Advanced Medical Therapies in the Management of Non-Scarring Alopecia: Areata and Androgenic Alopecia

The value of immunohistochemical expression of SOX9 and CD34 in alopecia areata

BACKGROUND

Alopecia areata (AA), an immune-mediated disorder, is marked by temporary, nonscarring hair loss. The bulge area is protected from immune attacks by immune privilege; however, recent studies demonstrated immune cells infiltrating the bulge area.

OBJECTIVE

This study aims to investigate the immunohistochemical expression of the sex-determining region Y-box 9 (SOX9) and cluster of differentiation 34 (CD34) in AA patients as markers of hair follicle stem cells (HFSCs) and progenitor cells, respectively.

METHODS

Immunohistochemical staining of SOX9 and CD34 was applied on skin samples of 20 AA patients and 20 healthy controls.

RESULTS

SOX9 and CD34 were significantly lower in lesional samples of cases compared to perilesional and control skin biopsies. Furthermore, SOX9 level was negatively correlated with the severity of alopecia tool score (SALT score) among the studied AA patients. Moreover, lowered SOX9 expression was present in patients with recurrent attacks.

CONCLUSIONS

The significant reduction of stem cell markers (SOX9 and CD34) in our studied AA cases signifies the pathological affection of HFSCs and their progeny in AA. This is thought to cause a loss of competence in generating new hair in some AA cases, which needs to be validated in further research.

LIMITATIONS OF THE STUDY

This study has a small sample size.

Delivery Strategies of siRNA Therapeutics for Hair Loss Therapy

Therapeutic needs for hair loss are intended to find small interfering ribonucleic acid (siRNA) therapeutics for breakthrough. Since naked siRNA is restricted to meet a druggable target in clinic,, delivery systems are indispensable to overcome intrinsic and pathophysiological barriers, enhancing targetability and persistency to ensure safety, efficacy, and effectiveness. Diverse carriers repurposed from small molecules to siRNA can be systematically or locally employed in hair loss therapy, followed by the adoption of new compositions associated with structural and environmental modification. The siRNA delivery systems have been extensively studied via conjugation or nanoparticle formulation to improve their fate in vitro and in vivo. In this review, we introduce clinically tunable siRNA delivery systems for hair loss based on design principles, after analyzing clinical trials in hair loss and currently approved siRNA therapeutics. We further discuss a strategic research framework for optimized siRNA delivery in hair loss from the scientific perspective of clinical translation.

Use of autologous platelet-rich plasma in androgenetic alopecia in women: a systematic review and meta-analysis

OBJECTIVE

To conduct a systematic review and meta-analysis to verify the efficacy of using autologous platelet-rich plasma (PRP) in female pattern alopecia (FPA).

BACKGROUND

Androgenetic alopecia is the leading cause of hair loss in men andwomen and often impacts self-esteem and quality of life.

DATA SOURCES

MEDLINE/PubMed, Cochrane Library, ClinicalTrials.gov, and EMBASE up to May 2021.

STUDY SELECTION AND DATA EXTRACTION

We identified all studies evaluating the effect of PRP in FPA. A narrative synthesis was performed from data on the efficacy of PRP treatment and adverse effects; quantitative results of PRP use compared to control treatment for female androgenetic alopecia (AGA) were synthesized. The outcomes analyzed were terminal density and hair thickness.

RESULTS

Seven articles were selected for this review. Meta-analysis showed that PRP-based interventions were able to increase terminal hair density compared to control (standardized mean difference (SMD)=2.98, 95% confidence intervals (CIs)=1.10, 4.85), with no significant increase in hair thickness (SMD = 1.16, 95% CI= -0.96, 3.28). During and after treatment, no major side effects were reported by patients or researchers.

CONCLUSIONS

The use of autologous PRP injections in female AGA seems to be promising, with more consistent results on terminal hair density. However, caution is recommended in the interpretation of these results until they can be replicated in larger and more representative samples. PROSPERO registration number CRD42021257154.

Co-delivery of minoxidil and tocopherol acetate ethosomes to reshape the hair Follicular Microenvironment and promote hair regeneration in androgenetic alopecia

The most prevalent kind of hair loss is androgenic alopecia (AGA), which is characterized by hair follicle miniaturization and microenvironment dysfunction. Although topical Minoxidil (MXD) was considered to be a safe and effective treatment for AGA, excess reactive oxygen species (ROS) and lower sulfotransferase activity in the hair follicular microenvironment led to an unsatisfactory treatment of AGA. Here, we developed the ethosome (MTE) load of minoxidil and tocopherol acetate to improve the therapeutic effect of MXD on androgenic alopecia. It could regulate the microenvironment around hair follicles, promote the telogen-to-anagen transition of hair follicles, and boost hair regeneration, thus achieving a synergistic effect of 1 + 1 > 2. The results proved that MTE showed excellent stability, biosafety, and good dermal and follicular permeability in vitro. The hair regeneration ability of AGA model mice showed that the co-delivery ethosome might regulate the microenvironment around the hair follicles and improve hair regeneration in comparison to the commercial minoxidil tincture alone. As a result, the strategy provided a promising new strategy for the treatment of AGA.

Fabrication of carboxymethyl cellulose/hyaluronic acid/polyvinylpyrrolidone composite pastes incorporation of minoxidil-loaded ferulic acid-derived lignin nanoparticles and valproic acid for treatment of androgenetic alopecia

Androgenetic alopecia (AGA) is a transracial and cross-gender disease worldwide with a higher prevalence among young individuals. Traditional oral or subcutaneous injections are often used to treat AGA, however, they may cause severe side-effects and therefore effective treatments for AGA are currently lacking. In this work, to treat AGA, we developed a composite paste system based on minoxidil (MXD)-loaded nanoparticles and valproic acid (VPA) with the assistance of roller-microneedles (roller-MNs). The matrix of composite paste systems is carboxymethyl cellulose (CMC), hyaluronic acid (HA) and polyvinylpyrrolidone (PVP). The roller-MNs can create microchannels in the skin to enhance drug transdermal efficiency. With the combined effects of the stimulation hair follicle (HF) regrowth by upregulating Wnt/beta-catenin of VPA and the mechanical microchannels induced by roller-MNs, the as-prepared composite paste systems successfully boost perifollicular vascularization, and activate hair follicle stem cells, thereby inducing notably faster hair regeneration at a lower administration frequency on AGA mouse model compared with minoxidil. This approach offers several benefits, including the avoidance of efficacy loss due to the liver's first-pass effect associated with oral drug, reduction in the risk of infection from subcutaneous injection, and significant decrease in the side effects of lower-dose MXD.

New Target for Minoxidil in the Treatment of Androgenetic Alopecia

Objective

To investigate the mechanism of minoxidil in treating androgenetic alopecia (AGA).

Methods

The mechanism of action of minoxidil on AGA was first systematically investigated from the viewpoint of network pharmacology, including minoxidil-AGA target prediction, protein-protein interaction (PPI) network analysis, molecular docking and enrichment analysis of targets related to minoxidil and AGA, and dermal papilla cell assays to confirm the viability of prediction.

Results

The combined analysis revealed that minoxidil treatment of AGA not only acts on androgenic receptors (AR) but also on 2 new targets, steroid 17-alpha-hydroxylase/17,20 lyase (CYP17A1) and aromatase (CYP19A1). The biological processes linked to these targets were concentrated on several pathways, including enzymes and hormones. Further experiments have revealed that minoxidil suppresses the expression of AR and CYP17A1, boosts the activity of CYP19A1, decreases the formation and binding of dihydrotestosterone, and enhances the production of estradiol. Through these changes, minoxidil acts as a treatment for AGA.

Conclusion

Minoxidil may act by altering hormonal and enzymatic pathways. Our study finds two new targets (CYP17A1, CYP19A1) of minoxidil and demonstrates that minoxidil inhibits AR. These targets may provide new ideas for drug research.

A study of combination unilateral subcutaneous botulinum toxin a treatment for androgenetic alopecia

OBJECTIVE

To observe the efficacy of unilateral subcutaneous injection of botulinum toxin A combined with finasteride and minoxidil in the treatment of androgenic alopecia.

METHODS

Thirty-seven patients with androgenic alopecia were treated with finasteride and minoxidil as standard therapy and were randomly assigned to subcutaneous injections of botulinum toxin A in one hemisphere of the head at the beginning of a 6-month treatment. Before treatment, 3 months after treatment, and 6 months after treatment, the patient's head hair growth was photographed and evaluated.

RESULTS

After 3 and 6 months of treatment, hair density of the treated androgenic alopecia patients was higher than before treatment (p < 0.05), and the hair density of the botulinum toxin A injection side was higher than that of the control side (p < 0.05). After 6 months of treatment, the response rate of botulinum toxin A combined with finasteride and minoxidil was 77.5%, with no significant side effects observed.

CONCLUSION

Finasteride and minoxidil have a significant effect on androgenic alopecia, and the effect is further increased after combined with botulinum toxin A subcutaneous injection.

Alopecia Areata and Dexamethasone Mini-Pulse Therapy, A Prospective Cohort: Real World Evidence and Factors Related to Successful Response

The mini-pulse oral corticosteroids treatment for alopecia areata (AA) is an accessible treatment whose efficacy and adverse effects have not yet been properly described. The objective of the study was to assess the effectiveness and safety of the mini-pulse oral corticosteroids treatment in patients with AA, and to explore potential factors associated to the response in a real-world setting. An observational study of a prospective cohort to assess the effectiveness and safety of a mini-pulse dexamethasone treatment in patients with AA, who failed to improve with topical therapies, was performed. A SALT II score and other clinical and safety variables were recorded at baseline, 3, 6, 9, and 12 months. An overall significant and progressive decrease of the SALT score was found during treatment: SALT-50 response was achieved after 9 months in 51.8% of the patients. Hypothyroidism and early age of onset were predictors of the lack of response to treatment. The treatment combination with oral minoxidil showed no effect on the SALT score reduction. Dexamethasone daily and cumulative dose were associated with a higher percentage of side effects. To conclude, the mini-pulse oral corticosteroids treatment is an effective treatment for AA, although patients with an early onset of the disease and hypothyroidism may not benefit.

Tissue Engineering and Regeneration of the Human Hair Follicle in Androgenetic Alopecia: Literature Review

Androgenetic alopecia (AGA) is an androgen-dependent process and represents the most frequent non-scarring alopecia. Treatments for AGA do not always achieve a satisfactory result for the patient, and sometimes cause side effects that lead to discontinuation of treatment. AGA therapeutics currently includes topical and oral drugs, as well as follicular unit micro-transplantation techniques. Tissue engineering (TE) is postulated as one of the possible future solutions to the problem and aims to develop fully functional hair follicles that maintain their cyclic rhythm in a physiological manner. However, despite its great potential, reconstitution of fully functional hair follicles is still a challenge to overcome and the knowledge gained of the key processes in hair follicle morphogenesis and biology has not yet been translated into effective replacement therapies in clinical practice. To achieve this, it is necessary to research and develop new approaches, techniques and biomaterials. In this review, present and emerging hair follicle bioengineering strategies are evaluated. The current problems of these bioengineering techniques are discussed, as well as the advantages and disadvantages, and the future prospects for the field of TE and successful hair follicle regeneration.

Efficacy comparison of monotherapies and combination therapies for androgenetic alopecia: A Bayesian network meta-analysis

Even though a variety of treatments for androgenetic alopecia (AGA) currently have been using in clinical, satisfactory therapeutic methods are still lacking. We aimed to compare and rank these treatments for AGA according to their differences in efficacy via Bayesian network meta-analysis, suggesting the optimal therapy for clinical utility to refer. A systematic search of PubMed, Embase, Web of Science, and Cochrane Library database was performed and we included eligible randomized controlled trials. We compared differences in treatment effects of monotherapies and combination therapies using the Bayesian network model. The average difference in alteration from baseline of hair density and hair diameter, and variation value (mean ± SD) between the pre- and post-intervention was selected for main outcome measure and secondary outcome measure. Total 49 RCTs involving 3133 patients and six interventions were included. Regardless of based on hair density or hair diameter, topical/systemic combined with adjunctive therapeutics had the best treatment efficacy among all interventions (MD: 40.11; 95% CrI 25.65-54.59), followed by topical combined with systemic medical therapeutics (MD: 36.41; 95% CrI 17.54-55.24). In addition, in terms of hair density, treatment efficacy had significant difference sequentially among topical medical therapeutics (MD: 22.15; 95% CrI 12.88-31.42), systemic medical therapeutics (MD: 19.91; 95% CrI 6.504-33.22), and adjunctive therapeutics (MD: 18.60; 95% CrI 8.020-29.10) compared to placebo. In recent years, combination therapies are showing significant promise as potential therapies. Taken together with the outcomes of this study, despite the specific mechanism of the effect of combination therapies was not clear and further studies are needed, it may be the best treatment for AGA.

The potential role of hsa_circ_0001079 in androgenetic alopecia via sponging hsa-miR-136-5p

Background

Androgenetic alopecia (AGA) is an androgen‐dependent polygenic hereditary disease.

Methods

Diseased hair follicles from 5 AGA patients and normal hair follicles from 5 healthy individuals were selected as specimens to carry out whole transcriptome sequencing. Multiple high‐expression circular RNAs (circRNAs) were screened from the diseased group. We further verified the presence of the circRNAs in the clinical specimens by real‐time fluorescence quantitative PCR (qRT‐PCR).

Results

In total, 100 circRNAs were significantly upregulated, and 184 circRNAs were significantly downregulated. The top 10 upregulated circRNAs were hsa_circ_0101041, hsa_circ_0001578, hsa_circ_0135062, hsa_circ_0002980, hsa_circ_0005062, hsa_circ_0072688, hsa_circ_0133954, hsa_circ_0001079, hsa_circ_0005974, hsa_circ_0000489. The top 10 downregulated circRNAs were hsa_circ_0001278, hsa_circ_0031482, hsa_circ_0008285, hsa_circ_0003784, hsa_circ_0077096, hsa_circ_0001148, hsa_circ_0006886, hsa_circ_0000638, hsa_circ_0084521, and hsa_circ_0101074. Among top 10 upregulated circRNAs, hsa_circ_0001079 showed significantly high expression via large‐sample verification and clinical application potential. Based on a database comparison and base pairing analysis, we found that has‐miR‐136‐5p bound to hsa_circ_0001079 and that hsa‐miR‐136‐5p had potential binding sites with Wnt5A.

Conclusion

In summary, through high‐throughput sequencing and bioinformatic analysis, a potential diagnostic marker for alopecia and a key circRNA that might adsorb microRNA (miRNA) through a sponging mechanism, thus mediating alopecia, were discovered in this study.

Amphiregulin promotes hair regeneration of skin-derived precursors via the PI3K and MAPK pathways

Objectives

There are significant clinical challenges associated with alopecia treatment, including poor efficiency of related drugs and insufficient hair follicles (HFs) for transplantation. Skin‐derived precursors (SKPs) exhibit great potential as stem cell‐based therapies for hair regeneration; however, the proliferation and hair‐inducing capacity of SKPs gradually decrease during culturing.

Materials and Methods

We describe a 3D co‐culture system accompanied by kyoto encyclopaedia of genes and genomes and gene ontology enrichment analyses to determine the key factors and pathways that enhance SKP stemness and verified using alkaline phosphatase assays, Ki‐67 staining, HF reconstitution, Western blot and immunofluorescence staining. The upregulated genes were confirmed utilizing corresponding recombinant protein or small‐interfering RNA silencing in vitro, as well as the evaluation of telogen‐to‐anagen transition and HF reconstitution in vivo.

Results

The 3D co‐culture system revealed that epidermal stem cells and adipose‐derived stem cells enhanced SKP proliferation and HF regeneration capacity by amphiregulin (AREG), with the promoted stemness allowing SKPs to gain an earlier telogen‐to‐anagen transition and high‐efficiency HF reconstitution. By contrast, inhibitors of the phosphoinositide 3‐kinase (PI3K) and mitogen‐activated protein kinase (MAPK) pathways downstream of AREG signalling resulted in diametrically opposite activities.

Conclusions

By exploiting a 3D co‐culture model, we determined that AREG promoted SKP stemness by enhancing both proliferation and hair‐inducing capacity through the PI3K and MAPK pathways. These findings suggest AREG therapy as a potentially promising approach for treating alopecia.

Mesenchymal Stromal Cell-Conditioned Medium for Skin Diseases: A Systematic Review

The skin is the largest organ of the human body, and its dysfunction is related to many diseases. There is a need to find new potential effective therapies for some skin conditions such as inflammatory diseases, wound healing, or hair restoration. Mesenchymal stromal cell (MSC)-conditioned medium (CM) provides a potential opportunity in the treatment of skin disease. Thus, the objective of this review is to evaluate the uses of MSC-CM for treating skin diseases in both animal and human models. A systematic review was conducted regarding the use of MSC-CM for treating skin conditions. One hundred one studies were analyzed. MSC-CM was evaluated in wound healing (55), hypertrophic scars (9), flap reperfusion (4), hair restoration (15), skin rejuvenation (15), and inflammatory skin diseases (3). MSC-CM was obtained from different MSC sources, mainly adipose tissue, bone marrow, and umbilical cord blood. MSC-CM was tested intravenously, intraperitoneally, subcutaneously, intradermally or intralesionally injected or topically applied. MSC-CM was used in both animals and humans. MSC-CM improved wound healing, hair restoration, skin rejuvenation, atopic dermatitis, and psoriasis in both animals and humans. MSC-CM also decreased hypertrophic scars and flap ischemia in animal models. In conclusion, MSC-CM is a promising therapy for skin conditions. Further studies are needed to corroborate safety and effectiveness and to standardize CM manufacturing.

The Role of Exosomes Derived From Mesenchymal Stromal Cells in Dermatology

The skin is the largest organ of the human body and its main functions include providing protection from external harmful agents, regulating body temperature, and homeostatic maintenance. Skin injuries can damage this important barrier and its functions so research focuses on approaches to accelerate wound healing and treat inflammatory skin diseases. Due to their regenerative and immunomodulatory properties, mesenchymal stromal cells (MSCs) have been reported to play a significant role in skin repair and regeneration. However, it seems that the secretome of these cells and exosomes in particular may be responsible for their functions in skin regeneration and the immunomodulation field. The present review aims to gather the available information about the role of MSC-derived exosomes for both in vitro and in vivo models of different skin conditions and to highlight the need for further research in order to overcome any limitations for clinical translation.

Hair Transplantation Surgery Versus Other Modalities of Treatment in Androgenetic Alopecia: A Narrative Review

Androgenetic alopecia (AGA) is the most common type of baldness and its incidence has increased over the past few years with an earlier age of onset being widely reported all over the world. Although it is reported more often in men, it affects women as well. With the growing cosmetic concern of patients, emphasis has shifted from the more traditional treatment options such as finasteride and minoxidil to surgical options such as hair transplantation. This review briefly highlights all of the treatment options available for AGA so far. A special focus is on current data available on hair transplantation surgeries and the various methods, merits and demerits and limitations of surgery. The literature research considered published journal articles (scientific reviews) from 1990 to date. Studies were identified by searching electronic databases (MEDLINE and PubMed) and the reference lists of respective articles. Only articles available in English were considered for this review.

Current Advanced Therapies Based on Human Mesenchymal Stem Cells for Skin Diseases

Skin disease may be related with immunological disorders, external aggressions, or genetic conditions. Injuries or cutaneous diseases such as wounds, burns, psoriasis, and scleroderma among others are common pathologies in dermatology, and in some cases, conventional treatments are ineffective. In recent years, advanced therapies using human mesenchymal stem cells (hMSCs) from different sources has emerged as a promising strategy for the treatment of many pathologies. Due to their properties; regenerative, immunomodulatory and differentiation capacities, they could be applied for the treatment of cutaneous diseases. In this review, a total of thirteen types of hMSCs used as advanced therapy have been analyzed, considering the last 5 years (2015-2020). The most investigated types were those isolated from umbilical cord blood (hUCB-MSCs), adipose tissue (hAT-MSCs) and bone marrow (hBM-MSCs). The most studied diseases were wounds and ulcers, burns and psoriasis. At preclinical level, in vivo studies with mice and rats were the main animal models used, and a wide range of types of hMSCs were used. Clinical studies analyzed revealed that cell therapy by intravenous administration was the advanced therapy preferred except in the case of wounds and burns where tissue engineering was also reported. Although in most of the clinical trials reviewed results have not been posted yet, safety was high and only local slight adverse events (mild nausea or abdominal pain) were reported. In terms of effectiveness, it was difficult to compare the results due to the different doses administered and variables measured, but in general, percentage of wound's size reduction was higher than 80% in wounds, Psoriasis Area and Severity Index and Severity Scoring for Atopic Dermatitis were significantly reduced, for scleroderma, parameters such as Modified Rodnan skin score (MRSC) or European Scleroderma Study Group activity index reported an improvement of the disease and for hypertrophic scars, Vancouver Scar Scale (VSS) score was decreased after applying these therapies. On balance, hMSCs used for the treatment of cutaneous diseases is a promising strategy, however, the different experimental designs and endpoints stablished in each study, makes necessary more research to find the best way to treat each patient and disease.