Alopecia areata: Part 1: pathogenesis, diagnosis, and prognosis.

OBJECTIVE: To provide family physicians with a background understanding of the epidemiology, pathogenesis, histology, and clinical approach to the diagnosis of alopecia areata (AA). SOURCES OF INFORMATION: PubMed was searched for relevant articles regarding the pathogenesis, diagnosis, and prognosis of AA. MAIN MESSAGE: Alopecia areata is a form of autoimmune hair loss with a lifetime prevalence of approximately 2%. A personal or family history of concomitant autoimmune disorders, such as vitiligo or thyroid disease, might be noted in a small subset of patients. Diagnosis can often be made clinically, based on the characteristic nonscarring, circular areas of hair loss, with small "exclamation mark" hairs at the periphery in those with early stages of the condition. The diagnosis of more complex cases or unusual presentations can be facilitated by biopsy and histologic examination. The prognosis varies widely, and poor outcomes are associated with an early age of onset, extensive loss, the ophiasis variant, nail changes, a family history, or comorbid autoimmune disorders. CONCLUSION: Alopecia areata is an autoimmune form of hair loss seen regularly in primary care. Family physicians are well placed to identify AA, characterize the severity of disease, and form an appropriate differential diagnosis. Further, they are able educate their patients about the clinical course of AA, as well as the overall prognosis, depending on the patient subtype.

Alopecia areata: Part 2: treatment.

OBJECTIVE: To provide family physicians with a background understanding of the therapeutic regimens and treatment outcomes for alopecia areata (AA), as well as to help identify those patients for whom dermatologist referral might be required. SOURCES OF INFORMATION: PubMed was searched for relevant articles regarding the treatment of AA. MAIN MESSAGE: Alopecia areata is a form of autoimmune hair loss affecting both children and adults. While there is no associated mortality with the disease, morbidity from the psychological effects of hair loss can be devastating. Upon identification of AA and the disease subtype, an appropriate therapeutic regimen can be instituted to help halt hair loss or possibly initiate hair regrowth. First-line treatment involves intralesional triamcinolone with topical steroids or minoxidil or both. Primary care physicians can safely prescribe and institute these treatments. More advanced or refractory cases might require oral immunosuppressants, topical diphenylcyclopropenone, or topical anthralin. Eyelash loss can be treated with prostaglandin analogues. Those with extensive loss might choose camouflaging options or a hair prosthesis. It is important to monitor for psychiatric disorders owing to the profound psychological effects of hair loss. CONCLUSION: Family physicians will encounter many patients experiencing hair loss. Recognition of AA and an understanding of the underlying disease process will allow an appropriate therapeutic regimen to be instituted. More advanced or refractory cases need to be identified, allowing for an appropriate dermatologist referral when necessary.

Transversely sectioned biopsies in the diagnosis of end-stage traction alopecia.

The pathogenesis of scarring alopecia in African American women remains poorly understood. Furthermore, the overlapping clinical and histological features present diagnostic challenges. The diagnosis of end stage traction alopecia secondary to traumatic hair styling practices can sometimes present particular challenges. We present a young African American woman with a scarring alopecia. As we describe, a scalp biopsy processed by transverse sections enabled rapid diagnosis and presented advantages over a biopsy processed with vertical sections.

A review of scalp camouflaging agents and prostheses for individuals with hair loss.

Hair loss is a common problem for both men and women and may impact negatively on self-esteem. A variety of medical and surgical treatment options are available depending on the type of alopecia. Many patients also seek the advice of their physicians about options to hide or reduce the appearance of hair loss with hair prostheses (wigs, hairpieces, and extensions) or hair camouflaging agents (hair fibers, powder cakes, lotions, sprays, hair crayons, and scalp tattooing). Herein, we review current methods to hide or reduce the appearance of hair loss and discuss their associated costs, advantages, and disadvantages. Knowledge of products available to cover scalp, eyebrow, and eyelash hair loss may not only better equip clinicians to respond to questions from concerned patients, but may provide additional options to help these patients best cope with their hair loss.

Iron deficiency and diffuse nonscarring scalp alopecia in women: more pieces to the puzzle.

The relationship between nonscarring scalp alopecia in women and iron deficiency continues to be a subject of debate. We review the literature regarding the relationship between iron deficiency and nonscarring scalp alopecia and describe iron-dependent genes in the hair follicle bulge region that may be affected by iron deficiency. We conclude with a description of our approach to the diagnosis and treatment of nonscarring alopecia in women with low iron stores. Limitations include published studies with small numbers of patients, different study designs, and absence of randomized, controlled treatment protocols. Additional research regarding the potential role of iron during the normal hair cycle is needed, as is a well-designed clinical trial evaluating the effect of iron supplementation in iron-deficient women with nonscarring alopecia.

Mentorship in dermatology residency training programs: charting the right course.

Considerable attention is given to mentoring issues for dermatology trainees. Many residents consider it important to have mentors. Mentorship Programs are flourishing in residency training programs and a majority of the national dermatologic societies have established funded mentoring opportunities for residents. With the level of support for mentorship that has been established within the dermatology community, there are now several issues that need further evaluation in order to ensure that all residents have access to and achieve benefit from high-quality mentoring opportunities.

A survey of dermatology residency program directors' views on mentorship.

BACKGROUND: It is increasingly recognized that mentoring is important in the career development of resident physicians. The purpose of the study was to determine the views of residency Program Directors on mentorship through a cross sectional survey. METHODS: Respondents included program directors of academic dermatology departments in the United States. RESULTS: Fifty-three of 108 program directors completed an on-line survey (response rate 49%). Eighty-one percent of respondents indicated that mentorship played a 'somewhat' or 'very important' role in their own career development and a similar proportion considered it important for residents to have mentors. Fifty percent of program directors identified a need for more structured mentorship within the residency program. Compared to male program directors, a greater proportion of female program directors stated that mentorship played a very important role in their career development (89% vs. 36%, p=0.007) and a lesser proportion stated that it was important for female dermatology residents to specifically have access to female mentors (11.1% vs. 67.4%, p=0.003). CONCLUSION: Program Directors viewed mentoring as an important resource for their residents' professional development. A need was identified for additional strategies to help residents find mentors.

Scalp trauma: a risk factor for lichen planopilaris?

BACKGROUND: Lichen planopilaris is a type of primary scarring alopecia that is characterized by perifollicular lymphocytic inflammation and fibrosis. The cause remains poorly understood, although recent research has begun to unravel some of the molecular mechanisms implicated in the pathogenesis. OBJECTIVE: To present a case of biopsy-proven lichen planopilaris in a patient who had previously suffered serious head injury. Lichen planopilaris developed only in the areas of trauma. CONCLUSION: Our findings highlight the possible association between scalp trauma and the development of lichen planopilaris. Further research is needed to understand the role of scalp trauma in the pathogenesis of scarring alopecia.

Rapid development of allergic contact dermatitis from dicyclohexylmethane-4,4'-diisocyanate.

Isocyanates are widely used in the manufacturing of rigid and flexible foams, fibers, and coatings such as paints, varnishes, and elastomers but are rarely reported as contact sensitizers. The aliphatic diisocyanate dicyclohexylmethane-4,4'-diisocyanate (DMDI) is known to be a strong cutaneous sensitizer. We report a 27-year-old woman who developed a severe eczematous eruption on the arms, trunk, and abdomen within 2 weeks of employment at a company using the product Chem-Dec 808 isocyanate (containing 40-70% weight per weight DMDI). Patch testing was performed with the North American screening series, an isocyanate series, and 1% Chem-Dec 808 isocyanate. At day 7, a +++ reaction to Chem-Dec 808 isocyanate and a ++ reaction to the aromatic isocyanate diphenylmethane-4,4'-diisocyanate were observed. DMDI has strong sensitizing potential and requires rigorous safety monitoring in the workplace.