Italian National Registry of Alopecia Areata: an epidemiological study of 699 Italian patients

BACKGROUND

Alopecia areata (AA) is an organ-specific autoimmune disease that affects the hair follicles of the scalp and the rest of the body causing hair loss. Due to the unpredictable course of AA and the different degrees of severity of hair loss, only a few well-designed clinical studies with a low number of patients are available. Also, there is no specific cure, but topical and systemic anti-inflammatory and immune system suppressant drugs are used for treatment. The need to create a global registry of AA, comparable and reproducible in all countries, has recently emerged. An Italian multicentric electronic registry is proposed as a model to facilitate and guide the recording of epidemiological and clinical data and to monitor the introduction of new therapies in patients with AA.

METHODS

The aim of this study was to evaluate the epidemiological data of patients with AA by collecting detailed information on the course of the disease, associated diseases, concomitant and previous events, and the clinical response to traditional treatments. Estimate the impact on the quality of life of patients.

RESULTS

The creation of the National Register of AA has proven to be a valid tool for recording, with a standardized approach, epidemiological data, the trend of AA, response to therapies and quality of life.

CONCLUSIONS

AA is confirmed as a difficult hair disease to manage due to its unpredictable course and, in most cases, its chronic-relapsing course, capable of having a significant impact on the quality of life of patients.

Moving Beyond Boundaries: Utilization of Longitudinal Exposure-Response Model for Bounded Outcome Score to Inform Decision Making in the Accelerated Drug Development Paradigm

BACKGROUND AND OBJECTIVES

As drug development scientists strive to accelerate availability of therapies for patients, model-informed drug development (MIDD) plays an important role in contextualizing existing information and facilitating decision making. This paper describes an example of MIDD, where modeling and simulation informed decision making in the circumstance of a combined phase 2b and single pivotal study for ritlecitinib (JAK3/TEC family kinases inhibitor).

METHODS

Longitudinal exposure-response (ER) modeling was conducted to describe ritlecitinib efficacy in alopecia areata patients. The Severity of Alopecia Tool (SALT) score (a continuous bounded outcome [CBO] score [0-100]) was used as the efficacy response. The average concentration during the time interval between two adjacent SALT scores was used as the exposure metric driving efficacy.

RESULTS

The developed model well described the longitudinal SALT profile of ritlecitinib as well as the frequency of boundary data. The CBO model indicated tested doses in the phase 2b/3 clinical trial are in the ascending region of ER and contextualized a loading dose effect that impacted onset of efficacy without long-term benefit. It also identified disease severity as the only covariate impacting efficacy. The model-based simulation further informed impact of treatment interruption on the loss of efficacy in the absence of a dedicated treatment withdrawal study. Results indicated temporary treatment interruption ≤ 6 weeks is not expected to result in significant loss of efficacy.

CONCLUSION

The CBO modeling approach and simulation supported the single pivotal trial strategy and guided dose selection in the accelerated drug development program of ritlecitinib, which can be applied to many indications where efficacy is measured on a bounded scale.

Trichoscopy Pattern and Evaluation of Serum Vitamin D Status in Alopecia Areata

BACKGROUND

Vitamin D (VD) insufficiency has been linked to a number of autoimmune illnesses including, alopecia areata (AA). To distinguish between clinically common hair problems, trichoscopy is a beneficial non-invasive, rapid, and affordable procedure that is yet neglected.

OBJECTIVE

to evaluate trichoscopic patterns and severity in various clinical categories of AA considering vitamin D level (VDL). Also, focusing on specific patterns of trichoscopy in AA related to VDL.

SUBJECT AND METHODS

Severity of Alopecia Tool (SALT) was used to clinically assess patients with AA scores. Trichoscopic patterns were analyzed concerning VDL and disease severity. The VDL was estimated for 59 patients and 60 healthy controls.

RESULTS

VDL was higher in healthy controls than in AA patients. The most common trichoscopic findings seen in our study were yellow dots (77.97%), followed by black dots (67.8%), and broken hairs (59.32%). Short vellus hairs and yellow dots were the most common in remitting AA. In progressive AA, the most common findings were broken hairs, yellow dots, and tapering hairs. VDL was significantly higher in both mild and moderate AA.

CONCLUSIONS

VDL was significantly lower in severe AA and active progressive disease. Trichoscopic features could predict disease activity and VDL in patients with AA. Broken and tapering hairs will be more represented in patients with progressive disease. Short vellus hairs were seen more in stable or remitting disease. Furthermore, black dots and broken hairs were more prevalent in AA with deficient VDL.

Using qualitative methods to establish the clinically meaningful threshold for treatment success in alopecia areata

PURPOSE

Traditionally, appropriate anchors are used to investigate the amount of change on a clinician-reported outcome assessment that is meaningful to individual patients. However, novel qualitative methods involving input from disease state experts together with patients may better inform the individual improvement threshold for demonstrating the clinical benefit of new treatments. This study aimed to establish a clinically meaningful threshold for treatment success for the clinician-reported Severity of Alopecia Tool (SALT) score for patients with alopecia areata (AA).

METHODS

A purposive sample of 10 dermatologists expert in AA and 30 adult and adolescent patients with AA and a history of ≥ 50% scalp hair loss were recruited. Semi-structured interview questions explored the outcome that represented treatment success to clinicians and patients. Findings were analyzed using thematic methods to identify treatment success thresholds.

RESULTS

Both informant groups confirmed scalp hair amount as the outcome of priority. Most expert clinicians considered a static threshold of 80% (n = 5) or 75% (n = 3) of the scalp hair as a treatment success. Most patient responses ranged from 70 to 90% (median: 80% of the scalp hair). Subsequently, queried patients confirmed that achieving SALT score ≤ 20 with treatment would be a success, as reflected in the Alopecia Areata Investigator Global Assessment (AA-IGA™). The novel qualitative processes used to inform this meaningful threshold reflects a clinician-then-patient process for: (a) confirmation of the patient outcome of priority; and (b) clinician input on a preliminary treatment success level for independent understanding among patients.

CONCLUSION

This qualitative investigation of expert clinicians-then-patients with AA confirmed that achieving an amount of 80% or more scalp hair (SALT score ≤ 20) was an appropriate individual treatment success threshold indicating clinically meaningful improvement for patients with ≥ 50% scalp hair loss. A qualitative investigation of a quantifiable treatment success threshold is possible through a well-designed interview process with expert clinicians and the appropriate patient population.

Alopecia areata - Current understanding and management

Alopecia areata (AA) is a chronic, immune-mediated disease characterized by acute or chronic non-scarring hair loss, with a heterogeneity in clinical manifestations ranging from patchy hair loss to complete scalp and body hair loss. An overview of the up-to-date pathophysiology and the underlying signaling pathways involved in AA together with diagnostic and therapeutic recommendations will be provided. Current treatments, including topical, systemic and injectable interventions show varying response and frequent relapses reflecting the unmet clinical need. Thus, the new emerging concepts and therapeutic approaches, including Janus kinase inhibitors are eagerly awaited. Traditional and emerging therapies of AA will be discussed, in order to provide physicians with guidance for AA management. Since the latter is so challenging and often tends to take a chronic course, it can have an enormous psychosocial burden on patients, compromising their quality of life and often causing depression and anxiety. Therefore, the psychosocial aspects of the disease need to be evaluated and addressed, in order to implement appropriate psychological support when needed.

A qualitative interview study to explore adolescents' experience of alopecia areata and the content validity of sign/symptom patient-reported outcome (PRO) measures

BACKGROUND

The content validity (appropriateness and acceptability) of patient-reported outcome (PRO) measures for scalp hair loss, eyebrow loss, eyelash loss, nail damage and eye irritation has been demonstrated in adults with alopecia areata (AA) but not adolescents.

OBJECTIVE

To explore the content validity of the suite of AA PRO measures and accompanying photoguides in an adolescent sample.

METHODS

Semi-structured, 90-minute, combined concept elicitation and cognitive interviews were conducted face-to-face with adolescents who experienced ≥50% AA-related scalp hair loss. Transcripts underwent thematic and framework analysis.

RESULTS

Eleven adolescents (age 12-17 years, 55% female, 45% non-Caucasian/white) diagnosed with AA for 5.9 years (mean) participated. Participants had 69.6% scalp hair (mean) and current eyebrow (82%), eyelash loss (82%) and/or nail involvement (36%). Adolescents reported scalp, eyebrow and eyelash hair loss as their top three most bothersome signs/symptoms. Despite mostly accepting their AA, impacts related to visible areas of hair loss were prominent. Participants demonstrated good understanding and appropriate use of the PRO measures, and advocated including hair loss percentages alongside descriptive categories in the Scalp Hair Assessment PRO™. Results confirmed treatment success thresholds established with adults: achievement of ≤20% scalp hair loss, no/minimal eyebrow and eyelash loss, no/a little nail damage and eye irritation (PRO categories 0 or 1).

CONCLUSIONS

The Scalp Hair Assessment PRO™, PRO Measure for Eyebrows™, PRO Measure for Eyelashes™, PRO Measure for Nail Appearance™ and PRO Measure for Eye Irritation™ and accompanying photoguides are fit-for-purpose self-reported measures of AA signs/symptoms that are impactful to adolescents with AA.

Determination of serum 25-hydroxyvitamin D levels in patients with alopecia areata and their comparison with levels in healthy controls: A cross-sectional study

Background

Alopecia areata (AA) has been postulated to be an autoimmune disease affecting the hair follicles. Because vitamin D receptors are present in the immune system and hair follicles, vitamin D has been hypothesized to affect the disease.

Objective

The aim of this study was to determine serum 25-hydroxyvitamin D levels and the percentage of vitamin D deficiency in AA patients and compare them with those in healthy controls in a Philippine tertiary hospital.

Methods

This cross-sectional study included 29 AA patients and 29 healthy controls. The serum 25-hydroxyvitamin D levels were determined using the chemiluminescent immunoassay method.

Results

There was no significant difference in the mean vitamin D levels between AA patients (24.41 ± 6.87 ng/mL) and healthy controls (24.68 ± 6.68 ng/mL) (P = .88). The percentage of patients with vitamin D deficiency, defined as <20 ng/mL, trended to higher among AA patients (34.4%) than among healthy controls (17.2%), with an odds ratio of 2.53 (95% CI 0.73-8.65), though this was not statsitically significant.

Limitations

This study involved a limited number of patients in an urbanized area in the Philippines, and majority of the AA cases seen had mild AA.

Conclusion

The trend toward the increased percentage of vitamin D-deficient individuals among AA patients seen in this study may provide insight into the association of vitamin D with AA.

A combination of herbal formulas, acupuncture, and novel pine-needle stimulation for recurrent alopecia areata: A case report

INTRODUCTION

Head hair is a symbol of vitality, and hair loss by alopecia areata (AA) presents a burden on patients. Although traditional Japanese Kampo medicine (JKM) formulas, acupuncture, and moxibustion have historically been used for treating AA, no studies have utilized a combination of these modalities.

PATIENT CONCERNS

A 34-year-old male with a history of childhood asthma presented with a sudden hair loss at the top of his head without any preceding symptoms. Except for a hairless patch of 5 cm × 6 cm, his general appearance was otherwise good. The patient underwent topical immunotherapy on visiting a dermatologist. However, the patient noticed an exacerbation of his hairless lesion.

DIAGNOSIS

The AA diagnosis was established based on clinical appearance and dermatological findings. The Severity of Alopecia Tool (SALT) score for alopecia was 19% at diagnosis.

INTERVENTIONS

The patient received 2 JKM formulas (saikokaryukotsuboreito and shichimotsukokato) in combination with acupuncture. When relapse occurred, a novel self-administration of pine-needle acupuncture was initiated in combination with the JKM formulas.

OUTCOMES

A 50% recovery from the baseline SALT score was achieved using JKM formulas in combination with acupuncture for 4 months. The patient achieved complete remission for 5 months. However, another stressful event induced an AA relapse with multiple lesions harboring a SALT score of 13%. Pine-needle acupuncture was initiated, resulting in faster resolution than the first treatment. Recoveries of 50% and 75% were achieved 3 and 4 months after relapse, respectively, and a long-lasting response without relapse was obtained for at least 3 years.

CONCLUSION

A combination of multimodal traditional therapies, including JKM formulas, acupuncture, and self-administered pine-needle stimulation, represents an effective integrative treatment for patients with AA.

Cross talk between oxidative stress and inflammation in alopecia areata

BACKGROUND

Although the etiopathogenesis of alopecia areata (AA) is still unclear, inflammation, oxidative stress, and subsequent DNA damage might be considered role players in disease development.

AIM

We aimed at exploring the potential link between oxidative DNA damage and inflammation in AA patients through measuring 8-hydroxy deoxyguanosine (8-OHdG), high mobility group box 1 protein (HMGB1), and one of the inflammatory mediators, C-reactive protein (CRP).

METHODS

A total of 79 subjects (49 AA patients in addition to 30 apparently healthy control subjects) were tested for serum levels of 8-OHdG, HMBG1, and CRP.

RESULTS

Compared with the control group, serum 8-OHdG, HMBG1, and CRP levels were significantly elevated in the studied patients group (0.031, <0.001, and <0.001, respectively). Moreover, logistic regression analysis revealed that disease course, serum levels of 8-OHdG, and HMBG1 were considered independent predictors for AA severity in both uni- and multivariable analyses.

CONCLUSION

Our results suggest a possible role of oxidative stress together with proinflammatory biomarkers in development of AA and their benefit in predicting a severe form of the disease.

Trichloroacetic acid 35% as a therapeutic line for localized patchy alopecia areata in comparison with intralesional steroids: Clinical and trichoscopic evaluation

BACKGROUND

Intralesional corticosteroids (ILCs) is the first-line therapy for patients older than 10 years having patchy alopecia areata, however some patients do not respond effectively.

AIMS

To evaluate the efficacy of a chemical peel trichloro acetic acid (TCA 35%) in comparison to ILCs.

PATIENTS/METHODS

Twenty-two patients with two patches of alopecia areata were included. Two treatment modalities with ILCs and topical TCA 35% were performed in two randomly selected patches. Three sessions were done, 3 weeks apart and were followed-up for three months. Evaluation was done using Mac Donald Hull and Norris grading system and by counting trichoscopic parameters in each patch.

RESULTS

Both ILCs and TCA 35% treated patches showed measurable improvement with no statistically significant difference between the results of the two modalities (p>0.05) at different times of the study. Yellow dots, black dots, exclamation marks and dystrophic hair were all reduced by 100%, 82.0%, 100% and 88.3% in ILCs treated patches and by 70.4%, 69.1%, 100% and 75.0% in TCA treated patches, respectively.

CONCLUSION

Topical TCA 35% is an effective and safe treatment for the treatment of AA without serious side effects, despite the slower response when compared to ILCs.

Trichoscopy as an evaluation method for alopecia areata treatment: A comparative study

BACKGROUND

Trichoscopy is a useful tool for diagnosis and follow-up of alopecia areata (AA) patients. Both platelet-rich plasma (PRP) and intralesional corticosteroids (ILCs) are important treatment modalities of patchy AA.

AIM

Trichoscopic diagnosis of AA and monitoring the treatment response to PRP versus ILCs in patchy AA treatment.

PATIENTS/METHODS

This comparative study included 31 patients with patchy AA, divided into two groups: (group A) received ILCs while (group B) received PRP once monthly for 3 months. Evaluation was done by Severity of Alopecia Tool (SALT) score, Alopecia Areata Symptom Impact Scale (AASIS), photography, and dermoscopy.

RESULTS

There was a significant improvement in trichoscopic findings in both groups with regard to the number of follicular units per opening, black dots, broken hairs, and dystrophic changes. Final SALT score showed significant lower levels in both groups compared to baseline levels (P = .025 & P = .008). Final AASIS showed significant decrease in group B (P = .006) not in group A (P = .062).

CONCLUSION

Trichoscopy can help in the diagnosis, evaluation of the efficacy and safety of both modalities and might give a clue for treatment response. Both ILCs and PRP were effective in patchy AA treatment.

A Large Cross-Sectional Survey Study of the Prevalence of Alopecia Areata in the United States

Purpose

Alopecia areata (AA) is an autoimmune disease characterized by the development of non-scarring alopecia. The prevalence is not well known, and estimates vary considerably with no recent estimates in the United States (US). The objective of this study was to define the current AA point prevalence estimate among the general population in the US overall and by severity.

Patients and Methods

We administered an online, cross-sectional survey to a representative sample of the US population. Participants self-screening as positive for AA using the Alopecia Assessment Tool (ALTO) also completed the Severity of Alopecia Tool (SALT) to measure the severity of disease as a percent of scalp hair loss. Self-reported AA participants were invited to upload photographs for adjudication of AA by 3 clinicians.

Results

The average age of participants was 43 years. Approximately half of the participants (49.2%) were male, and the majority were white (77.1%) and not of Hispanic origin (93.2%). Among the 511 self-reported AA participants, 104 (20.4%) uploaded photographs for clinician evaluation. Clinician-adjudicated point prevalence of AA was 0.21% (95% CI: 0.17%, 0.25%) overall, 0.12% (95% CI: 0.09%, 0.15%) for “mild” disease (≤50% SALT score), and 0.09% (95% CI: 0.06%, 0.11%) for “moderate to severe” disease (>50% SALT score) with 0.04% (95% CI: 0.02%, 0.06%) for the alopecia totalis/alopecia universalis (100% SALT score) “moderate to severe” subgroup. The average SALT score was 44.4% overall, 8.8% for “mild”, and 93.4% for “moderate to severe”.

Conclusion

This study suggests that the current AA prevalence in the US is similar to the upper estimates from the 1970s at approximately 0.21% (700,000 persons) with the current prevalence of “moderate to severe” disease at approximately 0.09% (300,000 persons). Given this prevalence and the substantial impact of AA on quality of life, the burden of AA within the US is considerable.

Clinico-dermoscopic features and treatment responsiveness in pediatric alopecia – Experience from a tertiary care pediatric dermatology clinic

Background:

Data on clinical and epidemiologic profile on pediatric alopecia is relatively scarce.

Aims and Objectives:

We aimed to study the clinical, epidemiological, and dermoscopic profile of children presenting with alopecia, and assess the responsiveness to different treatment modalities in a real-life setting.

Materials and Methods:

This cohort study involved analyzing children presenting with hair loss during the study period. After a detailed history, clinical, and trichoscopic examination, treatment offered to patients and follow-up response to treatment along with relapse of symptoms were noted.

Results:

Around 119 children were included. Nearly 90% were of acquired etiology. The most common cause of alopecia was alopecia areata (AA) in 85 (71%) patients followed by tinea capitis 9 (7.5%), lichen planopilaris 4 (3.3%), and other less common causes. In patients of AA, dermoscopy showed the presence of black dots in 68% cases, exclamation mark hair in 54% of patients followed by off-white dots, yellow dots, and vellus hair. Patients with an acute course and black dots on dermoscopy responded better to treatment. Relapse was common in patients with early age of onset and longer disease duration.

Conclusions:

Hair loss is frequently seen in pediatric dermatology clinics. Dermoscopy of pediatric AA shows scarce yellow dots while off-white dots are more frequent; the presence of black dots is a good prognostic indicator.

Combined intravenous pulse and topical corticosteroid therapy for severe alopecia areata in children: Comparison of two regimens

There is no universally accepted treatment for severe pediatric alopecia areata (AA). This prospective study comprised 73 patients (aged 1-18 years) with severe AA (>30% of scalp surface area): 37 received 1-day intravenous dexamethasone pulses (1-DP) and 36 received 3-day pulses (3-DP), monthly, for 6-12 months. Also, all patients applied topical clobetasol propionate under plastic wrap occlusion. Patients achieving >50% regrowth were considered good responders (GR). All patients reached short term, while 65/73 were available for the long-term follow-up (mean 33.3 ± 15.3 vs. 27.7 ± 14.3 months, 1-DP and 3-DP, respectively). Relapses during therapy were more frequent in 1-DP group. 3-DP patients were more frequently GR in comparison with 1-DP. 3-DP patients with disease duration <6 months had better outcomes. Patients without Hashimoto thyroiditis (HT) had 9.8-fold higher chance of being GR in comparison with HT patients. The best results were achieved in AA plurifocalis (AAP). No patient had severe short-term side-effects. At the long-term follow-up, 67% of 3-DP patients had stable results. Only 14.2% AAP patients experienced relapses. Patients had no long-term side-effects. 3-DP were more efficacious than 1-DP. Short disease duration and no HT were good prognostic factors. 3-DP protocol is well-tolerated, with beneficial effects and long-lasting results in severe pediatric AA.

Dickkopf-1 Expression in Androgenetic Alopecia and Alopecia Areata in Male Patients

BACKGROUND

Androgenetic alopecia (AGA) results from shortening of the anagen phase of the hair cycle and, subsequently, miniaturization of hair follicles. Alopecia areata (AA) is a disease of autoimmunity where T cells attack anagen hair follicles and shows multifactorial etiology. Dickkopf-1 (DKK-1) is a gene that is responsible for transformation of anagen to catagen, which suggests that it is involved in development of both diseases.

OBJECTIVES

To evaluate the tissue levels of dickkopf-1 in male patients with AGA and AA in comparison with controls, in an attempt to know its role in the pathogenesis of both disorders.

METHODS

DKK-1 immunohistochemical expression was evaluated in lesional scalp biopsies taken from 20 male patients with AGA evaluated clinically by the modified Norwood-Hamilton score, 20 male patients with AA evaluated clinically by SALT score, and 20 healthy controls within the same age and sex of the studied patients.

RESULTS

A highly significant difference in DKK-1 expression between patients with AGA and healthy controls was found (P2 < 0.001). There were also significant differences in DKK-1 expression between patients with AA and healthy controls (P3 = 0.013), and between both patient groups (P1 = 0.002).

CONCLUSIONS

Both AGA and AA showed significant increase in DKK-1 immunohistochemical expression. This may enhance the idea of its possible role in the pathogenesis of AGA and AA, and being a new target for treatment of these hair disorders.

Serum concentrations of selected proinflammatory cytokines in children with alopecia areata

Introduction

Alopecia areata (AA) is considered an autoimmune disorder characterized by patchy loss of hair from the scalp and other body parts. Many patients develop the disease in childhood.

Aim

To answer the question whether abnormal production of some proinflammatory cytokines (IL-2, IL-6, IL-15, IL-17A and IFNγ) in children with AA may facilitate the development or progression of the disease.

Material and methods

The study group consisted of 42 children with AA, the control group – 37 healthy children. Peripheral venous blood samples were collected from patients with AA and healthy controls and the concentrations of serum cytokines, namely IL-2, IL-6, IL-15, IL-17A, IFN-γ were determined quantitatively by ELISA method.

Results

The serum IL-6, IL-15, IL-17A and IFNγ levels were significantly increased in patients with AA compared with control subjects (p < 0.05). The serum IL-15 level was found to be increased when the total duration of AA was increased (q = 0.30; p = 0.05). The serum cytokine level of IL-17A was found to be decreased when duration of the current episode was longer than 2 years (p < 0.05), but the correlation between IL-17A serum level and duration of the current episode was not confirmed in the Spearman test (q = –0.06; p = 0.68). The serum IL-17A level was found to be significantly decreased when the thyroiditis was present (q = –2.378; p < 0.05).

Conclusions

The increased levels of serum IL-6, IL-15, IL-17A and IFNγ in children suggest imbalance in the serum proinflammatory cytokines production in AA.

Ischemic modified albumin as a new biomarker in predicting oxidative stress in alopecia areata

Background/aim

Results show that oxidative stress is a pathophysiologic factor for alopecia areata (AA); however, the markers used can be confounding. Thus, we aimed to investigate the role of oxidative stress in the pathogenesis of AA through an evaluation of ischemia-modified albumin (IMA); other markers of the oxidant/antioxidant system, such as SOD, CAT, GSH-ST, and MDA; and contributing clinical risk factors.

Materials and methods

The usefulness of IMA as a new marker for oxidative stress was compared with that of other markers and evaluated in patients with AA.

Results

The mean serum level of IMA was of higher statistical significance in AA patients than in the control group (IMA: 0.57 ± 0.01 vs. 0.52 ± 0.02 ΔABSU, P < 0.0001). IMA (P = 0.03, OR = 25.8, 95% CI = 1.4–482.7) was found to be an independent predictor of oxidative stress in patients with AA. Increased severity of AA was found as an independent risk factor for IMA.

Conclusion

Long-lasting disease, male sex, >1 site of involvement of disease, and increased severity of disease were correlated with increased oxidation. Presence of AA, male sex, and severe disease were determined to be independent risk factors for antioxidant and oxidant systems. IMA has great potential as a biomarker of oxidative stress in AA when compared to other studied biomarkers.

Sequential cyclic changes of hair roots revealed by dermoscopy demonstrate a progressive mechanism of diffuse alopecia areata over time

BACKGROUND

Diffuse alopecia areata (DAA) often leads to a complete hair shedding within a few months.

OBJECTIVE

To explore features and mechanisms underlying DAA.

MATERIALS AND METHODS

Scalp and hair root dermoscopy were conducted on 23 DAA patients throughout the disease process, 20 patchy Alopecia areata patients, 23 acute telogen effluvium (ATE) patients and 10 normal controls. Histopathology was also evaluated.

RESULTS

We found almost all hair roots were anagen in early stage DAA in 18 patients (18/23, 78.3%) within the first 4-8 weeks after hair loss onset. Anagen effluvium (~4 weeks) was followed by catagen (~4 weeks) and then telogen/exogen (~8 weeks) effluvium with overlap. Hair root and proximal hair shaft depigmentation was more prominent in later DAA disease stages. Black dots, exclamation mark hairs and inconsistent thickness of hair shafts were found more often in early than later DAA (Ps < 0.01). Early DAA histopathology revealed more prominent inflammation and hair follicle regression than that observed in the later stages. Patchy alopecia areata patients showed mixed anagen, catagen and telogen hair roots while ATE patients showed increased exogen and mildly decreased hair root pigmentation.

CONCLUSION

Sequential cyclic staging of shed hairs in DAA indicates the insult may be hair-cycle specific. We suggest that DAA is initially an anagen effluvium disease involving an intense inflammatory insult, later progressing to a brief catagen effluvium, and then to telogen effluvium with premature exogen, in later stages of DAA.

Randomized controlled trial on a PRP-like cosmetic, biomimetic peptides based, for the treatment of alopecia areata

Background: Alopecia areata (AA) is a non-scarring auto-immune hair disorder. Recent researches explained the role of growth factors (GFs) in hair follicle cycling. The main reservoir of GFs are alpha-granules of platelets and novel procedures have been implemented aimed at collecting platelet-rich plasma (PRP). PRP has been safely implemented in many medical applications and has also been successfully used as alternative cell-based therapy for the treatment of hair growth disorders, among which also AA. Objectives: By means of a randomized double-blinded, placebo and active-controlled, parallel group study we have studied the efficacy of a cosmetic product (named TR-M-PRP plus) comprising biomimetic peptides specific for hair growth, mimicking PRP composition for the treatment of AA. Subjects were treated for three months and evaluated, at the end of the study and after one month of follow-up, as regards hair growth using SALT score. Results: TR-M-PRP plus-like topic produced a statistically significant (p < .001) clinical improvement in SALT score after 3 months of therapy, compared to baseline. Hair growth results further improved after 1 month of follow-up. Conclusions: This clinical investigation suggests that the biotechnological designed PRP-like cosmetic could represent a valid and safer alternative to autologous PRP for the treatment of AA.

Objective outcome measures: Collecting meaningful data on alopecia areata

BACKGROUND

Although alopecia areata is a common disorder, it has no US Food and Drug Administration-approved treatment and evidence-based therapeutic data are lacking.

OBJECTIVE

To develop guidelines for the diagnosis, evaluation, assessment, response criteria, and end points for alopecia areata.

METHODS

Literature review and expert opinion of a group of dermatologists specializing in hair disorders.

RESULTS

Standardized methods of assessing and tracking hair loss and growth, including new scoring techniques, response criteria, and end points in alopecia areata are presented.

LIMITATIONS

The additional time to perform the assessments is the primary limitation to use of the methodology in clinical practice.

CONCLUSION

Use of these measures will facilitate collection of standardized outcome data on therapeutic agents used in alopecia areata both in clinical practice and in clinical trials.

Stem cell therapy as a novel therapeutic intervention for resistant cases of alopecia areata and androgenetic alopecia

BACKGROUND

Management of alopecia areata (AA) and androgenetic alopecia (AGA) is often challenging as patients may be resistant to currently available modalities of treatment. The use of stem cells may be a novel option for resistant cases.

OBJECTIVE

To evaluate the safety and efficacy of the use of autologous bone marrow derived mononuclear cells (including stem cells) as compared to follicular stems cells for the management of resistant cases of AA and AGA.

METHODS

This study included 40 patients (20 AA patients and 20 AGA patients), all patients were treated with a single session of intradermal injection of autologous stem cells (SCs) therapy. They were divided into four groups according to the applied modality [either autologous bone marrow derived mononuclear cells (bone marrow mononuclear cells [BMMCs] or autologous follicular stem cells [FSC]).

RESULTS

Six months after stem cell therapy (SCT) injection, there was a significant improvement, confirmed by immunostaining and digital dermoscopy. The mean improvement in all groups was "very good". There was no significant difference between both methods in either type of alopecia. No serious adverse events were reported.

CONCLUSION

Autologous BMMCs and FSC seem to be a safe tolerable and effective treatment for the management of both resistant AA and AGA.

An investigation of vitamin D status in alopecia areata

Alopecia areata (AA) is a type of non-scarring, recurrent patchy loss of hair in hair-bearing areas and is mostly of autoimmune origin. Previous studies have suggested that some autoimmune diseases were found to be associated with vitamin D deficiency. The current study was designed to assess the levels of serum 25-hydroxy vitamin D and C-reactive protein in AA, as compared with controls and to further identify the association between vitamin D levels and disease severity in patients with AA. This cross-sectional study included 45 patients with AA and 45 healthy volunteers. Clinical and anthropometric parameters were recorded, according to a pre-designed proforma. Serum 25-hydroxy vitamin D and high-sensitivity C-reactive protein were estimated using ELISA kits. The severity of AA was determined using Severity of Alopecia Tool (SALT) score. We observed a significant rise in systemic inflammation as seen by elevated high-sensitive C-reactive protein levels and lowered 25-hydroxy vitamin D levels in patients with alopecia areata, compared to controls (p = 0.001). The levels of 25-hydroxy vitamin D showed a significant negative correlation with disease severity, while hs-CRP levels showed a significant positive correlation with disease severity (ρ = - 0.714, p = 0.001 and ρ = 0.818, p = 0.001). Our results suggest significant systemic inflammation and vitamin D deficiency in alopecia areata, more so with increasing disease severity. This gains particular importance in the treatment of alopecia areata in future, as supplementing vitamin D to AA patients would result in reducing the disease severity and inducing remission.

Quantifying Alopecia Areata via Texture Analysis to Automate the SALT Score Computation

Quantifying alopecia areata in real time has been a challenge for clinicians and investigators. Although several scoring systems exist, they can be cumbersome. Because there are more clinical trials in alopecia areata, there is an urgent need for a quantitative system that is reproducible, standardized, and simple. In this article, a computer imaging algorithm to recreate the Severity of Alopecia Tool scoring system in an automated way is presented. A pediatric alopecia areata image set of four view-standardized photographs was created, and texture analysis was used to distinguish between normal hair and bald scalp. By exploiting local image statistics and the similarity of hair appearance variations across the pediatric alopecia examples, we then used a reference set of hair textures, derived from intensity distributions over very small image patches, to provide global context and improve partitioning of each individual image into areas of different hair densities. This algorithm can mimic a Severity of Alopecia Tool (score) and may also provide more information about the continuum of changes in density of hair seen in alopecia areata.

Therapeutic Effect of Superficial Cryotherapy on Alopecia Areata: A Prospective, Split-scalp Study in Patients with Multiple Alopecia Patches

Background

Alopecia areata (AA) affects anagen hair follicles resulting in non-scarring hair loss. Since its introduction, superficial cryotherapy has been used as one of the meaningful treatment modalities for AA.

Objective

The purpose of this study is to clarify the therapeutic efficacy and safety of superficial cryotherapy for treatment of AA.

Methods

In 19 patients with multiple bilateral AA patches on their scalp, superficial cryotherapy was performed on the right side, every 2 weeks. Prednicarbate 0.25% solution was applied twice a day to both the treated and the control sides. Clinical improvement was estimated using the Severity of Alopecia Tool (SALT) score by 3 different dermatologists, along with the changes in terminal and vellus hair count and hair thickness analyzed by phototrichogram.

Results

After 4 months of treatment, mean terminal hair count on the right scalp was 1.6-fold increased (p=0.005), while mean terminal hair count on the left scalp showed no significant change (110.1% increase, p=0.285). Mean SALT score decrease on the right was 4-fold greater than that on the left (40.7% and 9.6%), without statistical significance (p=0.282). Mean vellus hair count and mean hair thickness did not show significant changes after superficial cryotherapy. No remarkable adverse event was observed.

Conclusion

Superficial cryotherapy is an efficacious treatment modality with advantages of simplicity and noninvasiveness. It can be considered as a meaningful therapeutic modality for AA, especially when the disease status is limited to minimal to mild, or the conventional AA treatment is not applicable.

Bilateral Half-Head Comparison of 1% Anthralin Ointment in Children with Alopecia Areata

BACKGROUND/OBJECTIVES

Alopecia areata (AA) is one of the most difficult skin diseases to manage well. In children, anthralin is commonly used for the treatment of AA. Available research consists of a limited number of uncontrolled trials that assessed the effectiveness of anthralin in promoting hair growth in patients with AA. The objective of this study was to validate the clinical effectiveness of short-contact anthralin 1% ointment in children with AA.

METHODS

Thirty children with chronic, severe, treatment-refractory, extensive AA were treated with 1% anthralin ointment. One side of the scalp was treated with anthralin for 12 months and the other side was left untreated. Outcomes were evaluated according to the Severity of Alopecia Tool (SALT) score.

RESULTS

The mean time to first response in terms of new hair growth was 3 months and the mean time to maximal response was 9 months. In the first 12-month period, 10 patients (33.4%) achieved complete response to treatment and 11 patients (36.6%) had a partial response. Of the 11 patients with partial response at the end of the first year, 6 achieved a complete response before the end of the study. Total SALT scores for the entire scalp decreased from the end of the first year to the end of the 2-year period. No serious adverse events were observed.

CONCLUSION

Anthralin 1% is an effective therapy for AA and should be continued at least 9 months. At 9 months of topical anthralin therapy, the patients with at least a 50% reduction in their pretreatment SALT scores should continue the same treatment for at least 1 year. Anthralin is safe in children with chronic, severe, treatment-refractory, extensive AA.

Efficacy and safety of topical calcipotriol in management of alopecia areata: A pilot study

Reports have highlighted serum vitamin D deficiency and reduced 1,25-dihydroxyvitamin D(3) receptors(VDR) expression on hair follicles of alopecia areata(AA) patients. Very few studies have demonstrated efficacy of topical calcipotriol (vitamin D analogue) in AA. We intended to study the efficacy of calcipotriol lotion 0.005% in AA and correlate its outcome with serum vitamin D levels. We conducted a prospective study, in which 22 patients with AA were treated with calcipotriol lotion 0.005% twice daily for 3 months. Clinico-epidemiological parameters including severity of AA and SALT score were calculated at baseline and at 12 weeks. Hair regrowth was assessed monthly at 4, 8, 12 weeks. Serum vitamin D levels were measured at baseline. After 12 weeks of treatment, hair regrowth was observed in 13 (59.1%) patients. Mean period for onset of disease stabilization and hair regrowth was 4 weeks and 4.21± 2.13 weeks, respectively. Among these 13 patients, SALT₅₀ and SALT₁₀₀ was observed in 6(46.2%) and 2(9%) patients, respectively. Response to treatment was better in patients with lower vitamin D levels (p < .009). Topical calcipotriol can be an alternative treatment in AA and it could prove to be more useful in patients who are vitamin D deficient.

The Frequency Distribution of Celiac Autoantibodies in Alopecia Areata

BACKGROUND

Alopecia areata (AA) is a noncicatricial (nonscarring) alopecia. The association between AA and celiac disease (CD) is debatable. Several studies declare the relationship between AA and CD as measurement of celiac autoantibodies (anti-gliadin IgA and anti-gliadin IgG), but a few studies consider anti-tissue transglutaminase IgA. The aim of this study was to evaluate the frequency distribution of celiac autoantibodies (all of them) in patients with AA compared with controls.

METHODS

This study is a case-control study. Thirty-five patients entered in each group. Anti-gliadin IgA, anti-gliadin IgG, and anti-tissue transglutaminase IgA were tested in all patients. Samples were examined in ELISA method with binding site's kits, and the result was reported as positive/negative. Finally, the frequency distribution of autoantibodies was examined.

RESULTS

The age average did not show a significant difference between two groups (P = 0.62). In addition, there was no significant difference between the two groups based on gender (P = 0.15). The prevalence of antibody in case and control groups was 2.85% and 0%, respectively. There was no significant difference between the two groups (P = 0.31).

CONCLUSIONS

There may be a relationship between CD and AA, but the absence of statistical association between AA and CD does not mean that there is no relationship between gluten and AA in certain patients. Thus, we have shown here that the biological tests to search for CD do not bring information and proof enough, and it is why we recommend another approach to disclose gluten intolerance in AA patients.

Vitamin D deficiency in alopecia areata

BACKGROUND

Alopecia areata (AA) is a T cell-mediated autoimmune disease that causes inflammation around anagen-stage hair follicles. Insufficient levels of vitamin D have been implicated in a variety of autoimmune diseases. Previous reports have described the effects of vitamin D on hair follicles.

OBJECTIVES

To evaluate the status of vitamin D in patients with AA, and the relationship between vitamin D levels and disease severity.

METHODS

A cross-sectional study of 86 patients with AA, 44 patients with vitiligo and 58 healthy controls was conducted. The serum vitamin D levels of the study group were determined by liquid chromatography/tandem mass spectrometry.

RESULTS

Serum 25-hydroxyvitamin D [25(OH)D] levels in patients with AA were significantly lower than those of the patients with vitiligo and the healthy controls (P = 0·001 and P < 0·001, respectively). The prevalence of 25(OH)D deficiency was significantly higher in patients with AA (91%) compared with patients with vitiligo (71%) and healthy controls (33%) (P = 0·003 and P < 0·001, respectively). Furthermore, a significant inverse correlation was found between disease severity and serum 25(OH)D level in patients with AA (r = -0·409; P < 0·001).

CONCLUSIONS

Deficient serum 25(OH)D levels are present in patients with AA and inversely correlate with disease severity. Accordingly, screening patients with AA for vitamin D deficiencies seems to be of value for the possibility of supplementing these patients with vitamin D.

ILK Index and Regrowth in Alopecia Areata

There is insufficient data in the literature concerning optimal intralesional kenalog (ILK) dosing for the treatment of alopecia areata (AA). The purpose of this pilot study was to evaluate the utility of using the ratio of ILK received to initial Severity of Alopecia Tool (SALT) score to guide ILK dosing in patients with AA. Using photographic data from patients at baseline and 4-months follow-up, hair loss in 15 patients treated with AA was retrospectively graded using the SALT scores. The ILK received/initial SALT score (ILK index) was calculated for each patient, and the mean ILK index for patients who experienced significant (≥50%) and suboptimal (<50%) hair regrowth at 4 months follow-up were compared. Patients who experienced suboptimal hair regrowth had a lower ILK index on average than patients who experienced significant improvement. Although the difference did not meet significance (<0.1), the trend suggests that the ILK index, a novel calculation, may be a useful tool for guiding ILK dosing in the treatment of AA.

Development of Uniform Protocol for Alopecia Areata Clinical Trials

Developing a successful treatment for alopecia areata (AA), clearly has not been at the forefront of the agenda for new drug/device development among the pharmaceutical and medical device industry. The National Alopecia Areata Foundation (NAAF), a patient advocacy group, initiated a plan to facilitate and drive clinical research toward finding safe and efficacious treatments for AA. As such, Alopecia Areata Uniform Protocols for clinical trials to test new treatments for AA were developed. The design of the uniform protocol is to accomplish the development of a plug-and-play template as well as to provide a framework wherein data from studies utilizing the uniform protocol can be compared through consistency of inclusions/exclusions, safety, and outcome assessment measures. A core uniform protocol for use by pharmaceutical companies in testing proof of concept for investigational products to treat AA. The core protocol includes standardized title, informed consent, inclusion/exclusion criteria, disease outcome assessments, and safety assessments. The statistical methodology to assess successful outcomes will also be standardized. The protocol as well as the informed consent form has been approved in concept by Liberty IRB and is ready to present to pharmaceutical companies.