Guidelines for clinical trials of frontal fibrosing alopecia: consensus recommendations from the International FFA Cooperative Group (IFFACG).

BACKGROUND: Frontal fibrosing alopecia (FFA) has become one of the most common causes of cicatricial alopecia worldwide. However, there is a lack of clear aetiology and robust clinical trial evidence for the efficacy and safety of agents currently used for treatment. OBJECTIVES: To enable data to be collected worldwide on FFA using common criteria and assessment methods. METHODS: A multicentre, international group of experts in hair loss was convened by email to create consensus recommendations for clinical trials. Consensus was defined at > 90% agreement on each recommended part of these guidelines. RESULTS: Standardized diagnostic criteria, severity rating, staging, and investigator and patient assessment of scalp hair loss and other clinical features of FFA were created. CONCLUSIONS: These guidelines should allow the collection of reliable aggregate data on FFA and advance efforts in both clinical and basic research to close knowledge gaps in this condition.

Alopecia totalis and universalis long-term outcomes: a review.

Alopecia totalis (AT) and universalis (AU) represent the most severe subtypes of alopecia areata with more dramatic features and worse prognosis. The goal of this review is to identify all studies with long-term prognostic data on patients with AT and AU and provide a long-term outcome estimate. The PubMed database was queried to identify all articles discussing the long-term prognosis of AT and AU. A total of nine articles discussing long-term recovery rates of AT and AU were identified. The articles described 689 (162 = AT, 245 = AU, 282 = not specified) total patients. Six of the nine studies identified complete recovery as a potential end point in a total of 375 (39 = AT, 75 = AU, 261 = not specified) patients. According to these studies 8.5% (32/375) of AT and AU patients achieved complete recovery. A larger proportion of patients will obtain at least transient recovery periods of partial or total hair regrowth. The poor long-term outcomes of AT and AU may cause patients to lose hope with treatment. Response to treatment is often unpredictable, and physicians should be aware of the prognosis and its effects in order to properly counsel patients.

Onychomycosis: a review.

Onychomycosis is a fungal infection of the nail, causing discoloration and thickening of the affected nail plate, and is the most common nail infection worldwide. Onychomycosis was initially thought to be predominantly caused by dermatophytes; however, new research has revealed that mixed infections and those caused by non-dermatophyte moulds (NDMs) are more prevalent than previously thought, especially in warmer climates. Microscopy and fungal culture are the gold standard techniques for onychomycosis diagnosis, but high false-negative rates have pushed for more accurate methods, such as histology and PCR. As NDMs are skin and laboratory contaminants, their presence as an infectious agent requires multiple confirmations and repeated sampling. There are several treatment options available, including oral antifungals, topicals and devices. Oral antifungals have higher cure rates and shorter treatment periods than topical treatments, but have adverse side effects such as hepatotoxicity and drug interactions. Terbinafine, itraconazole and fluconazole are most commonly used, with new oral antifungals such as fosravuconazole being evaluated. Topical treatments, such as efinaconazole, tavaborole, ciclopirox and amorolfine have less serious side effects, but also have generally lower cure rates and much longer treatment regimens. New topical formulations are being investigated as faster-acting alternatives to the currently available topical treatments. Devices such as lasers have shown promise in improving the cosmetic appearance of the nail, but due to a high variation of study methods and definitions of cure, their effectiveness for onychomycosis has yet to be sufficiently proven. Recurrence rates for onychomycosis are high; once infected, patients should seek medical treatment as soon as possible and sanitize their shoes and socks. Prophylactic application of topicals and avoiding walking barefoot in public places may help prevent recurrence.

Optical coherence tomography in diagnosis of inflammatory scalp disorders.

BACKGROUND: The common inflammatory scalp disorders share similar clinical manifestations, and patient work up require invasive, undesirable diagnostic procedures like biopsy to ensure correct diagnosis. Optical coherence tomography (OCT) is a non-invasive high-resolution imaging modality that has found a valuable tool to assist in the diagnose and evaluation of different skin diseases. OBJECTIVES: To describe the structural and vascular dynamic OCT (D-OCT) findings of inflammatory scalp disorders including scalp psoriasis, seborrhoeic dermatitis and contact dermatitis and to compare trichoscopy and OCT features. METHODS: Subjects with diagnosis of seborrhoeic dermatitis, psoriasis or contact dermatitis were enrolled in this study. OCT scans were taken on involved scalp, and the same scalp regions were evaluated by trichoscopy and compared with healthy scalp. RESULTS: A total of fourteen subjects (two healthy controls, four seborrhoeic dermatitis, five psoriasis and three contact dermatitis) participated. D-OCT imaging of vascular pattern in healthy scalp and the inflammatory scalp disorders were described. D-OCT images could enhance the clinician's ability to distinguish psoriasis from seborrhoeic dermatitis by objectively detect and assess red loop density. In scalp contact dermatitis, the vessels of the deep plexus were more dilated and fewer in number than those found in seborrhoeic dermatitis. CONCLUSION: Dynamic OCT provides information that more clearly elucidates changes at the level of the superficial and deep plexuses without invasively interfering with superficial structures. In the context of inflammatory scalp disorders, this is useful to discern disorders with overlapping symptoms and minimize the use of invasive biopsies to diagnose.

Pterygium inversum unguis secondary to gel polish.

BACKGROUND: Pterygium inversum unguis (PIU) is characterized by the abnormal adherence of the hyponychium to the ventral surface of the nail plate. It can be both unsightly and painful, resulting in morbidity for patients. Gel polish is a popular nail cosmetic that has been reported to cause several complications. PIU may be another adverse outcome. OBJECTIVE: To highlight a newly recognized adverse effect of a popular beauty technique. METHODS: This retrospective and prospective case series reports 17 women who developed PIU after gel polish use. All study-related activities occurred at a University of Miami dermatology outpatient clinic. RESULTS: All 17 subjects developed PIU after two to five years of gel polish application. Nine of 17 patients reported using both UVA and LED light to cure gel polish. Of the remaining eight, five used LED light only and three did not know or could not remember. All but two patients had a resolution of PIU a few weeks after switching from gel polish to regular polish manicures. CONCLUSION: While it remains undiscerned whether PIU is related to chemicals present in the gel polish or to the application and/or removal process of such, patients and dermatologists should be aware of the potential risks of gel manicures.

Microneedling for the treatment of hair loss?

Microneedling is a minimally invasive dermatological procedure in which fine needles are rolled over the skin to puncture the stratum corneum. This therapy is used to induce collagen formation, neovascularization and growth factor production of treated areas. It has been used in a wide range of dermatologic conditions, including androgenetic alopecia (AGA) and alopecia areata, among others. While there are a limited number of studies examining this therapy in the use of hair loss, microneedling has been successfully paired with other hair growth promoting therapies, such as minoxidil, platelet-rich plasma and topical steroids, and shown to stimulate hair follicle growth. It is thought that microneedling facilitates penetration of such first-line medications, and this is one mechanism by which it promotes hair growth. To date, the area most studied and with the most success has been microneedling treatment of AGA. While the current evidence does not allow one to conclude superiority of microneedling over existing standard therapies for hair loss, microneedling shows some promise in improving hair growth, especially in combination with existing techniques. This review summarizes the current literature regarding microneedling in the treatment of alopecia and calls for further studies to define a standard treatment protocol.

Optical coherence tomography for the investigation of frontal fibrosing alopecia.

BACKGROUND: Frontal fibrosing alopecia (FFA) is a cicatricial alopecia that affects the frontotemporal hairline, eyebrows and body hair. OCT is a non-invasive imaging technique useful in understanding skin architecture and vascularization. OBJECTIVE: To describe structural and vascular findings in FFA using OCT. METHODS: This was a case-control study conducted from the months of December 2016-February 2017. The study was IRB approved and conducted at the University of Miami Hospital outpatient dermatology hair and nail clinic in Miami, FL. Four patients with biopsy proven FFA, and three healthy age and sex-matched controls participated. OCT scans were taken on cicatricial alopecic band, inflammatory hairline, eyebrow, uninvolved scalp, facial papules, glabellar red dots and arm. The same body regions were evaluated in controls. RESULTS: Patients and controls were women aged 42-66. Results reveal epidermal thickness is increased in the inflammatory hairline (0.13 mm) and decreased in the alopecic band (0.08 mm) compared to controls (0.10 mm). Attenuation coefficient increased the inflammatory hairline and decreased in the alopecic band compared to controls. Vascular flow in the alopecic band is decreased compared to inflammatory scalp and controls in the superficial levels, but increased at deeper levels as compared to controls. Inflammatory tissue is consistently more vascular at all levels (P < 0.01). Vascular flows in each stage are significantly different than one another (P < 0.01). CONCLUSIONS: Increased vascular flow of the deep plexus in cicatricial stages can be a consequence of superficial tissue ischaemia or fibrosis. It is difficult to establish if the increased flow in the inflammatory stage is due to neovascularization as seen in other ischaemic diseases or is the result of the inflammatory response. OCT may be a useful non-invasive tool in imaging FFA. Not only can the technology assist in monitoring disease activity in a non-invasive manner, but it may elucidate new pathophysiologic findings.

Evidence-based (S3) guideline for the treatment of androgenetic alopecia in women and in men - short version.

Androgenetic alopecia is the most common hair loss disorder, affecting both men and women. Initial signs of androgenetic alopecia usually develop during teenage years leading to progressive hair loss with a pattern distribution. Moreover, its frequency increases with age and affects up to 80% Caucasian men and 42% of women. Patients afflicted with androgenetic alopecia may undergo significant impairment of quality of life. The European Dermatology Forum (EDF) initiated a project to develop evidence-based guidelines for the treatment of androgenetic alopecia. Based on a systematic literature research the efficacy of the currently available therapeutic options was assessed and therapeutic recommendations were passed in a consensus conference. The purpose of the guideline is to provide dermatologists with an evidence-based tool for choosing an efficacious and safe therapy for patients with androgenetic alopecia.

Tinea capitis in children: a systematic review of management.

BACKGROUND: Tinea capitis is the most common cutaneous fungal infection in children. OBJECTIVES: This review aims to evaluate the differences that exist between medications for the treatment of tinea capitis, to determine whether there are any significant adverse effects associated and to define the usefulness of sample collection methods. METHODS: We conducted a systematic literature search of available papers using the databases PubMed, OVID, Cochrane Libraries and ClinicalTrials.gov. Twenty-one RCTs and 17 CTs were found. RESULTS: Among the different antifungal therapies (oral and combination thereof), continuous itraconazole and terbinafine had the highest mycological cure rates (79% and 81%, respectively), griseofulvin and terbinafine had the highest clinical cure rates (46% and 58%, respectively) and griseofulvin and terbinafine had the highest complete cure rate (72% and 92%, respectively). Griseofulvin more effectively treated Microsporum infections; terbinafine and itraconazole more effectively cured Trichophyton infections. Only 1.0% of children had to discontinue medication based on adverse events. T. tonsurans was the most common organism found in North America, and hairbrush collection method is the most efficient method of sample collection. Additionally, using a hairbrush, toothbrush or cotton swab to identify the infecting organism(s) is the least invasive and most efficient method of tinea capitis sample collection in children. CONCLUSIONS: Current dosing regimens of reported drugs are effective and safe for use in tinea capitis in children.

Towards a consensus on how to diagnose and quantify female pattern hair loss - The 'Female Pattern Hair Loss Severity Index (FPHL-SI)'.

BACKGROUND: Female pattern hair loss (FPHL) is a common non-scarring alopecia characterized by widening of the midline hair part at the crown (vertex). In 1977, Ludwig developed a scale that graded the degree of visible vertex hair thinning from I (least severe) to III (most severe). However, by the time patients exhibit the full manifestations of 'Ludwig I', they have already lost a significant volume of hair. Although current therapies may realistically halt progression of hair loss, improvements in hair density is often more limited. Identification and grading of FPHL at an earlier stage is desirable to institute appropriate therapy before significant hair loss has occurred and to enable monitoring over time. AIM: To generate consensus guidance for the recognition and quantification of FPHL that can be used in the clinic. METHODS: Nine clinicians from Europe, North America and Australia experienced in the management of FPHL developed this scale by consensus. RESULTS: We propose a three-point severity scale (termed the FPHL Severity Index (FPHL-SI)) that combines validated measures of hair shedding, midline hair density and scalp trichoscopy criteria to produce a total FPHL-SI score (maximum score = 20). The score is designed to grade FPHL severity over time, while being sufficiently sensitive to identify early disease. A score of 0-4 makes FPHL unlikely; a score of 5-9 would indicate early-stage FPHL, with higher scores indicating greater disease severity. CONCLUSIONS: As a starting point for further public debate, we employ criteria already used in clinical practice to generate a pragmatic FPHL grading system (FPHL-SI) of sufficient sensitivity to identify and monitor early FPHL changes. This may have to be further optimized after systematic validation in clinical practice.