Primary scarring alopecias

Frontiers in Lichen Planopilaris and Frontal Fibrosing Alopecia Research: Pathobiology Progress and Translational Horizons

Lichen planopilaris (LPP) and frontal fibrosing alopecia (FFA) are primary, lymphocytic cicatricial hair loss disorders. These model epithelial stem cell (SC) diseases are thought to result from a CD8⁺ T-cell‒dominated immune attack on the hair follicle (HF) SC niche (bulge) after the latter has lost its immune privilege (IP) for as yet unknown reasons. This induces both apoptosis and pathological epithelial‒mesenchymal transition in epithelial SCs, thus depletes the bulge, causes fibrosis, and ultimately abrogates the HFs' capacity to regenerate. In this paper, we synthesize recent progress in LPP and FFA pathobiology research, integrate our limited current understanding of the roles that genetic, hormonal, environmental, and other factors may play, and define major open questions. We propose that LPP and FFA share a common initial pathobiology, which then bifurcates into two distinct clinical phenotypes, with macrophages possibly playing a key role in phenotype determination. As particularly promising translational research avenues toward direly needed progress in the management of these disfiguring, deeply distressful cicatricial alopecia variants, we advocate to focus on the development of bulge IP and epithelial SC protectants such as, for example, topically effective, HF‒penetrating and immunoinhibitory preparations that contain tacrolimus, peroxisome proliferator-activated receptor-γ, and/or CB1 agonists.

Mapping the Lipids of Skin Sebaceous Glands and Hair Follicles by High Spatial Resolution MALDI Imaging Mass Spectrometry

Matrix-assisted laser desorption/ionization (MALDI) imaging mass spectrometry (IMS) is a technology that utilizes the high sensitivity and specificity of mass spectrometry, combined with a high spatial resolution to characterize the molecular species present in skin tissue. In this article, we use MALDI IMS to map specific lipids characteristic of two important skin appendages in minipig skin: the sebaceous glands and hair follicles. A set of specific lipid markers linked to the synthesis of sebum, stages of sebum production, and the secretion of sebum for two different sebaceous gland subzones, the peripheral and central necrotic, were identified. Furthermore, biochemical pathway analysis of the identified markers provides potential drug-targeting strategies to reduce sebum overproduction in pathological conditions. In addition, specific lipid markers characteristic of the different layers in the hair follicle bulge area, including the outer root sheath, the inner root sheath, and the medulla that are associated with the growth cycles of the hair, were determined. This research highlights the ability of MALDI IMS to link a molecular distribution not only to the morphological features in skin tissue but to the physiological state as well. Thus, this platform can provide a basis for the investigation of biochemical pathways as well as the mechanisms of disease and pharmacology in the skin, which will ultimately be critical for drug discovery and the development of dermatology-related illnesses.

Single-Cell Sequencing Analysis and Weighted Co-Expression Network Analysis Based on Public Databases Identified That TNC Is a Novel Biomarker for Keloid

Background

The pathophysiology of keloid formation is not yet understood, so the identification of biomarkers for kelod can be one step towards designing new targeting therapies which will improve outcomes for patients with keloids or at risk of developing keloids.

Methods

In this study, we performed single-cell RNA sequencing analysis, weighted co-expression network analysis, and differential expression analysis of keloids based on public databases. And 3 RNA sequencing data from keloid patients in our center were used for validation. Besides, we performed QRT-PCR on keloid tissue and adjacent normal tissues from 16 patients for further verification.

Results

We identified the sensitive biomarker of keloid: Tenascin-C (TNC). Then, Pseudotime analysis found that the expression level of TNC decreased first, then stabilized and finally increased with fibroblast differentiation, suggesting that TNC may play an potential role in fibroblast differentiation. In addition, there were differences in the infiltration level of macrophages M0 between the TNC-high group and the TNC-low group. Macrophages M0 had a higher infiltration level in low TNC- group (P<0.05).

Conclusion

Our results can provide a new idea for the diagnosis and treatment of keloid.

Tufted hairs: A bouquet of flowers in different hair diseases

Tufted hairs, an unusual hair follicle dysplasia, are characterized by several hair shafts grouped together, emerging from a single hair follicle-like "doll's hair". This clinical picture is considered characteristic of folliculitis decalvans (FD). However, the emergence of grouped hair shafts from a single follicle can also be observed in other hair disorders, even if not as a distinctive diagnostic sign. This paper aims to collect and analyze all clinical and trichoscopic features of different hair diseases with tufted hairs to find distinctive features, helping the clinician with the diagnosis.

Breast Cancer-Related Neoplastic Alopecia: A Case Report and Review of the Literature

Neoplastic alopecia (NA) is defined as an organized hair loss in single or multiple areas of the scalp caused by a primary tumor that has metastasized to the skin of the scalp. Due to its localization and clinical appearance, NA should be placed in differential diagnosis with alopecia areata or other entities. To date, pathognomonic dermoscopic criteria of NA have not yet been described: the absence of classical criteria of other scalp diseases in addition to a major neovascularization with on-focus arborizing vessels and erosions or ulcerations may help the clinician to suspect a diagnosis of secondary alopecia. Dermatologists should pay more attention to these rare forms of secondarism because in exceptional cases, a simple alopecia of the scalp can hide a new, relapsing or metastatic neoplasia.

The role of interleukin-17 (IL-17) in the pathogenesis of discoid lupus erythematosus and lichen planopilaris: is immunohistochemistry for IL-17 a promising way to differentiate these entities?

BACKGROUND

Interleukin-17 (IL-17) is a pro-inflammatory mediator which its excess secretion by immune cells is found in many chronic autoimmune diseases. This survey is aimed to compare the amount and pattern of distribution of IL-17 positive cells in lichen planopilaris (LPP) and discoid lupus erythematosus (DLE) which are of the most frequent causes of primary cicatricial alopecia (CA).

METHODS

Biopsies of lesional scalp skin from adult LPP (n = 30), DLE patients (n = 19), and control scalp skin (n = 18) were analyzed by immunohistochemistry (IHC) method using rabbit polyclonal antibody against IL-17. Cells stained positive for IL-17 and their pattern of distribution were assessed and compared between these groups.

RESULTS

The mean of IL-17 positive cell counts per high power field (HPF) in both LPP and DLE groups was significantly higher in comparison with the control group (both p < .0001). The LPP group had higher values of IL-17 positive cell counts per HPF (47.56 ± 13.37) compared to the DLE group (22.21 ± 11.06) (p < .0001). More than 30 IL-17 positive cell counts in IHC have a sensitivity of 90% and a specificity of 78% for differentiating LPP from DLE.

CONCLUSIONS

Our findings suggest that IL-17 is effective in the pathogenesis of DLE and LPP and its role is more prominent in LPP. IL-17 positive cells in IHC can distinguish DLE from LPP with satisfactory sensitivity and specificity.

[Kerion Celsi due to Microsporum canis infection]

Tinea capitis is seen world-wide among children up to 12 years. The most severe type is Kerion Celsi with painful abscesses and lymphadenopathy. We report on an 11-year-old boy with Kerion Celsi, who was initially treated using antibiotics under the common misdiagnosis of a bacterial infection. Mycological investigations could identify Microsporum canis. The patient was treated orally with griseofulvin, which resulted in complete mycological remission after 8 weeks. Cicatrical alopecia, however, could not be prevented. Purulent infections of the scalp should lead to early mycological diagnostics in children.

Chinese SLE Treatment and Research Group Registry (CSTAR) XIII: prevalence and risk factors for chronic scarring alopecia in patients with systemic lupus erythematosus

Background

Scarring alopecia in systemic lupus erythematosus (SLE) patients caused reduced life quality and prolonged disease course. This case-control study aims to survey the prevalence of scarring alopecia during the disease course of SLE and evaluate the risk factors for scarring alopecia in Chinese SLE patients.

Methods

SLE patients in Chinese SLE treatment and Research group (CSTAR) were recruited. Scarring alopecia was defined according to SLICC/ACR-DI which was collected during follow-up visits or via self-reported questionnaires. We collected demographic characteristics, common comorbidities, autoantibody profiles, disease activity status, major organ involvements, and treatment strategies of these patients at registry. Univariate and multivariate logistic regression analyses were used to investigate the risk factors for scarring alopecia.

Results

We recruited 4792 SLE patients, and 374 (7.80%) patients had scarring alopecia. Mucocutaneous lesions (OR 2.062, p < 0.001), high SLICC/ACR-DI (OR 1.409, p < 0.001), and positive anti-Sm (OR 1.374, p = 0.029) were risk factors for scarring alopecia, while renal (OR 0.714, p = 0.028) and cardio-respiratory involvements (OR 0.347, p = 0.044), and immunosuppressant treatment (OR 0.675, p < 0.001) were significantly negative associated with it.

Conclusions

The prevalence of scarring alopecia in SLE patients is 7.80%. Active treatment strategies should be adopted to prevent scarring alopecia occurring.

Acne in the first three decades of life: An update of a disorder with profound implications for all decades of life

Acne vulgaris is a chronic, inflammatory, skin condition that involves the pilosebaceous follicles and is influenced by a variety of factors including genetics, androgen-stimulation of sebaceous glands with abnormal keratinization, colonization with Cutibacterium acnes (previously called Propionibacterium acnes), and pathological immune response to inflammation. Acne can occur at all ages and this discussion focuses on the first three decades of life. Conditions that are part of the differential diagnosis and/or are co-morbid with acne vulgaris are also considered. Acne in the first year of life includes neonatal acne (acne neonatorum) that presents in the first four weeks of life and infantile acne that usually presents between 3 and 6 months of the first year of life with a range of 3 to 16 months after birth. Acne rosacea is a chronic, inflammatory, skin condition that is distinct from acne vulgaris, typically presents in adults, and has four main types: erythemato-telangiectatic, papulopustular, phymatous and ocular. Treatment options for acne vulgaris include topical retinoids, topical benzoyl peroxide, antibiotics (topical, oral), oral contraceptive pills, isotretinoin, and others. Management must consider the increasing impact of antibiotic resistance in the 21st century. Psychological impact of acne can be quite severe and treatment of acne includes awareness of the potential emotional toll this disease may bring to the person with acne as well as assiduous attention to known side effects of various anti-acne medications (topical and systemic). Efforts should be directed at preventing acne-caused scars and depigmentation on the skin as well as emotional scars within the person suffering from acne.

Platelet-Rich Plasma and its Use for Cicatricial and Non-Cicatricial Alopecias: A Narrative Review

The concept and description of platelet-rich plasma (PRP) started in the field of hematology and is being extensively used in other fields of medicine. Interest in the application of PRP has been increasing in dermatology, such as in tissue regeneration, wound healing, scar revision, skin-rejuvenating effects, and alopecia. PRP is an autologous blood product containing high concentrations of platelets in a small volume of plasma. Different preparations of PRP may lead to different volumes of PRP, platelet concentration, and presence or absence of leukocytes. PRP is being used as a new therapy for some types of non-cicatricial alopecia such as androgenetic alopecia (AGA) and alopecia areata (AA) and, recently, new insights refer to the possibility of action in the field of cicatricial alopecia, like lichen planopillaris (LPP) and frontal fibrosing alopecia (FFA). This article aims to identify the major indications for the application of PRP in the field of hair disorders, including non-cicatricial and cicatricial alopecia.

NFI transcription factors provide chromatin access to maintain stem cell identity while preventing unintended lineage fate choices

Tissue homeostasis and regeneration rely on resident stem cells (SCs), whose behaviour is regulated through niche-dependent crosstalk. The mechanisms underlying SC identity are still unfolding. Here, using spatiotemporal gene ablation in murine hair follicles, we uncover a critical role for the transcription factors (TFs) nuclear factor IB (NFIB) and IX (NFIX) in maintaining SC identity. Without NFI TFs, SCs lose their hair-regenerating capability, and produce skin bearing striking resemblance to irreversible human alopecia, which also displays reduced NFIs. Through single-cell transcriptomics, ATAC-Seq and ChIP-Seq profiling, we expose a key role for NFIB and NFIX in governing super-enhancer maintenance of the key hair follicle SC-specific TF genes. When NFIB and NFIX are genetically removed, the stemness epigenetic landscape is lost. Super-enhancers driving SC identity are decommissioned, while unwanted lineages are de-repressed ectopically. Together, our findings expose NFIB and NFIX as crucial rheostats of tissue homeostasis, functioning to safeguard the SC epigenome from a breach in lineage confinement that otherwise triggers irreversible tissue degeneration.

A Systematic Review of the Outcome of Hair Transplantation in Primary Scarring Alopecia

Importance

Hair loss, or alopecia, is one of the most commonly presented problems in dermatology. Scarring alopecias are considered particularly damaging due to limited success in slowing permanent disease progression, and current treatment methods, such as intralesional and topical steroids and topical minoxidil, are largely ineffective.

Objective

Hair transplantation is a debated treatment option for advanced cases of primary scarring alopecia. This study reviews the efficacy of hair transplantation as a treatment option for primary scarring alopecia.

Evidence Review

A primary literature search was conducted using PubMed to identify articles in scarring alopecia and hair transplants published from 1960 to the present time.

Findings

Fifteen reports with 34 patients were included in this review. Twenty six patients experienced moderate to positive results, while 8 patients experienced negative results or recurrence of disease. Positive hair transplantation results have been reported in patients with central centrifugal cicatricial alopecia, en coup de sabre, discoid lupus erythematous, pseudopelade de brocq, and folliculitis decalvans. Positive and -negative results were observed in patients with lichen planopilaris and frontal fibrosing alopecia.

Conclusion and Relevance

Findings show that hair transplant surgery can be considered as a treatment option for certain primary scarring alopecias. However, data must be interpreted with caution due to concern for positive-result publication bias.

Treatment of lichen planopilaris: methotrexate or cyclosporine a therapy?

BACKGROUND

Because of irreversible outcome of the lichen planopilaris (LPP), systemic therapy should be used in early inflammatory stages of the disease, without allowing the irreversible scar formation and permanent hair loss.

OBJECTIVE

We assessed the efficacy and safety of methotrexate (MTX) and cyclosporine A (CsA) in the management of recalcitrant, extensive LPP and compared their efficacy and safety profile.

METHODS

We retrospectively analysed the 16 LPP cases treated with either CsA or MTX therapy. Clinical improvement was defined as the absence of reported symptoms, lack of progression and reduction in erythema and follicular hyperkeratosis found in SIAscopic images.

RESULTS

A total of 16 patients received either CsA (six cases) or MTX (10 cases) therapy. The dosage of CsA was between 3 and 5 mg/kg/day. The initial dosage of MTX was 10-15 mg/wk and tapered gradually. The clinical improvement was demonstrated significantly at SIAscopic images taken at the third months of therapy.

CONCLUSIONS

Our observations suggest that both MTX and CsA therapies provide similar clinical efficacy at the end of first month of therapy with dosages used in psoriasis therapy. MTX was found to be better tolerated in this study.