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

Trichoscopic Evaluation of Focal Non-Cicatricial Alopecia in Egyptian Children

INTRODUCTION

Dermoscopy is a noninvasive diagnostic tool that allows the recognition of morphologic structures not visible to the naked eye. Trichoscopy is useful for the diagnosis and follow-up of hair and scalp disorders.

OBJECTIVE

The aim of the present study was to evaluate the causes of focal non-cicatricial alopecia in Egyptian children and to assess the importance of the trichoscope in the diagnosis of each disease.

METHODS

This study was done with 200 Egyptian pediatric patients aged from 2 to 18 years who suffered from focal non-cicatricial alopecia. Clinical and dermoscopic evaluations were performed on all patients, and informed consent was obtained from their parents.

RESULTS

The most prevalent diagnoses were alopecia areata (42%) and tinea capitis (40.5%), followed by trichotillomania (8%) and tractional alopecia (7%). Congenital triangular alopecia (1.5%) and patchy androgenetic alopecia (1%) were less common. Trichoscopy revealed distinct features in alopecia areata cases, such as short vellus hair, exclamation mark hair, black dots, broken hair, pigtail hair, and upright regrowing hair. The most common trichoscopic features of tinea capitis were comma hair, corkscrew hair, broken hair, bent hair, zigzag hair, morse code hair, perifollicular scaling, and diffuse scaling. These findings contribute to understanding the etiology and clinical presentation of childhood alopecia, facilitating accurate diagnosis and appropriate management.

CONCLUSION

The routine use of trichoscopy in the clinical evaluation of scalp and hair disorders enhances diagnostic capabilities beyond simple clinical inspection. Trichoscopy reveals disease features that contribute to accurate diagnosis and improved management.

Noninfectious causes of alopecia in the pediatric population

PURPOSE OF REVIEW

To highlight recent advances in the knowledge base surrounding noninfectious causes of alopecia in the pediatric population.

RECENT FINDINGS

Recent developments in the literature included assessments of treatment efficacy, diagnostic utility of trichoscopy, and retrospective studies characterizing the clinical picture of pediatric cases.

SUMMARY

These findings will equip practitioners with the recent advances in the field's understanding of noninfectious causes of alopecia in the pediatric population.

Dermatological changes in a prospective cohort of acutely ill, hospitalised Malawian children, stratified according to nutritional status

RATIONALE

Since the first documentation of skin changes in malnutrition in the early 18th century, various hair and skin changes have been reported in severely malnourished children globally. We aimed to describe the frequency and types of skin conditions in children admitted with acute illness to Queen Elizabeth Central Hospital, Blantyre, Malawi across a spectrum of nutritional status and validate an existing skin assessment tool.

METHODS

Children between 1 week and 23 months of age with acute illness were enrolled and stratified by anthropometry. Standardised photographs were taken, and three dermatologists assessed skin changes and scored each child according to the SCORDoK tool.

RESULTS

Among 103 children, median age of 12 months, 31 (30%) had severe wasting, 11 (11%) kwashiorkor (nutritional oedema), 20 (19%) had moderate wasting, 41 (40%) had no nutritional wasting and 18 (17%) a positive HIV antibody test. Six (5.8%) of the included patients died. 51 (50%) of children presented with at least one skin change. Pigmentary changes were the most common, observed in 35 (34%), with hair loss and bullae, erosions and desquamation the second most prevalent skin condition. Common diagnoses were congenital dermal melanocytosis, diaper dermatitis, eczema and postinflammatory hyperpigmentation. Severe skin changes like flaky paint dermatosis were rarely identified. Inter-rater variability calculations showed only fair agreement (overall Fleiss' kappa 0.25) while intrarater variability had a fair-moderate agreement (Cohen's kappa score of 0.47-0.58).

DISCUSSION

Skin changes in hospitalised children with an acute illness and stratified according to nutritional status were not as prevalent as historically reported. Dermatological assessment by means of the SKORDoK tool using photographs is less reliable than expected.

Linear alopecia in pediatrics: RCM and dermoscopy reveal diagnostic cues

BACKGROUND

Alopecia areata (AA), trichotillomania (TM), nevus sebaceous (NS), and linear scleroderma en coup de sabre (LSCS) can all present with a patch of linear alopecia, making diagnosis challenging. The purpose of this study was to combine reflectance confocal microscopy (RCM) and dermoscopy in the diagnosis of these lesions in children.

METHODS

A total of 36 patients with linear alopecia were enrolled, of whom 14 had AA, seven had TM, nine had NS, and six had LSCS. We evaluated the characteristics and distinguishing features of the four conditions using RCM and dermoscopy.

RESULTS

The key to differential diagnosis was the dermal Hair follicle density in the dermis was decreased in AA, and the size and density of the follicular openings were normal in TM. In NS, the major features were petal-like and frogspawn-like structures. In LSCS, dermal papillary rings, sebaceous glands, and follicles were partially or completely missing, and abundant fibrous material was distributed in the dermis. Dermoscopy revealed alopecia, and all four conditions resulted in decreased hair density. AA patients exhibited yellow dots, black dots, and exclamation mark hairs. TM patients presented with irregularly broken hairs and blood spots. Both NS and LSCS patients exhibited an absence of follicular openings; NS patients demonstrated whitish and yellowish round structures, while an atrophic area with white patches, linear vessels, and no yellow or black dots was observed in LSCS patients CONCLUSION: RCM combined with dermoscopy can provide additional information on disease states and differentiate between AA, TM, NS, and LSCS.

Real-World Treatment Patterns among Patients with Alopecia Areata in the USA: A Retrospective Claims Analysis

Alopecia areata is an autoimmune disorder characterized by hair loss, for which there are few treatment options. This claims-based study characterized recent real-world treatment patterns among patients in the USA with alopecia areata, including the subtypes alopecia totalis and alopecia universalis, in the first year after diagnosis of an episode of alopecia areata. Approximately 5% of all patients (adults (age ≥ 18 years), n = 7,703; adolescents (age 12-17 years), n = 595) had alopecia totalis or alopecia universalis. Corticosteroids were the most common first-line (1L) and second-line (2L) treatments. The mean time from diagnosis of alopecia areata to initiation of 1L treatment was 2.2 days for adults and 2.6 days for adolescents; mean 1L duration was 76.9 and 64.3 days, respectively. For adults (57.5%) and adolescents (59.7%) with 2L therapy, the mean time from 1L discontinuation to 2L initiation was 57.2 and 53.6 days, respectively; the mean duration of 2L treatment was 55.5 and 50.1 days, respectively. More patients with vs without alopecia totalis or alopecia universalis initiated 2L therapy (adults: 71.9% vs 56.8%; adolescents: 71.4% vs 58.9%). The proportion of days covered during the first year post-diagnosis was 36.7% (adults) and 34.1% (adolescents). These results highlight the substantial disease burden of alopecia areata and a need for more effective treatments.

Clinical and histopathological investigation of symmetrical alopecia with associated chronic pruritus in tufted capuchin monkeys (Sapajus apella apella)

BACKGROUND

Symmetrical alopecia is a common symptom of endocrine and autoimmune diseases, which are rarely manifested with pruritus. Increased levels of stress in primates have been presented with increased levels of pruritus and alopecia appearance.

METHODS

A pruritic and alopecic disease was investigated in a group of tufted capuchin monkeys (N = 12), but due to ethical reasons, four random animals were further investigated by numerous diagnostic methods. The impact of food and enclosure enrichment was assessed and observed over a 2-year period.

RESULTS

Histopathology of four random tufted capuchin monkeys revealed lymphocytic perifolliculitis, with an appearance of a "swarm of bees" which was suggestive of alopecia areata. Etiological classification of pruritus excluded dermatological, systemic, and neurological causes, making it behavioral. Enclosure and food enrichment had a beneficial impact on pruritus (12/12) and alopecia (10/12).

CONCLUSION

The findings were suggestive of alopecia areata, while the pruritus was considered behavioral in origin. Alopecia and pruritus improved upon enclosure and food enrichment.

Unilateral Ciliary Madarosis in a Child After Coronavirus Disease 2019 (COVID-19) Infection

Coronavirus disease 2019 life-threatening signs have aroused a great deal of attention since the beginning of the pandemic. In the initial stages of the pandemic, the pediatric population was mostly protected, and the symptoms in affected children were mild. Here, the authors present a 7-year-old boy with left upper eyelid ciliary madarosis that developed 9 weeks after coronavirus disease 2019 infection. During comprehensive ophthalmologic examination, no conjunctival injection, chemosis, erythema, or crusts on the eyelids and no other meibomian gland disease findings were detected. Comprehensive laboratory workup was performed to exclude any other possible causes of ciliary madarosis. All laboratory parameters tested within normal limits. In addition to the patient's ocular surface and physical examination findings, laboratory results and the timing of the symptoms as well as spontaneous recovery at follow-up visits led the authors to conclude that telogen effluvium was to cause of the isolated, unilateral ciliary madarosis in this case.

Healthcare Utilization and Costs Among US Adolescents With Alopecia Areata

Background: Alopecia areata (AA) is an autoimmune disease of hair loss affecting people of all ages. Alopecia totalis (AT) and universalis (AU) involve scalp and total body hair loss, respectively. AA significantly affects quality of life, but evidence on the economic burden in adolescents is limited. Objectives: To assess healthcare resource utilization (HCRU) and all-cause direct healthcare costs, including out-of-pocket (OOP) costs, of US adolescents with AA. Methods: IBM MarketScan® Commercial and Medicare databases were used to identify patients aged 12-17 years with ≥2 claims with AA/AT/AU diagnosis (prevalent cases), from October 1, 2015, to March 31, 2018, enrolled for ≥12 months before and after the first AA diagnosis (index). Patients were matched 1:3 to non-AA controls on index year, demographics, plan type, and Charlson Comorbidity Index. Per patient per year HCRU and costs were compared post-index. Results: Patients comprised 130 AT/AU adolescents and 1105 non-AT/AU adolescents (53.8% female; mean age, 14.6 years). Post-index, AT/AU vs controls had more outpatient (14.5 vs 7.1) and dermatologist (3.6 vs 0.3) visits, higher mean plan costs ($9397 vs $2267), including medical ($7480 vs $1780) and pharmacy ($1918 vs $487) costs, and higher OOP costs ($2081 vs $751) (all P<.001). The non-AT/AU cohort vs controls had more outpatient (11.6 vs 8.0) and dermatologist (3.4 vs 0.4) visits, higher mean plan costs ($7587 vs $4496), and higher OOP costs ($1579 vs $805) (all P<.001). Discussion: This large-sample, real-world analysis found that adolescents with prevalent AA had significantly higher HCRU and all-cause costs than matched controls. The greater burden was driven by more frequent outpatient visits, and higher payer medical and pharmacy costs in comparison with controls. Oral corticosteroid use was higher among patients with AT/AU; topical and injectable corticosteroid use was higher for non-AT/AU. Although the data preclude the identification of AA-attributable costs, the matched-control design allows an estimation of incremental all-cause costs associated with AA. Conclusions: Adolescents with AA incurred substantial incremental healthcare costs, with greater costs incurred among those with AT/AU. Study findings suggest that AA incurs costs as a medical condition with a high burden on adolescent patients and health plans.

Dramatic Improvement of Trichotillomania with 6 Months of Treatment With N-Acetylcysteine

We present a case of a 17-year-old male with recurrent hair twirling resulting in patchy alopecia, who improved dramatically on N-acetylcysteine (NAC). Trichotillomania is characterized by repetitive hair pulling, twisting, or twirling and can vary from a mild habit to an impulse-control disorder. Standard treatment for pediatric trichotillomania includes cognitive behavioral therapy or medical therapy with selective serotonin reuptake inhibitors. NAC is a more recently utilized, safe, and well-tolerated over-the-counter supplement with some evidence of benefit for habitual skin and hair disorders. For this patient, we recommended 600 mg twice daily, increasing to 1200 mg twice daily as tolerated. After 6 months, our patient reported decreased desire to twirl his hair and his hair had almost completely regrown. Pediatricians who see patients with trichotillomania or other habitual disorders can consider treating these patients with NAC given its potential benefits and favorable side effect profile.

Alopecia Totalis in a Five-Year-Old Boy: A Case Report

Background: Alopecia totalis (AT) represent the severe form of alopecia areata with a worse prognosis. In population the prevalences of alopecia totalis, is 0,08%. This study shows that Prosential, minoxidil 2% and clobetasol propionate 0.05% therapy for hair loss could be considered Case presentation: A 5-year-old boy weighing 13.4 kg came to the hospital complaining of hair loss all over his head, bald since two months before. The eyebrows, eyelashes, and nose hairs were also missing. The diagnosis is alopecia totalis. The patient was given Prosential therapy for four months. After two months of treatment, hair started to grow slightly, evenly across the head, eyebrows, and eyelashes. After that, the patient was lost contact. 4 months later, the patient returned with hair loss complaints again.The patient’s vital signs are normal. Eyes, ENT, heart, lungs, abdomen: normal. Skin: no hair. Laboratorium: Hemoglobin 12.1 g/dL, leukocytes 6,480/uL, platelets 324,000/uL, hematocrit 35.5%, Diff Count: basophils 0%, eosinophils 22%, stems 1%, segments 27%, lymphocytes 41%, monocytes 9%. Feces and urine analysis were normal. Glucose 86 mg/dL, total cholesterol 128 mg/dL, triglycerides 46 mg/dL. Albumin 4.33 g/dL, globulin 1.41 g/dL. Uric acid 4.64 mg/dL. Kidney and liver function were normal. Thyroid function: FT4: 1.1 ng/dL, TsHs 0.916 uIU/mL. The ANA test was negative. Diagnosis: Idiopathic alopecia totalis with hypereosinophilia. The therapy was Prosential, minoxidil 2% and clobetasol propionate 0.05%. Conclusion: The etiology of AT should be sought in as much detail as possible because alopecia management requires a holistic approach, including psychosocial support. Hair loss is a significant factor affecting the self-esteem of children.

Hair Loss in Children: A Clinicoetiological Study from South India

Background:

Scalp hair loss in children is one of the common complaints encountered in dermatological practice. Accurate diagnosis of hair loss in children is of major significance as it can have severe psychological implications given the cosmetic importance of hair.

Aims:

This study aims to study the different causes and clinical presentations of scalp hair loss in children.

Materials and Methods:

This was a hospital-based descriptive study that enrolled a total of 170 children with scalp hair loss. A detailed history, scalp, and hair examination were done. Bedside investigations such as KOH mount, hair shaft microscopy, and hair pull tests were conducted. Scalp biopsy and dermoscopy were done wherever necessary to confirm the diagnosis.

Results:

Majority of the children with scalp hair loss were school going and adolescents accounting for 62.4% of cases; 52.4% of patients were male and 47.6% were female. Asymptomatic hair loss was the most common presenting complaint contributing to 71.2% of cases. Patchy pattern of scalp hair loss formed a majority (86.5%) compared to diffuse pattern (13.5%). Around 89.4% of scalp hair loss were of acquired type and remaining 10.6% were of congenital type. Neonatal occipital alopecia (38.9%) was the most common cause of congenital hair loss. However, in the acquired group, 90.1% had nonscarring and 9.9% had scarring alopecia. In the nonscarring group, tinea capitis, alopecia areata, and telogen effluvium accounted for 47.4%, 37.9%, and 8.8% of cases, respectively.

Conclusion:

Childhood alopecia is different from adult alopecia in terms of causes and the pattern of presentation. There is a scarcity of literature on childhood alopecia from India, hence, this study can serve as a useful guide in understanding the different causes and its presentation in our population. In addition, this study signifies the importance of simple diagnostic tests such as KOH and hair shaft microscopy in the diagnosis of common hair loss conditions in children.

An Approach to Hair Loss in Pediatric Primary Care

Pediatric hair loss is a cause of concern for patients and families. Early diagnosis and treatment are crucial, as delays in care for certain diagnoses can cause permanent scarring alopecia. The evaluation of hair loss includes a thorough history, physical examination, and other potential tests. The causes of hair loss can be classified as either acquired versus congenital. Acquired causes of hair loss can be subdivided into scarring and nonscarring; however, some conditions may present as nonscarring and progress to scarring alopecia. Recommendations for the evaluation and treatment of pediatric hair loss for the primary care practitioner will be summarized.

Alopecia Areata Treatment Patterns, Healthcare Resource Utilization, and Comorbidities in the US Population Using Insurance Claims

Introduction

Alopecia areata (AA) is an autoimmune disorder causing sudden, non-scarring hair loss. There are currently no drugs approved for AA treatment. This study assessed prevalence of comorbidities, treatments, and healthcare costs and resource utilization among patients with AA in the USA.

Methods

Patients diagnosed with AA between January 2011 and December 2018 were identified in IBM MarketScan^® Research Databases. Eligible patients had no other hair loss-related disorders and were continuously enrolled with medical and pharmacy benefits at least 12 months before and after AA diagnosis. Descriptive statistics were used to summarize comorbid conditions, treatments related to AA or other autoimmune/inflammatory conditions, and all-cause and AA-specific healthcare costs and resource utilization identified from claims data.

Results

A total of 68,121 patients with AA were identified. Mean (SD) age was 40.3 (17.8) years and 61.0% were female. The most common comorbidities included hyperlipidemia (22.4%), hypertension (21.8%), thyroid disorders (13.1%), contact dermatitis or eczema (10.8%), depression (9.5%), and anxiety (8.4%). Comorbid autoimmune diseases included atopic dermatitis (2.8%), psoriasis (2.1%), chronic urticaria (1.5%), and rheumatoid arthritis (1.1%). During the 12-month follow-up period, 37,995 patients (55.8%) were prescribed treatment for their AA or other comorbid autoimmune/inflammatory disease; 44.9% of treated patients were prescribed therapy within 7 days of AA diagnosis. Of patients receiving treatment, 80.3% received topical steroids and 30.0% received oral steroids. Mean (SD) total healthcare costs were $11,241.21 ($43,839.69) for all-causes and $419.12 ($1534.99) for AA. AA-related expenses were driven by outpatient and prescription costs.

Conclusion

Patients with AA have a high comorbidity burden and lack of treatment. Current AA treatments, including systemic therapies other than oral steroids, were not frequently utilized in this study population. Healthcare costs incurred by patients with AA went beyond AA-related expenses. Longitudinal data are needed to better understand treatment trajectories and the disease burden in patients with AA.

Supplementary Information

The online version contains supplementary material available at 10.1007/s12325-021-01845-0.

The spectrum of pediatric scarring alopecia: A retrospective review of 27 patients seen at Mayo Clinic

BACKGROUND/OBJECTIVE

There are few studies examining pediatric scarring alopecia. The objective of this study is to characterize the clinicopathologic findings, comorbidities, and treatment outcomes of pediatric patients with scarring alopecia.

METHODS

Retrospective review of patients under age 18 diagnosed with scarring alopecia at Mayo Clinic from 01/01/1992 through 02/05/2019.

RESULTS

27 patients met inclusion criteria with a mean age of 11.2 years and a racial breakdown of 85.2% (23) White, 11.1% (3) Black, and 3.7% (1) Multiracial. Clinical scarring was noted in most (23, 85.2%). Biopsy confirmed the diagnosis in most (24, 88.9%). The most common diagnoses were folliculitis decalvans (6, 22.2%), lichen planopilaris (6, 22.2%), aplasia cutis congenita (4, 14.8%), tinea capitis (4, 14.8%), and morphea (3, 11.1%). Comorbid depression (6, 22.2%) and anxiety (6, 22.2%) were prevalent. Of the patients who received follow-up, most who pursued treatment achieved stabilization (55.5%) or slowing of progression (27.8%), with 44.4% of those treated experiencing regrowth. Mean time to stabilization in the treated population was 19.6 months. Two patients did not pursue treatment, but received follow-up and these untreated patients did not experience hair regrowth.

CONCLUSIONS

Most patients presented with clinically evident primary scarring alopecia. Biopsy may confirm the diagnosis. Active treatment should be pursued, and successful treatment often requires combination therapies. Time to stabilization often takes years. Screening for depression and anxiety should be pursued.

Types and Treatment of Hair Loss in Men and Women

In this article, the author focuses on 4 common hair loss disorders that occur in both men and women. The author discusses research related to androgenetic alopecia, telogen effluvium, alopecia areata, and scarring alopecia and provides details on how to approach and manage these diseases according to patient gender. There are a range of tools and tests that can assist with the diagnostic process and help ensure that relevant and high standards of patient care are maintained. In some cases, no medical intervention is always a treatment option. However, appropriate medical treatments, although still relatively limited in some cases, are safe and have proven efficacy. Hair loss has immense emotional and psychological impact in both genders, and it is always important to consider this when planning hair loss management pathways.

Types and Treatment of Hair Loss in Men and Women

In this article, the author focuses on 4 common hair loss disorders that occur in both men and women. The author discusses research related to androgenetic alopecia, telogen effluvium, alopecia areata, and scarring alopecia and provides details on how to approach and manage these diseases according to patient gender. There are a range of tools and tests that can assist with the diagnostic process and help ensure that relevant and high standards of patient care are maintained. In some cases, no medical intervention is always a treatment option. However, appropriate medical treatments, although still relatively limited in some cases, are safe and have proven efficacy. Hair loss has immense emotional and psychological impact in both genders, and it is always important to consider this when planning hair loss management pathways.

Alopecia difusa infantil causada por Serratia marcences

Alopecia infantil é uma doença rara, com uma ocorrência estimada em 1% das consultas dermatológicas pediátricas. Infecções cutâneas, oculares e do mesmo tecido por Serratia marcescens raramente são relatadas. Relata-se um caso de uma paciente do sexo feminino, 2 anos e 3 meses de idade, com quadro de lesões dolorosas em região biparietal do couro cabeludo há dois meses, de aspecto exulcerado, crostoso, associado a secreção serossanguinolenta, purulenta e com alopecia. Inicialmente tratada com antifúngico e antibioticoterapia empírica, sistêmica e tópica, pela hipótese de Kerion Celsi, sem melhora. Foi observado o crescimento isolado da bactéria Serratia marcescens, estabelecendo assim diagnóstico de alopecia por etiologia bacteriana, sendo iniciado tratamento com sulfametoxazol/trimetropin (30 + 6 mg/kg/dia) por 10 dias, com resolução do quadro infeccioso e início da repilação em área de alopecia, restando apenas pequenas áreas cicatriciais como sequela.

Topical and oral minoxidil for hair disorders in pediatric patients: What do we know so far?

Minoxidil is a strong arterial vasodilator, first introduced as an antihypertensive medication. In dermatology, topical minoxidil (TMX) has been used for many types of alopecia. TMX is not FDA-approved in patients under 18 years old and there are no guidelines for its pediatric use. Low-dose oral minoxidil (OMX) has been used off-label for hair loss treatment in adults expecting to achieve better therapeutic compliance and greater clinical efficacy. However, little is known about TMX and OMX in pediatric population. the literature presented on TMX and OMX in children to date was reviewed. The terms "minoxidil", "child", "children", "childhood", and "infant" were used to perform a literature search in MEDLINE through PubMed. The search was limited to articles about humans and available in English. While 25 relevant articles were selected, duplicate titles were excluded. This article pointed out the use of minoxidil in several pediatric hair diseases. Even when used topically, dermatologists should be aware of potential risks of systemic absorption. In particular situations, OMX in very low doses may be considered. To date, there are no guidelines regarding the ideal dose or minimum age for using the drug topically or systemically.

Atrichia with papular lesions: A case report

We present a case of clinically suspected atrichia with papular lesions in an 8-year-old male presenting with alopecia universalis and keratotic papules. We review the literature available on this rare genodermatosis.

Reliability of Histopathology for the Early Recognition of Fibrosis in Traction Alopecia: Correlation with Clinical Severity

Traction alopecia (TA) is hair loss caused by prolonged pulling or repetitive tension on scalp hair; it belongs to the biphasic group of primary alopecia. It is non-scarring, typically with preservation of follicular stem cells and the potential for regrowth of early lesions especially if traction hairstyles are stopped. However, the alopecia may become permanent (scarring) and fail to respond to treatment if the traction is excessive and prolonged. Hence, the ability to detect fibrosis early in these lesions could predict patients who respond to treatment. Histopathological diagnosis based on scalp biopsies has been used as a gold standard to delineate various forms of non-scarring alopecia and to differentiate them from scarring ones. However, due to potential discrepant reporting as a result of the type of biopsy, method of sectioning, and site of biopsy, histopathology often tends to be unreliable for the early recognition of fibrosis in TA. In this study, 45 patients were assessed using the marginal TA severity scoring system, and their biopsies (both longitudinal and transverse sections) were systematically assessed by three dermatopathologists, the aim being to correlate histopathological findings with clinical staging. Intraclass correlation coefficients were used to determine the level of agreement between the assessors. We found poor agreement of the identification and grading of perifollicular and interfollicular fibrosis (0.55 [0.23–0.75] and 0.01 [2.20–0.41], respectively), and no correlation could be drawn with the clinical severity score. Better methods of diagnosis are needed for grading and for recognition of early fibrosis in TA.

Alopecia in Autoimmune Blistering Diseases: A Systematic Review of Pathogenesis and Clinical Features of Disease

Background

Autoimmune blistering diseases (AIBD) are characterised by the body's production of autoantibodies against structural proteins in the epidermis and/or the basement membrane on cutaneous and mucosal surfaces. Alopecia is a complication of AIBD that has generally been overlooked in patients with severe blistering diseases because it is regarded as a cosmetic issue. Yet recent research into quality of life tools has found that stigmatisation by appearance plays a significant role in blistering diseases.

Aim

To review the current literature detailing the pathogenesis and clinical presentations of alopecia in AIBD patients.

Method

We searched Medline, PubMed and EMBASE electronic databases up to September 2018, for empirical human and animal studies.

Results

Only 36 human studies including 223 patients (190 pemphigus, 25 pemphigoid, 5 epidermolysis bullosa acquisita, 2 dermatitis herpetiformis and 1 linear IgA disease) detailed demographic and clinical manifestations of alopecia. A range of hair evaluation methods was demonstrated to reach alopecia diagnosis. Furthermore, with no universal validated scoring system for alopecia severity, alopecia patterns have been summarised.

Conclusion

Previous randomised trials have not highlighted alopecia as an important outcome of AIBD, so epidemiological evaluation of the available literature has been helpful in summarising trends between existing studies and demonstrating inconsistencies.

Off-Label Use of Topical Minoxidil in Alopecia: A Review

Topical minoxidil is a well-known and often-utilized drug in dermatological practice for the treatment of alopecia. It was approved by the United States Food and Drug Administration for the treatment of androgenetic alopecia in 1988. Since its approval, minoxidil has been used off-label for the treatment of many other types of alopecia, with minimal formal evidence of efficacy. Conditions for which the use of topical minoxidil has been reported include telogen effluvium, alopecia areata (AA), scarring alopecia, eyebrow hypotrichosis, monilethrix, and chemotherapy-induced alopecia (CIA). The evidence for the use of minoxidil in each condition is derived from a variety of studies, including clinical trials, case series, and case reports. A comprehensive review of the literature indicates that while minoxidil is routinely used in the management of many alopecic conditions, there is mixed evidence for its efficacy. For certain conditions, including AA and most scarring alopecias, the evidence seems to be inconclusive. For others, such as eyebrow hypotrichosis, monilethrix, early traction alopecia, and CIA, there is more support for the efficacy of minoxidil. Although the favorable safety profile of minoxidil is established in adults, its use in the treatment of pediatric alopecia may require heightened monitoring and patient education.

Safety concerns when using novel medications to treat alopecia

INTRODUCTION

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

Trichotillomania and Trichophagia: Modern Diagnostic and Therapeutic Methods

Trichotillomania is a chronic, mental disease of impulse control, characterized by repetitive, compulsive, and self-induced hair pulling. It can occur at any age but is observed more often in adolescents, with a strong predominance in females. Diagnosis of trichotillomania may be difficult, and its effective treatment challenging. The aim of this study is to critically review current literature regarding diagnostic procedures and treatment of trichotillomania, including psychotherapy, N-acetylcysteine, naltrexone, topiramate, atypical neuroleptics, and selective serotonin-reuptake inhibitors. The importance of cooperation between dermatologists and psychiatrists is emphasized to shorten the time to diagnose the disease and begin appropriate treatment. Finally, trichotillomania is also often connected with trichophagia, which may lead to formation of trichobezoars and cause a direct danger to the patient’s health and even life due to the risk of intestinal obstruction and the need for surgical intervention. Based on thorough literature review, we conclude that diagnosis of trichotillomania can be challenging. Trichoscopy could help to distinguish trichotillomania from other types of hair loss. Most clinical trials using various treatment options have been conducted on small groups of patients, and the potential benefits determined using various scales. Therefore, it is difficult to compare the effectiveness of different treatment methods. There is also a lack of studies assessing treatment efficacy over longer periods of time. Thus, there is a need to perform better-designed studies in the near future to optimize current treatment modalities for trichotillomania.