Optimal management of hair loss (alopecia) in children

Dosimetric impact of adding non-coplanar arcs for scalp-avoidance whole-brain irradiation with volumetric-modulated arc radiotherapy on scalp dose reduction in pediatric patients with medulloblastomas

PURPOSE

We performed scalp-avoidance whole-brain irradiation with volumetric-modulated arc therapy (SAWB-VMAT) as a component of craniospinal irradiation. In SAWB-VMAT with two coplanar arcs, radiation oncologists and medical physicists sometimes experience difficulty in reducing the dose to the scalp to below the cut-off equivalent dose in 2 Gy per fraction (assuming α/β = 2) to 50% (EQD50%scalp ). To investigate the advantage of adding coplanar or non-coplanar arcs in reducing the dose to the scalp in SAWB-VMAT, we conducted a planning study to compare the EQD50%scalp , the dose to other organs at risk (OARs), and target coverage in VMAT with two coplanar arcs (Co2arcVMAT), VMAT with three coplanar arcs (Co3arcVMAT), and VMAT with two coplanar and two non-coplanar arcs (NcVMAT).

METHODS

Co2arcVMAT, Co3arcVMAT, and NcVMAT plans were created for 10 pediatric patients with medulloblastoma. The planned target volume (PTV) included the regions of the whole brain, cervical spinal cord, cerebrospinal fluid space, and intervertebral foramen. The EQD50%scalp was evaluated separately for four areas (top, back, left, and right) in each case. The prescribed dose for the PTV was 35.2 Gy in 22 fractions.

RESULTS

The median EQD50%scalp of the top area was 21.9 , 22.1 , and 18.3 Gy for Co2arcVMAT, Co3arcVMAT, and NcVMAT, respectively. The EQD50%scalp of the top area was significantly reduced in NcVMAT compared to those in Co2arcVMAT and Co3arcVMAT (p < 0.05). The median EQD50%scalp of the top area for NcVMAT was < 19.9 Gy, which is the cut-off dose for severe permanent alopecia. There were no significant differences in EQD50%scalp in the three other areas, the dose to other OARs, or the dose coverage of PTV among the three techniques.

CONCLUSION

NcVMAT could reduce the EQD50%scalp of the top area below the cut-off dose of 19.9 Gy. NcVMAT appears to be a promising treatment technique for SAWB-VMAT.

Pediatric androgenetic alopecia: an updated review

Pediatric androgenetic alopecia is an underrecognized disorder. A clinical evaluation with trichoscopy should be made in children and adolescents with hair loss and/or reduced hair density. Diagnosis is usually clinical, by observation of the hair loss pattern and performance of trichoscopy. In some cases, hyperandrogenism should be excluded. Although there is no approved therapy for androgenetic alopecia in pediatric age, topical minoxidil, oral minoxidil and topical finasteride may be very useful. Hair transplant may be an option for girls in selected cases. This article is a review of the current state of evidence concerning pediatric androgenetic alopecia.

Parental uveitis causes elevated hair loss in offspring of C57BL/6J mice

Our previous study demonstrated that parental uveitis in a susceptible population can cause hair loss and increase the susceptibility to experimental autoimmune uveitis (EAU) in offspring. However, it is unclear whether parental uveitis affects the development of offspring in an EAU-moderate-susceptible population. Herein, moderate-susceptible C57BL/6J mice were immunized with inter-photoreceptor retinoid binding protein (IRBP) 651-670 to develop EAU and were kept together for mating. Gross examination and histopathological changes of the offspring gestated with parental uveitis were observed to evaluate the impact of parental uveitis on the development of the offspring. Differentially expressed genes (DEGs) were screened by RNA sequencing in the affected skin and eyeball of the offspring on postnatal day 27. Adult offspring were injected 75 μg IRBP_651-670 to evaluate their susceptibility to EAU. Gross examination in the offspring revealed hair loss on postnatal days 11-31. Histopathological observation showed increased melanin granules and hair follicles of skin in the affected offspring with hair loss. Gene Ontology (GO) analysis in the skin revealed differential expression of genes involved in the mitotic cell cycle, response to endogenous stimulus, hair follicle development, and hair cycle. The DEGs in the skin were predominately associated with the cell cycle and peroxisome proliferator-activated receptor (PPAR) signaling pathway. The GO enrichment analysis in the eyeball showed differential expression of genes involved in the nervous system development, camera-type eye photoreceptor cell differentiation, neuron projection morphogenesis, axon development, and calcium-induced calcium release activity; enriched pathways included the circadian entrainment and glutamatergic synapses. No increased susceptibility to EAU in offspring gestated from parental remitting EAU was observed at a low-dose 75 μg IRBP induction. These results suggested that parental uveitis in a moderate-susceptible population could affect the skin development and DEG profiles of skin and eyeball related to the response to endogenous stimulus, the PPAR signaling pathway, and glutamatergic synapse, which provides the molecular evidence to explain the influence of parental uveitis on offspring development.

Italian Guidelines in diagnosis and treatment of alopecia areata

Alopecia areata (AA) is an organ-specific autoimmune disorder that targets anagen phase hair follicles. The course is unpredictable and current available treatments have variable efficacy. Nowadays, there is relatively little evidence on treatment of AA from well-designed clinical trials. Moreover, none of the treatments or devices commonly used to treat AA are specifically approved by the Food and Drug Administration. The Italian Study Group for Cutaneous Annexial Disease of the Italian Society of dermatology proposes these Italian guidelines for diagnosis and treatment of Alopecia Areata deeming useful for the daily management of the disease. This article summarizes evidence-based treatment associated with expert-based recommendations.

Hair disorders in cancer survivors

With increasing survival rates across all cancers, survivors represent a growing population that is frequently affected by persistent or permanent hair growth disorders as a result of systemic therapies, radiotherapy, surgical procedures, and therapeutic transplants. These hair disorders include persistent chemotherapy-induced alopecia, persistent radiotherapy-induced alopecia, endocrine therapy-induced alopecia and hirsutism, postsurgery alopecia and localized hypertrichosis, and persistent stem cell transplantation and targeted therapy-induced alopecia. The information contained in this continuing medical education series should facilitate a better understanding on hair disorders in cancer survivors so that adequate support and therapies may be provided.

A Practical Approach to the Diagnosis and Management of Hair Loss in Children and Adolescents

Hair loss or alopecia is a common and distressing clinical complaint in the primary care setting and can arise from heterogeneous etiologies. In the pediatric population, hair loss often presents with patterns that are different from that of their adult counterparts. Given the psychosocial complications that may arise from pediatric alopecia, prompt diagnosis and management is particularly important. Common causes of alopecia in children and adolescents include alopecia areata, tinea capitis, androgenetic alopecia, traction alopecia, trichotillomania, hair cycle disturbances, and congenital alopecia conditions. Diagnostic tools for hair loss in children include a detailed history, physical examination with a focused evaluation of the child’s hair and scalp, fungal screens, hair pull and tug test, and if possible, light microscopy and/or trichoscopy. Management of alopecia requires a holistic approach including psychosocial support because treatments are only available for some hair loss conditions, and even the available treatments are not always effective. This review outlines the clinical presentations, presents a diagnostic algorithm, and discusses management of these various hair loss disorders.

[Aetiology of childhood alopecia]

INTRODUCTION

Childhood alopecia is a relative rare event in general paediatric dermatology practice. Hair loss in children may have multiple causes, and there are different types of alopecia according to age groups. The aim of the study was to describe the clinical and epidemiological profile of alopecia in children from two Chilean paediatric hospitals.

PATIENTS AND METHOD

Descriptive analysis of clinical records of patients from the Dermatology Department of Roberto del Rio and Luis Calvo Mackenna Hospitals between January 2007 and June 2010. Patients with clinical diagnosis of alopecia were included.

RESULTS

A total of 345 clinical records were analysed, with 179 males (51.9%). The median age was 72 months. Overall, the most common diagnoses were: alopecia areata (AA), (36.8%), tinea capitis (TC), (21%), nevus sebaceous (13.2%), and tellogen effluvium (8.7%). According to age groups, in newborns, the most common causes were aplasia cutis and nevus sebaceous. In toddlers, pre-school and school children, the principal causes were nevus sebaceous, AA and TC. Trichotillomania was also significant in school children. In adolescents, nevus sebaceous, AA and tellogen effluvium were the most frequent diagnoses. AA was statistically associated with autoimmune disease, thyroid disease, nail disorder, psychiatric disease, and Down's syndrome. The most common aetiological agent in TC was M. canis (86.6%). Trichotillomania was also statistically associated to psychiatric disorders.

CONCLUSIONS

In this study, the main causes of alopecia in children were acquired and non-scarring alopecia. In our results, the type of alopecia varies according to age group. Some types of childhood alopecia showed a close correlation to psychiatric disorders.

Quality of life in alopecia areata: a disease-specific questionnaire

BACKGROUND

Alopecia areata (AA) is an autoimmune disease affecting about 2% of the population, which has a considerable impact on quality of life (QoL). There are no disease-specific questionnaires to assess QoL in patients suffering from AA.

OBJECTIVE

To validate a new disease-specific questionnaire for AA, named AA-QLI, and to compare the consequent Quality of Life Index (QLI) with the commonly known Dermatology Life Quality Index (DLQI) to verify if it can provide a more comprehensive tool for patients.

METHODS

A total of 50 patients affected by AA were administered both the AA-QLI, created by us, and the well-known DLQI. With the aim to detect suitable QLI, we propose to use two multivariate analyses: • a principal component analysis approach on the data collected with both questionnaires to compare their capability to measure the QoL; • a structural equation modelling on our AA-QLI to identify which category of symptoms mostly affects the QoL.

RESULTS

The scores of both the questionnaires are quite close, except for a few cases. Statistical analysis shows a higher specificity of the AA-QLI for evaluating QoL. Among the three areas in which AA-QLI is divided, 'Relationship' has a major impact on the QLI, followed by 'Subjective symptoms'; 'Objective signs' has a lower weight on the QLI.

CONCLUSION

AA-QLI is a good instrument to evaluate the real impact of AA on QoL. It can be helpful both for the physician and for the patient.

Comparison of permanent hair loss in children with standard risk PNETS of the posterior fossa following radiotherapy alone or chemotherapy and radiotherapy after surgical resection

Hair loss was compared between surgery followed by craniospinal radiotherapy (CSRT) or chemotherapy then CSRT (C-CSRT) for medulloblastoma. The proportion of patients exhibiting hair loss in the cranial field was 70.0% (C-CSRT) versus 30.0% (CSRT) (95% CI: 14.7% to 58.9%; P = 0.002). The C-CSRT group also experienced more virtual/complete hair loss over the posterior fossa boost. Age was a significant contributor to hair loss in the cranial field. Persistent significant hair loss is an under-reported late effect of treatment that could influence quality of survival and should be considered in future trial design.

Development and evaluation of formulations of microbial biotransformed extract of tobacco leaves for hair growth potential

BACKGROUND

Extensive researches are going on to explore the effective and safe drug for their hair growth. Tobacco leaves are traditionally known to potentiate hair growth promotion. Therefore, the aim of present study was to formulate and evaluate the microbial biotransformed extract of tobacco leaves for hair growth potential in male albino wister rats.

MATERIALS AND METHODS

The extract of was prepared by microbial biotransformation of tobacco leaves in cow urine for 28 days. The herbal formulations (lotion) were formulated by general method using o/w type base in various rations or concentrations such as 10%, 20% and 30% of extract. These lotions were applied on shaved skin area of rats for 30 days once in a day and hair length, serum total protein, and total testosterone were measured.

RESULTS

Our formulations show increase in hair growth and serum total protein at concentration dependent manner with effect to standard and control groups. Serum total testosterone decreases according to a concentration dependent manner.

CONCLUSION

Further, series of investigations are, however, necessary to remain exploration, which includes their structural elucidation, characterization, clinical safety, reliability and molecular mechanism involved in this pharmacological activity.

Temporal triangular alopecia with decreased follicular density

Temporal triangular alopecia (TTA) is a type of alopecia that is often congenital, and clinically exhibits hair loss on one or both temples. It is characterized histologically by a normal number of small hair follicles without significant inflammation. We report a patient with TTA whose biopsy exhibited a decreased number of hair follicles. There are limited reports of the histopathology of TTA, and most have utilized standard vertical sections. Of the handful of patients with transversely sectioned biopsies, follicular numbers have been reportedly normal. Our finding of a patient with TTA with a decreased number of hair follicles broadens the histologic spectrum of this disorder, and may have implications for pathogenesis.

Alopecia in congenital hidrotic ectodermal dysplasia responding to treatment with a combination of topical minoxidil and tretinoin

Clouston's syndrome is an ectodermal dysplasia characterized by dystrophic nails, alopecia, and palmoplantar hyperkeratosis. Alopecia is due to decrease in number and degree of maturation of the hair follicles. Tretinoin is a mitogen by itself and also enhances the absorption of minoxidil which acts by enlarging the miniaturized hair follicles. We report a case of alopecia in Clouston's syndrome who responded to treatment with topical minoxidil and tretinoin.

Protection Against Chemotherapy-Induced Alopecia

PURPOSE

The goal is to provide an overview on the advances in protection against chemotherapy-induced alopecia (CIA).

MATERIALS AND METHODS

The four major parts of this review are (a) overview of the hair follicle biology, (b) characteristics of CIA, (c) state-of-the-art animal models of CIA, and (d) experimental approaches on protection against CIA.

RESULTS

The hair follicle represents an unintended target of cancer chemotherapy. CIA is a significant side effect that compromises the quality of life of patients. Overcoming CIA represents an area of unmet needs, especially for females and children. Significant progresses have been made in the last decade on the pathobiology of CIA. The pharmacological agents under evaluation include drug-specific antibodies, hair growth cycle modifiers, cytokines and growth factors, antioxidants, cell cycle or proliferation modifiers, and inhibitors of apoptosis. Their potential applications and limitations are discussed.

CONCLUSION

Multiple classes of agents with different action mechanisms have been evaluated in animal CIA models. Most of these protective agents have activity limited to a single chemotherapeutic agent. In comparison, calcitriol and cyclosporine A have broader spectrum of activity and can prevent against CIA by multiple chemotherapeutic agents. Among the three agents that have been evaluated in humans, AS101 and Minoxidil were able to reduce the severity or shorten the duration of CIA but could not prevent CIA.

Comparison of azelaic acid and anthralin for the therapy of patchy alopecia areata: a pilot study

BACKGROUND

Although topical azelaic acid has been previously used for the treatment of alopecia, no controlled trials of azelaic acid for this condition have been conducted to date.

OBJECTIVE

The goal of this study was to determine the efficacy, tolerability, and safety of azelaic acid treatment in patients with patchy alopecia areata (AA) in comparison with anthralin (dithranol) treatment.

SUBJECTS AND METHODS

This study included 31 subjects with patchy AA who did not receive any treatment for at least 1 month prior to the study. Demographic and clinical characteristics of these subjects were recorded at baseline. Subjects were randomized to apply either 20% azelaic acid (15 subjects) or 0.5% anthralin (16 subjects) for 12 consecutive weeks. In a subsequent 8-week follow-up period no cream was applied. Two independent investigators performed an efficacy evaluation with clinical examination using a terminal hair regrowth score (RGS) with a scale ranging from 0 (inadequate response) to 2 (complete response) at week 20. Partial response was accepted as score 1.

RESULTS

Both groups were well matched for the relevant demographic and clinical indicators affecting treatment response at baseline. All subjects completed the trial. At week 20 the RGS was 1.27 +/- 0.9 in the azelaic acid group versus 1.37 +/- 0.8 in the anthralin group (p > 0.05). A complete response was observed in 53.3% of cases in the azelaic acid group (8 of 15) compared with 56.2% (9 of 16) in the anthralin group (p > 0.05). No serious adverse events were observed in either group during the study.

CONCLUSION

The present pilot study showed that the use of azelaic acid gave similar results to anthralin with regard to hair regrowth, and that it can be an effective topical therapy for patchy AA. More extensive trials are necessary, however, to reach a definitive conclusion.