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Al Hammadi A, Parmar NV, Aljefri K, Al Sharif O, Abdallah M, Ahmed HM, Ammoury A. Review on Alopecia Areata in the Middle East and Africa: Landscape and Unmet Needs. Dermatol Ther (Heidelb) 2023:10.1007/s13555-023-00946-8. [PMID: 37338721 DOI: 10.1007/s13555-023-00946-8] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/20/2023] [Accepted: 05/24/2023] [Indexed: 06/21/2023] Open
Abstract
BACKGROUND Alopecia areata (AA) is an autoimmune disease characterized by non-scarring hair loss in adults and children. Clinical manifestations range from hair loss in small, well-circumscribed patches to total hair loss on the scalp or any other hair-bearing areas. Although the exact pathogenesis of AA is not fully understood, it is thought that loss of immune privilege caused by immunological dysregulation of the hair follicle is key. Genetic susceptibility also plays a role. Response to currently available treatments is widely variable, causing patient dissatisfaction and creating an unmet need. AA is frequently associated with multiple comorbidities, further affecting patient quality of life. AIMS AND FINDINGS AA causes a significant burden on dermatologists and healthcare systems in the Middle East and Africa. There is a lack of data registries, local consensus, and treatment guidelines in the region. Limited public awareness, availability of treatments, and patient support need to be addressed to improve disease management in the region. A literature review was conducted to identify relevant publications and highlight regional data on prevalence rates, diagnosis, quality of life, treatment modalities, and unmet needs for AA in the Middle East and Africa.
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Affiliation(s)
| | - Nisha V Parmar
- Department of Dermatology, Rashid Hospital, Dubai Health Authority, Dubai, UAE
| | | | - Osama Al Sharif
- King Fahad General Hospital, Medina, Kingdom of Saudi Arabia
| | | | | | - Alfred Ammoury
- Division of Dermatology, St George University Medical Center, Beirut, Lebanon
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Dai C, Chen H, Jiao M, Zhang N, Tang X, Fan A, Liu S, Qian Z, Wang C, Xu Y, Tan Z, Zeng F, Zheng F. IL-33 Contributes to the Pathological Changes of Hair Follicles in Psoriasis: A Potential Target for Psoriatic Alopecia. Clin Cosmet Investig Dermatol 2023; 16:639-650. [PMID: 36936754 PMCID: PMC10019523 DOI: 10.2147/ccid.s403075] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/29/2022] [Accepted: 03/07/2023] [Indexed: 03/13/2023]
Abstract
Purpose IL-33 is constitutively expressed in skin tissues. Alopecia, a T cells-driven disorder of the hair follicles (HFs), is a common complication in the development of psoriasis. However, the role of IL-33 in psoriatic alopecia remains uncovered. Here, we investigated the roles of IL-33 in inducing pathological changes of hair follicles in psoriasis. Patients and Methods Clinical samples and imiquimod (IMQ)-induced psoriatic mice samples were used to investigate the pathological changes and T-cell infiltration of HFs. By using immunohistochemistry staining, the distribution and expression alteration of IL-33 in HFs were determined. Next, by using IL-33 and ST2 knockout mice, we investigated the role of IL-33/ST2 axis in the pathological changes of HFs in psoriasis. Meanwhile, recombinant IL-33 protein was subcutaneous injected to confirm its effect. Finally, RNA sequencing was used to clarify the genes and signaling pathways that involved in this process. Differentially expressed genes were further verified by RT-PCR in cultured HFs in vitro. Results We found that the pathological changes of HFs and T cells infiltration in imiquimod-induced psoriatic mice were similar to that in psoriasis patients. The IL-33 positive keratinocytes in the outer root sheath of HFs were increased in both psoriasis patients and psoriatic model mice compared with the controls. By using gene knockout mice, we found that the pathological changes and T cell infiltration were attenuated in IL-33-/- and ST2-/- psoriatic model mice. In addition, subcutaneous injection of recombinant IL-33 exacerbated the pathological changes of HFs and T cell infiltration. RNA sequencing and RT-RCR revealed that IL-33 upregulated the transcription of genes related to keratinocytes proliferation and T lymphocytes chemotaxis. Conclusion Our study identifies that IL-33 promotes the pathological changes of HFs in psoriasis, which contributes to psoriatic alopecia. Inhibition of IL-33 may be a potential therapeutic approach for psoriatic alopecia.
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Affiliation(s)
- Chan Dai
- Department of Immunology, School of Basic Medicine, Tongji Medical College, Huazhong University of Science and Technology, Wuhan, Hubei, People’s Republic of China
| | - Huoying Chen
- Department of Laboratory Medicine, The Second Affiliated Hospital of Guilin Medical University, Guilin, Guizhou, People’s Republic of China
| | - Mengya Jiao
- Department of Immunology, School of Basic Medicine, Tongji Medical College, Huazhong University of Science and Technology, Wuhan, Hubei, People’s Republic of China
| | - Na Zhang
- Department of Immunology, School of Basic Medicine, Tongji Medical College, Huazhong University of Science and Technology, Wuhan, Hubei, People’s Republic of China
| | - Xuhuan Tang
- Department of Immunology, School of Basic Medicine, Tongji Medical College, Huazhong University of Science and Technology, Wuhan, Hubei, People’s Republic of China
| | - Anqi Fan
- College of Life Science, Yangtze University, Jingzhou, Hubei, People’s Republic of China
| | - Shiwang Liu
- Department of Immunology, School of Basic Medicine, Tongji Medical College, Huazhong University of Science and Technology, Wuhan, Hubei, People’s Republic of China
| | - Zhigang Qian
- Department of Immunology, School of Basic Medicine, Tongji Medical College, Huazhong University of Science and Technology, Wuhan, Hubei, People’s Republic of China
| | - Chenchen Wang
- Department of Immunology, School of Basic Medicine, Tongji Medical College, Huazhong University of Science and Technology, Wuhan, Hubei, People’s Republic of China
| | - Yong Xu
- Department of Immunology, School of Basic Medicine, Tongji Medical College, Huazhong University of Science and Technology, Wuhan, Hubei, People’s Republic of China
| | - Zheng Tan
- Department of Immunology, School of Basic Medicine, Tongji Medical College, Huazhong University of Science and Technology, Wuhan, Hubei, People’s Republic of China
- Key Laboratory of Organ Transplantation, Ministry of Education, NHC Key Laboratory of Organ Transplantation, Key Laboratory of Organ Transplantation, Chinese Academy of Medical Sciences, Wuhan, Hubei, People’s Republic of China
| | - Fanfan Zeng
- Department of Clinical Laboratory, Union Hospital, Tongji Medical College, Huazhong University of Science and Technology, Wuhan, Hubei, People’s Republic of China
- Fanfan Zeng, Department of Clinical Laboratory, Union Hospital, Tongji Medical College, Huazhong University of Science and Technology, Wuhan, 430000, Hubei, People’s Republic of China, Email
| | - Fang Zheng
- Department of Immunology, School of Basic Medicine, Tongji Medical College, Huazhong University of Science and Technology, Wuhan, Hubei, People’s Republic of China
- Key Laboratory of Organ Transplantation, Ministry of Education, NHC Key Laboratory of Organ Transplantation, Key Laboratory of Organ Transplantation, Chinese Academy of Medical Sciences, Wuhan, Hubei, People’s Republic of China
- Correspondence: Fang Zheng, Department of Immunology, School of Basic Medicine, Tongji Medical College, Huazhong University of Science and Technology, Wuhan, 430000, Hubei, People’s Republic of China, Email
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Behrangi E, Roohaninasab M, Sadeghzadeh-Bazargan A, Najar Nobari N, Ghassemi M, Seirafianpour F, Goodarzi A, Dodangeh M. A systematic review on the treatment of pediatric severe alopecia areata by topical immunotherapy or Anthralin (contact sensitization) or low-level light/laser therapy (LLLT): focus on efficacy, safety, treatment duration, recurrence, and follow-up based on clinical studies. J Cosmet Dermatol 2021; 21:2727-2741. [PMID: 34606676 DOI: 10.1111/jocd.14480] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/21/2021] [Accepted: 09/08/2021] [Indexed: 01/10/2023]
Abstract
INTRODUCTION Alopecia areata (AA) in its extensive and severe forms is treatment-challenging, especially in pediatrics. METHOD A PRISMA-compliant systematic review of seven electronic databases was searched by the terms "alopecia areata," "pediatric," "topical immunotherapy," "Anthralin," and "light therapy" from inception until March 2021. All the alternative names of the disease and therapies have been included in the search terms. 790 articles went to title abstract review by two independent reviewers. In the subsequent level, a review of the full text of studies was conducted. RESULTS Finally, 10 relevant articles in terms of content structure, subject coverage, and purpose, were selected for further review. The highest percentages of complete hair regrowth were 79.6% and 63.61% by SADBE (topical immunotherapy) and laser therapy. By Anthralin (contact sensitization), the complete response rate was below 50% (between 30 and 35%). Regarding average response, the most effective methods were local immunotherapy (with an average effectiveness of 53.8%), laser therapy (52.55%), and the use of Anthralin-induced contact dermatitis (30.86%), respectively. However, recurrence rate-after treatment with induced contact dermatitis by topical medications like Anthralin (contact sensitization)-was lower (mean 43.53%) in comparison with local immunotherapy (57%). In topical immunotherapy, light base therapy, and contact sensitization, the highest percentage of complete hair regrowth and the average response rate were (63.61% and 52.55%), (79.6% and 53.8%) and (32% and 30.8%), respectively. These methods are considered safe in children. CONCLUSION A high and more than 50% efficacy in hair regrowth could be expected by topical immunotherapy and light/laser therapy method. No serious side effects have been observed by these methods that are well tolerated in children. Therefore, a combination of local immunotherapy and light/laser therapy could be suggested for the treatment of extensive AA in children. The use of Anthralin could be associated with a lower but more durable response. These points are important for patient selection in individualized situations.
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Affiliation(s)
- Elham Behrangi
- Department of Dermatology, Rasool Akram Medical Complex, Iran University of Medical Sciences (IUMS), Tehran, Iran
| | - Masoumeh Roohaninasab
- Department of Dermatology, Rasool Akram Medical Complex, Iran University of Medical Sciences (IUMS), Tehran, Iran
| | - Afsaneh Sadeghzadeh-Bazargan
- Department of Dermatology, Rasool Akram Medical Complex, Iran University of Medical Sciences (IUMS), Tehran, Iran
| | - Niloufar Najar Nobari
- Department of Dermatology, Rasool Akram Medical Complex, Iran University of Medical Sciences (IUMS), Tehran, Iran
| | - Mohammadreza Ghassemi
- Department of Dermatology, Rasool Akram Medical Complex, Iran University of Medical Sciences (IUMS), Tehran, Iran
| | - Farnoosh Seirafianpour
- Student Research Committee, School of Medicine, Iran University of Medical Sciences, Tehran, Iran
| | - Azadeh Goodarzi
- Department of Dermatology, Rasool Akram Medical Complex, Iran University of Medical Sciences (IUMS), Tehran, Iran
| | - Milad Dodangeh
- Student Research Committee, School of Medicine, Iran University of Medical Sciences, Tehran, Iran
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Suzuki T, Ito T, Gilhar A, Tokura Y, Reich K, Paus R. The hair follicle-psoriasis axis: Shared regulatory mechanisms and therapeutic targets. Exp Dermatol 2021; 31:266-279. [PMID: 34587317 DOI: 10.1111/exd.14462] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/08/2021] [Revised: 09/09/2021] [Accepted: 09/24/2021] [Indexed: 12/17/2022]
Abstract
It has long been known that there is a special affinity of psoriasis for the scalp: Here, it occurs most frequently, lesions terminate sharply in frontal skin beyond the hair line and are difficult to treat. Yet, surprisingly, scalp psoriasis only rarely causes alopecia, even though the pilosebaceous unit clearly is affected. Here, we systematically explore the peculiar, insufficiently investigated connection between psoriasis and growing (anagen) terminal scalp hair follicles (HFs), with emphasis on shared regulatory mechanism and therapeutic targets. Interestingly, several drugs and stressors that can trigger/aggravate psoriasis can inhibit hair growth (e.g. beta-blockers, chloroquine, carbamazepine, interferon-alpha, perceived stress). Instead, several anti-psoriatic agents can stimulate hair growth (e.g. cyclosporine, glucocorticoids, dithranol, UV irradiation), while skin/HF trauma (Köbner phenomenon/depilation) favours the development of psoriatic lesions and induces anagen in "quiescent" (telogen) HFs. On this basis, we propose two interconnected working models: (a) the existence of a bidirectional "hair follicle-psoriasis axis," along which keratinocytes of anagen scalp HFs secrete signals that favour the development and maintenance of psoriatic scalp lesions and respond to signals from these lesions, and (b) that anagen induction and psoriatic lesions share molecular "switch-on" mechanisms, which invite pharmacological targeting, once identified. Therefore, we advocate a novel, cross-fertilizing and integrative approach to psoriasis and hair research that systematically characterizes the "HF-psoriasis axis," focused on identification and therapeutic targeting of selected, shared signalling pathways in the future management of both, psoriasis and hair growth disorders.
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Affiliation(s)
- Takahiro Suzuki
- Dr. Phillip Frost Department of Dermatology & Cutaneous Surgery, University of Miami Miller School of Medicine, Miami, Florida, USA
| | - Taisuke Ito
- Department of Dermatology, Hamamatsu University School of Medicine, Hamamatsu, Japan
| | - Amos Gilhar
- Skin Research Laboratory, Rappaport Faculty of Medicine, Technion-Israel Institute of Technology, Haifa, Israel
| | - Yoshiki Tokura
- Department of Dermatology, Hamamatsu University School of Medicine, Hamamatsu, Japan.,Allergic Disease Research Center, Chutoen General Medical Center, Kakegawa, Japan
| | - Kristian Reich
- Institute for Health Services Research in Dermatology and Nursing, University Medical Center Hamburg-Eppendorf, Hamburg, Germany.,Monasterium Laboratory, Münster, Germany
| | - Ralf Paus
- Dr. Phillip Frost Department of Dermatology & Cutaneous Surgery, University of Miami Miller School of Medicine, Miami, Florida, USA.,Monasterium Laboratory, Münster, Germany.,Centre for Dermatology Research, University of Manchester, Manchester, UK.,NIHR Manchester Biomedical Research Center, Manchester, UK
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Benezeder T, Gehad A, Patra V, Clark R, Wolf P. Induction of IL-1β and antimicrobial peptides as a potential mechanism for topical dithranol. Exp Dermatol 2021; 30:841-846. [PMID: 33629779 PMCID: PMC8247942 DOI: 10.1111/exd.14310] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/23/2020] [Revised: 01/27/2021] [Accepted: 02/13/2021] [Indexed: 01/01/2023]
Abstract
Topical dithranol is effective in autoimmune conditions like alopecia areata, inducing hair regrowth in a high percentage of cases. Exact mechanisms of dithranol in alopecia areata, with seemingly healthy epidermis besides altered hair follicles, are not well understood. To better understand dithranol's mechanisms on healthy skin, we analysed its effect on normal murine as well as xenografted human skin. We found a strong increase in mRNA expression of anti-microbial peptides (AMPs) (eg Lcn2, Defb1, Defb3, S100a8, S100a9), keratinocyte differentiation markers (eg Serpinb3a, Flg, Krt16, Lce3e) and inflammatory cytokines (eg Il1b and Il17) in healthy murine skin. This effect was paralleled by inflammation and disturbed skin barrier, as well as an injury response resulting in epidermal hyperproliferation, as observed in murine and xenografted adult human skin. This contact response and disturbed barrier induced by dithranol might lead via a vicious loop between AMPs such as S100a8/a9 (that led to skin swelling itself after topical application) and cytokines such as IL-1β to an immune suppressive environment in the skin. A better understanding of the skin's physiologic response to dithranol may open up new avenues for the establishment of novel therapeutics (including AMP-related/interfering molecules) for certain skin conditions, such as alopecia areata.
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Affiliation(s)
- Theresa Benezeder
- Department of DermatologyMedical University of GrazGrazStyriaAustria
- Department of DermatologyBrigham and Women’s HospitalHarvard Medical SchoolBostonMAUSA
| | - Ahmed Gehad
- Department of DermatologyBrigham and Women’s HospitalHarvard Medical SchoolBostonMAUSA
| | - VijayKumar Patra
- Department of DermatologyMedical University of GrazGrazStyriaAustria
- Centre International de Recherche en InfectiologieInstitut National de la Santé et de la Recherche Médicale, U1111LyonFrance
| | - Rachael Clark
- Department of DermatologyBrigham and Women’s HospitalHarvard Medical SchoolBostonMAUSA
| | - Peter Wolf
- Department of DermatologyMedical University of GrazGrazStyriaAustria
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Rocha VB, Kakizaki P, Donati A, Machado CJ, Pires MC, Contin LA. Randomized controlled study comparing the use of diphencyprone and anthralin in the treatment of extensive chronic alopecia areata. An Bras Dermatol 2021; 96:372-376. [PMID: 33849753 PMCID: PMC8178552 DOI: 10.1016/j.abd.2020.06.018] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/21/2019] [Accepted: 06/16/2020] [Indexed: 10/27/2022] Open
Affiliation(s)
- Vanessa Barreto Rocha
- Instituto de Assistência Médica do Servidor Público Estadual, São Paulo, SP, Brazil; Hospital do Servidor Municipal de São Paulo, São Paulo, SP, Brazil.
| | - Priscila Kakizaki
- Instituto de Assistência Médica do Servidor Público Estadual, São Paulo, SP, Brazil; Hospital do Servidor Municipal de São Paulo, São Paulo, SP, Brazil
| | - Aline Donati
- Hospital do Servidor Municipal de São Paulo, São Paulo, SP, Brazil
| | - Carla Jorge Machado
- Departamento de Saúde Pública, Faculdade de Medicina, Universidade Federal de Minas Gerais, Minas Gerais, MG, Brazil
| | - Mario Cezar Pires
- Instituto de Assistência Médica do Servidor Público Estadual, São Paulo, SP, Brazil
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7
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Benezeder T, Painsi C, Patra V, Dey S, Holcmann M, Lange-Asschenfeldt B, Sibilia M, Wolf P. Dithranol targets keratinocytes, their crosstalk with neutrophils and inhibits the IL-36 inflammatory loop in psoriasis. eLife 2020; 9:e56991. [PMID: 32484435 PMCID: PMC7266641 DOI: 10.7554/elife.56991] [Citation(s) in RCA: 21] [Impact Index Per Article: 5.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/17/2020] [Accepted: 05/18/2020] [Indexed: 12/18/2022] Open
Abstract
Despite the introduction of biologics, topical dithranol (anthralin) has remained one of the most effective anti-psoriatic agents. Serial biopsies from human psoriatic lesions and both the c-Jun/JunB and imiquimod psoriasis mouse model allowed us to study the therapeutic mechanism of this drug. Top differentially expressed genes in the early response to dithranol belonged to keratinocyte and epidermal differentiation pathways and IL-1 family members (i.e. IL36RN) but not elements of the IL-17/IL-23 axis. In human psoriatic response to dithranol, rapid decrease in expression of keratinocyte differentiation regulators (e.g. involucrin, SERPINB7 and SERPINB13), antimicrobial peptides (e.g. ß-defensins like DEFB4A, DEFB4B, DEFB103A, S100 proteins like S100A7, S100A12), chemotactic factors for neutrophils (e.g. CXCL5, CXCL8) and neutrophilic infiltration was followed with much delay by reduction in T cell infiltration. Targeting keratinocytes rather than immune cells may be an alternative approach in particular for topical anti-psoriatic treatment, an area with high need for new drugs.
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Affiliation(s)
| | - Clemens Painsi
- State Hospital KlagenfurtKlagenfurt am WörtherseeAustria
| | - VijayKumar Patra
- Department of Dermatology, Medical University of GrazGrazAustria
| | - Saptaswa Dey
- Department of Dermatology, Medical University of GrazGrazAustria
| | - Martin Holcmann
- Institute of Cancer Research, Department of Medicine I, Comprehensive Cancer Center, Medical University of ViennaViennaAustria
| | | | - Maria Sibilia
- Institute of Cancer Research, Department of Medicine I, Comprehensive Cancer Center, Medical University of ViennaViennaAustria
| | - Peter Wolf
- Department of Dermatology, Medical University of GrazGrazAustria
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Ibrahim S, Amer A, Nofal H, Abdellatif A. Practical compendium for psoriasis management. Dermatol Ther 2020; 33:e13243. [PMID: 32022374 DOI: 10.1111/dth.13243] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/05/2019] [Revised: 01/05/2020] [Accepted: 01/22/2020] [Indexed: 12/11/2022]
Abstract
Psoriasis management is complex and challenging. It should be tailored for each patient. Treatment strategy differs according to patient's age, sex, disease type, disease severity, burden on patient's quality of life, comorbidities, involvement of specific sites, and pregnancy. The choice of the appropriate therapeutic must take into consideration the availability, the price, and the patient's preferences. It is very important that the chosen treatment is not more unpleasant, intolerable, or dangerous than the disease itself. According to the disease type, severity, and effect on patient's quality of life, dermatologist chooses whether to start with topical therapy, phototherapy or systemic therapy, or a combination of two or more of them. Under each category, there are different types of therapies that can be the first line therapeutics, second line, or even contraindicated. In this compendium, we provide dermatologists with different treatment plans considering all the mentioned variables so that a dermatologist can choose the optimum plan for the patient.
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Affiliation(s)
- Samia Ibrahim
- Dermatology Department, Faculty of Medicine, Zagazig University, Zagazig, Egypt
| | - Amin Amer
- Dermatology Department, Faculty of Medicine, Zagazig University, Zagazig, Egypt
| | - Hagar Nofal
- Dermatology Department, Faculty of Medicine, Zagazig University, Zagazig, Egypt.,Department of Biology, School of Sciences and Engineering, The American University in Cairo, New Cairo, Egypt
| | - Ahmed Abdellatif
- Department of Biology, School of Sciences and Engineering, The American University in Cairo, New Cairo, Egypt
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Nasimi M, Ghandi N, Abedini R, Mirshamsi A, Shakoei S, Seirafi H. Efficacy and safety of anthralin in combination with diphenylcyclopropenone in the treatment of alopecia areata: a retrospective case series. Arch Dermatol Res 2019; 311:607-613. [DOI: 10.1007/s00403-019-01940-x] [Citation(s) in RCA: 15] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/10/2018] [Revised: 05/21/2019] [Accepted: 05/29/2019] [Indexed: 01/01/2023]
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10
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Daunton A, Harries M. Efficacy of topical dithranol (Dithrocream ® ) in the treatment of alopecia areata: a retrospective case series. Br J Dermatol 2018; 180:1246-1247. [PMID: 30536990 DOI: 10.1111/bjd.17515] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/27/2022]
Affiliation(s)
- A Daunton
- The Dermatology Centre, Salford Royal NHS Foundation Trust, Salford, U.K
| | - M Harries
- The Dermatology Centre, Salford Royal NHS Foundation Trust, Salford, U.K.,Centre for Dermatology Research, University of Manchester, MAHSC and NIHR Manchester Biomedical Research Centre, Manchester, U.K
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