EEMCO Guidance for the Assessment of Hair Shedding and Alopecia

The Ratio of Typical Clubbing in Pulled-Out Hairs as a Useful Marker in Predicting the Course of Alopecia Areata

BACKGROUND

Analysis of hair microscopic morphology is a simple and less invasive method to differentiate alopecia areata (AA) from other alopecic diseases. However, there is limited information on the distribution of the microscopic characteristics.

OBJECTIVE

This study evaluated the microscopic morphological characteristics of pulled-out hair and their correlation with disease course in AA.

METHODS

Morphological characteristics of pulled-out hair were classified into 5 categories: the presence of typical clubbing, surface undulation, tapering, breakage, and depigmentation in proximal hair shaft. Clinical course of AA was investigated through assessment of Severity of Alopecia Tool (SALT) score (initial score, maximal score and difference of them [ΔSALT]).

RESULTS

Among 1,272 pulled-out hairs (n=179) obtained at initial visit, depigmentation (59.5%) was the most common, followed by loss of typical clubbing (57.2%) and surface undulation (55.2%). The percentage of loss of typical clubbing and proximal tapering was significantly higher in severe type of AA, younger age of onset and shorter disease duration. The ratio of typical clubbing (<50% vs. ≥50%) was associated with difference in maximal score and ΔSALT (p<0.05). Strong activity group (pulled-out hair ≥10, n=33) showed difference in clinical course (maximal score, ΔSALT) as well as distribution of microscopic features (loss of typical clubbing) compared with those in non-strong activity group. The ratio of typical clubbing significantly increased at follow-up than initially in strong activity group (p<0.05).

CONCLUSION

Microscopic hair morphology, especially loss of typical clubbing and proximal tapering, could be useful tool to predict the course of AA.

Alopecias in humans: biology, pathomechanisms and emerging therapies

BACKGROUND

The hair follicle is a complete mini-organ with a complex biology. Recent discoveries have shed light on the pathogenesis and genetic basis of a number of hair loss conditions, offering novel treatment alternatives.

OBJECTIVE

To explore the biology and physiology of hair growth, the pathomechanism behind alopecias and emerging therapies.

CONCLUSION AND CLINICAL IMPORTANCE

Hair growth is influenced by numerous physiological moderators. Greater understanding of the biology and physiology of the hair follicle and the pathomechanisms of hair disease facilitates development of targeted treatments. Sublingual minoxidil is a promising therapy in humans where optimised drug delivery enhances efficacy and reduces systemic adverse effects. Janice kinase inhibitors, which disrupt the inflammatory cascade, help maintain the hair follicle, preserve immune privilege, and regrow hair in alopecia areata. As the pathomechanisms of other forms of alopecia become better understood, new targeted therapies with greater efficacy will emerge.

Analysis of Microscopic Examination of Pulled Out Hair in Telogen Effluvium Patients

Background

Telogen effluvium (TE) is characterized by massive hair shedding and results from an abrupt conversion of anagen to telogen. Differentiation of TE with other hair disorders showing massive hair shedding is difficult.

Objective

To evaluate the morphologic characteristics of pulled out hair of TE.

Methods

We analyzed microscopic examination of pulled out hairs by hair pull test in TE patients, and compared these hairs with pulled out hairs in diffuse alopecia areata (AA) patients and healthy volunteers.

Results

Hair microscopic examination in 44 TE patients (370 hairs) and 30 healthy volunteers (295 hairs) were as follows: typical club hair, 32.7%, 62.7%; club hair with tail, 23.5%, 23.7%; club hair with remnant sheath, 23.0%, 6.8%; club hair with both tail and remnant sheath, 18.9%, 5.4%; and unclassified hair, 1.9%, 1.4%. The examination in 7 diffuse AA patients (63 hairs) was as follows: typical club hair, 23.9%; atypical club hair, 47.7%; and distinctive AA hair, 28.4%. There was statistical difference between TE patients and healthy volunteers group (p=0.000).

Conclusion

Increased atypical club hair in microscopic hair examination might be characteristics of TE.

"Miliacin encapsulated by polar lipids stimulates cell proliferation in hair bulb and improves telogen effluvium in women"

BACKGROUND

Miliacin, the main triterpenoid from millet, is known to stimulate keratinocyte metabolism and proliferation. Polar lipids are able to form vesicles with active compounds and to improve their bioavailability.

OBJECTIVES

We aimed to demonstrate potential benefits of a solution of miliacin encapsulated within polar lipids (MePL) on telogen effluvium prevention and hair condition in women.

METHODS

After preliminary cell proliferation studies, a placebo-controlled, multicentric, randomized, double-blind trial was performed on sixty-five nonmenopausal women affected by telogen effluvium, to assess the efficacy of a 12-week oral supplementation with MePL. Telogen and anagen densities were determined by phototrichogram analysis. Scalp dryness and hair brightness were clinically evaluated using a Likert scale.

RESULTS

MePL further enhanced cell proliferation in hair bulb from human scalp than miliacin alone. Compared to the placebo treatment, MePL supplementation significantly reduced telogen density after 12 weeks of treatment. An increase of anagen density was observed in both groups, although there was no significant difference between the two treatments. Scalp dryness was more decreased in the MePL group than in the placebo group. A better improvement of hair brightness was also observed after 12 weeks of supplementation with MePL.

CONCLUSION

Twelve weeks of MePL supplementation significantly reduced the hair density in the telogen phase and, in parallel, improved scalp dryness and hair condition. These effects could be linked to MePL activity on cell proliferation in hair bulb. MePL is an original association of plant extract that could help to prevent and/or limit hair loss in women.

Hair Strengthening Evaluation of Anisotropic Osmolite Solutions (Inositol + Arginine): Cross-Talk between Dermal Papilla Fibroblast and Keratinocytes of the Outer Root Sheath Using a µHair Follicle 3D Model

The hair follicle (HF) is a dynamic “mini-organ” which undergoes bi-continuous cycles of growth, destruction and rest. The molecular mechanisms underlying the HF cycle are complex yet not fully understood. Anyhow, it is clear that the epithelial–mesenchymal interactions, and in particular the cross-talk between dermal papilla fibroblast (DPF) and the keratinocytes of the outer root sheath (ORSK) play a pivotal role. Aim of this study is the evaluation of the biological activity of anisotropic osmolyte solutions on the HF cycle. As reported in recent studies, dermal papilla cells deeply modify their gene expression profile when cultured as monolayers, but their transcriptional pattern can be partially restored when they are cultured as 3-dimensional spheroids. This draws our attention to the discovery that the spatial distribution of cells in the growth medium is fundamental in order to produce a verisimilar model. Therefore, we used the hanging drop technology to produce a scaffold-free micro-tissue model applied to a DPF-ORSK co-culture in order to create a µHF 3-dimensional model. As a result, this system was capable of evaluating the efficacy of the anisotropic osmolyte solutions on the progressive increase of the follicle turnover and ‘health’. Moreover, an in silico model was used in order to screen the most promising combination of osmolyte molecules. In vivo objective evaluations were finally carried out on volunteers having hair disorders.

An Open-Label Randomized Multicenter Study Assessing the Noninferiority of a Caffeine-Based Topical Liquid 0.2% versus Minoxidil 5% Solution in Male Androgenetic Alopecia

BACKGROUND

Androgenetic alopecia is a condition with a high prevalence worldwide and affects both males and females. Currently, only 2 approved treatments exist: finasteride (males only) and minoxidil 2 or 5% solution (males and females).

METHODS

We conducted a randomized, open-label, multicenter noninferiority study to determine whether a caffeine-based 0.2% topical liquid would be no less effective than minoxidil 5% solution in males (n = 210) with androgenetic alopecia. The primary end point was the percentage change in the proportion of anagen hairs from baseline to 6 months using a frontal and occipital trichogram.

RESULTS

At 6 months, the group of the 5% minoxidil solution showed a mean improvement in anagen ratio of the trichogram of 11.68%, and the group of the 0.2% caffeine solution had an anagen improvement of 10.59%. The difference of mean values between both groups was 1.09%. The statistical analysis was performed and reported in accordance with the CONSORT Guidelines 2010 for reporting of noninferiority and equivalence randomized trials.

CONCLUSION

A caffeine-based topical liquid should be considered as not inferior to minoxidil 5% solution in men with androgenetic alopecia.

Hair follicle characteristics as early marker of Type 2 Diabetes

Type 2 Diabetes mellitus (DM2) includes a continuum of metabolic disorders characterized by hyperglycemia that causes several chronic long-term complications such as coronary artery disease, peripheral arterial disease, nephropathy, and neuropathy. The hair follicle could reveal signs of early vascular impairment, yet its relationship to early metabolic injuries has been largely ignored. We propose that in earlier stages of the continuum of DM2-related metabolic disorders, a group of susceptible patients who do not yet meet the diagnostic criteria to be considered as persons with DM2 may present chronic vascular impairment and end organ damage, including hair follicle damage, which can be evaluated to identify an early risk marker. This hypothesis is based in the association found between insulin resistance and alopecia in non-diabetic persons, and the hair loss on the lower limbs as a manifestation of long-term peripheral arterial disease among subjects with DM2. In order to test this hypothesis, studies are required to evaluate if hair follicle characteristics are related to and can predict hyperglycemic complications, and if they do so, which feature of the hair follicle, such as hair growth, best characterizes such DM2-related conditions. If this hypothesis were proven to be true, significant advances towards a personalized approach for early prevention strategies and management of DM2 would be made. By focusing on the hair follicles, early stages of metabolic-related organ damage could be identified using non-invasive low-cost techniques. In so doing, this approach could provide early identification of DM2-susceptible individuals and lead to the early initiation of adequate primary prevention strategies to reduce or avoid the onset of large internal organ damage.

Pregnancy and the hair growth cycle: anagen induction against hair growth disruption using Nourkrin® with Marilex® , a proteoglycan replacement therapy

Postpartum effluvium is a well-known clinical fact. However, following some minor research activities in the 1960s, very little has happened on the research front of the subject. It was hypothesized that postpartum hair loss might be a manifestation of a change in the hair growth cycle occurring normally during pregnancy. Recently, new research has been published trying to explain the mechanism of action behind this frequently occurring hair growth disruption, and to develop a functional treatment schedule and regime. Under normal circumstances, postpartum effluvium will disappear by itself as a function of time, and therefore adequate information to the patient is important in order to reduce the anxiety that it will not be a permanent problem. However, in some subjects it can manifest itself for longer stages and even become permanent. At the present time, treatments aim at correcting underlying hormonal imbalances and at improving overall cosmetic appearance. Several treatments in the form of thyroid supplementation, topical progesterone and estradiol lotions, and even oral contraceptive have been studied. All the available studies have significant limitations in their scientific basis, such as small sample size, absence of control group, or highly subjective measurement of treatment response. It is evident from the available studies that no specific treatment has been investigated thoroughly enough to justify recommendation in clinical treatment or to be termed "effective." Without the ability to provide a pathogenic diagnosis or causality criteria, chances are low that a treatment by trial and error will adequately be able to control hair effluvium. Current hair treatment strategies are symptomatic and nonspecific; therefore, future research must aim at developing new and targeted methods with a point of departure in observing concomitant biological mechanisms. Based on the research in the 1960s, current knowledge about the hair follicle and the regulation of the hair cycles, we believe that an anagen inducer in the form of a specific proteoglycan replacement therapy (Nourkrin^® with Marilex^® from Pharma Medico) could be a proper solution to shorten the hair eclipse phenomenon - and give the patient a feeling of control and empowerment.

Possible Relationship between Chronic Telogen Effluvium and Changes in Lead, Cadmium, Zinc, and Iron Total Blood Levels in Females: A Case-Control Study

Introduction:

Hair loss is a common and distressing problem that can affect both males and females of all ages. Chronic telogen effluvium (CTE) is idiopathic diffuse scalp hair shedding of at least 6 months duration. Hair loss can be one of the symptoms of metal toxicity. Lead (Pb) and cadmium (Cd) are highly toxic metals that can cause acute and chronic health problems in human. The aim of the present study is to determine if there is a relationship between these metals and CTE in women and if CTE is also associated with changes in zinc (Zn) or iron (Fe) blood levels.

Materials and Methods:

Pb, Cd, Fe and Zn total blood levels were determined in 40 female patients fulfilling the criteria of CTH and compared with total blood levels of same elements in 30 well-matched healthy women.

Results:

Quantitative analysis of total blood Fe, Zn, Pb and Cd revealed that there were no significant differences between patients and controls regarding Fe, Zn, and Pb. Yet, Cd level was significantly higher in patients than controls. In addition, Cd level showed significant positive correlation with the patient's body weight.

Conclusion:

Estimation of blood Pb and Cd levels can be important in cases of CTE as Cd toxicity can be the underlying hidden cause of such idiopathic condition.

Alterations in hair follicle dynamics in women

Endocrine changes supervening after parturition and menopause participate in the control of sebum production and hair growth modulation. The ensuing conditions include some peculiar aspects of hair loss (effluvium), alopecia, and facial hirsutism. The hair cycling is of major clinical relevance because most hair growth disorders result from disturbances in this chronobiological feature. Of note, any correlation between a biologic abnormality and hair cycling disturbance does not prove a relationship of causality. The proportion of postmenopausal women is rising in the overall population. Therefore, the prevalence of these hair follicle disturbances is globally on the rise. Current therapies aim at correcting the underlying hormonal imbalances, and at improving the overall cosmetic appearance. However, in absence of pathogenic diagnosis and causality criteria, chances are low that a treatment given by the whims of fate will adequately control hair effluvium. The risk and frequency of therapeutic inertia are further increased. When the hair loss is not controlled and/or compensated by growth of new hairs, several clinical aspects of alopecia inexorably develop. Currently, there is little evidence supporting any specific treatment for these endocrine hair disorders in post-partum and postmenopausal women. Current hair treatment strategies are symptomatic and nonspecific so current researchers aim at developing new, targeted methods.

The skin landscape in diabetes mellitus. Focus on dermocosmetic management

Background

Some relationships are established between diabetes mellitus (DM) and a series of cutaneous disorders. Specific dermatoses are markers for undiagnosed DM. Other disorders represent supervening complications in an already treated DM patient.

Objective

To review the information about dermocosmetic care products and their appropriate use in the management and prevention of dermatoses related to DM.

Method

The peer-reviewed literature and empiric findings are covered. Owing to the limited clinical evidence available for the use of dermocosmetics, a review of the routine practices and common therapies in DM-related dermatoses was conducted.

Results

Some DM-related dermatoses (acanthosis nigricans, pigmented purpuric dermatosis) are markers of macrovascular complications. The same disorders and some others (xerosis, Dupuytren’s disease) have been found to be more frequently associated with microangiopathy. Other skin diseases (alopecia areata, vitiligo) were found to be markers of autoimmunity, particularly in type 1 DM. Unsurprisingly, using dermocosmetics and appropriate skin care has shown objective improvements of some DM-related dermatoses, such effects improve the quality of life. The most common skin manifestations of DM fall along continuum between “dry skin,” xerosis, and acquired ichthyosis, occurring predominately on the shins and feet. Dermocosmetic products improve the feeling of well-being for DM patients.

Challenging regional psoriasis and ustekinumab biotherapy: impact of the patterns of disease

In some patients, psoriasis appears refractory to many treatments, particularly when the disease is confined to some specific body regions. In this respect, palmoplantar psoriasis and palmoplantar pustulosis are possibly related conditions in their immunopathomechanisms involving Il-12, IL-23, and Th17. Nail psoriasis and scalp psoriasis are two other particular psoriasis manifestations. Accordingly, ustekinumab was tested in a few of these patients. The present paper is limited to peer-reviewed case reports. Data were not supported by bioinstrumental assessments and controlled trials. Overall, they are indicative of potential efficacy. The cost-effectiveness and the risk-benefit assessments merit further investigations.

Hair evaluation methods: merits and demerits

Various methods are available for evaluation (for diagnosis and/or quantification) of a patient presenting with hair loss. Hair evaluation methods are grouped into three main categories: Non-invasive methods (e.g., questionnaire, daily hair counts, standardized wash test, 60-s hair count, global photographs, dermoscopy, hair weight, contrasting felt examination, phototrichogram, TrichoScan and polarizing and surface electron microscopy), semi-invasive methods (e.g., trichogram and unit area trichogram) and invasive methods (e.g., scalp biopsy). Any single method is neither 'ideal' nor feasible. However, when interpreted with caution, these are valuable tools for patient diagnosis and monitoring. Daily hair counts, wash test, etc. are good methods for primary evaluation of the patient and to get an approximate assessment of the amount of shedding. Some methods like global photography form an important part of any hair clinic. Analytical methods like phototrichogram are usually possible only in the setting of a clinical trial. Many of these methods (like the scalp biopsy) require expertise for both processing and interpreting. We reviewed the available literature in detail in light of merits and demerits of each method. A plethora of newer methods is being introduced, which are relevant to the cosmetic industry/research. Such methods as well as metabolic/hormonal evaluation are not included in this review.

Dandruff: the most commercially exploited skin disease

The article discuss in detail about the prevalence, pathophysiology, clinical manifestations of dandruff including the etio-pathology. The article also discusses in detail about various treatment methods available for dandruff. The status of dandruff being amphibious – a disease/disorder, and relatively less medical intervention is sought after for the treatment, dandruff is the most commercially exploited skin and scalp disorder/disease by personal care industries.

Revisiting dandruff

Dandruff is a common scalp disorder affecting almost half of the postpubertal population of any ethnicity and both genders. It may, however, represent a stubborn esthetical disturbance often source of pruritus. Skin biocenosis, in particular the Malassezia spp. flora, plays a key aetiologic role, in combination with the unusual capacity of some corneocytes to be coated by these yeasts. Substantial evidence indicates that keratinocytes play an active role in the generation and expression of immunopathological reactions. This is probably the case in dandruff. Upon stimulation of a critical colonization of corneocytes by Malassezia yeasts, the release of pro-inflammatory mediators is increased. This could lead to the subclinical microinflammation present in dandruff. In seborrheic dermatitis, local deposits of immunoglobulins and the release of lymphokines are responsible for the recruitment and local activation of leukocytes leading to the eventual amplification of the inflammatory reaction. Some ancillary non-microbial causes of dandruff may operate through physical or chemical irritants. Many methods have been described for rating dandruff. Our favourite tools are clinical examination and squamometry. Dandruff can precipitate telogen effluvium and exacerbate androgenic alopecia. Antidandruff formulations exhibiting some direct or indirect anti-inflammatory activity can improve both dandruff and its subsequent hair cycle disturbance.

Increased hair shedding may be associated with the presence of Pityrosporum ovale

BACKGROUND AND OBJECTIVE

Although the available data show that hair loss is an important cosmetic problem worldwide, the pathogenesis of common hair shedding is not fully understood. The aim of this study was to evaluate the association between hair shedding and cutaneous Malassezia infection. Malassezia fungi have been the suspected cause of dandruff for more than a century. Previously referred to as Pityrosporum ovale or P. orbiculare, these fungi are now known to consist of at least seven species.

METHODS

Over a 4-year period, we obtained 300 hair samples from medical students. Based on the clinical history and a hair-pull test, the participants were divided into two groups: normal subjects and subjects with hair shedding. The students' scalp skin was gently scraped, smeared on a slide, colored by methylene blue, and observed under 10x magnification.

RESULTS

All participants who had positive smears with >or=3 P. ovale organisms per low-power microscopic field (10x) were defined as 'carriers.' Seventy-six percent of students were Malassezia carriers. The prevalence of positive smears was significantly higher among subjects with hair shedding than among normal subjects (89.92% vs 9.52%, p<0.001). Furthermore, participants with positive smears had a significantly higher frequency of hair loss complaints and positive hair-pull tests.

CONCLUSION

The proportion of subjects who were carriers of Malassezia yeasts was significantly higher in the group with hair shedding, and our results therefore raise the possibility of a relationship between this unicellular organism and hair loss. Our study findings should be explored in a larger series of patients.

Critical study of hair growth analysis with computer-assisted methods

BACKGROUND

Computer-assisted image analysis has been proposed for human hair growth studies.

METHODS

The performances of Trichoscan, a commercially available automated system combining epiluminiscence microscopy with digital image analysis, developed for office-based hair growth measurements, have been evaluated comparatively on the same skin sites using standardized photographic equipment and calibrated processing for contrast-enhanced phototrichogram (CE-PTG) analysis. This reference method has been validated with scalp biopsies and histological examination of serial sectioning.

RESULTS

Besides edge effects, hair fibres escaped the Trichoscan analysis for various reasons including, but not limited to, thickness, pigmentation, closeness and crossing.

CONCLUSION

Most of these problems have been identified in the late 1980s and remain largely unsolved by the processing software that was evaluated in 2004. Therefore claims promoting the Trichoscan method for accurate hair measurements in clinical trials on scalp and body hair are not supported by the present investigation. The speed at which the analysis is performed is outweighed by the errors in signal detection. Therefore we suggest that improvements must be clearly documented before Trichoscan is established for quantified diagnostic purposes and detailed hair cycle monitoring during hair trials.

Hair Follicles – A Long-Term Reservoir for Drug Delivery

Nanoparticles represent an important drug carrier system. Recently, we have reported on the penetration and storage behavior of particular and non-particular substances revealing the superiority of particular substances in the range of 300-400 nm. In this regard, it was assumed that the rigid hair shaft acts as a geared pump, moving the particles deeper into the hair follicle. In the present investigation, the storage reservoir capacity of the stratum corneum and the hair follicle infundibulum and canal are compared. Interestingly, we could demonstrate a 10 times longer storage within the hair follicles. These results underscore the importance of the hair follicle for drug delivery purposes, mainly highlighting new possibilities for the future concerning retarded delivery, application frequency, and galenic design.

Dandruff-associated smouldering alopecia: a chronobiological assessment over 5 years

BACKGROUND

In some individuals, dandruff may be recurrent and even chronic. This represents a difficult-to-treat condition. Excessive hair shedding and diffuse alopecia may develop.

OBJECTIVES

To evaluate the chronobiological aspects of dandruff, hair shedding and alopecia.

METHODS

This study was performed in eight men suffering from such a scalp condition. They were examined 40 times at regular intervals for five consecutive years. Hair-density assessments and trichograms were performed at least twice per trimester on the parietal region of the scalp, corresponding to an area where dandruff was present.

RESULTS

A positive correlation was found between the percentage of telogen hairs and dandruff severity as assessed by the squamometry index. Bimodal yearly biorhythms were found for dandruff severity, telogen counts and hair loss between two consecutive visits. The chronobiological fluctuations were prominent in some study participants, but remained inconspicuous in others. The biorhythms were almost synchronized in all participants, showing variations over the year.

CONCLUSIONS

The biorhythms on the hair cycle in dandruff are not fundamentally different from those previously reported in subjects without dandruff. The periodicity may be an intrinsic feature of human skin.