Frontal fibrosing alopecia and lichen planus pigmentosus: diagnosis and therapeutic challenge

Abstract Frontal fibrosing alopecia is a variant of lichen planopilaris with marginal progressive hair loss on the scalp, eyebrows and axillae. We report a case of frontal fibrosing alopecia and lichen planus pigmentosus in a postmenopausal woman, that started with alopecia on the eyebrows and then on the frontoparietal region, with periocular and cervical hyperpigmentation of difficult management. The condition was controlled with systemic corticosteroid therapy and finasteride. Lichen planus pigmentosus is an uncommon variant of lichen planus frequently associated with frontal fibrosing alopecia in darker phototipes. It should be considered in patients affected by scarring alopecia with a pattern of lichen planopilaris and areas of skin hyperpigmentation revealing perifollicular hyperpigmentation refractory to multiple treatments. This case illustrates diagnostic and therapeutic challenge in face of scarring alopecia and perifollicular hyperpigmentation.

Efectos adversos de finasteride: mitos y realidades. una revisión actualizada / Finasteride adverse effects: an update

Finasteride is a 5-α reductase inhibitor that is widely used in the management of benign prostate hyperplasia and male pattern hair loss. It is well known that these agents improve the quality of life in men suffering from these conditions. However, they are associated with some transient and even permanent adverse effects. The aim of this article is to clarify the controversies about the safety of finasteride by analyzing the evidence available in the literature.

The effectiveness of finasteride and dutasteride used for 3 years in women with androgenetic alopecia.

Background: The effectiveness of finasteride and dutasteride in women with androgenetic alopecia has been the subject of debate. Aim: To evaluate the effectiveness of finasteride and dutasteride on hair loss in women with androgenetic alopecia over a period of 3 years. Methods: From a database containing systematically retrieved data on 3500 women treated for androgenetic alopecia between 2002 and 2012 with finasteride 1.25 mg or dutasteride 0.15 mg, a random sample stratified for age and type of medication was taken to yield 30 women in two age categories: below and above 50 years, and for both medications. Hair thickness of the three thinnest hairs was measured from standardized microscopic images at three sites of the scalp at the start of the treatment and after 3 years of continuous medication intake. The macroscopic images were evaluated independently by three European dermatologists/hair experts. The diagnostic task was to identify the image displaying superior density of the hair. Results: Both age categories showed a statistically significant increase in hair thickness from baseline over the 3‑year period for finasteride and dutasteride (signed rank test, P = 0.02). Hair thickness increase was observed in 49 (81.7%) women in the finasteride group and in 50 (83.3%) women in the dutasteride group. On average, the number of post‑treatment images rated as displaying superior density was 124 (68.9%) in the finasteride group, and 118 (65.6%) in the dutasteride group. Dutasteride performed statistically significantly better than finasteride in the age category below 50 years at the central and vertex sites of the scalp. Conclusions: Finasteride 1.25 mg and dutasteride 0.15 mg given daily for 3 years effectively increased hair thickness and arrested further deterioration in women with androgenetic alopecia.

Impact of Metabolic Syndrome on Response to Medical Treatment of Benign Prostatic Hyperplasia

PURPOSE: To investigate the effect of metabolic syndrome (MetS) on the response to medical therapy of benign prostatic hyperplasia (BPH) after a 3-month period of treatment. MATERIALS AND METHODS: This was a cohort study of 100 patients, 47 with MetS and 53 without MetS, referred to either the primary care unit or referral hospital with BPH who had moderate lower urinary tract symptoms of prostate involvement and were candidates for medical treatment. Our main outcome was response to medical treatment with prazosin 1 mg twice a day and finasteride 5 mg daily in patients with BPH on the basis of International Prostate Symptom Score (IPSS). Multivariate analysis of covariance was used to compare BPH treatment response in patients with and without MetS before and after receiving treatment. RESULTS: The mean volume of the prostate was significantly higher in MetS patients than in patients without MetS (57+/-32.65 mL compared with 46.00+/-20.19 mL, p=0.036). The control group demonstrated an 11-unit reduction in IPSS, whereas those with MetS showed a reduction in the symptom score of only 6 units (p<0.001). Regarding the components of MetS separately, triglyceride (p<0.001), fasting blood sugar (p=0.001), and waist circumference (p=0.028) significantly affected the clinical progression of BPH. The observational nature of this study may be a limitation in comparison with an interventional study. CONCLUSIONS: The results of the present study showed that MetS can negatively affect the response to medical treatment of BPH. Therefore, it is necessary to consider MetS in selecting patients with BPH for drug therapy.

Female pattern hair loss.

Female pattern hair loss (FPHL) is a common cause of hair loss in women characterized by diffuse reduction in hair density over the crown and frontal scalp with retention of the frontal hairline. Its prevalence increases with advancing age and is associated with significant psychological morbidity. The pathophysiology of FPHL is still not completely understood and seems to be multifactorial. Although androgens have been implicated, the involvement of androgen-independent mechanisms is evident from frequent lack of clinical or biochemical markers of hyperandrogenism in affected women. The role of genetic polymorphisms involving the androgen and estrogen receptors is being increasingly recognized in its causation and predicting treatment response to anti-androgens. There are different clinical patterns and classifications of FPHL, knowledge of which facilitates patient management and research. Chronic telogen effluvium remains as the most important differential diagnosis. Thorough history, clinical examination, and evaluation are essential to confirm diagnosis. Patients with clinical signs of androgen excess require assessment of biochemical parameters and imaging studies. It is prudent to screen the patients for metabolic syndrome and cardiovascular risk factors. The treatment comprises medical and/or surgical modalities. Medical treatment should be initiated early as it effectively arrests hair loss progression rather than stimulating regrowth. Minoxidil continues to be the first line therapy whereas anti-androgens form the second line of treatment. The progressive nature of FPHL mandates long-term treatment for sustained effect. Medical therapy may be supplemented with cosmetic concealment in those desirous of greater hair density. Surgery may be worthwhile in some carefully selected patients.

Androgenetic alopecia: An update.

Androgenetic alopecia (AGA) is one of the commonest reasons for dermatological consultation. Over the last few years our understanding of the pathophysiology of AGA has improved and this has paved way for better diagnostic and therapeutic options. Recent research has dwelled on the role of stem cells in the pathophysiology of AGA and has also identified newer genetic basis for the condition. Dermoscopy/trichoscopy has emerged as a useful diagnostic tool for AGA. While the major treatment options continue to be topical minoxidil, systemic Finasteride and hair transplantations, newer modalities are under investigation. Specific diagnostic and treatment recommendations have also been developed on evidence based principles. This article reviews the recent concepts in relation to AGA. With regards to the pathophysiology we have tried to stress on recent knowledge of the molecular and genetic basis of AGA. We have emphasized on an evidence based approach for treatment and diagnosis.

Cost-effectiveness analysis of medical treatment of benign prostatic hyperplasia in the Brazilian public health system

OBJECTIVE: To perform a cost-effectiveness analysis of medical treatment of benign prostatic hyperplasia (BPH) under Brazilian public health system perspective (Unified Health System - "Sistema Único de Saúde (SUS)"). MATERIAL AND METHODS: A revision of the literature of the medical treatment of BPH using alpha-blockers, 5-alpha-reductase inhibitors and combinations was carried out. A panel of specialists defined the use of public health resources during episodes of acute urinary retention (AUR), the treatment and the evolution of these patients in public hospitals. A model of economic analysis(Markov) predicted the number of episodes of AUR and surgeries (open prostatectomy and transurethral resection of the prostate) related to BPH according to stages of evolution of the disease. Brazilian currency was converted to American dollars according to the theory of Purchasing Power Parity (PPP 2010: US$ 1 = R$ 1.70). RESULTS: The use of finasteride reduced 59.6% of AUR episodes and 57.9% the need of surgery compared to placebo, in a period of six years and taking into account a treatment discontinuity rate of 34%. The mean cost of treatment was R$ 764.11 (US$449.78) and R$ 579.57 (US$ 340.92) per patient in the finasteride and placebo groups, respectively. The incremental cost-effectiveness ratio (ICERs) was R$ 4.130 (US$ 2.429) per episode of AUR avoided and R$ 2.735 (US$ 1.609) per episode of surgery avoided. The comparison of finasteride + doxazosine to placebo showed a reduction of 75.7% of AUR episodes and 66.8% of surgeries in a 4 year time horizon, with a ICERs of R$ 21.191 (US$ 12.918) per AUR episodes avoided and R$ 11.980 (US$ 7.047) per surgery avoided. In the sensitivity analysis the adhesion rate to treatment and the cost of finasteride were the main variables that influenced the results. CONCLUSIONS: These findings suggest that the treatment of BPH with finasteride is cost-effective compared to placebo in the Brazilian public health system perspective.

Tratamento hormonal da acne baseado em evidências / Hormonal treatment of acne based on evidence

Este trabalho de revisão apresenta o tratamento hormonal da acne baseado em evidências. O trabalho resume a clínica, a classificação, a fisiopatologia e a etiologia da acne. A avaliação de estudos selecionados mostrou que o tratamento hormonal da acne deve ser complementado por tratamento cosmiátrico, e não está indicado para gestantes ou mulheres com planos de engravidar. A primeira escolha para esse tratamento são os contraceptivos hormonais orais, pois são efetivos e seguros para tratamento da acne e também para anticoncepção. Após tempo estabelecido, se o resultado for insatisfatório, outro medicamento, como acetato de ciproterona ou espironolactona, deve ser adicionado. A finasterida é o medicamento indicado para acne de origem idiopática, e a flutamida apresenta efeitos colaterais significativos, não constituindo indicação segura até o momento.

This review shows the hormonal treatment of acne. The review summarizes the clinical aspects, classification, physiopathology and etiology of the acne. The evaluation of selected papers showed that hormonal treatment of acne with hormones has to be complemented by esthetics treatment and is not prescribed for pregnant women or those who want to get pregnant. The first choice of treatment is the hormonal oral contraceptive one, because it is effective and safe for treatment of acne and also for contraception. After an established period with unsatisfactory results, other medicines, such as ciproterone acetate or spironolactone, can be added. The finasteride is prescribed for idiopathic acne and flutamide has many relevant side effects and is also not safe.

Alopecia de patrón femenino / Female pattern hair loss

La alopecia androgénetica femenina, o alopecia de patrón femenino, es una de las causas más frecuentes de caída de pelo. Su aparición origina importante estrés y problemas psicológicos; de ahí la importancia de un manejo adecuado. Hay casos que se asocian a hiperandrogenismo. En este trabajo revisamos las distintas formas clínicas, discutimos las pruebas de laboratorio más indicadas y los distintos tratamientos, entre ellos, la finasterida.

Female androgenetic alopecia or female pattern hair loss is one of the most frequent causes of hair loss. It can originate high stress and psychological problems, and a correct approach is therefore important. Certain cases are associated with hyperandrogenism. In this report we review the different clinical patterns, the most indicated laboratory tests and the different treatments, including finasteride.

Comparison of efficacy between Tamsulosin and Finasteride on symptomatic Benign Prostatic Hyperplasia.

This prospective study was done to compare the efficacy of Tamsulosin and Finasteride for the medical treatment of symptomatic Benign Prostatic Hyperplasia (BPH) at the surgery and urology outpatient department of Mymensingh Medical College Hospital during the period from January 2003 to December 2004. Closely matched 70 patients in the age range of 50-80 years presented with lower urinary tract symptoms and clinically diagnosed as BPH were selected in the present study. Among them, 36 patients (Group I) and 34 patients (Group II) were treated with Tamsulosin (0.4 mg once daily) and Finasteride (5 mg once daily) for a duration of 06 months respectively. The efficacy of two drugs was compared on the basis of IPSS and Qmax. The base-line parameters of both groups were statistically insignificant. A significant improvement of IPSS and Qmax was found after 06 months of treatment in both groups (P<0.001). A significant improvement of IPSS Qmax was found in both groups (p<0.001) during follow-up at 1st, 2nd, 4th and 6th month. It was also observed that Tamsulosin improved the IPSS and Qmax more quickly than Finasteride.

Actualización de la terapia del hirsutismo / Update in the treatment of hirsutism

El hirsutismo es un síntoma del hiperandrogenismo femenino a nivel dermatológico y constituye en sí mismo un problema estético y psicosocial para la mujer. Se analizan las drogas involucradas en el tratamiento, el mecanismo de acción y efectos colaterales. La eficiencia y seguridad de ciproterona, espironolactona y flutamida en 3 grupos de mujeres hirsutas se comparan con los datos de la literatura.

Efficacy of terazosin and finasteride in symptomatic benign prostatic hyperplasia: A comparative study.

Medical treatment for symptomatic Benign Prostatic Hyperplasia (BPH) has become popular for the last few years. This study was designed to find out and compare the efficacy of terazosin, a alpha1 adrenoceptor blocker and finasteride, a 5alpha-reductase inhibitor in symptomatic BPH. A total of 60 patients (30 in terazosin group and 30 finasteride group) of symptomatic BPH were selected. Terazosin group received 1 mg daily at bedtime for 3 days, 2 mg at bedtime for 7 days, thereafter 5 mg at bedtime daily for 6 months. Finasteride group received 5 mg once daily. In terazosin treated patients, improvement after 3 months were as follows, IPSS 3.93 +/- .74 points reduction, Qmax 2.13 +/- .68 ml/s increase, post-voided residual urine volume (PVR) 20.67 +/- 10.56 ml reduction (significant, p<0.001) and prostate volume 0.57 +/- 1.54 ml reduction (not significant). Similar statistical differences were observed at 6 months follow up. In finasteride treated patients, improvements after 3 months were as follows, International Prostate Symptom Score (IPSS) 1.38 +/- .63 points reduction, Qmax 0.55 +/- 0.78 ml/s increase, PVR 5.93 +/- 7.64 ml reduction (significant, p<0.001) and prostate volume 0.17 +/- 5.6 ml reduction (non-significant). At 6 month follow up statistical differences were significant in all parameters including prostate volume 4.57 +/- 5.30 ml reduction (p<0.001). In comparison, statistically significant superiority of terazosin over finasteride was found in improving IPSS, Qmax and PVR in both follow up visits. But terazosin had nonsignificant effect in reducing prostate volume; in contrast, finasteride had significant effect in second visit. It can be concluded from this study that terazosin 5mg once daily is effective in mild to moderate cases of symptomatic BPH. On the other hand, finasteride 5mg once daily may be useful in large prostate and to be given for at least 6 months.

Tratamiento de la hiperplasia prostática benigna / Treatment of benign prostatic hyperplasia

En el campo de la Urología, una de las causas més frecuentes de consulta la constituye la patología prostática y dentro de ésta, la hiperplasia benigna de la próstata. Esta consiste en un incremento de células en el área periuretral prostática, lo que puede ser debido a una proliferación celular aumentada, a una alteración de la apoptosis, o a una combinación de ambos mecanismos. Entre las principales opciones terapÚuticas actuales para la hiperplasia prostática benigna están: - Tratamiento quirúrgico, que continua siendo la principal alternativa de terapia, representado principalmente por la resección transuretral. Tratamiento farmacológico, utilizado como alternativa y/o complemento a la cirugía y representado por dos grandes grupos de fármacos: los antagonistas adrenÚrgicos y la terapia endocronológica (finasteride). El presente trabajo es una revisión bibliográfica actualizada sobre las distintas opciones de tratamiento disponibles para la hiperplasia prostática benigna y sus respectivas indicaciones.

Eficacia y seguridad de la terapia combinada finasteride + prazosin vs. finasteride + placebo en pacientes con hiperplasia prostática benigna / Effectiveness and security of the therapy combined finasteride + prazosin vs. finasteride + placebo in patient with hiperplasia benign prostática

Se realizó un estudio doble ciego, propectivo, comparativo y controlado con placebo, con el propósito de investigar la eficacia y seguridad de la terapia concomitante de finasteride y prazosín vs. finasteride más placebo en pacientes con hiperplasia prostática beninga (HPB), sobre los síntomas de prostatismo, velocidad de flujo urinario máximo y volumen prostático. Ingresaron al estudio 20 hombres portadores de HPB. Luego de un período de tratamiento de 2 semanas con placebo, los pacientes se distribuyeron en tres grupos de medicación activa: 1A, IB, y 2. Los pacientes de los grupos 1A (n=5) y 1B (n=5) recibieron finasteride (5 mg/día) más prazosín (4mg/día); los pacintes (n=10) del grupo 2 recibieron finasteride (5 mg/día) más placebo. El primer período de tratamiento se extendió durante 24 semanas. Las siguientes 12 semanas (hasta un total de 38 semanas) los pacientes de los grupos 1B y 2 continuaron con su mismo esquema de tratamiento; en los pacientes del grupo 1A, el prazosín se sustituyó por placebo. De los 20 pacientes inicialmente incluidos, finalizaron 16. Al comparar los grupos de tratamiento, se puede apreciar cómo la terapia combinada de finasteride más prazosín produce una mejoría o reducción del puntaje total de síntomas y un incremeto en la velicidad del flujo urinario máximo que son significativamente mejores (p<0.0003 y p<0.0075, respectivamente) que la terapia de finasteride más placebo, desde el inicio del tratamiento. La medicación fue bien tolerada, y hubo una baja incidencia 10 por ciento de efectos adversos relacionados con la medicación durante el estudio. En vista de estos hallazgos, y tomando este estudio como un estudio piloto, podemos concluir que la terapia combinada de finasteride más prazosín, probablemente como consecuencia del mecanismo sinérgico entre ambos medicamentos, ofrece un ventajas en cuanto a mejoría sintomática y urodinámica, en comparación con la monoterapia, en el tratamiento de la hiperplasia prostática benigna

Hiperplasia adrenal congénita no clásica: deficiencia de 21-hidroxilasa / Non classic congenital adrenal hyperplasia: 21-hydroxylase deficiency

Los síndromes de hiperandrogenismo de diferente grado constituyen un motivo de consulta frecuente en un consultorio de Ginecología Infantojuvenil. Estos cuadros suelen provocar preocupación en las adolescentes tanto por sus manifestaciones estéticas (hirsutismo, acné, alopecía) como por la presencia de alteraciones del ciclo mestrual que puede crearles dudas sobre su fertilidad futura. Una de las causas de hiperandrogenismo, la Hiperplasia Adrenal Congénita No Clásica (HACNC), cobra importancia debido a su origen genético y a que no existen elementos de la clínica que permitan diferenciarla de otras etiologías como síndrome de ovarios poliquísticos. El presente trabajo propone una actualización sobre HACNC, en cuanto a su fisiopatología, aspectos genéticos, clínica, metodología diagnóstica y tratamiento. Se consideran en forma particular sus posibles repercusiones sobre la fertilidad, así como el asesoramiento genético que requieren estas pacientes

Alopecia androgenética e finasterida / Androgenetic alopecia and finasteride

A alopecia androgenética (AAG), popularmente conhecida como calvície, é uma patologia muito comum em nosso meio, acometendo além dos homens as mulheres, com menor incidência. Possui forte influência androgênica e genética. Recentemente uma nova droga, a finasterida, surgiu com muito bons resultados no seu tratamento, ajudando a esclarecer, em parte, a sua fisiopatologia. É o que registramos neste artigo