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.

Topical Treatment of Psoriasis Vulgaris: The Swiss Treatment Pathway.

Topical treatment is crucial for the successful management of plaque psoriasis. Topicals are used either as a stand-alone therapy for mild psoriasis or else in combination with UV or systemic treatment for moderate-to-severe disease. For the choice of a suitable topical treatment, the formulation matters and not just the active substances. This expert opinion paper was developed via a non-structured consensus process by Swiss dermatologists in hospitals and private practices to illustrate the current treatment options to general practitioners and dermatologists in Switzerland. Defining treatment goals together with the patient is crucial and increases treatment adherence. Patients' personal preferences and pre-existing experiences should be considered and their satisfaction with treatment and outcome regularly assessed. During the induction phase of "classical" mild-to-moderate psoriasis, the fixed combination of topical calcipotriol (Cal) 50 µg/g and betamethasone dipropionate (BD) 0.5 mg/g once daily is frequently used for 4-8 weeks. During the maintenance phase, a twice weekly (proactive) management has proved to reduce the risk of relapse. Of the fixed combinations, Cal/BD aerosol foam is the most effective formulation. However, the individual choice of formulation should be based on a patient's preference and the location of the psoriatic plaques. Tailored recommendations are given for the topical management of specific areas (scalp, facial, intertriginous/genital, or palmoplantar lesions), certain symptoms (hyperkeratotic or hyperinflammatory forms) as well as during pregnancy or a period of breastfeeding. As concomitant basic therapy, several emollients are recommended. If topical treatment alone does not appear to be sufficient, the regimen should be escalated according to the Swiss S1-guideline for the systemic treatment of psoriasis.

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.

Lichenoid folliculitis of the scalp in four patients with ichthyosiform skin disorders and cicatricial alopecia.

Ichthyosis is a heterogeneous group of inherited skin disorders characterized by a defect of keratinization. Patients diagnosed with lamellar ichthyosis (LI) and some ichthyosiform syndromes, such as the Conradi-Hünermann-Happle syndrome (CHHS), usually present with hair loss. Even though only few dermatologic complaints carry as many emotional overtones as hair loss, there are very few data available in the literature regarding scalp histopathological features in ichthyosis. A better understanding of scalp changes in such context may result in new therapeutic strategies that in turn would enhance patients' self-esteem and quality of life. The aim of this paper is to describe the scalp histopathological findings of four young patients with cicatricial alopecia: three diagnosed as having LI and the fourth with CHHS.

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 and tolerability of two scalp cooling systems for the prevention of alopecia associated with docetaxel treatment.

PURPOSE: Chemotherapy-induced alopecia is very distressing for a patient and may have an impact on treatment decisions. On docetaxel-based therapy, alopecia occurs in a substantial proportion of patients. We aimed to investigate whether two different methods of scalp cooling can prevent hair loss. METHODS: In this open-label, prospective, nonrandomized trial, patients with solid tumors receiving docetaxel in a palliative setting were allocated according to patients' preference to short-term cooling (over 45 min postinfusion) with a Paxman PSC-2 machine (PAX), with cold cap (CC), or no cooling. The combined endpoint was alopecia World Health Organisation (WHO) III or IV or the necessity to wear a wig. Study identifier is Clinicaltrials.gov NCT01008774. RESULTS: Two hundred thirty-eight patients were included in the trial (128 patients PAX, 71 CC, and 39 no cooling). Number of cycles (median 4) and median docetaxel doses were similar across groups (55-60 mg/day on weekly therapy, 135-140 mg/day on 3-weekly therapy). Alopecia occurred with PAX, CC, and no cooling under 3-weekly docetaxel in 23, 27, and 74% and under weekly docetaxel in 7, 8, and 17%, respectively. Overall, cooling (PAX and CC combined) reduced risk of alopecia by 78% (hazard ratio 0.22; 95% confidence interval 0.12 to 0.41). CC and PAX prophylaxis led to the same degree of prevention of alopecia. Adverse events (AE) were reported in 5% (most frequently, sensation of cold), and 30 patients (13%) discontinued cooling measures after cycle 1. CONCLUSIONS: In this first comparison published to date, both PAX and CC offer efficacious protection against hair loss, in particular when docetaxel is administered in a 3-weekly interval.

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.