Sun Yat-sen University, Guangzhou, China
| | - Kevin J McElwee
- Centre for Skin Sciences, University of Bradford, Bradford, UK.,Department of Dermatology and Skin Science, University of British Columbia, Vancouver, BC, Canada
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Azzawi S, Penzi LR, Senna MM. Immune Privilege Collapse and Alopecia Development: Is Stress a Factor. Skin Appendage Disord 2018; 4:236-244. [PMID: 30410890 PMCID: PMC6219219 DOI: 10.1159/000485080] [Citation(s) in RCA: 32] [Impact Index Per Article: 5.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/06/2017] [Accepted: 11/07/2017] [Indexed: 01/05/2023] Open
Abstract
Hair is a defining mammalian feature that serves as a hallmark of human communication. Given the critical significance of hair in social, religious, and political contexts, it is important to understand factors that play a role in hair loss disorders. The hair follicle is an immune privileged site, and mounting evidence suggests that the collapse of immune privilege contributes to the pathogenesis of autoimmune hair loss disorders, including alopecia areata and lichen planopilaris. This review comprehensively appraises the current literature to shed light on mechanisms for immune privilege collapse, and examines the role of neurogenic stress in triggering this process.
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Affiliation(s)
| | - Lauren R. Penzi
- Department of Dermatology, Massachusetts General Hospital, Boston, MA, USA
| | - Maryanne M. Senna
- Harvard Medical School, Boston, MA, USA
- Department of Dermatology, Massachusetts General Hospital, Boston, MA, USA
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6
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Affiliation(s)
- Solam Lee
- Department of Dermatology; Institute of Hair and Cosmetic Medicine; Yonsei University Wonju College of Medicine; Wonju Korea
| | - Won-Soo Lee
- Department of Dermatology; Institute of Hair and Cosmetic Medicine; Yonsei University Wonju College of Medicine; Wonju Korea
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Bertolini M, Zilio F, Rossi A, Kleditzsch P, Emelianov VE, Gilhar A, Keren A, Meyer KC, Wang E, Funk W, McElwee K, Paus R. Abnormal interactions between perifollicular mast cells and CD8+ T-cells may contribute to the pathogenesis of alopecia areata. PLoS One 2014; 9:e94260. [PMID: 24832234 PMCID: PMC4022513 DOI: 10.1371/journal.pone.0094260] [Citation(s) in RCA: 99] [Impact Index Per Article: 9.9] [Reference Citation Analysis] [Abstract] [MESH Headings] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/26/2013] [Accepted: 03/12/2014] [Indexed: 02/08/2023] Open
Abstract
Alopecia areata (AA) is a CD8+ T-cell dependent autoimmune disease of the hair follicle (HF) in which the collapse of HF immune privilege (IP) plays a key role. Mast cells (MCs) are crucial immunomodulatory cells implicated in the regulation of T cell-dependent immunity, IP, and hair growth. Therefore, we explored the role of MCs in AA pathogenesis, focusing on MC interactions with CD8+ T-cells in vivo, in both human and mouse skin with AA lesions. Quantitative (immuno-)histomorphometry revealed that the number, degranulation and proliferation of perifollicular MCs are significantly increased in human AA lesions compared to healthy or non-lesional control skin, most prominently in subacute AA. In AA patients, perifollicular MCs showed decreased TGFβ1 and IL-10 but increased tryptase immunoreactivity, suggesting that MCs switch from an immuno-inhibitory to a pro-inflammatory phenotype. This concept was supported by a decreased number of IL-10+ and PD-L1+ MCs, while OX40L+, CD30L+, 4–1BBL+ or ICAM-1+ MCs were increased in AA. Lesional AA-HFs also displayed significantly more peri- and intrafollicular- CD8+ T-cells as well as more physical MC/CD8+ T-cell contacts than healthy or non-lesional human control skin. During the interaction with CD8+ T-cells, AA MCs prominently expressed MHC class I and OX40L, and sometimes 4–1BBL or ICAM-1, suggesting that MC may present autoantigens to CD8+ T-cells and/or co-stimulatory signals. Abnormal MC numbers, activities, and interactions with CD8+ T-cells were also seen in the grafted C3H/HeJ mouse model of AA and in a new humanized mouse model for AA. These phenomenological in vivo data suggest the novel AA pathobiology concept that perifollicular MCs are skewed towards pro-inflammatory activities that facilitate cross-talk with CD8+ T-cells in this disease, thus contributing to triggering HF-IP collapse in AA. If confirmed, MCs and their CD8+ T-cell interactions could become a promising new therapeutic target in the future management of AA.
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Affiliation(s)
- Marta Bertolini
- Department of Dermatology, University of Lübeck, Lübeck, Germany
- Department of Dermatology, University of Münster, Münster, Germany
| | - Federica Zilio
- Department of Dermatology, University of Lübeck, Lübeck, Germany
| | - Alfredo Rossi
- Department of Internal Medicine and Medical Specialties, University “La Sapienza”, Rome, Italy
| | - Patrick Kleditzsch
- Department of Gynaecology and Obstetrics, University of Rostock, Rostock, Germany
| | - Vladimir E. Emelianov
- Department of Pharmacology, Clinical Pharmacology and Biochemistry, Chuvash State University Medical School, Cheboksary, Russia
| | - Amos Gilhar
- Laboratory for Skin Research, Rappaport Faculty of Medicine, Technion–Israel Institute of Technology, Haifa, Israel
- Flieman Medical Center, Haifa, Israel
| | - Aviad Keren
- Laboratory for Skin Research, Rappaport Faculty of Medicine, Technion–Israel Institute of Technology, Haifa, Israel
| | - Katja C. Meyer
- Department of Dermatology, University of Lübeck, Lübeck, Germany
| | - Eddy Wang
- Department of Dermatology and Skin Science, University of British Columbia, Vancouver, British Columbia, Canada
| | | | - Kevin McElwee
- Department of Dermatology and Skin Science, University of British Columbia, Vancouver, British Columbia, Canada
| | - Ralf Paus
- Department of Dermatology, University of Lübeck, Lübeck, Germany
- Department of Dermatology, University of Münster, Münster, Germany
- Institute for Inflammation and Repair, University of Manchester, Manchester, United Kingdom
- * E-mail:
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McElwee KJ, Gilhar A, Tobin DJ, Ramot Y, Sundberg JP, Nakamura M, Bertolini M, Inui S, Tokura Y, Jr LEK, Duque-Estrada B, Tosti A, Keren A, Itami S, Shoenfeld Y, Zlotogorski A, Paus R. What causes alopecia areata? Exp Dermatol 2013; 22:609-26. [PMID: 23947678 PMCID: PMC4094373 DOI: 10.1111/exd.12209] [Citation(s) in RCA: 116] [Impact Index Per Article: 10.5] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/17/2022]
Abstract
The pathobiology of alopecia areata (AA), one of the most frequent autoimmune diseases and a major unsolved clinical problem, has intrigued dermatologists, hair biologists and immunologists for decades. Simultaneously, both affected patients and the physicians who take care of them are increasingly frustrated that there is still no fully satisfactory treatment. Much of this frustration results from the fact that the pathobiology of AA remains unclear, and no single AA pathogenesis concept can claim to be universally accepted. In fact, some investigators still harbour doubts whether this even is an autoimmune disease, and the relative importance of CD8(+) T cells, CD4(+) T cells and NKGD2(+) NK or NKT cells and the exact role of genetic factors in AA pathogenesis remain bones of contention. Also, is AA one disease, a spectrum of distinct disease entities or only a response pattern of normal hair follicles to immunologically mediated damage? During the past decade, substantial progress has been made in basic AA-related research, in the development of new models for translationally relevant AA research and in the identification of new therapeutic agents and targets for future AA management. This calls for a re-evaluation and public debate of currently prevalent AA pathobiology concepts. The present Controversies feature takes on this challenge, hoping to attract more skin biologists, immunologists and professional autoimmunity experts to this biologically fascinating and clinically important model disease.
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Affiliation(s)
- K. J. McElwee
- Department of Dermatology and Skin Science, University of British Columbia, Vancouver, BC, Canada
| | - A. Gilhar
- Laboratory for Skin, Research, Rappaport Faculty of Medicine, Technion–Israel Institute of Technology, Haifa, Israel Marta Bertolini
| | - D. J. Tobin
- Centre for Skin Sciences, School of Life Sciences, University of Bradford, Bradford, West Yorkshire, BD7 1DP, UK
| | - Y. Ramot
- Department of Dermatology, Hadassah- Hebrew University Medical Center, Jerusalem 91120, Israel
| | - J. P. Sundberg
- The Jackson Laboratory, Bar Harbor, ME, USA; Division of Dermatology, Skin Disease Research Center, Vanderbilt University, Nashville, TN, USA
| | - M. Nakamura
- Department of Dermatology, University of Occupational and Environmental Health, Kitakyushu, Japan Yoshiki Tokura
| | - M. Bertolini
- Department of Dermatology, University of Lübeck, Germany Yehuda Shoenfeld
| | - S. Inui
- Department of Regenerative Dermatology, Graduate School of Medicine, Osaka University, Suita, Osaka, Japan
| | - Y. Tokura
- Department of Dermatology, Hamamatsu University School of Medicine, Hamamatsu, Japan
| | - L. E. King Jr
- The Jackson Laboratory, Bar Harbor, ME, USA; Division of Dermatology, Skin Disease Research Center, Vanderbilt University, Nashville, TN, USA
| | - B. Duque-Estrada
- Instituto de Dermatologia Prof. Rubem David Azulay, Rio de Janeiro, Brazil Antonella Tosti
| | - A Tosti
- Department of Dermatology, University of Miami, Miami, FL, USA
| | - A. Keren
- Laboratory for Skin, Research, Rappaport Faculty of Medicine, Technion–Israel Institute of Technology, Haifa, Israel Marta Bertolini
| | - S. Itami
- Department of Regenerative Dermatology, Graduate School of Medicine, Osaka University, Suita, Osaka, Japan
| | - Y. Shoenfeld
- Center for Autoimmune Diseases, Sheba Medical Center, Tel Hashomer and Sackler Faculty of Medicine, Tel Aviv University, Ramat Aviv, Israel
| | - A. Zlotogorski
- Department of Dermatology, Hadassah- Hebrew University Medical Center, Jerusalem 91120, Israel
| | - R. Paus
- Department of Dermatology, University of Lübeck, Germany; Institute of Inflammation and Repair, University of Manchester, Manchester, UK ,
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NONOMURA Y, OTSUKA A, MIYACHI Y, KABASHIMA K. Case of intractable ophiasis type of alopecia areata presumably improved by fexofenadine. J Dermatol 2012; 39:1063-4. [DOI: 10.1111/j.1346-8138.2012.01571.x] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/01/2022]
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10
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Hair follicle is a target of stress hormone and autoimmune reactions. J Dermatol Sci 2010; 60:67-73. [DOI: 10.1016/j.jdermsci.2010.09.006] [Citation(s) in RCA: 46] [Impact Index Per Article: 3.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/09/2010] [Accepted: 09/21/2010] [Indexed: 11/16/2022]
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Inui S, Nakajima T, Itami S. Coudability hairs: a revisited sign of alopecia areata assessed by trichoscopy. Clin Exp Dermatol 2009; 35:361-5. [PMID: 19874321 DOI: 10.1111/j.1365-2230.2009.03510.x] [Citation(s) in RCA: 31] [Impact Index Per Article: 2.1] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/19/2022]
Abstract
BACKGROUND We have previously reported several trichoscopic (dermatoscopic) characteristics, such as black dots, 'exclamation-mark' hairs, broken hairs, yellow dots and clustered short vellus hairs as being useful clinical indicators for alopecia areata (AA). 'Coudability hairs', which are normal-looking hairs tapered at the proximal end, have been previously reported as another sign of AA. AIMS To use trichoscopy to evaluate coudability hairs as a clinical indicator for the disease activity of AA and a substitute-marker for the hair-pull test. METHODS Trichoscopic examinations of hair loss and perilesional areas on the scalps of 100 East Asian patients with AA were performed using a dermatoscope. Using Spearman's rank-order correlation coefficient by rank test, we examined the correlations of scores between coudability and AA disease activity, severity or duration and other trichoscopic features, and then evaluated the coudability score as a surrogate-marker for the hair-pull test. RESULTS Coudability scores correlated positively with AA disease activity, hair-pull tests, short duration, black dots and exclamation-mark hairs, and correlated negatively with short vellus hairs. CONCLUSIONS Coudability hairs, more closely perceived by trichoscopy, are useful-markers for disease activity in AA and provide a surrogate-marker for the hair-pull test.
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Affiliation(s)
- S Inui
- Department of Regenerative Dermatology, Osaka University School of Medicine, Suita-shi, Osaka, Japan.
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INUI S, NAKAJIMA T, TODA N, ITAMI S. Fexofenadine hydrochloride enhances the efficacy of contact immunotherapy for extensive alopecia areata: Retrospective analysis of 121 cases. J Dermatol 2009; 36:323-7. [DOI: 10.1111/j.1346-8138.2009.00647.x] [Citation(s) in RCA: 30] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/30/2022]
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