European expert consensus statement on the systemic treatment of alopecia areata.

Alopecia areata is an autoimmune form of non-scarring hair loss. It is usually characterized by limited areas of hair loss. However, the disease may progress to complete scalp and body hair loss (alopecia totalis, alopecia universalis). In patients with alopecia areata hair loss significantly impacts the quality of life. Children and adolescents with alopecia areata often experience bullying, including physical aggression. The disease severity evaluation tools used in clinical practice are: the Severity of Alopecia Tool (SALT) score and the Alopecia Areata Scale (AAS). A SALT score equal to or greater than 20 constitutes a commonly accepted indication for systemic therapy in alopecia areata. When using the AAS, moderate to severe alopecia areata should be considered a medical indication for systemic treatment. Currently, the only two EMA-approved medications for alopecia areata are baricitinib (JAK 1/2 inhibitor) for adults and ritlecitinib (JAK 3/TEC inhibitor) for individuals aged 12 and older. Both are EMA-approved for patients with severe alopecia areata. Other systemic medications used off-label in alopecia areata include glucocorticosteroids, cyclosporine, methotrexate and azathioprine. Oral minoxidil is considered an adjuvant therapy with limited data confirming its possible efficacy. This consensus statement is to outline a systemic treatment algorithm for alopecia areata, indications for systemic treatment, available therapeutic options, their efficacy and safety, as well as the duration of the therapy.

Position statement: Recommendations on the diagnosis and treatment of Malassezia folliculitis.

Malassezia is a lipophilic yeast that is a part of the human mycobiome. Malassezia folliculitis appears when the benign colonization of the hair follicles, by the Malassezia yeasts, becomes symptomatic with pruritic papules and pustules. Although Malassezia folliculitis is common in hospital departments, diagnosing and treating it varies among dermatologists and countries. The European Academy of Dermatology and Venereology Mycology Task Force Malassezia folliculitis working group has, therefore, sought to develop these recommendations for the diagnosis and management of Malassezia folliculitis. Recommendations comprise methods for diagnosing Malassezia folliculitis, required positive findings before starting therapies and specific treatment algorithms for individuals who are immunocompetent, immunocompromised or who have compromised liver function. In conclusion, this study provides a clinical strategy for diagnosing and managing Malassezia folliculitis.

Self-induced nail disorders (SINDs): What do we know so far?

Self-induced nail disorders are a broad group of different clinical manifestations that share the common trait of being caused more or less voluntarily by the patient. These are distinct conditions within the clinical spectrum of onychotillomania. Most patients diagnosed with these disorders have psychiatric co-morbidities, and a multidisciplinary approach is thus highly recommended. The purpose of this review is to describe the most common clinical features encountered during daily nail consultations and to provide useful diagnostic tools and therapeutic tips for the best approach to these conditions.

Scalp dysaesthesia and lichen simplex chronicus: diagnostic and therapeutic update with literature review.

Scalp dysaesthesia, considered a variant of the cutaneous dysaesthesia syndrome, is characterized by chronic sensory symptoms, including pruritus, pain, burning and stinging in a well-defined location, without objective findings. Its aetiology is not well elucidated and treatment options are limited, thus it can be challenging and frustrating for both patient and physician. It can be associated with lichen simplex chronicus. In this paper, we review the literature on the pathogenetic factors, diagnostic methods and therapeutic options in the management of scalp dysaesthesia. Dissociation, cervical spine disease and muscle tension seem to be the most important pathogenetic factors. Trichoscopy, reflectance confocal microscopy and biopsy are all helpful for the diagnosis of the disease. Therapies include high-potency topical or intralesional corticosteroids, capsaicin and topical anaesthetics, sedative antihistamines, tricyclic antidepressants, transcutaneous electric nerve stimulation, botulinum toxin and vitamin B12.

Efficacy and safety of topical finasteride spray solution for male androgenetic alopecia: a phase III, randomized, controlled clinical trial.

BACKGROUND: Oral finasteride is a well-established treatment for men with androgenetic alopecia (AGA), but long-term therapy is not always acceptable to patients. A topical finasteride formulation has been developed to minimize systemic exposure by acting specifically on hair follicles. OBJECTIVES: To evaluate the efficacy and safety of topical finasteride compared with placebo, and to analyse systemic exposure and overall benefit compared with oral finasteride. METHODS: This randomized, double-blind, double dummy, parallel-group, 24-week study was conducted in adult male outpatients with AGA at 45 sites in Europe. Efficacy and safety were evaluated. Finasteride, testosterone and dihydrotestosterone (DHT) concentrations were measured. RESULTS: Of 458 randomized patients, 323 completed the study and 446 were evaluated for safety. Change from baseline in target area hair count (TAHC) at week 24 (primary efficacy endpoint) was significantly greater with topical finasteride than placebo (adjusted mean change 20.2 vs. 6.7 hairs; P < 0.001), and numerically similar between topical and oral finasteride. Statistically significant differences favouring topical finasteride over placebo were observed for change from baseline in TAHC at week 12 and investigator-assessed change from baseline in patient hair growth/loss at week 24. Incidence and type of adverse events, and cause of discontinuation, did not differ meaningfully between topical finasteride and placebo. No serious adverse events were treatment related. As maximum plasma finasteride concentrations were >100 times lower, and reduction from baseline in mean serum DHT concentration was lower (34.5 vs. 55.6%), with topical vs. oral finasteride, there is less likelihood of systemic adverse reactions of a sexual nature related to a decrease in DHT with topical finasteride. CONCLUSION: Topical finasteride significantly improves hair count compared to placebo and is well tolerated. Its effect is similar to that of oral finasteride, but with markedly lower systemic exposure and less impact on serum DHT concentrations.

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.

Clinical and trichoscopic features in various forms of scalp psoriasis.

BACKGROUND: Scalp psoriasis is often undiagnosed or inadequately treated. The patient himself underestimates the seriousness of this hair disease and consults too late to a dermatologist. OBJECTIVES: The aim of our study was to create a correlation between the clinical patterns and trichoscopy of scalp psoriasis such in a way to help the clinician to make the diagnosis and select the appropriate therapy. MATERIAL AND METHODS: We gathered all patients affected of scalp psoriasis afferent to Outpatient's hair consultation of the Department of Experimental, Diagnostic and Specialty Medicine, University of Bologna, from January 2012 to December 2018. All patients were evaluated through clinical, trichoscopic examination and a skin biopsy only in doubtful cases. We quantified the severity of the disease with several objective and subjective parameters every 4 months, up to 1 year. We recorded therapies, outcome data and quality of life. RESULTS: We collected 156 patients affected by scalp psoriasis, identifying seven clinical patterns with specific trichoscopical correlation. In the order of frequency, the clinical patterns were as follows: plaque psoriasis (with a prevalence of erythema, silver-white scales and twisted red loops vessels and red dots); thin scales (with silvery-white scales, simple red lines and signet red ring vessels); sebopsoriasis (with greasy scales, erythema with red dots, globules and twisted and bushy red loops at high magnification); psoriatic cap (with silver-white scales, erythema and polymorphic vascular pattern); pityriasis amiantacea (with yellowish adherent scales, erythema and simple red loops capillaries); cicatricial psoriatic alopecia (with erythema associated with yellowish, silver-white scales with twisted and bushy red loops capillaries) and pustular psoriasis (with 'flower shape' pustular lesions, erythema simple red loops capillaries). CONCLUSIONS: The description of different clinical patterns of scalp psoriasis and its trichoscopical correlations may help the clinician to make the diagnosis also in atypical presentations and to prescribe an adequate therapeutic regimen.

Common causes of hair loss - clinical manifestations, trichoscopy and therapy.

The field of hair disorders is constantly growing. The most important hair diseases are divided in non- cicatricial and cicatricial ones. Non-cicatricial alopecia are more frequent than cicatricial alopecia. The first step is to obtain a good history and physical examination. Laboratory testing is often unnecessary, while trichoscopy is fundamental for all hair diseases. Scalp biopsy is strongly suggested in cicatricial alopecia and in doubtful cases. Androgenetic alopecia, alopecia areata, telogen effluvium, trichotillomania are common causes of non- cicatricial alopecia. Frontal fibrosing alopecia, discoid lupus erythematosus, lichen planopilaris, follicullitis decalvans are some of the most common forms of cicatricial hair loss. Many treatments are available, and a prompt diagnosis is very important for the prognosis.

The value of dermoscopy of the nail plate free edge and hyponychium.

The non-invasive examination of the nail unit using a dermoscope is known as onychoscopy. This technique has become increasingly appreciated to facilitate the clinical diagnosis of nail disorders, opening up a valuable second front with a potential to avoid invasive diagnostic procedures. During a nail consultation, the nail unit should always be examined with the aid of a dermatoscope in all its components. The aim of this paper was to provide practical information about onychoscopy of the nail plate free edge and hyponychium, two components of the nail unit difficult to evaluate at naked eye and often forgotten, but of paramount importance.

Current controversies in trichology: a European expert consensus statement.

INTRODUCTION: Hair disorders are one of the most common conditions within dermatology practice but, although new diagnostic tools and therapeutic options have arisen, the management of these patients still represents a major clinical challenge. OBJECTIVE: This study aimed at gathering information and achieving consensus on relevant recommendations on the latest advances in alopecia, trichoscopy and hair dermocosmetics. METHODS: Experts of the steering committee consulted the available evidence on trichology-related areas from the past 5 years and formulated recommendations based on the evidence and their experience. A modified two-round Delphi procedure was performed among 45 European dermatologists experts in trichology to consult their degree of agreement on twenty recommendations, using a 4-point Likert scale. Consensus was defined as >80% of participants scoring either 1 (totally agree) or 2 (agree). RESULTS: In the first round of the Delphi questionnaire, 75% of the recommendations reached consensus. Those that were not agreed upon were reformulated by the steering committee and voted again after an online meeting, where consensus was achieved in all recommendations. CONCLUSIONS: All recommendations reached consensus after the two-round Delphi questionnaire and may be useful in clinical practice for dermatologists. The participants agreed that besides this consensus, further clinical studies are needed to assess the benefits of the emerging tools and treatments and to clarify the controversies that still exist in the field, aiming at improving patients' quality of life.

Emerging antifungal treatment failure of dermatophytosis in Europe: take care or it may become endemic.

BACKGROUND: Dermatophytosis is a world-wide distributed common infection. Antifungal drug resistance in dermatophytosis used to be rare, but unfortunately the current Indian epidemic of atypical widespread recalcitrant and terbinafine-resistant dermatophytosis is spreading and has sporadically been reported in Europe. OBJECTIVES: To explore the occurrence of clinical and mycological proven antifungal drug resistance in dermatophytes in Europe. METHODS: A standardized questionnaire was distributed through the EADV Task Force of Mycology network to dermatologists in Europe. RESULTS: Representatives from 20 countries completed the questionnaires of which 17 (85 %) had observed clinical and/or mycological confirmed antifungal resistance, two countries published cases of antifungal resistance and one country had no known cases. CONCLUSIONS: This pilot study confirms that both clinical and mycological antifungal resistance exist in Europe.

Trachyonychia: a retrospective study of 122 patients in a period of 30 years.

BACKGROUND: Trachyonychia is a nail disease characterized by longitudinal striations, ridges, fissures and/or pitting. This condition can be both idiopathic and associated with other dermatologic diseases. OBJECTIVE AND METHODS: The aim of this retrospective study was to analyse the clinical features, onychoscopy, therapy efficacy and outcome of 122 patients with trachyonychia visited at the Hair Disease Outpatient Consultations of the Dermatology Unit of the Department of Experimental, Diagnostic and Specialty Medicine of the University of Bologna, from 1988 to 2018. RESULTS: Opaque trachyonychia was the most observed type while shiny trachyonychia, less common, was present especially in milder cases. Pitting was the most frequently observed feature (80.3%), followed by koilonychia (45%) and hyperkeratosis (19.6%). Nail matrix longitudinal biopsy was performed for diagnosis confirmation in 29 cases, and spongiotic was the most common pattern. Topical therapy was prescribed in 109 patients while systemic treatments were reserved for severe cases (38 patients); 22 patients did not receive any treatment. A marked improvement in the appearance of the nails or even a total resolution was seen in 63 patients. CONCLUSIONS: Trachyonychia can occur at any age but is more frequent in children and often associated with alopecia areata. The pathological diagnosis of trachyonychia is not mandatory as the disease has generally a benign outcome. Considering the absence of pain and the high rate of spontaneous resolution, treatment is often prescribed only for cosmetic reasons or reserved for severe cases.

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.

Erosive pustular dermatosis of the scalp: a multicentre study.

BACKGROUND: Erosive pustular dermatosis of the scalp (EPDS) is characterized by crusted erosions or superficial ulcerations that lead to scarring alopecia. OBJECTIVES AND METHODS: We performed a multicentre retrospective clinical study including 56 patients (29 females and 27 males, mean age 62.7) with a confirmed EPDS in order to describe epidemiology, clinical findings and therapeutic choices of this disease. RESULTS: Mechanical/chemical trauma was reported in 28.6%, a previous infection in 10.7%, a previous cryotherapy in 5.4% androgenetic alopecia in 48.2% and severe actinic damage in 25%. Trichoscopy showed absence of follicular ostia, tufted and broken hair, crusts, serous exudate, dilated vessels, pustules and hyperkeratosis. Histopathology revealed three different features, depending on the disease duration. The most prescribed therapy was topical steroids (62.5%), followed by the combination of topical steroids and topical tacrolimus (8.9%), systemic steroids (7.1%) and topical tacrolimus (5.4%). A reduction of inflammatory signs was observed in 28 patients (50%) treated with topical steroids and in all three patients treated with topical tacrolimus. CONCLUSION: The relatively high number of patients collected allowed us to identify a better diagnostic approach, using trichoscopy and a more effective therapeutic strategy, with high-potency steroids or tacrolimus, which should be considered as first-line treatment.

Frontal fibrosing alopecia: a case series of 65 patients seen in a single Italian centre.

BACKGROUND: Frontal fibrosing alopecia (FFA) is increasing in prevalence worldwide and several series from different countries have been published, in order to detect possible causes of the disease outbreak. OBJECTIVE: To analyze the epidemiological, clinical and trichoscopic features of FFA seen in an Italian Dermatology Unit. METHODS: Clinical, trichoscopy, histopathology and medical details of all patients were compared with literature and general population data. RESULTS: From 2005 to 2017, we diagnosed FFA in 65 Caucasian females, with the number of diagnoses per year progressively rising. Premenopausal onset was detected in 21%. Frontal hair line recession was associated with parietal involvement in 80% of cases, occipital in 12.3% and eyebrows alopecia in 86.1%. In six cases, eyebrow alopecia preceded hair loss. Non-inflammatory facial papules were detected in 1/3 of the patients. Itching was reported by 2/3 of the patients and was indicative of disease progression. Trichoscopy showed empty follicles/yellow dots, absence of follicular ostia, mild follicular hyperkeratosis, perifollicular erythema and 'lonely hair'. Scalp lichen plano-pilaris was seen in 15 patients, female pattern hair loss in 22. Therapy included short-term treatment with systemic or intralesional corticosteroids followed by therapy with 5α-reductase inhibitors of hydroxychloroquine and topical drugs. Arrest of FFA progression was seen in 75% of the patients, while 16 experienced worsening of the hairline despite therapy. CONCLUSIONS: Frontal fibrosing alopecia not rarely starts before menopause, loss of the eyebrows can be the first sign of the disease, about 50% of the patients have other autoimmune conditions, FFA severity is not related to its duration, itching, follicular hyperkeratosis and erythema at trichoscopy are signs of disease progression, 25% of the patients show progression of hairline recession despite therapy.

HrQoL in hair loss-affected patients with alopecia areata, androgenetic alopecia and telogen effluvium: the role of personality traits and psychosocial anxiety.

BACKGROUND: Illness impact on HrQoL has been widely studied in hair loss-affected patients, yet no study has addressed whether individual differences modulate HrQoL in patients with alopecia areata (AA), androgenetic alopecia (AGA) and telogen effluvium (TE). OBJECTIVE: To identify the personality dimensions most predictive of the impact of disease on HrQoL. METHOD: A single-site cross-sectional study was carried out in the Dermatology Unit of Sant'Orsola-Malpighi Hospital, Bologna between September 2016 and September 2017. The study included 143 patients (105 females, ages 18-60 years) diagnosed with AA (n = 27), AGA (n = 80) and TE (n = 36). Illness severity, alopecia type, age, gender, education and civil status were documented. Health-related quality of life (HrQoL), personality traits, trait anxiety, emotional intelligence, social anxiety and social phobia were also measured. RESULTS: AA, AGA and TE groups differed significantly for illness severity with most severe patients falling in AA type. For HrQoL, Gender × Group interaction resulted significant with AGA females reporting a higher impact of hair loss on quality of life than males, while TE males were more impacted by hair loss than AA and AGA males. Lower scores were obtained by AGA females than males on emotional intelligence while no significant differences were evidenced on other groups. A significant Gender × Group interaction was also found for trait anxiety, social phobia and social anxiety: consistently, AGA females reported higher scores than AGA males in all three measures. Finally, discriminant analysis evidenced that anxiety-related traits can contribute to reliably predict hair loss impact on HrQoL, regardless of illness severity and alopecia type. CONCLUSIONS: We recommend that gender and individual differences in anxiety-related dimensions be considered as key factors in gaining a deeper understanding of hair loss impact on quality of life as well as in reducing the burden of illness in alopecia-affected patients.

Onychoscopy with red light for vascular pattern identification: a study of 33 patients.

BACKGROUND: Nail dermoscopy (onychoscopy) during physical examination assists in correct diagnosis. Often further magnifications are necessary for an effective differential diagnosis. With the addition of a red light to the dermoscope, important vascular features can be visualized. OBJECTIVE: To describe common features observed at onychoscopy with a new device that combines the regular white light with the red light illumination, demonstrating that it is useful for diagnosis of nail disorders. METHODS: We enrolled 33 consecutive patients referred to the Nail Diseases Dermatology Unit of the University of Modena and Reggio Emilia and to the Outpatient Consultation for Nail Disease of the Dermatology Unit of the University of Bologna. Patients were assessed with a standard hand-held dermoscope and at the red light dermoscope. Dermoscopic images were collected. RESULTS: The new prototype was used during daily clinical practice and allowed a more accurate visualization of some details that classic onychoscopy can miss. In particular, with the help of the red light it was possible to better visualize nail lesions that were characterized by some kind of colour change or vascular alterations. CONCLUSION: The new device of red light for vascular pattern onychoscopy can be a new investigation method to observe nail alterations, especially due to vascular pattern, even with low magnification, without the necessity to use higher resolutions.

A survey among dermatologists: diagnostics of superficial fungal infections - what is used and what is needed to initiate therapy and assess efficacy?

BACKGROUND: Superficial fungal infections are common. It is important to confirm the clinical diagnosis by mycological laboratory methods before initiating systemic antifungal treatment, especially as antifungal sensitivity and in vitro susceptibility may differ between different genera and species. For many years, the gold standard for diagnosis of superficial fungal infections has been direct fungal detection in the clinical specimen (microscopy) supplemented by culturing. Lately, newer molecular based methods for fungal identification have been developed. OBJECTIVE: This study was initiated to focus on the current usage of mycological diagnostics for superficial fungal infections by dermatologists. It was designed to investigate whether it was necessary to differentiate between initial diagnostic tests and those used at treatment follow-up in specific superficial fungal infections. METHODS: An online questionnaire was distributed among members of the EADV mycology Task Force and other dermatologists with a special interest in mycology and nail disease. RESULTS: The survey was distributed to 62 dermatologists of whom 38 (61%) completed the whole survey, 7 (11%) partially completed and 17 (27%) did not respond. Nearly, all respondents (82-100%) said that ideally they would use the result of direct microscopy (or histology) combined with a genus/species directed treatment of onychomycosis, dermatophytosis, Candida- and Malassezia-related infections. The majority of the dermatologists used a combination of clinical assessment and direct microscopy for treatment assessment and the viability of the fungus was considered more important at this visit than when initiating the treatment. Molecular based methods were not available for all responders. CONCLUSION: The available diagnostic methods are heterogeneous and their usage differs between different practices as well as between countries. The survey confirmed that dermatologists find it important to make a mycological diagnosis, particularly prior to starting oral antifungal treatment in order to confirm the diagnose and target the therapy according to genus and species.