The Alopecia Areata Severity and Morbidity Index (ASAMI) Study: Results From a Global Expert Consensus Exercise on Determinants of Alopecia Areata Severity.

Importance: Current measures of alopecia areata (AA) severity, such as the Severity of Alopecia Tool score, do not adequately capture overall disease impact. Objective: To explore factors associated with AA severity beyond scalp hair loss, and to support the development of the Alopecia Areata Severity and Morbidity Index (ASAMI). Evidence Review: A total of 74 hair and scalp disorder specialists from multiple continents were invited to participate in an eDelphi project consisting of 3 survey rounds. The first 2 sessions took place via a text-based web application following the Delphi study design. The final round took place virtually among participants via video conferencing software on April 30, 2022. Findings: Of all invited experts, 64 completed the first survey round (global representation: Africa [4.7%], Asia [9.4%], Australia [14.1%], Europe [43.8%], North America [23.4%], and South America [4.7%]; health care setting: public [20.3%], private [28.1%], and both [51.6%]). A total of 58 specialists completed the second round, and 42 participated in the final video conference meeting. Overall, consensus was achieved in 96 of 107 questions. Several factors, independent of the Severity of Alopecia Tool score, were identified as potentially worsening AA severity outcomes. These factors included a disease duration of 12 months or more, 3 or more relapses, inadequate response to topical or systemic treatments, rapid disease progression, difficulty in cosmetically concealing hair loss, facial hair involvement (eyebrows, eyelashes, and/or beard), nail involvement, impaired quality of life, and a history of anxiety, depression, or suicidal ideation due to or exacerbated by AA. Consensus was reached that the Alopecia Areata Investigator Global Assessment scale adequately classified the severity of scalp hair loss. Conclusions and Relevance: This eDelphi survey study, with consensus among global experts, identified various determinants of AA severity, encompassing not only scalp hair loss but also other outcomes. These findings are expected to facilitate the development of a multicomponent severity tool that endeavors to competently measure disease impact. The findings are also anticipated to aid in identifying candidates for current and emerging systemic treatments. Future research must incorporate the perspectives of patients and the public to assign weight to the domains recognized in this project as associated with AA severity.

Pseudo Green Hair.

Green hair is due to insoluble copper deposits in the hair of blonde people. Although it is most frequently due to an increase in the copper content of algaecides in swimming pools, other causes have been recognized. Herewith, we present a case of a blonde girl who had previously commercially highlighted her hair and the hair had turned green following a swim in a pool with excess copper content in the water. Lifeguard swimming pool commented another previously affected blonde female swimmer 2 days ago. To date, <10 cases involving swimming pools with clearly increased copper concentrations have been published, and to the best of our knowledge, no similar case without traces of copper in X-ray microanalysis has been reported in the literature.

Atypical Congenital Triangular Alopecia (Brauer Nevus): Case Report and Review of Literature in Occipital and Mid-Frontal Localizations.

INTRODUCTION: Brauer nevus, also known as congenital triangular alopecia (CTA) is a localized alopecia that rarely affects the occipital or mid-frontal region. CTA is a localized follicular hypoplasia, commonly misdiagnosed as alopecia areata. Although named congenital, onset in adulthood is possible. CASE PRESENTATION: We present a review of literature of eighteen atypical locations, providing 4 new cases to the 9 previously published, with particular attention to trichoscopy and histopathological descriptions in this exceptional presentation forms. DISCUSSION: Occipital and mid-frontal Brauer nevus are unusual findings with very few cases reported so far. Because of its rarity and atypical presentation, it can often lead to a misdiagnosis. A higher incidence in the male sex stands clear in these locations. Detection at birth is slightly more frequent than in the classical CTA. Histopathological and trichoscopy findings do not differ from the classical entity, although white or hypopigmented hairs do not seem to be an item present in the mid-frontal forms.

Recent Progress Using De Novo Design to Study Protein Structure, Design and Binding Interactions.

De novo protein design is a powerful methodology used to study natural functions in an artificial-protein context. Since its inception, it has been used to reproduce a plethora of reactions and uncover biophysical principles that are often difficult to extract from direct studies of natural proteins. Natural proteins are capable of assuming a variety of different structures and subsequently binding ligands at impressively high levels of both specificity and affinity. Here, we will review recent examples of de novo design studies on binding reactions for small molecules, nucleic acids, and the formation of protein-protein interactions. We will then discuss some new structural advances in the field. Finally, we will discuss some advancements in computational modeling and design approaches and provide an overview of some modern algorithmic tools being used to design these proteins.

Multiple primary melanoma with the Meyerson phenomenon in a young patient.

Meyerson phenomenon (MP), also called halo eczema or halo dermatitis, was first described in 1971 as a symmetric eczematous halo around acquired melanocytic nevi. Since then, cases of MP have been described in any kind of melanocytic nevi and also in non-melanocytic tumors. To the best of our knowledge, only four cases of melanoma associated with MP have been reported. We report the singular case of a young adult diagnosed with two primary melanomas in the context of dysplastic nevi syndrome who presented several flares-up associated with MP in both benign and malignant melanocytic tumors. MP usually manifests as a halo of erythema and scaling similar to plaques of eczema symmetrically surrounding a central cutaneous tumor. Dermoscopic findings of MP show it as similar to other forms of dermatitis. Histopathology usually shows epidermal changes compatible with subacute eczematous dermatitis. Immunohistochemical studies have shown inflammatory infiltrate composed mainly of CD4+ lymphocytes, which supports the suggested pathogenesis of an immune-mediated reaction. It usually resolves spontaneously, and the use of topical corticosteroids has a good response. In conclusion, MP is not specific for benignity, even when multiple simultaneous lesions are affected. Inflammatory changes can make melanocytic lesions difficult to interpret, both on dermoscopic regression features and on histopathologic examination. Therefore, it is recommended to consider the complete excision of melanocytic lesions with atypical vessels and/or extensive regression phenomena more than 50%. Further studies are needed to know whether the presence of a melanoma could induce a remote immune response in other benign melanocytic lesions.

A comparative analysis of the pharmacovigilance systems of Brazil, Spain, the European Union and the United States based on the information provided by their regulatory agency websites.

BACKGROUND: Pharmacovigilance (PV) plays an essential role in monitoring and raising awareness of adverse drug reactions (ADRs). Increasingly, ADRs are reported and PV information and activities are circulated via the Internet. PV actions are carried out by the Regulatory Agencies (RAs) responsible for medicinal products in each country. OBJECTIVE: The objective of this study is to ascertain and assess the operation and areas of competence of the PV system in Brazil and to compare them with those of Spain, the European Union (EU) and the United States (USA), through the information available on the websites of the RAs in each country. METHODS: A search of the information provided on the websites of these countries' RAs, establishing indicators to assess how far the information is available and accessible. RESULTS: The RAs we studied are similarly organised and they complied with most of the 38 indicators we defined to obtain and assess the information they provide on PV procedures and their systems for electronic reporting of ADRs. Brazil's RA, ANVISA, complied with 100% of the areas of competence analysed and with 92.11% of the indicators established for the study. CONCLUSIONS: Brazil's PV system, through ANVISA, achieves a good level of performance, both in itself and compared to the other RAs. There is room for improvement in three of the indicators analysed.

Nuchal Nevus Flammeus and Alopecia Areata: When Size Matters.

INTRODUCTION: Alopecia areata (AA) is a high-prevalence immuno-mediated hair loss disorder. Extra follicular affections, including nail and ocular abnormalities, are classically related to a worse prognosis of the disease, and previous studies have suggested that the presence of a persistent nuchal nevus flammeus (NNF) also indicates a greater severity and duration of the disease. The association between AA and persistent NNF was first described by Hatzis et al in 1988, who demonstrated that the relation was statistically evident and not due to a simple observer bias. OBJECTIVES: To determine and compare the presence/absence and size of the NNF in 80 individuals (40 patients diagnosed with AA and 40 controls). RESULTS: We found a statistically significant association not only between AA and the presence of NNF, but also with its size. Moreover, we found that the size of the NNF was also associated with the severity of AA. CONCLUSION: The size of the NNF in AA patients might be a useful marker of widespread and chronic disease.

A Proposal of an Effective Platelet-rich Plasma Protocol for the Treatment of Androgenetic Alopecia.

BACKGROUND: Platelet-rich plasma (PRP) has emerged as a promising treatment for androgenetic alopecia (AGA). In spite of the several studies previously reported, to date, a standardized protocol for PRP preparation and application, as well as a standard method for evaluating results has not been established. AIMS: The aim of this study is to propose a standardized method for preparation and application of PRP for male AGA (MAGA) and female AGA (FAGA) and assess its safety and efficacy as a co-adjuvant therapy. MATERIALS AND METHODS: Seventy-eight patients, 19 men and 59 women with AGA Grades II-IV in Ebling's scale, currently on treatment with topical minoxidil and/or oral finasteride for more than a year without improvement, were included in this study. PRP was prepared using a single spin method, and injected in affected areas for 3 monthly sessions, followed by 3 bimonthly sessions. A decrease of at least one grade in Ebling's scale was considered a successful result. RESULTS: After the 6° session, 71.4% of MAGA and 73.4% of FAGA patients reached a successful outcome while 21.4% and 16.3%, respectively, remained without changes. Only 7.1% of MAGA and 10.2% of FAGA presented worsening of their condition. CONCLUSIONS: PRP together with a periodical application protocol can be considered effective as a coadjuvant therapy in patients who no longer respond to pharmacological treatments. Ebling's scale was a practical and reliable parameter to allow a better evaluation in both MAGA and FAGA.

Alopecic and aseptic nodule of the scalp in a girl.

Alopecic and aseptic nodule of the scalp is a rare entity characterized by the presence of nodules or cysts with sterile punctured material and negative cultures accompanied by nonscarring alopecia in the scalp of young men. We describe a case in which an 11-year-old girl presented with a nodular, fluctuant, round lesion on the vertex with localized alopecia. High-resolution ultrasound showed a hypoechoic lesion with increased flow on Doppler imaging and culture of the citrine-yellowish material obtained by puncture was negative. The patient showed complete clinical response to treatment with topical indomethacin.

Primary Scarring Alopecia: Clinical-Pathological Review of 72 Cases and Review of the Literature.

PURPOSE OF THE STUDY: To analyze the epidemiologic, demographic, clinical, and histological characteristics of primary scarring alopecia (PSA) cases diagnosed over a 7-year period at the Department of Dermatology, Hospital Clinic, Barcelona, Spain. PROCEDURES: Seventy-two patients diagnosed with PSA between 2006 and 2012 were included. Age, sex, ethnic group, clinical pattern, predominant histological infiltrate, final clinical diagnosis, time of onset, treatments used, and clinical evolution were evaluated and correlated. RESULTS: The ethnic groups were distributed as follows: 93% European-Caucasian, 5% Mestizo-American, 1% oriental, and 1% Afro-American. Most cases were females (71%), and mean age was 51 ± 6 years. The follicular pattern was the most common, and the predominant inflammatory infiltrate was lymphocytic. Lichen planopilaris and frontal fibrosing alopecia were the main diagnoses. When correlating clinical aspects and histopathology, lymphocytic PSAs had a subacute onset and resulted in a nonchanging, more stable form, while neutrophilic PSAs had a more acute onset with an evolution of acute outbreaks. PSAs in a late stage with an absent/mild infiltrate had a subclinical onset and a slowly progressive or stable evolution. CONCLUSIONS: The PSAs are severe trichological conditions. Their high clinical and histopathological variability make them a diagnostic and therapeutic challenge. MESSAGE OF THE PAPER: Knowing the clinical and histopathological aspects of PSAs should be of crucial importance to the dermatologist.

Scanning Electron Microscopy and X-ray Microanalysis of Reconstructive Hair Fibers.

BACKGROUND: Reconstructive hair fibers are an innovative tool in cosmetic dermatology based on electrostatic adherent powder which bonds to the hair shaft and can disguise hair loss in men and women. AIM: This study aims to analyze and compare five different brands of organic hair fibers. MATERIALS AND METHODS: A scanning electron microscope (SEM) was used to obtain amplified images of samples to study their shape and morphological structure. X-ray microanalysis was performed to study the chemical composition of reconstructive hair fibers. The five samples were tested in patients attending a trichology unit of a tertiary hospital. RESULTS: The main component in hair fibers products 1 (Blum Secret™) and 3 (Keratin™) was cotton (cellulose of vegetal origin), while product 2 (Viviscal™) was made of a vegetal keratin. All three samples appeared as parallel-arranged fibres on the scanning electron microscope. The X-ray microanalysis showed an organic polymer mainly composed of C, O, and Si. Hair fibers 4 (Toppik™) and 5 (Nanogen™) were similar. Sample 4 derived from a keratin organic fiber and sample 5 from pure, positively charged keratin. In both cases, SEM revealed microfibers covered by a fine squamous. The X-ray microanalysis in both cases revealed a high presence of S. CONCLUSION: There was no discrepancy among the cosmetic results of the five samples, providing a successful esthetic effect in all of our patients despite the chemical differences found in the X-ray microanalysis.

Porokeratosis ptychotropica responding to photodynamic therapy: An alternative treatment for a refractory disease.

BACKGROUND: Porokeratosis ptychotropica (PP) is a rare variant of porokeratosis with a special predisposition to affect body folds, particularly the intergluteal cleft. This disease is resistant to most topical and systemic treatments, as shown in the review of the literature we provide here. Itching and discomfort are often a difficult problem to solve. PATIENTS AND METHODS: Two patients with PP that had not responded to multiple topical treatments were treated with photodynamic therapy (PDT). Changes in plaque size, thickness and symptoms were assessed after treatment. RESULTS: Pruritus disappearance was observed in both patients after treatment with PDT. Partial clearance of the plaques was observed in one case. In the other case, a moderate clearance of hyperkeratosis was observed, although the size of the lesions persisted unchanged. CONCLUSIONS: PDT seems to be a good therapeutic alternative in the treatment of PP, as it can provide symptomatic relief and clinical improvement of the lesions. However, it does not appear to be a curative treatment. Moreover, long-term response is still unknown.

Effectiveness of Inclusion of Dry Needling in a Multimodal Therapy Program for Patellofemoral Pain: A Randomized Parallel-Group Trial.

Study Design Randomized controlled trial. Background Evidence suggests that multimodal interventions that include exercise therapy may be effective for patellofemoral pain (PFP); however, no study has investigated the effects of trigger point (TrP) dry needling (DN) in people with PFP. Objectives To compare the effects of adding TrP DN to a manual therapy and exercise program on pain, function, and disability in individuals with PFP. Methods Individuals with PFP (n = 60) recruited from a public hospital in Valencia, Spain were randomly allocated to manual therapy and exercises (n = 30) or manual therapy and exercise plus TrP DN (n = 30). Both groups received the same manual therapy and strengthening exercise program for 3 sessions (once a week for 3 weeks), and 1 group also received TrP DN to active TrPs within the vastus medialis and vastus lateralis muscles. The pain subscale of the Knee injury and Osteoarthritis Outcome Score (KOOS; 0-100 scale) was used as the primary outcome. Secondary outcomes included other subscales of the KOOS, the Knee Society Score, the International Knee Documentation Committee Subjective Knee Evaluation Form (IKDC), and the numeric pain-rating scale. Patients were assessed at baseline and at 15-day (posttreatment) and 3-month follow-ups. Analysis was conducted with mixed analyses of covariance, adjusted for baseline scores. Results At 3 months, 58 subjects (97%) completed the follow-up. No significant between-group differences (all, P>.391) were observed for any outcome: KOOS pain subscale mean difference, -2.1 (95% confidence interval [CI]: -4.6, 0.4); IKDC mean difference, 2.3 (95% CI: -0.1, 4.7); knee pain intensity mean difference, 0.3 (95% CI: -0.2, 0.8). Both groups experienced similar moderate-to-large within-group improvements in all outcomes (standardized mean differences of 0.6 to 1.1); however, only the KOOS function in sport and recreation subscale surpassed the prespecified minimum important change. Conclusion The current clinical trial suggests that the inclusion of 3 sessions of TrP DN in a manual therapy and exercise program did not result in improved outcomes for pain and disability in individuals with PFP at 3-month follow-up. Level of Evidence Therapy, level 1b. Prospectively registered July 27, 2015 at www.clinicaltrials.gov (NCT02514005). J Orthop Sports Phys Ther 2017;47(6):392-401. doi:10.2519/jospt.2017.7389.

Spontaneous repigmentation of silvery hair in an infant with congenital hydrops fetalis and hypoproteinemia.

Silvery hair is a characteristic finding of 3 rare autosomal recessive disorders: Chédiak-Higashi syndrome (CHS), Elejalde syndrome (ES), and Griscelli syndrome (GS). We report the case of a 2-month-old male infant with transient silvery hair and generalized hypopigmentation of the skin and eyes who did not have one of these classic causative disorders. The patient was delivered at 35 weeks' gestation with congenital hydrops fetalis associated with a chromosomal abnormality (46,XY,add[2],[p23]), hypothyroidism, hypoproteinemia, and hypogammaglobulinemia. Over the course of follow-up, spontaneous brown repigmentation of the silvery hair was noted. We concluded that the silvery hair was induced by hypoproteinemia secondary to congenital hydrops fetalis.

Anagen Effluvium Following Acute Colchicine Poisoning.

We present a case of a 17-year-old girl admitted to the Psychiatric Department recovering from a suicide attempt with colchicine. One week after poisoning, a sudden onset of hair loss was observed. Positive hair pull test and trichoscopy demonstrated the presence of anagen hairs with pigmented long roots covered by the root sheaths. Colchicine poisoning is an uncommon, but potentially life-threatening toxicologic emergency. An overdose of colchicine inhibits cell division, and thus the most affected organs are those which have a high rate of cell turnover. Hair loss resulting from colchicine poisoning presents as anagen effluvium, as it occurs with an exposure to toxic chemicals. Pharmacotherapy or specific treatment is not usually required, since the follicle resumes its normal activity after withdrawal of the antimitotic factors.