Current standards in the diagnostics and therapy of hair diseases - hair consultation

Novel laser hair removal in all skin types

BACKGROUND

Laser has been long accepted as a solution for excess or unwanted hair growth yet traditional lasers are not always ideal for safe and effective outcome for all skin types and hair characteristics. A diode laser module combining three wavelengths (755, 810, and 1064 nm) in a single pulse was developed to provide a fast and long-term solution for subjects with various profiles.

AIMS

To evaluate the safety and efficacy of a Triple wavelength diode laser module for hair removal treatment in all skin types (Fitzpatrick I-VI).

SUBJECTS AND METHODS

This was a prospective, dual centered, single-arm study. Subjects were treated with a novel diode laser module. Thirty-six subjects were enrolled, sixteen with Fitzpatrick skin types I-IV (46%) and twenty with Fitzpatrick skin types V-VI (54%). Treatment areas were axilla and bikini lines. Subjects underwent 4 treatment sessions at 6 weeks ± 5 days intervals and attended a follow-up visit 3 months after the last treatment session. 2D digital photographs were taken at baseline and at the follow-up visit, and a hair count was conducted by three blinded evaluators.

RESULTS

A significant reduction in hair count between baseline and the 3-month follow-up visit was observed in both axilla and bikini lines for all skin types. The mean hair reduction was 41.5 ± 19.4% and 48.1 ± 20.9% in the axilla and bikini line, respectively. A significant hair reduction was also observed within skin type groups; mean hair reduction 45.5 ± 16.9% and 40.3 ± 17.2% in skin types I-IV and V-VI, respectively, indicating similar efficacy for both light and dark skin types. No serious adverse events were reported.

CONCLUSIONS

This study demonstrates that the Soprano Titanium laser platform is safe and effective for hair removal treatment in all skin types.

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.

Lasers for reduction of unwanted hair in skin of colour: a systematic review and meta-analysis

Light-based therapies are one of the most effective and widely used strategies for removal of undesired hair, with a broadly favourable safety profile. However, subjects with pigmented skin are found to be more prone to laser-related adverse events. While prolonged pulse-width and longer treatment duration were proposed to minimize adverse events, the optimal treatment option among available phototherapy modalities - long-pulsed (Nd:YAG), pulsed diode and alexandrite lasers as well as intense pulsed light (IPL) - remains unclear, particularly for skin of colour. To determine superiority in terms of effectiveness and tolerability, we conducted a systematic review of literature on different types of in-office laser and IPL for hair removal in subjects with Fitzpatrick skin types III-VI. The meta-analysis was performed using Review Manager (RevMan) version 5.3 and included 12 eligible comparative trials (nine randomized controlled trials and three quasi-randomized). In terms of hair count reduction, pooled effect estimates for long-pulsed ND:YAG laser [OR: 0.26, 95% CI (0.1, 0.78)] and diode laser [standardized mean difference (SMD): -0.11, 95% CI (-0.62, 0.39)] were not statistically significant from those of IPL; in contrast, alexandrite laser was found to be superior to IPL in reducing hair count [SMD: -1.7, 95% CI (-2.6, -0.78)]. In terms of adverse events, the pooled effect estimates favoured long-pulsed Nd:YAG laser to IPL with respect to postinflammatory hyperpigmentation [OR: 0.26, 95% CI: (0.1, 0.78)]. However, both pulsed diode and alexandrite lasers exhibited a comparable safety profile to IPL, despite higher pain scores with lasers. In conclusion, this systematic review suggests that treatment outcomes for different in-office laser devices and IPL in subjects with skin type III-VI are broadly similar; nevertheless, we observed a trend towards greater hair reduction following laser therapy compared with IPL.

The Diagnosis and Treatment of Hair and Scalp Diseases

BACKGROUND

Hair loss is caused by a variety of hair growth disorders, each with its own pathogenetic mechanism.

METHODS

This review is based on pertinent articles retrieved by a selective search in PubMed, on the current German and European guidelines, and on the authors' clinical and scientific experience.

RESULTS

Excessive daily hair loss (effluvium) may be physiological, as in the postpartum state, or pathological, due for example to thyroid disturbances, drug effects, iron deficiency, or syphilis. Androgenetic alopecia generally manifests itself in women as diffuse thinning of the hair over the top of the scalp, and in men as receding temporal hairlines and loss of hair in the region of the whorl on the back of the head. Alopecia areata is patchy hair loss arising over a short time and involving the scalp, eyebrows, beard, or entire body. The hair loss of alopecia areata is reversible in principle but hard to treat. Folliculitis decalvans is a form of alopecia with scarring, characterized by inflamed papules, pustules, and crusts at the edges of the lesions. Lichen planopilaris generally presents with small patches of baldness, peripilar erythema, and round areas of skin scaling. Kossard's frontal fibrosing alopecia is characterized by a receding hairline and loss of eyebrows.

CONCLUSION

Hair loss is a symptom, not a diagnosis. The pathogenesis of the alopecias involves a range of genetic, endocrine, immune, and inflammatory processes, each of which calls for its own form of treatment.

Interventions for hirsutism (excluding laser and photoepilation therapy alone)

BACKGROUND

Hirsutism occurs in 5% to 10% of women of reproductive age when there is excessive terminal hair growth in androgen-sensitive areas (male pattern). It is a distressing disorder with a major impact on quality of life. The most common cause is polycystic ovary syndrome. There are many treatment options, but it is not clear which are most effective.

OBJECTIVES

To assess the effects of interventions (except laser and light-based therapies alone) for hirsutism.

SEARCH METHODS

We searched the Cochrane Skin Group Specialised Register, CENTRAL (2014, Issue 6), MEDLINE (from 1946), EMBASE (from 1974), and five trials registers, and checked reference lists of included studies for additional trials. The last search was in June 2014.

SELECTION CRITERIA

Randomised controlled trials (RCTs) in hirsute women with polycystic ovary syndrome, idiopathic hirsutism, or idiopathic hyperandrogenism.

DATA COLLECTION AND ANALYSIS

Two independent authors carried out study selection, data extraction, 'Risk of bias' assessment, and analyses.

MAIN RESULTS

We included 157 studies (sample size 30 to 80) comprising 10,550 women (mean age 25 years). The majority of studies (123/157) were 'high', 30 'unclear', and four 'low' risk of bias. Lack of blinding was the most frequent source of bias. Treatment duration was six to 12 months. Forty-eight studies provided no usable or retrievable data, i.e. lack of separate data for hirsute women, conference proceedings, and losses to follow-up above 40%.Primary outcomes, 'participant-reported improvement of hirsutism' and 'change in health-related quality of life', were addressed in few studies, and adverse events in only half. In most comparisons there was insufficient evidence to determine if the number of reported adverse events differed. These included known adverse events: gastrointestinal discomfort, breast tenderness, reduced libido, dry skin (flutamide and finasteride); irregular bleeding (spironolactone); nausea, diarrhoea, bloating (metformin); hot flushes, decreased libido, vaginal dryness, headaches (gonadotropin-releasing hormone (GnRH) analogues)).Clinician's evaluation of hirsutism and change in androgen levels were addressed in most comparisons, change in body mass index (BMI) and improvement of other clinical signs of hyperandrogenism in one-third of studies.The quality of evidence was moderate to very low for most outcomes.There was low quality evidence for the effect of two oral contraceptive pills (OCPs) (ethinyl estradiol + cyproterone acetate versus ethinyl estradiol + desogestrel) on change from baseline of Ferriman-Gallwey scores. The mean difference (MD) was -1.84 (95% confidence interval (CI) -3.86 to 0.18).There was very low quality evidence that flutamide 250 mg, twice daily, reduced Ferriman-Gallwey scores more effectively than placebo (MD -7.60, 95% CI -10.53 to -4.67 and MD -7.20, 95% CI -10.15 to -4.25). Participants' evaluations in one study with 20 participants confirmed these results (risk ratio (RR) 17.00, 95% CI 1.11 to 259.87).Spironolactone 100 mg daily was more effective than placebo in reducing Ferriman-Gallwey scores (MD -7.69, 95% CI -10.12 to -5.26) (low quality evidence). It showed similar effectiveness to flutamide in two studies (MD -1.90, 95% CI -5.01 to 1.21 and MD 0.49, 95% CI -1.99 to 2.97) (very low quality evidence), as well as to finasteride in two studies (MD 1.49, 95% CI -0.58 to 3.56 and MD 0.40, 95% CI -1.18 to 1.98) (low quality evidence).Although there was very low quality evidence of a difference in reduction of Ferriman-Gallwey scores for finasteride 5 mg to 7.5 mg daily versus placebo (MD -5.73, 95% CI -6.87 to -4.58), it was unlikely it was clinically meaningful. These results were reinforced by participants' assessments (RR 2.06, 95% CI 0.99 to 4.29 and RR 11.00, 95% CI 0.69 to 175.86). However, finasteride showed inconsistent results in comparisons with other treatments, and no firm conclusions could be reached.Metformin demonstrated no benefit over placebo in reduction of Ferriman-Gallwey scores (MD 0.05, 95% CI -1.02 to 1.12), but the quality of evidence was low. Results regarding the effectiveness of GnRH analogues were inconsistent, varying from minimal to important improvements.We were unable to pool data for OCPs with cyproterone acetate 20 mg to 100 mg due to clinical and methodological heterogeneity between studies. However, addition of cyproterone acetate to OCPs provided greater reductions in Ferriman-Gallwey scores.Two studies, comparing finasteride 5 mg and spironolactone 100 mg, did not show differences in participant assessments and reduction of Ferriman-Gallwey scores (low quality evidence). Ferriman-Gallwey scores from three studies comparing flutamide versus metformin could not be pooled (I² = 62%). One study comparing flutamide 250 mg twice daily with metformin 850 mg twice daily for 12 months, which reached a higher cumulative dosage than two other studies evaluating this comparison, showed flutamide to be more effective (MD -6.30, 95% CI -9.83 to -2.77) (very low quality evidence). Data showing reductions in Ferriman-Gallwey scores could not be pooled for four studies comparing finasteride with flutamide as the results were inconsistent (I² = 67%).Studies examining effects of hypocaloric diets reported reductions in BMI, but which did not result in reductions in Ferriman-Gallwey scores. Although certain cosmetic measures are commonly used, we did not identify any relevant RCTs.

AUTHORS' CONCLUSIONS

Treatments may need to incorporate pharmacological therapies, cosmetic procedures, and psychological support. For mild hirsutism there is evidence of limited quality that OCPs are effective. Flutamide 250 mg twice daily and spironolactone 100 mg daily appeared to be effective and safe, albeit the evidence was low to very low quality. Finasteride 5 mg daily showed inconsistent results in different comparisons, therefore no firm conclusions can be made. As the side effects of antiandrogens and finasteride are well known, these should be accounted for in any clinical decision-making. There was low quality evidence that metformin was ineffective for hirsutism and although GnRH analogues showed inconsistent results in reducing hirsutism they do have significant side effects.Further research should consist of well-designed, rigorously reported, head-to-head trials examining OCPs combined with antiandrogens or 5α-reductase inhibitor against OCP monotherapy, as well as the different antiandrogens and 5α-reductase inhibitors against each other. Outcomes should be based on standardised scales of participants' assessment of treatment efficacy, with a greater emphasis on change in quality of life as a result of treatment.

Dermatosis associated with menopause

Menopause is defined as permanent irreversible cessation of menses brought by decline in ovarian follicular activity. Hormonal alteration results in various physical, psychological, and sexual changes in menopausal women. Associated dermatological problems can be classified as physiological changes, age-related changes, changes due to estrogen deficiency and due to hormone replacement therapy. Dermatosis seen due to estrogen deficiency includes Atrophic Vulvovaginitis, Vulvar Lichen Sclerosus, Dyaesthetic Vulvodynia, Hirsutism, Alopecia, Menopausal Flushing, Keratoderma Climactericum, Vulvovaginal Candidiasis. Dermatologists and gynecologists need to be familiar with the problems of menopausal women, as with increase in life expectancy, women passing through this phase is rising.