A Comment on Mercantilism in the Trichological Sciences.

A quasi-scientific interest in hair loss and hair care originated in a London barbershop, and became known as trichology, with the Institute of Trichologists being founded. Other corporations successively followed, offering paid courses by home-study for training of initiates who desire more knowledge about hair. Trichologists are not medically qualified but are taught the practice of care and treatment of the hair and scalp in health and disease within their restricted but specialized role. With the advent of opportunities in the social media, and of epiluminiscence microscopy, a procedure practiced by the guild of trichologists long before its nominal introduction as trichoscopy into dermatologic practice, representatives of the medical profession are following the example of the trichologists in offering online courses, though with a better understanding of clinical-pathological correlations based on their academic learning. Despite the enthusiasm emerging with its establishment as a dermatologic tool in the diagnosis of hair and scalp disorders, caution is warranted not to elevate trichoscopy to something like a fetish status. As a diagnostic procedure, trichoscopy is to be understood as representing an integral part of a comprehensive dermatological examination. The Hippocratic Oath is one of the oldest binding documents in history, allegedly still held sacred by physicians: to treat the ill to the best of one's ability, to preserve a patient's privacy, and to teach the secrets of medicine to the next generation without fee. And yet, as in no other field of medicine, paid online courses on trichoscopy are flourishing and with a primary commercial aim. However, dermato-trichology, or trichiatry require the same due diligence as any other medical discipline, with respect to its practice and its ethics. Medical artistry is neither reducible to a single hand-held diagnostic technique nor is it negotiable.

Efficacy, Tolerability, and Superiority of Propylene Glycol-Free, North American Witch-Hazel (Hamamelis virginiana)-Based Solution of 5% Minoxidil Sulfate for the Treatment of Female Androgenetic Alopecia.

Background: Androgenetic alopecia leads to progressive hair loss in susceptible individuals if left untreated. Topical minoxidil represents an evidence-based treatment for female androgenetic alopecia, though with variable success. Aims and Objectives: Treatment of minoxidil non-responders remains challenging, as does treatment of patients with propylene glycol sensitivity or irritable scalp syndrome. Materials and Methods: Single-center, retrospective cohort of 50 female patients with androgenetic alopecia failing to respond to a minimum of 6 months of standard 5% topical minoxidil solution either once daily or b.i.d. depending on the severity of the alopecia. Patients were switched to propylene glycol-free, North American Witch Hazel (Hamamelis virginiana)-based solution of 5% minoxidil sulfate (5% minoxidil sensitive solution). Efficacy and safety of treatment were evaluated, including stereotactic global photography and epiluminiscence microscopy with digital imaging taken at baseline, at 3, and at 6 months of treatment. Results: 70% of patients showed observable clinical improvement with combined global photographic and epiluminiscence microscopic assessment with digital imaging, and 22% epiluminiscence microscopic-only improvement as evidence of treatment efficacy. The treatment was well tolerated, particularly in patients with propylene glycol sensitivity and patients with irritable scalp syndrome. Conclusions: These results suggest that propylene glycol-free, North American witch hazel (Hamamelis virginiana)-based solution of 5% minoxidil is effective and safe for treatment of female androgenetic alopecia, specifically in minoxidil non-responders and patients with propylene glycol sensitivity or irritable scalp syndrome.

Comment on Topical Dapsone for Folliculitis Decalvans.

Folliculitis decalvans (FD) represents a chronic and recurrent pustulofollicular scalp inflammation resulting in scarring alopecia. The presence of a bacterial bioflilm at the interface of the hair shaft may provide an explanation for the chronicity and high relapse rate of FD, even after prolonged systemic antibiotic treatments. We originally read with enthusiasm Melián-Olivera et al.'s retrospective study of patients with FD treated with topical dapsone published in the Journal of the American Academy of Dermatology. However, we experienced an unsuccessful trial of 5% dapsone gel in a patient with FD resulting in worsening of the disease with a pustular flareup and questioned why positive study reports with novel therapeutic options in dermatology often fail in practice. The authors admitted the limitations of their study: small sample size, retrospective, uncontrolled nature of the study, and concomitant use of other treatments. Clinical research ultimately aims at improving the patient outcome. For this purpose, trials must evaluate the outcomes that genuinely reflect the clinical utility of drugs. Therefore, we postulate stricter criteria for treatment trials and statistics in dermatology before publication in peer-reviewed scientific journals to avoid frustrations of physicians and patients alike.

The Problem with Capitalism in the Trichological Sciences.

Karl Marx and Friedrich Engels exposed a pattern of societal conduct they chose to name capitalistic bourgeoisie. The bourgeoisie created a common language of communication through collaboration, gathered in circles such as free academies, scientific academies, literary circles, and the media, that provided forums for the emerging bourgeoisie to conceive of new social orders. One aspect of bourgeoisie culture is conspicuous consumption, central to which, is a culture of prestige through material consumption. Capitalism is an economic system based on private ownership and the operation for profit. Characteristic features of capitalism include competitive market, commercialism, property rights recognition, capital accumulation, material consumption, culture of prestige, sycophancy, and coterie. Critiques of capitalism allege that it is exploitative, alienating, unstable, unsustainable, and inefficient. In turn, critical theory inspired philosophers such as Michel Foucault to conceptualize how we form identities through social interaction. When the patient's body entered the field of medicine, it also entered the field of power where the patient can be manipulated by professional authority. Without forcibly being a proponent of political theory, as an academic, one is inevitably confronted with Marxism in terms of philosophy. As a discipline at the interface of medicine, lifestyle, and cosmetics, trichology is particularly susceptible to the primary aims of profit, consumption, and prestige that characterize the capitalistic bourgeoisie. The trichological sciences, particularly trichoscopy, have discovered a profitable market for itself. The practice of trichology is not immune to malpractice. It has created an industry that dwells on the autistic thinking of patients and doctors, and because it is prosperous, makes propaganda among lay people and doctors that necessarily leads to abuses.

Targeted Nutritional Supplementation for Telogen Effluvium: Multicenter Study on Efficacy of a Hydrolyzed Collagen, Vitamin-, and Mineral-Based Induction and Maintenance Treatment.

Background: The condition of the hair is closely related to the nutritional state. Normal supply, uptake, and transport of nutrients are of fundamental importance in tissues with a high biosynthetic activity such as the hair follicle. Objective: The objective of the study was to evaluate the efficacy of a nutritional-based induction and maintenance treatment for telogen effluvium formulated with a combination of hydrolyzed collagen, amino acids, vitamins, and minerals. Patients and Methods: The clinical studies were conducted with each nutritional treatment individually, and both in sequential combination. Anagen/telogen ratio, hair density, and tolerability of treatment were assessed at baseline, 4 weeks of induction therapy, and another 12 weeks of maintenance treatment. Trichogram results showed a significant improvement of the anagen/telogen ratio between baseline and final visit at 16 weeks, with an increase of hair in anagen and a reduction of hair in telogen. Furthermore, a significant increase was observed in hair density. The effect size of the combination treatment was higher than that of each of the two products used separately as monotherapy. Conclusions: The study results provide a proof of concept for targeted nutritional supplementation for the treatment of telogen effluvium, with a special emphasis on the role of collagen, besides specific amino acids, vitamins, and minerals.

Alopecic and Aseptic Nodules of the Scalp: A New Entity or a Minor Form of Dissecting Cellulitis?

Since the original report in 1992 and revised nomenclature in 2009, pseudocysts of the scalp and alopecic and aseptic nodules of the scalp (AANS), respectively, have been regarded as a new entity that is rare and not understood in its pathogenesis. We observed 26 cases of AANS. Except for the extent and severity of disease, we found no single feature that justifies distinguishing AANS as a nosologic entity in its own right from dissecting cellulitis of the scalp (DCS). The scarring alopecias represent a diverse group of disorders with the potential of permanent destruction of the pilosebaceous unit and hair loss. Within the maze of varied conditions leading to scarring alopecia, the most important is to keep a neat nosologic classification in mind, based both on morphology and a pathogenic understanding. We believe that AANS represents a minor form of DCS, so far predominantly observed in patients of non-African origin, and therefore, is a disease of follicular occlusion with a favorable prognosis.

Saint Rita of Cascia: Patron Saint for Women with Frontal Fibrosing Alopecia?

Roman Catholic tradition has made Saints the protectors of various aspects of life. Christian hagiography deals with the account of the Saints' lives and passion, and Christian iconography with the Saints' depiction in religious art. Catholic churches are full of images of Saints. Appreciation of religious art is deepened by knowledge of what is depicted. Saints are only sometimes labeled with their names. The clues to their identity are rather given in their appearance or in what they are holding. St. Rita of Cascia (1381-1457) is a Saint venerated in the Roman Catholic Church and bestowed the title of Patroness for impossible causes. Various miracles have been attributed to her. In Christian iconography, she is depicted with a bleeding forehead wound and sometimes holding a thorn. The forehead wound is understood to represent partial religious stigmatization and external sign of mystical union with Christ. In our opinion, it is at the same time reminiscent of the thorn frontal fibrosing alopecia represents to women affected with the condition, and its treatment with intralesional triamcinolone injections along the frontal hairline, much alike the forehead wounds caused by the crown of thorns. Few practices of the Catholic Church are so misunderstood as the devotion to patron Saints. Nevertheless, Saints help to find community and to break out of the isolation, anonymity, and dumbness of modern society. The communion of Saints is a spiritual union, in which each member shares in the welfare of all. The patron Saints help to believe in the possibility of miracles and miraculous healings. Ultimately, the exemplary lives of the Saints show us how salvation can be the positive effect of suffering.

Autistic-Undisciplined Thinking in the Practice of Medical Trichology.

Medical trichology is the branch of dermatology that deals with the scientific study of the hair and scalp in health and disease. As any discipline, the practice of medical trichology is not immune to malpractice, either deliberately or carelessly. In his publication "Autistic Undisciplined Thinking in Medicine and How to Overcome It," Swiss psychiatrist Eugen Bleuler describes yet another form of malpractice in medicine reflecting autistic-undisciplined thinking. Autism is not limited to psychopathology, but inherent to the thinking of man throughout history in his drive for knowledge, with thousands of theories lacking any basis in reality. Bleuler recognized the drive character of autistic thinking and how it leads to conclusions that are unshakable because they are determined by, and fulfill, emotional needs, rather than rational argumentation. Even with correct questions, the complexity and incalculability of some problems are often so great that it cannot do justice to realistic thinking and the boundaries between inadequately substantiated hypothesis and autistic sham explanation disappear. Statistics, careful research design, and the attempt to impose stringent methods on our thinking are to be commended. The habituation of the public to useless medicine, to misconceptions, is not hygiene, but negligent endangerment. It has created an industry that largely lives on the autistic thinking of patients and doctors and because it is prosperous, makes propaganda among lay people as well as among doctors that necessarily leads to abuses. This article aims at exposing the most prevalent among abuses in trichological practice due to autistic-undisciplined thinking, specifically: iron supplementation, antiandrogenic treatment, and individualized cell-based therapy in female androgenetic alopecia, treatment of folliculitis decalvans with retinoids, and the value of nutritional therapies.

Lichen Planopilaris Caused by Wig Attachment: A Case of Koebner Phenomenon in Frontal Fibrosing Alopecia.

Frontal fibrosing alopecia (FFA) represents a distinctive condition with a marginal scarring alopecia along the frontal and temporal hairline. Since its original description, the condition has been recognized to represent a more generalized than localized process, with extension beyond the frontotemporal hairline to include the parieto-occipital hairline and involve peculiar facial papules as evidence of facial vellus hair involvement and loss of peripheral body hair. Finally, the association of FFA with oral lichen planus, nail involvement, and concomitant lichen planopilaris (LPP) points to a close relationship to lichen planus. The Koebner phenomenon or isomorphic reaction has been described in lichen planus, LPP, and ultimately FFA, with face-lift procedures and hair restoration surgery having been implicated as the culprits in the latter. We report the first case of FFA in whom LPP developed at the sites of wig attachments, providing the evidence for Koebner phenomenon. Therefore, wigs are to be included to the list of procedures for hair restoration at risk of eliciting an isomorphic reaction in patients with FFA. Ultimately, the association of Koebner phenomenon with LPP-type lesions in FFA may provide further insight into the underlying pathology and nosology of the condition.

A Comment on JAK Inhibitors for Treatment of Alopecia Areata.

A meta-analysis of published trials on the treatment of alopecia areata (AA) came to the conclusion that most have been reported poorly and so small that any important clinical benefits are inconclusive, and considering the possibility of spontaneous remission, especially for those in the early stages of the disease, the options of not being treated or depending on individual preference, and of wearing a wig may be alternative ways of dealing with the condition. And yet, from clinical practice, we know that depending on patient age, surface area, disease duration, and comorbidities an empiric treatment algorithm can be designed that is successful in a significant proportion of patients. More recently, it has been suggested that Janus kinase (JAK) inhibitors may represent the drug of choice for AA, based on robust scientific background and preliminary clinical study results. The fact is that a sophisticated treatment of AA cannot be reduced to one drug, while in many patients, depending on disease duration and surface area, either intravenous methylprednisolone pulse therapy, intralesional triamcinolone acetonide or subcutaneous methotrexate will achieve remission rates in the range of the efficacy of the JAK inhibitors. Moreover, at this time point, affordability of the JAK inhibitors for long-term treatment, sustainability of treatment result, and long-term safety are major issues with regard to the treatment of AA with JAK inhibitors.

Graft versus Host Disease Presenting as Fibrosing Alopecia in a Pattern Distribution: A Model for Pathophysiological Understanding of Cicatricial Pattern Hair Loss.

A case of cutaneous graft versus host disease (GvHD) presenting as fibrosing alopecia in a pattern distribution (FAPD) is discussed, possibly providing a mechanistic model for a better understanding of the pathogenic events underlying cicatricial pattern hair loss. The implication of a follicular inflammation and fibrosis associated with patterned hair loss has emerged from several independent studies. Eventually, Zinkernagel and Trüeb reported a peculiar type of cicatricial pattern hair loss with histopathological features consistent with lichen planopilaris (LPP) associated with androgenetic alopecia (AGA). With regard to its pathogenesis, LPP is regarded to constitute a T-cell-mediated autoimmune reaction. An as yet unknown antigenic stimulus from the malfunctioning hair follicle may initiate a lichenoid tissue reaction that triggers apoptosis of the follicular epithelial cells in the susceptible individual. GvHD is a complication following allogeneic tissue transplantation and is induced and maintained by immunocompetent cells from the donor tissue that particularly attack epithelia of fast-proliferating tissues in the recipient. Due to its analogies with lichen planus, GvHD constitutes a valid immunologic model for lichen planus, LPP and ultimately FAPD. Specifically, the presentation of GvHD of the scalp combines features of AGA and of LPP, as originally proposed in earlier observations on permanent alopecia after bone marrow transplantation.

A Comment on the Post-Finasteride Syndrome.

The post-Finasteride syndrome (PFS) has been claimed to occur in men who have taken oral finasteride to treat hair loss or benign prostatic hyperplasia. While the incidence of persistent sexual, mental, and physical side effects despite quitting finasteride is unknown, and the condition is not recognized by the scientific community, individuals who suffer from PFS do present with very distinctive and homogenous symptoms. The concept has emerged from reports of nondermatologists, neuroendocrinological research, case reports, and uncontrolled studies. These have been scrutinized by hair experts who found that persistent sexual side effects were only documented in low-quality studies with a strong bias selection and a significant nocebo effect. Others totally dispute the credibility of the PFS. In any case, the PFS is a problem that has to be dealt with. Low-quality studies neither confirm nor refute the condition as a valid nosologic entity. Therefore, it is as inappropriate to dismiss the condition, as it would be to demonize finasteride for the treatment of male pattern hair loss. Whether the PFS represents a nocebo reaction or a real drug adverse event is irrelevant, while the best way to alleviate the emotional distress related to hair loss is to effectively treat the condition causing the problem. It is not sufficient to only discuss the plausibility of the PFS. There is a need for practical recommendations to include such important issues as patient selection and risk assessment, appropriate patient information, how to react in case of drug-related adverse events, issues of fertility and malignancy, management of the PFS, and alternatives, specifically the use of topical finasteride. It is the aim of this commentary to provide the respective information.

Trichologist, Dermatotrichologist, or Trichiatrist? A Global Perspective on a Strictly Medical Discipline.

Few dermatologic problems carry as much emotional overtones as the complaint of hair loss. The best way to alleviate the distress related to hair loss is to effectively treat it. In fact, one of the oldest medical professions is the Egyptian physician who specialized on diseases of the head. And yet, from ancient Egypt down to modern times, human hair has been the object of superstition and mystery. Remarkably and despite the genuine advances in effective medical treatments, hair cosmetics, and surgical procedures, phony hair loss solutions continue to be marketed with an amazing success. In 1860, a quasi-scientific interest in hair loss and hair care originated in a London barbershop and became known as trichology, with the Institute of Trichologists being founded. Other corporations successively followed internationally, but it was only in 2010 that the term dermatotrichologist was proposed for board-certified dermatologists dealing with the scientific study of the hair and scalp, in contrast to the trichologist who is rather associated with laity and cosmetics than with medical professionalism, or - worse - offers opportunities to possible imposters with a primary commercial interest. The new term "trichiatrist" is proposed, literally meaning the "medical treatment of the hair," to designate the strictly medical professional dealing with the hair and scalp in health and disease. Trichiatrists differ from trichologists by virtue of being physicians. The quality and stringency of their graduate medical training is identical to that of other physicians.

Familial Cicatricial Alopecia: Report of Familial Frontal Fibrosing Alopecia and Fibrosing Alopecia in a Pattern Distribution.

Frontal fibrosing alopecia (FFA) and fibrosing alopecia in a pattern distribution (FAPD) as originally reported by Kossard in 1994 and by Zinkernagel and Trüeb in 2000, respectively, represent two distinct patterns of cicatricial pattern hair loss. Both share a patterned distribution and histological evidence of a lichenoid follicular inflammation with fibrosis. FFA is characterized by a marginal alopecia along the frontotemporal hairline, and FAPD by a progressive alopecia of the centroparietal scalp. Since the original reports, evidence has accumulated that there exists considerable clinical overlap among FFA, FAPD, and lichen planopilaris, with coexistence of features of the three conditions within the same individual. Moreover, familial cases of FFA have been reported, pointing to a possible genetic background to the condition. Our observation of familial occurrence of FFA and FAPD in daughter and mother, respectively, further underscore a nosologic relationship between the two conditions with respect to both an androgenetic background and the (lichenoid) inflammatory reaction pattern.

Acute diffuse and total alopecia of the female scalp associated with borrelia-infection.

A case of acute diffuse and total alopecia of the female scalp associated with Borrelia-infection (acrodermatitis chronica atrophicans) is presented. Today, acute diffuse and total alopecia of the female scalp is recognized as a distinct variant of alopecia areata (AA) predominantly observed in women. Cases of AA have formerly been reported in association with infections. AA is understood to represent an organ-specific autoimmune disease of the hair follicle. It is conceivable that the antigenic stimulus provided by the infection may act as a trigger for alopecia. Vice versa, alopecia may act as a marker for detection of undiagnosed infection. Treatment of the patient with intravenous ceftriaxone led to the resolution of cutaneous borreliosis, and in addition to topical clobetasol foam to complete recovery of hair.