Trichoscopy of Frontal Fibrosing Alopecia Affecting Black Scalp: A Literature Review.

Background: Frontal fibrosing alopecia (FFA) is a primary lymphocytic scarring alopecia characterized by progressive recession of the frontotemporal hairline, affecting mainly postmenopausal and, lately, premenopausal women of African descent. Considering the importance of trichoscopy on FFA diagnosis and the peculiarities found in patients with higher skin phototypes, this study aimed to review the FFA trichoscopy in the black scalp (Fitzpatrick IV-VI), a topic that remains sparsely described in the existing literature. Summary: In black patients, FFA may manifest singular features on presentation posing diagnostic clinical and trichoscopic challenges. This group has lower prevalence of the FFA compared to other alopecias. It may have an earlier age of onset and often exhibits more severe manifestations due to the coexistence of other types of alopecia and delay in diagnosis. The early signs of the disease in black patients may manifest in the eyebrows before scalp hair loss and lichen planus pigmentosus may be a herald sign. Key Messages: Our research analyzes FFA trichoscopy findings in black patients to help precise diagnosis and treatment. Raising awareness of the disease characteristics on trichoscopy contributes to improving hair care in this population.

Trichoscopy of Central Centrifugal Cicatricial Alopecia: A Retrospective Study and Literature Review.

Introduction: Central centrifugal cicatricial alopecia (CCCA) is the most common cause of scarring alopecia in middle-aged black women. Trichoscopy is a noninvasive tool for diagnosis and follow-up of hair and scalp disorders. To date, limited studies have focused on its applicability to CCCA in existing literature. Methods: The present study aimed to describe the trichoscopic findings of 11 dark-skinned women with confirmed CCCA and provide a comprehensive discussion of our current knowledge regarding trichoscopy of this disease through a literature review. A thorough understanding of CCCA trichoscopy holds significant promise for early confirmation and treatment. Conclusion: By doing so, it is possible to mitigate the development of complications and alleviate the subsequent impact on patients' quality of life.

A phase 2a trial of brepocitinib for cicatricial alopecia.

BACKGROUND: Cicatricial alopecias (CA) are chronic, progressive scarring hair-loss conditions. Molecular dysregulation is not fully understood, hindering treatment development. Th1/IFNγ signaling and JAK dysregulation has shown involvement, providing rationale for this phase 2a trial with TYK2/JAK1 inhibitor brepocitinib. METHODS: Randomized, placebo-controlled phase 2a trial spanning 52 weeks. Adults (18≥years of age) with lichen planopilaris, frontal fibrosing alopecia, or central centrifugal cicatricial alopecia diagnosis were randomized 3:1 to brepocitinib 45mg daily or placebo for 24 weeks, after which all patients received brepocitinib for another 24 weeks, with a safety follow up 4 weeks later. Lesional scalp biopsies were collected at baseline, week 24, and week 48. Co-primary endpoints were changes in lesional expression of CCL5, changes in lesional expression of fibrosis-related markers, and safety at week 24. RESULTS: Patients receiving brepocitinib showed significant downregulation in CCL5 expression at week 24 (p=0.004). Enrichment analysis of a subset of fibrosis markers showed trending upregulation in placebo patients (p<0.1). Brepocitinib was well tolerated and improved clinical severity scores. LIMITATIONS: Single-dose regimen, small placebo group. CONCLUSION: Brepocitinib significantly reduces CCL5 expression and was well tolerated at week 24, meeting co-primary endpoints. Brepocitinib reduces inflammatory biomarker expression and improves clinical severity, while maintaining favorable safety profile.

Treatment of Ocular Surface Disease in Ocular Cicatricial Pemphigoid.

PURPOSE: While substantial research has focused on systemic immunomodulatory therapy for ocular cicatricial pemphigoid (OCP), limited data exist on managing associated ocular surface disease (OSD). This study evaluates treatments for OCP-related OSD at our institution. METHODS: We conducted a retrospective analysis of patients diagnosed with cicatrizing conjunctivitis at the University of Colorado Hospital from January 1, 2013, to October 31, 2023. Patients with cicatrizing conjunctivitis due to non-OCP conditions were excluded, and disease severity was classified using the Foster Staging System. RESULTS: Our review included 30 patients with OCP, all with at least six months of follow-up. The mean age of symptom onset (n = 19) was 62.2 years (SD = 16.4), while the mean age at diagnosis (n = 28) was 65.1 years (SD = 12.7). The most common OSD treatments at the last visit were preservative-free artificial tears (87%), topical corticosteroids (43%), autologous serum eye drops (40%), topical antibiotics (30%), and topical immunomodulators (23%). All patients used at least one treatment, with 83.3% on prescription therapies. Patients averaged 3.33 (SD: 1.4) treatments, with 1.7 (SD: 1.2) being prescriptions. Topical immunomodulators had the highest discontinuation rate at 73.1% (n = 19/26). Autologous serum eye drops and topical corticosteroids were the least discontinued treatments. Number of total treatments, prescriptions, and procedures sharply increased at stage three OCP. CONCLUSIONS: The number of treatments and procedures increased with OCP severity, indicating that advanced OCP often necessitated more intensive OSD management.

Authors Reply to Letter to the Editor - In Response to: Comment on Bocanegra-Oyola et al.'s "Clinical Characteristics of Ocular Mucous Membrane Pemphigoid: A Systematic Review and Meta-Analysis".

In response to Dr. Kasperkiewicz's commentary on our meta-analysis conducted by Bocanegra-Oyola et al., we fully agree with refining diagnostic processes for ocular pemphigoid, particularly in differentiating it from pseudopemphigoid. We concur that relying solely on clinical findings may result in misdiagnoses. Confirming the diagnosis via biopsy can be challenging, requiring multiple biopsies in some patients, and should always be supported by a multidisciplinary clinical assessment involving ophthalmologists and dermatologists.

Incidence of alopecia and hair loss among female active component service members, 2010-2022.

This study aimed to determine the incidence of hair loss among U.S. active component service women, describe the types of hair loss, and summarize potential racial and ethnic disparities of hair loss among service women over the last 12 years. Estimates of traction alopecia among service members have been difficult, as there are no specific diagnosis codes for traction alopecia in the International Classification of Diseases, 9th and 10th revisions (ICD-9/ICD-10). A prior study on the prevalence of alopecia among female active component service women between 2010 and 2019 reported that 2.7% had traction alopecia diagnoses. That estimate may not be accurate, as the previous study used the ICD-9 code 704.01 (alopecia areata) and ICD-10 code Q84.0 (congenital alopecia), which are not fully representative of traction alopecia cases in administrative health records. This study used ICD-9/ICD-10 diagnostic codes 704.0 (ICD-9), L63, L64, L65, and L66 (ICD-10) to define cases of alopecia. The study population included female active component service members in the U.S. Army, Navy, Air Force, and Marine Corps between January 1, 2010 and December 31, 2022. The overall incidence rate of alopecia was 804.4 per 100,000 person-years. Non-Hispanic Black and Hispanic female active component service members had the highest incidence rates among all races and ethnicities, at 1,138.7 and 1,013.6 per 100,000 person-years, respectively. Non-Hispanic Black female active component service members were more than twice as likely to be diagnosed with alopecia compared to non-Hispanic White female active component service members.

[Laryngotracheal resection with tracheoesophageal fistula closure in a patient with post-tracheostomy total cicatricial atresia of the larynx and tracheal stenosis combined with cricoid cartilage fracture]. / Laringotrakheal'naya rezektsiya po tipu H. Grillo s razobshcheniem trakheopishchevodnogo svishcha u bol'nogo s posttrakheostomicheskoi total'noi rubtsovoi atreziei gortani i stenozom sheinogo otdela trakhei v sochetanii s perelomom perstnevidnogo khryashcha.

Treatment of patients with post-intubation (post-tracheostomy) stenotic laryngotracheal lesions combined with tracheoesophageal fistula is the most difficult problem for various specialists. A 20-year-old patient received a severe concomitant injury with necessary prolonged mechanical ventilation and tracheostomy. Decannulation was followed by shortness of breath and cough with discharge of sputum mixed with liquid and food. Post-tracheostomy total cicatricial atresia of the larynx and cervical trachea combined with cricoid cartilage fracture, as well as tracheoesophageal fistula of cervical trachea was diagnosed. Tracheostomy and gastrostomy were performed. After 3-month rehabilitation, the patient admitted to the Vishnevsky National Medical Research Center of Surgery. After additional examination, the patient underwent circular laryngotracheal resection, closure of tracheoesophageal fistula, laryngotracheal reconstruction (laryngotracheal anastomosis by Grillo with thyroid cartilage repair), re-tracheostomy. A favorable outcome was obtained. In such patients, treatment strategy cannot be standardized and require a personalized approach.

Vitamin D deficiency in non-scarring and scarring alopecias: a systematic review and meta-analysis.

Background: Numerous studies have linked vitamin D deficiency (VDD) to the pathogenesis of various alopecia disorders. Objective: This study aimed to investigate whether patients with alopecia are more likely to have VDD or lower vitamin D levels than controls, and the prevalence of VDD among patients with certain alopecia disorders. Methods: Electronic searches were conducted using PubMed, Embase, Scopus, and Cochrane Library databases from the dates of their inception until September 2024. Studies that reported data allowing for the calculation of odds ratios, mean differences, or correlation coefficients related to vitamin D levels and alopecia were included, while studies without a confirmed diagnosis of alopecia or those involving patients taking vitamin D supplements were excluded. Results: It was found that 51.94% of patients with alopecia areata (AA), 50.38% of patients with female pattern hair loss (FPHL), 47.38% of patients with male androgenic alopecia (MAGA), 53.51% of patients with telogen effluvium (TE), and 38.85% of patients with primary scarring alopecia had VDD. Compared to controls, AA patients had a pooled odds ratio (OR) of VDD of 2.84 (95% confidence interval: 1.89-4.26, I2 = 84.29%, p < 0.01) and a pooled unstandardized mean difference (UMD) of vitamin D levels of -8.20 (-10.28 - -6.12, I2 = 74.25%, p < 0.01) ng/mL. For FPHL patients, a pooled OR of VDD of 5.24 (1.50-18.33, I2 = 81.65%, p < 0.01) and a pooled UMD of vitamin D levels of -15.67 (-24.55 - -6.79, I2 = 91.60%, p < 0.01) ng/mL were found. However, for MAGA, a pooled VDD OR of 4.42 (0.53-36.61, I2 = 88.40%, p < 0.01), and a pooled UMD of vitamin D levels of -2.19 ng/mL (-4.07 - -0.31 ng/mL, I2 = 7.64%, p = 0.37) were found. For TE patients, pooled UMD of vitamin D levels of -5.71 (-10.10 - -1.32) ng/mL were found. Conclusion: People with alopecia frequently have VDD; however, only in patients with AA or FPHL was the association of VDD and decreased vitamin D levels statistically significant compared to control. The findings indicate screening for vitamin D could benefit patients with AA or FPHL, potentially addressing vitamin D deficiency. Further study on vitamin D supplementation as a treatment for alopecia is recommended.

Dermatology Update on the Challenging Trichodynia. / Actualización de la tricodinia, un reto para los dermatólogos.

Trichodynia is the sensation of pain in the scalp, which, in most cases, is associated with certain types of alopecia. Despite being a term coined by Rebora back in 1996 to described patients with diffuse alopecia consistent with telogen effluvium, this symptom has currently been reported in other entities. Androgenic alopecia, scarring alopecia, alopecia areata, trichotillomania, and chemotherapy-induced alopecia are common causes of trichodynia. Similarly, its association with psychiatric comorbidities, including depression, anxiety, obsessive-compulsive disorder and somatoform disorders has been reported with a higher prevalence among women. Although its pathogenesis is still to be elucidate, some factors involved are substanceP, psychiatric comorbidities and perifollicular inflammation. Clinically it exhibits pain or discomfort of the scalp, almost always in association with hair los. The sensation of pain can occur throughout the scalp or locally in some specific areas. Diagnosis is clinical and one of exclusion. Regarding treatment, there are no specific therapies for trichodynia. However, the use of botulinum toxinA, antidepressants, neuromodulators, propranolol, topical corticosteroids, oral corticosteroids and topical cannabinoids are therapeutic alternatives that should be taken into consideration. Since treatment of trichodynia is still therapeutically challenging for dermatologists more prospective studies are needed to evaluate new therapies.

Long-term outcomes of eyelash-sparing surgical technique for severe segmental cicatricial entropion.

PURPOSE: To assess the long-term outcomes of segmental entropion correction using anterior lamellar recession (ALR) with mucous membrane graft (MMG). METHODS: Prospective interventional study of 16 patients (mean age, 35.3 ± 16.3 years; 10 females) with severe segmental cicatricial entropion, managed using ALR and MMG. Outcome measures include eyelid and eyelash status, changes in the ocular surface, visual acuity, and cosmetic appearance at a minimum nine months of follow-up. RESULTS: Of 16 patients (16 eyelids), 11 had Stevens-Johnson Syndrome (SJS) and five had chemical injury. The most common location of entropion was medial (87.5%) followed by central and lateral. All patients had severe entropion with trichiatic eyelashes. Anatomical success was 87.5% (14/16) at six weeks of follow-up. Residual trichiasis was managed with a repeat ALR with MMG in one and eyelash resection in the other eyelid. The etiology-wise success rates were 90% in SJS and 80% in chemical injury. At the final mean follow-up of 14.8 months, entropion was corrected in 100% of eyelids. None of the patients had cosmetic concerns. Ocular surface symptomatology and visual acuity improved in 87.5% of patients and 40% of eyes, respectively. CONCLUSION: Anterior lamellar recession with lid margin mucous membrane grafting successfully repairs the severe segmental cicatricial entropion without raising any cosmetic concerns.

The Role of Serology in the Diagnosis of Ocular Predominant Mucous Membrane Pemphigoid and the Search for an Ocular-Specific Autoantigen.

Ocular predominant mucous membrane pemphigoid (oMMP) is a severe subtype of MMP that can lead to scarring and blindness. While conjunctival biopsy for direct immunofluorescence (DIF) is considered the gold standard for diagnosis, limited sensitivity results in a false-negative rate upwards of 40%. Likewise, it remains unclear to what extent a negative biopsy, whether false-negative or true-negative, results in a different prognosis, with patients previously termed "pseudopemphigoid" demonstrating comparable disease progression. Serologic testing allows for a less invasive means to demonstrate circulating autoantibodies against known autoantigens in pemphigoid diseases. Patients with MMP, particularly oMMP, however, typically demonstrate low titers of circulating autoantibodies, limiting the diagnostic utility of these tests. The autoantigen integrin ß4 has been previously reported to be a specific marker of pure ocular MMP, while in the majority of patients with oMMP, the identified target antigens are BP180 (type XVII collagen) and laminin 332. Recent studies have, however, demonstrated inconsistent reactivity and specificity for integrin ß4 as an ocular-specific marker in MMP. Herein, we review the role of serologic testing in the diagnosis and prognosis of oMMP, as well as the current understanding of autoantigens in oMMP.Abbreviations: BMZ - basement membrane zone, DIF - direct immunofluorescence, IIF - indirect immunofluorescence, MMP - mucous membrane pemphigoid, oMMP - ocular predominant mucous membrane pemphigoid.

Hematoporphyrin photodynamic therapy for treatment of pathological scar with ulceration: A case report.

Pathological scars result from abnormal wound healing and represent a fibrotic process in the repair of skin injuries. Post-burn scars are prone to malignant transformation, especially when ulceration occurs, raising concerns for precancerous lesions. We report a case of a 56-year-old female with a 50-year history of a large burn scar on her left forearm. The scar developed non-healing ulceration with local pain and itching over the past three years. Treatment with hematoporphyrin photodynamic therapy (HpD-PDT) led to resolution of the ulceration, thinning of the scar tissue, and significant alleviation of pain and itching. After a five-year follow-up, there has been no recurrence of ulceration, suggesting that photodynamic therapy effectively promotes wound healing in scarred tissue with ulcerations.

Surgical Outcomes of Rhegmatogenous Retinal Detachment Associated with Regressed Retinopathy of Prematurity.

Objectives: To evaluate the characteristics and surgical outcomes of late-onset rhegmatogenous retinal detachment (RRD) associated with regressed retinopathy of prematurity (ROP) and the status of fellow eyes. Materials and Methods: Retrospective review of consecutive cases undergoing surgery for regressed ROP-related RRD and the fellow eyes between 2012-2022. Demographic data, fundus findings, retinal detachment characteristics, surgical procedures, and anatomic and functional outcomes were analyzed. Anatomic success was defined as retinal attachment after silicone oil removal at final follow-up. Results: Fifteen eyes of 14 patients with a history of regressed ROP underwent surgical repair for RRD at a mean age of 12 (range, 3-26) years. Primary surgical intervention yielded a 53% failure rate overall. This rate was 33% for scleral buckling (SB), 100% for pars plana vitrectomy (PPV), and 40% for combined SB-PPV surgery. Eyes with posterior cicatricial changes and/or proliferative vitreoretinopathy (PVR) demonstrated a higher tendency for recurrence. The final anatomic success rate was 73% after a mean number of 2.3 (range, 1-5) surgeries. The chances of restoring useful vision diminished with repeated surgery despite the improvement in anatomic success. In the fellow eyes, peripheral retinal pathologies were universally observed, with posterior cicatricial changes noted in 33%. Conclusion: The study reveals a significant initial failure rate in surgical treatment of cases with late-onset RRD associated with regressed ROP, particularly in eyes with posterior cicatricial changes or PVR, suggesting the need for a combined surgical approach as an initial strategy in such high-risk cases. The consistent presence of retinal abnormalities in fellow eyes calls for proactive monitoring and potential prophylactic intervention.

The Effects of Environmental Pollutants and Exposures on Hair Follicle Pathophysiology.

Background: Environmental exposures profoundly impact cutaneous physiology, with hair follicles (HFs) being particularly vulnerable due to their high levels of proliferation and perfusion. HFs are exposed directly to contaminants that are absorbed transcutaneously and exposed indirectly to ingested and inhaled pollutants via the bloodstream. Summary: Some pollutants, such as particulate matter, trigger inflammatory responses and have been associated with alopecia areata. Others, like tobacco smoke and phthalates, exert endocrine effects with unclear ramifications for HF function. Pesticides and heavy metals have both been linked to alopecia areata and acute anagen effluvium, while polyaromatic hydrocarbons - ligands of aryl hydrocarbon receptors - are linked to androgenetic alopecia. Finally, UV exposure, which has increased due to anthropogenic ozone depletion, causes oxidative damage and perifollicular mast cell degranulation. Key Messages: Pollutants have far-reaching consequences for hair pathology, which remain incompletely characterized. The effects of environmental exposures on HFs are an active area of research that deserve further attention.

Serial Excision Technique to Reduce Cicatricial Alopecia.

Introduction: Cicatricial alopecia (CA) poses a challenge for dermatologists due to irreversible hair follicle damage. While pharmacological treatments offer limited efficacy, surgical interventions aim to improve aesthetic outcomes. This article explores the serial excision technique (SET) as a viable option for stable cases of inflammatory CA. Case Report/Case Presentation: Three adult females with different forms of CA underwent staged surgeries to correct CA patches. Procedures included different incision and closure methods based on individual characteristics such as age, type and extent of alopecia, location, and tissue mobility in the scarred area. Discussion: CA significantly impacts patients' quality of life, demanding comprehensive treatment approaches. SET emerges as an encouraging possibility for stable cases, providing notable cosmetic improvements and enhancing patients' well-being. This technique offers cost-effective benefits with potential standalone efficacy or in combination with hair transplantation, providing promising outcomes for individuals with CA.

Line-field confocal optical coherence tomography: Characteristic hints for the diagnosis of scarring alopecia due to lupus erythematodes: A preliminary study.

INTRODUCTION: Lupus erythematosus (LE) is an inflammatory autoimmune disease, that can affect the skin to varying degree. In particular, discoid LE (DLE) and the rare form of lupus panniculitis/profundus are associated with scarring alopecia. The heterogeneity of the clinical, dermatoscopic, and histologic presentation poses a major challenge to the clinician in the diagnosis and differential diagnosis of other forms of scarring alopecia. OBJECTIVE: While noninvasive imaging techniques using optical coherence tomography (OCT) and reflectance confocal microscopy (RCM) have proven to be helpful in the diagnosis of scarring alopecia in the context of LE, this study aimed to investigate line-field confocal OCT (LC-OCT) to identify characteristic features of cicatricial alopecia in LE. METHODS: Fifteen patients with cicatricial alopecia in LE were included and the most affected/inflamed areas of the scalp were prospectively examined. In analogy to histopathology and previously reported criteria in RCM, all images were evaluated according to seven established criteria and underwent descriptive analyses. RESULTS: LC-OCT revealed characteristic features of cicatricial alopecia, such as lymphocytic interface dermatitis (14/15; 93.3%) and basal cell vacuolization (13/15; 86.7%). The most impressive feature was the occurrence of prominent hyperreflective fibers in 14/15 patients (93.3%). CONCLUSION: LC-OCT imaging can noninvasively detect morphologic criteria such as lymphocytic and vacuolar interface dermatitis of cicatricial alopecia due to LE. In particular, the presence of hyperreflective collagen fibers appears to be a characteristic easily recognizable feature that may facilitate differential diagnosis with other forms of cicatricial alopecia. Further studies are mandatory to differentiate other forms of scarring alopecia.

Dyspnea Due to Laryngeal Cicatricial Pemphigoid: A Case Report.

Cicatricial pemphigoid (CP) is a rare, chronic, vesiculobullous disease characteristically affecting the mucous membranes and healing with cicatrization. Laryngeal involvement is rare and leads to airway stenosis. We present a 74-year-old Caucasian woman with CP, affecting the oral cavity, esophagus, lower eyelids, and larynx. Regardless of regular treatment with hydrocortisone and azathioprine, she developed bilateral cicatrization of the aryepiglottic folds and ovoid stenosis of the laryngeal introitus, leading to dyspnea. To avoid tracheostomy, we were able to utilize infraglottic high-frequency jet ventilation under total intravenous anesthesia to perform a CO2 laser supraglottoplasty with sectioning of the aryepiglottic folds. Post-operatively, her dyspnea at rest resolved; there was no progression at the six- and 12-month follow-up, and she was satisfied with the result.

[Non-standard long-term tracheal stenting with silicone endoprosthesis for cicatricial stenosis]. / Nestandartnoe dlitel'noe stentirovanie trakhei silikonovym endoprotezom pri rubtsovom stenoze.

Endoscopic approach with recanalization and stenting is one of the methods for cicatricial tracheal stenosis. Major complications may occur if service life of stents is not observed. However, there are currently no clear timing for stenting. In world practice, there are no indications on lifelong stenting for cicatricial tracheal stenosis. Restenosis is more common after stent removal and requires repeated stenting or another treatment. In case of prolonged stenting, silicone stent should be periodically replaced with a similar one due to destruction of silicone rubber. As a rule, this maneuver is necessary after 1-3 years. Currently, there is no information about maximum allowable duration of stent without replacement and possible complications. Condition of trachea after prolonged stenting is also unknown. We present long-term (27 years) tracheal stenting with a silicone stent. Stent fragmentation and dislocation throughout this period led to respiratory failure and emergency removal. Tracheal lumen was satisfactory immediately after procedure. However, restenosis appeared after 1.5 months and required endoscopic dilation with discussion of appropriate treatment option. However, the patient refused tracheal resection with anastomosis and underwent repeated stenting with similar stent and favorable immediate result.