Efficacy of Minoxidil Combined With Photobiomodulation for the Treatment of Male Androgenetic Alopecia. A Double-Blind Half-Head Controlled Trial.

BACKGROUND: Androgenetic alopecia (AGA) is a hair loss disorder that frequently affects the male population. Conventional treatment modalities are limited to minoxidil, 5α reductase inhibitors, and hair transplantation procedures. The efficacy of low-level laser therapy (LLLT), also known as photobiomodulation, in the treatment of AGA has been reported, yet little is known about the outcomes of combining photobiomodulation with other conventional therapies. OBJECTIVE: To evaluate hair growth improvement in males with AGA, during the administration of minoxidil with and without photobiomodulation, using a half-head model. STUDY DESIGN/MATERIALS AND METHODS: Twenty-one men with AGA agreed to undergo 12 minutes of low-level laser irradiation (using a modified Capellux®), followed by topical minoxidil application (1 ml of 5% solution), to the affected scalp two times per day for 6 months. The photobiomodulation devices were modified such that the left half emitted light, and the right half did not. Efficacy was assessed by blinded analyses of clinical photos and automated phototrichograms (Trichoscan®) taken before treatment and after 3 and 6 months of therapy. RESULTS: None of the study participants experienced any adverse events. All patients showed improvements in hair coverage on both sides of the scalp at 3 and 6 months. On the side with combined treatments, the number of total hairs was significantly increased after 3 (P < 0.001) and 6 months (P = 0.001). A similar increase was also observed on the minoxidil-only side, at both 3 (P < 0.001) and 6 months (P < 0.001). No statistically significant differences were detected between sides (P > 0.05). CONCLUSION: Additional improvement was not observed with the association of photobiomodulation to topical minoxidil in male AGA. Differences from previous studies that might have influenced our result include non-collimated light source, higher dosimetry, and a cohort with darker skin phototype and more severe alopecia. Lasers Surg. Med. 2021. © 2021 Wiley Periodicals LLC.

Assessment of the Efficacy and Durability of IncobotulinumtoxinA in the Treatment of the Upper Face in Adult Women.

INTRODUCTION: IncobotulinumtoxinA (Xeomin®) is used in the treatment of dynamic wrinkles and the aesthetic repositioning of facial structures. The duration of its muscular effect typically extends for around 4 months. However, the residual aesthetic benefit can be observed for a longer period. To date, the long-term aesthetic benefit of incobotulinumtoxinA in facial aesthetics has not been systematically evaluated. This study aimed to evaluate longitudinally the duration and aesthetic benefits of incobotulinumtoxinA in the treatment of the upper face in adult women. METHODS: A quasi-experimental, evaluator-blind, clinical trial involving 28 adult women (30-60 years old) with facial movement lines, undergoing treatment of the upper face with incobotulinumtoxinA by two injectors, following an individualized protocol (ONE21 and glabellar contraction patterns) was performed. Participants were evaluated on the day of the intervention (day 0) and days 30, 120, 180, and 240, and subjected to standardized photographs. The following outcomes were evaluated blindly at each visit: Merz Aesthetics Facial Contraction Scale (MAS), GAIS (Global Aesthetic Improvement Scale), and patient satisfaction. Adverse effects were evaluated at each visit. RESULTS: Participants ranged in age from 30 to 60 years, 93% were self-declared white, and most of their baseline MAS scores for dynamic lines were moderate and severe. All the parameters presented significative reduction from baseline until day 180. At day 240, the dynamic MAS scores were lower than baseline for forehead lines in 15.4% (95% confidence interval (CI) 0.8-30.0%) of the participants, for glabellar lines in 38.5% (95% CI 18.8-58.1%), and for crow's feet lines in 26.9% (95% CI 9.0-44.8%). Aesthetic improvement compared to baseline was identified in 35% (CI 95% 23‒50%) of the participants at day 240, and 62% (CI 95% 42‒81%) of the sample kept reporting some satisfaction with the procedure. CONCLUSION: The aesthetic treatment of the upper face with incobotulinumtoxinA demonstrates enduring clinical benefits, and patient satisfaction lasting up to 180 days in most participants. The length of efficacy, which exceeded those reported in the literature, may be attributed to the use of techniques based on individualized assessment such as ONE21 and glabellar patterns of contraction.

Normal Trichoscopic Findings after Hair Transplantation in Androgenetic Alopecia: A Prospective Case Series.

Background: Trichoscopy can be very useful for evaluation for hair transplantation (HT), helping rule out simulators of androgenetic alopecia (AGA). There are only a few reports about normal trichoscopic findings after HT. Objective: The aim of this study was to evaluate donor and recipient area trichoscopy after FUE in HT without complications in AGA patients. Method: A prospective study was carried out with 10 patients, for 24 weeks, with photographic follow-up, using FotoFinder®. Patients were evaluated from week 1 (w1) to week 8 weekly, then, at week 12 and week 24 post-HT. Results: Main results were perifollicular crusts, donor area erythema, recipient area erythema, perifollicular erythema, white circles, perifollicular whitish halos, repilation black dots, dystrophic hairs, folliculitis, yellow dots. We discussed the meaning of each of these findings in the period in which they occurred. Conclusion: Normal trichoscopic findings in post-transplant patients have not been well established yet. Our findings are an attempt to define a normal pattern. Future studies with a longer follow-up may be necessary to corroborate these results.

Efficacy and Safety of Scalp Microneedling in Male Pattern Hair Loss.

Introduction: There are few reports involving scalp microneedling in MPHL patients, and in most of them, physical stimulus is associated with other therapeutic agents. The aim of this study was to evaluate the efficacy and risks of isolated scalp microneedling in MPHL patients. Methods: Thirty patients were included in this randomized single-blinded study and submitted to 4 monthly scalp microneedling sessions. Two different microneedling devices were used: roller (n = 15) and tattoo cartridge (n = 15). Scalp coverage and hair density changes were measured 4 and 16 weeks after the last session. Adverse events were observed throughout the study, and scalp biopsies were performed before and after to investigate scarring changes. Results: Four of 12 participants in the roller group and 2 of 14 participants in the tattoo cartridge group showed an improvement in clinical pictures at the first follow-up visit. Only half of these patients sustained an improvement until the last follow-up visit. No benefit in hair density was observed in either group. No reports of adverse events were made. Neocollagenesis and elastolysis were noted in scalp biopsies. Discussion/Conclusion: Isolated scalp microneedling did not show improvement in scalp coverage or hair density of MPHL participants in this study.

Efficacy and Tolerability of Hyperdiluted Calcium Hydroxylapatite (Radiesse) for Neck Rejuvenation: Clinical and Ultrasonographic Assessment.

Background: The subdermal injection of calcium hydroxylapatite (CaHA) can improve the mechanical properties of the skin, providing immediate correction and stimulating the endogenous production of collagen, elastin, angiogenesis, and dermal cell proliferation; however, few studies have examined the neck region. Purpose: This study assessed the clinical and ultrasonographic improvement induced by two sessions of subdermal injection of hyperdiluted (1:4) CaHA for neck rejuvenation in 22 women. Patients and Methods: A quasi-experimental longitudinal trial (before and after) was performed by enrolling 22 adult women with mild and moderate neck aging (grades 1 and 2) on Merz Neck Volume Scale at rest (laxity) and Neck Horizontal Lines. They were submitted to two sessions of subdermal hyperdiluted CaHA (D0 and D45) treatments and assessed clinically and ultrasonographically at D0, D45, and D120. The main outcomes were the blinded photographic assessment (Merz scales of neck laxity and horizontal lines), dermal thickness (at three points), and the GAIS (Global Aesthetic Improvement Scale) score. Results: The mean (SD) age was 43.5 (5.6) years. At the inclusion, the Merz scores for neck laxity were mild for 27% and moderate for 73% of participants, and the Merz scores for necklines were mild for 32% and moderate for 68%. At D120, scores decreased in 86% (95% CI 68-99%) of the participants by at least one degree on the necklines scale and in 82% (95% CI 73-90%) for neck laxity. According to the GAIS, 91% (95% CI 77-99%) of the participants evidenced improvement at D120. The mean dermal thickness increased by 15% (95% CI 8-21%) at D120. No severe adverse effects were recorded, and high satisfaction was reported by 82% of the participants. Conclusion: Two sessions of subdermal hyperdiluted CaHA were well-tolerated and improved necklines, neck laxity, and dermal thickness in adult women with mild and moderate cervical aging.

Reconstruction of Scalp Anterior Hairline with Tissue Expansion and Skin Flap.

Introduction: Cutaneous defects involving the frontal region and anterior hairline of the scalp can result from congenital or acquired conditions. The negative esthetic impact can cause disturbances in the psychic and social sphere of the patient, causing problems in interpersonal relationships and in the body image itself. The use of skin expanders is usually effective in this region due to the bone base providing support and stability for its use. Case Report: We describe the case of a 64-year-old woman submitted to reconstruction of the anterior hairline of the scalp due to scar sequelae after coronal rhytidoplasty followed by pustular erosive dermatosis. We used tissue expansion (50 mL of saline per week until it reached 300 mL) and advancement flap. Discussion/Conclusion: Scalp reconstruction also includes vascularized soft tissue coverage, acceptable cosmetic appearance, and minimal morbidity for the donor area. The correction of scalp scars must obey 2 basic principles: tissue similarity and natural capillary pattern (direction, angle, capillary growth, and proper capillary line design). Tissue expansion and skin flap techniques can successfully correct defects in extensive scarring alopecia such as in the presented case.

Acute telogen effluvium triad after resolution.

Five cases of telogen effluvium undergoing resolution are shown, with the presence of frontal, bitemporal, and occipital hair regrowth. Diagnosing acute telogen effluvium after the end of the active phase can be challenging, especially when the pull test is negative. The differential diagnosis includes alopecia areata and traction alopecia. Clinical signs of hair regrowth after telogen effluvium can help in the diagnosis. The frontal and temporal areas have more telogen hairs and are more affected. On the occipital area, hairs seem to have the same behavior. The acute telogen effluvium triad during resolution is proposed: frontal fringe, temporal recess and occipital fringe.

Anagen Effluvium after Therapeutic Scalp Surgery: Unreported Phenomenon.

INTRODUCTION: Many procedures are performed on the scalp, such as excision of pilar and sebaceous cysts, melanocytic nevi, and reduction surgery for scarring alopecia, among others. In hair transplants, telogen effluvium is often reported 3 months after surgery; however, hair loss usually happens much earlier, around second week after the procedure, not compatible with the time required for hair to enter telogen and exogenous phases in normal conditions. CASE REPORTS: We report 3 cases of anagen hair loss 4 weeks after surgeries, with perilesional trichoscopy suggesting anagen effluvium, with typical signs such as black dots and exclamation hairs. DISCUSSION: There are only a few reports about hair loss around operated areas. The cause of this postoperative anagen effluvium is probably a transient ischemia. CONCLUSION: The practical importance of this phenomenon is to properly orient patients because most of the hair will be lost, since 85% of them are anagens, and also will have spontaneous recovery in the next 3 months.

Histopathological Findings of Uncomplicated Hair Transplant for Male Androgenetic Alopecia: Can Lichen Planopilaris Features Be Present?

INTRODUCTION: Insufficient hair growth after hair transplant, as well as erythema and perifollicular scaling, may be diagnosed as lichen planopilaris and treated as such based on clinical and histopathological findings. The purpose of this study is to observe graft biopsies of patients after uncomplicated hair transplants and to discuss if histological findings are enough to diagnose lichen planopilaris. METHODS AND RESULTS: Eight patients diagnosed with androgenetic alopecia who were submitted to hair transplant were enrolled. In each of the participants, a scalp biopsy was performed in the receptor area and in the adjacent area. Biopsies were performed between 6 months and 1 year after surgery. Exams were analyzed by 3 pathologists. The t test was performed for paired observations, comparing the transplanted and the nontransplanted area for lymphocytic infiltrate and fibrosis. The significance level was considered as 5% (p < 0.05). Four of 8 participants had perifollicular lymphocytic infiltrate, from moderate to dense intensity in the recipient area. Fibrosis was seen in 6 patients. These findings were not seen in the control area. CONCLUSIONS: It is questioned whether lymphocytic infiltrate and fibrosis may be expected in patients who are submitted to normal hair transplants.

Frontal Fibrosing Alopecia Coexisting with Lupus Erythematosus: Poor Response to Hydroxychloroquine.

Lupus erythematosus, especially the discoid form, and lichen planopilaris may be associated and can occur in different topographies (coexistence) or in the same lesion (lupus eythematosus/lichen planus overlap syndrome). Frontal fibrosing alopecia is considered a variant form of lichen planopilaris and is characterized by frontotemporal hairline and eyebrow involvement. Of the association with lupus erythematosus we have only a few descriptions. Hydroxychloroquine and chloroquine diphosphate are antimalarial drugs described as viable treatment options for both diseases, due to an antilymphocytic effect. The association between frontal fibrosing alopecia and lupus erythematosus (discoid or systemic) is reported in this article, showing a progressive alopecia in the frontotemporal hairline despite treatment with hydroxychloroquine.

Patchy Frontal Fibrosing Alopecia: Description of an Incomplete Clinical Presentation.

We describe 6 incomplete cases of frontal fibrosing alopecia (FFA). All patients were postmenopausal women. Their average age was 60 years; 2 of the women were Caucasian, and the remaining 4 women were of a mixed ethnicity. The disease duration ranged from 3 to 17 years. The patients' lesions presented as irregular alopecic plaques in the frontal and/or temporal regions, with few signs of perifollicular inflammation, slow progression, and progressive loss of the vellus hair in the frontal area. Loss of the eyebrows, facial hyperpigmentation, and loss of the body hair were observed in 3 patients, 1 patient, and 2 patients, respectively. Localized pruritus and dysesthesia were reported in 5 patients and 3 patients, respectively. Dermatoscopic examination indicated the absence of viable ostia at the centers and edges of the lesions and the absence of peripilar erythema; moreover, peripilar hyperkeratosis was less intense than it would be expected in classical cases of lichen planopilaris (LPP) and FFA. Histological examination revealed that all cases featured the presence of a perifollicular lichenoid infiltrate in the infundibulum and isthmus as well as concentric areas of fibrosis. All samples were subjected to direct immunofluorescence (DIF), which produced negative results. FFA has been recently diagnosed and is considered a subtype of LPP. FFA can present with incomplete clinical manifestations, a histology similar to LPP, and negative DIF findings. The correct diagnosis of FFA-associated lesions is critical for providing appropriate treatment, developing prognostic definitions, and excluding other types of scarring and nonscarring alopecia. The diagnosis of incomplete FFA is essential to avoid diagnostic and therapeutic errors.

Acute telogen effluvium triad after resolution

Abstract Five cases of telogen effluvium undergoing resolution are shown, with the presence of frontal, bitemporal, and occipital hair regrowth. Diagnosing acute telogen effluvium after the end of the active phase can be challenging, especially when the pull test is negative. The differential diagnosis includes alopecia areata and traction alopecia. Clinical signs of hair regrowth after telogen effluvium can help in the diagnosis. The frontal and temporal areas have more telogen hairs and are more affected. On the occipital area, hairs seem to have the same behavior. The acute telogen effluvium triad during resolution is proposed: frontal fringe, temporal recess and occipital fringe.

Ensaio clínico cego randomizado comparando MMP®, MMP® com 5-FU e injeção intradérmica de 5-FU para o tratamento da hipomelanose gutata idiopática: um estudo- piloto / A single blind, randomized clinical trial comparing MMP®, MMP® with 5-FU, and 5-FU intradermal injection for the treatment of idiopathic guttate hypomelanosis: a pilot study

Introdução: A hipomelanose gutata idiopática (IGH) é uma manifestação comum de fotoenvelhecimento, ainda sem tratamento padrão, apresentando resultados variados às intervenções. Atualmente, no Brasil, o uso de microagulhamento associado ao 5-fluorouracil (5-FU) tem sido proposto para o tratamento da IGH. Objetivo: Comparar três tratamentos, quais sejam: o uso do MMP® (microinfusão de medicamentos na pele) com 5-FU, MMP® apenas para microagulhamento, e com o 5-FU intralesional injetado com seringa de insulina no tratamento da IGH. Métodos: Em um ensaio clínico randomizado e cego, comparamos o MMP® ao 5-FU com: microagulhamento isolado e com 5-FU intralesional por punção para o tratamento de 180 lesões de IGH no antebraço de nove pacientes. Resultados: Após duas sessões de tratamento, o 5-FU intralesional foi o tratamento mais efetivo, com significância estatística quando comparado ao uso de microagulhamento. A eficácia da MMP + 5-FU foi inferior a 5-FU injetável e superior ao microagulhamento isoladamente, embora sem significância estatística. Conclusões: A aplicação intralesional do 5-FU foi mais eficaz no tratamento da leucodermia solar. O uso de menor quantidade de medicamentos é a grande vantagem da técnica MMP + 5-FU. São necessários mais estudos para padronizar estas técnicas.

Introduction: Idiopathic guttate hypomelanosis (IGH) is a common photoaging manifestation, with no standard treatment and presenting mixed results to interventions. In Brazil, the use of micro-needling associated with 5-fluorouracil (5-FU) has been proposed to treat IGH. Objective: To compare the use of MMP® (micro-infusion of drugs on the skin) with 5-FU, with MMP® only as micro-needling (with no drugs), and intralesional 5-FU injected with an insulin syringe in the treatment of IGH. Methods: In a single blind randomized clinical trial, we compared the three treatments: MMP® versus MMP with 5-FU and intralesional 5-FU injection for 180 IGH lesions in the forearm of nine patients. Results: After two treatment sessions, 5-FU alone was the most effective treatment, with statistical significance, compared with micro-needling alone. MMP+5-FU efficacy was lower than intralesional 5-FU injection and higher than micro-needling alone, although without statistical significance. Conclusions: The intralesional application of 5-FU was more effective in the treatment of solar leukoderma. The use of a smaller quantity of medication is the great advantage of the MMP + 5-FU technique. Further studies are needed to standardize these techniques.