New investigational drugs for androgenetic alopecia

Malus pumila Mill. cv Annurca apple extract might be therapeutically useful against oxidative stress and patterned hair loss

Patterned hair loss (PHL) or androgenetic alopecia is a condition affecting about 50% of people worldwide. Several pharmacological medications have been developed over the years, but few studies have investigated their effectiveness. Therefore, new, safer and more effective strategies are required. Recent investigations showed that Annurca apple extract application could induce keratin production and promote hair growth thanks to the high amount of procyanidin B2 contained in. Hence, this study aimed to investigate the role of an Annurca apple extract in preventing PHL by testing it on human follicle dermal papilla cells (HFDPCs) for the first time. Treatment of HFDPCs with Annurca apple extract counteracted intracellular reactive oxygen species accumulation by increasing the activity of antioxidant enzymes such as superoxide dismutase 2 and catalase. Furthermore, treatment with Annurca apple extract increased β-catenin and fibroblast growth factor 2, which are involved in hair growth stimulation. These data suggest that Annurca apple extract may be a potential therapeutically useful nutraceutical product for preventing or treating hair loss by reducing oxidative stress and inducing the expression of hair growth-related factors.

Alopecia Areata: Current Treatments and New Directions

Alopecia areata is an autoimmune hair loss disease that is non-scarring and is characterized by chronic inflammation at the hair follicle level. Clinically, patients' presentation varies from patchy, circumscribed scalp involvement to total body and scalp hair loss. Current management is guided by the degree of scalp and body involvement, with topical and intralesional steroid injections as primarily first-line for mild cases and broad immunosuppressants as the mainstay for more severe cases. Until recently, the limited number of blinded, randomized, placebo-controlled clinical trials for this disease had made establishing an evidence-based treatment paradigm challenging. However, growing insights into the pathogenesis of alopecia areata through blood and tissue analysis of human lesions have identified several promising targets for therapy. T-helper (Th) 1/interferon skewing has traditionally been described as the driver of disease; however, recent investigations suggest activation of additional immune mediators, including the Th2 pathway, interleukin (IL)-9, IL-23, and IL-32, as contributors to alopecia areata pathogenesis. The landscape of alopecia areata treatment has the potential to be transformed, as several novel targeted drugs are currently undergoing clinical trials. Given the recent US FDA approval of baricitinib and ritlecitinib, Janus kinase (JAK) inhibitors are a promising drug class for treating severe alopecia areata cases. This article will review the efficacy, safety, and tolerability of current treatments for alopecia areata, and will provide an overview of the emerging therapies that are leading the revolution in the management of this challenging disease.

Growth Factor Cocktail Including Fibroblast Growth Factor 9 (Cellcurin) in the Treatment of Androgenetic Alopecia in Men and Women: A Randomized Controlled Trial

Objectives

Androgenetic alopecia (AGA) is the most common cause of hair loss in men and women, affecting about 30% of men and 15% of women at 30 years and 80% and 48% at 70 years, respectively. This study aims to assess the effectiveness of growth factor cocktail therapy including fibroblast growth factor 9 (FGF9) (Cellcurin) in men and women with AGA.

Materials and Methods

This is a single-center randomized controlled trial, conducted with 10 men and 10 women with AGA. Eight men participated in the therapeutic group and two men in the control group. Eight women participated in the therapeutic group and two women in the control group. All were classified by sex, age, duration, and degrees of progression of AGA. The study obtained approval from the Research Ethics Committee (REC) of the Federal University of Uberlandia at approval number: 36918620.8.0000.5152. Six microneedling sessions were performed with an electromedical pen with an interval of 15 days between sessions. In the therapeutic group, sterile injectable Cellcurin was used and, in the control group, injectable sterile minoxidil 5 mg/ml 2 ml, both through the drug delivery system. Trichoscopic photos were taken before and after 12 weeks in the frontal and vertex regions. Descriptive statistics were performed using the t-test with the IBM SPSS-25 software.

Results

Men and women showed an expressive and significant increase in the amount of hair per cm2 after Cellcurin therapy, as well as an increase in the amount of terminal hair, vellus hair, sum of the terminal hair diameters, and mean of the terminal hair diameters in both regions, frontal and vertex.

Conclusions

In this study, we demonstrated that the use of Cellcurin in the treatment of AGA in men and women is associated with an increase in the amount of hair per cm2, in the amount of terminal hair per cm2, in the amount of vellus hair per cm2, in the number obtained by the sum of the terminal hair diameters per cm2, as well as an increase in the mean diameter of the terminal hairs.

Noninvasive Hair Rejuvenation

Both nonsurgical and surgical modalities for the treatment of hair loss are being used by providers at an increasing rate worldwide. Men and woman are affected by hair loss, but the pathophysiology of the hair loss is thought to be different between sexes; therefore, gender must play a role in treatment decisions. Currently, there are 3 Food and Drug Administration-approved nonsurgical androgenetic alopecia treatments: minoxidil, finasteride, and low-light laser therapy. Platelet-rich plasma injections are showing promise as a single modality and as an adjunct to other nonsurgical and surgical treatments of androgenetic alopecia.

Female Pattern Hair Loss: An Overview with Focus on the Genetics

Pattern hair loss can occur in both men and women, and the underlying molecular mechanisms have been continuously studied in recent years. Male androgenetic alopecia (M-AGA), also termed male pattern hair loss, is the most common type of hair loss in men. M-AGA is considered an androgen-dependent trait with a background of genetic predisposition. The interplay between genetic and non-genetic factors leads to the phenotype of follicular miniaturization. Although this similar pattern of phenotypic miniaturization can also be found in female pattern hair loss (FPHL), the corresponding genetic factors in M-AGA do not account for the phenotype in FPHL, indicating that there are different genes contributing to FPHL. Therefore, the role of genetic factors in FPHL is still uncertain. Understanding the genetic mechanism that causes FPHL is crucial for the future development of personalized treatment strategies. This review aims to highlight the differences in the ethnic prevalence and genetic background of FPHL, as well as the current genetic research progress in nutrition, Wnt signaling, and sex hormones related to FPHL.

Androgenetic Alopecia: Therapy Update

Androgenetic alopecia (AGA), also known as male pattern hair loss (MPHL) or female pattern hair loss (FPHL), is the most common form of alopecia worldwide, and arises from an excessive response to androgens. AGA presents itself in a characteristic distribution unique to both sexes. Despite its prevalence, AGA can be quite challenging to treat. The condition is chronic in nature and stems from an interplay of genetic and environmental factors. There are only two US Food and Drug Administration (FDA)-approved drugs for the condition: topical minoxidil and oral finasteride. However, numerous non-FDA-approved treatments have been shown to be effective in treating AGA in various studies. Some of these treatments are relatively new and still to be explored, thus emphasizing the need for an updated review of the literature. In this comprehensive review, we discuss the evaluation of AGA and the mechanisms of action, costs, efficacies, and safety profiles of existing, alternative, and upcoming therapeutics for this widespread condition.

Dorsal Wrist Ganglion: Pilot for Randomized Control Trial Comparing Aspiration Alone or Combined with Injection of Platelet-Rich Plasma

This pilot study assessed the feasibility of performing a randomized control trial (RCT) investigating injection with platelet-rich plasma (PRP) for dorsal wrist ganglion (DWG). Aspiration alone was compared with aspiration plus injection of PRP. Seventeen patients were enrolled. Nine patients received PRP and eight aspiration alone. Patients were followed up at 6 weeks and 1 year; recurrence of the ganglion and Patient Evaluation Measure scores were measured. At 6 weeks seven patients in the aspiration group had a recurrence and five in the PRP group, but by 1 year, this has increased to seven out of eight in the PRP group whereas in the aspiration group four had resolved leaving three out of eight patients with a ganglion still present. From the basis of our work an RCT would require a minimum of 46 patients per group; however, it is unlikely that PRP will be a panacea for ganglia. This is a Level II study.

Comparison between topical cetirizine with minoxidil versus topical placebo with minoxidil in female androgenetic alopecia: a randomized, double-blind, placebo-controlled study

Androgenetic alopecia (AGA) is the most common cause of hair loss in both genders with a higher psychological impact on females. Currently, topical minoxidil is the only FDA-approved treatment for female AGA and it needs life-long application and causes side effects. Cetirizine is an antihistamine that may be effective in hair loss treatment. This study aimed to compare the efficacy and safety of topical cetirizine with minoxidil (group 1) versus topical minoxidil with placebo (group 2) in female patients with AGA. This was a double-blind, randomized, controlled, parallel study conducted at Dermatology Clinic, Cairo University Teaching Hospital (Kasr- Al- Ainy), Egypt. Sixty-six patients with female AGA, aged 20-50 years, Sinclair (II-IV), were randomly assigned to one of the 2 groups for 24 weeks. The trichoscopic parameters, patients' self-assessment, side effects and global photographic assessment were evaluated. There was a statistically significant change from baseline in frontal and vertex terminal and vellus hair density (P < 0.0005) with a significant increase in vertex hair shaft thickness and average number of hairs per follicular unit in group 1 (P < 0.05). Patients reported significantly better scores in patient self-assessment in group 1 (P < 0.05). Side effects were not significantly different between groups (P > 0.05). Topical cetirizine increases hair shaft thickness and results in a higher clinical improvement from patients' perspective with a good safety profile (NCT04481412, study start date: July 2020).

Evaluation of the safety and efficacy of platelet-rich plasma in the treatment of female patients with chronic telogen effluvium: A randomised, controlled, double-blind, pilot clinical trial

BACKGROUND

Chronic telogen effluvium is characterised by diffuse loss of hair of the scalp. One of the emerging lines of treatment is platelet-rich plasma. However, not much of published data exist.

AIMS

A pilot study was conducted on chronic telogen effluvium patients to evaluate the efficacy and safety of platelet-rich plasma, and to compare two different methods of platelet-rich plasma preparation.

METHODS

The study included 30 female patients with chronic telogen effluvium. Patients were randomised into three groups: Group (1): Special platelet-rich plasma tubes centrifuged at 3500 rpm; Group (2): Ordinary laboratory tubes centrifuged at 1000 rpm; Group (3): Normal saline as a placebo. Patients' evaluation was done with visual analog scale, hair pull test, trichoscopy, photos, satisfaction questionnaire, and safety. All patients received four monthly sessions. Patients were evaluated one month and three months after the last session.

RESULTS

The hair pull test,visual analogue scale, and patient satisfaction results showed a statistically significant difference between group 1 vs. group 3 and group 2 vs.group 3 at one and three months after the sessions, while there was no difference between group1 vs. group 2. Trichoscopy results (baseline, one and three months after treatment) showed a significant increase in hair density and thickness in the frontal area, temporal area, and the vertex in groups 1 and 2 only. There was no statistically significant difference between the three groups with regards to side effects.

LIMITATIONS

The sample size was small with ten patients in each group. Furthermore, the follow-up of patients was for only three months.

CONCLUSIONS

Platelet-rich plasma could be considered as a promising therapy for patients with chronic telogen effluvium with an excellent safety profile. The ordinary laboratory low-cost tubes might be a reliable alternative to the expensive special platelet-rich plasma kits tubes. The trial registry number is PACTR202006539654415.

Cyanidin 3-O-arabinoside suppresses DHT-induced dermal papilla cell senescence by modulating p38-dependent ER-mitochondria contacts

Background

Androgenetic alopecia (AGA) is a genetic disorder caused by dihydrotestosterone (DHT), accompanied by the senescence of androgen-sensitive dermal papilla cells (DPCs) located in the base of hair follicles. DHT causes DPC senescence in AGA through mitochondrial dysfunction. However, the mechanism of this pathogenesis remains unknown. In this study, we investigated the protective role of cyanidins on DHT-induced mitochondrial dysfunction and DPC senescence and the regulatory mechanism involved.

Methods

DPCs were used to investigate the effect of DHT on mitochondrial dysfunction with MitoSOX and Rhod-2 staining. Senescence-associated β-galactosidase activity assay was performed to examine the involvement of membrane AR-mediated signaling in DHT-induced DPC senescence. AGA mice model was used to study the cyanidins on DHT-induced hair growth deceleration.

Results

Cyanidin 3-O-arabinoside (C3A) effectively decreased DHT-induced mtROS accumulation in DPCs, and C3A reversed the DHT-induced DPC senescence. Excessive mitochondrial calcium accumulation was blocked by C3A. C3A inhibited p38-mediated voltage-dependent anion channel 1 (VDAC1) expression that contributes to mitochondria-associated ER membrane (MAM) formation and transfer of calcium via VDAC1–IP3R1 interactions. DHT-induced MAM formation resulted in increase of DPC senescence. In AGA mice models, C3A restored DHT-induced hair growth deceleration, which activated hair follicle stem cell proliferation.

Conclusions

C3A is a promising natural compound for AGA treatments against DHT-induced DPC senescence through reduction of MAM formation and mitochondrial dysfunction.

Supplementary Information

The online version contains supplementary material available at 10.1186/s12929-022-00800-7.

Epidermal Stem Cells in Hair Follicle Cycling and Skin Regeneration: A View From the Perspective of Inflammation

There are many studies devoted to the role of hair follicle stem cells in wound healing as well as in follicle self-restoration. At the same time, the influence of the inflammatory cells on the hair follicle cycling in both injured and intact skin is well established. Immune cells of all wound healing stages, including macrophages, γδT cells, and T regs, may activate epidermal stem cells to provide re-epithelization and wound-induced hair follicle neogenesis. In addition to the ability of epidermal cells to maintain epidermal morphogenesis through differentiation program, they can undergo de-differentiation and acquire stem features under the influence of inflammatory milieu. Simultaneously, a stem cell compartment may undergo re-programming to adopt another fate. The proportion of skin resident immune cells and wound-attracted inflammatory cells (e.g., neutrophils and macrophages) in wound-induced hair follicle anagen and plucking-induced anagen is still under discussion to date. Experimental data suggesting the role of reactive oxygen species and prostaglandins, which are uncharacteristic of the intact skin, in the hair follicle cycling indicates the role of neutrophils in injury-induced conditions. In this review, we discuss some of the hair follicles stem cell activities, such as wound-induced hair follicle neogenesis, hair follicle cycling, and re-epithelization, through the prism of inflammation. The plasticity of epidermal stem cells under the influence of inflammatory microenvironment is considered. The relationship between inflammation, scarring, and follicle neogenesis as an indicator of complete wound healing is also highlighted. Taking into consideration the available data, we also conclude that there may exist a presumptive interlink between the stem cell activation, inflammation and the components of programmed cell death pathways.

Platelet-Rich Plasma in the Treatment of Alopecia Areata: A Review

Platelet-rich plasma (PRP) is an autologous preparation of plasma with concentrated platelets containing various growth factors and cytokines that enhance the body's inherent capacity to repair and regenerate hair follicles. A few studies and case reports support the use of PRP for the treatment of alopecia areata (AA). Further large-scale studies are needed to evaluate the efficacy of PRP as monotherapy or in association with other therapeutic modalities for AA. Although PRP is relatively safe and potentially effective, there is no standardized protocol or recommendations for the number of PRP sessions required to treat and maintain hair growth.

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.

Effect of High-Dose Topical Minoxidil on Erythrocyte Quality in SKH1 Hairless Mice

Simple Summary

In any animal species, involuntary exposure to unknown agents may increase genetic material damage. This genetic damage can also induce the appearance of diseases such as cancer or other pathologies, including problems that can be passed on to the offspring of the damaged individual. For instance, living organisms may be affected due to the use of medications or exposure to certain chemical, physical, or biological agents which cause cell failure. This impaired function acts as an indicator that helps identify and evaluate damage in order to avoid or minimize it. In this work, excessive doses of a cosmetic drug for topical use in dermatological treatments, known as minoxidil, produced defects in the blood of hairless mice, particularly in red cells, indicating loss of DNA, a situation that may compromise life or the offspring by causing damage to their genetic material. It is important to consider that compounds may be tissue- or species-specific, although we cannot rule out the possibility that similar damage could occur in other animal species. Thus, excessive exposure to this compound should be prevented.

Abstract

SKH1 hairless mice are widely used in carcinogenesis and dermatology research due to their bare skin, as exposure to different agents is facilitated. Minoxidil is a cosmetic drug that is recognized as a mitogenic agent, and mitogens are suggested to have carcinogenic and mutagenic potential by inducing cell division and increasing the possibility of perpetuating DNA damage. Therefore, we hypothesized that the application of high doses of minoxidil to the skin of hairless mice would increase the number of micronucleated erythrocytes (MNEs) in peripheral blood. The objective of this study was to evaluate the topical administration of high doses of minoxidil on peripheral blood erythrocytes of SKH1 mice by means of micronucleus assay. Minoxidil was administered on the entire body surface of mice every 12 or 24 h. Minoxidil dosing every 24 h increased the number of micronucleated polychromatic erythrocytes (MNPCEs), and dosing every 12 h increased the number of MNEs and MNPCEs, as compared to baseline and the negative control group. No decrease in polychromatic erythrocyte frequencies was observed in the minoxidil groups. Therefore, topical application of high minoxidil doses to mice can produce DNA damage, as observed through an increase in the number of MNEs, without producing cytotoxicity, possibly due to its mitogenic effect.

Finasteride Enhances Stem Cell Signals of Human Dermal Papilla Cells

BACKGROUND/AIM

Finasteride (FN) has been widely used to treat androgenetic alopecia (AGA). This study aimed at exploring the effect of FN on DP stem cell properties.

MATERIALS AND METHODS

Effect of FN on stem cell properties was tested in a DP cell line and 2 human primary DP cells (HDPCs1 and HDPCs2). Cell toxicity and growth were analyzed by 3-(4,5-dimethylthiazol-2-yl)-2,5-diphenyltetrazolium bromide (MTT) assay. The aggregation behavior was observed by phase-contrast microscopy and a scanning electron microscope (SEM). Effects of FN on cell signaling were determined by western blotting and immunocytochemistry.

RESULTS

Treatment of DPCs with FN was able to significantly increase their aggregation behavior and the expression of stem cell transcription factors Nanog and Sox-2, when compared to the non-treated control. FN up-regulated stem cell regulatory proteins through the activation of protein kinase B (AKT), β-catenin, and integrin-β1.

CONCLUSION

FN had an interesting biological effect on stem cell induction. These findings support the use of this drug for hair loss control and the development of regeneration approaches.

Serenoa repens and N-acetyl glucosamine/milk proteins complex differentially affect the paracrine communication between endothelial and follicle dermal papilla cells

Current treatments for hair follicle (HF) disruption are based on 5-α reductase inhibitors and prostaglandin modulators. Botanicals and nutraceutical compounds interfere with hair loss or stimulate its partial regrowth. Here, we used in vitro cocultures to investigate the activity of Serenoa repens ( SR) and N-acetyl glucosamine + milk proteins (NAG/Lac) on the paracrine interactions between human microvascular endothelial cells (HMVEC) and HF dermal papilla cells (FDPC). Both SR and NAG/Lac-induced endothelial tubulogenesis were enhanced by FDPC. SR promoted proliferation of both the cell types, while NAG/Lac was effective on endothelium. Vascular endothelial growth factor production, enhanced by SR, was further augmented by FDPC. In FDPC 5-α reductase-II and β-catenin expressions were modified by SR and less by NAG/Lac, with no additional effect by HMVEC. SR and NAG/Lac prevented lipid peroxidation, whereas NAG/Lac was effective on interleukin 1β production. Finally, SR and NAG/Lac differentially affected HMVEC permeability and tight junction proteins content. These data provide a mechanistic background for the potential use of these compounds as promoters of HF vascularization.

Safety concerns when using novel medications to treat alopecia

INTRODUCTION

Alopecia is often a cause of great concern to patients for cosmetic and psychologic reasons. The aim of treating non-scarring alopecias is to reduce hair loss and, to some extent, enhance hair regrowth. However, therapies for scarring alopecias are limited and aiming to halt disease progression. Nonetheless, available modalities of treatment come with numerous side effects. Areas covered: Many new treatments for non-scarring alopecias have been introduced in recent years. This review summarizes the safety concerns when using novel therapeutic modalities such as JAK inhibitors, hair transplantation, mesotherapy, oral minoxidil, platelet-rich plasma, microneedling, and 5α-reductase inhibitors for treating hair loss. A broad literature search was performed using PubMed and Google Scholar in April 2018 to compile published articles that reported the adverse effects of new therapeutic modalities for alopecia. Expert opinion: Although emerging therapeutic modalities for alopecia have demonstrated efficacy in hair regrowth and treating established disease, their safety profiles vary widely. When considering the new treatments for alopecia, physicians should weigh the potential benefits and risks of each treatment or combination treatment to ensure safe and successful outcomes.

Annurca Apple Polyphenols Ignite Keratin Production in Hair Follicles by Inhibiting the Pentose Phosphate Pathway and Amino Acid Oxidation

Patterned hair loss (PHL) affects around 50% of the adult population worldwide. The negative impact that this condition exerts on people’s life quality has boosted the appearance of over-the-counter products endowed with hair-promoting activity. Nutraceuticals enriched in polyphenols have been recently shown to promote hair growth and counteract PHL. Malus pumila Miller cv. Annurca is an apple native to Southern Italy presenting one of the highest contents of Procyanidin B2. We have recently shown that oral consumption of Annurca polyphenolic extracts (AAE) stimulates hair growth, hair number, hair weight and keratin content in healthy human subjects. Despite its activity, the analysis of the molecular mechanism behind its hair promoting effect is still partially unclear. In this work we performed an unprecedented metabolite analysis of hair follicles (HFs) in mice topically treated with AAE. The metabolomic profile, based on a high-resolution mass spectrometry approach, revealed that AAE re-programs murine HF metabolism. AAE acts by inhibiting several NADPH dependent reactions. Glutaminolysis, pentose phosphate pathway, glutathione, citrulline and nucleotide synthesis are all halted in vivo by the treatment of HFs with AAE. On the contrary, mitochondrial respiration, β-oxidation and keratin production are stimulated by the treatment with AAE. The metabolic shift induced by AAE spares amino acids from being oxidized, ultimately keeping them available for keratin biosynthesis.

Female pattern hair loss: A clinical, pathophysiologic, and therapeutic review

Female pattern hair loss (FPHL) is the most common form of alopecia in women. Affected women may experience psychological distress and impaired social functioning. Early diagnosis and initiation of treatment are desirable because treatments are more effective to avoid the progression of hair loss than stimulating regrowth. Typically, a diagnosis of FPHL can be confirmed by review of a patient's medical history and a physical examination alone. Testing a scalp biopsy is diagnostic but usually not required. In women with signs of hyperandrogenism, an investigation for ovarian or adrenal disorders should be performed. Treatment for FPHL is obscured by myths. The aim of FPHL treatment could be two-fold: Reverse or stabilize the process of hair follicle miniaturization. Mild-to-moderate FPHL in women can be treated with oral antiandrogen therapies (cyproterone acetate and spironolactone) and/or topical minoxidil with good results in many cases. If used correctly, available medical treatments arrest the progression of the disease and reverse miniaturization in most patients with mild-to-moderate FPHL. Hair systems and surgery may be considered for selected cases of severe FPHL.

Conventional and novel stem cell based therapies for androgenic alopecia

The prevalence of androgenic alopecia (AGA) increases with age and it affects both men and women. Patients diagnosed with AGA may experience decreased quality of life, depression, and feel self-conscious. There are a variety of therapeutic options ranging from prescription drugs to non-prescription medications. Currently, AGA involves an annual global market revenue of US$4 billion and a growth rate of 1.8%, indicating a growing consumer market. Although natural and synthetic ingredients can promote hair growth and, therefore, be useful to treat AGA, some of them have important adverse effects and unknown mechanisms of action that limit their use and benefits. Biologic factors that include signaling from stem cells, dermal papilla cells, and platelet-rich plasma are some of the current therapeutic agents being studied for hair restoration with milder side effects. However, most of the mechanisms exerted by these factors in hair restoration are still being researched. In this review, we analyze the therapeutic agents that have been used for AGA and emphasize the potential of new therapies based on advances in stem cell technologies and regenerative medicine.

New Treatments for Hair Loss

The treatment of hair loss is an important part of clinical dermatology given the prevalence of the problem and great impact on patients' quality of life. Many new treatments have been introduced in recent years. This review summarizes the main ones in 4 groups: a) For androgenetic alopecia, we discuss new excipients for oral minoxidil, dutasteride, and finasteride as well as new forms of topical application; prostaglandin agonists and antagonists; low-level laser therapy; and regenerative medicine with Wnt signaling activators and stem cell therapy. b) For alopecia areata, Janus kinase inhibitors are reviewed. c) For frontal fibrosing alopecia, we discuss the use of antiandrogens and, for some patients, pioglitazone. d) Finally, we mention new robotic devices for hair transplant procedures and techniques for optimal follicular unit extraction.

Platelet-rich Plasma by Single Spin Process in Male Pattern Androgenetic Alopecia: Is it an Effective Treatment?

Introduction and Objective:

Platelet-rich plasma (PRP) is an autologous preparation of platelets in concentrated plasma. The platelet is a natural source of different growth factors and cytokines. These growth factors act on stem cells in the bulge area of the follicles and stimulate the development of new follicles, and promote neovascularization. The aim of this study was to investigate the efficacy and safety of PRP injections in androgenetic alopecia (AGA) in men.

Patients and Methods:

Fifteen male patients (mean age: 39 ± 9.7 years) with AGA grades III–VI were enrolled in the study. Five injections of 2–4 ml PRP (Regenlab PRP Kit-RegenACR®, Le Mont-sur-Lausanne Switzerland) by single spin process were administered every 2 weeks. Standard photographs, trichogram, and measurement of hair density and diameter in an area marked with a tattoo (with digital photographic hair analyzer) were done at baseline and 3 months after the last injection. In addition, patients completed a patient satisfaction questionnaire at each visit on a −2 to +2 score (−2: much worse, −1: slightly worse, 0: without change, +1: slightly better, +2: much better).

Results:

Thirteen patients completed the study. The number of hairs increased slightly from 149.62 ± 49.56 to 168.46 ± 43.703/cm², however, this increase was not statistically significant (P = 0.24). On the other hand, the thickness of hairs decreased from 0.051 ± 0.105 to 0.045 ± 0.011 mm, which was also not significant (P = 0.37). There was a significant decrease in anagen hairs and increase in telogen hairs, and anagen/telogen ratio decreased significantly from 6.38 ± 4.57 to 2.67 ± 1.87 (P = 0.003).

Conclusion:

Our study could not show any benefit from PRP injections in the treatment of male AGA. There is a strong need for well-designed, randomized controlled trials with large sample size, proper control group, standard treatment protocols (concerning the amount, number and interval of PRP injections, method of preparation and activation, etc.), and long follow-up periods to evaluate the safety and efficacy of PRP in the treatment of male AGA.

Female sexual dysfunction in androgenetic alopecia: Case-control study

INTRODUCTION

We sought to evaluate the association of female sexual dysfunction (FSD) with androgenetic alopecia (AGA) and metabolic syndrome (MetS) in premenopausal women.

METHODS

From December 2013 to June 2015, we performed a case-control, prospective study of 115 patients with AGA and 97 age-matched control patients without AGA from among premenopausal women who visited dermatology clinics of the two reference hospitals. Comprehensive history, anthropometric measurements, and questionnaire administration were performed for each of the total of 212 women. The Female Sexual Function Index (FSFI) was used to assess the key dimensions of female sexual function. AGA was assessed and graded by an experienced dermatologist according to Ludwig's classification. The MetS assessment was made according to the NCEP-ATP III criteria.

RESULTS

In univariate analysis, age, weight, waist circumference, hip circumference, waist-to-hip ratio, body mass index (BMI), AGA, MetS, cardiovascular event, marital status, hypertension, high fasting plasma glucose, high triglyceride, large waist, total testosterone, and free testosterone were associated with presence of FSD. In logistic regression analysis, age (odds ratio [OR] 1.21, 95% confidence interval [CI] 1.13-1.30; p<0.001), AGA (OR 3.42, 95% CI 1.31-8.94; p=0.017), MetS (OR 5.39, 95% CI 1.34-21.62; p=0.012), and free testosterone (OR 0.18, 95% CI 0.09-0.37; p<0.001) were independently associated with FSD.

CONCLUSIONS

Our study suggests that age, AGA, MetS, and free testosterone may have strong impact on sexual function in premenopausal women. Further studies with population-based and longitudinal design should be conducted to confirm this finding.

Response to Microneedling Treatment in Men with Androgenetic Alopecia Who Failed to Respond to Conventional Therapy

Introduction:

The efficacy of conventional therapy viz. finasteride and minoxidil in androgenetic alopecia (AGA) that is based on both preventing hair loss and promoting new hair growth, varies between 30% and 60%. This has led to a large number of patients unsatisfied who demand for a better cosmetic coverage over the scalp. Microneedling has recently been reported to be promising, effective and a safe treatment modality in the treatment of AGA. This augments the response of conventional therapy.

Materials and Methods:

Four men with AGA were on finasteride and 5% minoxidil solution since 2 to 5 years. Though there was no worsening in their respective AGA stages with the therapy, they showed no new hair growth. They were subjected to microneedling procedure over a period of 6 months along with their ongoing therapy. Patients were assessed with the use of the standardized 7-point evaluation scale and patients’ subjective hair growth assessment scale. The patients were followed up for 18 months post microneedling procedure to assess the sustainability of the response.

Results:

All patients showed a response of + 2 to + 3 on standardized 7-point evaluation scale. The response in the form of new hair growth started after 8-10 sessions. The patients’ satisfaction was more than 75% in three patients and more 50% in one patient, on patients’ subjective hair growth assessment scale. The obtained results were sustained post procedure during 18 months follow-up period.

Conclusion

Treatment with microneedling showed an accelerated response with addition of microneedling procedure leading to significant scalp density. This is the first case series to report the boosting effect of microneedling with respect to new hair follicle stimulation in patients with androgenetic alopecia who were poor responders to conventional therapy.

Epidermal stem cells and skin tissue engineering in hair follicle regeneration

The reconstitution of a fully organized and functional hair follicle from dissociated cells propagated under defined tissue culture conditions is a challenge still pending in tissue engineering. The loss of hair follicles caused by injuries or pathologies such as alopecia not only affects the patients' psychological well-being, but also endangers certain inherent functions of the skin. It is then of great interest to find different strategies aiming to regenerate or neogenerate the hair follicle under conditions proper of an adult individual. Based upon current knowledge on the epithelial and dermal cells and their interactions during the embryonic hair generation and adult hair cycling, many researchers have tried to obtain mature hair follicles using different strategies and approaches depending on the causes of hair loss. This review summarizes current advances in the different experimental strategies to regenerate or neogenerate hair follicles, with emphasis on those involving neogenesis of hair follicles in adult individuals using isolated cells and tissue engineering. Most of these experiments were performed using rodent cells, particularly from embryonic or newborn origin. However, no successful strategy to generate human hair follicles from adult cells has yet been reported. This review identifies several issues that should be considered to achieve this objective. Perhaps the most important challenge is to provide three-dimensional culture conditions mimicking the structure of living tissue. Improving culture conditions that allow the expansion of specific cells while protecting their inductive properties, as well as methods for selecting populations of epithelial stem cells, should give us the necessary tools to overcome the difficulties that constrain human hair follicle neogenesis. An analysis of patent trends shows that the number of patent applications aimed at hair follicle regeneration and neogenesis has been increasing during the last decade. This field is attractive not only to academic researchers but also to the companies that own almost half of the patents in this field.

Progression of surgical hair restoration techniques

BACKGROUND

Early surgical hair restoration (SHR) techniques were fraught with limitations. Major advancements and refinements have taken place yielding minimally invasive, relatively scar-free, and natural-looking hair transplantations.

OBJECTIVE

Our aim was to review the origins and advancements of SHR and to discuss future directions for the field.

METHODS

Searches were performed using: Pubmed, Scopus, and the International Society of Hair Restoration Surgery's Hair Transplant Forum International for articles related to SHR. Reference sections of articles obtained were reviewed. Relevant textbooks obtained were reviewed.

RESULTS AND CONCLUSION

SHR techniques originated as macro-level graft transplantations and excision of scalp tissue. They progressed toward micro-level graft transplantations performed with extreme caution and precision. However, all SHR techniques are limited by their reliance on existing donor hair to fill balding areas. Further advancements in hair follicle cell cloning and regeneration of growth may offer a solution to this overarching limitation.

Emerging treatments in alopecia

INTRODUCTION

Alopecia is a common concern encountered in the medical practice. Treatment approach varies according to the type and severity of alopecia. However, available treatment options have limited efficacy and several adverse effects. Presently, there are different treatment options being studied to overcome these limitations. Additionally, cellular pathways involved in the pathophysiology of alopecia are further being clarified to potentially target pathogenic molecules.

AREAS COVERED

We searched the literature for recently published articles discussing new treatment options as well as mechanisms involved in alopecia. We discuss the use of stem cells, growth factors, cellular pathways and robotic hair transplant, among other emerging therapies used for alopecia.

EXPERT OPINION

Future looks very promising and new effective treatments such as janus kinase inhibitors could possibly be available for alopecia areata. The stem-cell technology is advancing and companies involved in hair follicle neogenesis are starting clinical trials on patients with androgenetic alopecia.

Androgenetic alopecia: an evidence-based treatment update

BACKGROUND

Androgenetic alopecia (AGA) is one of the most common chronic problems seen by dermatologists worldwide. It is characterized by progressive hair loss, especially of scalp hair, and has distinctive patterns of loss in women versus men, but in both genders the central scalp is most severely affected. It often begins around puberty and is known to effect self-esteem and the individual's quality of life. In contrast to the high prevalence of AGA, approved therapeutic options are limited. In addition to the scarce pharmacologic treatments, there are numerous nonprescription products claimed to be effective in restoring hair in androgenetic alopecia.

OBJECTIVES

The purpose of this paper is to review published medical and non-medical treatments for male and female AGA using the American College of Physicians evidence assessment methods. MEDLINE, EMBASE and Cochrane Library were searched for systematic reviews, randomized controlled trials, open studies, case reports and relevant studies of the treatment of male and female AGA. The relevant articles were classified according to grade and level of evidence.

RESULTS

The medical treatments with the best level of evidence classification for efficacy and safety for male AGA are oral finasteride and topical minoxidil solution. For female AGA, topical minoxidil solution appears to be the most effective and safe treatment. The medical treatments corresponding to the next level of evidence quality are some commonly used therapeutic non-FDA-approved options including oral and topical anti-hormonal treatments. Surgical treatment of follicular unit hair transplantation is an option in cases that have failed medical treatment although there is high variation in outcomes.

LIMITATIONS

Some articles, especially those concerning traditional herbs claimed to promote hair regrowth, were published in non-English, local journals.

CONCLUSIONS

An assessment of the evidence quality of current publications indicates that oral finasteride (for men only) and topical minoxidil (for men and women) are the best treatments of AGA.

"Cold" X5 Hairlaser™ used to treat male androgenic alopecia and hair growth: an uncontrolled pilot study

Background

Various trials have been conducted on the management and treatment of androgenic alopecia (AGA) or male pattern hair loss using a variety of laser and light sources.

Methods

For this feasibility study, the population was composed of males between the ages of 20 and 60 years who have been experiencing active hair loss within the last 12 months and the diagnosis of AGA. They also had a Norwood-Hamilton classification of 3, 3A, 3 V, 4, 4A, or 5 for the hair thinning patterns and skin type I, II, III, or IV on the Fitzpatrick skin type scale. This two-arm randomized, parallel group study design employed stratifying randomization to balance treatment assignment within three investigational centers with at least 2 subjects enrolled in each Fitzpatrick skin type.

Results

A statistically significant positive trend in hair growth was observed from this pilot study, to evaluate the efficacy of the novel cold X5 hairlaser device for treating male androgenic alopecia. From the repeated measures analysis of variance, difference in mean hair counts over time was statistically significant (F = 7.70; p-value < 0.0001). Subsequent, linear regression of mean hair counts at each time point was performed, and post-hoc analysis found an increasing trend of hair growth over time that was statistically significant (p-value < 0.0001) with the estimated slope of 1.406. Increased hair counts from the baseline to the end of the 26-week period were found to be strongly significant (p-value = 0.0003).

Conclusion

Albeit, sham device failure and resultant missing data from the control group, the positive trend hair growth, was observed due to the chronic use of X5hairlaser device. This positive benefit while in full agreement with other low laser hair devices requires intensive further investigation.

Trial registration

NCT02067260