Trichotillomania treatment update

Trichotillomania (TTM) is an obsessive-compulsive disorder in which affected individuals recurrently pull-out hair from any region of the body, causing hair loss or alopecia. The management of TTM is a therapeutic challenge for dermatologists and consists of a combination of pharmacological and non-pharmacological alternatives. Cognitive-behavioral therapy has successfully been used to treat TTM. However, not all patients are willing to follow this treatment strategy. Unconventional support tools are proposed, such as electronic devices, internet therapies and microneedling. N-acetylcysteine and memantine are considered suitable first-line therapies thanks to their favorable safety and efficacy profile, low risk of adverse effects, and significant benefits. The use of other drugs, including fluoxetine, clomipramine, olanzapine, and naltrexone has limited evidence of variable efficacy. The present review illustrates the current treatment modalities for the management of TTM.

[Translated article] Recommendations on the Clinical Management of Androgenetic Alopecia: A Consensus Statement From the Spanish Hair Disorders Group of the Spanish Academy of Dermatology and Venererology (AEDV)

Androgenetic alopecia can be challenging to treat due to the wide range of available treatments, most of which are not based on evidence from clinical trials. In addition many of the options do not include androgenetic alopecia among the approved indications according to their summaries of product characteristics. A panel of 34 dermatologists from the Spanish Hair Disorders Society of the Spanish Academy of Dermatology and Venereology (AEDV) used the Delphi method to develop a consensus statement on the management of androgenetic alopecia. Over a 2-round process the experts agreed on 138 (86%) of the 160 proposed items, which were structured into 4 blocks of recommendations: general considerations, pharmacologic treatment, procedures and hair transplant, and special cases. The resulting consensus statement based on expert opinion of the scientific evidence can guide professionals in the routine management of androgenetic alopecia.

Recommendations on the Clinical Management of Androgenetic Alopecia: A Consensus Statement From the Spanish Trichology Group of the Spanish Academy of Dermatology and Venererology (AEDV)

Androgenetic alopecia can be challenging to treat due to the wide range of available treatments, most of which are not based on evidence from clinical trials. In addition many of the options do not include androgenetic alopecia among the approved indications according to their summaries of product characteristics. A panel of 34 dermatologists from the Spanish Trichology Society of the Spanish Academy of Dermatology and Venereology (AEDV) used the Delphi method to develop a consensus statement on the management of androgenetic alopecia. Over a 2-round process the experts agreed on 138 (86%) of the 160 proposed items, which were structured into 4 blocks of recommendations: general considerations, pharmacologic treatment, procedures and hair transplant, and special cases. The resulting consensus statement based on expert opinion of the scientific evidence can guide professionals in the routine management of androgenetic alopecia.

Safety of Low-Dose Oral Minoxidil in Patients With Hypertension and Arrhythmia: A Multicenter Study of 264 Patients

BACKGROUND AND OBJECTIVE

Systemic adverse effects (AE) are a major concern of low-dose oral minoxidil (LDOM) treatment, especially in patients with arterial hypertension or arrhythmia. The objective of this study was to evaluate the safety of LDOM in patients with hypertension or arrhythmia.

PATIENTS AND METHODS

Retrospective multicenter study of patients with hypertension or arrhythmia treated with LDOM for any type of alopecia.

RESULTS

A total of 254 patients with hypertension [176 women (69.3%) and 78 men (30.7%)] with a mean age of 56.9 years (range 19-82) were included. From them, the dose of LDOM was titrated in 128 patients, allowing the analysis of 382 doses. Patients were receiving a mean of 1.45 (range 0-5) antihypertensive drugs. Systemic AE were detected in 26 cases (6.8%) and included lightheadedness (3.1%), fluid retention (2.6%), general malaise (0.8%), tachycardia (0.8%) and headache (0.5%), leading to LDOM discontinuation in 6 cases (1.5%). Prior treatment with doxazosin (P<0.001), or with three or more antihypertensive drugs (P=0.012) was associated with a higher risk of discontinuation of LDOM.

CONCLUSIONS

LDOM treatment showed a favorable safety profile in patients with hypertension or arrhythmia, similar to general population.

Safety of Low-Dose Oral Minoxidil in Patients With Hypertension and Arrhythmia: A Multicenter Study of 264 Patients

BACKGROUND AND OBJECTIVE

Systemic adverse effects (AE) are a major concern of low-dose oral minoxidil (LDOM) treatment, especially in patients with arterial hypertension or arrhythmia. The objective of this study was to evaluate the safety of LDOM in patients with hypertension or arrhythmia.

PATIENTS AND METHODS

Retrospective multicenter study of patients with hypertension or arrhythmia treated with LDOM for any type of alopecia.

RESULTS

A total of 254 patients with hypertension [176 women (69.3%) and 78 men (30.7%)] with a mean age of 56.9 years (range 19-82) were included. From them, the dose of LDOM was titrated in 128 patients, allowing the analysis of 382 doses. Patients were receiving a mean of 1.45 (range 0-5) antihypertensive drugs. Systemic AE were detected in 26 cases (6.8%) and included lightheadedness (3.1%), fluid retention (2.6%), general malaise (0.8%), tachycardia (0.8%) and headache (0.5%), leading to LDOM discontinuation in 6 cases (1.5%). Prior treatment with doxazosin (P<0.001), or with three or more antihypertensive drugs (P=0.012) was associated with a higher risk of discontinuation of LDOM.

CONCLUSIONS

LDOM treatment showed a favorable safety profile in patients with hypertension or arrhythmia, similar to general population.

Trichoscopy in Alopecia Areata

Alopecia areata is an autoimmune disease that affects the hair follicle and can present as bald patches on the scalp and hair loss in other parts of the body. Diagnosis is clinical but can be aided by trichoscopy, a simple, rapid technique that reduces the need for invasive procedures and can also help with monitoring treatment response. We review the usefulness of trichoscopy in alopecia areata. The most common trichoscopic findings are yellow dots, black dots, exclamation mark hairs, short vellus hairs, and coudability hairs. Other, less common, findings can also help establish a diagnosis. Good response to treatment is indicated by the disappearance of black dots, broken hairs, and exclamation mark hairs. The observation of yellow dots, by contrast, indicates chronic disease and poor response to treatment.

Current controversies in trichology: a European expert consensus statement

INTRODUCTION

Hair disorders are one of the most common conditions within dermatology practice but, although new diagnostic tools and therapeutic options have arisen, the management of these patients still represents a major clinical challenge.

OBJECTIVE

This study aimed at gathering information and achieving consensus on relevant recommendations on the latest advances in alopecia, trichoscopy and hair dermocosmetics.

METHODS

Experts of the steering committee consulted the available evidence on trichology-related areas from the past 5 years and formulated recommendations based on the evidence and their experience. A modified two-round Delphi procedure was performed among 45 European dermatologists experts in trichology to consult their degree of agreement on twenty recommendations, using a 4-point Likert scale. Consensus was defined as >80% of participants scoring either 1 (totally agree) or 2 (agree).

RESULTS

In the first round of the Delphi questionnaire, 75% of the recommendations reached consensus. Those that were not agreed upon were reformulated by the steering committee and voted again after an online meeting, where consensus was achieved in all recommendations.

CONCLUSIONS

All recommendations reached consensus after the two-round Delphi questionnaire and may be useful in clinical practice for dermatologists. The participants agreed that besides this consensus, further clinical studies are needed to assess the benefits of the emerging tools and treatments and to clarify the controversies that still exist in the field, aiming at improving patients' quality of life.

Guidelines for clinical trials of frontal fibrosing alopecia: consensus recommendations from the International FFA Cooperative Group (IFFACG)

BACKGROUND

Frontal fibrosing alopecia (FFA) has become one of the most common causes of cicatricial alopecia worldwide. However, there is a lack of clear aetiology and robust clinical trial evidence for the efficacy and safety of agents currently used for treatment.

OBJECTIVES

To enable data to be collected worldwide on FFA using common criteria and assessment methods.

METHODS

A multicentre, international group of experts in hair loss was convened by email to create consensus recommendations for clinical trials. Consensus was defined at > 90% agreement on each recommended part of these guidelines.

RESULTS

Standardized diagnostic criteria, severity rating, staging, and investigator and patient assessment of scalp hair loss and other clinical features of FFA were created.

CONCLUSIONS

These guidelines should allow the collection of reliable aggregate data on FFA and advance efforts in both clinical and basic research to close knowledge gaps in this condition.

Analysis of the gut microbiota in alopecia areata: identification of bacterial biomarkers

BACKGROUND

Alopecia areata is a T-cell-mediated autoimmune disease with an unknown etiopathogenesis. Gut microbiota has been revealed as a key modulator of systemic immunity.

OBJECTIVE

To determine whether patients affected by alopecia universalis present differences in gut bacteria composition compared with healthy controls and investigate possible bacterial biomarkers of the disease.

METHODS

We conducted a cross-sectional study that involved 15 patients affected by alopecia universalis and 15 controls. Gut microbiome of the study subjects was analysed by sequencing the 16SrRNA of stool samples. We searched for bacterial biomarkers of alopecia universalis using the linear discriminant analysis effect size (LEFse) tool.

RESULTS

In total, 30 study subjects (46.6% female; mean [SD] age, 40.1 [9.8] years) were enrolled. Neither alpha (Shannon diversity index 5.31 ± 0.43 vs. 5.03 ± 0.43, P 0.1) or beta diversity (ADONIS P value: 0.35) of gut microbiota showed statistically significant differences between cases and controls. In patients affected with alopecia, we found an enriched presence (LDA SCORE > 2) of Holdemania filiformis, Erysipelotrichacea, Lachnospiraceae, Parabacteroides johnsonii, Clostridiales vadin BB60 group, Bacteroides eggerthii and Parabacteroides distasonis. A predictive model based on the number of bacterial counts of Parabacteroides distasonis and Clostridiales vadin BB60 group correctly predicted disease status in 80% of patients (AUC 0.804 (0.633-0.976), P 0.004).

CONCLUSION

Alopecia universalis does not seem to affect broadly gut microbiota structure. Bacterial biomarkers found associated with the disease (Holdemania filiformis, Erysipelotrichacea, Lachnospiraceae, Parabacteroides johnsonii, Eggerthellaceae, Clostridiales vadin BB60 group, Bacteroides eggerthii and Parabacteroides distasonis) should be further studied as they could be involved in its pathophysiology or be used as diagnostic tools.

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La alopecia areata constituye un reto terapéutico, sobre todo en sus formas extensas. Antes de iniciar cualquier tratamiento es necesario tener en cuenta algunas consideraciones. Se trata de una enfermedad que no afecta de forma directa a la salud del paciente y que puede presentar resolución espontánea. Las formas extensas, las que se inician en la infancia y las de larga evolución son muy rebeldes a los tratamientos y asocian recaídas. Todos los tratamientos tienen efectos secundarios. Ningún tratamiento ha demostrado alterar el curso de la enfermedad, muy pocos han demostrado eficacia en ensayos clínicos aleatorizados y no existen guías terapéuticas salvo la publicada en 2003 y actualizada en 2012 en el British Journal of Dermatology. Por todo ello, es necesario elaborar un plan de tratamiento individualizado en cada paciente. Se debe comenzar con los fármacos más seguros e inocuos, y pasar al siguiente escalón terapéutico cuando el actual haya demostrado su ineficacia durante un periodo de 6 meses. Se revisan las principales propuestas farmacológicas para alopecia areata, aportando datos sobre su mecanismo de acción, efectos secundarios y posicionamiento terapéutico en función de los estudios disponibles. Finalmente, se propone un algoritmo terapéutico como guía en el manejo de esta patología.

Beard alopecia areata: a multicentre review of 55 patients

BACKGROUND

Alopecia areata on the beard area (BAA) is a common clinical manifestation, but there are no studies about its characteristics.

OBJECTIVE

To describe the epidemiology, comorbidities, clinical presentation, evolution, diagnostic findings and therapeutic choices in a series of patients with BAA.

METHODS

This retrospective multicentre review included patients diagnosed with BAA as the first and unique clinical manifestation with at least 12 months of follow-up. Diagnosis was performed based on the typical clinical features. Extra-beard involvement was monitored in all cases.

RESULTS

Overall, 55 male patients with a mean age of 39.1 years (range 20-74) were included. Twenty-five patients (45.5%) developed alopecia of the scalp during follow-up and more than 80% of cases appeared in the first 12.4 months. Clinical presentation of AA on the scalp was patchy AA (less than 5 patches) (52%), multifocal AA (28%), AA totalis (12%) and AA universalis (8%). Multivariate analysis revealed a trend of association between scalp involvement and family history of AA without statistical significance.

CONCLUSIONS

According to this study, BAA may progress to scalp AA in a significant number of patients (45.5% of the patients with a follow-up interval of at least 12 months). In the group of patients who developed scalp AA, 80% of them did it within the first 12 months, so follow-up of patients with BAA is highly encouraged.