Alopecia areata: revisão e atualização

Social isolation: main dermatosis and the impact of stress during the COVID-19 pandemic

Objective

To analyze the pattern of triggering and exacerbation of dermatological diseases between March and July 2020 and to compare this pattern to the corresponding period of 2019.

Methods

This was a quantitative, descriptive, comparative and documentary study that was carried out through the retrospective analysis of medical records (March to July 2019 and 2020) of individuals assisted at a private dermatology practice service located in the southern area of the city of São Paulo (SP).

Results

We evaluated 992 medical consultations in 2019 and 1,176 in 2020. In 2020, we observed a significant increase in cases of telogen effluvium (276%), psoriasis (1,400%), atopic dermatitis (178%), seborrheic dermatitis (200%), herpes zoster (1,200%) and vitiligo (433%). All diseases had stress as a possible initial trigger. In addition, fragile nail syndrome and contact dermatitis, pathologies associated with behavioral measures, also had an important increase in the prevalence (6,400% and 5,500%, respectively). However, the number of aesthetic procedures decreased by approximately 54% during the pandemic period.

Conclusion

During the pandemic period, the pattern of incidence of dermatoses had changed compared with the previous year. An emphasis was observed on diseases triggered by a psychological component, as well as those pathologies that have behavioral measures as the main cause. For this reason, the impacts of COVID-19 is greater than only among those infected.

Effectiveness of QR678 and QR678 Neo® with intralesional corticosteroid vs. intralesional corticosteroid alone in the treatment of alopecia areata -A randomized, comparative, prospective study

BACKGROUND

Alopecia areata (AA) is an inflammatory disorder, marked by chronic, persistent, and patchy loss of hair. At present intralesional/topical corticosteroids, Minoxidil solution, and topical immune-therapies are used for treatment. Though all these have side effects and high rate of relapse. As QR678 Neo^® is proved to be effective in hair regrowth in male and female pattern hair loss, the aim of the study is to compare the efficacy of QR678 Neo^® with intralesional steroid therapy vs. intralesional steroid alone in the treatment of AA of scalp in men and women.

MATERIALS AND METHODS

A total of 20 participants in age group of 20-50 years with nonscarring patchy hair loss were chosen for the study. Patients were arbitrarily divided into two groups (Group A-intralesional steroid with placebo and Group B-intralesional steroid with QR678 Neo^® ). All the participants were evaluated at baseline, 3 months and 6 months with standard global photography, dermoscopic assessment, and self-evaluation questionnaire at the end of study.

RESULT

Marked improvement was seen in the global assessment score after 6 months (mean- 6.6 SALT) as compared to baseline (38.5 SALT score) in group B. There was significant reduction of black dots, yellow dots, broken hairs, and tapered hair at 6 months on video dermoscopic examination in group B. Also, higher satisfaction was experienced with the treatment in group B patients.

CONCLUSION

QR678 Neo^® in combination with intralesional steroids therapy proved to be significantly beneficial, efficient, and can be considered as safer treatment option for alopecia areata.

A systematic review on the treatment of pediatric severe alopecia areata by topical immunotherapy or Anthralin (contact sensitization) or low-level light/laser therapy (LLLT): focus on efficacy, safety, treatment duration, recurrence, and follow-up based on clinical studies

INTRODUCTION

Alopecia areata (AA) in its extensive and severe forms is treatment-challenging, especially in pediatrics.

METHOD

A PRISMA-compliant systematic review of seven electronic databases was searched by the terms "alopecia areata," "pediatric," "topical immunotherapy," "Anthralin," and "light therapy" from inception until March 2021. All the alternative names of the disease and therapies have been included in the search terms. 790 articles went to title abstract review by two independent reviewers. In the subsequent level, a review of the full text of studies was conducted.

RESULTS

Finally, 10 relevant articles in terms of content structure, subject coverage, and purpose, were selected for further review. The highest percentages of complete hair regrowth were 79.6% and 63.61% by SADBE (topical immunotherapy) and laser therapy. By Anthralin (contact sensitization), the complete response rate was below 50% (between 30 and 35%). Regarding average response, the most effective methods were local immunotherapy (with an average effectiveness of 53.8%), laser therapy (52.55%), and the use of Anthralin-induced contact dermatitis (30.86%), respectively. However, recurrence rate-after treatment with induced contact dermatitis by topical medications like Anthralin (contact sensitization)-was lower (mean 43.53%) in comparison with local immunotherapy (57%). In topical immunotherapy, light base therapy, and contact sensitization, the highest percentage of complete hair regrowth and the average response rate were (63.61% and 52.55%), (79.6% and 53.8%) and (32% and 30.8%), respectively. These methods are considered safe in children.

CONCLUSION

A high and more than 50% efficacy in hair regrowth could be expected by topical immunotherapy and light/laser therapy method. No serious side effects have been observed by these methods that are well tolerated in children. Therefore, a combination of local immunotherapy and light/laser therapy could be suggested for the treatment of extensive AA in children. The use of Anthralin could be associated with a lower but more durable response. These points are important for patient selection in individualized situations.

Infantile generalized hypertrichosis caused by topical minoxidil

Rare cases of hypertrichosis have been associated with topically applied minoxidil. We present the first reported case in the Brazilian literature of generalized hypertrichosis affecting a 5-year-old child, following use of minoxidil 5%, 20 drops a day, for hair loss. The laboratory investigation excluded hyperandrogenism and thyroid dysfunction. Topical minoxidil should be used with caution in children.

Remarkable Improvement of Nail Changes in Alopecia Areata Universalis with 10 Months of Treatment with Tofacitinib: A Case Report

Alopecia areata (AA) is a chronic, autoimmune disease. The main symptom is massive hair loss, localized or diffuse, in the scalp and the whole body. However, nails may also be involved, and brittleness, fragility and pitting can be signs of nail dystrophy in AA patients. Here, we report the case of a male patient with AA refractory to various treatments, including oral, topical and intralesional corticosteroids, immunosuppressants, cyclosporin and PUVA (oxoralen plus ultraviolet light), all interrupted due to side effects. The patient's nails had erythematous blotches (striated lunulae) with regular and superficial pitting as well as fragility (trachyonychia), and he could no longer play the guitar because of these symptoms. With patient consent, we introduced tofacitinib (5 mg twice daily), which resulted in remarkable improvements not only regarding hair regrowth but also nail changes, with function recovery within 10 months.

Lack of association between alopecia areata and HLA class I and II in a southeastern Brazilian population

Background

Alopecia areata (AA) is a common disorder of unknown etiology that affects approximately 0.7% to 3.8% of patients among the general population. Currently, genetic and autoimmune factors are emphasized as etiopathogenic. Studies linking Human Leukocyte Antigens (HLA) to AA have suggested that immunogenetic factors may play a role in the disease's onset/development.

Objectives

To investigate an association between AA and HLA class I/II in white Brazilians. Methods: Patients and control groups comprised 33 and 112 individuals, respectively. DNA extraction was performed by column method with BioPur kit. Allele's classification was undertaken using the PCR-SSO technique. HLA frequencies were obtained through direct counting and subjected to comparison by means of the chi-square test.

Results

Most patients were aged over 16, with no familial history, and developed partial AA, with no recurrent episodes. Patients showed a higher frequency of HLA-B*40, HLA-B*45, HLA-B*53 and HLA-C*04 compared with controls, although P was not significant after Bonferroni correction. Regarding HLA class II, only HLA-DRB1*07 revealed statistical significance; nevertheless, it featured more prominently in controls than patients (P=0.04; Pc=0.52; OR=0.29; 95%; CI=0.07 to 1.25). P was not significant after Bonferroni correction.

Conclusions

The development of AA does not seem to be associated with HLA in white Brazilians, nor with susceptibility or resistance. The studies were carried out in populations with little or no miscegenation, unlike the Brazilian population in general, which could explain the inconsistency found.

Efficacy and safety of methotrexate in alopecia areata

BACKGROUND

Alopecia areata is a chronic disorder of the hair follicles and nails, of unknown etiology, with clear autoimmune components and genetic factors. Several therapeutic options have been suggested; however, no treatment is able to modify the disease course. Methotrexate is an immunosuppressant used in various dermatoses and recently introduced as a therapeutic option for alopecia areata.

OBJECTIVES

To evaluate the efficacy and safety of methotrexate in alopecia areata.

METHODS

In a retrospective, non-controlled study, we evaluated 31 patients with alopecia areata in current or prior treatment with methotrexate to assess the therapeutic response according to sex, age, pattern of alopecia areata, disease duration, cumulative dose of methotrexate, use of systemic corticosteroids or other treatments, and drug safety.

RESULTS

Regrowth greater than 50% was observed in 67.7% of patients, with the best responses observed in those with <5 years of disease progression (79%), age over 40 years (73.3%), male patients (72.8%), cumulative dose of methotrexate 1000-1500 mg, and multifocal alopecia areata (93%). Among patients receiving systemic corticosteroids in combination with methotrexate, 77.3% had greater than 50% regrowth, compared with 44.4% in those who used methotrexate alone. The therapeutic dose ranged from 10-25 mg/week. No patient had serious adverse effects. Relapse was observed in 33.3% of patients with more than 50% regrowth.

CONCLUSION

Methotrexate appears to be a promising and safe medication for the treatment of severe alopecia areata when used alone or in combination with corticosteroids.

HLA antigens in individuals with down syndrome and alopecia areata

AIM: To describe human leukocyte antigen (HLA) alleles in individuals with Down syndrome and alopecia areata.

METHODS: A cross-sectional study was conducted, which evaluated 109 individuals. Ten with down syndrome (DS) and alopecia areata (AA), ten with DS without AA and ten with AA without DS, and their families. The individuals were matched by gender and age. The following data were computed: gender, age, ethnic group, karyotype, clinical presentation and family history of alopecia areata. Descriptive analysis: measures of central tendency and frequency distribution. Inferential analysis: Fisher’s exact test to compare categorical data between the three groups and Kruskal-Wallis ANOVA test for numerical data.

RESULTS: Seventy per cent of evaluated individuals in the DS and AA group were male; presented mean age of 18.6 (SD ± 7.2) years and 70% were Caucasian. We observed involvement of the scalp, with a single lesion in 10% and multiple in 90% of subjects. It was observed that there is no significant difference in the frequency distributions of the alleles HLA loci A, B, C, DRB1 and DQB1 of subjects studied. However, according to Fisher’s exact test, there is a trend (P = 0.089) of DS group to present higher proportions of HLA-A 36 and HLA-B 15 than the AA group and AA and DS group.

CONCLUSION: There was a tendency for the DS group, to present proportion of HLA-A 36 and HLA-B 15 higher than the AA group and group of individuals with AA and DS. However, there was no significant difference in the frequency distribution of the alleles.

Comparison of zn, cu, and fe content in hair and serum in alopecia areata patients with normal group

Background. Alopecia areata (AA) is an autoimmune condition, in which hair is lost from some areas of the body. Though its etiopathogenesis is not fully understood, there are claims that imbalance of trace elements may trigger the onset of AA, by distorting immune functions. In this study, we tried to investigate the relationship between AA and iron, zinc, and copper levels of serum and hair. Materials and Methods. Sixteen female patients with AA (14–40 years old) and 27 healthy female controls were enrolled in this study. Serum and hair level of iron, zinc, and copper were measured by flame emission spectroscopy. The resulting data was analyzed with SPSS15. Results. We did not detect a significant difference in the serum and hair level of iron, zinc, and copper between patients and controls. There was a significant correlation between serum and hair level of iron (r = 0.504,  P = 0.001), zinc (r = 0.684,  P = 0.0001), and copper (r = 0.759, P = 0.0001) in patients and controls. Discussion and Conclusion. According to this study, there was no statistically significant difference between trace elements among AA patients and controls. So the trace elements level in hair and serum may not be relevant to the immunologic dysfunction that exists in AA patients.

Hematological and hepatic effects of vascular epidermal growth factor (VEGF) used to stimulate hair growth in an animal model

Background

Alopecia areata is the hair loss usually reversible, in sharply defined areas. The treatment of alopecia using growth factors shows interesting activity in promoting hair growth. In this concept, VEGF (vascular endothelial growth factor) is a marker of angiogenesis, stimulating hair growth by facilitating the supply of nutrients to the hair follicle, increasing follicular diameter. The aim of this study was the evaluation of a topical gel enriched with VEGF liposomes on the hair growth stimulation and its toxicological aspects.

Methods

Mesocricetus auratus were randomly divided into three groups. Control group was treated with Aristoflex® gel, 1% group with the same gel but added 1% VEGF and 3% group with 3% VEGF. Biochemical, hematological and histological analyses were done.

Results

At the end of the experiment (15th day of VEGF treatment) efficacy was determined macroscopically by hair density dermatoscopy analysis, and microscopically by hair diameter analysis. They both demonstrated that hair of the VEGF group increased faster and thicker than control. On the other hand, biochemical and hematological results had shown that VEGF was not 100% inert.

Conclusions

VEGF increased hair follicle area, but more studies are necessary to confirm its toxicity.

Clinical and histological challenge in the differential diagnosis of diffuse alopecia: female androgenetic alopecia, telogen effluvium and alopecia areata - part I

Diffuse androgenetic alopecia (female pattern hair loss), telogen effluvium, and diffuse alopecia areata may have similar clinical manifestations. Subtle details on physical examination and dermoscopy of the scalp may help to identify those disorders. The authors present a practical discussion on how to approach the patient with diffuse alopecia, considering clinical history, physical examination, and dermoscopic findings. If the diagnosis remains unclear after a careful analysis of the clinical signs, a scalp biopsy may help to distinguish between the three diseases. In this first part of our study, an objective review of female androgenetic alopecia is presented and the most important histological changes are discussed.

Dermoscopic clues to distinguish trichotillomania from patchy alopecia areata

BACKGROUND

Trichotillomania and patchy alopecia areata have similar clinical and dermoscopic features.

OBSERVATIONS

In trichotillomania, dermoscopy shows decreased hair density, short vellus hair, broken hairs with different shaft lengths, coiled hairs, short vellus hair, trichoptilosis, sparse yellow dots, which may or may not contain black dots and no exclamation mark hairs.

CONCLUSIONS

In the case of patchy alopecia and broken hairs, the absence of exclamation mark hairs suggests a diagnosis of trichotillomania. On the other hand, the finding of yellow dots without black dots does not exclude it.

A importância do exame tricológico no diagnóstico da alopecia areata

Neste artigo, destacam-se os aspectos propedêuticos da alopecia areata, em especial, os encontrados na dermatoscopia, ferramenta muito útil para o diagnóstico. A dermatoscopia facilita a detecção precoce das alterações características dos cabelos na alopecia areata, como: pelos em ponto de exclamação, pelos cadavéricos, fuzzy, pelos tipo velo e pontos amarelos.

[Immunosuppressive agents in Dermatology]

Immunosupressants are drugs that act in cell division and have anti-inflammatory effects. Therefore, they are essentially prescribed in the prevention of transplant rejection and in the treatment of autoimmune disorders and chronic inflammatory diseases, whose main example in Dermatology is psoriasis. In this work the most important immunosuppressive drugs and orientation to properly administer them are going to be described.

Experiências afetivo-familiares de mulheres com alopecia areata

Este estudo consistiu na análise da dinâmica emocional das experiências afetivas de mulheres com alopecia areata, tendo como eixo as relações de afeto mantidas com os pais e em suas relações conjugais. Foram entrevistadas cinco pacientes, atendidas no Instituto Lauro de Souza Lima, com idade entre 22 e 53 anos. O estudo baseou-se no método clínico de investigação e os dados foram obtidos mediante entrevistas semi-estruturadas. Nos depoimentos foram apontadas experiências dolorosas da relação conjugal e do adoecimento, que foram associadas a vivências traumáticas na infância. As associações realizadas pelas mulheres entre suas experiências passadas, relações conjugais, adoecimento e o impacto da doença na vida atual confirmaram os achados da literatura, e os dados encontrados puderam ser interpretados à luz das contribuições psicanalíticas. Os resultados obtidos podem contribuir para o esclarecimento de aspectos dinâmicos relacionados à alopecia areata e a outras psicodermatoses, bem como favorecer intervenções interdisciplinares e psicoterápicas mais efetivas com pacientes dermatológicos crônicos.

Papel das células T reguladoras no desenvolvimento de dermatoses

Células T, em particular as células T CD4+, têm sido associadas a muitos aspectos das doenças de pele. A evidência atual sugere, porém, que o papel dos linfócitos T CD4+ no desenvolvimento de inflamação cutânea excede o de ativador pró-inflamatório das células T de ação que dirigem a resposta imune. Subtipos de células T com capacidade reguladora, tais como Tregs CD4+CD25+high, têm sido identificadas. Observações recentes sugerem que em algumas doenças da pele a função dessas células está modificada. Portanto, o desenvolvimento e a função de Tregs na dermatologia são atualmente um tópico atraente devido a sua importância no controle da resposta do sistema imune contra tumores e doenças infecciosas, bem como inibindo o desenvolvimento de auto-imunidade e alergia. Assim, mecanismos reguladores defeituosos podem permitir a quebra da tolerância imune periférica seguida por inflamação crônica e doença. Detalham-se as anormalidades funcionais e a contribuição de diferentes subtipos de células T reguladoras no desenvolvimento de doenças dermatológicas nesta revisão. Acentuam-se os possíveis alvos terapêuticos e as modificações dos T reguladores causados por imunomoduladores usados no campo da dermatologia.