Towards a consensus on how to diagnose and quantify female pattern hair loss - The ‘Female Pattern Hair Loss Severity Index (FPHL-SI)’

Female Pattern Hair Loss and Negative Psychological Impact: Possible Role of Brain-derived Neurotrophic Factor (BDNF)

INTRODUCTION

Female Pattern Hair Loss (FPHL) is considered the most common type of hair loss in females. Women with FPHL may suffer from psychological distress and defective social functioning. Patients with psychiatric and neurodegenerative disorders almost have a deficient brain and blood brain-derived neurotrophic factor levels (BDNF). This serum BDNF level may act as a diagnostic marker for negative psychological impact in FPHL patients.

OBJECTIVES

Evaluate the levels of serum BDNF in patients with FPHL and correlate its level to the severity of alopecia and the degree of psychological impact.

METHODS

Forty-six female patients with FPHL and 41 healthy age-matched female volunteers as a control were included in the study. Patients filled out a Dermatology Life Quality Index questionnaire. Both patients and controls filled Beck Depression Inventory, Beck Anxiety Inventory, and Perceived Stress Scale (PSS) questionnaires. Serum levels of BDNF were measured for all the participants using the ELISA technique.

RESULTS

Patients with FPHL had significantly lower levels of BDNF and significantly higher Beck depression inventory score and PSS questionnaire scores. There is a significant negative correlation between serum levels of BDNF and Beck Depression Inventory, Beck Anxiety Inventory, and PSS questionnaire scores.

CONCLUSIONS

Patients with FPHL are at a high risk to develop chronic stress and depression. The serum level of BDNF is a good predictor for the assessment of chronic stress and depression in FPHL patients.

Assessment of Multidimensional Health Care Parameters Among Adults in Japan for Developing a Virtual Human Generative Model: Protocol for a Cross-sectional Study

BACKGROUND

Human health status can be measured on the basis of many different parameters. Statistical relationships among these different health parameters will enable several possible health care applications and an approximation of the current health status of individuals, which will allow for more personalized and preventive health care by informing the potential risks and developing personalized interventions. Furthermore, a better understanding of the modifiable risk factors related to lifestyle, diet, and physical activity will facilitate the design of optimal treatment approaches for individuals.

OBJECTIVE

This study aims to provide a high-dimensional, cross-sectional data set of comprehensive health care information to construct a combined statistical model as a single joint probability distribution and enable further studies on individual relationships among the multidimensional data obtained.

METHODS

In this cross-sectional observational study, data were collected from a population of 1000 adult men and women (aged ≥20 years) matching the age ratio of the typical adult Japanese population. Data include biochemical and metabolic profiles from blood, urine, saliva, and oral glucose tolerance tests; bacterial profiles from feces, facial skin, scalp skin, and saliva; messenger RNA, proteome, and metabolite analyses of facial and scalp skin surface lipids; lifestyle surveys and questionnaires; physical, motor, cognitive, and vascular function analyses; alopecia analysis; and comprehensive analyses of body odor components. Statistical analyses will be performed in 2 modes: one to train a joint probability distribution by combining a commercially available health care data set containing large amounts of relatively low-dimensional data with the cross-sectional data set described in this paper and another to individually investigate the relationships among the variables obtained in this study.

RESULTS

Recruitment for this study started in October 2021 and ended in February 2022, with a total of 997 participants enrolled. The collected data will be used to build a joint probability distribution called a Virtual Human Generative Model. Both the model and the collected data are expected to provide information on the relationships between various health statuses.

CONCLUSIONS

As different degrees of health status correlations are expected to differentially affect individual health status, this study will contribute to the development of empirically justified interventions based on the population.

INTERNATIONAL REGISTERED REPORT IDENTIFIER (IRRID)

DERR1-10.2196/47024.

Recent Advances in Understanding of the Etiopathogenesis, Diagnosis, and Management of Hair Loss Diseases

Hair-loss diseases comprise heterogenous conditions with respective pathophysiology and clinicopathological characteristics. Major breakthroughs in hair follicle biology and immunology have led to the elucidation of etiopathogenesis of non-scarring alopecia (e.g., alopecia areata, AA) and cicatricial alopecia (e.g., lichen planopilaris, LPP). High-throughput genetic analyses revealed molecular mechanism underlying the disease susceptibility of hair loss conditions, such as androgenetic alopecia (AGA) and female pattern hair loss (FPHL). Hair loss attracted public interest during the COVID-19 pandemic. The knowledge of hair loss diseases is robustly expanding and thus requires timely updates. In this review, the diagnostic and measurement methodologies applied to hair loss diseases are updated. Of note, novel criteria and classification/scoring systems published in the last decade are reviewed, highlighting their advantages over conventional ones. Emerging diagnostic techniques are itemized with clinical pearls enabling efficient utilization. Recent advances in understanding the etiopathogenesis and management for representative hair diseases, namely AGA, FPHL, AA, and major primary cicatricial alopecia, including LPP, are comprehensively summarized, focusing on causative factors, genetic predisposition, new disease entity, and novel therapeutic options. Lastly, the association between COVID-19 and hair loss is discussed to delineate telogen effluvium as the predominating pathomechanism accounting for this sequela.

Chronic Telogen Effluvium: Is it a Distinct Condition? A Systematic Review

BACKGROUND

Whilst there are several recognised explanations for persistent telogen-phase hair loss, for a proportion of cases, no clear underlying cause can be identified. These cases have been given the diagnostic label chronic telogen effluvium: a poorly characterised condition where there is legitimate uncertainty as to whether it represents a truly distinct disorder.

OBJECTIVE

The aim of this review was to evaluate published cases of purported chronic telogen effluvium and how strongly they support its existence as a distinct disorder.

METHODS

We systematically reviewed the literature identified from searching Embase, MEDLINE and Web-of-Science. An additional manual search was performed from the reference lists of publications identified. The review followed PRISMA (Preferred Reporting Items for Systematic Reviews and Meta-Analyses) guidelines. The Joanna Briggs Institute's checklists for case reports, case-series, case-control studies and analytical cross-sectional-studies were used to appraise the quality of identified articles.

RESULTS

Eighteen studies (comprising five case-series, seven cross-sectional studies, three case-control studies, one case report, one quasi-experimental study and one diagnostic-accuracy study) were included for evaluation, containing 1628 cases. Eleven were rated of good quality. 97.5% of all cases were female. No studies documented that they had excluded all possible causes of telogen hair shedding. Only three studies (encompassing eight cases) featured a prospective follow-up. All eight studies that undertook biopsies reported a normal terminal to vellus hair ratio in the samples analysed. No studies objectively evaluated the influence of hair length or psychological distress/preoccupation on the likelihood of being diagnosed with chronic telogen effluvium.

CONCLUSIONS

The lack of a consensual consistent definition for chronic telogen effluvium is a significant limitation. Many cases presently labelled chronic telogen effluvium likely either represent early female pattern hair loss or incipient secondary telogen effluvium owing to an unidentified underlying secondary cause. Where triggering factors have been definitively excluded, hair shedding may represent an alteration in the hair cycle away from normal total asynchronous cycling. Some cases may also represent a preoccupation with normal hair shedding in anxious long-haired individuals.

A cross-sectional, observational study of the clinico-epidemiological profile of female pattern hair loss in Western India and its association with metabolic syndrome

Background

The increasing prevalence of female pattern hair loss (FPHL) is an alarming concern. There are many studies on FPHL in the world literature but there is a dearth of Indian data on the same.

Aims and objectives

The present study aims to ascertain the demographic variables and clinical features of FPHL in Western India and its association with metabolic syndrome (MetS) to add over and above the existing data.

Materials and Methods

Ninety females who were diagnosed with FPHL were included after approval of the institutional ethics committee. Demographic details, detailed history, and clinical features were noted, following which a few blood investigations for diagnosis of MetS were advised and evaluated.

Results

Our study population's age ranged from 17 to 65 years, with the mean age of 34.7 ± 1.3 years. According to the Basic and Specific (BASP) classification, The basic pattern prevalence as found in our study was 46.7% for M type, 35.6% for L type, and 17.7% for C type. The FPHL severity score revealed that 82 (91.1%) had advanced disease at presentation. Prevalence of MetS was found to be 34.4% and had a significant correlation with age of onset in years (p=0.041) and severity score (p=0.013) implying that it leads to an early onset and greater severity of FPHL.

Conclusion

FPHL is increasingly common among Indian women, who frequently present with a bitemporal recession of the hairline. Calculation of the female pattern hair loss severity index (FPHL-SI) can help in the categorization of patients and assessment of prognosis. MetS should be actively looked for in patients of FPHL and managed accordingly.

Intermediate Hair Follicles from Patients with Female Pattern Hair Loss Are Associated with Nutrient Insufficiency and a Quiescent Metabolic Phenotype

Female pattern hair loss (FPHL) is a non-scarring alopecia resulting from the progressive conversion of the terminal (t) scalp hair follicles (HFs) into intermediate/miniaturized (i/m) HFs. Although data supporting nutrient deficiency in FPHL HFs are lacking, therapeutic strategies are often associated with nutritional supplementation. Here, we show by metabolic analysis that selected nutrients important for hair growth such as essential amino acids and vitamins are indeed decreased in affected iHFs compared to tHFs in FPHL scalp skin, confirming nutrient insufficiency. iHFs also displayed a more quiescent metabolic phenotype, as indicated by altered metabolite abundance in freshly collected HFs and release/consumption during organ culture of products/substrates of TCA cycle, aerobic glycolysis, and glutaminolysis. Yet, as assessed by exogenous nutrient supplementation ex vivo, nutrient uptake mechanisms are not impaired in affected FPHL iHFs. Moreover, blood vessel density is not diminished in iHFs versus tHFs, despite differences in tHFs from different FPHL scalp locations or versus healthy scalp or changes in the expression of angiogenesis-associated growth factors. Thus, our data reveal that affected iHFs in FPHL display a relative nutrient insufficiency and dormant metabolism, but are still capable of absorbing nutrients, supporting the potential of nutritional supplementation as an adjunct therapy for FPHL.

New Diagnostic Tools to Evaluate Hair Loss

The precise and reliable diagnosis of hair loss disorders is essential for developing a successful management plan. It is, thus, the responsibility of the dermatologist to select the appropriate diagnostic tools to effectively evaluate patients presenting with hair loss concerns. Fortunately, there is a growing body of noninvasive and invasive diagnostic resources, each with advantages and disadvantages. For the practicing dermatologist, tactile assessments and direct visualization are enhanced with scoring instruments, questionnaires, handheld trichoscopy, and scalp biopsy. For research and clinical study purposes, the more precise, high-resolution tools such as videodermoscopy, optical coherence tomography, and phototrichograms, may be useful.

Resolution of warfarin-induced alopecia with conversion to apixaban

Warfarin is frequently prescribed as a long-term anticoagulant in patients with end-stage kidney disease as direct oral anticoagulants undergo renal excretion. Anticoagulation is a rare cause of alopecia in adults and is thought to be due to the promotion of the 'resting phase' of hair follicles. In this case report, a prevalent haemodialysis female patient required long-term anticoagulation following a complex pulmonary embolus and dialysis access complications. After commencing warfarin therapy, the patient reported generalised loss and thinning of her hair. All other potential causes were excluded. Cessation of warfarin therapy and conversion to apixaban with close monitoring alleviated the hair loss. Warfarin therapy is a rare cause of alopecia but should be considered in patients on long-term anticoagulation when other diagnoses have been excluded. Hair loss has a profoundly negative impact on patient quality of life and should prompt investigation to determine the underlying cause.

Clinical characteristics, trichoscopy, histopathology and treatment outcomes of frontal fibrosing alopecia in an Asian population: A retro-prospective cohort study

Frontal fibrosing alopecia (FFA) is a distinctive lymphocytic scarring alopecia with rapid increase in prevalence. Most FFA series are retrospectively reported from Caucasians with only few from Asians. The objective of this study was to characterize the clinical, trichoscopic and histopathological findings as well as treatment outcomes. This was a retro-prospective cohort study of patients diagnosed with FFA from 1 January 2010 to 1 November 2019. All patients were asked to present for re-examination. Clinical, trichoscopic, histopathological and laboratory data were recorded. A questionnaire was used to investigate hair care, hairstyle and facial skin care compared with age-matched normal controls. Multivariate analysis was performed in order to clarify factors associated with severity. All 58 FFA patients were female, of whom 27.6% were premenopausal, 37.7% had a history of surgical menopause, 13.8% had thyroid diseases, 69% had eyebrow loss and 32.8% facial papules. On physical examination, 10.3% showed linear pattern, 46.6% diffuse pattern and 43.1% pseudo-fringe sign. Concomitant lichen planopilaris was found in 25.9%, lichen planus pigmentosus in 24.1% and female pattern hair loss in 48.3%. The most common trichoscopic characteristics in the frontal hairline were lack of follicular ostia (91.4%), perifollicular scales (79.3%) and perifollicular erythema (63.8%). Up to 90% of patients reported FFA as improved or stable after receiving antiandrogen (finasteride or dutasteride) or antimalarial with topical treatment. Multivariate analyses revealed that facial lentiginous macules and trichoscopic perifollicular erythema at the frontal area were FFA severity-associated factors. "Front puff" Thai hairstyle was associated with FFA, while sunscreens and other cosmetic products were not. In conclusion, diffuse and pseudo-fringe sign pattern are common in Asian FFA. The most common autoimmune systemic comorbidity is thyroid disease, while common concomitant dermatological diseases are female pattern hair loss, lichen planopilaris and lichen planus pigmentosus. Antiandrogens or antimalarial plus topical treatment are the most useful therapy.

Topical L-thyroxine: The Cinderella among hormones waiting to dance on the floor of dermatological therapy?

Topical hormone therapy with natural or synthetic ligands of nuclear hormone receptors such as glucocorticoids, vitamin D analogues and retinoids has a long and highly successful tradition in dermatology. Yet the dermatological potential of thyroid hormone receptor (TR) agonists has been widely ignored, despite abundant clinical, cell and molecular biology, mouse in vivo, and human skin and hair follicle organ culture data documenting a role of TR-mediated signalling in skin physiology and pathology. Here, we review this evidence, with emphasis on wound healing and hair growth, and specifically highlight the therapeutic potential of repurposing topical L-thyroxine (T4) for selected applications in future dermatological therapy. We underscore the known systemic safety and efficacy profile of T4 in clinical medicine, and the well-documented impact of thyroid hormones on, for example, human epidermal and hair follicle physiology, hair follicle epithelial stem cells and pigmentation, keratin expression, mitochondrial energy metabolism and wound healing. On this background, we argue that short-term topical T4 treatment deserves careful further preclinical and clinical exploration for repurposing as a low-cost, effective and widely available dermatotherapeutic, namely in the management of skin ulcers and telogen effluvium, and that its predictable adverse effects are well-manageable.

Female Pattern Hair Loss-An Update

Female pattern hair loss (FPHL) is nonscarring progressive thinning of hair with gradual decrease in the number of hair, especially in the frontal, central, and parietal scalp, due to a process known as follicular miniaturization. The etiopathogenesis of FPHL is complex with multiple factors such as genetics, inflammation, hormones, and environment playing role in it. It usually manifests as slowly progressive hair thinning, mainly over the vertex and upper parietal scalp, the frontal hairline is often spared and the miniaturization is also not as severe as in men. A thorough history, clinical examination, hair loss evaluation tests, dermoscopy, and scalp biopsy can help in establishing the diagnosis. Various biochemical tests may be needed in patients with hyperandrogenism. The treatment includes medical and surgical modalities. Topical minoxidil is still considered the first line of treatment. Along with medical therapy, cosmetic camouflage may also be needed in some cases.

Topical odorant application of the specific olfactory receptor OR2AT4 agonist, Sandalore® , improves telogen effluvium-associated parameters

BACKGROUND

Human hair follicles (HFs) express the olfactory receptor (OR)2AT4, which is selectively stimulated by the synthetic sandalwood-like odorant, Sandalore^® . In organ-cultured, human scalp HFs, Sandalore^® prolongs anagen and suppresses apoptosis by up-regulating intrafollicular IGF-1 mediated signaling.

AIMS

The objective of this study is to demonstrate whether effects of Sandalore^® observed ex vivo translate into a clinically relevant effect in patients with telogen effluvium.

PATIENTS/METHODS

In a randomized, double-blinded, placebo-controlled, clinical trial, 60 female volunteers (18-65 years) affected by telogen effluvium received over a period of 24 weeks treatment with either 1% Sandalore^® solution (n = 30) or placebo (identically smelling, but non-OR2AT4 activating sandalwood oil n = 30). The study read-out parameters were the degree of hair shedding, hair volume, terminal/vellus hair ratio, anagen/catagen-telogen ratio, and patient self-assessment.

RESULTS

Sandalore^® 1% ameliorated clinical signs of telogen effluvium, namely it reduced hair shedding, and increased hair volume and the percentage of anagen HFs, the latter two parameters significantly more than placebo when changes were calculated to baseline. Sandalore^® also increased the ratio of terminal/vellus hairs at week 8. Most of the anti-hair shedding effects were seen after 8 weeks and maintained at week 24. Patient questionnaire showed that verum group patients were more satisfied than the placebo group in regard to the overall results.

CONCLUSION

This clinical trial supports previous findings of anagen-prolonging effects of Sandalore^® ex vivo with similar results now reproduced in clinical practice. It also provides proof-of-principle that a topically applied cosmetic odorant acting through HF olfactory receptors can be a therapeutic alternative to treat hair loss disorders characterized by excessive hair shedding such as telogen effluvium.

Caffeine and Its Pharmacological Benefits in the Management of Androgenetic Alopecia: A Review

Caffeine, particularly after ingestion, is well known to exert various pharmacological effects. A growing body of evidence implicates the ingestion of caffeine with beneficial effects on several diseases. The easy penetration of caffeine across the skin barrier and into human skin makes caffeine an ideal compound for topical application. Hair loss is known to negatively affect the quality of life and predispose to depression and anxiety. Androgenetic alopecia (AGA) is the most common type of hair loss in both men and women. To date, only few approved drug-based treatments for AGA exist, and these are inevitably associated with side effects. Therefore, the development of topical treatments based on well-tolerated natural ingredients such as caffeine to alleviate hair loss may provide a much-needed alternative to drug-based approaches.

Follicular Map: A Novel Approach to Quantitative Trichoscopy

Background

Trichoscopy (hair and scalp dermoscopy) is gaining importance as an easy-to-use diagnostic and monitoring tool in various hair and scalp conditions.

Objective

The demand for a method to identify exactly the same site on scalp skin for subsequent examinations is growing constantly.

Methods

In total, 40,000 trichoscopic images of 70-fold magnification were analyzed. Graphical pattern recognition was used to identify hair shafts in trichoscopy images and to derive the coordinates of all follicular orifices. Determination of the relative positions of hair follicle orifices formed the Follicular Map (FMap). Processing and matching of FMaps involves conceptually simple but computationally complex numerical algorithms.

Results

FMaps were shown to be unique for specific locations on the scalp in each human individual. The follicular patterns were not affected by natural hair cycling processes and remained unchanged over the course of time. It has been tentatively verified that FMaps remain unaffected by noncicatricial alopecia.

Conclusions

The concept of FMap presents a novel approach to qualitative trichoscopy, allowing precise evaluation of treatment efficiency, clinical trial quality control, validation of diagnostic tools, and potentially other applications still to be discovered. The FMap enables the location of hair follicles to be precisely measured and recorded.

Female Pattern Hair Loss and Androgen Excess: A Report From the Multidisciplinary Androgen Excess and PCOS Committee

OBJECTIVE

To determine the current state of knowledge and provide evidence-based recommendations that could be valid for all specialists taking care of female pattern hair loss (FPHL), a common form of hair loss in women that is characterized by the reduction of hair density in the central area of the scalp, whereas the frontal hairline is generally well conserved.

PARTICIPANTS

An expert task force appointed by the Androgen Excess and PCOS Society, which included specialists from dermatology, endocrinology, and reproductive endocrinology.

DESIGN

Levels of evidence were assessed and graded from A to D. Peer-reviewed studies evaluating FPHL published through December 2017 were reviewed. Criteria for inclusion/exclusion of the published papers were agreed on by at least two reviewers in each area and arbitrated by a third when necessary.

CONCLUSIONS

(i) The term "female pattern hair loss" should be used, avoiding the previous terms of alopecia or androgenetic alopecia. (ii) The two typical patterns of hair loss in FPHL are centrifugal expansion in the mid scalp, and a frontal accentuation or Christmas tree pattern. (iii) Isolated FPHL should not be considered a sign of hyperandrogenism when androgen levels are normal. (iv) The assessment of patients with FPHL is primarily clinical. (v) In all patients with FPHL, assessment of a possible androgen excess is mandatory. Measurement of vitamin D, iron, zinc, thyroid hormones, and prolactin are optional but recommended. (vi) Treatment of FPHL should start with minoxidil (5%), adding 5α-reductase inhibitors or antiandrogens when there is severe hair loss or hyperandrogenism.

New pattern hair loss in young Turkish women; What's wrong in their daily life?

BACKGROUND

The application of heat, used to straighten the typically coiled hair, has long been hypothesized to play a role in the etiologic factor for central centrifugal cicatricial alopecia (CCCA). The aim of this study was to evaluate the effect of thermal hair straightening on hair loss pattern in Asian women exist.

MATERIALS AND METHODS

Thirty-five patients with hair loss who have been using hair straightening devices and 25 patients with telogen effluvium were enrolled in this prospective study. Laboratory analysis and dermatoscopic findings were used to compare these groups.

RESULTS

The peripilar white halo around hairs, peripilar dark/gray halo around follicular orifices, the predominance of a single hair perifollicular unit (FU), hair diameter diversity, the thin miniaturized hair, interfollicular pinpoint white dots, and white patches were statistically higher in hair straightener group (P < 0.001). White patches of the scalp increased by the time of the application of these devices (P < 0.01). White patches of vertex region were significantly higher than the midfrontal region (P < 0.01).

CONCLUSION

The common side effects of thermal hot comb strengtheners' were summarized as damage to the hair shaft; decreasing in the brightness of the hair, burns, and scars on the scalp; and lastly CCCA-like hair loss.

The Trichoscopy Derived Sinclair Scale: Enhancing visual assessment through quantitative trichoscopy

INTRODUCTION

The Sinclair Scale of hair midline density is commonly used in clinical dermatology practice as a tool to evaluate the severity of female pattern hair loss (synonym androgenetic alopecia, AGA) and to monitor patient response to treatment. The Sinclair Scale involves a visual evaluation of central hair parting line width, that is performed quickly and with no optical instrumentation. Another approach used to score severity of hair loss is quantitative trichoscopy. While quantitative trichoscopy is more accurate in terms of reproducibility and objectivity, it is more time-consuming.

MATERIALS AND METHODS

Patients with different stages of AGA were evaluated using both the Sinclair Scale and quantitative trichoscopy. A correlation analysis was performed between the Sinclair Scale and different parameters derived from statistical analysis of trichoscopy images. A novel parameter, cumulative hair thickness density was introduced.

RESULTS

Very good correlation was observed between Sinclair Scale and the cumulative hair thickness density. The quality of correlation is sufficient to estimate Sinclair Scale from cumulative hair thickness density. A formula to calculate the 'Trichoscopy Derived Sinclair Scale' from trichoscopy statistics was derived.

DISCUSSION

We propose the term 'Trichoscopy Derived Sinclair Scale' to describe the hair midline density as derived from trichoscopy and to differentiate this assessment of midline hair density from the traditional one based on visual inspection alone.

A New Classification of Early Female Pattern Hair Loss

Background:

Global photographs (GPs) have been widely used to grade the severity in female pattern hair loss (FPHL). However, existing classifications for FPHL are not useful in the evaluation of early FPHL. Although there are some variations in early FPHL, even to a mild degree, all types of early FPHL are included in just one category. Therefore, the authors have devised a grading system for early FPHL with five levels focusing on the changes revealed by the surface reflected light of flash generated on GPs.

Aims:

This study aims to examine the possibility of evaluating the treatment course of early FPHL using the grading system based on changes in hair surface reflection patterns.

Subjects and Methods:

Retrospective chart review of 114 early FPHL patients was performed. GPs of these patients were classified into five grades. Photographs of the lowest and the highest grades of each patient were selected and paired. First, the relevance between the value of FPHL-severity index (FPHL-SI) and grades of all the selected photos was analyzed. Next three volunteers graded the paired photographs and chose the milder degree, and then, the concordance rate among author's and volunteers' evaluations were analyzed.

Results:

The value of FPHL-SI and incidence rate of hair diameter diversity tended to rise along with increasing of GP grade. Concordance rate of grading among author and more than two volunteers was 57%. The concordance rate of course evaluation between author and two volunteers was 97%.

Conclusion:

The new classification can finely classify the grade of early FPHL and can be used for treatment course evaluation.