What can the hair tell us about COVID-19?

The novel viral pandemic coronavirus disease 2019 (COVID-19) has sparked uncertainties as to its origin, epidemiology and natural course. The study of the cutaneous manifestations of COVID-19 has evolved with the hope that they may be useful as markers for the disease, prognostication and pathogenic insights into the disease. With regard to the hair, clinicopathological correlations have remained elusive. More recently, androgenetic alopecia and grey hair have been proposed as cutaneous markers for elevated severity risk. So far, we have only observed postinfectious effluvium in a causal association with COVID-19. The onset and acuity of hair shedding depended on the clinical severity of disease. There was complete recovery of hair.

Fibrosing alopecia in a pattern distribution.

BACKGROUND/OBJECTIVES: Fibrosing alopecia in a pattern distribution (FAPD) is a newly recognized form of scarring alopecia sharing characteristics of both androgenetic alopecia (AGA) and lichen planopilaris. The existing literature on FAPD and current understanding of the epidemiology, pathogenesis, clinical features, diagnosis, and treatment of this disease are reviewed. METHODS: PubMed searches were performed to identify all articles discussing FAPD. The references of articles were used to identify additional articles. RESULTS: A total of 15 articles were found describing FAPD in a total of 188 patients (164 women and 24 men; average age, 53.8). CONCLUSIONS: FAPD affects the androgen-dependent scalp and is typically associated with hair follicle miniaturization. The scalp affected by FAPD shows features of both lichen planopilaris and AGA, and FAPD may possibly represent an exaggerated inflammatory response to damaged hair follicles, triggered by AGA. Physical examination and trichoscopic evidence of follicular inflammation and, occasionally, fibrosis are important to identify the condition, and a dermoscopy-guided biopsy can confirm the diagnosis. Unless recognized, clinicians may misdiagnose FAPD as AGA associated with seborrheic dermatitis. Data on treatment modalities are limited; however, based on pathogenesis, combined therapy with anti-inflammatory and hair growth-promoting agents is warranted.

Oxidative stress and its impact on skin, scalp and hair.

Oxidative stress is an unbalanced condition in which the tissues of the body are not sufficiently able to counteract either exogenous or endogenous sources of reactive oxygen species. Oxidative stress is strongly associated with ageing, both local and systemic, as well as a wide range of local health conditions. This review focuses on the oxidative stress data known for skin, scalp and hair. This oxidative stress may be the 'currency' by which an unhealthy scalp leads to deleterious consequences to the hair. The ramifications of this scalp oxidative stress to normal hair elongation, retention and replacement are discussed.

Le stress oxydatif est une condition déséquilibrée dans laquelle les tissus du corps ne sont pas suffisamment capables de contrer la source exogène ou endogène d'espèces réactives de l'oxygène. Le stress oxydatif est fortement associé au vieillissement, à la fois local et systémique, ainsi qu'à un large éventail de problèmes de santé locaux. Cette revue se concentre sur les données de stress oxydatif connues pour la peau, le cuir chevelu et les cheveux. Ce stress oxydatif peut être la « devise ¼ par laquelle un cuir chevelu malsain entraîne des conséquences délétères pour les cheveux. Les ramifications de ce stress oxydatif du cuir chevelu sur l'allongement, la rétention et le remplacement normaux des cheveux sont discutées.

Understanding Pattern Hair Loss-Hair Biology Impacted by Genes, Androgens, Prostaglandins and Epigenetic Factors.

Pattern hair loss (PHL) is the most frequent cause of hair loss in men and women, accounting for 65% of consultations in a hair referral center. PHL is understood to represent a hereditary, age-dependent progressive thinning of the scalp hair, which follows distinct clinical patterns with notable differences depending on sex and age of onset. Clinical and investigative advances have helped us to understand some of the pathogenic steps, leading to PHL. Besides genetic factors and peculiarities of androgen metabolism, additional pathogenic factors that are suspected include microbiomata, oxidative stress, and microinflammation. While further suspects are likely to be exposed, individual diversity of causal agents, as well as of the sequence of events, or combined factors, must be kept in mind. A large number of therapeutic molecules claimed to be active and patented in this field, and their limited efficacy in offering a definitive cure of PHL confirm the complexity of PHL. The aim of therapy is to retard progression of hair thinning and increase hair coverage of the scalp. As yet, two FDA-approved drugs are available for this purpose, oral finasteride, and topical solution of minoxidil. Variations in posology and formulation allow for an enhancement of patient comfort and treatment efficacy. Antiandrogen treatments in women with normal androgen levels have questionable efficacy while having health risks.

Tretinoin enhances minoxidil response in androgenetic alopecia patients by upregulating follicular sulfotransferase enzymes.

Minoxidil sulfate is the active metabolite required to exert the vasodilatory and hair growing effects of minoxidil. For hair growth, sulfotransferase enzymes expressed in outer root sheath of the hair follicle sulfonate minoxidil. The large intra-subject variability in follicular sulfotransferase was found to predict minoxidil response and thus explain the low response rate to topical minoxidil in the treatment of androgenetic alopecia. A method to increase minoxidil response would be of significant clinical utility. Retinoids have been reported to increase minoxidil response. The purported mechanism of action was retinoid modulation of skin permeation to minoxidil; however, evidence to the contrary supports retinoids increase dermal thickness. In order to elucidate the effect of topical retinoids on minoxidil response, we studied the effect of topical tretinoin on follicular sulfotransferase. In this study, we demonstrate that topical tretinoin application influences the expression of follicular sulfotransferase. Of clinical significance, in our cohort, 43% of subjects initially predicted to be nonresponders to minoxidil were converted to responders following 5 days of topical tretinoin application. To the best of our knowledge, this is the first study to elucidate the interaction mechanism between topical minoxidil and retinoids and thus provides a pathway for the development of future androgenetic alopecia treatments.

High Relapse Rates Despite Early Intervention with Intravenous Methylprednisolone Pulse Therapy for Severe Childhood Alopecia Areata.

BACKGROUND: Previous data suggest that early application of intravenous methylprednisolone pulse therapy (IV-MPPT) may improve the disease course of alopecia areata. The objective of this study was to investigate the outcome of IV-MPPT in severe childhood alopecia areata, predominantly with short disease duration. METHODS: Eighteen children (10 girls, 8 boys) younger than 17 years old (median age 7.7 yrs, range 2.1-16.5 yrs) treated with IV-MPPT for severe childhood alopecia areata in a referral center for pediatric dermatology over 3 years (median disease duration 4 mos, range 1-12 mos) were retrospectively evaluated. Five patients had alopecia areata totalis or universalis and 13 had alopecia multilocularis. The median scalp area affected by alopecia was 60% (range 30%-100%). All patients underwent two or three cycles of IV-MPPT at monthly intervals (maximum 500 mg/day on three consecutive days). RESULTS: Within 7 months after the last IV-MPPT session, 10 of 18 children had good response (≥75% of hair regrowth), with eight showing improvement within the first 4 months. Of the remaining eight patients, one had moderate response (50%-74% regrowth), three had poor response (1%-49% regrowth), and four (all with alopecia areata universalis or totalis) had no response. Seven of the initial 10 good responders experienced relapses, with marked hair loss after the last IV-MPPT session. The estimated median time to relapse was 8 months (95% confidence interval 7, 9 mos). CONCLUSION: IV-MPPT, even early in the course of disease, did not affect long-term outcome of alopecia areata in our group of severely affected patients.

A narrative review of fixed combination calcipotriol/betamethasone aerosol foam (Enstilar®) in the management of psoriasis with scalp involvement.

The scalp is the most common site affected in patients with psoriasis with up to 80% of these patients having some degree of scalp involvement. In this narrative review, we evaluate available data on the use of an innovative aerosol foam formulation of calcipotriol plus betamethasone dipropionate (Cal/BD) to treat patients with psoriasis and scalp involvement. The full PubMed database was searched using the terms "calcipotriol", "betamethasone dipropionate" and "aerosol foam", and all articles relating to "psoriasis with scalp involvement" were retrieved and used in the preparation of this review. The evidence supporting the clinical effectiveness, tolerability and impact on health outcomes of Cal/BD aerosol foam in patients with scalp psoriasis was obtained from a phase II clinical trial and real-world evidence data from a non-interventional study as well as from two case series. The findings from these studies show that Cal/BD aerosol foam is rapidly effective, improves skin condition, alleviates symptoms such as itch, and has a positive impact on patient quality of life. These attributes address several unmet needs for patients with psoriasis with scalp involvement and have the potential to improve individual adherence to treatment.

Efficacy of Calcipotriol/Betamethasone Dipropionate Fixed-Combination Aerosol Foam in the Treatment of Localized Scalp Psoriasis: A Real-Life Case Series from Switzerland.

INTRODUCTION: Scalp psoriasis is one of the most common and challenging manifestations of plaque psoriasis for general practitioners, dermatologists, and patients, as successful topical management requires the choice of effective ingredients, an appropriate formulation, and clear application instructions to patients. To date, only limited experience is available for the calcipotriol (50 µg/g)/betamethasone dipropionate (0.5 mg/g) aerosol foam formulation (Cal/BD foam) in the treatment of scalp psoriasis. METHODS: In this Swiss real-world patient case series, we asked 10 consecutive patients with active scalp psoriasis to apply the Cal/BD foam once daily before bedtime for a period of 4 weeks. Clear application and rinse-off instructions were provided. RESULTS: A total of 10 consecutive adult patients were treated between April and May 2019. Two patients suffered from mild, five from moderate, and three from severe scalp psoriasis. In eight out of the 10 patients, scalp psoriasis was the only manifestation of disease. All patients had received previous topical treatments, mainly topical corticosteroids (TCS), tar shampoo, and salicylic acid. After 4 weeks of treatment with Cal/BD foam, the scalp psoriasis improved in all 10 patients by ≥ 2 points on a 5-point severity assessment scale. Eight out of 10 patients achieved clear/almost clear skin after 4 weeks of treatment, with no further keratolytic treatments needed. Adverse events were not observed in any of the patients. Overall, patients were very satisfied with the ease of use, the efficacy, and the safety of the Cal/BD foam. CONCLUSION: Our case series confirms that Cal/BD foam is a rapid, effective, and convenient treatment for localized scalp psoriasis in a nonselected real-world patient cohort refractory to TCS or other local treatments. Clear application instructions are crucial for treatment success and cosmetic acceptance, however.

How to Deal with the Issues of Fertility, Malignancies, and the Postfinasteride Syndrome while Prescribing Finasteride for Male Pattern Hair Loss.

Oral finasteride represented a breakthrough for treatment of male pattern hair loss (MPHL), with clinical studies having demonstrated high efficacy of treatment and a favorable safety profile. And yet, fertility issues, malignancy, and postfinasteride syndrome have been concerns of users and prescribers of the drug. Pre-existing mental health disorder may put patients at an increased risk of nocebo, while the prevalence of personality disorders in subjects with MPHL is known to be higher than in the general population, specifically histrionic personality disorder. We devised a system for patient selection and risk assessment, including fertility issues, regular PSA determinations, and specific mental health assessment. For those who choose regular prostate cancer screening, the use of finasteride meaningfully reduces the risk of prostate cancer. While gynecomastia is a known, rare adverse effect of finasteride, so far, studies support the view that exposure to finasteride is not associated with male breast cancer risk. Patient understanding and involvement are central to optimal treatment selection and active patient role in treatment.

Not So Uncommon Cause of Foot Pain: Cutaneous Hair Splinter of the Sole.

Introduction: A fragment of hair penetrating the skin has been referred to as cutaneous pili migrans in the literature. The condition is regarded rare and the cause unknown. Case Presentation: A 55-year-old female experienced painful sensations of the sole. Dermoscopy revealed hair fragments penetrating the skin, and histopathology a hair shaft embedded in the stratum corneum. The hairs were mechanically extracted with immediate relief from the pain. Discussion and Conclusion: Hair splinters of the sole may be a cause of foot pain related to the skin. The hair splinter is yet another form of hair that has embedded itself in the skin. Patients may believe the hair is growing out of the feet, while the soles are among the specialized skin regions that are hairless. The origin of the hair is exogenous and related to an exposure to freshly cut human or animal hair. Cutaneous embedded hairs can be classified based on the clinical presentation, the location, and association with hair follicles into hair splinters, interdigital pilonidal sinus, migrating hair, or ingrown hair. The condition is an important cause of foot pain and should be considered on clinical examination of the skin of the soles.

Herpes simplex virus reactivation as a complication of photodynamic therapy.

We report the case of an 81-year-old male patient who developed a reactivation of herpes simplex virus localized to the right forehead, where photodynamic therapy (PDT) for actinic keratosis was performed. Considering the wide use of PDT, herpes virus infection or reactivation as well as other infections seem to be a very rare but potentially serious complication that has to be distinguished from common inflammatory reactions after PDT. Further applications of PDT under antiviral prophylaxis were well tolerated by our patient, with no further herpetic reactivation and successful treatment of actinic keratoses.

Trichodynia Revisited.

Trichodynia refers to the painful sensation of the scalp related to the complaint of hair loss. Originally suggested to be distinguishing for telogen effluvium and related to hair loss activity and follicular inflammation, further studies have found trichodynia to be common in androgenetic alopecia as well and coexisting with psychopathologic findings. The respective studies failed to demonstrate correlations between trichodynia and quantifiable hair loss activity, nor histopathologic evidence for follicular inflammation. A symptomatic scalp is a frequent condition in specific dermatological conditions of the scalp. By definition of exclusion, we are not dealing with trichodynia in these cases. It is conceivable that neuropeptides are key players between the central nervous system and the skin immune and microvascular system. Such mechanisms would explain the noxious effects of both external stimuli and emotional distress in eliciting cutaneous nociception. Since we have begun to understand the diverse etiologies of trichodynia, and a single term does not measure up to this circumstance, it may be wiser to describe the condition depending on the type of scalp sensation and its specific disease association. Further studies are warranted into the neural/endothelial/follicular interactions both in hair growth and shedding and the psychosomatic diseases of the hair and scalp.

Control of widespread hypertrophic lupus erythematosus with T-cell-directed biologic efalizumab.

BACKGROUND/AIMS: Hypertrophic lupus erythematosus (HLE) produces not only disfiguring and long-lasting skin changes, but also proves to be particularly resistant to therapy. In a patient with a disease refractory to conventional therapy, we observed a predominantly CD4+ T cell infiltrate that we sought to target therapeutically. METHODS: The patient was treated with the CD11a-directed monoclonal antibody efalizumab together with 10 mg isotretinoin and 5 mg prednisone. RESULTS: Within 6 months, the inflammatory hyperkeratotic plaques were almost completely healed, with minimal residual erythema and scarring. The cutaneous lupus activity and severity index score decreased from 8 to 4 of a total of 14 points, and pseudoepitheliomatous hyperplasia and CD4 T cell infiltrates within the lesions were reduced. CONCLUSION: HLE features interface dermatitis and epidermal hyperplasia, which are both explainable by T-cell-mediated immunologic effects. Correspondingly, our case responded well to the treatment with efalizumab. While the withdrawal of efalizumab from the market leaves patients with psoriasis many other options for effective therapy, it disproportionately affects patients with T-cell-mediated orphan diseases like refractory HLE.

Ecthyma-gangrenosum-like bullous pemphigoid.

Bullous pemphigoid (BP) is a chronic, autoimmune, subepidermal blistering skin disease with varied clinical presentations. Diagnosis is based on the clinical picture, histopathological findings, and direct and indirect immunofluorescence studies. In unclear cases, ELISA or Western blot analysis helps to establish a definite diagnosis by the detection of immunoglobulin G autoantibodies specific for the hemidesmosomal BP antigens BP230 and BP180. We report 3 cases of BP with an as yet not characterized, distinctive ecthyma-gangrenosum-like presentation. Patients were female, above 80 years of age, physically immobile, and skin lesions showed truncal localization and bacterial colonization. Factors contributing to physical immobility were a high body mass index, psychiatric disease, sedative medication and rheumatic disease. The clinical picture resembled ecthyma gangrenosum but lacked systemic infection with Pseudomonas aeruginosa. Lesional bacteriological studies revealed Staphylococcusaureus and/or P. aeruginosa. Diagnosis proved challenging in all cases. Suspicion has to be high, and repeated diagnostic procedures and additional laboratory studies may be necessary to establish a definitive diagnosis of BP. In summary, we propose this combination of truncal ecthyma-gangrenosum-like lesions with bacterial colonization in the context of older age and immobility as a clinically distinct presentation or variant of BP.