Summary of North American Hair Research Society (NAHRS)-sponsored Workshop on Cicatricial Alopecia, Duke University Medical Center, February 10 and 11, 2001

Systemic Treatments for Lichen Planopilaris and Frontal Fibrosing Alopecia: A Retrospective Study of 315 Patients

Lichen planopilaris and frontal fibrosing alopecia are common variants of primary lymphocytic cicatricial alopecia, leading to permanent hair loss. Despite widespread use of various systemic treatments, evidence-based guidelines for these conditions are lacking. This study investigates the effectiveness of systemic treatment options in patients with lichen planopilaris and frontal fibrosing alopecia through a retrospective cohort analysis. Medical records of patients treated at the Department of Dermatology between 2016 and 2022 at the Erasmus University Medical Center Rotterdam, the Netherlands were reviewed. Of 315 patients identified (161 lichen planopilaris and 154 frontal fibrosing alopecia), the majority were female (90.5%), with hydroxychloroquine being the most common systemic treatment, used by 65.2% of lichen planopilaris and 57.8% of frontal fibrosing alopecia patients. Methotrexate had the highest response rate for lichen planopilaris (79.2%), while retinoids showed the highest response for frontal fibrosing alopecia (73.9%). However, treatments with cyclosporine A and retinoids had higher discontinuation rates due to side effects. This study suggests methotrexate and cyclosporine A may be most effective for lichen planopilaris, and cyclosporine A and retinoids for frontal fibrosing alopecia, though side effects remain a concern. Limitations include the retrospective design and the absence of standardized outcomes. Prospective studies are recommended to validate these findings.

Lichen Planopilaris Trichoscopy in Caucasian Scalp: A Review

Background

Lichen planopilaris (LPP) is a primary lymphocytic cicatricial alopecia characterized by several different patterns of permanent hair loss.

Summary

Trichoscopy plays an essential role in the context of LPP, as recognizing the distinctive signs of the disease facilitates the diagnosis of all forms of lichenoid alopecia.

Key Messages

This review aimed to recognizing the trichoscopic signs early on, enabling timely intervention, potentially preventing the disease from advancing to its permanent scarring stage.

Extra-follicular cutaneous manifestations of frontal fibrosing alopecia

Frontal fibrosing alopecia (FFA) is an inflammatory cicatricial alopecia, which is considered to be a variant of lichen planopilaris. In addition to follicular changes, FFA often presents with associated cutaneous manifestations in most patients, including lichen planus pigmentosus, implantation line hypochromia and facial papules. The objective of the present article is to provide a detailed overview of the non-follicular cutaneous clinical manifestations of FFA and discuss their impact on the diagnosis and treatment of patients with this condition.

Cross-sectional study to evaluate the utility of elastic tissue staining in primary cicatricial alopecia

BACKGROUND AND AIMS

Diagnosing end-stage primary cicatricial alopecia (PCA) on routine histology is challenging since the major diagnostic feature (inflammatory infiltrate) may be minimal or absent. This study aimed to assess various staining patterns and diagnostic utility of elastic tissue staining by Verhoeff-Van Gieson (VVG) method and trichoscopy in PCA.

STUDY DESIGN

Cross-sectional study.

METHODS

Fifty-three patients clinically diagnosed with PCA underwent biopsy and trichoscopy in this cross-sectional study. Clinically active edge, if present, was biopsied. Twenty serial tissue sections were stained using H&E and VVG stain. Clinicopathological diagnoses were lichen planopilaris (LPP), discoid lupus erythematosus (DLE), folliculitis decalvans and unclassified PCA (UPCA) in 30 (56.6%), 11 (20.75%), 1 (1.9%) and 11 (20.75%) patients, respectively. Utility of VVG stain was ascertained considering clincopathological correlation (CPC) as the reference standard. Association of characteristic trichoscopic and VVG staining patterns was ascertained.

RESULTS

Diagnostic definition was achieved on VVG staining in 19/30 sections of LPP (wedge-shaped pattern) with 63.33% sensitivity; 7/11 cases of DLE (absent upper and mid dermal elastic fibres) with 63.64% sensitivity and 7/11 cases of UPCA (wedge-shaped pattern-3/7; recoil pattern-4/7). Routine histology suggested diagnosis only in 13/53 sections (24.52%). However, diagnosis on VVG staining corresponded with diagnosis on CPC in 33/53 cases (62.3%). Comparison of H&E versus VVG stain both overall and in the LPP and UPCA cohorts proved utility of VVG staining using Fisher's exact test (p<0.05). Statistical significance was also noted when trichoscopy was correlated with patterns on VVG staining (p<0.05).

CONCLUSION

Increased diagnostic yield is noted with trichoscopy and VVG stain in PCA especially when routine histopathology is non-diagnostic.

Telogen Effluvium Following the Treatment of Euglycemic Diabetic Ketoacidosis in a Patient With Heavy Soft Drink Intake: A Case Report

Telogen effluvium can be triggered by physical exhaustion, drug use, and emotional stress. However, in approximately 33% of cases, the triggers are unknown. Telogen effluvium can develop two to three months after exposure to triggers and improve three to six months after trigger removal. This case report discusses a man with type 2 diabetes mellitus associated with heavy soft drink intake who developed telogen effluvium following treatment for euglycemic diabetic ketoacidosis with luseogliflozin. A 28-year-old man was hospitalized for euglycemic diabetic ketoacidosis. Two months after discharge, he experienced hair loss that persisted for three months. Physical wasting due to hyperglycemia and ketoacidosis was assumed to have triggered hair loss, resulting in rapid weight loss. Investigating the triggers associated with alopecia is crucial for diagnosing and treating telogen effluvium.

Treatment of Lichen Planopilaris and Frontal Fibrosing Alopecia: A Retrospective, Real-Life Analysis in a Tertiary Center in Germany

Background: Lichen planopilaris (LPP) is an inflammatory cicatricial alopecia characterized by an irreversible destruction of the hair follicle resulting in its permeant destruction. The clinical presentation of LPP is a progressive patchy scarring alopecia. A variety of systemic agents is used to treat LPP with varying success. The aim of this retrospective, real-life analysis was to evaluate the treatment of hydroxychloroquine for LPP. Method: In this retrospective, single-center study, we analyzed 110 patients with LPP and frontal fibrosing alopecia (FFA) who received treatment over a 12-month period from March 2014 to March 2021 at the Department of Dermatology, University of Mainz Medical Center. Patient records were analyzed for response to treatment, co-morbidities, disease progression-free survival (DPFS), and safety. Clinical parameters associated with treatment response were determined with Cox regression modelling and logistic regression. Results: Overall, 77 of 110 patients were treated with a systemic agent. There was a clear association between LPP and the occurrence of Hashimoto thyroiditis. Topical treatment with corticosteroids did not improve clinical symptoms in the majority of patients (15 out of 101). In 71% of patients treated with systemic cyclosporine A and 62% of patients treated with hydroxychloroquine, we observed a significant resolution of the inflammatory process, which correlated with a robust durable clinical response (p < 0.001). Toxicity was observed in 17% (n = 9) of patients receiving systemic treatment with hydroxychloroquine and correlated with the duration of systemic treatment (p < 0.001). Treatment discontinuation was associated with a flare-up of clinical symptoms (29%), which required the re-initiation of second-line therapy in 13 out of 51 patients. Overall, the initiation of second-line treatment, either hydroxychloroquine or Cyclosporine A (CsA), yielded positive results, especially in the patient cohort treated with hydroxychloroquine (overall response rate, ORR = 100%), who showed disease progression during CsA or retinoids. Conclusions: Our results from this contemporary cohort of patients with LPP and FFA indicate that hydroxychloroquine and cyclosporine are effective systemic agents in decreasing clinical symptoms. However, our data also show that the discontinuation of treatment is often associated with the exacerbation of clinical symptoms. Response rates to second-line treatment were especially favorable in the patient cohort with hydroxychloroquine.

Lessons from a scoping review: Clinical presentations of central centrifugal cicatricial alopecia

BACKGROUND

Central centrifugal cicatricial alopecia (CCCA) nomenclature describes a typical clinical presentation of cicatricial hair loss that begins on the vertex scalp with progressive, symmetric, and centrifugal evolution. However, atypical presentations have been noted clinically by the authors and reported in the literature.

OBJECTIVE

We sought to characterize the distribution of hair loss in published cases of adult patients with CCCA.

METHODS

A 3-step search process was used to evaluate research articles in Cumulative Index to Nursing & Allied Health, EMBASE, Google Scholar, MEDLINE, Scopus, and Web of Science databases. Studies with scalp photography or description of hair loss distribution were included. Three researchers evaluated eligible studies for clinical subtypes. Preferred Reporting Items for Systematic Reviews and Meta-Analyses Extension for Scoping Review was used to report results.

RESULTS

Ninety-nine studies consisting of 281 cases of CCCA were included. Hair loss distributions included variants of the classic presentation along with distinct subtypes such as patchy, occipital, parietal, frontal, temporal, and trichorrhexis.

LIMITATIONS

Studies had significant homogeneity, as the classic distribution of CCCA was commonly reported. Additionally, clinically diagnosed cases may have concurrent diagnoses, and numerous studies did not report trichoscopy findings.

CONCLUSION

CCCA terminology may not always be reflective of clinical presentation. Understanding atypical presentations is essential to inform appropriate and targeted treatment.

Quantification of mast cells in central centrifugal cicatricial alopecia

Background

Mast cells (MCs) have recently been implicated in lymphocytic scarring alopecias, which may share a common pathogenesis. MCs in central centrifugal cicatricial alopecia (CCCA) have not been studied.

Objective

We looked for the presence of MCs in CCCA using 2 different stains to see if their numbers correlated with the number of hair follicles, the degree of inflammation and perifollicular fibrosis, disease duration and severity, and patient symptoms.

Methods

We performed a retrospective review of biopsies of patients diagnosed with CCCA, tabulated MC counts and correlated them with histopathologic and clinical findings.

Results

MC counts were significantly greater using immunoperoxidase staining with CD117 than Giemsa stain, and more were present when the isthmus level was included with the infundibulum. MC counts with CD117 immunostain significantly correlated with the degree of inflammation. MC counts with both stains were significantly associated with the degree of fibrosis independently and after controlling for other factors.

Limitations

The study was limited by insufficient tissue remaining in a small number of the transversely cut blocks.

Conclusion

Our findings may have therapeutic implications for CCCA and other types of lymphocytic scarring alopecia.

Endocrine and metabolic comorbidities in primary cicatricial alopecia: A nationwide population-based study

Primary cicatricial alopecia (PCA) is a rare, scarring, hair loss disorder. Due to its low incidence, little is known about endocrine and metabolic comorbidities in patients with PCA. Thus, we aimed to investigate the association between PCA and endocrine and metabolic disorders. This nationwide, population-based, cross-sectional study included patients diagnosed with PCA or non-cicatricial alopecia (NCA) and normal individuals without history of alopecia registered in the Korean National Health Insurance Service database between January 1, 2011, and December 31, 2020. We calculated the odds ratios of endocrine and metabolic comorbidities of patients with PCA compared to all patients or age- and sex-matched patients with NCA or normal individuals using multivariable logistic regression models. A total of 3 021 483 individuals (mean age [SD], 38.7 [15.0] years, 1 607 380 [53.2%] men), including 11 956 patients with PCA, 601 852 patients with NCA, and 2 407 675 normal participants, were identified. Patients with PCA had an increased risk for dyslipidemia (adjusted odds ratio [aOR] 1.14, 95% confidence interval [CI] 1.06-1.24), diabetes (aOR 1.38, 95% CI 1.24-1.53), and hypertension (aOR 1.10, 95% CI 1.02-1.19) compared to matched patients with NCA. Regarding PCA subtypes, lichen planopilaris/frontal fibrosing alopecia was positively associated with hypothyroidism (aOR 2.03, 95% CI 1.44-2.86) compared to NCA. Folliculitis decalvans and dissecting cellulitis were positively associated with dyslipidemia (aOR 1.16, 95% CI 1.05-1.28 and aOR 1.16, 95% CI 1.04-1.29, respectively), diabetes (aOR 1.38, 95% CI 1.20-1.58 and aOR 1.52, 95% CI 1.32-1.74, respectively), and hypertension (aOR 1.10, 95% CI 1.00-1.20 and aOR 1.14, 95% CI 1.02-1.27, respectively). Similar trends were observed when each PCA subgroup was compared with the normal control group. This study demonstrates that patients with PCA are more likely to have endocrine and metabolic comorbidities than patients without PCA. Further research on these comorbidities may improve the understanding of PCA.

Tumor necrosis factor inhibitors and janus kinase inhibitors in the treatment of cicatricial alopecia: A systematic review

BACKGROUND

Cicatricial alopecia (CA) refers to various conditions that result in permanent hair loss. Treatment of CA has always been challenging. Regarding immune-mediated pathophysiology for many CA subtypes, the administration of Janus kinase (JAK) and tumor necrosis factor (TNF) inhibitors have potentiated the treatments of CA.

METHODS

After a thorough systematic search in PubMed/Medline, Embase, Web of Science, Scopus, Google Scholar, ClinicalTrials.gov, and WHO ICTRP, a total of 3,532 relevant records were retrieved and screened. Accordingly, 56 studies met the eligibility criteria and entered the review.

RESULTS

Among JAK inhibitors, oral tofacitinib was the most frequently reported and the most effective treatment in improving signs and symptoms of CA with minimal adverse effects (AEs). Baricitinib was another JAK inhibitor with sustained improvement while causing mild AEs. As a TNF inhibitor, adalimumab induced a rapid and stable improvement in signs and symptoms in most patients with rare, tolerable AEs. Thalidomide was the other frequently reported yet controversial TNF inhibitor, which caused a rapid and significant improvement in the condition. However, it may result in mild to severe AEs, particularly neuropathies. Infliximab is a TNF inhibitor with mostly favorable results, albeit in a few patients caused treatable dermatological AEs. Apremilast and certolizumab pegol caused an incomplete amelioration of signs and symptoms with no AEs. Lenalidomide is another TNF inhibitor that can induce temporary improvement in CA with probable AEs. It is noteworthy that utilizing adalimumab, infliximab, etanercept, golimumab, and an anonymous TNF inhibitor has induced paradoxical CA and other A.E.s in some patients.

CONCLUSION

Recent studies have recommended JAK and TNF inhibitors, especially oral tofacitinib and adalimumab, as a new modality or adjuvant therapy to previous medications for primary CA. Nonetheless, monitoring AEs on a regular basis is suggested, and further extensive studies are required before definitive recommendations.

Health-related quality of life (hrQoL) among patients with primary cicatricial alopecia (PCA): A systematic review

Cicatricial alopecia may lead to an enormous emotional burden, social distress, and psychological impairment affecting the quality of life. The objective of this review is to systematically describe the health-related quality of life in adults with primary cicatricial alopecia and its subtypes. Studies that (i) reported quality of life in patients with primary cicatricial alopecia or its subtypes; (ii) were original research and not a conference abstract or review (iii) with patients >18 years of age were included in the review. The studies not mentioning quality of life specifically for the cicatricial alopecia cohort were excluded. We searched for literature via OVID in Medline and Embase, in Web of Science, CINAHL, EBSCO (APA PsycArticles, APA PsycInfo, and PSYNDEX Literature), in the Cochrane Library and for grey literature from its inception date till 12 November 2022. The risk of bias was assessed by using the AXIS tool for cross-sectional studies by two independent authors. Thirteen observational cross-sectional and one single-arm study, including 572 patients and eight different instruments, fulfilled the inclusion criteria. Results are descriptively synthesized, and associated factors of quality of life are presented. The data from studies that used the Dermatology Life Quality Index tool (DLQI) showed that more than 70% of the patients have an impaired life quality. While trichodynia and anxiety have a negative effect on the quality of life, disease duration, education, employment, and marital status have no effect. The findings were inconsistent for other factors. Most of these studies failed to justify the sample size. Furthermore, the risk of bias assessment could not surely rule out a non-response bias. Our results suggest that cicatricial alopecia treatments must be integrated with psychosocial intervention and indicate the need for further research with homogenous and more comprehensive tools to identify and address this patient population's unmet mental health needs.

The Paper Sign Test - Assessment, Evaluation, and Diagnosis Method for Reactivated Lichen Planopilaris by Physician and Patient

Background

Lichen planopilaris (LPP) is an inflammatory disease that results in destruction of the hair follicle and replaces it with patchy permanent scarring alopecia; after stabilizing by treatment, reactivation is common and may be insidious. During remission, various methods are available for realizing that the disease is activated or not, but neither of them is practical for patients.

Objectives

This study aims to evaluate the paper sign test for reactivated LPP by physician and patient.

Patients and Methods

In a prospective study, during 2 years, 83 treated LPP patients have been divided into two groups of 41 and 42. Group 1 instructed for paper sign test which is to comb their hair over a white paper sheet to catch any fallen hairs, then turn the paper upside down, if all collected hair on paper completely separated, test is considered negative, if even one hair hangs onto the paper, the test is considered positive. Group 2 trained for clinical symptoms (hair shedding, scaling, itching, pain, tenderness, and burning).

Results

From the first group, 13 patients had positive paper sign, and from the second group, 35 patients had clinical symptoms; after clinical examination and biopsy, 13 from Group 1 and 17 from Group 2 were confirmed to have reactivated disease. Patients in the first group who had been trained for paper sign test became aware of relapse sooner and came earlier for the evaluation of disease.

Conclusion

Paper sign test is a reliable, noninvasive, and practical test for early detection of reactivated LPP by patients during remission period.

Skin of color in dermatopathology: does color matter?

Skin of color (SoC) remains an understudied and under taught area of dermatology despite its rising importance. Race and ethnicity play a particularly important role in dermatology as skin pigmentation can affect the manifestation and presentation of many common dermatoses. With this review, we seek to review pertinent differences in SoC histology, as well as highlight the histopathology of conditions more common in SoC and address inherent bias that may affect accurate dermatopathology sign out.

Patterns of Mucin Deposition in Lichen Planopilaris: A Journey From Follicular "Bubbles" to Perifollicular Fibroplasia

ABSTRACT

Lichen Planopiolaris (LPP) is a scarring alopecia characterised by a perifollicular lymphoid cell infiltrate at the level of the infundibulum and isthmus. While perifollicular mucinous fibroplasia is an established finding in LPP, intrafollicular mucin deposition has not been previously reported. We describe two cases with this histopathology and suggest it may represent a helpful clue to the diagnosis of LPP, in the appropriate clinical setting.

Unveiling a Shared Precursor Condition for Acne Keloidalis Nuchae and Primary Cicatricial Alopecias

Purpose

Small observational studies suggest subclinical disease occurrence in the normal-appearing scalp zones of several primary cicatricial alopecias. To aid patient management, we began routinely evaluating the entire scalp of patients with acne keloidalis nuchae (AKN), including trichoscopy-guided biopsies.

Patients and Methods

This retrospective study evaluated 41 patients sequentially presenting with AKN at a single clinic between June and December 2022. Primary lesions and normal-appearing scalp in the superior parietal scalp at least 5 cm away from AKN-affected zones were clinically evaluated, and areas showing perifollicular erythema or scales/casts on trichoscopy were biopsied and histologically analyzed.

Results

Forty-one men with AKN, including 20 men of African descent, 17 Hispanic, and 4 European-descended Whites, were evaluated. All patients, including 22% with associated folliculitis decalvans, showed scalp-wide trichoscopy signs of perifollicular erythema or scaling in normal-appearing scalp areas. All patients showed histologic evidence of perifollicular infundibulo-isthmic lymphocytoplasmic infiltrates and fibrosis (PIILIF), with 96% showing Vellus or miniaturized hair absence. PIILIF was often clinically mistaken for seborrheic dermatitis (44-51%). All White patients had mild papular acne keloidalis nuchae lesions mistaken for seborrheic dermatitis.

Conclusion

PIILIF may be a precursor to a wide spectrum of primary cicatricial alopecias, including AKN and folliculitis decalvans. This finding carries implications for the early diagnosis and management of AKN and other primary cicatricial alopecias.

Alopecias: Practical Tips for the Management of Biopsies and Main Diagnostic Clues for General Pathologists and Dermatopathologists

Accurately diagnosing specific variants of alopecia remains challenging for pathologists, potentially delaying appropriate therapeutic decisions by dermatologists. Issues such as limited knowledge on optimal biopsy types and processing methods add complexity. Understanding the normal histology of hair follicles and their changes throughout the follicular cycle further complicates microscopic evaluation. This paper aims to summarize these characteristics and highlight essential diagnostic clues for pathologists to confidently suggest a diagnosis, therefore playing a key role in alopecia diagnosis. Ongoing education, collaboration with dermatologists, and staying up to date on advancements is crucial for the accurate diagnosis and effective management of different types of alopecia.

Histopathologic Spectrum of Alopecias Seen in a Jamaican Setting

ABSTRACT

Alopecia is common in Jamaican, primarily Afro-Caribbean patients. We performed a retrospective review examining the histopathologic alopecia diagnoses over ∼5 years. Requisition forms and pathology reports were assessed. Demographic/clinical/technical/diagnostic and pathologic findings of chronicity/severity data were recorded. Three hundred thirty-eight biopsies were included. The majority were 4 mm punches, grossed horizontally. The F:M ratio was 4.8:1, mean age = 42.7 years, and mean duration of alopecia = 5.1 years. Cicatricial alopecias (CAs) predominated over non-CAs (NCAs). The top 10 diagnoses were central centrifugal CA (21.9%), folliculitis decalvans (10.9%), multifactorial alopecias (10.1%), pattern hair loss (8%), lichen planopilaris (7.1%), alopecia areata (6.2%), discoid lupus erythematosus (6.2%), nonclassifiable lymphocytic scarring alopecias (5.6%), frontal fibrosing alopecia (5.3%), and nonspecific NCAs (5%). This contrasted with other richly pigmented populations where discoid lupus erythematosus predominates. Other interesting findings included relatively frequent folliculitis decalvans and lichen planus pigmentosus in 40.9% of frontal fibrosing alopecia cases. Scarring/nonscarring clinicopathologic congruence occurred in 83.4%.Regarding histopathologic features of severity/chronicity, CAs had markedly decreased hair counts. Perifollicular fibrosis affecting retained hairs occurred in 75% of CAs, moderate to severe in >50% of these. Approximately 50% of NCA samples demonstrated advanced miniaturization (T:V ratio <2:1). In our study, relatively young women with chronic hair loss and CA are most frequently biopsied. Central centrifugal CA is the most common diagnosis. Local features of chronic/severe disease are seen microscopically. Clinical impression of scarring/nonscarring correlates well with histopathology.

Recent Advances in Understanding of the Etiopathogenesis, Diagnosis, and Management of Hair Loss Diseases

Hair-loss diseases comprise heterogenous conditions with respective pathophysiology and clinicopathological characteristics. Major breakthroughs in hair follicle biology and immunology have led to the elucidation of etiopathogenesis of non-scarring alopecia (e.g., alopecia areata, AA) and cicatricial alopecia (e.g., lichen planopilaris, LPP). High-throughput genetic analyses revealed molecular mechanism underlying the disease susceptibility of hair loss conditions, such as androgenetic alopecia (AGA) and female pattern hair loss (FPHL). Hair loss attracted public interest during the COVID-19 pandemic. The knowledge of hair loss diseases is robustly expanding and thus requires timely updates. In this review, the diagnostic and measurement methodologies applied to hair loss diseases are updated. Of note, novel criteria and classification/scoring systems published in the last decade are reviewed, highlighting their advantages over conventional ones. Emerging diagnostic techniques are itemized with clinical pearls enabling efficient utilization. Recent advances in understanding the etiopathogenesis and management for representative hair diseases, namely AGA, FPHL, AA, and major primary cicatricial alopecia, including LPP, are comprehensively summarized, focusing on causative factors, genetic predisposition, new disease entity, and novel therapeutic options. Lastly, the association between COVID-19 and hair loss is discussed to delineate telogen effluvium as the predominating pathomechanism accounting for this sequela.

Wound-Induced Hair Neogenesis: A Portal to the Development of New Therapies for Hair Loss and Wound Regeneration

Adult mammals retain the remarkable ability to regenerate hair follicles after wounding. Wound-induced hair neogenesis (WIHN) in many ways recapitulates embryogenesis. The origin of the stem cells that give rise to a nascent hair follicle after wounding and the role of mesenchymal cells and signaling pathways responsible for this regenerative phenomenon are slowly being elucidated. WIHN provides a potential therapeutic window for manipulating cell fate by the introduction of factors during the wound healing process to enhance hair follicle formation.

Folliculitis decalvans: a case report of satisfactory recovery after implementing isotretinoin therapy

Introduction: Folliculitis decalvans is a rare skin disease characterized by the presence of painful papules and pustules with an underlying neutrophilic infiltrate, usually on the scalp. Its treatment is lengthy and challenging, and recurrence is relatively common. Although its etiology is unknown, several theories explaining its development have been proposed, including colonization by Staphylococcus aureus. Case description: This is the case of a 26-year-old male healthcare worker who visited the outpatient service after experiencing a 4-year history of painful pustules on the scalp; initially these lesions were located in the occipital region, but then also started to appear in the temporal and parietal regions. After being treated for bacterial folliculitis and having several recurrences, a skin biopsy was performed, which allowed diagnosing him with folliculitis decalvans. Once the diagnosis was made, isotretinoin (20mg) treatment was implemented for a year and a half, achieving complete remission of the lesions. Conclusion: Although this case has some limitations, such as the lack of histopathology images and some control laboratory tests, it clearly shows the difficulties faced when treating this type of skin disorders and presents an overview of the use of isotretinoin, evidencing that although this drug is well tolerated, possible adverse reactions from drug interactions with trimethoprim/sulfamethoxazole may arise. In addition, this case is of great importance since the possible presence of a familial cluster of folliculitis decalvans could be confirmed, if further genetic testing is performed.

Folliculitis Decalvans and Lichen Planopilaris Phenotypic Spectrum: A Case Report

The folliculitis decalvans (FD) and lichen planopilaris (LPP) phenotypic spectrum combines biphasic features of FD and LPP. It is characterized by successive or concomitant occurrence of pustules, crusts, follicular tufts, perifollicular erythema, perifollicular scales, and cicatricial alopecia and includes mixed histologic features of both FD and LPP. Here, we report the case of a 33-year-old female patient with a 30-year history of FD-LPP phenotypic spectrum lesions.

Immune-mediated alopecias and their mechanobiological aspects

Alopecia is a non-specific term for hair loss clinically diagnosed by the hair loss pattern and histological analysis of patient scalp biopsies. The immune-mediated alopecia subtypes, including alopecia areata, lichen planopilaris, frontal fibrosing alopecia, and central centrifugal cicatricial alopecia, are common, significant forms of alopecia subtypes. For example, alopecia areata is the most common autoimmune disease with a lifetime incidence of approximately 2% of the world's population. In this perspective, we discuss major results from studies of immune-mediated alopecia subtypes. These studies suggest the key event in disease onset as the collapse in immune privilege, which alters the hair follicle microenvironment, e.g., upregulation of major histocompatibility complex molecules and increase of cytokine production, and results in immune cell infiltration, inflammatory responses, and damage of hair follicles. We note that previous studies have established that the hair follicle has a complex mechanical microenvironment, which may regulate the function of not only tissue cells but also immune cell infiltrates. This suggests a potential for mechanobiology to contribute to alopecia research by adding new methods, new approaches, and new ways of thinking, which is missing in the existing literature. To fill this a gap in the alopecia research space, we develop a mechanobiological hypothesis that alterations in the hair follicle microenvironment, specifically in the mechanically responsive tissues and cells, partially due to loss of immune privilege, may be contributors to disease pathology. We further focus our discussion on the potential for applying mechanoimmunology to the study of T cell infiltrates in the hair follicle, as they are considered primary contributors to alopecia pathology. To establish the connection between the mechanoimmunological hypothesis and immune-mediated alopecia subtypes, we discuss what is known about the role of T cells in immune-mediated alopecia subtypes, using the most extensively studied AA as our model.

An overview of the genetic aspects of hair loss and its connection with nutrition

Hair loss is a widespread concern in dermatology clinics, affecting both men's and women's quality of life. Hair loss can have many different causes, which are critical to identify in order to provide appropriate treatment. Hair loss can happen due to many variables, such as genetic factors or predisposition, vitamin and mineral deficiencies, skin problems, hair growth disorders, poor diet, hormonal problems, certain internal diseases, drug use, stress and depression, cosmetic factors, childbirth, and the chemotherapy process. Treatment for hair loss varies depending on the type of alopecia, deficiency, or excess of structures such as vitamins and minerals, and also on hair and skin structure. The Mediterranean diet is characterized by low amounts of saturated fat, animal protein, and high amounts of unsaturated fat, fiber, polyphenols, and antioxidants. The main nutrients found in the Mediterranean Diet are rich in antioxidant, anti-inflammatory components. It also has an important place in hair loss treatment, since recently treatment strategies have included polyphenols and unsaturated oils more and more frequently. The goal of this work was to review published articles examining alopecia and its types, the many micronutrients that affect alopecia, and the role of the Mediterranean diet in alopecia. The literature shows that little is known about hair loss, nutritional factors, and diet, and that the data collected are conflicting. Given these differences, research into the function of diet and nutrition in the treatment of baldness is a dynamic and growing topic.

The associated burden of mental health conditions in alopecia areata: A population-based study in UK primary care

Background

Alopecia areata (AA) is a common cause of nonscarring hair loss that can have a profound psychological impact.

Objectives

To assess the co‐occurrence of depression and anxiety in adults with AA compared with the general population, and to evaluate the mental health treatment burden and impact on time off work and unemployment.

Methods

In total, 5435 people with newly diagnosed AA in UK primary care were identified from the Oxford Royal College of General Practitioners Research and Surveillance Centre network database, and matched to 21 740 controls. In cases and controls, we compared the prevalence and incidence of depressive episodes, recurrent depressive disorder and anxiety disorder, rates of time off work and unemployment, and, in those with pre‐existing mental health conditions, rates of mental health‐related prescribing and referral rates. This observational was registered with ClinicalTrials.gov (NCT04239521).

Results

Depression and anxiety were more prevalent in people diagnosed with AA than in controls (P < 0·001). People with AA were also more likely to subsequently develop new‐onset depression and anxiety: adjusted hazard ratio (aHR) for recurrent depressive disorder 1·38 [95% confidence interval (CI) 1·13–1·69], depressive episodes aHR 1·30 (95% CI 1·04–1·62) and anxiety disorder aHR 1·33 (95% CI 1·09–1·63); to be issued time off work certificates (aHR 1·56, 95% CI 1·43–1·71); and to be recorded as unemployed (aHR 1·82, 95% CI 1·33–2·49). Higher rates of antidepressant prescribing were also seen in people with AA.

Conclusions

People with AA have higher rates of depression and anxiety than those without AA. This impacts deleteriously on mental health treatment burden, time off work and unemployment. Evidence‐based mental health treatment programmes are needed for people with AA.

Horizontal Histopathology Correlation with In Vivo Reflectance Confocal Microscopy in Inflammatory Skin Diseases: A Review

Horizontal histopathological sections (HHSs) have been reported to show a strong correlation with images obtained via in vivo reflectance confocal microscopy (RCM), as both reflect the same horizontal plane of the skin. Although vertical histopathology remains the diagnostic gold standard for most neoplastic and inflammatory skin diseases, HHSs represent a useful tool to validate the RCM features of some inflammatory disorders, including psoriasis, discoid lupus erythematosus, and eczema. The aim of the present review is to summarize the state of the art on the existing correlations between HHS and RCM in this field and to emphasize that RCM may represent a useful diagnostic tool to discriminate between diseases with similar clinical presentations.

The epidemiology of alopecia areata: a population-based cohort study in UK primary care

BACKGROUND

There is a lack of population-based information on the disease burden and management of alopecia areata (AA).

OBJECTIVES

To describe the epidemiology of AA, focusing on incidence, demographics and patterns of healthcare utilization.

METHODS

Population-based cohort study of 4·16 million adults and children, using UK electronic primary care records from the Oxford-Royal College of General Practitioners (RCGP) Research and Surveillance Centre (RSC) network database, 2009-2018. The incidence and point prevalence of AA were estimated. Variation in AA incidence by age, sex, deprivation, geographical distribution and ethnicity was examined. Patterns of healthcare utilization were evaluated in people with incident AA.

RESULTS

The AA incidence rate was 0·26 per 1000 person-years. AA point prevalence in 2018 was 0·58% in adults. AA onset peaked at age 25-29 years for both sexes, although the peak was broader in females. People of nonwhite ethnicity were more likely to present with AA, especially those of Asian ethnicity [incidence rate ratio (IRR) 3·32 (95% confidence interval 3·11-3·55)]. Higher AA incidence was associated with social deprivation [IRR most vs. least deprived quintile 1·47 (1·37-1·59)] and urban living [IRR 1·23 (1·14-1·32)]. People of higher social deprivation were less likely to be referred for specialist dermatology review.

CONCLUSIONS

By providing the first large-scale estimates of the incidence and point prevalence of AA, our study helps to understand the burden of AA on the population. Understanding the variation in AA onset between different population groups may give insight into the pathogenesis of AA and its management.

Beware of the Impostors-Scalp Pathology Primer for the Hair Transplant Surgeon

Histopathological features are important for the practicing hair transplant surgeon to ensure proper case selection, diagnosis, choice of proper treatment, and successful outcome. While the primary focus of the hair transplant surgeon is androgenetic alopecia (AGA), it is important to be aware of other conditions that can mimic AGA, whose treatment may be different. This article outlines some of these conditions such as scarring alopecias, alopecia areata, etc., and how to distinguish them. Proper identification will ensure proper treatment and avoid potential missteps in management.

Lichen planopilaris arising between two linear surgical scars

Lichen planopilaris (LPP) is a type of lymphocytic cicatricial alopecia, which can occur at unusual sites. It can be difficult to diagnose at an early stage and may be misdiagnosed as seborrheic dermatitis or psoriasis in early stages before alopecia occurs. We report a rare case in which alopecia occurred between two long surgical scars on the scalp several years after surgery. Dermoscopy and biopsy led to a diagnosis of LPP. The localization of the lesions in our case suggests that oxidative stress from the failure of lymph flow might have induced LPP. Oral roxithromycin, a macrolide antibiotic, with anti-oxidative and anti-inflammatory was effective at stopping its progression.

Primary cicatricial alopecia: Recent advances in evaluation and diagnosis based on trichoscopic and histopathological observation, including overlapping and specific features

Primary cicatricial alopecia (PCA) is a form of alopecia in which inflammatory cells target follicles, including the bulge region containing follicular stem cells, leading to permanent alopecia. New classifications of PCA subtypes have recently been proposed, including those that account for novel trichoscopic and histopathological features of PCA, enabling greater precision in the evaluation and diagnosis of this condition. Nonetheless, diagnosis remains challenging clinically and histopathologically because the etiology of PCA is multifactorial. Inconsistent use of terminology, overlapping disease concepts, and changes in the clinical or histopathological severity of inflammation in the disease course in the same patient also make diagnosis quite challenging. The present study comprehensively reviews recent progress in diagnostic techniques, including the use of clinical, trichoscopic, and histopathological features, in evaluating each PCA subtype, containing overlapping and specific features. Elucidating the features of PCA, including those that are common to multiple subtypes as well as specific to each in both early and advanced-stage lesions, is important for accurate diagnosis. Improving the evaluation and treatment of this disease depends on having a broader clinical understanding that takes into account not only the features of the disease at a given point in time, but also the changes that occur during the entire disease course.

Cicatricial Pemphigoid Brunsting-Perry Variant Masquerading as Neutrophil-Medicated Cicatricial Alopecia

A 72-year-old male presented with scarring alopecia on the scalp vertex, multiple crusted plaques on the hairline, and a history of vesicular eruption on the face. The scalp showed crusted plaques with loss of follicular ostia. No follicular pustules or compound follicles were present. An initial transverse scalp biopsy showed perifollicular neutrophils, lymphocytes, and plasma cells along with dermal fibrosis. Focal epidermal/dermal and follicular/adventitial dermal clefts were apparent but were thought to be secondary to fibrosis, and the biopsy was interpreted to represent a neutrophil-mediated cicatricial alopecia. Concurrently, direct immunofluorescence (DIF) analysis demonstrated linear junctional deposition of IgG and C3. A repeat scalp biopsy revealed more prominent epidermal/dermal clefts, fibrosis, mixed infiltrate with neutrophils, lymphocytes, histiocytes and plasma cells and prominent follicular/adventitial dermal clefts with perifollicular neutrophils. Given the combination of clefts, perijunctional neutrophils, and positive DIF findings, it became clear that this eruption represented the Brunsting-Perry variant of cicatricial pemphigoid. Here, we illustrated that a neutrophil-rich form of cicatricial pemphigoid can masquerade as a neutrophil-mediated scarring alopecia. In evaluating a specimen suspected to be a neutrophil-mediated scarring alopecia, one should be alert to the presence of subepidermal and perifollicular clefting, and consider cicatricial pemphigoid. This article is protected by copyright. All rights reserved.

Scarring Alopecias: Pathology and an Update on Digital Developments

Primary cicatricial alopecias (PCA) represent a challenging group of disorders that result in irreversible hair loss from the destruction and fibrosis of hair follicles. Scalp skin biopsies are considered essential in investigating these conditions. Unfortunately, the recognised complexity of histopathologic interpretation is compounded by inadequate sampling and inappropriate laboratory processing. By sharing our successes in developing the communication pathway between the clinician, laboratory and histopathologist, we hope to mitigate some of the difficulties that can arise in managing these conditions. We provide insight from clinical and pathology practice into how diagnoses are derived and the key histological features observed across the most common PCAs seen in practice. Additionally, we highlight the opportunities that have emerged with advances in digital pathology and how these technologies may be used to develop clinicopathological relationships, improve working practices, enhance remote learning, reduce inefficiencies, optimise diagnostic yield, and harness the potential of artificial intelligence (AI).

Differentiation of frontal fibrosing alopecia and Lichen planopilaris on trichoscopy: A comprehensive review

Trichoscopy in dermatology has opened up the new concept in overcoming the optical challenge faced clinically. It reveals the diagnostic details to the depth of superficial dermis, and thereby increasing the clinician's diagnostic accuracy and the level of confidence. The importance of trichoscopy in cicatricial alopecia is very evident in the current scenario for its precise diagnosis. The clinical picture in delineating lichen planopilaris (LPP) and frontal fibrosing alopecia (FFA) from each other and also from other close mimickers such as androgenetic alopecia, alopecia areata, female patterned hair loss, and other cicatricial alopecia is bewildered due to its varied presentation and co-existence with the above disease. The indecisive comparative findings on histopathology make the situation even more perplexed. In this article, we have reviewed the characteristic trichoscopy patterns that can differentiate LPP and FFA and from their close mimickers.

Scarring Alopecia With Coexisting Lichen Planus in a Child: A Rare Phenomenon

Lichen planopilaris (LPP) is characterized by chronic cicatricial alopecia that is lymphocytic in nature. The underlying pathophysiology of LPP is not well understood. Failure of therapeutic management occurs quite often resulting in significant psychosocial stress on the patient when they are unable to prevent further hair loss or reverse it. Although the occurrence of LPP is rare, it is especially seldom observed in the pediatric population. Herein, we discuss a case of a nine-year-old child who was recently diagnosed with LPP.

Primary nonessential cutis verticis gyrata with acne keloidalis nuchae

Cutis verticis gyrata is a rare disorder characterized by redundant skin forming deep furrows and convolutions. It has been associated with several systemic and cutaneous disorders. We report a case of primary non-essential cutis verticis gyrata in association with acne keloidalis nuchae in a schizophrenic patient.

A Cell Membrane-Level Approach to Cicatricial Alopecia Management: Is Caveolin-1 a Viable Therapeutic Target in Frontal Fibrosing Alopecia?

Irreversible destruction of the hair follicle (HF) in primary cicatricial alopecia and its most common variant, frontal fibrosing alopecia (FFA), results from apoptosis and pathological epithelial-mesenchymal transition (EMT) of epithelial HF stem cells (eHFSCs), in conjunction with the collapse of bulge immune privilege (IP) and interferon-gamma-mediated chronic inflammation. The scaffolding protein caveolin-1 (Cav1) is a key component of specialized cell membrane microdomains (caveolae) that regulates multiple signaling events, and even though Cav1 is most prominently expressed in the bulge area of human scalp HFs, it has not been investigated in any cicatricial alopecia context. Interestingly, in mice, Cav1 is involved in the regulation of (1) key HF IP guardians (TGF-β and α-MSH signaling), (2) IP collapse inducers/markers (IFNγ, substance P and MICA), and (3) EMT. Therefore, we hypothesize that Cav1 may be an unrecognized, important player in the pathobiology of cicatricial alopecias, and particularly, in FFA, which is currently considered as the most common type of primary lymphocytic scarring alopecia in the world. We envision that localized therapeutic inhibition of Cav1 in management of FFA (by cholesterol depleting agents, i.e., cyclodextrins/statins), could inhibit and potentially reverse bulge IP collapse and pathological EMT. Moreover, manipulation of HF Cav1 expression/localization would not only be relevant for management of cicatricial alopecia, but FFA could also serve as a model disease for elucidating the role of Cav1 in other stem cell- and/or IP collapse-related pathologies.

Central Centrifugal Cicatricial Alopecia: Challenges and Treatments

Central centrifugal cicatricial alopecia (CCCA) is the most common form of primary scarring alopecia diagnosed in women of African descent. Although the etiology was originally attributed exclusively to hairstyling practices common among women of African descent, more recent research on CCCA supports the concept that there are several contributing factors, including variants in gene expression, hair grooming practices that increase fragility on the hair follicle, and associations with other systemic conditions. Treatment of CCCA involves a combination of patient counseling and education on alternative hairstyles, medical therapies, and procedural methods when necessary.

Design of In Vitro Hair Follicles for Different Applications in the Treatment of Alopecia-A Review

The hair research field has seen great improvement in recent decades, with in vitro hair follicle (HF) models being extensively developed. However, due to the cellular complexity and number of various molecular interactions that must be coordinated, a fully functional in vitro model of HFs remains elusive. The most common bioengineering approach to grow HFs in vitro is to manipulate their features on cellular and molecular levels, with dermal papilla cells being the main focus. In this study, we focus on providing a better understanding of HFs in general and how they behave in vitro. The first part of the review presents skin morphology with an emphasis on HFs and hair loss. The remainder of the paper evaluates cells, materials, and methods of in vitro growth of HFs. Lastly, in vitro models and assays for evaluating the effects of active compounds on alopecia and hair growth are presented, with the final emphasis on applications of in vitro HFs in hair transplantation. Since the growth of in vitro HFs is a complicated procedure, there is still a great number of unanswered questions aimed at understanding the long-term cycling of HFs without losing inductivity. Incorporating other regions of HFs that lead to the successful formation of different hair classes remains a difficult challenge.

Suitability of high-frequency ultrasonography (20 MHz) in evaluation of various forms of primary cicatricial alopecia in relation to trichoscopy - pilot study

BACKGROUND

Primary cicatricial alopecia is a potentially irreversible process of hair loss, in which for proper diagnosis a skin biopsy is necessary. Searching for new, non-invasive diagnostic methods may shorten the time for final diagnosis, initiating appropriate treatment and reduce the need for biopsy. The aim of this study was to evaluate the usefulness of high-frequency ultrasonography (HF-USG) as a diagnostic method in patients with primary scarring alopecia and to compare it with trichoscopy.

MATERIALS AND METHODS

The study covered a total of 44 adults: 8 with classic lichen planopilaris (LPP), 11 with discoid lupus erythematosus (DLE), 14 with frontal fibrosing alopecia (FFA), and 11 healthy volunteers. Each patient underwent physical and trichoscopic examination which was the base for qualification for active/inactive stage of the disease. Then, HF-USG was performed using a probe with a frequency of 20 MHz. In HF-USG images, the following elements were evaluated and measured: entrance echo (EE), follicular structures (FS), dermal background (DB), and dermal/subdermal border (D/SB).

RESULTS

Inactive phase was characterized by significantly lower number/lack of FS compared to the active phase of scarring alopecia. HF-USG of active LPP/FFA presented cigar-like shaped FS, while inactive stage pronounced D/SB forming saw-like pattern. Active DLE in HF-USG were associated with focal, doubled EE and widened FS with a tendency to create hypoechogenic wide, structureless bands within the skin. In inactive DLE, there was no specific pattern of D/SB or rarely puzzle-like pattern.

CONCLUSION

HF-USG images differ depending on the phase of the disease and the type of scarring alopecia, similarly to trichoscopic examination.