Alopecia areata: a new treatment plan

Sexual Dysfunction in Alopecia Areata: A Systematic Review

Background: Alopecia areata (AA) contributes to clinically significant suffering, and impaired social functioning. Among AA patients, there is a clear impact of the disease on their sense of attractiveness and desirability as sexual partners. This review explores the development of sexual disorders among AA patients, highlighting their importance in the clinical diagnosis of comorbid health disorders with hair loss. Methods: A systematic review was conducted by searching electronic databases, including MEDLINE and Google Scholar, without date limitations, according to the PRISMA guidelines. Key search terms included "sexuality" or "sexual health" or "sexual dysfunction" or "sexual disorder" AND "alopecia areata". Data synthesis included findings from eight relevant studies. Results: Hair loss in the course of AA has a negative impact on the sexual sphere, significantly reducing the quality of life of patients and their partners. Proper sexual functioning is an integral part of every person, so special attention should be paid to the possibility of developing sexual dysfunction in the course of AA. Conclusions: Small sample sizes and heterogeneous populations make it difficult to draw firm conclusions. Continued research with standardized criteria for SD diagnosis and appropriately large cohorts will be essential to fully establish psychosexual disorders among AA patients.

Safety and Efficacy of Ritlecitinib for the Treatment of Patients with Alopecia Areata: A Systematic Review and Meta-Analysis of Controlled Trials

Background: Alopecia areata (AA) typically presents as round patches of hair loss (e.g., scalp, eyebrow/eyelash, and body), has an unpredictable disease course, and may relapse and remit. AA is a condition with a lifetime risk of approximately 2% in the global population with an annual incidence rate ranging from 2.53 to 26 per 100,000. This comprehensive systematic review and meta-analysis was performed to determine the safety and efficacy of Ritlecitinib in patients with AA. Methods: A systematic search was conducted in PubMed and Cochrane CENTRAL Library for randomized controlled trials (RCTs). We used mean difference with 95% confidence intervals to assess the effectiveness and odds ratio to assess the safety profile. A total of 65 publications were identified through a database search. Following two stages of screening, we included 13 publications. All the studies were parallel and double-blind RCTs and published between 2020 and 2022. Results: Our analysis revealed a significant reduction in SALT score at week 12 and week 24 of (-17.43 [-24.67 to -10.20]; p < 0.0001) and (-20.95 [-29.01 to -12.89]; p < 0.0001), respectively, in patients treated with Ritlecitinib compared to placebo. Furthermore, a significant improvement in PGIC score at week 24 was observed. Additionally, Ritlecitinib revealed a slightly higher reduction in AASIS score compared to placebo; however, this difference was statistically non-significant. Notably, the Ritlecitinib group experienced a higher frequency of headaches, acne and nasopharyngitis compared to placebo, while the placebo group reported a greater occurrence of serious adverse events compared to the Ritlecitinib group. This higher rate of serious events in the placebo arm could be explained by the placebo effect, although these differences were statistically non-significant. Conclusions: These findings suggest that Ritlecitinib holds promise as an effective treatment for AA with an acceptable safety profile, warranting further investigation in larger cohorts and long-term studies.

Alopecia areata: review of epidemiology, pathophysiology, current treatments and nanoparticulate delivery system

Alopecia areata (AA) is a kind of alopecia that affects hair follicles and nails. It typically comes with round patches and is a type of nonscarring hair loss. Various therapies are accessible for the management and treatment of AA, including topical, systemic and injectable modalities. It is a very complex type of autoimmune disease and is identified as round patches of hair loss and may occur at any age. This review paper highlights the epidemiology, clinical features, pathogenesis and new treatment options for AA, with a specific emphasis on nanoparticulate drug-delivery systems. By exploring these innovative treatment approaches, researchers aim to enhance the effectiveness and targeted delivery of therapeutic agents, ultimately improving outcomes for individuals living with AA.

"Hair is your crown and glory" - Black women's experiences of living with alopecia and the role of social support

BACKGROUND

Alopecia is an autoimmune condition that results in hair loss, mainly from the scalp. There are three specific types of autoimmune alopecia: alopecia areata (AA; small patches of hair loss), alopecia totalis (AT; total hair loss from the scalp) and alopecia universalis (AU; total hair loss from the scalp and body). Whilst research has explored the experiences of White women living with alopecia, there is a lack of research exploring the impact of alopecia on women in the Black community. The current study aimed to explore Black women's experience of living with autoimmune types of alopecia with a focus on the cultural importance of hair within the Black community and the impact of social support.

PARTICIPANTS AND PROCEDURE

Seven Black women (age range: 37-68 years; mean age: 51 years) were recruited purposively through alopecia support group organisations and social media to participate in a semi-structured interview; four participants were diagnosed with AA, two participants were diagnosed with AU, and one participant was diagnosed with AT. One-to-one interviews were conducted online, and interpretative phenomenological analysis was used to guide data collection and analysis.

RESULTS

Participants discussed the significance of hair specifically within the Black community and the complex relationship between psychological wellbeing, coping and seeking support.

CONCLUSIONS

This novel area, specific to Black women's psychological experience of alopecia, acknowledges the influence of cultural and ethnic differences. The findings suggest that proactive awareness from health professionals and social support groups are needed due to the nuances of Black women's alopecia experience to provide better support and to enhance the quality of life for Black women to manage their alopecia.

Alopecia Areata: Current Treatments and New Directions

Alopecia areata is an autoimmune hair loss disease that is non-scarring and is characterized by chronic inflammation at the hair follicle level. Clinically, patients' presentation varies from patchy, circumscribed scalp involvement to total body and scalp hair loss. Current management is guided by the degree of scalp and body involvement, with topical and intralesional steroid injections as primarily first-line for mild cases and broad immunosuppressants as the mainstay for more severe cases. Until recently, the limited number of blinded, randomized, placebo-controlled clinical trials for this disease had made establishing an evidence-based treatment paradigm challenging. However, growing insights into the pathogenesis of alopecia areata through blood and tissue analysis of human lesions have identified several promising targets for therapy. T-helper (Th) 1/interferon skewing has traditionally been described as the driver of disease; however, recent investigations suggest activation of additional immune mediators, including the Th2 pathway, interleukin (IL)-9, IL-23, and IL-32, as contributors to alopecia areata pathogenesis. The landscape of alopecia areata treatment has the potential to be transformed, as several novel targeted drugs are currently undergoing clinical trials. Given the recent US FDA approval of baricitinib and ritlecitinib, Janus kinase (JAK) inhibitors are a promising drug class for treating severe alopecia areata cases. This article will review the efficacy, safety, and tolerability of current treatments for alopecia areata, and will provide an overview of the emerging therapies that are leading the revolution in the management of this challenging disease.

Treatments for alopecia areata: a network meta-analysis

BACKGROUND

Alopecia areata is an autoimmune disease leading to nonscarring hair loss on the scalp or body. There are different treatments including immunosuppressants, hair growth stimulants, and contact immunotherapy.

OBJECTIVES

To assess the benefits and harms of the treatments for alopecia areata (AA), alopecia totalis (AT), and alopecia universalis (AU) in children and adults.

SEARCH METHODS

The Cochrane Skin Specialised Register, CENTRAL, MEDLINE, Embase, ClinicalTrials.gov and WHO ICTRP were searched up to July 2022.

SELECTION CRITERIA

We included randomised controlled trials (RCTs) that evaluated classical immunosuppressants, biologics, small molecule inhibitors, contact immunotherapy, hair growth stimulants, and other therapies in paediatric and adult populations with AA.

DATA COLLECTION AND ANALYSIS

We used the standard procedures expected by Cochrane including assessment of risks of bias using RoB2 and the certainty of the evidence using GRADE. The primary outcomes were short-term hair regrowth ≥ 75% (between 12 and 26 weeks of follow-up), and incidence of serious adverse events. The secondary outcomes were long-term hair regrowth ≥ 75% (greater than 26 weeks of follow-up) and health-related quality of life. We could not perform a network meta-analysis as very few trials compared the same treatments. We presented direct comparisons and made a narrative description of the findings.

MAIN RESULTS

We included 63 studies that tested 47 different treatments in 4817 randomised participants. All trials used a parallel-group design except one that used a cross-over design. The mean sample size was 78 participants. All trials recruited outpatients from dermatology clinics. Participants were between 2 and 74 years old. The trials included patients with AA (n = 25), AT (n = 1), AU (n = 1), mixed cases (n = 31), and unclear types of alopecia (n = 4). Thirty-three out of 63 studies (52.3%) reported the proportion of participants achieving short-term hair regrowth ≥ 75% (between 12 and 26 weeks). Forty-seven studies (74.6%) reported serious adverse events and only one study (1.5%) reported health-related quality of life. Five studies (7.9%) reported the proportion of participants with long-term hair regrowth ≥ 75% (greater than 26 weeks). Amongst the variety of interventions found, we prioritised some groups of interventions for their relevance to clinical practice: systemic therapies (classical immunosuppressants, biologics, and small molecule inhibitors), and local therapies (intralesional corticosteroids, topical small molecule inhibitors, contact immunotherapy, hair growth stimulants and cryotherapy). Considering only the prioritised interventions, 14 studies from 12 comparisons reported short-term hair regrowth ≥ 75% and 22 studies from 10 comparisons reported serious adverse events (18 reported zero events and 4 reported at least one). One study (1 comparison) reported quality of life, and two studies (1 comparison) reported long-term hair regrowth ≥ 75%. For the main outcome of short-term hair regrowth ≥ 75%, the evidence is very uncertain about the effect of oral prednisolone or cyclosporine versus placebo (RR 4.68, 95% CI 0.57 to 38.27; 79 participants; 2 studies; very low-certainty evidence), intralesional betamethasone or triamcinolone versus placebo (RR 13.84, 95% CI 0.87 to 219.76; 231 participants; 1 study; very low-certainty evidence), oral ruxolitinib versus oral tofacitinib (RR 1.08, 95% CI 0.77 to 1.52; 80 participants; 1 study; very low-certainty evidence), diphencyprone or squaric acid dibutil ester versus placebo (RR 1.16, 95% CI 0.79 to 1.71; 99 participants; 1 study; very-low-certainty evidence), diphencyprone or squaric acid dibutyl ester versus topical minoxidil (RR 1.16, 95% CI 0.79 to 1.71; 99 participants; 1 study; very low-certainty evidence), diphencyprone plus topical minoxidil versus diphencyprone (RR 0.67, 95% CI 0.13 to 3.44; 30 participants; 1 study; very low-certainty evidence), topical minoxidil 1% and 2% versus placebo (RR 2.31, 95% CI 1.34 to 3.96; 202 participants; 2 studies; very low-certainty evidence) and cryotherapy versus fractional CO2 laser (RR 0.31, 95% CI 0.11 to 0.86; 80 participants; 1 study; very low-certainty evidence). The evidence suggests oral betamethasone may increase short-term hair regrowth ≥ 75% compared to prednisolone or azathioprine (RR 1.67, 95% CI 0.96 to 2.88; 80 participants; 2 studies; low-certainty evidence). There may be little to no difference between subcutaneous dupilumab and placebo in short-term hair regrowth ≥ 75% (RR 3.59, 95% CI 0.19 to 66.22; 60 participants; 1 study; low-certainty evidence) as well as between topical ruxolitinib and placebo (RR 5.00, 95% CI 0.25 to 100.89; 78 participants; 1 study; low-certainty evidence). However, baricitinib results in an increase in short-term hair regrowth ≥ 75% when compared to placebo (RR 7.54, 95% CI 3.90 to 14.58; 1200 participants; 2 studies; high-certainty evidence). For the incidence of serious adverse events, the evidence is very uncertain about the effect of topical ruxolitinib versus placebo (RR 0.33, 95% CI 0.01 to 7.94; 78 participants; 1 study; very low-certainty evidence). Baricitinib and apremilast may result in little to no difference in the incidence of serious adverse events versus placebo (RR 1.47, 95% CI 0.60 to 3.60; 1224 participants; 3 studies; low-certainty evidence). The same result is observed for subcutaneous dupilumab compared to placebo (RR 1.54, 95% CI 0.07 to 36.11; 60 participants; 1 study; low-certainty evidence). For health-related quality of life, the evidence is very uncertain about the effect of oral cyclosporine compared to placebo (MD 0.01, 95% CI -0.04 to 0.07; very low-certainty evidence). Baricitinib results in an increase in long-term hair regrowth ≥ 75% compared to placebo (RR 8.49, 95% CI 4.70 to 15.34; 1200 participants; 2 studies; high-certainty evidence). Regarding the risk of bias, the most relevant issues were the lack of details about randomisation and allocation concealment, the limited efforts to keep patients and assessors unaware of the assigned intervention, and losses to follow-up.

AUTHORS' CONCLUSIONS

We found that treatment with baricitinib results in an increase in short- and long-term hair regrowth compared to placebo. Although we found inconclusive results for the risk of serious adverse effects with baricitinib, the reported small incidence of serious adverse events in the baricitinib arm should be balanced with the expected benefits. We also found that the impact of other treatments on hair regrowth is very uncertain. Evidence for health-related quality of life is still scant.

The Efficacy and Adverse Effects of Corticosteroid Pulse Therapy in Alopecia Areata: A Review Article

INTRODUCTION

Alopecia areata (AA) is a common, non-scarring, autoimmune hair loss disorder, varying in severity from small round hairless patches to the total loss of scalp or body hair. As steroid pulse therapy outcomes for AA vary, this study aimed to review the related literature regarding the efficacy, relapse rates, side effects, and prognostic factors associated with the response to different pulse corticosteroid treatments.

METHODS

We performed a literature search on August 29, 2022, to provide an overview of the efficacy of pulse steroid therapy in patients with AA. The terms "pulse steroid therapy AND alopecia areata" and "pulse corticosteroid therapy AND alopecia areata" were searched on PubMed and Google Scholar.

RESULTS

A total of 24 articles were assessed. There was no difference in outcomes and side effects between intravenous and oral pulse corticosteroid therapy. The relapse rate and efficacy depended on the time of AA onset, age, and AA type: improved outcomes and decreased relapse were linked with recent onset (<6 months), a younger age (<10 years), and the multifocal type of AA. Patients with a past medical history of atopy, nail pitting, or thyroid disease and those with severe forms of AA like alopecia totalis and alopecia universalis had the least improvement.

CONCLUSIONS

All kinds of mentioned systemic pulse corticosteroids effectively induce hair regrowth in AA. Betamethasone pulse seems to be the most effective agent (followed by intramuscular triamcinolone), especially in severe cases, but more side effects may accompany it. Combining this agent with other medications can reduce the dosage and side effects. Pulses of prednisolone and methylprednisolone are less effective but safer, as they have low relapse rates and adverse effects. A combination of them with other drugs can increase their efficacy.

Fractional carbon dioxide laser alone and as an assisted drug delivery for treatment of alopecia areata: a clinical, dermoscopic and immunohistochemical study

Alopecia areata (AA) is a common cause of hair loss with no available universally successful treatment. Thus, new innovative treatments are urgently needed. This research aimed to evaluate the effectiveness of fractional carbon dioxide laser (FCL) alone or combined with triamcinolone acetonide (TA) solution, platelet-rich plasma (PRP), or vitamin D3 solution in treating AA. Sixty-four AA patients with 185 lesions were recruited and divided into four treatment groups. All patients received FCL either alone (group A, n = 19) or followed by topical TA (group B, n = 16) or PRP (group C, n = 15), or vitamin D3 solution (group D, n = 14). The response was assessed using Alopecia Areata Severity Index (AASI), MacDonald Hull and Norris grading, and trichoscopy. Histopathological features and immunohistochemical decorin expression were studied. All groups showed significant improvement in AASI compared to the baseline, with insignificant differences between them. Post-treatment, trichoscopic features of disease activity significantly decreased in all groups. Compared to control biopsies, both anagen follicles and decorin expression were significantly decreased in all pretreatment specimens. After treatment, all groups showed significantly increased anagen follicles and decorin expression compared to the baseline. Accordingly, FCL is an effective treatment for AA alone or combined with TA, PRP, or vitamin D3 solution. In AA, Decorin expression was downregulated, while enhanced expression following successful treatment occurred. This suggests the role of decorin in AA pathogenesis. However, further research is still recommended to clarify the exact role of decorin in AA pathogenesis and to investigate the therapeutic benefits of decorin-based therapy.

Design and Characterization of Baricitinib Incorporated PLA 3D Printed Pills by Fused Deposition Modeling: An Oral Pill for Treating Alopecia Areata

This study aimed to develop three-dimensional (3D) baricitinib (BAB) pills using polylactic acid (PLA) by fused deposition modeling. Two strengths of BAB (2 and 4% w/v) were dissolved into the (1:1) PEG-400 individually, diluting it with a solvent blend of acetone and ethanol (27.8:18:2) followed by soaking the unprocessed 200 cm~6157.94 mg PLA filament in the solvent blend acetone-ethanol. FTIR spectrums of the 3DP1 and 3DP2 filaments calculated and recognized drug encapsulation in PLA. Herein, 3D-printed pills showed the amorphousness of infused BAB in the filament, as indicated by DSC thermograms. Fabricated pills shaped like doughnuts increased the surface area and drug diffusion. The releases from 3DP1 and 3DP2 were found to be 43.76 ± 3.34% and 59.14 ± 4.54% for 24 h. The improved dissolution in 3DP2 could be due to the higher loading of BAB due to higher concentration. Both pills followed Korsmeyer-Peppas' order of drug release. BAB is a novel JAK inhibitor that U.S. FDA has recently approved to treat alopecia areata (AA). Therefore, the proposed 3D printed tablets can be easily fabricated with FDM technology and effectively used in various acute and chronic conditions as personalized medicine at an economical cost.

A phase 2a randomized vehicle-controlled multi-center study of the safety and efficacy of delgocitinib in subjects with moderate-to-severe alopecia areata

Alopecia areata/AA is an autoimmune cause of nonscarring hair loss. The pathogenesis of AA involves many immune axes, including Th1/Th2 pathways. Delgocitinib is a pan-Janus kinase/JAK inhibitor that broadly blocks pro-inflammatory cytokines and has been effective in other inflammatory skin conditions. Recent human studies/reports have shown that use of some systemic JAK inhibitors led to hair regrowth, suggesting this medication class as a potential therapy for AA. However, topical treatment is desirable due to potential systemic side effects. To assess the efficacy and safety of topical delgocitinib in AA, we conducted a double-blind, randomized, vehicle-controlled clinical trial in 31 moderate-to-severe AA patients that were randomized 2:1 to receive delgocitinib ointment 30 mg/g (n = 20) or ointment vehicle (n = 11) for 12 weeks. The primary endpoint was change in severity of Alopecia Tool/SALT score from baseline to week 12. The secondary endpoint included safety profile by reported adverse events. Twenty-three subjects completed the trial, with eight discontinuing mostly due to voluntary withdrawal. Ten patients receiving delgocitinib ointment and three patients receiving vehicle showed SALT score improvements after 12 weeks, but the mean percent SALT improvement at week 12 compared to baseline between the two arms was not significant (p = 0.92). Our study suggests that delgocitinib ointment is not effective in moderate-to-severe AA, likely due to its inability to penetrate sufficiently deeply into the dermis of the scalp, but larger studies are necessary to assess whether a different formulation of topical JAK inhibitors may be suitable to treat mild or more localized forms of AA.

Stem cell secretome as a mechanism for restoring hair loss due to stress, particularly alopecia areata: narrative review

Background

Living organisms are continuously exposed to multiple internal and external stimuli which may influence their emotional, psychological, and physical behaviors. Stress can modify brain structures, reduces functional memory and results in many diseases such as skin disorders like acne, psoriasis, telogen effluvium, and alopecia areata. In this review, we aim to discuss the effect of secretome on treating alopecia, especially alopecia areata. We will shed the light on the mechanism of action of the secretome in the recovery of hair loss and this by reviewing all reported in vitro and in vivo literature.

Main body

Hair loss has been widely known to be enhanced by stressful events. Alopecia areata is one of the skin disorders which can be highly induced by neurogenic stress especially if the patient has a predisposed genetic background. This condition is an autoimmune disease where stress in this case activates the immune response to attack the body itself leading to hair cycle destruction. The currently available treatments include medicines, laser therapy, phototherapy, and alternative medicine therapies with little or no satisfactory results. Regenerative medicine is a new era in medicine showing promising results in treating many medical conditions including Alopecia. The therapeutic effects of stem cells are due to their paracrine and trophic effects which are due to their secretions (secretome).

Conclusion

Stem cells should be more used as an alternative to conventional  therapies due to their positive outcomes. More clinical trials on humans should be done to maximize the dose needed and type of stem cells that must be used to treat alopecia areata.

Ayurvedic management of alopecia areata: A case report

Índralupta is a disease characterized by patches of hair loss spread throughout the body and scalp. It can be considered alopecia areata according to conventional medical care. The present case report is on the effectiveness of shodhana (treatment in which aggravated doshas are expelled from the body) and shamana (treatment that pacifies the aggravated doshas) in the patient of índralupta. A patient 25 years old, had hair loss patches on the scalp and many other areas of the body. The patient took conventional modern medicine as well as ayurveda treatment but didn't get a satisfactory result. The patient was hospitalized and treated with vamana (medicated emesis), virechana (medicated purgation), basti (administration of medicine through procto-colonic route), raktamokshana (blood-letting), and nasya (medicine administered through nasal route) along with shamana treatment for more than 6 weeks. The hair eruption started from many patches of the scalp and whole body. In this case, regrowth of hair from hair follicles was evident within 15 days of treatment. The collected data of this study suggest that shodhana and shamana treatment can provide noteworthy relief in índralupta.

Advancing Regenerative Cellular Therapies in Non-Scarring Alopecia

Alopecia or baldness is a common diagnosis in clinical practice. Alopecia can be scarring or non-scarring, diffuse or patchy. The most prevalent type of alopecia is non-scarring alopecia, with the majority of cases being androgenetic alopecia (AGA) or alopecia areata (AA). AGA is traditionally treated with minoxidil and finasteride, while AA is treated with immune modulators; however, both treatments have significant downsides. These drawbacks compel us to explore regenerative therapies that are relatively devoid of adverse effects. A thorough literature review was conducted to explore the existing proven and experimental regenerative treatment modalities in non-scarring alopecia. Multiple treatment options compelled us to classify them into growth factor-rich and stem cell-rich. The growth factor-rich group included platelet-rich plasma, stem cell-conditioned medium, exosomes and placental extract whereas adult stem cells (adipose-derived stem cell-nano fat and stromal vascular fraction; bone marrow stem cell and hair follicle stem cells) and perinatal stem cells (umbilical cord blood-derived mesenchymal stem cells (hUCB-MSCs), Wharton jelly-derived MSCs (WJ-MSCs), amniotic fluid-derived MSCs (AF-MSCs), and placental MSCs) were grouped into the stem cell-rich group. Because of its regenerative and proliferative capabilities, MSC lies at the heart of regenerative cellular treatment for hair restoration. A literature review revealed that both adult and perinatal MSCs are successful as a mesotherapy for hair regrowth. However, there is a lack of standardization in terms of preparation, dose, and route of administration. To better understand the source and mode of action of regenerative cellular therapies in hair restoration, we have proposed the "À La Mode Classification". In addition, available evidence-based cellular treatments for hair regrowth have been thoroughly described.

A network pharmacology-based approach to explore mechanism of action of medicinal herbs for alopecia treatment

Hair loss is one of the most common skin problems experienced by more than half of the world's population. In East Asia, medicinal herbs have been used widely in clinical practice to treat hair loss. Recent studies, including systematic literature reviews, indicate that medicinal herbs may demonstrate potential effects for hair loss treatment. In a previous study, we identified medical herbs used frequently for alopecia treatment. Herein, we explored the potential novel therapeutic mechanisms of 20 vital medicinal herbs for alopecia treatment that could distinguish them from known mechanisms of conventional drugs using network pharmacology analysis methods. We determined the herb-ingredient–target protein networks and ingredient-associated protein (gene)-associated pathway networks and calculated the weighted degree centrality to define the strength of the connections. Data showed that 20 vital medicinal herbs could exert therapeutic effects on alopecia mainly mediated via regulation of various target genes and proteins, including acetylcholinesterase (AChE), phospholipase A2 (PLA2) subtypes, ecto-5-nucleotidase (NTE5), folate receptor (FR), nicotinamide N-methyltransferase (NNMT), and quinolinate phosphoribosyltransferase (QPRT). Findings regarding target genes/proteins and pathways of medicinal herbs associated with alopecia treatment offer insights for further research to better understand the pathogenesis and therapeutic mechanism of medicinal herbs for alopecia treatment with traditional herbal medicine.

Successful Therapy of Alopecia Universalis Using a Combination of Systemic Methotrexate and Corticosteroids and Topical 5% Minoxidil

Alopecia areata (AA) is an autoimmune disease-specific to specific organs mediated by T lymphocytes with hair follicles as targets. Severe AA could be in the form of alopecia universalis (AU). AU therapy is relatively difficult and challenging with varying outcomes. Herein, we reported a case of AU in a 19-year-old man with alopecia in the hairy scalp area, eyebrows, eyelashes, moustache, beard, and axillary hair since 2.5 years ago. The patient’s severity of alopecia tool (SALT) score was 100%. The patient was given a combination therapy of 15 mg methotrexate per week and 16 mg methylprednisolone per day orally and topical treatment with minoxidil 5%. Observations after nine months of treatment showed an improvement in the decrease in SALT scores to 41%. However, striae were found after 3rd month of therapy. Systemic combination therapy of methotrexate and low-dose corticosteroids and topical minoxidil 5% in this patient gave responsive results. Performed the hematological examination, liver function levels, blood glucose levels, and cortisol during long-term use of methotrexate and corticosteroids are necessary. The combination of systemic methotrexate and corticosteroids, and topical minoxidil showed promising results in AU. Nevertheless, long-term observation is still needed to monitor the side effects of therapy.

Efficacy and predictive factors of cyclosporine A in alopecia areata: a systematic review with meta-analysis

INTRODUCTION

Drugs for alopecia areata (AA) can induce hair regrowth, but do not change the disease course. Dual properties of cyclosporine A (CsA) as hypetrichotic and immunosuppressive agent have encouraged use in AA. We aimed to determine the most meaningful efficacy of CsA and reveal features helping enhance its efficacy and reduce relapses.

METHOD

Efficacy of CsA and predictive factors were investigated. Cochrane, MEDLINE, Pubmed and Embase databases were searched.

RESULTS

2,189 papers were retrieved. Based on 344 patients, mean proportion of responders was 73%. CsA monotherapy showed proportion of hair regrowth of 66%, whereas CsA combined with systemic corticosteroids yielded 78%. Overall efficacy in studies with duration of CsA treatment <6 months was: 74% (53-88%), while in those with duration ≥6 months was: 73% (47-89%). Recurrence with CsA monotherapy was 55% (6-96%) whereas when CsA was combined with systemic corticosteroids it was 28% (6-72%).

CONCLUSION

CsA confers a favorable therapeutic effect and concomitant use of steroids slightly enhances efficacy, but it dramatically decreases relapses. Longer treatments seem to lead to less relapse likelihood, but daily dose does not influence recurrence. Optimal CsA dosage is 5 mg/kg/day in single therapy regimen, whereas it is 3 mg/kg/day in the steroid-associated regimen. KEY POINTSWhat is already known about this subject? Most treatments for alopecia areata have not been critically evaluated. Current outcomes about the efficacy and relapse rate of cyclosporine A (CsA) are inconsistent and predictive factors about the clinical response are lacking.What this study adds? CsA confers a favorable therapeutic hair regrowth. Longer treatment seems to lead to less likelihood of relapse of AA, but the daily dose does not exert any effect on the recurrence of the disease. The concomitant use of corticosteroids broadly decreases relapses, and it also enhances efficacy.Impact on clinical practice The combination with corticosteroids is the most predictive feature to prevent relapse of AA, followed by the duration of CsA therapy. The daily dose of CsA is the feature with the least or null impact on the clinical course of AA.

Candida antigen immunotherapy versus steroid in the treatment of alopecia areata

Alopecia areata (AA) is an autoimmune hair follicle disorder that is challenging to treat. Although there are multiple topical immunotherapeutic agents, their side effects limit their use. Candida antigen can serve as another immunotherapeutic treatment, with an easier application and fewer side effects. To evaluate the efficacy of Candida antigen versus intralesional steroids for the treatment of AA. About 48 adult patients with AA were divided into two groups. The Candida group included 24 patients who were injected monthly with 0.1 mL of Candida albicans antigen in one patch of alopecia, and the intralesional corticosteroid group included 24 patients who were injected monthly with 0.1 mL of triamcinolone acetonide, as a control group, in all alopecia patches. After 5 months, there was a highly significant decrease in the severity of AA in both groups with no significant difference between them. In the Candida group, 8 patients showed complete hair regrowth and 9 patients showed partial regrowth. Side effects were mild and transient such as pain during injection, which was significantly lower in the Candida group than in the corticosteroid group. Intralesional Candida antigen is a promising effective treatment for AA with differing severities.

Emerging era of microneedle array for pharmaceutical and biomedical applications: recent advances and toxicological perspectives

Background

Microneedles (MNs) are the utmost unique, efficient, and minimally invasive inventions in the pharmaceutical field. Over the past decades, many scientists around the globe have reported MNs cautious because of their superb future in distinct areas. Concerning the wise use of MNs herein, we deal in depth with the present applications of MNs in drug delivery.

Main text

The present review comprises various fabrication materials and methods used for MN synthesis. The article also noted the distinctive advantages of these MNs, which holds huge potential for pharmaceutical and biomedical applications. The role of MNs in serving as a platform to treat various ailments has been explained accompanied by unusual approaches. The review also inculcates the pharmacokinetics of MNs, which includes permeation, absorption, and bioavailability enhancement. Besides this, the in vitro/in vivo toxicity, biosafety, and marketed product of MNs have been reviewed. We have also discussed the clinical trials and patents on the pharmaceutical applications of MNs in brief.

Conclusion

To sum up, this article gives insight into the MNs and provides a recent advancement in MNs, which pave the pathway for future pharmaceutical and biomedical applications.

Graphical abstract

Pharmaceutical and biomedical applications of MNs

Alopecia areata: a review on diagnosis, immunological etiopathogenesis and treatment options

Patients suffering from alopecia areata (AA) can lose hair in focal regions, the complete scalp, including eyelashes and eyebrows, or even the entire body. The exact pathology is not yet known, but the most described theory is a collapse of the immune privilege system, which can be found in some specific regions of the body. Different treatment options, local and systemic, are available, but none of them have been proven to be effective in the long term as well for every treatment there should be considered for the possible side effects. In many cases, treated or non-treated, relapse often occurs. The prognosis is uncertain and is negatively influenced by the subtypes alopecia totalis and alopecia universalis and characteristics such as associated nail lesions, hair loss for more than 10 years and a positive familial history. The unpredictable course of the disease also makes it a mental struggle and AA patients are more often associated with depression and anxiety compared to the healthy population. Research into immunology and genetics, more particularly in the field of dendritic cells (DC), is recommended for AA as there is evidence of the possible role of DC in the treatment of other autoimmune diseases such as multiple Sclerosis and cancer. Promising therapies for the future treatment of AA are JAK-STAT inhibitors and PRP.

Identification of novel step-up regimen of intralesional triamcinolone acetonide in scalp alopecia areata based on a double-blind randomized controlled trial

Although intralesional triamcinolone acetonide (TA) is the most commonly prescribed treatment for localized alopecia areata (AA), the literature regarding the optimal concentration for attaining better efficacy with the most acceptable side effects is scarce. To compare hair regrowth and local side effects of various concentrations of intralesional TA in scalp AA using clinical and dermoscopic parameters. A double-blind randomized control trial with four treatment groups (10, 5, 2.5 mg/ml TA and normal saline [NS]) was conducted between March 2018 and August 2019. After recruitment, each AA patch was divided into quadrants and randomized before first injection. Injections were given and outcome parameters were analyzed every 4-weekly till 12-weeks. Statistical analysis was done by the R software employing generalized estimation equation. P-value <.05 was considered significant. Out of 105-patients (168-AA patches), 75-patients (121-patches) completed the study. Hair regrowth scale of all TA concentrations was better than NS group (P < .001). Other parameters such as quadrants with poor clinical response and dermoscopic disease activity signs were also favorable in TA groups in comparison to NS. However the evidence of atrophy and telangiectasia was maximum in 10 mg/mL group. 10 mg/mL TA showed a comparatively better response at the cost of increased adverse effects. Based on the clinical benefit and adverse risk assessment from our study, it may be better to start with 2.5 mg/mL intralesional TA in limited scalp AA patients. It can be implied that the concentration of TA can be increased as a step-up regimen based on the serial clinical and dermoscopic response.

Therapeutic implications of psychological state in patients with alopecia areata: A qualitative study

Hair loss can significantly impact an individual's psychological state, self-image, and can lead to numerous personal, social, and occupational problems. Although these impairments are well documented in primary studies and reviews, and the need for appropriate psychological help is emphasized, there is still a lack of knowledge for a broader and specific picture. The patient's perspective is vital while seeking to understand the content of the variables like "impaired body image" or "low self-esteem." This article advocates the need for studies involving methodologies allowing to explore the complexity and depth of experience. A better understanding of patients' states, reactions, and needs might contribute to the practice of healthcare professionals seeking the best possible help. This study aimed to explore the lived experience of people with alopecia areata in Lithuania using a phenomenological approach. Experiences of six patients with varying degrees of alopecia areata, four women and two men (mean age 27 years), were explored. Data were obtained using an unstructured interview and were analyzed based on Colaizzi's phenomenological approach. This article explores findings related to patient's psychological state covering two superordinate themes: (a) devastating loss of perceived self and (b) grieving and the process of acceptance. The insights for the appropriate therapeutic intervention were formulated.

Trichoscopy as an evaluation method for alopecia areata treatment: A comparative study

BACKGROUND

Trichoscopy is a useful tool for diagnosis and follow-up of alopecia areata (AA) patients. Both platelet-rich plasma (PRP) and intralesional corticosteroids (ILCs) are important treatment modalities of patchy AA.

AIM

Trichoscopic diagnosis of AA and monitoring the treatment response to PRP versus ILCs in patchy AA treatment.

PATIENTS/METHODS

This comparative study included 31 patients with patchy AA, divided into two groups: (group A) received ILCs while (group B) received PRP once monthly for 3 months. Evaluation was done by Severity of Alopecia Tool (SALT) score, Alopecia Areata Symptom Impact Scale (AASIS), photography, and dermoscopy.

RESULTS

There was a significant improvement in trichoscopic findings in both groups with regard to the number of follicular units per opening, black dots, broken hairs, and dystrophic changes. Final SALT score showed significant lower levels in both groups compared to baseline levels (P = .025 & P = .008). Final AASIS showed significant decrease in group B (P = .006) not in group A (P = .062).

CONCLUSION

Trichoscopy can help in the diagnosis, evaluation of the efficacy and safety of both modalities and might give a clue for treatment response. Both ILCs and PRP were effective in patchy AA treatment.

Development and ex-vivo skin permeation studies of finasteride–poly(lactic acid-co-glycolic acid) and minoxidil–chitosan nanoparticulate systems

This study was designed to improve the permeability of two drugs (finasteride and minoxidil) through the skin. Finasteride-loaded poly(lactic acid- co-glycolic acid) and minoxidil-loaded chitosan nanoparticles were prepared by nanoprecipitation and ionic gelation method, respectively, and subsequently incorporated into semisolid Carbopol 940 gel. These fabricated nanoparticles were characterized for their pharmaceutical and chemical behavior. Nanoparticles were found a nearly spherical shape in the scanning electron microscopic studies and exhibited particle size in a range of 211–1012 nm. Finasteride- and minoxidil-loaded nanoparticles were optimized for relatively higher entrapment efficiency of 98% and 95%, respectively, by using the optimal concentration of polymers and stabilizers. All formulations were clear with smooth homogeneous texture and having pH values compatible with that of skin. This nanoparticulate system suspended in gel prolonged the release of drugs for up to 24 h and enhanced the drug permeability through the skin and retention of drug-loaded nanoparticles within the hair follicular routes. Therefore, these nanoparticles incorporated in the gel were found as a promising candidate for topical application in the treatment of alopecia by reducing the dosing frequency and adverse effects and as an effective strategy for improving the patient compliance toward therapy.

Protein tyrosine phosphatase nonreceptor type 22 gene polymorphism in alopecia areata: Does it have an association with disease severity?

BACKGROUND

Alopecia areata is a condition involving hair loss from certain or all areas of the body. It has been considered as an immune-mediated disease, characterized by the infiltration of CD4+ and CD8+ lymphocytes in the hair follicles.

AIM OF THE STUDY

The study aimed to assess whether protein tyrosine phosphatase nonreceptor type 22 gene single nucleotide polymorphism 1858C/T has any relationship with alopecia areata in Egyptian patients and whether it is associated with disease severity or not.

SUBJECTS AND METHODS

Protein tyrosine phosphatase nonreceptor type 22 (PTPN22) C1858T gene polymorphism was identified using polymerase chain reaction-restriction fragment length polymorphism analysis technique in 60 patients suffering from alopecia areata and 30 age- and sex-matched healthy controls. Disease severity was assessed using SALT score.

RESULTS

CT and TT genotypes were significantly higher in the patients' group (P = .005), OR = 4.38 95% CI [1.48-12.96], with significant statistical predominance of T allele in patients, P = .003, OR = 3.86, 95% CI [1.52-9.77]. There was also a positive significant relationship between protein tyrosine phosphatase nonreceptor type 22 genotype CT and SALT score.

CONCLUSION

PTPN22 1858T allele is associated with the development and severity of alopecia areata in Egyptians.

Childhood Alopecia Areata: An Overview of Treatment and Recent Patents

BACKGROUND

Alopecia Areata (AA) is a systemic autoimmune condition that usually starts in childhood.

OBJECTIVE

This article aims to review genetics, therapy, prognosis, and recent patents for AA.

METHODS

We used clinical queries and keywords "alopecia areata" AND "childhood" as a search engine. Patents were searched using the key term "alopecia areata" in Patents.google.com and freepatentsonline. com.

RESULTS

Due to an immune-mediated damage to the hair follicles, hair is lost from the scalp and other areas of the body temporarily or even permanently. Children with AA are generally healthy. Evidence of genetic association and increased predisposition for AA was found by studying families with affected members. Pathophysiologically, T- lymphocytes attack hair follicles and cause inflammation and destruction of the hair follicles and hair loss. In mild cases, there would be well-demarcated round patchy scalp hair loss. The pathognomonic "exclamation mark hairs" may be seen at the lesion periphery. In more severe cases, the hair loss may affect the whole scalp and even the whole body. The clinical course is also variable, which may range from transient episodes of recurrent patchy hair loss to an indolent gradually deteriorating severe hair loss. The treatment of AA depends on factors including patients' age, the extent of the hair loss, duration of disease, psychological impact, availability and side effect profile of the treatments. For localized patchy alopecia, topical application of corticosteroids and/or intralesional corticosteroids are the treatment of choice. Other topical treatments include minoxidil, anthralin, coal tar and immunotherapy. In severe resistant cases, systemic immunosuppressants may be considered. Although herbal medicine, acupuncture, complementary and alternative medicine may be tried on children in some Asian communities, the evidence to support these practices is lacking. To date, only a few recent patents exist in topical treatments, including Il-31, laser and herbal medications. Clinical efficacy is pending for these treatment modalities.

CONCLUSION

None of the established therapeutic options are curative. However, newer treatment modalities, including excimer laser, interleukin-31 antibodies and biologics, are evolving so that there may be significant advances in treatment in the near future. AA can be psychosocially devastating. It is important to assess the quality of life, degree of anxiety, social phobia and mood of the patients and their families. Psychological support is imperative for those who are adversely affected psychosocially.

Evaluation of platelet-rich plasma vs intralesional steroid in treatment of alopecia areata

BACKGROUND

Alopecia areata (AA) is nonscarring patchy area of hair loss. Platelets rich plasma (PRP) promotes development of new hair follicles. Dermoscopy is a diagnostic tool that helps in evaluation of skin microstructures which are not visible to naked eye.

AIM

To evaluate safety and efficacy of (PRP) vs intralesional corticosteroid (ILCs) in treatment of AA.

PATIENTS AND METHODS

This study was conducted on 80 patients of both sexes who had AA. Patients were classified into Group I treated by ILCs and group II treated by (PRP). Results were assessed by dermoscopic evaluation and by hair re-growth score (RGS) at (baseline), 2, 4, 6, 8, and 12 weeks. Patients were followed up for 6 months.

RESULTS

There was greater hair re-growth after treatment in both groups. In group I, (26) patients (65%) showed improvement >70% compared to 29 patients (72.5%) in group II. There was significant re-growth of pigmented hair and decrease in dystrophic hair (P < 0.001) by dermoscopic evaluation in both groups. The difference between both groups was insignificant (P = 0.57). At follow-up, two (5%) patients in group II had relapse compared to 10 (25%) patients in group I.

CONCLUSION

Platelets rich plasma is safe and promising therapeutic option in AA.

Efficacy and Safety of Methotrexate in Combination with Mini Pulse Doses of Methylprednisolone in Severe Alopecia Areata. The Vietnamese Experience

BACKGROUND

Treatment of severe alopecia areata remains very difficult, especially in alopecia areata totalis and alopecia areata universalis. Methotrexate is known to be effective in the treatment of severe and chronic autoimmune disorders.

OBJECTIVE

To assess the effectiveness and safety of MTX in combination with mini pulse dose of methylprednisolone in the treatment of severe alopecia areata.

PATIENTS AND METHODS

The open, uncontrolled study compared pre-treatment and after-treatment. Thirty-eight patients (age 16-64) with severity AA (SALT score > 50 %) visiting National hospital of Dermatology and Venereology from April-2004 to September-2015 were enrolled. All patients received oral methylprednisolone 24mg/day for 3 consecutive days of a week in combination with oral MTX 7,5 mg weekly. This regimen is maintained up to 12 weeks and follow-up until to 6 months.

RESULTS

After 6 months, 60.5% of patients show complete hair growth (good response) and 18.4% shows the medium response. There is a significant SALT score reduction: mean baseline SALT score 84.39 ± 17.03 compared to mean post-treatment SALT score 24.19 ± 29.42. Good clinical improvement noted in after 3 months. We do not observe any side- effects related to oral MTX and oral methylprednisolone, and no patients had to withdrawal treatment due to side- effects.

CONCLUSION

Combination Methotrexate and mini pulse dose of methylprednisolone are effective and safe in treatment severity alopecia areata.

Janus Kinase Inhibitors for the Treatment of Severe Alopecia Areata: An Open-Label Comparative Study

<b><i>Background:</i></b> Alopecia areata (AA) is a common autoimmune disorder characterized by patchy hair loss. There are many treatments available for AA. However, treatments of severe forms of AA are not satisfactory. Recently, oral Janus kinase (JAK) inhibitors were found to be effective for the treatment of severe AA variants. <b><i>Objective:</i></b> The aim of this work was to evaluate and compare the efficacy, side effects, and durability of two oral JAK inhibitor medications (ruxolitinib and tofacitinib) in the treatment of severe AA. <b><i>Methods:</i></b> This study included 75 patients with AA with more than 30% scalp hair loss, alopecia totalis, and alopecia universalis randomized into 2 groups. The first group (<i>n</i> = 38) received ruxolitinib 20 mg twice daily, and the second group (<i>n</i> = 37) received oral tofacitinib 5 mg twice daily. The treatment continued for 6 months followed by 3 months of follow-up off therapy. Efficacy of treatment was assessed by monitoring the change in the Severity of Alopecia Tool (SALT) score. <b><i>Results:</i></b> Both tofacitinib and ruxolitinib induced remarkable hair regrowth, with a mean change in SALT score of 93.8 ± 3.25 in the ruxolitinib group and 95.2 ± 2.69 in the tofacitinib group. However, the ruxolitinib group showed a shorter duration for initial hair regrowth. There was no statistically significant difference between the groups regarding hair regrowth at the end of the 6-month treatment and relapse rate at the end of the 3-month follow-up. Around two thirds of cases experienced relapse. Both drugs were well tolerated, with no reported serious adverse effects. <b><i>Conclusion:</i></b> Both ruxolitinib and tofacitinib could be considered effective and well-tolerated treatments for extensive AA.

In vivo evaluation of insect wax for hair growth potential

Insect wax is secreted by Ericerus pela Chavanness. It has been traditionally used to treat hair loss in China, but few reports have been published on the hair growth-promoting effect of insect wax. In this work, we examined the hair growth-promoting effects of insect wax on model animals. Different concentrations of insect wax were topically applied to the denuded backs of mice, and 5% minoxidil was applied topically as a positive control. We found that insect wax significantly promoted hair growth in a dose-dependent manner, 45% and 30% insect wax both induced hair to regrow, while less visible hair growth was observed in blank controls on the 16^th day. The experimental areas treated with 45% and 30% insect wax exhibited significant differences in hair scores compared to blank controls, and hair lengths in the 45% and 30% insect wax group was significantly longer than in blank controls on the 16^th and 20^th days. There were no new hair follicles forming in the treated areas, and the hair follicles were prematurely converted to the anagen phase from the telogen phase in experimental areas treated with 45% and 30% insect wax. Both 45% and 30% insect wax upregulated vascular endothelial growth factor expression. The results indicated that 45% and 30% insect wax showed hair growth-promoting potential approximately as potent as 5% minoxidil by inducing the premature conversion of telogen-to-anagen and by prolonging the mature anagen phase rather than increasing the number of hair follicles, which was likely related to the upregulation of VEGF expression. The dissociative policosanol in insect wax was considered the key ingredient most likely responsible for the hair growth promoting potential.

Efficacy of fractional lasers in treating alopecia: a literature review

Hair loss stemming from different types of alopecia, such as androgenic alopecia and alopecia areata, negatively affects over half the population and, in many circumstances, causes serious psychosocial distress. Current treatment options for alopecia, such as minoxidil, anthralin, and intralesional corticosteroids, vary efficacy and side effect profiles. It is known that low-level laser/light therapies (LLLT), or photobiomodulations, such as the US FDA-cleared HairMax Lasercomb®, He-Ne laser, and excimer laser, are relatively affordable, user-friendly, safe, and effective forms of treatment for hair loss. While less is known about the effectiveness of fractional lasers for combating hair loss, research suggests that by creating microscopic thermal injury zones, fractional lasers may cause an increase in hair growth from a wound healing process, making them potential therapeutic options for alopecia. A literature review was performed to evaluate the effectiveness of fractional lasers on hair regrowth. The specific fractional laser therapies include the 1550-nm nonablative fractional erbium-glass laser, the ablative fractional 2940-nm erbium:YAG laser, and the ablative fractional CO₂ fractional laser. Additional randomized controlled trials are necessary to further evaluate the effectiveness of the lasers, as well as to establish appropriate parameters and treatment intervals.

Treating Alopecia Areata: Current Practices Versus New Directions

Alopecia areata (AA) is non-scarring hair loss resulting from an autoimmune disorder. Severity varies from patchy hair loss that often spontaneously resolves to severe and chronic cases that can progress to total loss of scalp and body hair. Many treatments are available; however, the efficacy of these treatments has not been confirmed, especially in severe cases, and relapse rates are high. First-line treatment often includes corticosteroids such as intralesional or topical steroids for mild cases and systemic steroids or topical immunotherapy with diphenylcyclopropenone or squaric acid dibutylester in severe cases. Minoxidil and bimatoprost may also be recommended, usually in combination with another treatment. Ongoing research and new insights into mechanisms have led to proposals of innovative therapies. New directions include biologics targeting immune response as well as lasers and autologous platelet-rich plasma therapy. Preliminary data are encouraging, and it is hoped this research will translate into new options for the treatment of AA in the near future.

Utilization of Mental Health Resources and Complementary and Alternative Therapies for Alopecia Areata: A U.S. Survey

Background

The efficacy of traditional medical treatments for alopecia areata (AA) is limited, leading some to pursue alternative treatments. The utilization and nature of these treatments are unclear.

Objective

To assess the extent to which patients with AA pursue alternative treatments and to characterize these treatments.

Methods

A 13-item electronic survey was E-mailed by the National Alopecia Areata Foundation (NAAF) to their patient database and shared on the NAAF social media to individuals with AA.

Results

Of 1083 respondents, 78.1% of patients were very or somewhat unsatisfied, compared to 7.7% who were very or somewhat satisfied with the current medical treatments for AA. Approximately a third of patients pursued therapy-related mental health services (31.2%) and attended support groups (29.0%). Patients were more likely to pursue a mental health-related therapy if they had long-standing alopecia, or if they were young, female, or white.

Limitations

This was a convenience sample of patients recruited online and via the NAAF AA registry.

Conclusion

Many patients with AA are dissatisfied with current treatments and are seeking mental health treatment for AA. While the efficacy of alternative therapies is unknown, further research is needed to determine their role in the treatment of AA.

Angiotensin converting enzyme activity in alopecia areata

Background. Alopecia areata (AA) is a chronic inflammatory disease of the hair follicle. The exact pathogenesis of AA remains unknown, although recent studies support a T-cell mediated autoimmune process. On the other hand, some studies have proposed that the renin-angiotensin-aldosterone system (RAAS) may play a role in autoimmunity. Therefore, we assessed serum activity of angiotensin converting enzyme (ACE), a component of this system, in AA. Methods. ACE activity was measured in the sera of 19 patients with AA and 16 healthy control subjects. In addition, the relationship between severity and duration of the disease and ACE activity was evaluated. Results. Serum ACE activity was higher in the patient group (55.81 U/L) compared to the control group (46.41 U/L), but the difference was not statistically significant (P = 0.085). Also, there was no correlation between ACE activity and severity (P = 0.13) and duration of disease (P = 0.25) in the patient group. Conclusion. The increased serum ACE activity found in this study may demonstrate local involvement of the RAAS in the pathogenesis of AA. Assessment of ACE in a study with a larger sample size as well as in tissue samples is recommended in order to further evaluate the possible role of RAAS in AA.

New aspects of the treatment of alopecia areata

Alopecia areata (AA) is a disease involving non-scarring hair loss determined by autoimmune disorders and inflammation. The disease affects hair on the scalp and/or other parts of the body. The AA occurs in people of all ages and affects 1–2% of humans. The purpose of this paper is to present the latest knowledge on the treatment of AA. The decision on the type of treatment depends on the type of hair loss, extent of changes, general health status, the patient's age, and his/her motivation. Treatment methods should be chosen individually for each patient.

Treatment options for alopecia: an update, looking to the future

INTRODUCTION

Hair loss is a very common complaint. The diagnosis is based on clinical, dermoscopic and pathological examination. The treatment is usually continuous and requires strong compliance.

AREAS COVERED

This article aims to i) summarize current treatment options for the most common forms of hair loss; ii) update the literature on treatment options to emerge over the 3 years since the release of the first edition of this article in 2009; and iii) outline future strategies for treating alopecia.

EXPERT OPINION

There is good evidence-based information for the treatment of androgenetic alopecia. There are very few good-quality randomized studies, and no information about long-term results for most of the available treatments for alopecia areata and cicatricial alopecias. Significant research success has been achieved over the past few years through i) discovering the genetic profile of alopecia areata; ii) working on follicular neogenesis in androgenetic alopecia; and iii) discovering the PPAR-γ pathway in scarring alopecia.