Efficacy of the association of topical minoxidil and topical finasteride compared to their use in monotherapy in men with androgenetic alopecia: A prospective, randomized, controlled, assessor blinded, 3-arm, pilot trial

PURPOSE

Topical minoxidil (MNX) 2%-5% and oral finasteride (F) 1 mg/day are the only two pharmacological treatments authorized for androgenetic alopecia (AGA). Recently, a 2.2 mg/mL topical formulation of F was developed to minimize the systemic adverse effects associated with the oral formula. MNX and F act through different mechanisms; therefore, their association could improve clinical efficacy. To evaluate the efficacy of the association of 5% MNX and 0.25% topical F compared to their use in monotherapy, a 6-month, prospective, randomized, assessor-blinded trial was conducted.

PATIENTS AND METHODS

Forty-two males, mean age 24 ± 3 years, with AGA (I-VII of Norwood-Hamilton Grading Scale), treatment naive or free from any therapy for at least 6 months, were enrolled and randomly assigned to three arm treatment groups (2:1:1): group A (n = 19, the subjects applied 5% MNX in the morning and F spray in the evening), group B (n = 12, the subjects applied F spray in the evening), and group C (n = 11, the subjects applied 5% MNX twice daily). The efficacy of treatments was evaluated at baseline and after 3 and 6 months using a global photography score (GPAS; from -3 to +3) and trichoscopy evaluation and assessed by an investigator unaware of treatment allocation. At baseline and after treatments, the serum levels of follicle-stimulating hormone (FSH), luteinizing hormone (LH), dehydroepiandrosterone sulfate (DHEA-S), and testosterone were also evaluated.

RESULTS

All treatments resulted in an increase in hair density compared to baseline. However, this improvement was significant only for group A (MNX + F), both at three (+56 density/cm2 , p < 0.05) and six (+81 density/cm2 , p < 0.001) months. The mean change from baseline in hair density was higher for group A compared to other groups and statistically different compared to group B (F) (p < 0.01), both after 3 and 6 months. Group A showed a global photographic assessment score (GPAS) significantly higher compared to group B (p < 0.001) and group C (p < 0.05) both at 3 and 6 months (2.0 ± 0.7 vs. 0.6 ± 0.8 and 1.3 ± 0.6; respectively). A significantly greater percentage of subjects in Group A achieved a GPAS score of ≥2 in comparison with Groups B and C both after 3 and 6 months (79% vs. 8% and 41%, respectively). No significant differences were observed in mean hair diameter and hormonal levels between the three groups. Good tolerability was observed in all treated groups.

CONCLUSION

The association of 5% MNX lotion and 0.25% F in spray formulation in patients with AGA showed a significantly higher clinical and instrumental efficacy compared to the monotherapies, with comparable tolerability and safety profile.

Clinical study on the efficacy and tolerability of a topical regenerative treatment in patients with telogen effluvium and mild androgenetic alopecia

Hair loss may change the quality of life since modern society considers hair an essential element in beauty definition. The most common causes of hair loss are androgenetic alopecia (AGA) and telogen effluvium (TE). AGA requires a lifetime use of minoxidil or finasteride (and sometimes they lose efficacy over the years), whereas TE has no standardized therapy available. Our study focuses on a novel topical regenerative preparation that, by mimicking autologous PRP, can safely and efficiently improve hair loss in patients affected by TE and AGA.

A Machine Learning Algorithm Applied to Trichoscopy for Androgenic Alopecia Staging and Severity Assessment

INTRODUCTION

Androgenic alopecia (AGA) staging is still based on macroscopic scales, yet the introduction of trichoscopy is gradually bringing an important change, even though it remains an eye-based method. However, recently developed artificial intelligence-assisted programs can execute automated count of trichoscopic patterns. Nevertheless, to interpret data elaborated by these programs can be complex. Machine learning algorithms might represent an innovative solution. Among them, support vector machine (SVM) models are among the best methods for classification.

OBJECTIVES

Our aim was to develop a SVM algorithm, based on three trichoscopic patterns, able to classify AGA patients and to calculate a severity index.

METHODS

We retrospectively analyzed trichoscopic images from 200 AGA patients using Trichoscale Pro® software, calculating the number of vellus hair, empty follicles and single hair follicular units. Then, we elaborated a SVM model, based on these three patterns and on sex, able to classify patients as affected by mild AGA or moderate-severe AGA, and able to calculate the probability of the classification being correct, expressed as percentage (from 50% to 100%). This probability estimate is higher in patients with more AGA trichoscopic patterns and, thus, it might serve as a severity index.

RESULTS

For training and test datasets, accuracy was 94.3% and 90.0% respectively, while the Area Under the Curve was 0.99 and 0.95 respectively.

CONCLUSIONS

We believe our SVM model could be of great support for dermatologists in the management of AGA, especially in better assessing disease severity and, thus, in prescribing a more appropriate therapy.

Detection of novel therapies using a multi-national, multi-institutional registry of cutaneous immune-related adverse events and management

BACKGROUND

Cutaneous immune-related adverse events (cirAEs) remain a prevalent and common sequelae of immune checkpoint inhibitor (ICI) therapy, often necessitating treatment interruption and prolonged immune suppression. Treatment algorithms are still poorly defined, based on single-institution case reports without adequate safety assessments, and subject to publication bias.

METHODS

Data in this registry were collected through a standardized REDCap form distributed to dermatologists via email listserv.

RESULTS

Ninety-seven cirAEs were reported from 13 institutions in this registry. Topical and systemic steroids were the most common treatments used; however, targeted treatment matched to disease morphology was identified at numerous sites. Novel cirAE therapy uses that to our knowledge have not been previously described were captured including tacrolimus for the treatment of follicular, bullous, and eczematous eruptions and phototherapy for eczematous eruptions. Moreover, further evidence of cirAE treatment applications sparsely described in literature were also captured in this study including dupilumab and rituximab for bullous eruptions, phototherapy for lichenoid and psoriasiform eruptions, and acitretin for psoriasiform eruptions, among others. No serious adverse events were reported. Numerous targeted therapeutics including dupilumab, rituximab, and psoriasis biologics, among others, were associated with a cirAE grade improvement of ≥2 grades in every patient treated.

CONCLUSION

This study suggests that a multi-institutional registry of cirAEs and management is not only feasible but that the information collected can be used to detect, evaluate, and rigorously assess targeted treatments for cirAEs. Further expansion and modification to include treatment progression may allow for sufficient data for specific treatment recommendations to be made.

Multinational Association of Supportive Care in Cancer (MASCC) clinical practice guidelines for the prevention and management of acute radiation dermatitis: international Delphi consensus-based recommendations

Acute radiation dermatitis is a frequent adverse effect of radiotherapy, but standardisation of care for acute radiation dermatitis is lacking. Due to the conflicting evidence and variability in current guidelines, a four-round Delphi consensus process was used to compile opinions of 42 international experts on care for people with acute radiation dermatitis on the basis of the evidence in existing medical literature. Interventions for acute radiation dermatitis prevention or management that reached at least 75% consensus were recommended for clinical use. Six interventions could be recommended for the prevention of acute radiation dermatitis: photobiomodulation therapy and Mepitel film in people with breast cancer, Hydrofilm, mometasone, betamethasone, and olive oil. Mepilex Lite dressings were recommended for the management of acute radiation dermatitis. Most interventions were not recommended due to insufficient evidence, conflicting evidence, or lack of consensus to support use, suggesting a need for further research. Clinicians can consider implementing recommended interventions in their practice to prevent and manage acute radiation dermatitis until additional evidence becomes available.

Clinical and Trichoscopic Graded Live Visual Scale for Androgenetic Alopecia

Introduction

Currently, the mostly used classifications of androgenetic alopecia (AGA) only provide a macroscopic and subjective description of this disorder, without evaluating trichoscopic features.

Objectives

The aim of this study is to elaborate a graded live visual AGA severity scale including macroscopic and microscopic (trichoscopic) pictures, and to determine the most frequent trichoscopic characteristics associated to each grade.

Methods

A retrospective observational study was conducted on 122 patients (50 females and 72 males) affected by AGA. Macroscopic and trichoscopic photographs were taken at standardized scalp points.

Results

Each picture was ranked from AGA stage I to VII, according to Hamilton scale for men and Sinclair scale for women, and the most representative images of each severity degree were collected to produce a graded live visual scale. In males, 2 live visual scales, 1 for the anterior and 1 for posterior region of the scalp were created. In females, only 1 scale of the anterior region was realized. For each stage of severity, the corresponding trichoscopic parameters were statistically analyzed.

Conclusions

We realized new macroscopic and trichoscopic graded live visual scales for male and female patients affected by AGA, which could help physicians in giving an objective evaluation of the disease and in better managing it.

Recurrence of alopecia areata after covid-19 vaccination: A report of three cases in Italy

BACKGROUND

Common COVID-19 vaccines side effects are pain at the injection site, muscle pain, fever, headaches, fatigue. Possible immune-related side effects in predisposed individuals have not been established so far.

MATERIALS AND METHODS

We report three cases of recurrence of alopecia areata (AA) occurred after the first dose of COVID-19 vaccine.

RESULTS

All patients had previous episodes of AA with total hair regrowth and stable remission during the months preceding the vaccination. Rapid hair loss occurred 2-3 weeks after BNT162b2 mRNA (patient 1) and AZD1222/ChAdOx1 vaccine (patient 2 and 3), with widespread hair loss in two cases and a single patch of the vertex in one case, with typical trichoscopic features of AA.

DISCUSSION

Both BNT162b2 mRNA and AZD1222/ChAdOx1 vaccines share the same goal of inducing the immune system, with antibodies production and Th1 cells activation with release of pro-inflammatory cytokines. Thus, in patients with pre-existing inflammatory dysregulated pathways, the interaction between the immune system and vaccines may enhance other autoimmune mechanisms. In our cases, we speculate that vaccine may have induced the hair loss focusing on components having a key role in both COVID-19 vaccination and AA pathogenesis.

CONCLUSION

This report may help to collect new data concerning possible immune-related effects of vaccines. Certainly, only three cases are not sufficient to draw conclusion, thus a large-scale study is necessary. Immune-mediated side effects remain a rare event, thus the benefits of COVID-19 vaccines outweigh the risk of disease flares and we strongly recommend it in all eligible patients with AA.

Clinical aspect, pathogenesis and therapy options of alopecia induced by hormonal therapy for breast cancer

Adjuvant hormonal therapy is one of the most important treatments of hormone-receptor-positive breast cancer and includes selective estrogen receptor modulators, aromatase inhibitors, and luteinizing hormone-releasing hormone analogs. In patients receiving these drugs, a progressive recession of frontal-temporal hairlines is often observed, such as a certain grade of hair miniaturization in the same areas and the central scalp area, producing a pseudo-female androgenic alopecia, which has to be considered oncotherapy-induced alopecia. The aim of this work, is to describe the clinical aspects and pathogenesis of this type of alopecia and to analyze the different drugs which have been proposed until now. The authors concude that topical hormones should not be considered as a therapeutic approach because of their direct or indirect oncogenic potential. A therapeutic approach that could be both safe and effective is proposed.

Are dissecting cellulitis and hidradenitis suppurativa different diseases?

Although dissecting cellulitis (DC) and hidradenitis suppurativa (HS) are classified separately, they share many clinical, dermatoscopic, pathogenetic, and histologic aspects, as well as therapeutic options. The association between DC, HS, and acne conglobata represents the follicular occlusion triad or follicular occlusion tetrad, which may include a pilonidal sinus. DC, also known as "folliculitis et perifolliculitis capitis abscendes et suffoidens," is classified as a secondary cicatricial and neutrophilic alopecia. It occurs with perifolliculitis of the scalp, dermal abscesses, sinus tract development, and secondary scarring alopecia. HS, sometimes known as acne inversa, is a chronic relapsing inflammatory disease afflicting apocrine gland-rich areas of the body with painful nodules and abscesses, sinus tracts, and scarring. Given the overlap between the clinical features and the pathogenesis of DC and HS, it would be more appropriate to consider these conditions as two different localizations of the same disease rather than two different pathologies, being a follicular occlusion disease occurring on the scalp and on the apocrine gland-rich areas of the body.

Frontal Fibrosing Alopecia: A New Association with Lichen Sclerosus in Men

BACKGROUND

Frontal fibrosing alopecia (FFA) is a scarring alopecia that has been reported mostly in postmenopausal women and is characterized by frontotemporal hairline. Currently, there are only a few reports about FFA in male patients.

OBJECTIVE

This study sought to analyze clinical and trichoscopic features of FFA in a case series of men and to describe the main features of FFA in male patients through a review of the literature.

METHODS

Male patients with clinical and trichoscopical signs of FFA, histologically confirmed, who attended to our clinic from 2014 to 2019 were included in our study. From each patient, clinical and trichoscopic data were collected.

RESULTS

Eight men with an average age of 59 years were recruited. In five patients, serrated hairline recession (i.e., a "zig-zag" pattern) was present, while three presented with linear hairline recession. Also, the eyebrows (n=3 patients), sideburns (n=2 patients), and beard (n=2 patients) were involved. Surprisingly, in two patients, an association with lichen sclerosus (LS) was present.

CONCLUSION

To the best of our knowledge, this is the first report of a serrated hairline recession pattern in male patients with FFA. A new association between FFA and LS in men was also found. Further studies need to establish the extent of this association and facilitate a better comprehension of the pathophysiologic mechanisms underlying these two diseases.

Fluorescence advanced videodermoscopy: a new method of hairs and scalp evaluation. Comparison with trichoscopy

INTRODUCTION

Non-invasive diagnostic methods in clinical dermatology are widely used to reduce the need for invasive techniques, with great advantages in terms of cost and time. Dermoscopy is the reference test for the in vivo diagnosis of cutaneous lesions, and when it is performed on the scalp region it is named trichoscopy. Fluorescence advanced videodermoscopy (FAV) has been lately proposed as a new non-invasive method for the in vivo skin examination at high magnification, with cell-level resolution. So far, it has shown promising results for the assessment of melanocytic and vascular lesions and for the in vivo diagnosis of parasitosis.

OBJECTIVES

This observational study aims to perform, for the first time, a morphologic study of healthy scalp and scalp elementary lesions using FAV and to compare it with trichoscopy.

METHODS

We enrolled 90 healthy individuals for the evaluation of the scalp using FAV. Then, we recruited 53 patients with alopecia and collected images of the elementary lesions using FAV and trichoscopy.

RESULTS

Three hundred healthy scalp FAV images of different epidermal layers, papillary dermis, follicular ostia and healthy hair shafts were collected. Three hundred and eighty FAV and trichoscopic images of alopecic scalp elementary lesions were collected, showing that FAV provided a more detailed observation than trichoscopy, with higher magnification and cellular resolution.

CONCLUSION

Fluorescence advanced videodermoscopy may represent a new valid technique of support to trichoscopy, adding further information, increasing chances of diagnosis and decreasing the need of invasive procedures.

Telogen Effluvium after SARS-CoV-2 Infection: A Series of Cases and Possible Pathogenetic Mechanisms

INTRODUCTION

Physicians have largely studied the cutaneous involvement of coronavirus disease 2019 (COVID-19), but only few reports have focused on telogen effluvium (TE) as a possible sequela of COVID-19. We assessed 14 cases of hair loss occurring after SARS-CoV-2 infection using trichoscopy and trichogram to investigate patterns related to COVID-19. Furthermore, we discussed possible mechanisms involved in COVID-19 TE.

CASE PRESENTATION

Fourteen individuals were referred to our post-COVID-19 dermatology office complaining acute hair loss after SARS-CoV-2 infection. Clinical evaluation included pull test, trichoscopy, and trichogram. CO-VID-19 TE occurred after a median of 2 months (range 1-3 months) following SARS-CoV-2 infection. The median duration of hair loss was 5 months (range 1-6 months). Trichoscopy showed variable but typical TE patterns. Trichogram showed different telogen/anagen ratio depending on the interval between onset of hair loss and trichological visit.

DISCUSSION/CONCLUSION

Our cases showed TE between 1 and 3 months after the onset of SARS-CoV-2 infection, thus earlier than classic TE. Trichoscopic features and trichogram showed no variations from classic TE. Different pathogenetic mechanisms including pro-inflammatory cytokines and direct viral damage on the hair follicle can be hypothesized; further studies on a larger sample are needed to better understand this condition.

A new combination of molecules for the treatment of androgenetic alopecia and telogen effluvium: a double-blind randomized, monocentric, placebo-controlled study

BACKGROUND

Androgenetic alopecia (AGA) is the most frequent form of alopecia. Telogen effluvium (TE) is a common form of diffuse hair loss mainly observed in women. The aim of our study was to evaluate the efficacy of a topical trichological treatment containing a new combination of molecules for the treatment of AGA and TE.

METHODS

In-vitro tests were performed analyzing different combinations and concentrations of arginine, zinc and a third enzymatically neutral substance called AA on human follicles dermal papillae cells. These tests evaluated the capability of inhibiting the 5α-reductase (5-AR) enzyme and the 5-AR gene expression. We also performed an in-vivo study. Forty individuals affected by AGA and TE were divided into two groups. One group was administered a combination of zinc and arginine (lotion A), whilst the other placebo (lotion B). Therapy duration was 23 consecutive weeks. Follow-up examinations and pull tests occurred at baseline, after 6 weeks and at the end of the therapy. On 20 randomly selected patients we also performed noninvasive phototrichograms.

RESULTS

In-vitro tests showed that the combination had a strong statistically significant inhibitory activity on 5-AR of dermal papillae cells. Number of hairs removed by pull-test significantly decreased at T0, T1 and T2 in patient treated with lotion A. We also observed an increase in the percentage of anagen hair and a decrease in telogen hairs. Concerning phototrichograms, all objective parameters evaluated showed better results in the lotion A group when compared with the placebo group.

CONCLUSIONS

Based on our results, the combination of arginine and zinc tested in our study could represent a good therapeutic option for the treatment of AGA and TE and it might represent a valid alternative to finasteride.

Alopecia areata treated with topical and systemic brevilin A: A case series

Alopecia areata (AA) is an autoimmune T CD8 cell mediated condition clinically characterized by hair loss from single or few small patches to complete hair loss. The management of AA is challenging and all available therapies does not ensure a long-term remission. To assess the safety and efficacy of both systemic and topical brevilin A, a natural compound, in AA patients not responding to other treatments. After obtaining informed consent, we administered off-label brevilin A to 13 adult patients affected by AA, for a period ranging from 6 to 18 months. Medical records for each patient and the severity of alopecia tool (SALT) score before and after brevilin A administration were recorded. The mean SALT score of our patients was 81.03 (SD 34.9) at baseline and 75.8 (SD 37.4) after brevilin A therapy, meaning no statistically significant improvement was observed (P = .2385 Paired t test). However, three multifocal AA (MAA) patients out of four attained an improvement (75%) suggesting that brevilin A may be represent an alternative therapy in this form of AA. Authors conclude that brevilin A could represent in the future a possible effective treatment in MAA forms but further studies are required.

Alopecia areata treated with dimethyl fumarate: A case series

Alopecia areata is an autoimmune condition leading to non-scarring hair loss. Clinically, several presentations ranging from single or few small patches to complete hair loss are documented. The management of alopecia areata is challenging and all available treatments do not ensure a long-term remission to assess the safety and efficacy of systemic dimethyl fumarate in alopecia areata patients not responding to other systemic treatments. After obtaining informed consent, we administered off-label dimethyl fumarate to 10 adult patients with alopecia areata, for a period ranging from 4 to 37 weeks. Medical information for each patient and the severity of alopecia tool (SALT) score before and after dimethyl fumarate administration were recorded. During the treatment, 50% of patients (5 patients out of 10) had a slight improvement of hair regrowth; it was mainly as partial hair regrowth (ranging from 8% to 32%) and only one patient (10%) achieved > 50% terminal hair regrowth. Authors conclude that dimethyl fumarate is not advisable as a treatment of alopecia areata, also considering the risk of fumaric acid esters toxicity.

Frontal fibrosing alopecia and genital Lichen sclerosus: Single-center experience

BACKGROUND

Despite the incidence of Frontal fibrosing alopecia (FFA) has been increasing in last two decades, the pathophysiology and trigger factors of FFA have not been yet fully understood.

AIMS

The aim of this study was to describe epidemiology, clinical and trichoscopic features and comorbidities of FFA patients, in order to improve the understanding of this disease.

PATIENTS/METHODS

A retrospective, observational monocentric study was conducted from 2003 to 2019. Data concerning epidemiology (age, gender, age of menopause, and age of FFA onset), comorbidities, current therapies, localization of FFA (such as frontotemporal hairline, occipital, eyebrow, eyelash, beard, sideburns, and body hair), presence of papules and sign of Lichen planus (LP) at skin, mucosae and/or nail were collected for each patient included.

RESULTS

A total of 119 Caucasian, adult patients (8 men and 111 female) with FFA were enrolled in the study. Cutaneous, mucosal, or nail localization of LP were found in 16% of our subjects. Interestingly, 15 out of 119 subjects (10.61%) were affected by concomitant genital Lichen sclerosus (LS) and 5 out of these 15 patients (4.38%) presented both LS and LP in association with FFA.

CONCLUSION

Considering the high prevalence of LS in FFA patients in our case series, and the frequency of autoimmune comorbidities in both LS and FFA, it is possible to hypothesize an autoimmune process in both conditions. Further studies are needed for a better understanding of the nature of the association between LS and FFA.

Dermatologic management of oncotherapy side effects: A proposed algorithm

Since the introduction of the first chemotherapeutic regimens for the treatment of oncological disease, hundreds of drugs have been approved for cancer treatment and many more are under investigation. The development of newer drugs such as target therapies, immuno-oncotherapies, and hormonal therapies has increased in specificity with the development of smaller molecules and more selective targets. Cutaneous side effects are now well known for both standard chemotherapy and targeted therapies. The correct diagnosis and management of these effects are of vital importance both to optimize therapeutic success rates and to reduce the patient's suffering. In fact, the appearance of a cutaneous adverse event can be responsible for a reduction in drug dosage or worse its suspension. In order to achieve this objective, we propose a management algorithm, based on three different steps, before, during, and after the oncological treatments, respectively. Our proposal underlines the importance of correct skin care measures to limit or reduce the severity of side effects.

Prevention and Treatment of Chemotherapy-Induced Alopecia

Background

Chemotherapy-induced alopecia (CIA) is one of the most dramatic side effects of chemotherapy. Currently no guidelines are available for its prevention and treatment. Several devices and drugs are used, but results are often disappointing.

Aims

Our aim is to analyze drugs and devices proposed in the literature for prevention and treatment of CIA induced by cytotoxic drugs and to discuss the evidenced-based opinion.

Methods and Results

Scalp cooling is the only agent that has been approved by the US Food and Drug Administration for CIA prevention. Minoxidil and bimatoprost should not be used during chemotherapy administration, but they can be used after chemotherapy discontinuation to obtain greater regrowth.

Conclusions

Therapy should always be modulated for the patient and no fixed protocol should be used. Trichoscopy and trichogram could be useful tools in supporting this treatment.

A new treatment of alopecia induced by palbociclib: Topical cetirizine

INTRODUCTION

Recently CDK4/6 inhibitors have been introduced for the treatment of hormone positive breast cancer resistant to endocrine therapy. Among their side effects, alopecia is often reported being associated to patients' distress and depressive symptoms.

CASE REPORT

We report the case of a 70-year-old woman affected by breast cancer in treatment with Palbociclib, who developed alopecia.Management and Outcome: We prescribed a topical solution with cetirizine. Global photography, trichoscopy and trichogram were assessed. All evaluations demonstrated alopecia improvement.

DISCUSSION

Currently, no treatment options for CDK 4/6 inhibitors induced alopecia have been proposed. Herein, we report the use of topical cetirizine.

Efficacy of Topical Finasteride 0.5% vs 17α-Estradiol 0.05% in the Treatment of Postmenopausal Female Pattern Hair Loss: A Retrospective, Single-Blind Study of 119 Patients

Background and Objectives

Female pattern hair loss (FPHL) is a common form of scalp hair loss that occurs in 38% of females. Currently, minoxidil solution is the only therapy approved by the US Food and Drug Administration, but many other treatments are used, including cyproterone acetate, spironolactone, topical 17α-estradiol, and prostaglandin analogs. Systemic finasteride has been considered a treatment option in women even though its teratogenic effects tend to limit its prescription. Recently, topical finasteride has been evaluated to limit the side effect profile of the drug. The objective of the present study is to compare retrospectively the efficacy of topical 0.05% 17α-estradiol solution and a 0.5% finasteride lotion in the treatment of FPHL.

Patients and Methods

We enrolled 119 postmenopausal female patients. The first group comprised 69 women treated with finasteride 0.5% and minoxidil 2%. The second group included 50 women treated with 17α-estradiol 0.05% and minoxidil 2%. At baseline and at 6- and 12- to 18-month follow-up, global photographs were systematically taken. Three operators blind to the prescribed treatment evaluated photographs using a 7-point scale. One-way analysis of variance and unpaired Student t tests were performed to analyze 7-point scale scores.

Results

The improvement was statistically significant from 6 months to 12-18 months, both for finasteride (P < 0.005) and 17α-estradiol (P < 0.05). The efficacy of topical finasteride was significantly greater than that of 17α-estradiol solution, both at the 6-month (P < 0.05) and at the 12- to 18-month follow-up (P < 0.005). In general, the highest improvement was observed after 12-18 months of treatment with topical finasteride therapy.

Conclusions

Topical finasteride 0.5% in combination with minoxidil 2% could represent a valid therapeutic option for the treatment of postmenopausal FPHL, showing higher efficacy than topical 17α-estradiol with minoxidil 2% both at 6-month and 12- to 18-month follow-up.

Capillaroscopy: a new application for the evaluation of vascular side-effects induced by chemotherapy

BACKGROUND

Cancer survivors are rising up, but this better survival is accompanied by possible treatments side-effects. In particular, cardiovascular effects are commonly reported, even if vascular damage is not necessarily connected to clinical manifestations. Periungual microcircle evaluation through capillaroscopy could identify asymptomatic patients with high risk of cerebro-cardio-vascular disease. The aim of this pivotal study was to evaluate videocapillaroscopy in patients who undergo chemotherapy, in order to understand if it could represent in future a prognostic tool to predict the risk of cardio-cerebro-vascular events.

METHODS

We conducted an open-label, uncontrolled study. Patients affected by solid tumors were enrolled. Each subject underwent a clinical evaluation and a videocapillaroscopic examination.

RESULTS

We selected 25 patients. Mean age was 55.48 years. Time interval between the start of chemotherapy and capillaroscopy: average 41 months. From our analysis it emerges that ectasia and hemorrhages could be a possible marker of capillary insult caused by chemotherapy.

CONCLUSIONS

Our study showed the presence of capillaroscopic features that may be peculiar in chemotherapy-induced endothelial damage. The individuation of capillaroscopic alteration specific for chemotherapy-induced endothelial injury could be an important tool to identify patients with high cardiovascular risk.

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.

The diagnosis of androgenetic alopecia in children: Considerations of pathophysiological plausibility

Androgenetic alopecia (AGA), one of the most common causes of hair loss in men and women, is an infrequent cause of alopecia in children. In AGA, patients generally start noticing hair thinning after the onset of puberty due to progressive miniaturisation of the hair follicle which leads to vellus transformation of terminal hair. However, the occurrence of prepubertal AGA has rarely been reported in the literature. The pathophysiology of AGA is tightly linked to androgen hormones; prepubertal children do not usually produce significant amounts of adrenal or gonadal androgens. When it does occur, an underlying abnormality should be suspected. Secondary causes of AGA must be excluded when evaluating a patient before the appearance of puberty. Premature puberty, polycystic ovarian syndrome and other causes of hyperandrogenism can present with hair loss in an androgenetic pattern. This article reviews the normal physiology of androgen hormones and their role in the pathophysiology of childhood AGA.

Sono-activated persulfate oxidation of diclofenac: Degradation, kinetics, pathway and contribution of the different radicals involved

Degradation of a diclofenac aqueous solution was performed using persulfate anions activated by ultrasound. The objective of this study was to analyze different parameters affecting the diclofenac (DCF) removal reaction by the ultrasonic persulfate (US/PS) process and to evaluate the role played by various intermediate oxidative species such as hydroxyl- and sulfate radicals, superoxide radical anion or singlet oxygen in the removal process as well as to determine a possible reaction pathway. The effects of pH, initial persulfate anion concentration, ultrasonic amplitude and temperature on DCF degradation were examined. Sulfate and hydroxyl radicals were involved in the main reaction pathway of diclofenac. Diclofenac amide and three hydroxy-diclofenac isomers (3´-hydroxy diclofenac, 4´-hydroxy diclofenac and 5-hydroxy diclofenac) were identified as reaction intermediates.

Androgenetic alopecia: a review

PURPOSE

Androgenetic alopecia, commonly known as male pattern baldness, is the most common type of progressive hair loss disorder in men. The aim of this paper is to review recent advances in understanding the pathophysiology and molecular mechanism of androgenetic alopecia.

METHODS

Using the PubMed database, we conducted a systematic review of the literature, selecting studies published from 1916 to 2016.

RESULTS

The occurrence and development of androgenetic alopecia depends on the interaction of endocrine factors and genetic predisposition. Androgenetic alopecia is characterized by progressive hair follicular miniaturization, caused by the actions of androgens on the epithelial cells of genetically susceptible hair follicles in androgen-dependent areas. Although the exact pathogenesis of androgenetic alopecia remains to be clarified, research has shown that it is a polygenetic condition. Numerous studies have unequivocally identified two major genetic risk loci for androgenetic alopecia, on the X-chromosome AR⁄EDA2R locus and the chromosome 20p11 locus.

CONCLUSIONS

Candidate gene and genome-wide association studies have reported that single-nucleotide polymorphisms at different genomic loci are associated with androgenetic alopecia development. A number of genes determine the predisposition for androgenetic alopecia in a polygenic fashion. However, further studies are needed before the specific genetic factors of this polygenic condition can be fully explained.

Chemotherapy-induced alopecia management: Clinical experience and practical advice

BACKGROUND

Chemotherapy-induced alopecia (CIA) is probably one of the most shocking aspects for oncological patients and underestimated by physicians. Among hair loss risk factors, there are treatment-related aspects such as drug dose, administration regimen, and exposure to X-rays, but also patient-related characteristics. To the best of our knowledge, no guidelines are available about CIA management.

AIMS AND METHODS

With this study, based on literature background and our clinical experience, we would like to propose a list of actions in order to estimate the risk of hair loss before starting chemotherapy and to manage this condition before, during, and after drug administration and to create a sort of practical guide for dermatologists and oncologists.

RESULTS AND CONCLUSION

There is an urgent need for prospective studies to clarify the mechanistic basis of alopecia associated with these drugs and consequently to design evidence-based management strategies.

Multi-therapies in androgenetic alopecia: review and clinical experiences

Androgenetic alopecia (AGA) is a genetically determined progressive hair-loss condition which represents the most common cause of hair loss in men. The use of the medical term androgenetic alopecia reflects current knowledge about the important role of androgens and genetic factors in its etiology. In addition to androgen-dependent changes in the hair cycle, sustained microscopic follicular inflammation contributes to its onset. Furthermore, Prostaglandins have been demonstrated to have the ability in modulating hair follicle cycle; in particular, PGD2 inhibits hair growth while PGE2/F2a promote growth. Due to the progressive nature of AGA, the treatment should be started early and continued indefinitely, since the benefit will not be maintained upon ceasing therapy. To date, only two therapeutic agents have been approved by the Food and Drug Administration and European Medicines Agency for the treatment of AGA: topical minoxidil and oral finasteride. Considering the many pathogenetic mechanisms involved in AGA, various treatment options are available: topical and systemic drugs may be used and the choice depends on various factors including grading of AGA, patients' pathological conditions, practicability, costs and risks. So, the treatment for AGA should be based on personalized therapy and targeted at the different pathophysiological aspects of AGA.

Efficacy and tolerability of a spray product containing hydroxypropyl chitosan, climbazole and piroctone olamine, applied twice weekly for the treatment of the pitiriasis versicolor

BACKGROUND

The aim of this study was to demonstrate the effectiveness of a product containing hydroxypropyl chitosan, climbazole and piroctone olamine, by monitoring the adherence and the penetration of the molecules in the skin. Confocal microscopy led us to show the persistence of the active compound for a long time in the stratum corneum, thanks to the presence of hydroxypropyl chitosan. This evidence suggests a new protocol of application (a biweekly application, rather than daily).

METHODS

Thirty patients (17 males, 13 females; average age 20.8 years) were selected from 3 dermatological centers: the Dermatological Clinic of "Federico II" University of Naples; the Dermatological outpatient clinic of Bologna private hospital "Villa Nigrisoli"; the Section of Cutaneous Appendages of the European Dermatological Institute of Milan. The study protocol entailed application of a topical spray product 2 evenings a week for 2 months. Confocal microscopy, dermoscopy and photographic documentation were performed at the moment of diagnosis (T0), 12 hours after the first application (T1), after 7 days (T2), after 1 month (T3) and after 2 months (T4).

RESULTS

The improvements of clinical symptoms were documented by dermoscopy and digital photos. Confocal microscopy shows the persistence of the product in the stratum corneum, at different times of observations.

CONCLUSIONS

A biweekly application of a product containing hydroxypropyl chitosan, climbazole and piroctone olamine shows a clinical significative improvement, evaluated through digital photographs and dermoscopic images, with complete resolution at T4 in 100% of cases.

Acneiform Rash Induced by EGFR Inhibitors: Review of the Literature and New Insights

Acneiform rash is the most common side effect of epidermal growth factor receptor (EGFR) inhibitors (EGFRis), and it occurs in 50-100% of patients. This condition can affect the quality of life of these patients and can sometimes lead to a discontinuation of the antineoplastic therapy. Several recent prospective studies have addressed and evaluated different interventions to mitigate or reduce the severity of EGFRis-associated skin rash. With this aim, we have established a dermocosmetological outpatient clinic for cancer patients at the Department of Clinical Medicine and Surgery, University of Naples Federico II in collaboration with the Department of Dermatology and Cutaneous Surgery, Miller School of Medicine, University of Miami. An interdisciplinary network of physicians can improve the quality of life of the cancer patients, focusing on such important aspects as dermocosmetological skin care, but also on the evaluation of new therapeutic and diagnostic algorithms in order to make further progress in the field of prevention. In this review, we summarize the state of the art of the epidemiology, pathogenesis, and treatment of EGFRis acneiform rash, and we describe our outpatient clinical experience.

Assessment of health economics in Alzheimer's disease (AHEAD): galantamine treatment in Canada

BACKGROUND

Given the high costs of caring for patients with AD in Canada, it is important to evaluate the costs of new therapies that halt or delay the advancement of AD, relative to the savings associated with delaying disease progression.

METHODS

The Assessment of Health Economics in Alzheimer's Disease (AHEAD) model, which uses algorithms to predict the time until patients with AD require full-time care (FTC), was adapted to Canada to compare treatment with galantamine versus no pharmacologic treatment. Data from two clinical trials provided inputs into the algorithms, and forecasts were made for up to 10 years. Drug and health care costs were evaluated according to the stage of disease based on Quebec unit costs along with follow-up data from the Canadian Study of Health and Aging.

RESULTS

Galantamine is predicted to reduce the duration of FTC by almost 10%. Approximately 5.6 patients with mild to moderate disease must be placed on treatment to avoid one year of FTC, resulting in savings averaging $788 CAD ($528 USD) per patient. For patients with moderate disease, 3.9 patients must be placed on treatment to avoid one year of FTC, with savings predicted at $3718 CAD ($2533 USD) per patient.

CONCLUSION

Galantamine cannot only potentially increase the time before patients require FTC, but may also lead to overall savings because treatment costs are offset by reductions in other health care expenditures.

Treatment of migraine in Canada with naratriptan: a cost-effectiveness analysis

OBJECTIVE

To evaluate the cost-effectiveness of naratriptan for the treatment of migraine in Canada.

BACKGROUND

The substantial disability brought on by migraine, coupled with the high prevalence of this disorder, leads to substantial costs. Naratriptan is a newly developed triptan shown to be effective in the treatment of migraine.

METHODS

Monte Carlo modeling techniques were used to simulate the experience of Canadian migraineurs over the course of 1 year. Data from a multinational study comparing oral naratriptan 2.5 mg to customary therapies were used in the cost-effectiveness analysis.

RESULTS

Naratriptan leads to an annual reduction in symptom duration of 225 hours compared to customary therapy not including other triptans. Reductions in lost productivity yield savings of Can $390 (1998 Canadian dollars) relative to customary therapy, which exceed the increase in drug costs resulting in overall savings of Can $109 per year.

CONCLUSIONS

The use of naratriptan in the treatment of migraine is an economically attractive option, leading to savings in overall costs. Increases in drug costs seem acceptable in light of reductions in symptom duration.

Sumatriptan: economic evidence for its use in the treatment of migraine, the Canadian comparative economic analysis

The objective of this study was to evaluate economic and health effects of sumatriptan relative to customary therapy in Canada. The relationship between treatment and functionality was established based on analysis of existing data from a multinational study. A Monte Carlo model was developed to simulate 1 year for each of customary therapy and six sumatriptan formulations. Costs are expressed in 1998 Canadian dollars. Sumatriptan is expected to reduce the time spent with migraine symptoms and resulting time lost. Under customary therapy, the annual cost of lost time is estimated at pound908 ($1973). With sumatriptan, these costs ranged from pound406 ($882) with subcutaneous sumatriptan to pound577 ($1254) with nasal sumatriptan 10 mg, saving pound331-502 ($719-1091) in the annual cost of time lost. All these benefits are expected to be obtained at an additional drug cost ranging from pound869 ($1889) for subcutaneous sumatriptan to pound278 ($605) for sumatriptan suppository. The cost of sumatriptan treatment is significantly offset by a substantial reduction of costs associated with time lost due to migraine symptoms.