Drug-induced hair loss and hair growth. Incidence, management and avoidance

Therapeutic drug monitoring of corticosteroids/β2-agonists in the hair of patients with asthma: an open-label feasibility study

Background: Although adherence to inhaled medication is critically important for treatment efficiency, around half of patients taking these drugs are non-adherent or make critical errors when using their delivery device. Segmental hair analysis might be a valuable tool for therapeutic monitoring because hair concentrations reflect exposure from month to month. The objective of the present proof-of-concept study was to establish the feasibility of segmental hair analysis of inhaled budesonide and formoterol in asthma patients. Methods: We conducted a prospective, open-label, interventional study of adult patients being treated with budesonide/formoterol for controlled, moderate-to-severe asthma (CorticHair, NCT03691961). Asthma control, lung function, and medication adherence were recorded. Hair samples were taken 4 months after enrolment and cut into four 1 cm segments. Results: Samples were available from 21 patients (20 women; median age: 53; median budesonide dose: 600 μg/d). Budesonide and formoterol were detected in samples from 18 to 13 patients, respectively. The median hair concentrations were 6.25 pg/mg for budesonide and 0.9 pg/mg for formoterol. The intrapatient coefficient of variation between hair segments was 21% for budesonide and 40% for formoterol. Pearson's coefficients for the correlations between the hair concentration and the self-reported drug dose and the prescribed drug dose were respectively 0.42 (p = 0.08) and 0.29 (p = 0.25) for budesonide and 0.24 (p = 0.44) and 0.17 (p = 0.57) for formoterol. Conclusion: Segmental hair analysis of inhaled medications was feasible, with low intrapatient variability. This innovative, non-invasive means of assessing monthly drug exposure might help physicians to personalize drug regimens for patients with difficult-to-treat asthma.

Modulation of hair growth by topical drug delivery enhanced by STAR particles

Topical treatments to modulate hair growth are generally limited by low drug bioavailability due to poor skin permeability. Here, we studied the use of STAR particles, which are millimeter-sized ceramic particles with protruding microneedles, to form micropores in the skin to increase skin permeability to hair growth-modulating drugs. STAR particle design and fabrication were optimized, and the resulting STAR particles were shown to reduce lag time and increase skin permeability to minoxidil and acyclovir by more than three-fold compared to no treatment in pig skin ex vivo. In rats, STAR particles also improved topical delivery of minoxidil and acyclovir, which resulted in an increase or a decrease in the number, length and/or thickness of hairs and/or the number of anagen-phase hair follicles after minoxidil or acyclovir treatment, respectively. Clinical exam and histological evaluation showed no evidence of skin irritation or other adverse effects of the treatments. We conclude that STAR particles can increase topical delivery of minoxidil and acyclovir to improve modulation of hair growth promotion and inhibition, respectively.

Medication-induced hair loss: An update

This article discusses drug-induced hair loss, which can occur with many drugs including cytotoxic agents, biologics, and immunomodulating agents, among others. It outlines the diagnosis and management of drug-induced alopecia, with a focus on recently implicated drugs.

Antiseizure Medication-Induced Alopecia: A Literature Review

Background: Adverse effects of antiseizure medications (ASMs) remain one of the major causes of non-adherence. Cosmetic side effects (CSEs) are among the most commonly reported side effects of ASMs. In this context, alopecia is one of the CSEs that has a high intolerance rate leading to poor therapeutical compliance. Methods: We performed a literature review concerning alopecia as a secondary effect of ASMs. Results: There are 1656 individuals reported with ASM-induced alopecia. Valproate (983), lamotrigine (355), and carbamazepine (225) have been extensively reported. Other ASMs associated with alopecia were cenobamate (18), levetiracetam (14), topiramate (13), lacosamide (7), vigabatrin (6), phenobarbital (5), gabapentin (5), phenytoin (4), pregabalin (4), eslicarbazepine (3), brivaracetam (2), clobazam (2), perampanel (2), trimethadione (2), rufinamide (2), zonisamide (2), primidone (1), and tiagabine (1). There were no reports of oxcarbazepine and felbamate with drug-induced alopecia. Hair loss seen with ASMs was diffuse and non-scarring. Telogen effluvium was the most common cause of alopecia. A characteristic feature was the reversibility of alopecia after ASM dose adjustment. Conclusions: Alopecia should be considered one important adverse effect of ASMs. Patients reporting hair loss with ASM therapy should be further investigated, and specialist consultation is recommended.

Commonly prescribed medications associated with alopecia

BACKGROUND

The diagnosis and treatment of medication-associated alopecia often challenges patients and physicians. While numerous studies on the topic exist, limited information on the strength and magnitude of these studies exists.

OBJECTIVES

We investigated the most commonly prescribed medications with high levels of evidence to support associations with alopecia.

METHODS

A list of most commonly prescribed medications was compiled using the "Top 100 Prescriptions, Sales" (Intercontinental Marketing Services) and "Top 200 Names Searched" (RxList.com). PubMed, Embase, and Web of Science were searched for "generic drug name" AND "alopecia" and "generic drug name" AND "hair loss." Two reviewers independently reviewed articles for drug, study type and level of evidence, and number of alopecia cases.

RESULTS

A total of 192 unique drugs were investigated, with 110 yielding positive search results. Of these, 13 were associated with alopecia in studies with strong levels of evidence (adalimumab, infliximab, budesonide, interferon β-1α, tacrolimus, enoxaparin, zoster vaccine, lamotrigine, docetaxel, capecitabine, erlotinib, imatinib, and bortezomib).

LIMITATIONS

Only full-length articles available in the English language were included. The methodology used relied on lists of drugs based on their sales rather than number of prescriptions, which likely overrepresented expensive drugs.

CONCLUSIONS

Few studies with high levels of evidence have been conducted on the topic of medication-associated alopecia. The mechanisms of hair loss must be further identified to provide effective management.

Hair Aging and Hair Disorders in Elderly Patients

Hair loss in elderly patients is a common complaint. It can be related to different conditions that affect patients' quality of life and represents a challenge for dermatologists. It affects both men and women during the aging process with an estimated percentage of balding after 65 years of age of 53% and 37%, respectively. Androgenetic alopecia, frontal fibrosing alopecia, senile alopecia, and erosive pustular dermatosis of the scalp are the hair diseases most frequently described in this age group. The objective of this review is to summarize the current knowledge about alopecia affecting elderly patients, differentiating between chronological hair aging signs and pathological changes, to help clinicians, offer an adequate management of these disorders to their patients.

Valproate-associated hair abnormalities: Pathophysiology and management strategies

OBJECTIVE

To review the literature on valproate-associated hair abnormalities and the available treatment options.

METHODS

We searched PubMed and Google Scholar with keywords including "valproate", "valproic acid", "hair", "alopecia", and "effluvium," supplemented with hand search from cross-references. We included all types of studies including case reports in this review.

RESULTS

The pathophysiology of hair loss includes telogen effluvium, biotin, mineral deficiency, and possibly hyperandrogenism. Diagnosis is based on history of hair loss or abnormalities following valproate treatment, and is confirmed by use of simple clinical tests such as pull test and modified wash test. Treatment involves reassurance and advice on hair care, and if possible drug discontinuation or dose reduction. Medications such as biotin and other vitamins with minerals supplementation is effective for most individuals with hair loss. Other treatment options are agomelatine, topical valproate or minoxidil, though these lack evidence.

CONCLUSION

Hair abnormalities with valproate are common, benign adverse effects, and management includes general measures and specific treatment options.

Morus alba Root Extract Induces the Anagen Phase in the Human Hair Follicle Dermal Papilla Cells

Restoring hair follicles by inducing the anagen phase is a promising approach to prevent hair loss. Hair follicle dermal papilla cells (HFDPCs) play a major role in hair growth via the telogen-to-anagen transition. The therapeutic effect of Morus alba activates β-catenin in HFDPCs, thereby inducing the anagen phase. The HFDPCs were treated with M. alba root extract (MARE) to promote hair growth. It contains chlorogenic acid and umbelliferone and is not cytotoxic to HFDPCs at a concentration of 20%. It was demonstrated that a small amount of MARE enhances growth factor secretion (related to the telogen-to-anagen transition). Activation of β-catenin was observed in MARE-treated HFDPCs, which is crucial for inducing the anagen phase. The effect of conditioned medium derived from MARE-treated HFDPCs on keratinocytes and endothelial cells was also investigated. The findings of this study demonstrate the potency of MARE in eliciting the telogen-to-anagen transition.

Spray-Dried Rosuvastatin Nanoparticles for Promoting Hair Growth

In this research, we examined the effect of rosuvastatin calcium-loaded nanoparticles on the hair growth-promoting activity on Albino rats. Nanoparticles were prepared using 2:1 weight ratio of drug to methyl-β-cyclodextrin with 10, 20, and 30% stabilizers (phospholipid, polyvinyl pyrrolidone K30, and Compritol 888 ATO) using nanospray dryer. Subsequently, the prepared nanoparticles were evaluated for their process yield, particle size, polydispersity index, zeta potential, and in vitro drug release as well as in vivo studies. The dried nanoparticles showed process yield values up to 84% with particle size values ranging from 218 to 6258 nm, polydispersity index values ranging from 0.32 to 0.99, and zeta potential values ranging from - 6.1 to - 11.9 mV. Combination of methyl-β-cyclodextrin with 10% polyvinyl pyrrolidone K30 accomplished nanoparticles with the lowest particle size (218 nm) and polydispersity index (0.32) values. These nanoparticles had suitable process yield value (70.5%) and were able to retard drug release. The hair growth-promoting activity for the selected nanoparticles revealed the highest hair length values in Albino rats after 14 days of the hair growth study compared with non-medicated nanoparticles, nanoparticles' physical mixture, rosuvastatin solution, and marketed minoxidil preparation groups as well as the control group. The immunohistochemistry images for both selected nanoparticles and marketed minoxidil groups showed a significant increase in the diameter of hair follicle and percent area fraction of cytokeratin 19 in the outer root sheath of hair follicle compared with other tested groups. Rosuvastatin nanoparticles prepared by nanospray drying technique could be a good competitor to minoxidil for hair growth-promoting activity. Graphical abstract.

Drug reactions affecting hair and nails

Drug-induced changes of hair and nails have been observed with a variety of different pharmaceutical agents, both topical and systemic. These compounds or their metabolites may interfere with hair cycling and texture, nail matrix, nail bed, nail folds, and microvasculature. Phototoxic reactions may also occur. Before initiating treatment, physicians and patients should be aware of possible adverse events to hair and nails and should be aware of the preventive measures, if available, as quality of life can be reduced, and adherence and compliance to treatment may be impaired.

Rat 90-day oral toxicity study of a novel coccidiostat - Ethanamizuril

In the current study, to support the safety assessment of ethanamizuril as a new potent anticoccidial agent of triazine compounds, a 90-day repeated-dose oral toxicity assay of ethanamizuril was investigated. Treatment related clinical signs of alopecia on back and neck have been observed in some male and female at the 65 and 130 mg/kg dose groups. The body weight and feed conversion efficacy of 65 and 130 mg/kg females and 65 mg/kg males were significantly increase than those of the control in treatment time, but noted decreased in the 130 mg/kg males. Dose related changes of hematologic and biochemical parameters such as MCV, MCH, TG, and the significant increased in the organ weight and the relative organ weight of the liver, kidney, heart, lung and spleen in both genders in the 65 and 130 mg/kg treated groups were observed. Furthermore, histopathological observations revealed that 65 and 130 mg/kg ethanamizuril induced pathological damage such as hepatocyte steatosis and focal necrosis, renal tubular atrophy, tubule protein casts. Fortunately, the observed toxicities were recoverable in convalescence. The results indicated that liver, kidneys and lung were the main target organs. The NOAEL of ethanamizuril for rats was estimated to be 20 mg/kg dietary dose level.

Acute and 30-day oral toxicity studies of a novel coccidiostat - ethanamizuril

Ethanamizuril is a novel triazine compound that exhibits remarkable anticoccidial activity. Owing to its pharmacological properties, this study was conducted to evaluate the acute and 30-day oral toxicity of ethanamizuril. In the acute study, ethanamizuril was administered once by oral gavage to mice and rats. The calculated LD50 values for mice and rats were 5776 and 4743 mg per kg b.w, respectively, but the LD50 value for male rats was higher than that of female rats. In the subchronic study, male and female rats were fed with diets supplemented with 0, 20, 60 or 120 mg kg-1 ethanamizuril for 30 days. Treatment related clinical signs of alopecia on the back and neck of the animals were observed in the 60 and 120 mg kg-1 dose groups from the third week of treatment. Significant differences in haematological and biochemical parameters as well as organ-to-body weight ratios were detected between the 60 and 120 mg kg-1 groups. Histopathological observations revealed that 60 and 120 mg kg-1 ethanamizuril could induce focal hepatocellular necrosis and split phase. Slight renal tubule protein casts in the kidneys and alveolar wall thickening in the lungs were also observed in the high dose groups of both genders. The dietary no-observed-adverse-effect level (NOAEL) of ethanamizuril for 30 days was 20 mg kg-1 feed.

TREATMENT OF CUSHING'S SYNDROME : WHAT PLACE FOR MEDICAL TREATMENT?

Surgery plays a major role as a first-line treatment of the different etiologies of Cushing's syndrome (CS) and bilateral adrenalectomy (BA) is extremely effective as a second line, so that there seems to be little room for medical treatment (MT). However, during the past years several drugs acting either on ACTH secretion or cortisol synthesis have been developed, so that MT of CS might be reassessed. After briefly analyzing the efficiency and tolerance of surgical and medical treatments of CS we try to distinguish consensual and controversial indications for MT. We believe the former include "pre-operative treatment" in rare patients in whom the severity of CS is likely to increase the risks of surgery; "inoperability" for rare patients who cannot be operated even when CS is controlled and "surgical failure or recurrence", mainly in patients Cushing's disease (CD) not in remission after TSS. Controversial indications include "unavailability of an expert surgeon", which we believe does not make sense when the cost of MT is taken into consideration. Finally in patients with the "surgical failure or recurrence" indication the balance between efficacy and side effects of MT should be balanced with the efficacy and side effects of BA.

Incidence and risk factors for alopecia in survivors of critical illness: A multi-centre observational study

PURPOSE

To investigate the incidence, nature and risk factors for patient-reported alopecia in survivors of critical illness.

MATERIALS AND METHODS

A multi-centre, mixed methods observational study in the intensive care units (ICU) of ten hospitals in Wales. All patients with an ICU stay of 5 days or more, able to give consent were included. Demographic variables and risk factors were collected. A pre-designed survey was completed at three months post-ICU discharge. Statistical analysis included numbers and percentages (categorical variables) and medians and interquartile ranges (continuous variables). Comparisons between patients with and without alopecia were made using Fisher's Exact test (categorical variables) and Mann Whitney U test (continuous variables). Multivariate logistic regression analysis was used to determine the risk factors for alopecia.

RESULTS

The survey was completed by 123 patients with alopecia reported in 44 (36%) patients. The only risk factor for alopecia on analysis was sepsis / septic shock (p < .001; OR: 5.1, 95%CI: 2.1-12.4).

CONCLUSIONS

Limited research exists examining the incidence, nature and risk factors for patient-reported alopecia in adult survivors of critical illness. The results of this study highlight the need to discuss the potential for alopecia with survivors of critical illness, who had sepsis / septic shock.

A bald statement - Current approaches to manipulate miniaturisation focus only on promoting hair growth

Hair plays a large part in communication and society with its role changing through time and across cultures. Most people do not leave the house before combing their hair or shaving their beard and for many hair loss or irregular hair growth can have a significant impact on their psychological health. Somewhat unsurprisingly, according to GMR Data, today's global hair care industry is worth an estimated $87 Billion, with hair loss estimated at $2.8 Billion. Considering that no current hair loss-related products can completely reverse hair loss, it is reasonable to believe this market could expand significantly with the discovery of a comprehensive therapy. As such, a great deal of research focuses on overcoming hair loss, and in particular, a common form of hair loss known as androgenetic alopecia (AGA) or male pattern baldness. In AGA, hair follicles miniaturise in a large step change from a terminal to a vellus state. Within this viewpoint article, we discuss how influx and efflux of cells into and out from the dermal papilla (DP) can modulate DP size during the hair cycle. As DP size is positively correlated with the size of the hair fibre produced by a follicle, we argue here that therapies for treating AGA should be developed which can alter DP size, rather than just promote hair growth. We also discuss current therapeutics for AGA and emphasise the importance of using the right model systems to analyse miniaturisation.

Hair disorders in patients with cancer

Cytotoxic chemotherapies, molecularly targeted therapies, immunotherapies, radiotherapy, stem cell transplants, and endocrine therapies may lead to hair disorders, including alopecia, hirsutism, hypertrichosis, and pigmentary and textural hair changes. The mechanisms underlying these changes are varied and remain incompletely understood, hampering the development of preventive or therapeutic guidelines. The psychosocial impact of chemotherapy-induced alopecia has been well documented primarily in the oncology literature; however, the effect of other alterations, such as radiation-induced alopecia, hirsutism, and changes in hair color or texture on quality of life have not been described. This article reviews clinically significant therapy-related hair disorders in oncology patients, including the underlying pathophysiological mechanisms, severity grading scales, patient-reported quality of life questionnaires, management strategies, and future translational research opportunities.

A Practical Approach to the Diagnosis and Management of Hair Loss in Children and Adolescents

Hair loss or alopecia is a common and distressing clinical complaint in the primary care setting and can arise from heterogeneous etiologies. In the pediatric population, hair loss often presents with patterns that are different from that of their adult counterparts. Given the psychosocial complications that may arise from pediatric alopecia, prompt diagnosis and management is particularly important. Common causes of alopecia in children and adolescents include alopecia areata, tinea capitis, androgenetic alopecia, traction alopecia, trichotillomania, hair cycle disturbances, and congenital alopecia conditions. Diagnostic tools for hair loss in children include a detailed history, physical examination with a focused evaluation of the child’s hair and scalp, fungal screens, hair pull and tug test, and if possible, light microscopy and/or trichoscopy. Management of alopecia requires a holistic approach including psychosocial support because treatments are only available for some hair loss conditions, and even the available treatments are not always effective. This review outlines the clinical presentations, presents a diagnostic algorithm, and discusses management of these various hair loss disorders.

Systemic causes of hair loss

Hair loss is both a common chief complaint by patients and a clinical challenge for physicians, especially general practitioners, yet few dermatological problems yield as much patient satisfaction when resolved as hair loss. The diagnosis is often attributed to androgen-related hair loss, while other causes, some of which are life-threatening but treatable, are overlooked. We searched for relevant literature on hair loss and supported these findings with our clinical experience to identify seven major systemic etiologies of hair loss, ranging from infectious agents to consumption of unsafe supplements. Many causes are only described in the literature through case studies, though some original articles and meta-analyses are available. Careful history taking, proper examination techniques, and judicious use of laboratory tests are essential to reach at the correct diagnosis in a cost-effective manner when performing patient work-up. Such methodical evaluation of hair loss can result in the appropriate treatment plan and provide significant patient satisfaction. Key messages Hair loss is a common chief complaint and a difficult challenge for both general practitioners and dermatology consultants. We identified seven major categories of systemic hair loss etiology and present a framework for their clinical evaluation. A methodical approach to hair loss can result in the appropriate treatment plan and provide significant patient satisfaction.

5-Bromo-2'-deoxyuridine induced effluvium via p53-mediated CD326-positive keratinocyte apoptosis in C57BL/6 mice

Anagen effluvium develops because of disturbances in the hair follicle cycle, leading to acute and severe hair loss in humans. The objective of this study was to establish a mouse model of anagen effluvium by 5-bromo-2'-deoxyuridine (BrdU) treatment, and evaluate the pathological changes and underlying mechanisms. We treated 9-10-day-old pups and 3-7-week-old C57BL/6 mice with BrdU. After successfully inducing hair loss in the neonatal pups, microscopic, immunohistochemical and flow cytometry analyses were conducted. BrdU induced early onset alopecia in neonates and caused epidermal thickening and hair shaft breakage. BrdU appeared to incorporate the CD326-positive keratinocyte layer and induced p53-related apoptosis. Keratinocyte apoptosis caused immune cell infiltration in the dermal region; M2 macrophages and neutrophils were dominant. The BrdU-induced hair loss was dose-dependent, and alopecia was visible at a dose range of 25-200 μg/g bodyweight. The BrdU-induced anagen effluvium mouse model is novel and easily established by administrating four simple BrdU injections to pups; these mice showed synchronized onset of alopecia symptoms with little individual variation. Moreover, this model showed an alopecia phenotype similar to that of human anagen effluvium with acute, severe and widespread hair loss.

Psychiatric shades of grey: mirtazapine-induced hair discoloration and hair loss

Introduction

Mirtazapine is indicated in the treatment of major depressive disorder particularly in selective serotonin re-uptake inhibitors resistance. Its effect on hair loss is rare with no previous documented effect on hair colour.

Method

Review of relevant literature and description of a case report of a 54-year-old male patient who developed alopecia and hair discoloration after initiation of mirtazapine treatment.

Results

Upon cessation of mirtazapine treatment full restoration of hair colour and regrowth of hair was attained within 10 weeks.

Discussion

There was clear temporal relationship between experiencing hair loss and commencing mirtazapine treatment. No other more likely medical reason to explain such experience was established. A noticeable restoration of the hair colour occurred following mirtazapine cessation.

Conclusion

Mirtazapine is associated with hair discoloration and hair loss. The possibility of such distressing adverse effects needs to be conveyed to patients by clinicians and to be further explored by researchers.

Analysis of dermal papilla cell interactome using STRING database to profile the ex vivo hair growth inhibition effect of a vinca alkaloid drug, colchicine

Dermal papillae (DPs) control the formation of hair shafts. In clinical settings, colchicine (CLC) induces patients' hair shedding. Compared to the control, the ex vivo hair fiber elongation of organ cultured vibrissa hair follicles (HFs) declined significantly after seven days of CLC treatment. The cultured DP cells (DPCs) were used as the experimental model to study the influence of CLC on the protein dynamics of DPs. CLC could alter the morphology and down-regulate the expression of alkaline phosphatase (ALP), the marker of DPC activity, and induce IκBα phosphorylation of DPCs. The proteomic results showed that CLC modulated the expression patterns (fold>2) of 24 identified proteins, seven down-regulated and 17 up-regulated. Most of these proteins were presumably associated with protein turnover, metabolism, structure and signal transduction. Protein-protein interactions (PPI) among these proteins, established by Search Tool for the Retrieval of Interacting Genes/Proteins (STRING) database, revealed that they participate in protein metabolic process, translation, and energy production. Furthermore, ubiquitin C (UbC) was predicted to be the controlling hub, suggesting the involvement of ubiquitin-proteasome system in modulating the pathogenic effect of CLC on DPC.

Hirsutism following the use of bimatoprost eyedrops for glaucoma

Prostaglandin F2 alpha (PGF2α) analogues including bimatoprost are often the first line drugs used in the treatment of glaucoma. We present a case of a 62-year-old female patient who was started on bimatoprost in both the eyes for primary open angle glaucoma. The intraocular pressures reached the target level but she developed hair growth over the chin and upper lip after six months of commencing of the treatment. The regional hypertrichosis did not reduce much after stopping the drug. Hirsutism is a potential side effect of prostaglandin analogues which has rarely been reported. Doctors and patients need to be aware of this noticeable and unwanted side effect. The effect seems to occur in patients already having few non-vellus hairs in these areas.

Hormonal profile and androgen receptor study in prepubertal girls with hypertrichosis

Background

Prepubertal hypertrichosis is a reportedly benign condition characterized by an excessive growth of vellous hair in non-androgen dependent areas of the body compared to the amount usually present in normal subjects of the same age, race and sex. Although this condition is usually considered idiopathic and regarded as benign, it may be very disturbing cosmetically, causing significant patient and parental anxiety.

Method

We performed a hormonal and androgen receptor study in 42 prepubertal girls with hypertrichosis and 29 control girls from 2 to 8 years of age. Both groups underwent a determination of basal LH, FSH, 17OH progesterone, androstenedione, testosterone, estradiol and SHBG, abdominal ultrasound to assess ovarian morphology, and the number of androgen receptor CAG/GGC repeats in DNA obtained from peripheral leukocytes.

Results

The hypertrichosis score was higher in the cases compared to controls. Serum gonadotropins and sex steroids were similar in both groups, but SHBG was significantly lower in the girls with hypertrichosis (71.1 ± 2.9 vs 81.9 ± 3.0 nmol/L, p < 0.02). The distribution of shorter, larger and total alleles was not statistically different between cases and controls. The combined analysis of CAG/GGC, however, showed a significantly higher prevalence of the most androgen-sensitive haplotypes (1–2: <22CAG + 17/17GGC- < 14CAG + 17/18GGC) in girls with hypertrichosis compared to controls.

Conclusions

We conclude that girls with hypertrychosis exhibit AR(s) with enhanced sensitivity, which may facilitate the growth of their body hair.

Alopecia following oral acyclovir for the treatment of herpes simplex keratitis

The authors report acyclovir-induced alopecia in a patient treated for herpetic keratouveitis. A 32-years-old female was diagnosed with herpetic keratouveitis. She was placed on prednisolone acetate (1%) suspension four times a day, atropine sulfate (1%) thrice a day, and oral acyclovir 400 mg twice-daily. Three weeks following oral acylovir, keratouveitis improved, but she developed alopecia without any drug eruptions. Oral acyclovir was discontinued. Three months later, alopecia completely resolved. Alopecia may be considered a possible complication following oral acyclovir.

Anidulafungin-Induced Alopecia

Objetive: To report a case of a woman in whom alopecia appeared after several months of treatment with anidulafungin. Case Summary: A 34-year-old woman with chronic femoral osteomyelitis with the presence of persistent suppuration, developed a Candida albicans infection, isolated in the fistula exudate cultures. After initial failures of single therapy with azoles, it was decided to administer fluconazole and anidulafungin 100 mg/d. One month after starting the treatment, the patient mentioned a greater hair loss than usual. At 3 months, the patient stopped taking the drug on noting the loss and easy falling out of her hair, with alopecia plaques 1 to 2 cm in size. At 2 months after stopping the anidulafungin, it was decided to restart combined antifungal treatment using micafungin and fluconazole; there was no mention of new or greater loss of hair. It was decided to change micafungin to anidulafungin again 90 days after starting treatment. In the first month of treatment, there appeared to be a reactivation in hair loss that later stabilized and improved. Discussion: Drug-induced hair loss is an adverse reaction that has been identified during different hair growth phases. It has been described for the azoles group and has not been associated with candins until now. Results of the causality analysis, using the probability scale established by Naranjo, found the relationship as probable. Conclusions: Anidulafungin could be associated with hair loss. Physicians must be aware of this adverse effect in order to approach it properly and to detect possible nonadherence to treatment.

Serum drug level-related sodium valproate-induced hair loss

Sodium valproate is a well-established treatment in epilepsy and mood disorders. Its utility is compromised by its adverse effects such as tremor, weight gain, hair loss, and liver dysfunction. Hair loss may occur when drug is used in higher dose. Drug-induced hair loss is diffused and non-scarring, which is reversible upon withdrawal. But there are no case reports showing relation between serum levels of valproate and occurrence of hair loss. So we took interest in reporting this case report.

Hair loss with levetiracetam in five patients with epilepsy

PURPOSE

To report cases of hair loss with levetiracetam (LEV) in epilepsy patient and summarise their demographic and clinical features.

METHOD

All patients reported attended the epilepsy outpatient clinic of the West China Hospital, Sichuan University. Demographic and clinical information was obtained from medical records and by interview. All the patients were under regular follow up.

RESULTS

Five epilepsy patients (4 females and 1 male) are reported. All developed hair loss within two months of starting LEV treatment. Three had idiopathic epilepsy, two symptomatic epilepsy. Three patients received LEV monotherapy, two combination treatment. None decided to switch away from LEV to another drug after developing hair loss, although the dose of LEV was reduced in one patient.

CONCLUSION

Hair loss may be a rare side effect of LEV treatment in patients with epilepsy. LEV-related hair loss appears reversible if the dose is reduced or treatment is stopped.

Treatment for chemotherapy-induced alopecia in mice using parathyroid hormone agonists and antagonists linked to a collagen binding domain

Parathyroid hormone (PTH) agonists and antagonists have been shown to improve hair growth after chemotherapy; however, rapid clearance and systemic side-effects complicate their usage. To facilitate delivery and retention to skin, we fused PTH agonists and antagonists to the collagen binding domain (CBD) of Clostridium histolyticum collagenase. in-vitro studies showed that the agonist fusion protein, PTH-CBD, bound collagen and activated the PTH/parathyroid hormone-related peptide receptor in SaOS-2 cells. The antagonist fusion proteins, PTH(7-33)-CBD and PTH([-1]-33)-CBD, also bound collagen and antagonized PTH(1-34) effect in SaOS-2 cells; however, PTH(7-33)-CBD had lower intrinsic activity. Distribution studies confirmed uptake of PTH-CBD to the skin at 1 and 12 hr after subcutaneous injection. We assessed in vivo efficacy of PTH-CBD and PTH(7-33)-CBD in C57BL/6J mice. Animals were depilated to synchronize the hair follicles; treated on Day 7 with agonist, antagonist, or vehicle; treated on Day 9 with cyclophosphamide (150 mg/kg i.p.) or vehicle; and sacrificed on Day 39. Normal mice (no chemo and no treatment) showed rapid regrowth of hair and normal histology. Chemo+Vehicle mice showed reduced hair regrowth and decreased pigmentation; histology revealed reduced number and dystrophic anagen/catagen follicles. Chemo+Antagonist mice were grossly and histologically indistinguishable from Chemo+Vehicle mice. Chemo+Agonist mice showed more rapid regrowth and repigmentation of hair; histologically, there was a normal number of hair follicles, most of which were in the anagen phase. Overall, the agonist PTH-CBD had prominent effects in reducing chemotherapy-induced damage of hair follicles and may show promise as a therapy for chemotherapy-induced alopecia.

Isoniazid-induced alopecia

Isoniazid is a safe and very effective antituberculosis drug. Antimitotic agents routinely cause alopecia. Drug-induced alopecia is usually reversible upon withdrawal of the drug. Isoniazid, thiacetazone and ethionamide are the antituberculosis drugs which have been associated with alopecia. Isoniazid-induced alopecia was observed in one case and confirmed by the finding that hair growth resumed when drug removed from the regimen.

Hair loss induced by lopinavir-ritonavir

A 38-year-old Caucasian woman with uncontrolled human immunodeficiency virus (HIV) infection was treated with highly active antiretroviral therapy (HAART) consisting of zidovudine, lamivudine, and nevirapine. Because her therapeutic response was inadequate, the HAART regimen was changed to abacavir, lamivudine, and lopinavir-ritonavir. Three months after this therapy was started, the patient developed progressive and notable hair loss. Her hair became fair and thin, and her appearance deteriorated considerably. Hair loss due to HAART was diagnosed. Lopinavir-ritonavir was stopped, and efavirenz was substituted; abacavir and lamivudine were continued. After 4 weeks, her hair growth substantially improved, as evidenced by rapid growth of new hair. Her general condition also improved. No relapse was observed with the new HAART regimen, and the patient's hair loss completely reversed in 8 weeks. Alopecia is a possible adverse event in HIV-infected patients treated with protease inhibitors, particularly indinavir. Our patient's severe and generalized alopecia was temporally related to the initiation and discontinuation of lopinavir-ritonavir. On the basis of the Naranjo adverse drug reaction probability scale, the adverse reaction was considered probable. Although generalized hair loss due to lopinavir-ritonavir is rare, clinicians should be aware of this potential adverse reaction of this widely used drug. If alopecia is severe or particularly distressing to the patient, the offending drug should be discontinued, and therapy with another HIV drug should be started.

Alopecia associated with quetiapine

Alopecia has previously been reported with the atypical antipsychotic medicines olanzapine and risperidone, but has not been described with quetiapine. Case reports of alopecia associated with quetiapine reported to the New Zealand Intensive Medicines Monitoring Programme were reviewed. The World Health Organization international spontaneous reporting database was also searched for additional case reports. Literature searches were conducted for previous reports of alopecia associated with quetiapine. The Intensive Medicines Monitoring Programme database included two case reports of alopecia associated with quetiapine. Assessment of these cases suggested a causal relationship with the medicine. The World Health Organization international database included a further 15 case reports, providing evidence supporting this association. No previously published reports of alopecia associated with quetiapine were identified. In conclusion, these are the first published case reports of alopecia associated with quetiapine.

Enoxaparin-induced alopecia in patients with cerebral venous thrombosis

OBJECTIVE

To report three cases of alopecia induced by the anticoagulant enoxaparin in cerebral venous thrombosis (CVT) patients.

CASE SUMMARY

Three female patients were treated initially with direct intrasinus urokinase, and then followed by low-molecular-weight heparin (LMWH) enoxaparin at 1 mg/kg given subcutaneously twice daily for 3 weeks. It was switched to oral anticoagulant warfarin at 5 mg daily for another 6 months. Nearly 3 weeks after the initiation of anticoagulation, all of the three patients complained of excessive hair loss with large areas of patchy, non-scarring alopecia. Hair growth returned to normal within 1 month after the completion of enoxaparin.

DISCUSSION

Unfractionated heparin remains the first-line treatment of CVT because of its efficacy, safety and feasibility. Alopecia has been reported as a side effect of LMWHs dalteparin and tinzaparin. The pattern of hair loss, telogen effluvium, involves the induction of the hair follicle into a resting phase without apparent pathologic implication. In addition, this article also reviewed other medications taken by the patients that are possibly associated with hair loss.

CONCLUSION

From the review of literature, there is no report of alopecia caused by urokinase. Using the Naranjo ADR Probability Scale, a score of 6 suggests that enoxaparin was the probable cause of alopecia in our three patients. This report introduces evidence of alopecia as a probable side effect of enoxaparin, but stresses the efficacy and safety of LMWH. As this is not a life-threatening disorder, we hope to increase the awareness of pharmacists and clinicians to this relatively rare but important side effect.

Associaton of Insulin Resistance Linked Diseases and Hair Loss in Elderly Men. Finnish Population-based Study

Previous investigations have shown an association of androgenetic alopecia (AGA) with insulin resistance related disorders such as ischemic heart disease. An association between AGA and anthropometric abnormalities linked with insulin resistance and heredity in women aged 63 years has also been shown. We therefore compared 63-year-old men with AGA and ones with normal hair status for insulin resistance linked parameters. A population of 245 men aged 63 years, who were participants in a population-based cross-sectional study in the City of Oulu, underwent a medical check-up including assessment of hair status on the Hamilton-Norwood scale and determination of anthropometric measures, blood pressure, fasting glucose and serum lipids. Fifty eight per cent of the men reported extensive hair loss (grade III-VII). Hypertension and the use of antihypertensive drugs were common among men with AGA (61% vs. 45% and 50% vs. 26%, respectively). The rates of diabetes and hyperinsulinemia (21% vs. 12% and 61% vs. 49%) were higher among men with AGA compared to those with normal hair status but no difference was seen in other factors. Our findings show that AGA is common among Finnish men aged 63 years but that it is also associated with insulin linked disturbances, such as hypertension and diabetes. Such men developing AGA might benefit from attention in medical check-up.

Clinical Approach to the Patient With Alopecia

Hair loss, or alopecia, is a common patient complaint and a source of significant psychological and physical distress. The majority of common hair loss disorders can be accurately diagnosed in the outpatient setting with a systematic evaluation of the patient. This review will present a clinical approach to the patient with alopecia by describing the history, clinical findings, and diagnosis of various hair loss disorders.

Detection of functionally active melanocortin receptors and evidence for an immunoregulatory activity of alpha-melanocyte-stimulating hormone in human dermal papilla cells

Proopiomelanocortin (POMC)-derived peptides and their receptors have been identified in many peripheral organs including the skin in which they exert a diversity of biological actions. We investigated the expression and potential role of the POMC system in human dermal papilla cells (DPCs), a specialized cutaneous mesenchymal cell type regulating hair follicle activity. In culture, these cells expressed POMC and displayed immunoreactivity for ACTH, alphaMSH, and beta-endorphin. Among the prohormone convertases (PCs) tested, only PC2, its chaperone 7B2, and furin convertase but not PC1 and paired basic amino acid cleaving enzyme 4 gene were detected. Human DPCs in vitro expressed both the melanocortin-1 receptor (MC-1R) and MC-4R, and immunoreactivity for these receptors was also present in cells of the human dermal papilla in situ. In contrast to the dermal papilla of agouti mice, agouti signaling protein, a natural and highly selective MC-1R and MC-4R antagonist, was undetectable in human DPCs. The MC-Rs detected in human DPCs were functionally active because alphaMSH increased intracellular cAMP and calcium. Preincubation of the cells with a synthetic peptide corresponding to the C-terminal domain of agouti signaling protein abrogated cAMP induction by alphaMSH. Furthermore, alphaMSH was capable of antagonizing the expression of intercellular adhesion molecule-1 induced by the proinflammatory cytokine interferon-gamma. Our data suggest a regulatory function of alphaMSH within the dermal papilla whose disruption may lead to deregulation of immune and inflammatory responses of the hair follicle, thereby possibly contributing to the development of inflammatory forms of alopecia.

Anti-alopecia mechanisms of soymetide-4, an immunostimulating peptide derived from soy beta-conglycinin

Previously, we found that orally administered soymetide-4 (MITL), an immunostimulating peptide derived from soybean beta-conglycinin alpha' subunit, suppressed alopecia induced by the anti-cancer drug etoposide in neonatal rats. Soymetide-4 has weak affinity for N-formyl-methionyl-leucyl-phenylalanine (fMLP) receptor. fMLP showed an anti-alopecia effect after intraperitoneal administration, though it was inactive after oral administration. Anti-alopecia effect of fMLP was blocked by pyrilamine or cimetidine, antagonists for histamine H1 or H2 receptor, respectively. However, the anti-alopecia effect of soymetide-4 was not inhibited by the histamine antagonists but by indomethacin, an inhibitor of cyclooxygenase (COX), or AH-23848B, an antagonist of the EP4 receptor for PGE2. Anti-alopecia effect of soymetide-4 was also blocked by pyrrolidine dithiocarbamate, an inhibitor of nuclear factor-kappaB (NF-kappaB). These results suggest that PGE2, which is produced after activation of COX by soymetide-4, might suppress apoptosis of hair matrix cells and etoposide-induced alopecia by activating NF-kappaB.