Management of hair loss

An Updated Review on Current Treatment of Alopecia Areata and Newer Therapeutic Options

Alopecia areata (AA) is a dermatological disease that causes nonscarring hair loss. It can occur at any age and has an unpredictable and variable evolution in individuals. The aim of this review is to provide an update on the novel therapies currently being used, as well as upcoming therapeutic options in the treatment of AA.

Efficacy and predictive factors of cyclosporine A in alopecia areata: a systematic review with meta-analysis

INTRODUCTION

Drugs for alopecia areata (AA) can induce hair regrowth, but do not change the disease course. Dual properties of cyclosporine A (CsA) as hypetrichotic and immunosuppressive agent have encouraged use in AA. We aimed to determine the most meaningful efficacy of CsA and reveal features helping enhance its efficacy and reduce relapses.

METHOD

Efficacy of CsA and predictive factors were investigated. Cochrane, MEDLINE, Pubmed and Embase databases were searched.

RESULTS

2,189 papers were retrieved. Based on 344 patients, mean proportion of responders was 73%. CsA monotherapy showed proportion of hair regrowth of 66%, whereas CsA combined with systemic corticosteroids yielded 78%. Overall efficacy in studies with duration of CsA treatment <6 months was: 74% (53-88%), while in those with duration ≥6 months was: 73% (47-89%). Recurrence with CsA monotherapy was 55% (6-96%) whereas when CsA was combined with systemic corticosteroids it was 28% (6-72%).

CONCLUSION

CsA confers a favorable therapeutic effect and concomitant use of steroids slightly enhances efficacy, but it dramatically decreases relapses. Longer treatments seem to lead to less relapse likelihood, but daily dose does not influence recurrence. Optimal CsA dosage is 5 mg/kg/day in single therapy regimen, whereas it is 3 mg/kg/day in the steroid-associated regimen. KEY POINTSWhat is already known about this subject? Most treatments for alopecia areata have not been critically evaluated. Current outcomes about the efficacy and relapse rate of cyclosporine A (CsA) are inconsistent and predictive factors about the clinical response are lacking.What this study adds? CsA confers a favorable therapeutic hair regrowth. Longer treatment seems to lead to less likelihood of relapse of AA, but the daily dose does not exert any effect on the recurrence of the disease. The concomitant use of corticosteroids broadly decreases relapses, and it also enhances efficacy.Impact on clinical practice The combination with corticosteroids is the most predictive feature to prevent relapse of AA, followed by the duration of CsA therapy. The daily dose of CsA is the feature with the least or null impact on the clinical course of AA.

The role of sleep in telogen effluvium and trichodynia: A commentary in the context of the current pandemic

Telogen effluvium (TE), a common hair disease, is supposed to be related to stress, which could be secondary to poor sleep. We call attention to the current COVID-19 pandemic, that is leading to an increase in the prevalence of sleep disturbances, and as a consequence, higher states of stress and anxiety, which are possible triggers for TE. In parallel, trichodynia is a sensorial symptom that is commonly related with hair diseases, including TE. We argue that substance P, a neuropeptide that has participation in the neuroinflammation and in the sleep regulation, may play a possible role in this scalp paresthesia. We suggest that there may be an association between this substrate and sleep, which can aggravate trichodynia and TE. Further studies on this subject could provide more evidence on these relationships, and help to improve the patients' quality of life and management of the condition.

Types and Treatment of Hair Loss in Men and Women

In this article, the author focuses on 4 common hair loss disorders that occur in both men and women. The author discusses research related to androgenetic alopecia, telogen effluvium, alopecia areata, and scarring alopecia and provides details on how to approach and manage these diseases according to patient gender. There are a range of tools and tests that can assist with the diagnostic process and help ensure that relevant and high standards of patient care are maintained. In some cases, no medical intervention is always a treatment option. However, appropriate medical treatments, although still relatively limited in some cases, are safe and have proven efficacy. Hair loss has immense emotional and psychological impact in both genders, and it is always important to consider this when planning hair loss management pathways.

A Comparative Study of Therapeutic Response to Intralesional Injections of Platelet-Rich Plasma Versus Triamcinolone Acetonide in Alopecia Areata

Background:

Alopecia areata (AA) is a chronic nonscarring alopecia that involves hair follicles and is characterized by patchy areas of hair loss without any signs of clinical inflammation. Platelet-ri-ch plasma (PRP) has a high platelet concentration. Anti-inflammatory effect of PRP may be of great help in AA.

Aims and Objectives:

Study was conducted to compare the outcome of treatment and side effects of intralesional PRP versus triamcinolone in AA.

Materials and Methods:

40 patients with alopecia areata were allocated into 2 groups and treated with triamcinolone and PRP injections. The response was analyzed by SALT score (severity of alopecia tool score) and hair regrowth grade (HRG) scale. Inferential statistical tools such as t-test, Mann–Whitney U test, and Chi-square test were used.

Results:

16 patients in each group completed the study. While comparing the decrease in SALT score at different intervals of time, there was a significant difference in SALT score reduction during the second review between PRP group and triamcinolone group (P = 0.028). After the first and final review, results did not show any statistically significant difference between the two groups. While comparing the hair regrowth scale between treatments, there was no statistical significance. 12.5% patients in PRP group reported excellent response after final review (HRG scale 4), compared to none in triamcinolone group.

Conclusions:

Platelet-rich plasma is a safe, effective, steroid sparing, and suitable alternative in AA. Only side effect noted was pain during injections in both the groups.

Types and Treatment of Hair Loss in Men and Women

In this article, the author focuses on 4 common hair loss disorders that occur in both men and women. The author discusses research related to androgenetic alopecia, telogen effluvium, alopecia areata, and scarring alopecia and provides details on how to approach and manage these diseases according to patient gender. There are a range of tools and tests that can assist with the diagnostic process and help ensure that relevant and high standards of patient care are maintained. In some cases, no medical intervention is always a treatment option. However, appropriate medical treatments, although still relatively limited in some cases, are safe and have proven efficacy. Hair loss has immense emotional and psychological impact in both genders, and it is always important to consider this when planning hair loss management pathways.

Cell Enriched Autologous Fat Grafts to Follicular Niche Improves Hair Regrowth in Early Androgenetic Alopecia

BACKGROUND

Adipose and adipose derived regenerative cells (ADRCs) play an increasing role in androgenetic alopecia.

OBJECTIVES

The authors sought to evaluate the safety and feasibility of fat grafts enriched with ADRCs in early androgenetic alopecia.

METHODS

Seventy-one patients were treated: 16 with Puregraft fat and 1.0 × 106 ADRCs/cm2 scalp; 22 with Puregraft fat and 0.5 × 106 ADRCs/cm2 scalp, 24 with Puregraft fat alone, and 9 with saline control. Treatments were delivered into the skin and subcutaneous layer of the scalp. A total of 40 cm2 of scalp was treated and macrophotography and global photography were obtained at baseline and at 6, 24, and 52 weeks.

RESULTS

A total of 71 patients tolerated the procedures well. No unanticipated associated adverse events were reported. When evaluating all patients at 24 weeks, there were no statistical differences between any of the treatment groups with respect to nonvellus (terminal) hair counts or width. There were increases (mean change from baseline) in terminal hair count for the low-dose ADRC group in the Norwood Hamilton 3 subgroup at week 6 (13.90 ± 16.68), week 12 (11.75 ± 19.42), week 24 (16.56 ± 14.68), and week 52 (2.78 ± 16.15). For this subgroup, the difference in hair count between the low-dose ADRC group and no-fat saline control was statistically significant (P = 0.0318) at week 24.

CONCLUSIONS

Puregraft fat and ADRCs are safe and well tolerated. In early male hair loss, this therapy demonstrated a statistically significant increase in terminal hair counts relative to the control population at 24 weeks and represents a promising approach for early androgenetic alopecia.

LEVEL OF EVIDENCE: 2

Autologous adipose transplantation an effective method to treat alopecia after trauma: a case report

Finding new therapies for male and female pattern hair loss treatment remains as great interest. The autologous fat grafting technique is a new method, and clinical experience was increased over the past 10–15 years. Adipose tissue is a biologically active and important tissue and can help drive the complex hair growth cycle. Surgeons have previously reported that autologous fat not only have a positive affect for reconstructive volume and esthetics after transplant but can also have positive skin and hair changes post-transplantation. In this study, lipoaspiration of adipose was performed by cannula and scalp injection was done. In this case report, the authors report that scalp injection of adipose tissue has a positive effect on a patient with alopecia after trauma. The findings suggest adipose tissue can be a promising alternative method to treating men and women alopecia.

Adipose-derived cellular and cell-derived regenerative therapies in dermatology and aesthetic rejuvenation

Cellular and cell-derived components of adipose-derived tissue for the purposes of dermatologic and aesthetic rejuvenation applications have become increasingly studied and integrated into clinical practice. These components include micro-fragmented fat (nanofat), the stromal vascular fraction (SVF), adipose-derived mesenchymal stem cells (ASC), and extracellular vesicles (EVs), which have all shown capability to repair, regenerate, and rejuvenate surrounding tissue. Various aesthetic applications including hair growth, scar reduction, skin ischemia-reperfusion recovery, and facial rejuvenation are reviewed. In particular, results from preclinical and clinical studies are discussed, with a focus on clarification of nomenclature.

Review of Human Hair Follicle Biology: Dynamics of Niches and Stem Cell Regulation for Possible Therapeutic Hair Stimulation for Plastic Surgeons

Plastic surgeons are frequently asked to manage male- and female-pattern hair loss in their practice. This article discusses the epidemiology, pathophysiology, and current management of androgenetic alopecia and emphasizes more recent knowledge of stem cell niches in hair follicles that drive hair cycling, alopecia, and its treatment. The many treatment programs available for hair loss include newer strategies that involve the usage of growth factors, platelet-rich plasma, and fat to stimulate follicle growth. Future research may clarify novel biomolecular mechanisms that target specific cells that promote hair regeneration.Level of Evidence V This journal requires that authors assign a level of evidence to each article. For a full description of these Evidence-Based Medicine ratings, please refer to the Table of Contents or the online Instructions to Authors www.springer.com/00266 .

Serum Levels of Androgen-Associated Hormones Are Correlated with Curative Effect in Androgenic Alopecia in Young Men

Background

Androgenic alopecia (AGA) is the most common type of hair loss in men. However, the pathogenesis is not yet fully understood and therapeutic approaches are limited. This retrospective study investigated the association between levels of androgen-associated hormones and curative effect in androgenic alopecia in young male AGA patients.

Material/Methods

By using chemiluminescence immunoassay, serum levels of androgens and upstream regulated hormones were measured in 178 young male patients with AGA and in 61 normal controls before therapy, 1 and 2 weeks after administration of finasteride.

Results

Before oral finasteride therapy, we found significantly higher levels of serum free testosterone (FT) and dihydrotestosterone (DHT) in AGA patients than in normal controls. The levels of serum sex hormone-binding globulin (SHBG), luteinizing hormone (LH), and follicle-stimulating hormone (FSH) were similar in the 2 groups. There were no significant differences in serum androgen levels, including DHT and FT, among AGA patients with different grades of hair loss severity (p>0.05). After finasteride therapy, the levels of DHT decreased significantly (p<0.05). Increased serum levels of LSH or LH were also observed in 55 patients after therapy (p<0.05). The levels of SHGB did not change significantly after therapy (p>0.05). Patients with lower levels of serum FT and DHT than before who accepted finasteride therapy had a higher ratio of curative effect manifested by improved severity grade (p<0.05). Patients with higher levels of LSH or LH had a lower curative rate compared to those without change after therapy (p<0.05).

Conclusions

We confirmed the role of the androgens hypothalamus-hypophysis-sexual gland axis in the pathogenesis of AGA and the treatment effect of oral anti-androgen therapy in young male Chinese patients.

Mesenchymal Stem Cells and Stromal Vascular Fraction for Hair Loss: Current Status

The current state of the applicability of cell therapy for the treatment of various conditions of hair loss reveals a promising and potentially effective role. Further research, based on published work to date, is indicated to further explore the potential roles of autologous fat grafting, mesenchymal stem cells, and stromal vascular fraction therapy. The authors' evolving experience matches these promising scientific findings.

Hair follicle growth by stromal vascular fraction-enhanced adipose transplantation in baldness

Great interest remains in finding new and emerging therapies for the treatment of male and female pattern hair loss. The autologous fat grafting technique is >100 years old, with a recent and dramatic increase in clinical experience over the past 10-15 years. Recently, in 2001, Zuk et al published the presence of adipose-derived stem cells, and abundant research has shown that adipose is a complex, biological active, and important tissue. Festa et al, in 2011, reported that adipocyte lineage cells support the stem cell niche and help drive the complex hair growth cycle. Adipose-derived regenerative cells (also known as stromal vascular fraction [SVF]) is a heterogeneous group of noncultured cells that can be reliably extracted from adipose by using automated systems, and these cells work largely by paracrine mechanisms to support adipocyte viability. While, today, autologous fat is transplanted primarily for esthetic and reconstructive volume, surgeons have previously reported positive skin and hair changes posttransplantation. This follicular regenerative approach is intriguing and raises the possibility that one can drive or restore the hair cycle in male and female pattern baldness by stimulating the niche with autologous fat enriched with SVF. In this first of a kind patient series, the authors report on the safety, tolerability, and quantitative, as well as photographic changes, in a group of patients with early genetic alopecia treated with subcutaneous scalp injection of enriched adipose tissue. The findings suggest that scalp stem cell-enriched fat grafting may represent a promising alternative approach to treating baldness in men and women.

Efficacy of topical latanoprost versus minoxidil and betamethasone valerate on the treatment of alopecia areata

BACKGROUND

Alopecia areata (AA) is one of the most common causes of localized hair loss. There is no universally proven therapy that induces and sustains remission of hair growth in AA.

OBJECTIVE

To compare the efficacy and safety of topical latanoprost, minoxidil and betamethasone valerate on hair growth in patients with AA.

PATIENTS AND METHODS

Hundred patients with AA classified into five groups of 20 treated with: Group I, latanoprost 0.1% lotion; Group II, minoxidil 5% lotion; Group III, betamethasone valerate 0.1% solution; Group IV, combination of latanoprost lotion and betamethasone valerate solution and Group V, a vehicle lotion control group.

RESULTS

There was a statistically significant improvement in all therapeutic groups when compared with control group and reduction of severity of alopecia tool score of scalp and beard before and after treatment for all therapeutic groups.

CONCLUSION

Latanoprost, minoxidil and betamethasone valerate are effective and safe in the treatment of patchy AA. The use of latanoprost added to the therapeutic efficacy of topical betamethasone valerate in the treatment of AA and could be an effective adjunctive topical therapy for AA.

Multiple sclerosis disease-modifying therapies: adverse effect surveillance and management

There are five approved, partially effective, parenteral disease-modifying therapies for multiple sclerosis (MS), including three interferon-beta preparations, glatiramer acetate and the antineoplastic agent mitoxantrone. A sixth drug, natalizumab, was withdrawn from the market in 2005 but could return with increased safety measures. Careful surveillance for, and management of, the minor and serious adverse effects associated with these therapies in routine practice provides the best opportunity for maintaining compliance and achieving maximal therapeutic efficacy. This review outlines the strategies for the prevention, identification and management of the complications associated with administration and ongoing use of current MS therapies. These skills will become increasingly important to those caring for MS patients as contemporary treatment regimens become increasingly complex.

[Genetic hair diseases. An update]

Patients suffering from hair loss or undesirable excessive hair growth are a challenge for dermatologists because the pathogenesis of most hair diseases is not well understood and therapeutic options are limited. This particularly holds true for genetic hair disorders, in which all current treatment attempts are unsuccessful. Furthermore, these diseases also pose a diagnostic challenge due to a broad range of clinical and genetic heterogeneity. However, the enormous progress in molecular biology over the past 20 years, in particular the availability of different new techniques such as whole exome and genome sequencing, has enabled us to elucidate the genetic basis of most monogenic hair disorders, given the availability of suitable index patients and families as well as adequate technical equipment and sufficient financial resources. In this review we provide an update on clinical and genetic aspects of selected monogenic and polygenic hair diseases manifesting with hypertrichosis and hypotrichosis.

Cicatricial (scarring) alopecias: an overview of pathogenesis, classification, diagnosis, and treatment

Cicatricial (scarring) alopecia forms a group of disorders in which the common final pathway is the destruction of the hair follicle unit that is replaced by fibrous tissue. Hair loss may occur as a primary event when the follicle is the main target of the disease process (primary cicatricial alopecias) or as a secondary event when the follicle act as an 'innocent bystander' in the course of a disease occurring outside of the follicular unit (secondary cicatricial alopecias). Permanent hair loss may also occur in the late phases of some nonscarring alopecias that are called 'biphasic alopecias.' Primary cicatricial alopecia accounts for 5% of all trichologic consultations at the Section of Dermatology, University of Genoa, Genoa, Italy. Considering that hair loss has a strong impact on patients' psychology and quality of life, and that cicatricial alopecias can be associated with underlying systemic implications, it is extremely important that every clinician is familiar with the diagnosis and treatment of the different types of cicatricial alopecia. An accurate clinical assessment integrated with (video) dermatoscopy and histopathologic studies permits a high standard performance of correct diagnoses. A brief review of our current knowledge of disease pathogenesis and the hypothetical disease mechanisms is presented. Some practical considerations for improving the 2001 North American Hair Research Society working classification of the primary cicatricial alopecias are suggested. The aim of treatment is to slow or stop the progression of the inflammatory waves and the scarring process at the earliest phase of involvement. Recommendations for therapy are based upon a literature review, personal experience, expected adverse effects, and some pragmatic considerations such as the cost and patient compliance.

Characteristics of androgenetic alopecia in asian

Androgenetic alopecia (AGA), or pattern hair loss, is a common disorder in Asian men and women, with a reported incidence of up to 73% among general population. There are several descriptions regarding the characteristics of AGA in patients of European descent. Asian patients with AGA have different types of hair loss and family histories from Europeans, which may affect treatment response. Therefore, in this review, prevalence, hair loss patterns, familial factors, androgen receptor gene polymorphisms of Asian AGA patients, and management based on algorithmic guidelines for AGA are discussed. This review may be useful for dermatologists in clinical practice for diagnosing and designing management approaches for Asian patients with AGA.

Alopecia areata: a new treatment plan

Many therapeutic modalities have been used to treat alopecia areata, with variable efficacy and safety profiles. Unfortunately, none of these agents is curative or preventive. Also, many of these therapeutic agents have not been subjected to randomized, controlled trials, and, except for topical immunotherapy, there are few published studies on long-term outcomes. The treatment plan is designed according to the patient's age and extent of disease. In this paper, the therapeutic agents are organized according to their efficacy and safety profiles into first-line, second-line, and third-line options.

Types of hair loss and treatment options, including the novel low-level light therapy and its proposed mechanism

Androgenetic alopecia (AGA) is the most common form of hair loss in men, and female pattern hair loss (FPHL) is the most common form of hair loss in women. Traditional methods of treating hair loss have included minoxidil, finasteride, and surgical transplantation. Currently there is a myriad of new and experimental treatments. In addition, low-level light therapy (LLLT) has recently been approved by the United States Food and Drug Administration (FDA) for the treatment of hair loss. There are several theories and minimal clinical evidence of the safety and efficacy of LLLT, although most experts agree that it is safe. More in vitro studies are necessary to elucidate the mechanism and effectiveness at the cellular level, and more controlled studies are necessary to assess the role of this new treatment in the general population.

Attitudes of dermatologists in the southeastern United States regarding treatment of alopecia areata: a cross-sectional survey study

Background

Little evidence exists to guide treatment of alopecia areata (AA). The current practices in treatment of children compared to adults and of progressive stages of hair loss are unknown. The objective of this study was to examine the current practices of southeastern United States dermatologists for the treatment of AA.

Methods

Dermatologists were sent anonymous questionnaires regarding their treatment practices by mail. Respondents' frequencies of treatment in children compared to adults and in patchy hair loss compared to widespread hair loss were compared with Wilcoxon signed-ranks tests and Friedman tests. As a secondary source, the National Alopecia Areata Registry (NAAR) database was analyzed for patients' treatment histories.

Results

Survey results suggested that dermatologists recommend treatment less frequently for children than adults and for more advanced hair loss. NAAR data confirmed that offering no treatment for AA is relatively common.

Conclusion

Dermatologists' treatment of AA is inconsistent. A stronger evidence base will provide more consistent treatment options.

Diseases of the hair and nails

The hair and nails are rapidly growing structures and as such their cell division can be interrupted by disease states and iatrogenic treatments. Other internal diseases can alter the structure and color of the hair and nails. These alterations in the hair and nails supply important information to the physician regarding the underlying diagnosis.

Medium-dose prednisolone pulse therapy in alopecia areata

BACKGROUND

Although the exact etiology of alopecia areata is still unknown, systemic prednisolone treatment seem to be effective in early stages but significant side effects may occur leading to discontinuation of treatment.

OBJECTIVE

Evaluation of efficacy and saftety of a short-term medium-dose pulse prednisolone treatment in alopecia areata.

RESULTS

84% of the patients with multifocal alopecia areata markedly improved after the completion of the three courses. A patient with the ophiasis type only responded after the third course, but relapsed 7 months later. The patients with alopecia areata totalis and universalis did not respond to the treatment. No major side effects were observed.

METHODS

Monocenter prospective study of intravenous 100 mg intravenous prednisolone pulse therapy on 3 consecutive days at 1-month-intervals for three courses in 23 patients with active alopecia areata rapidly evolving and/or resistant to topical therapies and no contraindication for systemic steroids.

CONCLUSION

A series of three monthly courses of medium-dose prednisolone pulse therapy is effective and well tolerated in most patients with active, multifocal alopecia areata. The results are rather disappointing in patients with alopecia areara totalis/universalis.

Androgens and hair growth

Hair's importance in human communication means that abnormalities like excess hair in hirsutism or hair loss in alopecia cause psychological distress. Androgens are the main regulator of human hair follicles, changing small vellus follicles producing tiny, virtually invisible hairs into larger intermediate and terminal follicles making bigger, pigmented hairs. The response to androgens varies with the body site as it is specific to the hair follicle itself. Normally around puberty, androgens stimulate axillary and pubic hair in both sexes, plus the beard, etc. in men, while later they may also inhibit scalp hair growth causing androgenetic alopecia. Androgens act within the follicle to alter the mesenchyme-epithelial cell interactions, changing the length of time the hair is growing, the dermal papilla size and dermal papilla cell, keratinocyte and melanocyte activity. Greater understanding of the mechanisms of androgen action in follicles should improve therapies for poorly controlled hair disorders like hirsutism and alopecia.

Human hair follicles contain two forms of ATP-sensitive potassium channels, only one of which is sensitive to minoxidil

Hair disorders cause psychological distress but are generally poorly controlled; more effective treatments are required. Despite the long-standing use of minoxidil for balding, its mechanism is unclear; suggestions include action on vasculature or follicle cells. Similar drugs also stimulate hair, implicating ATP-sensitive potassium (K(ATP)) channels. To investigate whether K(ATP) channels are present in human follicles, we used organ culture, molecular biological, and immunohistological approaches. Minoxidil and tolbutamide, a K(ATP) channel blocker, opposed each other's effects on the growing phase (anagen) of scalp follicles cultured in media with and without insulin. Reverse transcriptase-polymerase chain reaction identified K(ATP) channel component gene expression including regulatory sulfonylurea receptors (SUR) SUR1 and SUR2B but not SUR2A and pore-forming subunits (Kir) Kir6.1 and Kir6.2. When hair bulb tissues were examined separately, epithelial matrix expressed SUR1 and Kir6.2, whereas both dermal papilla and sheath exhibited SUR2B and Kir6.1. Immunohistochemistry demonstrated similar protein distributions. Thus, human follicles respond biologically to K(ATP) channel regulators in culture and express genes and proteins for two K(ATP) channels, Kir6.2/SUR1 and Kir6.1/SUR2B; minoxidil only stimulates SUR2 channels. These findings indicate that human follicular dermal papillae contain K(ATP) channels that can respond to minoxidil and that tolbutamide may suppress hair growth clinically; novel drugs designed specifically for these channels could treat hair disorders.

Alopecia areata

Alopecia areata (AA) is a nonscarring, autoimmune, inflammatory, hair loss on the scalp, and/or body. Etiology and pathogenesis are still unknown. The most common site affected is the scalp. Histopathology is characterized by an increased number of the catagen and telogen follicles, the presence of inflammatory lymphocytic infiltrate in the peribulbar region ("swarm of bees"). Corticosteroids are the most popular drugs for the treatment of this disease. Etiologic and pathogenic mechanisms, as well as other current treatments available will be discussed in this article.