Traction alopecia: the root of the problem

Updates on disorders in curly hair

Hair disorders, including central centrifugal cicatricial alopecia (CCCA), traction alopecia (TA), and acquired trichorrhexis nodosa (ATN), commonly occur in individuals with curly textured hair. Curly textured hair in individuals of African descent has unique properties and can present diagnostic and therapeutic challenges. CCCA has been linked to uterine leiomyoma and type 2 diabetes mellitus, as well as fibroproliferation. TA often presents with a fringe sign and can arise from high-tension hairstyles presumed to be protective. Trichoscopy is useful in establishing a diagnosis; perifollicular halos are more commonly seen than perifollicular erythema or scale in CCCA. In TA, miniaturized follicles, hair casts, and "flambeau sign" can be seen. Hairstyling practices likely contribute to TA and ATN; however, the data are mixed on the role of chemical relaxers and heat styling in CCCA. Unique considerations in the presentation of frontal fibrosing alopecia in curly textured hair have also been published recently. This review provides a comprehensive, up-to-date summary of these disorders with an emphasis on their unique properties, as well as considerations in hair care for curly textured hair.

Factors associated with traction alopecia in women living in Yaoundé (Cameroon)

BACKGROUND

Traction alopecia (TA) is very common in Africa but few studies on African population are available. We sought to determine factors associated with TA and measure the association between these factors and TA.

METHODS

We carried out an analytical cross-sectional study in 29 hairdressing saloons in the city of Yaoundé. A questionnaire was administered and scalp exams were performed in order to look for TA and determine Marginal TA severity score if present. Participants were separated in two groups: TA group and a group without TA.

RESULTS

We finally included 223 women (77 having TA and 146 without TA). The median age was 26 years for women with TA and 24 years for women without TA. The factors associated with traction alopecia we found included: age ≥ 35 years (adjusted OR = 4; p = 0.016). Hairdressing undertaken by hairdressers only (adjusted OR = 0.2; p = 0.008), the avoidance of the regular use of nets, caps and head ties (OR = 0.2; p = 0.006) and relaxing hairs once a year or less (adjusted OR = 0.2; p = 0.005) could be protective factors. As well, we found a positive correlation between age and TA severity (r = 0.235; p < 0.001).

CONCLUSION

Age and some haircare practices are associated to TA occurrence in our context. Women therefore need to be educated on these various factors that could be able to cause, worsen or prevent TA.

An Update on Alopecia and its Association With Thyroid Autoimmune Diseases

Alopecia is comorbid with several illnesses, including various autoimmune conditions such as thyroid disease. Leukocyte-mediated inflammation of hair follicles in alopecia was first described over a century ago. However, the high prevalence of the role of thyroid autoimmune disease in the pathogenesis of alopecia has only recently come to light, together with a strong association between the two. Therefore, this review focuses on articles published between 2011 and 2022 on alopecia's association with thyroid autoimmune disease, and the mechanism behind it. In addition, it highlights the link between alopecia and thyroid cancer, as patients with alopecia have increased risk of thyroid cancer. In conclusion, this comprehensive, focused, scoping review will serve as a reference highlighting recent information on alopecia, exploring its association with thyroid autoimmune diseases.

Considerations and recommendations on camouflage in alopecia in Black women

Alopecia is among the leading dermatological concerns affecting Black women. For many women, hair is a central component of identity and self-expression, the loss of which can have significant psychosocial effects. Hair camouflage is often utilized to minimize the visibility of hair loss, provide aesthetic benefits, and improve quality of life. The versatility and affordability of hair camouflage allows patients with alopecia to conceal hair loss, increasing self-confidence, and decreasing social stigma. However, hair camouflage practices often involve adhesives, chemicals, and/or high-tension braiding, all of which can exacerbate alopecia. Accordingly, special considerations should be made to protect patients' natural hair from damage while using these styling practices. A better understanding of best practices for some of the most widely used camouflage options-wigs, extensions, topical hair fibers, and micropigmentation-can help clinicians establish rapport with Black women and optimize individually-tailored therapeutic plans during active treatment and end-stage hair loss.

The histopathologic diagnosis of traction alopecia: An evidence-based model

BACKGROUND

Traction alopecia (TA) is common, but histopathologic criteria for TA have not been objectively defined.

OBJECTIVE

Determine whether the pauci-follicular unit (PFU) can be used as a diagnostic criterion for TA. Compared to a normal follicular unit (NFU), the PFU is a noninflamed follicular unit with an intact sebaceous gland but fewer than 2 follicles.

METHODS

A retrospective review of 25 cases of TA and 25 cases of "normal scalp" was performed. Data included all follicles (by size and phase), sebaceous glands, and total follicular units.

RESULTS

Comparing data (traction vs normal), we found a significantly higher number of PFUs in cases of TA (median 6 vs 0, P < .001), which can be used as a helpful and easily recognizable diagnostic tool in diagnosing cases of TA.

LIMITATIONS

Comparison to other forms of alopecia was not performed.

CONCLUSIONS

The number of PFUs in an alopecia biopsy can be used to establish the diagnosis of TA.

Dermatological Implications of the Taqiyah and Imamah: Recommendations for Delivering Culturally Conscious Care

Background and objective The growing cultural and religious diversity in healthcare settings necessitates clinicians to integrate cultural competence and sensitivity into their practice. Despite significant research focusing on the hijab worn by Muslim women, there is a gap in understanding the dermatological implications of the taqiyah and imamah, worn by Muslim men. In light of this, this study aimed to offer insights into delivering culturally conscious dermatological care for Muslim men wearing these garments, thereby bridging a crucial knowledge gap. Materials and methods The study employed a comprehensive research strategy that encompassed both medical literature and foundational Islamic texts. PubMed, Web of Science, and Scopus were used for medical literature searches, while al-Maktabah al-Shamela and Sunnah.com, along with Quranic and Hadith translations were consulted for religious insights. A thematic analysis was employed to identify patterns, challenges, and unique points, ensuring a holistic understanding of the subject. Results Our findings revealed that wearing a taqiyah or imamah has both beneficial and detrimental dermatological effects, depending on factors such as climate, fabric, and hygiene practices. While the garments are rooted in Islamic tradition, their use varies based on cultural context rather than strict religious guidelines. Moreover, gender dynamics and the concept of privacy ('awrah) within Islamic teachings have implications for healthcare interactions. The study offers practical guidelines for dermatological care tailored to Muslim men wearing a taqiyah or imamah. It emphasizes the importance of material choice, hygiene practices, and the willingness of many Muslim men to be accommodating in medical settings, albeit with some reservations. The paper also discusses the role of telemedicine in culturally sensitive healthcare delivery, recommending measures such as secure communication channels and self-imaging options. Conclusion The paper provides comprehensive recommendations aimed at delivering culturally and religiously sensitive dermatological care to Muslim men wearing a taqiyah or imamah. By integrating both medical best practices and a nuanced understanding of Islamic customs, healthcare providers can foster a more trusting and effective care relationship, thereby improving patient satisfaction and dermatological outcomes.

Beard Alopecia: An Updated and Comprehensive Review of Etiologies, Presentation and Treatment

Facial hair is an important social and psychologic aspect of clinical appearance for men. The purpose of this review is to provide a comprehensive overview of the causes of alopecia of the beard including the prevalence, pathophysiology, clinical presentation, and treatment. In this review, we highlight more common causes of beard alopecia including alopecia areata and pseudofolliculitis barbae, infectious causes such as tinea barbae and herpes simplex folliculitis, and rare causes including dermatopathia pigmentosa reticularis and frontal fibrosing alopecia. This review serves as an important resource for clinicians when faced with patients suffering from beard alopecia.

Scarring Alopecia

African hair shaft and pigmented scalp have unique features that challenge diagnosis in scarring alopecia. In addition, Black patients may associate 2 or more types of hair disorders. Therefore, it is imperative to understand their findings thoroughly to establish a good diagnosis. Differential diagnosis on the frontal scalp includes traction alopecia and frontal fibrosing alopecia. Disorders such as central centrifugal cicatricial alopecia, fibrosing alopecia in a pattern distribution, discoid lupus erythematosus, and lichen planopilaris usually affect the middle scalp. Folliculitis decalvans, dissecting cellulitis, and acne keloidalis nuchae are the main differential diagnosis of the posterior scalp.

Free the Bun: Prevalence of Alopecia Among Active Duty Service Women, Fiscal Years 2010-2019

INTRODUCTION

Active duty service women (ADSW) constitute 16% of the force. The prevalence of alopecia, a dermatologic condition characterized by hair loss, is understudied in regard to hairstyle regulations across the U.S. military services. Alopecia has several causes; one of which is due to tension on the scalp secondary to tight hairstyles. In the U.S., alopecia has a lifetime prevalence of 1.7-2.1%; no previous studies which evaluated this condition in service women were found.

MATERIALS AND METHODS

We used the Military Health System Data Repository to perform a retrospective study to assess the prevalence of alopecia in ADSW from fiscal years (FYs) 2010 to 2019. Statistical analyses included descriptive statistics on patient demographics and trend analysis on the prevalence of alopecia over the 10-year study period.

RESULTS

A total of 498,219 ADSW were identified over the 10-year study period, of which 2.40% had a diagnosis of alopecia. Overall, the prevalence of alopecia decreases over the 10-year period, with two observed periods of slight increase (FY 2013 to 2014 and FY 2018 to 2019) when comparing prevalence year-to-year. Of those diagnosed, the majority were young, Black, with a senior enlisted rank, and in the U.S. Army.

CONCLUSION

The prevalence of alopecia in ADSW is slightly higher than that in civilian populations and is most likely underreported. It is more commonly diagnosed in Black women than would be expected based on ratios of this population in military service. Policy changes to ensure that traction alopecia is a qualifying medical condition for Veterans Affairs disability compensation, mechanisms are in place for more specific coding in the electronic medical record, and treatment options to be covered by TRICARE are recommended. All U.S. military services should consider updating and evaluating regulations to improve the health and quality of life of ADSW.

[Translated article] Trichoscopy: An Update

Trichoscopy is a simple, noninvasive office procedure that can be performed using a handheld or digital dermatoscope. This tool has gained popularity in recent years, because it provides useful diagnostic information for hair loss and scalp disorders by enabling the visualization and identification of distinctive signs and structures. We present an updated review of the trichoscopic features described for some of the most common hair loss disorders seen in clinical practice. Dermatologists should be familiar with these helpful features, as they can significantly aid the diagnosis and follow-up of numerous conditions, such as alopecia areata, trichotillomania, and frontal fibrosing alopecia.

Relevant Dermatoses Among U.S. Military Service Members: An Operational Review of Management Strategies and Telemedicine Utilization

Despite skin being the largest and most exposed organ of the human body, skin issues can be challenging to diagnose in deployed military service members. Common reasons deployed soldiers seek dermatological evaluation include infections, inflammatory skin conditions, and skin growth. Due to limited access to specialized care in deployed settings, dermatological conditions are undertreated and underdiagnosed. As a result, dermatological conditions are a leading contributor to decreased combat effectiveness among deployed medical forces. To lessen the burden of dermatological diseases, military providers should promptly identify operational skin diseases and alleviate modifiable barriers faced by service members. In a post-pandemic era with novel Severe Acute Respiratory Syndrome Coronavirus 2 (SARS-CoV-2) and monkeypox infections, the duty to effectively treat operational skin lesions is ever important. The need for military dermatologists continues to rise as the global landscape continues to evolve with unprecedented infections and increased bioterrorism threats. Teledermatology offers many solutions to mitigate the high demand for dermatologists during pandemics. Dermatological consultations account for the highest number of telemedicine visits in the US Military Health System (MHS). As such, increased utilization of teledermatology will reduce infection-related dermatological sequelae and prevent the medical evacuation of service members from military operations. This review collates and categorizes relevant dermatological conditions encountered among deployed personnel. This report outlines the standard of care and modified treatments recommended according to potential barriers faced in operational settings.

Trichoscopy: An Update

Trichoscopy is a simple, noninvasive office procedure that can be performed using a handheld or digital dermatoscope. This tool has gained popularity in recent years, because it provides useful diagnostic information for hair loss and scalp disorders by enabling the visualization and identification of distinctive signs and structures. We present an updated review of the trichoscopic features described for some of the most common hair loss disorders seen in clinical practice. Dermatologists should be familiar with these helpful features, as they can significantly aid the diagnosis and follow-up of numerous conditions, such as alopecia areata, trichotillomania, and fibrosing frontal alopecia.

Alopecia Areata in Latin America: Where are We and Where are We Going?

Alopecia areata (AA) represents an underrecognized burden in Latin America (LA), severely impacting quality of life (QoL). This impact is exacerbated by limited access to specialized dermatologic care and therapies for AA within and among nations. Many of the unmet needs for AA globally also exist in LA. The region has geographic, ethnic, cultural, and economic conditions. With new AA medicines targeting immunologic pathways on the horizon, LA must prepare regarding regulatory issues, reimbursement, awareness, and education to give adequate and timely treatment for patients with AA. To address these issues, the Americas Health Foundation convened a panel of six dermatologists from Argentina, Brazil, Colombia, and Mexico who are experts in AA and its comorbidities for a 3-day virtual meeting to discuss AA diagnosis and treatment in LA and create a manuscript offering recommendations to address discussed barriers. This publication examines unmet AA needs in LA, treatment, and innovative therapies and recommends improving AA care. Access constraints to conventional and novel medicines hinder appropriate treatments for patients. Therapy initiation delays can affect QoL, mental health, and disease progression. People with AA face stigmas, discrimination, and misconceptions owing to a lack of disease awareness. With promising new treatments for AA on the horizon, all stakeholders must coordinate efforts to enhance LA's AA management landscape and improve patient outcomes.

Hair care and epidemiological-clinical profile of traction alopecia among women in hair salons in Yaoundé, Cameroon

Background

Hair is valued by all individuals especially women. The perception of beauty is specific to everyone. In order to fulfil their ideal beauty, women use various methods to modify their hair's appearance. Afro hair is particularly fragile, so using these methods can be particularly deleterious for black women's hair.

Objectives

Describe hair care practices of women living in Yaoundé, determine the prevalence of traction alopecia (TA) and describe its clinical profile.

Methods

We carried out a cross-sectional study in hairdressing saloon in Yaoundé. A questionnaire was administered and scalp exams were performed to determine Marginal TA severity score.

Results

We included 223 women with a mean age of 24.9 ± 7 years. The prevalence of TA was 34.5%. Mild and moderate stages were most represented. As far as haircare is concerned, extensions were regularly used by 95.1% of participants. Wigs were regularly worn by 58.7% of participants. Chemical hair straightening was done by 87.9% of women and was performed twice to thrice a year by 43.9%. Almost 76% of women used hair straightener and hair dryer. Hair washing was done monthly by 43.8% of participants and the main cosmetic used was shampoo (75.3%).

Conclusion

Traction alopecia is a very common disease in women living in Yaoundé. Extensions, wigs and shampooing are their main hair care practices.

Unrevealing the Potential of Sansevieria trifasciata Prain Fraction for the Treatment of Androgenetic Alopecia by Inhibiting Androgen Receptors Based on LC-MS/MS Analysis, and In-Silico Studies

Androgenetic Alopecia (AGA) occurs due to over-response to androgens causing severe hair loss on the scalp, and requires the development of new and efficient drugs to treat this condition. This study explores and identifies secondary metabolites from Sansevieriatrifasciata Prain using the LC-MS/MS and in-silico method. The inhibitory activity of bioactive compounds from S. trifasciata Prain against androgen receptors (PDB ID: 4K7A) was evaluated molecularly using docking and dynamics studies by comparing their binding energies, interactions, and stability with minoxidil. The results of the LC-MS/MS analysis identified Methyl pyrophaeophorbide A (1), Oliveramine (2), (2S)-3′, 4′-Methylenedioxy-5, 7-dimethoxyflavane (3), 1-Acetyl-β-carboline (4), Digiprolactone (5), Trichosanic acid (6) and Methyl gallate (7) from the leaves subfraction of this plant. Three alkaloid compounds (compounds 1, 3, and 4), and one flavonoid (compound 2), had lower docking scores of −7.0, −5.8, −5.2, and −6.3 kcal/mol, respectively. The prediction of binding energy using the MM-PBSA approach ensured that the potency of the four compounds was better than minoxidil, with energies of −66.13, −59.36, −40.39, and −40.25 kJ/mol for compounds 1, 3, 2, and 4, respectively. The dynamics simulation shows the stability of compound 1 based on the trajectory analysis for the 100 ns simulation. This research succeeded in identifying the compound and assessing the anti-alopecia activity of Sansevieria trifasciata Prain. Seven compounds were identified as new compounds never reported in Sansevieria trifasciata Prain. Four compounds were predicted to have better anti-alopecia activity than minoxidil in inhibiting androgen receptors through an in silico approach.

Afro-Ethnic Hairstyling Trends, Risks, and Recommendations

Hairstyling trends among Black women fluctuate with social, cultural, and environmental pressures. Dermatologists should be aware of current trends and their associated risks in order to provide the best care to this population. In order to summarize the updated trends and associated health risks for the most common hairstyles worn by Black women, a literature review was performed. PubMed and EMBASE were used to identify articles related to hair styling practices, studies on the effects or risks of various styling practices, and magazine articles citing current styling trends among women of African descent. All hairstyles were found to have associated health risks; however, natural styles had the fewest adverse associations of all styles reviewed. Central Centrifugal Cicatricial Alopecia (CCCA) is the most cited hair disorder in this population, possibly linked to both chemical relaxants and traction styles. Additional studies are needed to further establish causality between these styles and CCCA. Additionally, while acceptance of natural hairstyles is on the rise, there is more work to be done throughout society to help protect and encourage women who choose to wear Afrocentric styles. Dermatologists should be well versed in these hairstyles and ready to lend appropriate advice to patients when it is requested.

A Prospective Six-month Single-blind Study Evaluating Changes in Hair Growth and Quality Using a Nutraceutical Supplement in Men and Women of Diverse Ethnicities

OBJECTIVE

The goal of this study was to assess the perceived efficacy of a standardized nutraceutical to improve hair growth and quality in men and women of various ethnicities with self-perceived hair thinning.

METHODS

This prospective, single-blind study enrolled healthy men aged 20 to 55 years (n=47) and premenopausal women aged 20 to 45 years (n=51) with self-perceived, mild-to-moderate hair thinning and included African American, Asian, Hispanic Caucasian and Non-Hispanic Caucasian participants. The nutraceutical supplement (Nutrafol® Men or Women Capsules, Nutraceutical Wellness Inc., New York, New York) was taken daily for six months. Subjects were evaluated in the clinic at baseline and Weeks 12 and 24 with two self-assessments at Weeks 4 and 8. Study endpoints were standardized digital imaging and investigator rated assessments. Self-assessment questionnaires rated hair growth, hair satisfaction, and lifestyle factors.

RESULTS

Investigator ratings for baseline hair growth, coverage, density, and volume were significant at Weeks 12 and 24 for all subjects (for each, p<0.001). These significant improvements were seen in 83.7 percent of men and 79.5 percent of women at Week 24. Results were similar across ethnic subgroups with significant benefit at Weeks 12 and 24 (for each, p<0.05). All subjects reported significant improvements in baseline hair appearance/quality, volume/fullness, scalp coverage, thickness, and shedding at Weeks 4, 8, 12 and 24 (for each, p<0.01).

CONCLUSION

A standardized nutraceutical supplement improved visible hair growth with less notable shedding based on subjects' and investigators' overall perception of treatment benefit for men and women of various ethnic backgrounds.

Traction Alopecia: Clinical and Cultural Patterns

Background:

Traction alopecia is common and preventable but frequently overlooked disorder.

Objective:

To evaluate patients with traction alopecia.

Patients and Methods:

This study was conducted at the Dermatology Center, Medical City, Baghdad, Iraq, during the period from November 2005 to October 2019. Demographic features like age, gender, disease duration and special hair styling practices and accessories were recorded. Clinical patterns were studied.

Results:

Thirty female patients were included in this study. Their ages ranged from 6 to 47 years with mean age ± SD was 15.63 ± 9.806. Twenty-one (70%) were below the age of 16 years. No patient had tightly curled hair. All cases were asymptomatic apart from hair loss. The fringe sign was observed in 27 (90%) of cases. The response to therapy was poor.

Conclusion:

Traction alopecia is an important type of pressure-induced hair loss evident in children and adults with or without curly hair due mainly due to cultural hair styling practices with its frequency apparently increasing in recent years. The fringe sign is common and of diagnostic importance. It is a preventable form of hair loss which can be reversed if diagnosed early; otherwise, permanent scarring alopecia results. It represents a pressure phenomenon evident worldwide in both non-Sub-Saharan lineage and Sub-Saharan lineage individuals.

Review article: Emerging issues in pediatric skin of color, part 1

Dermatology for the pediatric skin of color population is the application of dermatology to the genetically diverse and distinctive segment of the pediatric population that includes children of non-White racial and ethnic groups with increased pigmentation including individuals of Asian, LatinX, African, Native American, Pacific Island descent, Indigenous Peoples, among others, with overlap in particular individuals, and mixtures thereof. Treating children of color is a unique skill set within the field of pediatric dermatology, requiring knowledge and sensitivity. The discipline of pediatric skin of color can be challenging. Difficulty in diagnosis of common conditions stems from underlying pigmentation, variations in common hairstyling practices, and differences in demographics of cutaneous disease, whereas some conditions are more common in children of color, other conditions have nuances in clinical appearance and/or therapeutics with regard to skin color. This article is the first in a series of two articles looking at recently published skin-related issues of high concern in children of color. Conditions reviewed in Part 1 include (1) hairstyling hair-related concerns (traction alopecia, central centrifugal cicatricial alopecia, endocrine disruption), (2) autoimmune concerns (cutaneous lupus, vitiligo), and (3) infections (tinea capitis, progressive macular hypomelanosis).

Acute onset traction-associated ulceration and alopecia

Traction alopecia is a protracted form of hair loss resulting from persistent tension on the hair follicle . We report a case of a 9-year-old African American girl who presented with extensive scalp ulceration and alopecia 11 days after placement of a synthetic hair braid. Over a period of months, with consistent wound care and low-tension hairstyling, most of the hair regrew. We propose that the ulceration and hair loss in this case represents an acute variant of traction alopecia due to pressure-induced ischemia and necrosis.

Review of traction alopecia in the pediatric patient: Diagnosis, prevention, and management

Hairstyles and practices that frequently apply tension to the hair follicle can result in traction alopecia (TA). Many of the hairstyles and hair practices associated with a higher risk of TA begin at a young age, making early intervention and education advantageous in the pediatric population. Recognizing TA at its reversible stage in the pediatric population is critical as early interventions, and counseling will prevent permanent scarring alopecia. While TA can affect any pediatric patient, this review highlights the reported literature on specific populations with a higher reported prevalence of TA.

Alopecia areata: A psychodermatological perspective

BACKGROUND

Alopecia Areata (AA) is an autoimmune dermatological disease that could be influenced by psychological factors as part of the pathophysiology of the illness.

AIMS

This review article aims to report on psychodermatological and psychopathological aspects involved in the etiopathogenesis and comorbidities of AA, as well as on the psychiatric and psychological management of affected patients.

METHODS

We conducted a literature search on PubMed and Google Scholar from January 1980 to May 2021 employing the search terms of alopecia areata, psychological factors, psychological impact, psychodermatology, and psychopathology. All lists of references from the identified articles were screened for further relevant studies. The search was limited to English and Spanish language articles and was supplemented with themed books and book chapters. No specific quality criteria were used for the studies selection.

RESULTS

Several authors have found a high comorbidity rate between AA and mental disorders, concluding that stress and psychological factors are involved in both the development and exacerbation of the illness. More evidences are needed in order to describe the associations between the immune response, stress, and the physiological factors observed in AA patients.

CONCLUSION

AA is a complex illness characterized by multifactorial etiology. An interaction between genetic, autoimmune, hormonal, neural, and psychological factors is supposed. Psychopathological aspects of illness need to be better described and considered in the clinical setting.

Acute telogen effluvium triad after resolution

Five cases of telogen effluvium undergoing resolution are shown, with the presence of frontal, bitemporal, and occipital hair regrowth. Diagnosing acute telogen effluvium after the end of the active phase can be challenging, especially when the pull test is negative. The differential diagnosis includes alopecia areata and traction alopecia. Clinical signs of hair regrowth after telogen effluvium can help in the diagnosis. The frontal and temporal areas have more telogen hairs and are more affected. On the occipital area, hairs seem to have the same behavior. The acute telogen effluvium triad during resolution is proposed: frontal fringe, temporal recess and occipital fringe.

The art of prevention: It's too tight-Loosen up and let your hair down

Traction alopecia is prevalent in patients of color. Its significance in clinical practice may be underemphasized due to the transient nature of the condition; however, it has the potential to become permanent and cause significant psychosocial distress. Understanding of afro-textured hair and cultural practices, as well as early recognition and treatment, provides an opportunity to prevent permanent traction alopecia and long-term sequelae.

Destruction of the stem cell Niche, Pathogenesis and Promising Treatment Targets for Primary Scarring Alopecias

The Primary Scarring Alopecias are characterised by the irreversible destruction and fibrosis of hair follicles, leading to permanent and often disfiguring loss of hair. The pathophysiology of these diseases is not well understood. However, follicular-fibrosis and loss of the stem-cell niche appears to be a common theme. This review explores the pathogenesis of primary scarring alopecias, asking what happens to the stem cells of the hair follicle and how they may contribute to the progression of these diseases. Bulge-resident cells are lost (leading to loss of capacity for hair growth) from the follicle either by inflammatory-mediate apoptosis or through epigenetic reprogramming to assume a mesenchymal-like identity. What proportion of bulge cells is lost to which process is unknown and probably differs depending on the individual PCA and its specific inflammatory cell infiltrate. The formation of fibroblast-like cells from follicular stem cells may also mean that the cells of the bulge have a direct role in the pathogenesis. The identification of specific cells involved in the pathogenesis of these diseases could provide unique diagnostic and therapeutic opportunities to prevent disease progression by preventing EMT and specific pro-fibrotic signals.

The Great Masquerader: Syphilis Mimicking Papilledema and Traction Alopecia

Syphilis is often referred to as "the great masquerader," as it may present with a wide array of clinical symptoms and may mimic a variety of other diseases making diagnosis challenging. We report the case of a young, married woman who presented with a one-month history of significant hair loss, unintentional weight loss, blurred vision, and intermittent headaches. In addition, she endorsed positional dizziness and intermittent arthralgias. Physical exam was only remarkable for a non-scarring alopecia over the frontal marginal hairline and optic disc edema on fundoscopic exam. Laboratory tests were largely unremarkable except for a rapid plasma reagin titer of 1:128 and a positive confirmatory treponemal test. Cerebrospinal fluid analysis showed lymphocytic pleocytosis and negative Venereal Disease Research Laboratory test. Opening pressure was 15 cm H2O twice, ruling out papilledema. She was treated with 4 million units of intravenous penicillin every four hours for 14 days, and her symptoms improved. A diagnosis of syphilis should remain high on the differential diagnosis in patients with unexplained hair loss or ocular abnormalities.

Common Skin Disorders in Pediatric Skin of Color

Children with skin of color represent a large proportion of the pediatric population. There are numerous skin conditions that commonly occur in this population, including but not limited to acne, atopic dermatitis, pityriasis alba, tinea versicolor, progressive macular hypomelanosis, traction alopecia, and confluent and reticulated papillomatosis. This article highlights the clinical presentations of these conditions in skin of color and briefly addresses pathophysiology and treatment modalities.

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.