White hair in alopecia areata: Clinical forms and proposed physiopathologic mechanisms

Alopecia areata (AA) is a common form of nonscarring hair loss. It is believed to be a consequence of an immune-mediated stimulus, probably involving autoreactive T cells against antigens present in the hair follicle. The exact antigen is still unknown; however, some authors have proposed that melanogenesis-associated molecules might trigger autoimmunity. Although transient white hair regrowth is a common and well-known situation in AA, there are other types of white hair phenomena in this context, including permanent white hair regrowth, sparing of white hair in a patchy pattern, or sparing in a diffuse pattern, giving the appearance of the so-called overnight graying phenomena or canitis subita. In this review, we aim to describe the different clinical aspects of white hair in AA, as well as the proposed pathophysiologic mechanisms involved in this phenomena.

Wickham striae on skin appendages: a helpful dermoscopic feature

Lichen planus (LP) is a chronic inflammatory disease, clinically characterized by purpuric, itchy papules that typically spread on the trunk and extremities. Other body sites can also be affected, including mucosal membranes, nails, and the scalp. The use of dermoscopy is essential in determining the diagnosis of LP, as it may highlight pathognomonic features such as Wickham striae (WS). WS are thin, pearly white structures arranged in a reticular pattern that is observed over LP lesions and histologically correspond to epidermal hypergranulosis. WS is usually most visible on the oral mucosa but can also cover almost every active LP papule. Here, we report two cases of biopsy-proven LP that show WS on dermoscopy in two specific sites: the scalp and proximal nail fold.

Dermoscopic Findings of Discoid Lupus Erythematosus Involving the Eyelids

Introduction

Although facial involvement in discoid lupus erythematosus (DLE) is common, eyelid involvement is atypical. Identifying this condition is challenging due to misdiagnosis, and it is essential to avoid potential deformities of the eyelid margin.

Case Presentation

We, herein, report the dermoscopic findings in 2 female patients with a confirmed diagnosis of DLE who presented eyelids involvement.

Discussion/Conclusion

This study highlights the importance of performing a dermoscopy examination to help physicians obtain an early diagnosis of DLE.

Efficacy of mechanical thrombectomy in patients with ischemic stroke and cancer

Cancer-related coagulopathy is a known cause of stroke and can lead to formation of thrombi with a unique composition. The effectiveness of mechanical thrombectomy in cancer patients is still unknown. The aim of the study was to evaluate the rate of successful reperfusion and the clinical outcome in cancer patients with stroke treated with endovascular therapies, compared to patients without cancer. We performed a retrospective analysis of consecutive patients with ischemic stroke treated with endovascular therapies at our hospital between January 2008 and January 2016. A sub-group analysis was performed including only patients with cryptogenic stroke. We included in the final analysis 14 patients with active cancer and 267 patients without cancer. Successful reperfusion was achieved in 79% of patients without cancer, and 71% of patients with active cancer (P = 0.68). Patients with cryptogenic stroke and active cancer had a lower reperfusion rate compared to patients with cryptogenic stroke without active cancer, although not significantly so (2/4 cancer patients, 50% vs 37/50, 74%, p: 0.31). Mortality rate was higher among cancer patients. Hemorrhagic transformation occurred in similar proportions in the two groups. Endovascular treatment in cancer patients seems, thus, effective.

'Colouring' wipes phenomenon: a peculiar skin pigmentation induced by ascorbic acid observed during lockdown

During the SARS‐CoV‐2 (COVID‐19) pandemic, an unusual outbreak of yellow–brown pigmentation on the skin of children was reported. Because of the restrictions on movement promulgated during the lockdown, most consultancies were performed using teledermatology. Data concerning personal care products and application of topical substances were collected, which revealed use of the same brand of wipes for all patients. A liquid chromatography–mass spectrometry analysis was performed to compare the components of the wipes before and after the observation of the pigmentation, in order to detect the responsible substance. This analysis revealed a level about 10‐fold higher than normal of ascorbic acid and its oxidation products (dehydroascorbic acid and L‐threonic acid) in the wipes associated with the pigmentation. These ‘colouring wipes’ represent a peculiar but harmless phenomenon that highlights the importance of careful questioning about personal care products used by patients.

Safety of low-dose oral minoxidil for hair loss: A multicenter study of 1404 patients

BACKGROUND

The major concern regarding the use of low-dose oral minoxidil (LDOM) for the treatment of hair loss is the potential risk of systemic adverse effects.

OBJECTIVE

To describe the safety of LDOM for the treatment of hair loss in a large cohort of patients.

METHODS

Retrospective multicenter study of patients treated with LDOM for at least 3 months for any type of alopecia.

RESULTS

A total of 1404 patients (943 women [67.2%] and 461 men [32.8%]) with a mean age of 43 years (range 8-86) were included. The dose of LDOM was titrated in 1065 patients, allowing the analysis of 2469 different cases. The most frequent adverse effect was hypertrichosis (15.1%), which led to treatment withdrawal in 14 patients (0.5%). Systemic adverse effects included lightheadedness (1.7%), fluid retention (1.3%), tachycardia (0.9%), headache (0.4%), periorbital edema (0.3%), and insomnia (0.2%), leading to drug discontinuation in 29 patients (1.2%). No life-threatening adverse effects were observed.

LIMITATIONS

Retrospective design and lack of a control group.

CONCLUSION

LDOM has a good safety profile as a treatment for hair loss. Systemic adverse effects were infrequent and only 1.7% of patients discontinued treatment owing to adverse effects.

Trichotillomania Incognito: Two Case Reports and Literature Review

Trichotillomania is a compulsive disorder characterized by repetitive hairpulling. It is an important cause of patchy alopecia, especially in children between 9 and 13 years of age. The aim of this paper is to report 2 pediatric cases presenting with trichotillomania without patches. This condition may be extremely distressful, impacting psychosocial development of children. In these case reports, we reinforce the relevance of trichoscopy in hair disorder evaluation, which allowed early recognition to better advise and conduct these unique pediatric cases.

Efficacy and Tolerability of a Shampoo Containing Broad-Spectrum Cannabidiol in the Treatment of Scalp Inflammation in Patients with Mild to Moderate Scalp Psoriasis or Seborrheic Dermatitis

Introduction

Scalp inflammation is commonly associated with scalp psoriasis or seborrheic dermatitis. It can aggravate the progression of androgenetic alopecia and cause troublesome itching and burning. Here, we evaluate the efficacy of a shampoo containing 0.075% broad-spectrum cannabidiol in 50 subjects with mild to moderate scalp psoriasis or seborrheic dermatitis.

Methods

Inflammation was assessed by evaluating the density of twisted/glomerular or arborizing vessels by trichoscopy using a 6-point scale at baseline and day 14. Symptoms of itching/burning sensation, clinical evaluation of erythema/scaling, overall tolerability, and subject satisfaction were evaluated using 10-point scales.

Results

There were significant reductions in arborizing vessel/twisted capillary inflammation and scaling by day 14. Severity scores reduced from 2.3 ± 0.1, 2.6 ± 0.1, and 3.6 ± 0.1, respectively, to 0.5 ± 0.05, 0.8 ± 0.05, and 0.6 ± 0.05 (all p < 0.0001). Symptom scores of itching and burning also reduced significantly from 6.9 ± 0.1 to 4.5 ± 0.1 to 1.5 ± 0.05 and 1.0 ± 0.05 (both p < 0.0001). Severity of erythema and scaling was also significantly reduced from 5.5 ± 0.1 and 7.0 ± 0.1, respectively, to 1.3 ± 0.05 and 1.6 ± 0.05 (both p < 0.0001). Tolerability and subject satisfaction were both excellent. There were no significant differences in treatment effect, tolerability, or subject satisfaction between men and women.

Discussion/Conclusion

Replacing current shampooing practices with a broad-spectrum cannabidiol-containing shampoo significantly reduces both severity and symptoms of scalp inflammation within 2 weeks, with excellent tolerability and treatment satisfaction in subjects with mild to moderate scalp psoriasis or seborrheic dermatitis.

Trichoscopy findings of frontal fibrosing alopecia on the eyebrows: A study of 151 cases

BACKGROUND

Eyebrow loss (madarosis) is a frequent sign of frontal fibrosing alopecia (FFA), and it can be the first sign of the disease.

OBJECTIVE

To describe trichoscopy findings of FFA on the eyebrows.

METHODS

The analysis included 151 women with histologically proven diagnosis of FFA and eyebrow loss. Trichoscopy of the eyebrow area was performed with either a FotoFinder videodermatoscope or handheld dermoscope DermLite II pro.

RESULTS

The most frequent signs on trichoscopy were yellow dots (92.7%), multiple pinpoint dots (79.5%), short thin hairs/vellus (76.2%), black dots (66.2%), and dystrophic hairs (60.9%). Tapering hairs were found in 21 (13.9%) patients and dystrophic hairs in 92 (60.9%) patients.

LIMITATIONS

Inner limitations of a case series (there was no comparison with healthy control individuals or patients with other hair disorders) and lack of histologic correlation to the trichoscopy findings.

CONCLUSIONS

Although FFA is a scarring alopecia, the most common trichoscopy signs found in the eyebrows are usually related to noncicatricial alopecia. Therefore, in most cases, trichoscopy of the eyebrows does not resemble the trichoscopy of FFA on the scalp. Black dots, dystrophic hairs, and broken hairs are frequent signs. Occasionally, tapered hairs can be present on the eyebrows in FFA, leading to misdiagnosis of alopecia areata.

Sonographic features of vaccination granulomas in children with delayed-type hypersensitivity to aluminum

In this article, we report the sonographic features of vaccination granulomas in three children sensitized to aluminum. Although the recognition of the vaccination granuloma relies on the clinical examination, misdiagnosis is frequent, leading to distressful procedures or prolonged antibiotic administration. In all our cases, sonography revealed a teardrop-shaped echogenic central structure, suggesting the deposition of aluminum crystals along the route of administration with consequent subcutaneous degenerative changes, and a surrounding hypoechoic cap, which reflects the changeable inflammatory reaction and the granuloma formation.

Italian Guidelines in diagnosis and treatment of alopecia areata

Alopecia areata (AA) is an organ-specific autoimmune disorder that targets anagen phase hair follicles. The course is unpredictable and current available treatments have variable efficacy. Nowadays, there is relatively little evidence on treatment of AA from well-designed clinical trials. Moreover, none of the treatments or devices commonly used to treat AA are specifically approved by the Food and Drug Administration. The Italian Study Group for Cutaneous Annexial Disease of the Italian Society of dermatology proposes these Italian guidelines for diagnosis and treatment of Alopecia Areata deeming useful for the daily management of the disease. This article summarizes evidence-based treatment associated with expert-based recommendations.

Pili Torti as a Sign of Eyebrow Involvement in Frontal Fibrosing Alopecia

Frontal fibrosing alopecia (FFA) is a disease characterized by progressive band-like scarring alopecia involving the frontotemporal hairline and eyebrow hair loss. It affects mainly postmenopausal women. Trichoscopy features of FFA include absence of vellus hair, perifollicular erythema and scaling (peri-pilar casts), and absence of follicular openings. Trichoscopy of eyebrows in FFA patients shows tapered and broken hair, absence of follicular openings, black dots, and hair growing in different directions. We report a case of FFA with numerous pili torti in the eyebrows.

Effects of a New Topical Treatment Containing Several Hair Growth Promoters in Women with Early Female Pattern Hair Loss

Background

Female pattern hair loss (FPHL) is increasing ly common and often presents with hair shedding. Spec tral. DNC-N® contains anti-inflammatory actives and hair growth promoters.

Objectives

To assess the efficacy and tolerability of Spectral DNC-N® (DS Laboratories, Inc.) in women with early FPHL and excessive shedding.

Methods

Forty-nine patients were treated with Spectral DNC-N®, applied twice daily for 3 months; 28 patients were included in the 3-month treatment extension. Efficacy assessments included the degree of hair shedding using the validated hair shedding visual scale, hair mass index (HMI), and photographic evaluation.

Results

There was a statistically significant decrease in hair shedding and a corresponding increase in HMI by month 3, which was maintained through month 6. The mean investigator-assessed hair shedding score decreased from 3.5 to 2.0 and the hair mass increased from 75.8 to 84.3 mm>sup<2>/sup</cm>sup<2>/sup< by month 3 (both p < 0.01 compared with baseline). By month 6, the hair shedding score was reduced to 1.6 and the hair mass was maintained. Most patients (75%) showed an increase in global hair density.

Conclusions

Spectral. DNC-N® significantly reduced hair shedding, with a corresponding increase in hair mass and density. These effects were already evident after 3 months' treatment and further improved in those patients who continued treatment to month 6. Tolerability was good and patient satisfaction levels were high.

Chilblain Lupus with Nail Involvement: A Case Report and a Brief Overview

Chilblain lupus erythematosus is a rare, chronic variant of cutaneous lupus erythematosus that occurs during cold or damp periods on the hands, fingers, or feet. It is often associated with other forms of cutaneous lupus and about 20% of patients develop systemic lupus erythematosus. Various medications have been put forward, including steroids, mycophenolate mofetil, calcium channel blockers, and hydroxychloroquine, but the symptoms do not remit completely.

Frontal Fibrosing Alopecia Severity Index: A Trichoscopic Visual Scale That Correlates Thickness of Peripilar Casts with Severity of Inflammatory Changes at Pathology

BACKGROUND

Frontal fibrosing alopecia (FFA) is a scarring alopecia that mainly affects postmenopausal women characterized by recession of the frontotemporal hairline and eyebrow loss. Current techniques to assess FFA activity are limited and involve noninvasive tools that assess disease progression or an invasive technique such as scalp biopsies. However, since progression of FFA is very slow, it is very important to develop a noninvasive technique to assess disease activity to monitor treatment response.

OBJECTIVES

To provide a standardized and objective method to assess FFA activity.

METHODS

We evaluated the correlation between trichoscopy and pathological features (degree of lymphocytic infiltration) in 20 dermoscopy-guided biopsies of FFA. At trichoscopy, we divided the severity of peripilar casts into 3 grades according to their thickness. To validate the trichoscopic visual scale, we showed the images to 7 dermatologists with interest in hair diseases. Concordance was assessed using the Kendall Tau-b concordance test.

RESULTS

A strong correlation between severity of peripilar casts at trichoscopy and degree of lymphocytic infiltrate was observed by the Kendall Tau-b test. Validation showed very good inter- and intraobserver agreement.

CONCLUSION

The trichoscopic visual scale allows noninvasive assessment of scalp inflammation in FFA in different scalp regions and therefore provides optimal guidance for treatment.

Alopecia Areata and Habit Tic Deformities

Nail involvement is a very common finding in patients with alopecia areata (AA). Most commonly evidenced by nail pitting, nail abnormalities can affect up to 66% of AA patients. We present two cases of the unusual association between habit tic nail deformities and AA.

Scalp Psoriasiform Contact Dermatitis with Acute Telogen Effluvium due to Topical Minoxidil Treatment

Topical minoxidil, the only approved treatment for female pattern hair loss (FPHL), has been associated with scalp allergic contact dermatitis (ACD). We report the case of 2 female patients who developed ACD from minoxidil solution with severe telogen effluvium and psoriasiform scalp dermatitis. Scalp dermoscopy was useful to identify the psoriasiform vascular pattern, whereas patch testing made it possible to differentiate the cause of sensitization. In one case, minoxidil was the sole cause of scalp dermatitis, while in the other patient it was only the vehicle, thus permitting the patient to continue the treatment for FPHL.

Effect of a nutritional supplement on hair loss in women

BACKGROUND

Female pattern hair loss is a frequent and distressing condition.

AIM

To evaluate vs. control, the effects on hair loss of a 6-month supplementation with specific omega 3&6 and antioxidants.

METHODS

One hundred and twenty healthy female subjects participated in this 6-month, randomized, comparative study. The primary endpoint was the change in hair density evaluated on standardized photographs. Secondary endpoints included changes in telogen hair percentage and diameter distribution of anagen hair (>40 µm vs. ≤40 µm) measured by trichogram. Overall changes in hair density and diameter were also measured by trichometer and by subjects' self-assessment.

RESULTS

After 6 months of treatment, photograph assessment demonstrated a superior improvement in the supplemented group (P < 0.001). The telogen hair percentage was significantly (P < 0.001) reduced in the supplemented group. The proportion of nonvellus anagen hair (>40 µm) increased compared to the control group. The trichometer index increased in the supplemented group, while it decreased in the control group. A large majority of supplemented subjects reported a reduction in hair loss (89.9% of subjects at 6 months), as well as an improvement in hair diameter (86.1%) and hair density (87.3%).

CONCLUSION

A 6-month supplementation with omega 3&6 and antioxidants acts efficiently against hair loss in improving hair density and reducing the telogen percentage and the proportion of miniaturized anagen hair. Objectively measured improvements were confirmed by the subjects' perception of efficacy.

Laparoscopic management of early stage ovarian cancer: is it feasible, safe, and adequate? A retrospective study

INTRODUCTION

Minimally invasive surgery to stage early ovarian cancer is still regarded as pioneering among gynecologic oncologists. Previous retrospective experiences demonstrated the safety and feasibility of laparoscopy in this field.

AIMS

To review the laparoscopic staging procedure in a series of patients with early ovarian cancer and compare results with the literature.

MATERIALS AND METHODS

From January 2004 to September 2011, 19 patients with apparent early stage ovarian/fallopian tube cancer Stage IA to IC underwent either primary treatment or completion staging by laparoscopy. Surgical, pathologic, and oncologic outcomes were analyzed.

RESULTS

The mean operative time was 212 +/- 69 minutes. Three patients (16%) underwent fertility sparing surgery. The mean estimated blood loss was two +/- two g/dl. The mean number of pelvic and para-aortic lymph nodes collected was 17 (range 7-27) and 14 (range 8-21), respectively. The mean volume of ovarian/tubal tumor was 119 cm3 (range 1.5-500). The disease was reclassified to a higher stage in ten women (52%). One major intraoperative complication (five percent) occurred which required the conversion to laparotomy. The mean follow up period was 30 +/- 16 months (range 10-74). Overall survival and disease-free survival were 100% and 84%, respectively.

CONCLUSIONS

Laparoscopic staging of early ovarian cancer appears to be feasible and comprehensive when performed by gynecologic oncologists experienced with advanced laparoscopy.

Quality of life in alopecia areata: a disease-specific questionnaire

BACKGROUND

Alopecia areata (AA) is an autoimmune disease affecting about 2% of the population, which has a considerable impact on quality of life (QoL). There are no disease-specific questionnaires to assess QoL in patients suffering from AA.

OBJECTIVE

To validate a new disease-specific questionnaire for AA, named AA-QLI, and to compare the consequent Quality of Life Index (QLI) with the commonly known Dermatology Life Quality Index (DLQI) to verify if it can provide a more comprehensive tool for patients.

METHODS

A total of 50 patients affected by AA were administered both the AA-QLI, created by us, and the well-known DLQI. With the aim to detect suitable QLI, we propose to use two multivariate analyses: • a principal component analysis approach on the data collected with both questionnaires to compare their capability to measure the QoL; • a structural equation modelling on our AA-QLI to identify which category of symptoms mostly affects the QoL.

RESULTS

The scores of both the questionnaires are quite close, except for a few cases. Statistical analysis shows a higher specificity of the AA-QLI for evaluating QoL. Among the three areas in which AA-QLI is divided, 'Relationship' has a major impact on the QLI, followed by 'Subjective symptoms'; 'Objective signs' has a lower weight on the QLI.

CONCLUSION

AA-QLI is a good instrument to evaluate the real impact of AA on QoL. It can be helpful both for the physician and for the patient.

Videodermoscopy does not enhance diagnosis of scalp contact dermatitis due to topical minoxidil

Background:

Videodermoscopy (VD) is a noninvasive diagnostic tool that provides useful information for the differential diagnosis of scalp disorders.

Objectives:

The aim of this study was to investigate if dermoscopy may help the clinician in the diagnosis of contact dermatitis of the scalp.

Materials and Methods:

We analyzed the dermoscopic images taken from 7 patients with contact dermatitis due to topical minoxidil, 6 patients complaining of intense scalp itching during treatment with topical minoxidil but with negative patch tests and 19 controls. The following dermoscopic patterns described for scalp diseases were evaluated: Vascular patterns (simple loops, twisted loops and arborizing lines), follicular/perifollicular patterns (yellow dots, empty ostia, white dots, peripilar signs), white scales, yellow scales, follicular plugging, hair diameter diversity, honeycomb pattern and short regrowing hairs. Findings were graded from 0-4, according to severity in 20-fold magnifications. Statistical analysis included univariate analysis and Chi-square test by SPSS version 12.

Results:

There were no statistical differences in the analysis of the vascular patterns and scales between the 3 groups.

Conclusions:

We were not able to detect dermoscopic features that can help the clinician in distinguishing scalp contact dermatitis due to topical minoxidil from other conditions that cause severe scalp itching. In particular, minoxidil contact dermatitis does not produce increase or alterations in the morphology of the scalp vessels or significant scalp scaling when evaluated with dermoscopy.