Hair loss in women: medical and cosmetic approaches to increase scalp hair fullness

Considerations and recommendations on camouflage in alopecia in Black women

Alopecia is among the leading dermatological concerns affecting Black women. For many women, hair is a central component of identity and self-expression, the loss of which can have significant psychosocial effects. Hair camouflage is often utilized to minimize the visibility of hair loss, provide aesthetic benefits, and improve quality of life. The versatility and affordability of hair camouflage allows patients with alopecia to conceal hair loss, increasing self-confidence, and decreasing social stigma. However, hair camouflage practices often involve adhesives, chemicals, and/or high-tension braiding, all of which can exacerbate alopecia. Accordingly, special considerations should be made to protect patients' natural hair from damage while using these styling practices. A better understanding of best practices for some of the most widely used camouflage options-wigs, extensions, topical hair fibers, and micropigmentation-can help clinicians establish rapport with Black women and optimize individually-tailored therapeutic plans during active treatment and end-stage hair loss.

Assessment of Occipital Involvement Among a Large Population of Females with Pattern Hair Loss in Saudi Arabia

Background

Cumulative evidence suggests the involvement of the occipital region in female pattern hair loss (FPHL). However, most of the studies that have been published so far concerned relatively small samples of patients.

Purpose

To assess the occipital involvement in FPHL and analyze its correlation with disease severity among a large sample of patients.

Patients and Methods

A retrospective study involved 1000 adult women with FPHL, between January 2020 and August 2022. Occipital involvement was defined as more than 10% of thin hairs (<0.03 mm). Baseline trichometry parameters in the frontal and occipital regions were analyzed.

Results

Occipital involvement was observed in 32.4% of the patients. Positive correlations between frontal and occipital regions were observed for all trichometry parameters; the strongest concerned average hair shaft thickness (Pearson's coefficient r=0.708), cumulative hair thickness (r=0.673), and trichometry-derived Sinclair scale (r=0.656). The risk of occipital involvement increased independently with the disease severity in frontal region; however, the disease progression was slower in the occipital compared to frontal region.

Conclusion

One-third of females in our study with FPHL had occipital involvement. This has a major impact on the methods used to diagnose pattern hair loss in females and their treatment plan including hair restoration surgery.

The Efficacy and Safety of Oral and Topical Spironolactone in Androgenetic Alopecia Treatment: A Systematic Review

Introduction

Androgenetic alopecia (AGA) has negative impacts on both men and women in terms of appearance and mental stress. Spironolactone is a synthetic aldosterone receptor antagonist known to stimulate hair growth and has been widely used by dermatologists to treat AGA.

Objective

To conduct a systematic review evaluating the efficacy and safety of topical and oral spironolactone in AGA treatment.

Methods

We searched PubMed, Embase, the Cochrane Library, and the Web of Science until October 23rd, 2022, for human studies evaluating the efficacy of spironolactone for the treatment of AGA, regardless of doses and routes.

Results

We retrieved 784 papers and ultimately 7 articles matched our inclusion criteria and comprised 618 AGA patients (65 men, 553 women), 414 of them received spironolactone treatment. Oral spironolactone doses ranged from 25mg to 200mg daily, with the vast majority between 80mg and 110 mg. Dosage forms for topical spironolactone use include gels of 1% and solutions of 5% twice daily. Both oral and topical spironolactone have been shown efficacy for alopecia recovery, but topical use has significantly fewer side effects and is suitable for any gender. It showed better efficacy in combination with other therapies such as oral or topical minoxidil compared with monotherapy.

Conclusion

Spironolactone is an effective and safe treatment of androgenic alopecia which can enhance the efficacy when combined with other conventional treatments such as minoxidil. Topical spironolactone is safer than oral administration and is suitable for both male and female patients, and is expected to become a common drug for those who do not have a good response to minoxidil. Furthermore, more high-quality clinical randomized controlled studies should be performed.

Regulation of signaling pathways in hair follicle stem cells

Hair follicle stem cells (HFSCs) reside in the bulge region of the outer root sheath of the hair follicle. They are considered slow-cycling cells that are endowed with multilineage differentiation potential and superior proliferative capacity. The normal morphology and periodic growth of HFSCs play a significant role in normal skin functions, wound repair and skin regeneration. The HFSCs involved in these pathophysiological processes are regulated by a series of cell signal transduction pathways, such as lymphoid enhancer factor/T-cell factor, Wnt/β-catenin, transforming growth factor-β/bone morphogenetic protein, Notch and Hedgehog. The mechanisms of the interactions among these signaling pathways and their regulatory effects on HFSCs have been previously studied, but many mechanisms are still unclear. This article reviews the regulation of hair follicles, HFSCs and related signaling pathways, with the aims of summarizing previous research results, revealing the regulatory mechanisms of HFSC proliferation and differentiation and providing important references and new ideas for treating clinical diseases.

Cure and Long-Term Remission Strategies

The majority of virally suppressed individuals will experience rapid viral rebound upon antiretroviral therapy (ART) interruption, providing a strong rationale for the development of cure strategies. Moreover, despite ART virological control, HIV infection is still associated with chronic immune activation, inflammation, comorbidities, and accelerated aging. These effects are believed to be due, in part, to low-grade persistent transcription and trickling production of viral proteins from the pool of latent proviruses constituting the viral reservoir. In recent years there has been an increasing interest in developing what has been termed a functional cure for HIV. This approach entails the long-term, durable control of viral expression in the absence of therapy, preventing disease progression and transmission, despite the presence of detectable integrated proviruses. One such strategy, the block-and-lock approach for a functional cure, proposes the epigenetic silencing of proviral expression, locking the virus in a profound latent state, from which reactivation is very unlikely. The proof-of-concept for this approach was demonstrated with the use of a specific small molecule targeting HIV transcription. Here we review the principles behind the block-and-lock approach and some of the additional strategies proposed to silence HIV expression.

Hair Regeneration Effects of Lespedeza bicolor Extract In Vivo and In Vitro

Alopecia is a chronic inflammatory skin disease with various causes. Lespedeza bicolor extract (LBE) has been reported to have anti-inflammatory and antioxidative effects. In this study, the activity and mechanisms of LBE as a hair growth agent were investigated. Effects of cell proliferation, cytotoxicity, and cell cycle regulation of LBE and its active component protocatechuic acid (PCA) were evaluated in human dermal papilla cells (DPCs). Hair regeneration effects of LBE in 6-week-old C57BL/6 male mice were also determined using positive control 5% minoxidil. The dose-dependent proliferation of DPCs was estimated in response to LBE treatment (0.8–20 µg/mL). Additionally, significant extension of the anagen phase during the hair cell cycle upon LBE treatment was observed histologically and morphologically. Cell cycle arrest gene expression was determined by quantitative real-time polymerase chain reaction. Lespedezabicolor could be a potent treatment against alopecia through enhancing DPC proliferation and hair regrowth via anagen phase arrest.

Platelet Rich Plasma Hybridized Adipose Transplant (PHAT) for the Treatment of Hair Loss: A Case Series

Background

Platelet-rich plasma (PRP) has long been used for the restoration of hair in conjunction with microneedling or on its own. Fat grafting to the scalp has also been utilized in the past to improve the quality of hair and the possibility of successful hair transplant. The novel therapy reported in this case series combines the natural progression of these two techniques and utilizes synergistic effects to improve the quality of hair, either in preparation for micrografting or without hair transplant.

Objectives

To demonstrate the principles behind the novel approach to restoration of hair and the rationale for its use.

Methods

A review of the evidence for PRP and fat transfer for non-scarring alopecia serves as the foundation for the combination treatment reported herein. Through presentation of three cases in this series, we provide examples of the utility of this approach for non-scarring alopecia. This report includes a female who suffered non-scarring alopecia following COVID-19 hospitalization and intensive care stay where she lost a large percentage of her hair, in addition to two male patients suffering from androgenic alopecia.

Results

Platelet-rich plasma-hybridized adipose transplant hair was shown in these three cases to improve both the quality and density of hair. It improved the density of hair in all patients and was characterized first by a short period of transient hair loss followed by new hair growth which develops starting at 4 weeks and was readily apparent at 12-week follow-up. Results were maintained at 6-month and 1-year follow-up.

Conclusions

PHAT hair offers a combination of beneficial effects—namely the unique healing properties and growth signaling provided by PRP, along with adipocyte angiogenic and growth signaling, which both work to improve scalp quality. The combination of these effects is better than previously characterized PRP injections alone in the hands of these individual practices. This may be due to synergistic interactions at a cellular level, but additional clinical studies are needed to better understand this novel treatment and the observed effects.

Level of Evidence IV

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.

Hair Cosmetics for the Hair Loss Patient

Medical professionals that treat patients with alopecia usually lack knowledge about hair cosmetics. Trichologists focus on hair cycling and growth problems and not on the hair shaft integrity. This may lead to abandon of the use of the prescribed treatment, such as topical minoxidil or to inadequate traumatic grooming habits that may jeopardize hair follicle health. Shampoos, hair dyes, and hair-straightening products may alter hair fiber structure, remove lipids, and elude protein. Hair procedures such as hair dying and straightening have side effects and health concerns, especially for pregnant women or sensitive hair and scalp patients. Hair breakage, follicle traction, frizz, contact dermatitis, and mutagenicity are possible side effects of hair cosmetics misuse. The proper use of hair care products may help to increase patients' adherence to alopecia treatments and avoid health problems related to inadequate application of hair cosmetics and procedures.

Topical Treatment of Human Skin and Cultured Keratinocytes with High-Dose Spironolactone Reduces XPB Expression and Induces Toxicity

Spironolactone (SP) is used to treat a variety of disparate disease states ranging from heart failure to acne through antagonism of the mineralocorticoid and androgen receptors. Although normally taken as an oral medication, recent studies have explored the topical application of SP onto the skin. However, because SP induces the proteolytic degradation of the XPB protein, which plays critical roles in DNA repair and transcription, there may be safety concerns with the use of topical SP. In this study, we show that the topical application of a high concentration of either SP or its metabolite canrenone onto human skin ex vivo lowers XPB protein levels and induces toxic responses in the epidermis. Interestingly, although SP and canrenone both inhibit cell proliferation, induce replication stress responses, and stimulate apoptotic signaling at high concentrations in cultured keratinocytes in vitro, these effects were not correlated with XPB protein loss. Thus, high concentrations of SP and canrenone likely inhibit cell proliferation and induce toxicity through additional mechanisms to XPB proteolytic degradation. This work suggests that care may need to be taken when using high concentrations of SP directly on human skin.

A systematic summary of survival and death signalling during the life of hair follicle stem cells

Hair follicle stem cells (HFSCs) are among the most widely available resources and most frequently approved model systems used for studying adult stem cells. HFSCs are particularly useful because of their self-renewal and differentiation properties. Additionally, the cyclic growth of hair follicles is driven by HFSCs. There are high expectations for the use of HFSCs as favourable systems for studying the molecular mechanisms that contribute to HFSC identification and can be applied to hair loss therapy, such as the activation or regeneration of hair follicles, and to the generation of hair using a tissue-engineering strategy. A variety of molecules are involved in the networks that critically regulate the fate of HFSCs, such as factors in hair follicle growth and development (in the Wnt pathway, Sonic hedgehog pathway, Notch pathway, and BMP pathway), and that suppress apoptotic cues (the apoptosis pathway). Here, we review the life cycle, biomarkers and functions of HFSCs, concluding with a summary of the signalling pathways involved in HFSC fate for promoting better understanding of the pathophysiological changes in the HFSC niche. Importantly, we highlight the potential mechanisms underlying the therapeutic targets involved in pathways associated with the treatment of hair loss and other disorders of skin and hair, including alopecia, skin cancer, skin inflammation, and skin wound healing.

The role of prostaglandins in androgenetic alopecia

BACKGROUND

Though androgenetic alopecia (AGA) is one of the most common diseases affecting both sexes and all races, its pathogenesis is not completely clarified. The aim of this study was to investigate the role of the four major prostaglandins (PGs) (PGE₂ , PGD₂ , PGF_2α , and PI₂ or prostacyclin) in the pathogenesis of AGA in males and females.

METHODS

Human scalp biopsies were obtained from 30 adults (17 males and 13 females) suffering from AGA and from 30 healthy adults (18 males and 12 females). In each subject, two skin biopsies were performed, one from the frontal bald area and another one from the occipital area with normal hair growth. In the healthy group, biopsies were taken from both areas too. In each sample, all four PGs were measured.

RESULTS

In the patient group, PGD₂ and prostacyclin or PGI₂ levels were increased in bald compared to haired scalp. On the contrary, measurements of PGE₂ and PGF_2α showed that they were diminished in bald areas compared to haired areas. PG levels in healthy samples were comparable to the haired areas.

CONCLUSION

These results support that there is a fine balance between these four proteins in scalp hair follicles, and its maintenance may be crucial for hair growth. Furthermore, their receptors could be potential targets for treatment of AGA.

The XPB Subunit of the TFIIH Complex Plays a Critical Role in HIV-1 Transcription and XPB Inhibition by Spironolactone Prevents HIV-1 Reactivation from Latency

HIV transcription requires assembly of cellular transcription factors at the HIV-1promoter. The TFIIH general transcription factor facilitates transcription initiation by opening the DNA strands around the transcription start site and phosphorylating the C-terminal domain for RNA polymerase II (RNAPII) for activation. Spironolactone (SP), an FDA approved aldosterone antagonist, triggers the proteasomal degradation of the XPB subunit of TFIIH, and concurrently suppresses acute HIV infection in vitro Here we investigated SP as a possible block-and-lock agent for a functional cure aimed at the transcriptional silencing of the viral reservoir. The long-term activity of SP was investigated in primary and cell line models of HIV-1 latency and reactivation. We show that SP rapidly inhibits HIV-1 transcription by reducing RNAPII recruitment to the HIV-1 genome. shRNA knockdown of XPB confirmed XPB degradation as the mechanism of action. Unfortunately, long-term pre-treatment with SP does not result in epigenetic suppression of HIV upon SP treatment interruption, since virus rapidly rebounds when XPB reemerges; however, SP alone without ART maintains the transcriptional suppression. Importantly, SP inhibits HIV reactivation from latency in both cell line models and resting CD4⁺T cells isolated from aviremic infected individuals upon cell stimulation with latency reversing agents. Furthermore, long-term treatment with concentrations of SP that potently degrade XPB does not lead to global dysregulation of cellular mRNA expression. Overall, these results suggest that XPB plays a key role in HIV transcriptional regulation and XPB degradation by SP strengthens the potential of HIV transcriptional inhibitors in block-and-lock HIV cure approaches.IMPORTANCE Antiretroviral therapy (ART) effectively reduces an individual's HIV loads to below the detection limit, nevertheless rapid viral rebound immediately ensues upon treatment interruption. Furthermore, virally suppressed individuals experience chronic immune activation from ongoing low-level virus expression. Thus, the importance of identifying novel therapeutics to explore in block-and-lock HIV functional cure approaches, aimed at the transcriptional and epigenetic silencing of the viral reservoir to block reactivation from latency. We investigated the potential of repurposing the FDA-approved spironolactone (SP), as one such drug. SP treatment rapidly degrades a host transcription factor subunit, XPB, inhibiting HIV transcription and blocking reactivation from latency. Long-term SP treatment does not affect cellular viability, cell cycle progression or global cellular transcription. SP alone blocks HIV transcription in the absence of ART but does not delay rebound upon drug removal as XPB rapidly reemerges. This study highlights XPB as a novel drug target in block-and-lock therapeutic approaches.

A Case of Contact Allergic Dermatitis to Topical Minoxidil

Coincidental findings of hypertrichosis in patients on minoxidil led to the development of a topical minoxidil formulation which has been approved by the Food and Drug Administration for the treatment of female pattern hair loss, the most common cause for hair loss in women. The most common side effect of topical minoxidil is irritant contact dermatitis with the typical symptoms of itching and scaling. Most commonly, these symptoms are a result of an allergic reaction to propylene glycol, or less commonly, to minoxidil itself. We present a case of a 27-year-old woman who developed facial swelling following allergic contact dermatitis to minoxidil 5% foam.

Intradermal injections with 0.5% minoxidil for the treatment of female androgenetic alopecia: A randomized, placebo-controlled trial

Female androgenetic alopecia is one cause of alopecia in women, although the ideal treatment for this condition remains far from defined. The objective of this study was to evaluate the efficacy and safety of intradermal injections with 0.5% minoxidil for the management of female androgenetic alopecia in a randomized, placebo-controlled trial. A total of 54 women diagnosed with female androgenetic alopecia were divided into two groups: one group received intradermal injections of 0.5% minoxidil, and the other received 0.9% saline. Biopsy, trichogram, Trichoscan (Tricholog GmbH, Freiburg, Germany), and self-assessment findings were used to evaluate the outcomes of treatment with minoxidil. In the treated group, there was a significant increase in the terminal-to-vellus hair ratio (P < .001) and in the percentage of anagen hairs (P = .048) and an improvement in hair loss and volume (P = .021 and P = .028, respectively). These results show that intradermal injections with minoxidil were more effective than placebo (P < .001) in the treatment of female androgenetic alopecia with a good safety profile.

Wanted, dead and alive: Why a multidisciplinary approach is needed to unlock hair treatment potential

Human recorded history is littered with attempts to improve the perceived appearance of scalp hair. Throughout history, treatments have included both biological and chemical interventions. Hair "quality" or "perceived appearance" is regulated by multiple biological intervention opportunities: adding more hairs by flipping follicles from telogen to anagen, or delaying anagen follicles transiting into catagen; altering hair "apparent amount" by modulating shaft diameter or shape; or, in principle, altering shaft physical properties changing its synthesis. By far the most common biological intervention strategy today is to increase the number of hairs, but to date this has proven difficult and has yielded minimal benefits. Chemical intervention primarily consists of active material surface deposition to improve shaft shine, fibre-fibre interactions and strength. Real, perceptible benefits will best be achieved by combining opportunity areas across the three primary sciences: biology, chemistry and physics. Shaft biogenesis begins with biology: proliferation in the germinative matrix, then crossing "Auber's Critical Line" and ceasing proliferation to synthesize shaft components. Biogenesis then shifts to oxidative chemistry, where previously synthesized components are organized and cross-linked into a shaft. We herein term the crossing point from biology to chemistry as "The Orwin Threshold." Historically, hair biology and chemistry have been conducted in different fields, with biological manipulation residing in biomedical communities and hair shaft chemistry and physics within the consumer care industry, with minimal cross-fertilization. Detailed understanding of hair shaft biogenesis should enable identification of factors necessary for optimum hair shaft production and new intervention opportunities.

Spironolactone and XPB: An Old Drug with a New Molecular Target

Spironolactone (SP) is commonly used for the treatment of heart failure, hypertension, and complications of cirrhosis by antagonizing the mineralocorticoid receptor. However, SP also antagonizes the androgen receptor, and thus SP has also been shown to be effective in the treatment of acne, hair loss, and hirsutism in women. Interestingly, recent drug repurposing screens have identified new and diverse functions for SP as a simulator of tumor immunosurveillance and as an inhibitor of DNA repair and viral infection. These novel pharmacological effects of SP have all been linked to the ability of SP to induce the rapid proteolytic degradation of the xeroderma pigmentosum group B (XPB) protein. XPB is a critical enzymatic component of the multi-subunit complex known as transcription factor II-H (TFIIH), which plays essential roles in both DNA repair and the initiation of transcription. Given the critical functions for XPB and TFIIH in these processes, the loss of XPB by SP could lead to mutagenesis. However, the ability of SP to promote cancer stem cell death and facilitate immune recognition may counteract the negative consequences of SP to mitigate carcinogenic risk. Thus, SP appears to have new and interesting pharmacological effects that may extend its potential uses.

Efficacy of Topical Combination of 0.25% Finasteride and 3% Minoxidil Versus 3% Minoxidil Solution in Female Pattern Hair Loss: A Randomized, Double-Blind, Controlled Study

BACKGROUND

The relationship between female pattern hair loss (FPHL) and androgenic hormones is not well established, but some evidence indicates oral finasteride may be efficacious in FPHL. Use of a topical formulation has been proposed to minimize unwanted effects.

OBJECTIVES

Our objective was to compare the efficacy and safety of topical 0.25% finasteride combined with 3% minoxidil solution and 3% minoxidil solution as monotherapy in the treatment of FPHL.

METHODS

This was a prospective, randomized, double-blind study in 30 postmenopausal women with FPHL. Each participant was randomized to receive either topical 0.25% finasteride combined with topical 3% minoxidil or topical 3% minoxidil solution as monotherapy for 24 weeks. To determine efficacy, the hair density and diameter was measured and global photographic assessment was conducted at baseline and 8, 16, and 24 weeks. Side effects and serum dihydrotestosterone levels were also evaluated.

RESULTS

By 24 weeks, hair density and diameter had increased in both groups, and finasteride/minoxidil was significantly superior to minoxidil solution in terms of hair diameter (p = 0.039). No systemic side effects were reported. However, serum dihydrotestosterone levels in the finasteride/minoxidil group significantly decreased from baseline (p = 0.016).

CONCLUSION

A topical combination of 0.25% finasteride and 3% minoxidil may be a promising option in the treatment of FPHL with an additional benefit of increasing hair diameter. Nevertheless, as it may be absorbed percutaneously, it should be reserved for postmenopausal women.

TRIAL REGISTRATION

clinicaltrials.in.th; identifier TCTR20160912002.

The new paradigm for androgenetic alopecia and plant-based folk remedies: 5α-reductase inhibition, reversal of secondary microinflammation and improving insulin resistance

ETHNOPHARMACOLOGICAL RELEVANCE

Research in the past half a century has gradually sketched the biological mechanism leading to androgenetic alopecia (AGA). Until recently the aetiological paradigm has been too limited to enable intelligent commentary on the use of folk remedies to treat or reduce the expression of this condition. However, our understanding is now at a point where we can describe how some folk remedies work, predict how effective they will be or why they fail.

RESULTS

The new paradigm of AGA is that inheritance and androgens (dihydrotestosterone) are the primary contributors and a secondary pathology, microinflammation, reinforces the process at more advanced stages of follicular miniaturisation. The main protagonist to microinflammation is believed to be microbial or Demodex over-colonisation of the infundibulum of the pilosebaceous unit, which can be ameliorated by antimicrobial/acaricidal or anti-inflammatory therapies that are used as adjuvants to androgen dependent treatments (either synthetic or natural). Furthermore, studies reveal that suboptimal androgen metabolism occurs in both AGA and insulin resistance (low SHBG or high DHT), suggesting comorbidity. Both can be ameliorated by dietary phytochemicals, such as specific classes of phenols (isoflavones, phenolic methoxy abietanes, hydroxylated anthraquinones) or polycyclic triterpenes (sterols, lupanes), by dual inhibition of key enzymes in AGA (5α-reductase) and insulin resistance (ie., DPP-4 or PTP1B) or agonism of nuclear receptors (PPARγ). Evidence strongly indicates that some plant-based folk remedies can ameliorate both primary and secondary aetiological factors in AGA and improve insulin resistance, or act merely as successful adjuvants to mainstream androgen dependent therapies.

CONCLUSION

Thus, if AGA is viewed as an outcome of primary and secondary factors, then it is better that a 'multimodal' or 'umbrella' approach, to achieve cessation and/or reversal, is put into practice, using complementation of chemical species (isoflavones, anthraquinones, procyanidins, triterpenes, saponins and hydrogen sulphide prodrugs), thereby targeting multiple 'factors'.

Clinical efficacy of oral administration of finasteride at a dose of 2.5 mg/day in women with female pattern hair loss

Female pattern hair loss (FPHL) presents with diffuse thinning over the mid-frontal scalp, for which various treatment modalities have been tried. Although currently, oral 5 α-reductase inhibitors such as finasteride are being used, their clinical efficacy remains controversial. We retrospectively investigated 544 premenopausal or postmenopausal patients with FPHL who were prescribed finasteride at a dose of 2.5 mg/day. Our study excluded patients with a follow-up period of < 3 months and patients who were prescribed other FPHL treatment modalities including topical minoxidil. Finally, 112 patients were evaluated based on their medical records and clinical photographs. Based on assessment using the Ludwig scale at the time of their initial visit, among 112 patients studied, 59 patients were classified as belonging to grade I, 47 were grade II, and 6 were grade III. Using global photographs, we found that 33 (29.5%) of the 112 patients studied showed slight improvement, 73 (65.2%) showed significant improvement, whereas no change was recorded in 6 (5.4%). We could demonstrate efficacy of administration of finasteride at a dose of 2.5 mg/day for patients with FPHL and also found that finasteride has a better effect on hair growth when patients had a lower Ludwig score and an older age at onset.

Treatment of chronic telogen effluvium with oral minoxidil: A retrospective study

Background: Chronic telogen effluvium (CTE) may be primary or secondary to various causes, including drug reaction, nutritional deficiency and female pattern hair loss (FPHL).  Oral minoxidil stimulates hair growth, and topical minoxidil is used in the treatment of FPHL and male androgenetic alopecia. minoxidil has not been used to treat CTE. This study aimed to assess the treatment of CTE with once daily oral minoxidil.

Methods: Women with a diagnosis of CTE based on >6 month history of increased telogen hair shedding, no visible mid frontal scalp hair loss (Sinclair stage 1) and no hair follicle miniaturization on scalp biopsy were treated with once daily oral minoxidil.  Hair shedding scores (HSS) at baseline, 6 and 12 months were analysed using the Wilcoxon rank sum test for pair-wise comparisons.

Results: Thirty-six women were treated with oral minoxidil (range, 0.25-2.5 mg) daily for 6 months.  Mean age was 46.9 years (range 20-83), HSS at baseline was 5.64, and duration of diagnosis was 6.55 years (range 1-27).  There was a reduction in mean HSS scores from baseline to 6 months of 1.7 (p<0.001) and baseline to 12 months of 2.58 (p<0.001). Five women who described trichodynia at baseline, noted improvement or resolution within 3 months.  Mean change in blood pressure was minus 0.5 mmHg systolic and plus 2.1 mmHg diastolic.  Two patients developed transient postural dizziness that resolved with continued treatment.  One patient developed ankle oedema.  Thirteen women developed facial hypertrichosis.  For 6 patients this was mild and did not require treatment; 4 had waxing of their upper lip or forehead; 3 had laser hair removal.  No patients developed any haematological abnormality.  All 36 women completed 12 months of treatment.

Conclusions: Once daily oral minoxidil appears to reduce hair shedding in CTE.  Placebo controlled studies are recommended to further assess this response.

Body Hair Transplant by Follicular Unit Extraction: My Experience With 122 Patients

Background

Body hair shafts from the beard, trunk, and extremities can be used to treat baldness when patients have inadequate amounts of scalp donor hair, but reports in the literature concerning use of body hair to treat baldness are confined to case reports.

Objectives

This study aimed to assess the outcome of body hair transplanted to bald areas of the scalp in selected patients.

Methods

From 2005 through 2011, 122 patients preselected for adequate body hair had donor hair transplanted from the beard, trunk, and the extremities to the scalp by follicular unit extraction (FUE) by the author at a single center. All patients were emailed surveys to assess surgical outcomes and overall satisfaction.

Results

Seventy-nine patients (64.8%) responded with a mean time of 2.9 years between date of last surgery and time of survey. Patients were generally very satisfied with results of their procedure, giving mean scores of at least a 7.8 on a Likert-like scale of 0 to 10 for their healing status, hair growth in recipient areas, and overall satisfaction with their surgeries. These scores were comparable to mean scores provided by patients whose transplants included scalp donor sources.

Conclusions

FUE using body hair can be an effective hair transplantation method for a select patient population of hirsute individuals who suffer from severe baldness or have inadequate scalp donor reserve.

Level of Evidence:

4 Therapeutic

Female Pattern Hair Loss: A Retrospective Study in a Tertiary Referral Center

Background:

Female pattern hair loss (FPHL) is a very common problem in women. The underlying pathophysiology remains unclear, and there are no universally agreed treatment guidelines.

Objective:

We explored the clinical features, relevant medical and family history, laboratory evaluation, and treatment and compliance of 210 patients with FPHL.

Methods:

Data analysis from case notes was performed on 210 patients with a diagnosis of FPHL seen from January 2011 to December 2011.

Results:

The youngest individual was 8 years old and the oldest was 86 years old. Nearly, 85% of the patients had a family history of androgenetic alopecia. Hypothyroidism and hypertension are the most common medical problems. Telogen effluvium (TE) is the most common concurrent hair loss condition. Only 38% of the patients were found to have normal Vitamin D level, 71% had ferritin level above 30 μg/L, and 85% had normal zinc level at the first consultation. Fifty-nine percent of the patients failed to attend any follow-up appointments.

Limitations:

One of the limitations of this study is its retrospective nature. Moreover, the severity of FPHL in terms of Ludwig score was not routinely documented in the medical charts.

Conclusion:

History of TE, hypothyroidism and hypertension, and low serum Vitamin D is common in our patients with FPHL.

Interventions for female pattern hair loss

BACKGROUND

Female pattern hair loss (FPHL), or androgenic alopecia, is the most common type of hair loss affecting women. It is characterised by progressive shortening of the duration of the growth phase of the hair with successive hair cycles, and progressive follicular miniaturisation with conversion of terminal to vellus hair follicles (terminal hairs are thicker and longer, while vellus hairs are soft, fine, and short). The frontal hair line may or may not be preserved. Hair loss can have a serious psychological impact on women.

OBJECTIVES

To determine the efficacy and safety of the available options for the treatment of female pattern hair loss in women.

SEARCH METHODS

We updated our searches of the following databases to July 2015: the Cochrane Skin Group Specialised Register, CENTRAL in the Cochrane Library (2015, Issue 6), MEDLINE (from 1946), EMBASE (from 1974), PsycINFO (from 1872), AMED (from 1985), LILACS (from 1982), PubMed (from 1947), and Web of Science (from 1945). We also searched five trial registries and checked the reference lists of included and excluded studies.

SELECTION CRITERIA

We included randomised controlled trials that assessed the efficacy of interventions for FPHL in women.

DATA COLLECTION AND ANALYSIS

Two review authors independently assessed trial quality, extracted data and carried out analyses.

MAIN RESULTS

We included 47 trials, with 5290 participants, of which 25 trials were new to this update. Only five trials were at 'low risk of bias', 26 were at 'unclear risk', and 16 were at 'high risk of bias'.The included trials evaluated a wide range of interventions, and 17 studies evaluated minoxidil. Pooled data from six studies indicated that a greater proportion of participants (157/593) treated with minoxidil (2% and one study with 1%) reported a moderate to marked increase in their hair regrowth when compared with placebo (77/555) (risk ratio (RR) = 1.93, 95% confidence interval (CI) 1.51 to 2.47; moderate quality evidence). These results were confirmed by the investigator-rated assessments in seven studies with 1181 participants (RR 2.35, 95% CI 1.68 to 3.28; moderate quality evidence). Only one study reported on quality of life (QoL) (260 participants), albeit inadequately (low quality evidence). There was an important increase of 13.18 in total hair count per cm² in the minoxidil group compared to the placebo group (95% CI 10.92 to 15.44; low quality evidence) in eight studies (1242 participants). There were 40/407 adverse events in the twice daily minoxidil 2% group versus 28/320 in the placebo group (RR 1.24, 95% CI 0.82 to 1.87; low quality evidence). There was also no statistically significant difference in adverse events between any of the individual concentrations against placebo.Four studies (1006 participants) evaluated minoxidil 2% versus 5%. In one study, 25/57 participants in the minoxidil 2% group experienced moderate to greatly increased hair regrowth versus 22/56 in the 5% group (RR 1.12, 95% CI 0.72 to 1.73). In another study, 209 participants experienced no difference based on a visual analogue scale (P = 0.062; low quality evidence). The assessments of the investigators based on three studies (586 participants) were in agreement with these findings (moderate quality evidence). One study assessed QoL (209 participants) and reported limited data (low quality evidence). Four trials (1006 participants) did not show a difference in number of adverse events between the two concentrations (RR 1.02, 95% CI 0.91 to 1.20; low quality evidence). Both concentrations did not show a difference in increase in total hair count at end of study in three trials with 631 participants (mean difference (MD) -2.12, 95% CI -5.47 to 1.23; low quality evidence).Three studies investigated finasteride 1 mg compared to placebo. In the finasteride group 30/67 participants experienced improvement compared to 33/70 in the placebo group (RR 0.95, 95% CI 0.66 to 1.37; low quality evidence). This was consistent with the investigators' assessments (RR 0.77, 95% CI 0.31 to 1.90; low quality evidence). QoL was not assessed. Only one study addressed adverse events (137 participants) (RR 1.03, 95% CI 0.45 to 2.34; low quality evidence). In two studies (219 participants) there was no clinically meaningful difference in change of hair count, whilst one study (12 participants) favoured finasteride (low quality evidence).Two studies (141 participants) evaluated low-level laser comb therapy compared to a sham device. According to the participants, the low-level laser comb was not more effective than the sham device (RR 1.54, 95% CI 0.96 to 2.49; and RR 1.18, 95% CI 0.74 to 1.89; moderate quality evidence). However, there was a difference in favour of low-level laser comb for change from baseline in hair count (MD 17.40, 95% CI 9.74 to 25.06; and MD 17.60, 95% CI 11.97 to 23.23; low quality evidence). These studies did not assess QoL and did not report adverse events per treatment arm and only in a generic way (low quality evidence). Low-level laser therapy against sham comparisons in two separate studies also showed an increase in total hair count but with limited further data.Single studies addressed the other comparisons and provided limited evidence of either the efficacy or safety of these interventions, or were unlikely to be examined in future trials.

AUTHORS' CONCLUSIONS

Although there was a predominance of included studies at unclear to high risk of bias, there was evidence to support the efficacy and safety of topical minoxidil in the treatment of FPHL (mainly moderate to low quality evidence). Furthermore, there was no difference in effect between the minoxidil 2% and 5% with the quality of evidence rated moderate to low for most outcomes. Finasteride was no more effective than placebo (low quality evidence). There were inconsistent results in the studies that evaluated laser devices (moderate to low quality evidence), but there was an improvement in total hair count measured from baseline.Further randomised controlled trials of other widely-used treatments, such as spironolactone, finasteride (different dosages), dutasteride, cyproterone acetate, and laser-based therapy are needed.

[Drug treatment of alopecia]

BACKGROUND

Alopecia is the term used to describe hairless areas of the scalp. They can follow a specific pattern, be diffuse or circumscript. Androgenetic alopecia (AGA) follows a pattern: in men thinning of temples and vertex up to total baldness; in women thinning of the midline or parietal area.

CAUSES

Lack of iron or cytostatic drugs cause diffuse alopecia, while in autoimmune diseases such as alopecia areata or lichen planus bizarre shapes of hairless areas are observed.

TREATMENT

For therapy, the following medications are used: topical minoxidil solution for AGA of men and women; systemic finasteride 1 mg for men with AGA; topical diphencyprone immunotherapy for alopecia areata; systemic antimycotic agents for tinea capitis; antibiotics such as clindamycin and rifampicin for folliculitis decalvans; systemic corticosteroids and isotretinoin for folliculitis et perifolliculitis capitis abscedens et suffodiens; topical corticosteroids for lichen planus and Kossard's frontal fibrosing alopecia.

Alterations in hair follicle dynamics in women

Endocrine changes supervening after parturition and menopause participate in the control of sebum production and hair growth modulation. The ensuing conditions include some peculiar aspects of hair loss (effluvium), alopecia, and facial hirsutism. The hair cycling is of major clinical relevance because most hair growth disorders result from disturbances in this chronobiological feature. Of note, any correlation between a biologic abnormality and hair cycling disturbance does not prove a relationship of causality. The proportion of postmenopausal women is rising in the overall population. Therefore, the prevalence of these hair follicle disturbances is globally on the rise. Current therapies aim at correcting the underlying hormonal imbalances, and at improving the overall cosmetic appearance. However, in absence of pathogenic diagnosis and causality criteria, chances are low that a treatment given by the whims of fate will adequately control hair effluvium. The risk and frequency of therapeutic inertia are further increased. When the hair loss is not controlled and/or compensated by growth of new hairs, several clinical aspects of alopecia inexorably develop. Currently, there is little evidence supporting any specific treatment for these endocrine hair disorders in post-partum and postmenopausal women. Current hair treatment strategies are symptomatic and nonspecific so current researchers aim at developing new, targeted methods.

Alopecia with endocrine therapies in patients with cancer

BACKGROUND

Whereas the frequency of alopecia to cytotoxic chemotherapies has been well described, the incidence of alopecia during endocrine therapies (i.e., anti-estrogens, aromatase inhibitors) has not been investigated. Endocrine agents are widely used in the treatment and prevention of many solid tumors, principally those of the breast and prostate. Adherence to these therapies is suboptimal, in part because of toxicities. We performed a systematic analysis of the literature to ascertain the incidence and risk for alopecia in patients receiving endocrine therapies.

METHODS

An independent search of citations was conducted using the PubMed database for all literature as of February 2013. Phase II-III studies using the terms "tamoxifen," "toremifene," "raloxifene," "anastrozole," "letrozole," "exemestane," "fulvestrant," "leuprolide," "flutamide," "bicalutamide," "nilutamide," "fluoxymesterone," "estradiol," "octreotide," "megestrol," "medroxyprogesterone acetate," "enzalutamide," and "abiraterone" were searched.

RESULTS

Data from 19,430 patients in 35 clinical trials were available for analysis. Of these, 13,415 patients had received endocrine treatments and 6,015 patients served as controls. The incidence of all-grade alopecia ranged from 0% to 25%, with an overall incidence of 4.4% (95% confidence interval: 3.3%-5.9%). The highest incidence of all-grade alopecia was observed in patients treated with tamoxifen in a phase II trial (25.4%); similarly, the overall incidence of grade 2 alopecia by meta-analysis was highest with tamoxifen (6.4%). The overall relative risk of alopecia in comparison with placebo was 12.88 (p < .001), with selective estrogen receptor modulators having the highest risk.

CONCLUSION

Alopecia is a common yet underreported adverse event of endocrine-based cancer therapies. Their long-term use heightens the importance of this condition on patients' quality of life. These findings are critical for pretherapy counseling, the identification of risk factors, and the development of interventions that could enhance adherence and mitigate this psychosocially difficult event.

Emerging concepts about prenatal genesis, aberrant metabolism and treatment paradigms in polycystic ovary syndrome

The interactive nature of the 8th Annual Meeting of the Androgen Excess and PCOS Society Annual Meeting in Munich, Germany (AEPCOS 2010) and subsequent exchanges between speakers led to emerging concepts in PCOS regarding its genesis, metabolic dysfunction, and clinical treatment of inflammation, metabolic dysfunction, anovulation and hirsutism. Transition of care in congenital adrenal hyperplasia from pediatric to adult providers emerged as a potential model for care transition involving PCOS adolescents.