Mesotherapy using dutasteride-containing preparation in treatment of female pattern hair loss: photographic, morphometric and ultrustructural evaluation

Comparison of the Efficacy of Two Different Local Anesthesia Techniques for Mesotherapy in Temporal Region Alopecia

Introduction Mesotherapy is a wide range of minimally invasive injections. In mesotherapy, a mixture of various tonics is injected into the skin. These include plant extracts, various medications, vitamins, enzymes, hormones, growth factors, and other factors that will help treat alopecia. Most commonly, a mixture of platelet-rich plasma (PRP) and vitamins is used. In mesotherapy treatment for hair regrowth in the temporal region, zygomaticotemporal nerve blocks, supratrochlear nerve blocks, and supraorbital nerve blocks are given. The zygomaticotemporal nerve, supraorbital nerve, and supratrochlear nerve are the branches of the trigeminal nerve. They provide sensation on the lateral side of the forehead, which is the temple region.  Methods A sample size of 100 people was taken for the study who were undergoing mesotherapy in the bilateral temporal region for alopecia. Each group had 50 subjects: group I was given supratrochlear, supraorbital, and zygomaticotemporal nerve blocks as local anesthesia techniques, and group II was given supratrochlear and supraorbital nerve blocks. PRP was injected using an insulin syringe. Pain was assessed using a visual analog scale (VAS). Results During the procedure, a mean VAS of 1 and 3 was observed in groups I and II, respectively, during the procedure (p-value 0.023). A mean VAS of 3 and 5 was observed in groups I and II, respectively, after three hours (p-value 0.000). This shows a significant difference in the pain experienced by the subjects between the groups.  Conclusion This study proves that the zygomaticotemporal nerve, used along with supratrochlear and supraorbital nerve blocks, is better at producing analgesia and reducing pain.

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

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

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

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

Autologous adipose tissue injection in the treatment of alopecia: A mini-review

BACKGROUND

Alopecia may decrease patients' quality of life and self-confidence by limiting their social life. Therefore, the main goal of the treatment is to limit or halt the progression of inflammation, scarring, and hair loss. The promising effect of fat injection on hair regrowth, limited adverse effects, and subsiding inflammation can be proof of its efficacy and safety in treating alopecia.

AIMS

This review sought to assess the role of autologous fat tissue injection in scarring and non-scarring alopecia.

METHODS

Accordingly, a thorough search was performed on the Web of Science, Scopus, and PubMed/Medline databases, as well as the Google Scholar search engine, for studies published from inception until September 1st, 2023, using the related keywords.

RESULTS

Autologous fat grafting (AFG) is a novel and potentially effective modality for treating alopecia, particularly primary and secondary cicatricial alopecia. AFG can be an effective semi-invasive option for treating refractory lichen planopilaris because it induces angiogenesis, which supports hair regrowth. In addition to cicatricial alopecia, AFG held promise for treating non-scarring alopecia, including androgenic alopecia and alopecia areata. The adipose-derived regenerative cells (ADRCs) in adipose tissue (AT) secrete different growth factors, further supporting hair regeneration. Moreover, different anti-inflammatory and anti-oxidative agents are known in AT, preventing further damage to hair follicles.

CONCLUSIONS

AFG can significantly control inflammatory processes, improve signs and symptoms, and increase hair density and diameter.

Systematic review of mesotherapy: a novel avenue for the treatment of hair loss

Mesotherapy is a technique by which lower doses of therapeutic agents and bioactive substances are administered by intradermal injections to the skin. Through intradermal injections, mesotherapy can increase the residence time of therapeutic agents in the affected area, thus allowing for the use of lower doses and longer intervals between sessions which may in turn improve the treatment outcome and patient compliance. This systematic review aims to summarize the current literature that evaluates the efficacy of this technique for the treatment of hair loss and provides an overview of the results observed. Of the 416 records identified, 27 articles met the inclusion criteria. To date, mesotherapy using 6 classes of agents and their combinations have been studied; this includes dutasteride, minoxidil, growth factors or autologous suspension, botulinum toxin A, stem cells, and mesh solutions/multivitamins. While several studies report statistically significant improvements in hair growth after treatment, there is currently a lack of standardized regimens. The emergence of adverse effects after mesotherapy has been reported. Further large-scale and controlled clinical trials are warranted to evaluate the utility of mesotherapy for hair loss disorders.

Intradermal Delivery of Alopecia Therapeutics: Current State and Future Prospects

BACKGROUND

Mesotherapy, a technique of transdermal microinjections of specific preparations, is increasingly used in fields such as dermatology and specifically for alopecia treatment. Its popularity stems from its ability to deliver drugs in a targeted manner while minimizing systemic side effects.

OBJECTIVE

To assess and review current knowledge regarding the use of mesotherapy to deliver alopecia medications and highlight future directions for research.

MATERIALS AND METHODS

The authors used research databases including PubMed and Google Scholar to identify current literature on mesotherapy and alopecia. The following search terms were used among other terms: "Mesotherapy" or "Intradermal" AND "Alopecia".

RESULTS

Recent studies are promising for the intradermal delivery of dutasteride and minoxidil in the treatment of androgenetic alopecia.

CONCLUSION

Although limitations exist with dutasteride and minoxidil therapies, further research regarding the preparation, delivery, and maintenance of these drugs is warranted as mesotherapy could establish this technique as a safe, effective, and viable treatment option for androgenetic alopecia.

What's New in Therapy for Male Androgenetic Alopecia?

Male androgenetic alopecia is a common condition and represents a major concern for patients who experience this condition. While there are different treatments to stop hair loss and improve hair density, the 5-alpha reductase inhibitors have demonstrated to be effective in improving androgenetic alopecia in men and can maintain a positive response for many years. Oral finasteride 1 mg is a US FDA-approved option, but dutasteride 0.5 mg has been proven to induce better responses, especially in the frontal area. Both have been shown to be safe in clinical trials but there is widespread concern about sexual adverse effects among patients. The use of topical finasteride has increased during the last few years as a useful option to avoid systemic therapy. The efficacy of topical finasteride 0.25% daily has been demonstrated in clinical trials, with a less marked decrease in serum dihydrotestosterone levels than with oral intake. Mesotherapy with dutasteride has also become more widespread recently, although evidence of its effectiveness is limited to retrospective studies in real clinical practice. The use of oral minoxidil in androgenetic alopecia has not been approved by the FDA, however several clinical studies have shown that it is an effective treatment option. The initial dose recommended to treat male hair loss is 2.5 mg daily, although the dose is frequently increased to 5 mg daily. The main adverse effect of oral minoxidil is hypertrichosis, followed by dizziness or lower limb edema, which are much less common. Platelet-rich plasma is a non-pharmacological option to treat male androgenetic alopecia, with some clinical trials demonstrating an improvement in hair count after several months. Among the published studies, the main limitation to compare its efficacy is the heterogeneity of the procedure. The most frequent regimens propose treatment every 4 weeks for 3 months initially to assess the individual response. Another treatment alternative is the use of light devices with wavelengths of between 630 and 660 nm, known as low-level laser therapy. These devices can be used at home every day for 15-30 min. Their efficacy has been shown in a limited number of clinical trials; however, there is a lack of evidence about the efficacy of these devices compared with other medical options or as a complementary therapy in hair loss. The pipeline of potential new treatments for male androgenetic alopecia is strong. Pyrilutamide and GT20029 are being studied as topical antagonists of the androgen receptor, while cetirizine is another topical option with some initial promising results. Furthermore, according to isolated studies with heterogeneous treatment schemes, the use of botulinum toxin in the scalp might improve androgenetic alopecia, and lastly, scalp threading might increase the total hair count as growth factors are released during implantation.

Alopecia After Cosmetic Injection Procedures: A Review

BACKGROUND

Cosmetic procedures for antiaging carry inherent risks of adverse events. One that has not yet been well characterized is transitory or permanent alopecia. This is attributable to numerous mechanisms including pressure, ischemia, inflammation, and necrosis. Cases of postcosmetic procedure alopecia have been reported after mesotherapy as well as hyaluronic acid filler, deoxycholic acid, and botulinum toxin injections.

OBJECTIVE

This review serves to describe the currently known causes of postcosmetic procedure alopecia and the mechanisms by which alopecia is attained. Furthermore, this review highlights the risk of unregulated mesotherapy injections for cosmetic enhancement and to bring attention to the increasing number reports of alopecia after these procedures.

METHODS

A systematic review of the literature from 2000 to 2022 was conducted looking for keywords such as "alopecia," "cosmetic procedures," "mesotherapy," and "hyaluronic acid" in Google Scholar and PubMed.

RESULTS

Ten articles met the criteria set forth in the authors' literature review. Many of the procedures resulted in partial or complete resolution of alopecia.

CONCLUSION

Alopecia after cosmetic injection procedures is an underreported adverse effect. More research is needed to further characterize the risk of alopecia after mesotherapy and other injection procedures.

Two Cases of Paradoxical Nonscarring Alopecia after Mesotherapy with Dutasteride

Alopecia after mesotherapy with dutasteride is an extremely rare complication. Dutasteride is a second-generation 5a-reductase enzyme inhibitor that decreases serum dihydrotestosterone levels by 90%. It inhibits both type 1 and 2 enzymes, whereas finasteride inhibits only type 2. Mesotherapy with dutasteride is a novel treatment for hair fall which involves microinjection of the drug into the dermis with negligible systemic absorption. Frequent mild transitory side effects in the site of injection are described in medical literature, but few cases of secondary alopecia have been reported. This stands out given that mesotherapy is becoming such an increasingly common procedure with a great number of patients treated with this technique. We present 2 cases of patchy alopecia after mesotherapy with dutasteride in a male and a female with androgenetic alopecia. One of them developed skin atrophy on the affected areas without improvement at short term follow-up. These cases highlight the possible paradoxical side effects of mesotherapy as a therapeutic technique for hair loss.

Treatment options for androgenetic alopecia: Efficacy, side effects, compliance, financial considerations, and ethics

Background

Androgenetic alopecia (AGA) is the most common form of hair loss consisting of a characteristic receding frontal hairline in men and diffuse hair thinning in women, with frontal hairline retention, and can impact an individual's quality of life. The condition is primarily mediated by 5‐alpha‐reductase and dihydrotestosterone (DHT) which causes hair follicles to undergo miniaturization and shortening of successive anagen cycles. Although a variety of medical, surgical, light‐based and nutraceutical treatment options are available to slow or reverse the progression of AGA, it can be challenging to select appropriate therapies for this chronic condition.

Aims

To highlight treatment options for androgenetic alopecia taking into consideration the efficacy, side effect profiles, practicality of treatment (compliance), and costs to help clinicians offer ethically appropriate treatment regimens to their patients.

Materials and Methods

A literature search was conducted using electronic databases (Medline, PubMed, Embase, CINAHL, EBSCO) and textbooks, in addition to the authors' and other practitioners' clinical experiences in treating androgenetic alopecia, and the findings are presented here.

Results

Although topical minoxidil, oral finasteride, and low‐level light therapy are the only FDA‐approved therapies to treat AGA, they are just a fraction of the treatment options available, including other oral and topical modalities, hormonal therapies, nutraceuticals, PRP and exosome treatments, and hair transplantation.

Discussion

Androgenetic alopecia therapy remains challenging as treatment selection involves ethical, evidence‐based decision‐making and consideration of each individual patient's needs, compliance, budget, extent of hair loss, and aesthetic goals, independent of potential financial benefits to the practitioners.

Current controversies in trichology: a European expert consensus statement

INTRODUCTION

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

OBJECTIVE

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

METHODS

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

RESULTS

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

CONCLUSIONS

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

Trichobiolight: A new, effective protocol in the treatment of androgenetic alopecia and telogen effluvium

Androgenetic alopecia (AGA) with its precursor miniaturization of anagen phase (MA) and telogen effluvium (TE) represent nonscarring hair loss diseases which causes moderate to severe aesthetic and psychologic discomfort in affected people. Several therapeutic approaches have been tested through the latest decades, with different degree of success. In this study we aim to analyze the efficacy and outcome of an innovative therapeutic protocol, named TRICHOBIOLIGHT, a combination of active principles conveyed by mesotherapy directly on the scalp with a subsequent photobiostimulation session with LED light (630 nm). About 107 patients (49 women, 58 men, mean age 45-year-old) with clinical and trichoscopic diagnosis of MA, AGA, and TE have been enrolled at Skin Center of L'Aquila, Avezzano and Pescara (Italy) and subsequently treated with the TRICHOBIOLIGHT protocol. 4 patients dropped out at the beginning of the study: 2 patients because of an histological diagnosis of scarring alopecia and lichen scleroatrophicus, and 2 patients dropped out because of adverse reaction to the treatment. Excellent to good outcome have been reached in the 82.5% of patients (85/103), 9 patients (8.7%) reached a sufficient result while 7 patients (6.8%) partially respond to the treatment. Two patients (2%) did not respond at all. TRICHOBIOLIGHT is a promising protocol, working through the combined action of the active principles and the photobiostimulation, that lead to a strengthening and thickening of the residual hair, giving an optical thickening effect that provides high quality aesthetic results and, consequently, appreciable psychological results.

Efficacy of Intralesional and Oral Dutasteride in the Treatment of Androgenetic Alopecia: A Systematic Review

Androgenetic alopecia is the most common cause of hair loss [Br J Dermatol. 2011 Jan;164(1):5-15]. Finasteride and minoxidil are the only approved treatments [J Am Acad Dermatol. 2008 Oct;59(4):547-8 and J Eur Acad Dermatology Venereol. 2018 Jan;32(1):11-22]. Dutasteride is more potent than finasteride due to its ability to inhibit both 5-α-reductase type I and II [Our Dermatol Online. 2017 Sep;9(1):75-9] though its adverse effects and long half-life contribute to the reluctance on its oral use. Mesotherapy could be a feasible alternative to avoid systemic exposure and side effects [J Pan-Arab League Dermatologist. 2009 Feb;20(1):137-45]. We aim to perform a systematic review to analyze scientific literature with the purpose of comparing efficacy and adverse effects of both administration routes. Five clinical trials using oral route and 3 intralesional in comparison with placebo met criteria for inclusion. Regarding intralesional dutasteride, only one study [Clin Dermatol. 2001 Mar;19(2):149-54] reported the mean change in hair count. Although both interventions favor over placebo, there are not enough data to reliably compare outcomes obtained between both routes. Mean increase in hair count observed with oral dutasteride was higher (MD: 15.92 hairs [95% CI: 9.87-21.96]; p = <0.00001; I ² = 90%) compared to intralesional dutasteride in Abdallah's study (MD: 7.90 hairs [95% CI: 7.14-8.66]; p = <0.00001). Future studies are required to assess the therapeutic efficacy of both treatment routes, including head-to-head treatments before well-supported conclusions can be established.

Clinical, trichoscopic, and folliscopic identification of the impact of metabolic syndrome on the response to intradermal dutasteride 0.02% injection in patients with female pattern hair loss: a prospective cohort study

BACKGROUND

No studies investigating the impact of metabolic syndrome (MetS) in treatment response of female pattern hair loss (FPHL).

OBJECTIVE

In this prospective cohort study, we studied the impact of MetS in response to intradermal dutasteride 0.02% injection in patients with FPHL.

METHODS

Fifty-one adult participants with FPHL were classified into study cohorts: with MetS and comparison cohorts without MetS. Both groups underwent clinical, trichoschopic, and digital folliscopic evaluation. Treatment was scheduled over a period of 3 months as four weekly sessions, followed by another four bimonthly sessions. Response was evaluated by digital folliscopy, investigator's, and patient's self assessments at 1 and 3 months post-treatment. Side effects were evaluated.

RESULTS

In participants with MetS, there was a significant reduction of the mean percentage of terminal hair with significant increase of the mean percentage of vellus hair (p = .003, .006, respectively) compared with participants without MetS at 1 month after treatment. These significant differences persisted at 3 months after treatment; for terminal and vellus hair (p = .000) with significant reduction in the mean hair thickness (p = .002) compared with participants without MetS.

CONCLUSIONS

MetS negatively impacted FPHL in terms of response to intradermal injection of dutasteride 0.02% and severity. Further studies are still needed.

Physiopathology and current treatments of androgenetic alopecia: Going beyond androgens and anti-androgens

Androgenetic alopecia (AGA) is the most diagnosed hair loss dysfunction. Its physiopathology comprises a genetic predisposition affording an exacerbated response of the hair follicles cells to androgens aggravated by scalp inflammation and extrinsic factors. This paper presents a review of the mechanisms and extrinsic factors involved in the AGA physiopathology as well as its conventional and emerging treatments. The research focused on reports regarding AGA physiopathology and treatments published between January 2001 and July 2019 in medical and related journals. The most used medical treatments for AGA-minoxidil and finasteride-present non satisfactory results in some cases. Currently, the low-level laser therapy is recognized as a safe and effective treatment for AGA. Some minimally invasive techniques-mesotherapy, microneedling, carboxytherapy, and platelet-rich plasma-are also used to stimulate hair growth. Pharmaceutical substances with mechanisms differing from the anti-androgen activity are under current investigation and many of them have botanical origins; however, formulations with higher performance are required, and the hair follicles ability of being a drug and nanoparticle reservoir has been researched. The association of different strategies, that is, substances with synergic mechanisms and the use of advantageous technologies associated with lifestyle changes could improve the treatment outcomes.

Mesotherapy: Safety profile and management of complications

BACKGROUND

Mesotherapy is a procedure that involves the injection of active substances into the dermis and subcutaneous tissue in order to treat several local medical and cosmetic conditions. Despite being considered as a relatively safe method, a series of adverse reactions can occur due to its wide application and lack of standardization processes.

OBJECTIVES

The aim of this paper is to summarize all the mesotherapy-related complications published so far, and to provide an insight into their management.

PATIENT/METHODS

Articles derived from the databases, PubMed, EMBASE, and SCOPUS, and published between 1992 and 2018, were analyzed for this review. The study was conducted according to the PRISMA guidelines.

RESULTS

In this literature, there is a number of case series and isolated case reports describing various side effects of different severities. The therapeutic management of these complications is-in most cases-individualized.

CONCLUSIONS

Larger systematic studies are needed in order to adequately evaluate the safety profile of mesotherapy, and in order to determine standardized therapy parameters, so as to minimize the risk of potential adverse reactions.

Safety concerns when using novel medications to treat alopecia

INTRODUCTION

Alopecia is often a cause of great concern to patients for cosmetic and psychologic reasons. The aim of treating non-scarring alopecias is to reduce hair loss and, to some extent, enhance hair regrowth. However, therapies for scarring alopecias are limited and aiming to halt disease progression. Nonetheless, available modalities of treatment come with numerous side effects. Areas covered: Many new treatments for non-scarring alopecias have been introduced in recent years. This review summarizes the safety concerns when using novel therapeutic modalities such as JAK inhibitors, hair transplantation, mesotherapy, oral minoxidil, platelet-rich plasma, microneedling, and 5α-reductase inhibitors for treating hair loss. A broad literature search was performed using PubMed and Google Scholar in April 2018 to compile published articles that reported the adverse effects of new therapeutic modalities for alopecia. Expert opinion: Although emerging therapeutic modalities for alopecia have demonstrated efficacy in hair regrowth and treating established disease, their safety profiles vary widely. When considering the new treatments for alopecia, physicians should weigh the potential benefits and risks of each treatment or combination treatment to ensure safe and successful outcomes.

New Treatments for Hair Loss

The treatment of hair loss is an important part of clinical dermatology given the prevalence of the problem and great impact on patients' quality of life. Many new treatments have been introduced in recent years. This review summarizes the main ones in 4 groups: a) For androgenetic alopecia, we discuss new excipients for oral minoxidil, dutasteride, and finasteride as well as new forms of topical application; prostaglandin agonists and antagonists; low-level laser therapy; and regenerative medicine with Wnt signaling activators and stem cell therapy. b) For alopecia areata, Janus kinase inhibitors are reviewed. c) For frontal fibrosing alopecia, we discuss the use of antiandrogens and, for some patients, pioglitazone. d) Finally, we mention new robotic devices for hair transplant procedures and techniques for optimal follicular unit extraction.

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.

5α-Reductase inhibitors in androgenetic alopecia

PURPOSE OF REVIEW

The authors will review the current literature on efficacy and safety of 5-alpha reductase inhibitors (5αRIs) for androgenetic alopecia (AGA).

RECENT FINDINGS

The 5αRI finasteride and dutasteride are effective in treating AGA and promoting hair regrowth. 5αRI can be given orally, topically and more recently through mesotherapy. However, there has been an increasing concern about permanent sexual adverse events such as impotence and infertility. Most of these reports are published as case reports, and two studies reporting persistent sexual side-effects after discontinuation of finasteride had serious method limitations, as patients were recruited from a website. To our knowledge, permanent sexual adverse events have yet to be published in higher quality studies, such as randomized controlled trials. Although patients treated with 5αRIs have an increased incidence of sexual adverse events, these events decrease if discontinued or over time with continued therapy.

SUMMARY

Sexual side-effects are uncommon and resolve spontaneously in most patients even without discontinuing therapy. Significant effort is underway to find delivery systems that optimize delivery and reduce systemic absorption of topical 5αRs including hydroxypropyl chitosan and liposomal and nanoparticulate systems.

Androgenetic alopecia: an evidence-based treatment update

BACKGROUND

Androgenetic alopecia (AGA) is one of the most common chronic problems seen by dermatologists worldwide. It is characterized by progressive hair loss, especially of scalp hair, and has distinctive patterns of loss in women versus men, but in both genders the central scalp is most severely affected. It often begins around puberty and is known to effect self-esteem and the individual's quality of life. In contrast to the high prevalence of AGA, approved therapeutic options are limited. In addition to the scarce pharmacologic treatments, there are numerous nonprescription products claimed to be effective in restoring hair in androgenetic alopecia.

OBJECTIVES

The purpose of this paper is to review published medical and non-medical treatments for male and female AGA using the American College of Physicians evidence assessment methods. MEDLINE, EMBASE and Cochrane Library were searched for systematic reviews, randomized controlled trials, open studies, case reports and relevant studies of the treatment of male and female AGA. The relevant articles were classified according to grade and level of evidence.

RESULTS

The medical treatments with the best level of evidence classification for efficacy and safety for male AGA are oral finasteride and topical minoxidil solution. For female AGA, topical minoxidil solution appears to be the most effective and safe treatment. The medical treatments corresponding to the next level of evidence quality are some commonly used therapeutic non-FDA-approved options including oral and topical anti-hormonal treatments. Surgical treatment of follicular unit hair transplantation is an option in cases that have failed medical treatment although there is high variation in outcomes.

LIMITATIONS

Some articles, especially those concerning traditional herbs claimed to promote hair regrowth, were published in non-English, local journals.

CONCLUSIONS

An assessment of the evidence quality of current publications indicates that oral finasteride (for men only) and topical minoxidil (for men and women) are the best treatments of AGA.

Nonsurgical therapy for hair loss

This article is an update of the currently available options for medical therapies to treat androgenetic alopecia in men and women. Emerging novel therapeutic modalities with potential for treating these patients are discussed. Because androgenetic alopecia is progressive in nature, stabilization of the process using medical therapy is an important adjunct to any surgical hair-restoration plan.

Female pattern hair loss

CONTEXT

Female pattern hair loss (FPHL) also known as female androgenetic alopecia is a common condition afflicting millions of women that can be cosmetically disrupting. Prompt diagnosis and treatment are essential for obtaining optimal outcome. This review addresses the clinical presentation of female pattern hair loss, its differential diagnosis and treatment modalities.

EVIDENCE ACQUISITION

A) Diffuse thinning of the crown region with preservation of the frontal hairline (Ludwig's type) B) The "Christmas tree pattern" where the thinning is wider in the frontal scalp giving the alopecic area a triangular shaped figure resembling a christmas tree. C) Thinning associated with bitemporal recession (Hamilton type). Generally, FPHL is not associated with elevated androgens. Less commonly females with FPHL may have other skin or general signs of hyperandrogenism such as hirsutism, acne, irregular menses, infertility, galactorrhea and insulin resistance. The most common endocrinological abnormality associated with FPHL is polycystic ovarian syndrome (PCOS).

RESULTS

The most important diseases to consider in the differential diagnosis of FPHL include Chronic Telogen Effluvium (CTE), Permanent Alopecia after Chemotherapy (PAC), Alopecia Areata Incognito (AAI) and Frontal Fibrosing Alopecia (FFA). This review describes criteria for distinguishing these conditions from FPHL.

CONCLUSIONS

The only approved treatment for FPHL, which is 2% topical Minoxidil, should be applied at the dosage of 1ml twice day for a minimum period of 12 months. This review will discuss off-label alternative modalities of treatment including 5-alfa reductase inhibitors, antiandrogens, estrogens, prostaglandin analogs, lasers, light treatments and hair transplantation.

Female pattern alopecia: current perspectives

Hair loss is a commonly encountered problem in clinical practice, with men presenting with a distinctive pattern involving hairline recession and vertex balding (Norwood-Hamilton classification) and women exhibiting diffuse hair thinning over the crown (increased part width) and sparing of the frontal hairline (Ludwig classification). Female pattern hair loss has a strikingly overwhelming psychological effect; thus, successful treatments are necessary. Difficulty lies in successful treatment interventions, as only two medications - minoxidil and finasteride - are approved for the treatment of androgenetic alopecia, and these medications offer mediocre results, lack of a permanent cure, and potential complications. Hair transplantation is the only current successful permanent option, and it requires surgical procedures. Several other medical options, such as antiandrogens (eg, spironolactone, oral contraceptives, cyproterone, flutamide, dutasteride), prostaglandin analogs (eg, bimatoprost, latanoprost), and ketoconazole are reported to be beneficial. Laser and light therapies have also become popular despite the lack of a profound benefit. Management of expectations is crucial, and the aim of therapy, given the current therapeutic options, is to slow or stop disease progression with contentment despite patient expectations of permanent hair regrowth. This article reviews current perspectives on therapeutic options for female pattern hair loss.