The Alopecia Areata Consensus of Experts (ACE) study part II: Results of an international expert opinion on diagnosis and laboratory evaluation for alopecia areata.

BACKGROUND: We previously reported the Alopecia Areata Consensus of Experts study, which presented results of an international expert opinion on treatments for alopecia areata. OBJECTIVE: To report the results of the Alopecia Areata Consensus of Experts international expert opinion on diagnosis and laboratory evaluation for alopecia areata. METHODS: Fifty hair experts from 5 continents were invited to participate in a 3-round Delphi process. Consensus threshold was set at greater than or equal to 66%. RESULTS: Of 148 questions, expert consensus was achieved in 82 (55%). Round 1 consensus was achieved in 10 of 148 questions (7%). Round 2 achieved consensus in 47 of 77 questions (61%). The final face-to-face achieved consensus in 25 of 32 questions (78%). Consensus was greatest for laboratory evaluation (12 of 14 questions [86%]), followed by diagnosis (11 of 14 questions [79%]) of alopecia areata. Overall, etiopathogenesis achieved the least category consensus (31 of 68 questions [46%]). LIMITATIONS: The study had low representation from Africa, South America, and Asia. CONCLUSION: There is expert consensus on aspects of epidemiology, etiopathogenesis, clinical features, diagnosis, laboratory evaluation, and prognostic indicators of alopecia areata. The study also highlights areas where future clinical research could be directed to address unresolved hypotheses in alopecia areata patient care.

The Alopecia Areata Consensus of Experts (ACE) study: Results of an international expert opinion on treatments for alopecia areata.

BACKGROUND: A systematic review failed to identify any systemic therapy used in alopecia areata (AA) where use is supported by robust evidence from high-quality randomized controlled trials. OBJECTIVE: To produce an international consensus statement on the use and utility of various treatments for AA. METHODS: Fifty hair experts from 5 continents were invited to participate in a 3-round Delphi process. Agreement of 66% or greater was considered consensus. RESULTS: In the first round, consensus was achieved in 22 of 423 (5%) questions. After a face-to-face meeting in round 3, overall, consensus was achieved for only 130 (33%) treatment-specific questions. There was greater consensus for intralesional treatment of AA (19 [68%]) followed by topical treatment (25 [43%]). Consensus was achieved in 45 (36%) questions pertaining to systemic therapies in AA. The categories with the least consensus were phototherapy and nonprescription therapies. LIMITATIONS: The study included a comprehensive list of systemic treatments for AA but not all treatments used. CONCLUSION: Despite divergent opinions among experts, consensus was achieved on a number of pertinent questions. The concluding statement also highlights areas where expert consensus is lacking and where an international patient registry could enable further research.

A newly discovered linkage between proteoglycans and hair biology: decorin acts as an anagen inducer.

Proteoglycans have been suggested to play pivotal roles in hair biology. Decorin is a prototypical member of the small leucine-rich proteoglycan family, which is involved in numerous biological processes. However, the role of decorin in the hair cycle has not been elucidated. Moreover, the effects of decorin on the activities of many growth factors are complex, and it is hard to predict whether decorin would affect hair growth or the hair cycle positively or negatively. Jing et al. focused on the potential role of decorin in the hair cycle and found that decorin is highly expressed in the epidermis, in hair follicle epithelial cells and in dermal papilla cells in the anagen phase. The expression of decorin was decreased during catagen to telogen, except for the bulge region. Exogenous administration of decorin accelerated anagen and delayed catagen transition as a positive regulator of the hair cycle. Because TGF-ß is one of the androgen-induced pathogenic factors in androgenetic alopecia, this study provides clues to understand the pathogenesis and new therapeutic targets of hair loss.

Hair cycle control by leptin as a new anagen inducer.

Our purpose is to clarify the physiological role of leptin in hair cycle as leptin reportedly causes activation of Stat3, which is indispensable for hair cycling. While hair follicles in dorsal skin of 5-week-old C57/BL6 mice had progressed to late anagen phase, those in dorsal skin of 5-week-old leptin receptor deficient db/db mice remained in the first telogen and later entered the anagen at postnatal day 40, indicating that deficiency in leptin receptor signalling delayed the second hair cycle progression. Next, we shaved dorsal hairs on wild-type mice at postnatal 7 weeks and injected skin with mouse leptin or a mock. After 20 days, although mock injection showed no effect, hair growth occurred around leptin injection area. Human leptin fragment (aa22-56) had similar effects. Although the hair cycle of ob/ob mice was similar to that of wild-type mice, injection of mouse leptin on ob/ob mice at postnatal 7 weeks induced anagen transition. Immunohistochemically, leptin is expressed in hair follicles from catagen to early anagen in wild-type mice, suggesting that leptin is an anagen inducer in vivo. Phosphorylation of Erk, Jak2 and Stat3 in human keratinocytes was stimulated by leptin and leptin fragment. In addition, RT-PCR and ELISA showed that the production of leptin by human dermal papilla cells increased under hypoxic condition, suggesting that hypoxia in catagen/telogen phase promotes leptin production, preparing for entry into the next anagen. In conclusion, leptin, a well-known adipokine, acts as an anagen inducer and represents a new player in hair biology.

Cell and Tissue Damage after Skin Exposure to Ionizing Radiation: Short- and Long-Term Effects after a Single and Fractional Doses.

Ionizing radiation is often used to treat progressive neoplasms. However, the consequences of long-term radiation exposure to healthy skin tissue are poorly understood. We aimed to evaluate the short- and long-term radiation damage to healthy skin of the same irradiation given either as single or fractional doses. C57BL/J6 mice were randomly assigned to one of three groups: a control and two exposure groups (5 Gy ×2 or 10 Gy ×1). The inguinal area was irradiated (6-MeV beam) 1 week after depilation in the treatment groups. Skin samples were evaluated macroscopically and histologically for up to 6 months after the final exposure. After anagen hair follicle injury by irradiation, hair cycling resumed in both groups, but hair graying was observed in the 10 Gy ×1 group but not in the 5 Gy ×2 group, suggesting the dose of each fractional exposure is more relevant to melanocyte stem cell damage than the total dose. On the other hand, in the long term, the fractional double exposures induced more severe atrophy and capillary reduction in the dermis and subcutis, suggesting fractional exposure may cause more depletion of tissue stem cells and endothelial cells in the tissue. Thus, our results indicated that there were differences between the degrees of damage that occurred as a result of a single exposure compared with fractional exposures to ionizing radiation: the former induces more severe acute injury to the skin with irreversible depigmentation of hairs, while the latter induces long-term damage to the dermis and subcutis.

Reduction of conspicuous facial pores by topical fullerene: possible role in the suppression of PGE2 production in the skin.

BACKGROUND: Conspicuous facial pores are therapeutic targets for cosmeceuticals. Here we examine the effect of topical fullerene on conspicuous facial pores using a new image analyser called the VISIA® system. Ten healthy Japanese females participated in this study, and they received applications of 1% fullerene lotion to the face twice a day for 8 weeks. FINDINGS: Fullerene lotion significantly decreased conspicuous pores by 17.6% (p < 0.05, Wilcoxon signed-rank test) after an 8-week treatment. A self-administered questionnaire indicated that this reduction achieved cosmetically appreciable effects. In addition, to investigate the mechanism of effect of fullerene, we examined its effect on UVB-induced prostaglandin E2 (PGE2) production in reconstructed human epidermis (RhE). The results showed that irradiation of RhE with 1000 mJ/cm2 increased PGE2 production by 62.3% (p < 0.05, Mann-Whitney U-test) and the addition of 28 µM fullerene significantly suppressed the UVB-induced PGE2 production by 18.3% (p < 0.05). CONCLUSIONS: Fullerene lotion significantly decreases conspicuous facial pores after an 8-week treatment possibly through the suppression of PGE2 production in the epidermis.

Androgen actions on the human hair follicle: perspectives.

Androgens stimulate beard growth but suppress hair growth in androgenetic alopecia (AGA). This condition is known as 'androgen paradox'. Human pilosebaceous units possess enough enzymes to form the active androgens testosterone and dihydrotestosterone. In hair follicles, 5α-reductase type 1 and 2, androgen receptors (AR) and AR coactivators can regulate androgen sensitivity of dermal papillae (DP). To regulate hair growth, androgens stimulate production of IGF-1 as positive mediators from beard DP cells and of TGF-ß1, TGF-ß2, dickkopf1 and IL-6 as negative mediators from balding DP cells. In addition, androgens enhance inducible nitric oxide synthase from occipital DP cells and stem cell factor for positive regulation of hair growth in beard and negative regulation of balding DP cells. Moreover, AGA involves crosstalk between androgen and Wnt/ß-catenin signalling. Finally, recent data on susceptibility genes have provided us with the impetus to investigate the molecular pathogenesis of AGA.

Identification and characterization of cartilage oligomeric matrix protein as a novel pathogenic factor in keloids.

To elucidate pathogenic molecules in keloids, microarray analysis was performed using RNAs extracted from keloid-derived fibroblasts and normal skin-derived fibroblasts from the same patient with a typical keloid. Among 11 up-regulated extracellular matrix genes, cartilage oligomeric matrix protein (COMP) was most prominently increased. Up-regulation of COMP mRNA and protein was confirmed in the keloid tissue by quantitative RT-PCR and Western blot. Using immunohistochemistry, we compared 15 keloids and 6 control normal tissues using a COMP-specific antibody and found that COMP stained positively in 10 keloids (66.7%), whereas no staining was observed in normal tissues, demonstrating the ectopic expression of COMP in keloids. Comparing keloids smaller or larger than 10 cm(2), the larger keloids were significantly more intensely stained with the COMP-specific antibody. Because COMP reportedly accelerates collagen type I fibril assembly, we examined whether extracellular type I collagen deposition is altered by silencing COMP mRNA by small interfering RNA (siRNA). Immunocytochemistry showed at 96 hours after transfection with COMP siRNA that the extracellular deposition of type I collagen was decreased compared to that observed with control siRNA. Further, COMP knockdown decreased amount collagens type I to V in the medium and on the cell surfaces. Our data suggest that COMP facilitates keloid formation by accelerating collagen deposition, thus providing a new therapeutic target.

Green light emitting diodes accelerate wound healing: characterization of the effect and its molecular basis in vitro and in vivo.

Because light-emitting diodes (LEDs) are low-coherent, quasimonochromatic, and nonthermal, they are an alternative for low level laser therapy, and have photobiostimulative effects on tissue repair. However, the molecular mechanism(s) are unclear, and potential effects of blue and/or green LEDs on wound healing are still unknown. Here, we investigated the effects of red (638 nm), blue (456 nm), and green (518 nm) LEDs on wound healing. In an in vivo study, wound sizes in the skin of ob/ob mice were significantly decreased on day 7 following exposure to green LEDs, and complete reepithelialization was accelerated by red and green LEDs compared with the control mice. To better understand the molecular mechanism(s) involved, we investigated the effects of LEDs on human fibroblasts in vitro by measuring mRNA and protein levels of cytokines secreted by fibroblasts during the process of wound healing and on the migration of HaCat keratinocytes. The results suggest that some cytokines are significantly increased by exposure to LEDs, especially leptin, IL-8, and VEGF, but only by green LEDs. The migration of HaCat keratinocytes was significantly promoted by red or green LEDs. In conclusion, we demonstrate that green LEDs promote wound healing by inducing migratory and proliferative mediators, which suggests that not only red LEDs but also green LEDs can be a new powerful therapeutic strategy for wound healing.

Stat3 links activated keratinocytes and immunocytes required for development of psoriasis in a novel transgenic mouse model.

Here we report that epidermal keratinocytes in psoriatic lesions are characterized by activated Stat3. Transgenic mice with keratinocytes expressing a constitutively active Stat3 (K5.Stat3C mice) develop a skin phenotype either spontaneously, or in response to wounding, that closely resembles psoriasis. Keratinocytes from K5.Stat3C mice show upregulation of several molecules linked to the pathogenesis of psoriasis. In addition, the development of psoriatic lesions in K5.Stat3C mice requires cooperation between Stat3 activation in keratinocytes and activated T cells. Finally, abrogation of Stat3 function by a decoy oligonucleotide inhibits the onset and reverses established psoriatic lesions in K5.Stat3C mice. Thus, targeting Stat3 may be potentially therapeutic in the treatment of psoriasis.

Paracrine regulation of growth factor signaling by shed leucine-rich repeats and immunoglobulin-like domains 1.

Leucine-rich repeats and immunoglobulin-like domains 1 (LRIG1) is a recently discovered negative regulator of growth factor signaling. The LRIG1 integral membrane protein has been demonstrated to regulate various oncogenic receptor tyrosine kinases, including epidermal growth factor (EGF) receptor (EGFR), by cell-autonomous mechanisms. Here, we investigated whether LRIG1 ectodomains were shed, and if LRIG1 could regulate cell proliferation and EGF signaling in a paracrine manner. Cells constitutively shed LRIG1 ectodomains in vitro, and shedding was modulated by known regulators of metalloproteases, including the ADAM17 specific inhibitor TAPI-2. Furthermore, shedding was enhanced by ectopic expression of Adam17. LRIG1 ectodomains appeared to be shed in vivo, as well, as demonstrated by immunoblotting of mouse and human tissue lysates. Ectopic expression of LRIG1 in lymphocytes suppressed EGF signaling in co-cultured fibroblastoid cells, demonstrating that shed LRIG1 ectodomains can function in a paracrine fashion. Purified LRIG1 ectodomains suppressed EGF signaling without any apparent downregulation of EGFR levels. Taken together, the results show that the LRIG1 ectodomain can be proteolytically shed and can function as a non-cell-autonomous regulator of growth factor signaling. Thus, LRIG1 or its ectodomain could have therapeutic potential in the treatment of growth factor receptor-dependent cancers.

Inhibition of sebum production and Propionibacterium acnes lipase activity by fullerenol, a novel polyhydroxylated fullerene: potential as a therapeutic reagent for acne.

Oxidative stress plays a major role in acne formation; this suggests that oxygen-radical scavengers could be potential therapeutic agents. Fullerenol C60(OH)44, a recently developed polyhydroxylated fullerene, is a spherical carbon molecule that has many hydroxyl groups capable of potent radical-scavenging activity. We have investigated its inhibitory effects in vitro on sebum production in hamster sebocytes and in Propionibacterium acnes lipase activity. Sebum production was significantly reduced by 1.5 microM of fullerenol in cells that had been irradiated with 10 mJ/cm2 UVB, although it was not altered in the non-irradiated cells, indicating that fullerene is a sebum suppressor for sebocytes under oxidative stress, such as that induced by UVB. It was also found that fullerenol has inhibitory activity against P. acnes lipase. These results suggest that fullerenol could be a beneficial skin care reagent for controlling acne vulgaris by suppressing sebum in the inflammatory response and by reducing P. acnes lipase activity.

Improvement of acne vulgaris by topical fullerene application: unique impact on skin care.

Oxidative stress plays a major role in acne formation, suggesting that oxygen radical scavengers are potential therapeutic agents. Fullerene is a spherical carbon molecule with strong radical sponge activity; therefore, we studied the effectiveness of fullerene gel in treating acne vulgaris. We performed an open trial using a fullerene gel twice a day; at 4 and 8 weeks, the mean number of inflammatory lesions (erythematous papules and pustules) significantly (P < 0.05) decreased from 16.09 ± 9.08 to 12.36 ± 7.03 (reduction rate 23.2%) and 10.0 ± 5.62 (reduction rate 37.8%), respectively. The number of pustules, consisting of accumulation of neutrophils, was significantly (P < 0.05) decreased from 1.45 ± 1.13 to 0.18 ± 0.60 (reduction rate 87.6%), and further in vitro assays of sebum production in hamster sebocytes revealed that 75 µM polyvinylpyrrolidone-fullerene inhibits sebum production, suggesting that fullerene suppresses acne through decreasing neutrophil infiltration and sebum production. After treatment for 8 weeks, the water content of the skin significantly (P < 0.05) increased from 51.7 ± 7.9 to 60.4 ± 10.3 instrumental units. Therefore, the fullerene gel may help in controlling acne vulgaris with skin care benefit. FROM THE CLINICAL EDITOR: Fullerenes, spherical carbon cages with strong oxygen radical scavenging, with formulated into a gel and used to successfully treat acne vulgaris, an inflammatory disease associated oxidative stress.

The Effects of Ischemia and Hyperoxygenation on Hair Growth and Cycle.

Alopecia has several causes, but its relationship with ischemia/hypoxia has not yet been investigated in detail. In this study, we studied the changes of hair follicles induced by ischemia and potential effects of normobaric hyperoxygenation (NBO) on the hair cycle and growth. We found that skin ischemia reduced hair growth rate, hair shaft size, and its pigmentation in the anagen phase of mice, which may reflect an aspect of pathophysiology of hair loss (alopecia) and depigmentation (gray/white hairs). Hyperoxygenation increased hair growth rate in organ culture of both human and murine hair follicles. Systemic NBO promoted hair growth in early anagen and mid-anagen, and delayed catagen onset in mice. However, telogen-to-anagen transition was not affected by NBO as far as non-ischemic skin is concerned. The results of this study indicated that the hair follicle is very sensitive to oxygen tension and oxygen tension affects the regulation of hair growth and cycle in vitro and in vivo. It was suggested that systemic NBO can be safely applied for a long period and can be a noninvasive therapeutic approach to alter hair growth and cycle by manipulating the microenvironment of hair follicles.

Mesenchymal-epithelial interactions in the skin: increased expression of dickkopf1 by palmoplantar fibroblasts inhibits melanocyte growth and differentiation.

We investigated whether or not the topographic regulation of melanocyte differentiation is determined by mesenchymal-epithelial interactions via fibroblast-derived factors. The melanocyte density in palmoplantar human skin (i.e., skin on the palms and the soles) is five times lower than that found in nonpalmoplantar sites. Palmoplantar fibroblasts significantly suppressed the growth and pigmentation of melanocytes compared with nonpalmoplantar fibroblasts. Using cDNA microarray analysis, fibroblasts derived from palmoplantar skin expressed high levels of dickkopf 1 (DKK1; an inhibitor of the canonical Wnt signaling pathway), whereas nonpalmoplantar fibroblasts expressed higher levels of DKK3. Transfection studies revealed that DKK1 decreased melanocyte function, probably through beta-catenin-mediated regulation of microphthalmia-associated transcription factor activity, which in turn modulates the growth and differentiation of melanocytes. Thus, our results provide a basis to explain why skin on the palms and the soles is generally hypopigmented compared with other areas of the body, and might explain why melanocytes stop migrating in the palmoplantar area during human embryogenesis.

Mice with defects in HB-EGF ectodomain shedding show severe developmental abnormalities.

Heparin-binding EGF-like growth factor (HB-EGF) is first synthesized as a membrane-anchored form (proHB-EGF), and its soluble form (sHB-EGF) is released by ectodomain shedding from proHB-EGF. To examine the significance of proHB-EGF processing in vivo, we generated mutant mice by targeted gene replacement, expressing either an uncleavable form (HBuc) or a transmembrane domain-truncated form (HBdeltatm) of the molecule. HB(uc/uc) mice developed severe heart failure and enlarged heart valves, phenotypes similar to those in proHB-EGF null mice. On the other hand, mice carrying HBdeltatm exhibited severe hyperplasia in both skin and heart. These results indicate that ectodomain shedding of proHB-EGF is essential for HB-EGF function in vivo, and that this process requires strict control.

Significance of dermoscopy in acute diffuse and total alopecia of the female scalp: review of twenty cases.

BACKGROUND: Acute diffuse and total alopecia of the female scalp (ADTAFS) is a new subtype of alopecia areata that is characterized by rapid progression of diffuse alopecia of the female scalp, marked female predominance and a favorable prognosis. Differential diagnosis of other types of diffuse alopecia such as female pattern hair loss (FPHL) is necessary in some cases. OBJECTIVE: To describe dermoscopic findings of ADTAFS and to investigate the possibility of utilizing dermoscopy as a diagnostic tool for ADTAFS. METHODS: Twenty cases of ADTAFS diagnosed by clinical and/or histological findings were examined by dermoscopy. RESULTS: Cadaverized hairs (black dots), exclamation mark hairs (tapering hairs), broken hairs or yellow dots were seen in 18, 13, 19 and 17 out of 20 cases, respectively. One of these signs was seen in all cases (20/20). On the other hand, none of 12 cases with exclusively FPHL showed the dermoscopic features such as cadaverized hairs, exclamation mark hairs or broken hairs. Only 1 FPHL patient showed a yellow dot in the hair loss area. CONCLUSION: Dermoscopy is a helpful diagnostic tool for ADTAFS, especially to distinguish it from FPHL.

Expression of estrogen receptor beta in normal skin, melanocytic nevi and malignant melanomas.

Sex hormones are known to be associated with increases of melanocytes and melanin production in human skin. However, the expression of estrogen receptor (ERalpha) in melanocytic lesions has been controversial. In 1996, a new subset of estrogen receptor was cloned, and named estrogen receptor beta (ERbeta). We used immunohistochemical staining to characterize the expression of ERalpha and ERbeta in normal skin and in melanocytic lesions. Normal sebaceous glands and hair follicles were positive for ERalpha and ERbeta. Other adnexal structures and constituents in the skin were positive for ERbeta, but not for ERalpha. Melanocytic nevi and malignant melanomas were negative for ERalpha, but both were positive for ERbeta. The ubiquitous expression of ERbeta may play a fundamental role in various normal skin cells and melanocytic tumors.

[Hair follicle regeneration].

Hair growth cycle is coordinated with complex processes that are dependent on the interactions of follicular stem cells and dermal papilla cells (DPCs). For the past 10 years, the developmental mechanism of hair follicles has been extensively studied, and spatial and temporal expressions of many molecules are required for the hair morphogenesis. These molecules are also required for hair cycle progression. Androgen receptor, which is a ligand dependent transcription factor, plays an important role in human hair cycle. Frontal scalp DPCs from androgenetic alopecia (AGA) are the target cells of androgen action. Minoxidil and Finasteride were recently introduced for the treatment of AGA, and cell therapy using DPCs is a next strategy for the innovative treatment.

Naturally Occurring Hair Growth Peptide: Water-Soluble Chicken Egg Yolk Peptides Stimulate Hair Growth Through Induction of Vascular Endothelial Growth Factor Production.

Alopecia is divided into two categories: androgenic alopecia and nonandrogenic alopecia. An androgen-dependent abnormality of biological functions causes alopecia in males, but the role of androgens is not yet elucidated in female pattern hair loss (FPHL). Modulation of androgenic activity is not effective in certain kinds of androgenic alopecia in females, as well as in cases of nonandrogenic alopecia in males and females. The hair growth drug, minoxidil, stimulates vascular endothelial growth factor (VEGF) production as well as vascularization and hair growth in females. Yet, because minoxidil has side effects with long-term use, a safe alternative hair growth agent is needed. Whereas hair develops after birth in mammalian species, hair mostly grows in a precocial bird, in the chicken, between hatching days 14 and 15. Therefore, we hypothesized that the chicken egg contains a key hair growth factor. In this study, we demonstrated that water-soluble peptides derived from the egg yolk stimulate VEGF production and human hair follicle dermal papilla cell growth. We also found that these peptides enhance murine hair growth and improve hair growth in FPHL. Finally, we characterized that water-soluble egg yolk peptides induce VEGF expression through insulin growth factor-1 receptor activation-induced hypoxia-inducible factor-1α transcription pathway. We have given the name "hair growth peptide (HGP)" to this water-soluble egg yolk peptide.