Editor's Highlights - August 2024.

Pigmentary and hair disorders have a significant cosmetic and psychological impact. In the August issue of the Journal, we highlight the use of reflectance confocal microscopy in diagnosing and monitoring treatment responses in patients with melasma. We will also discuss new therapeutic approaches involving oral melatonin and a combination of glutathione and resveratrol for melasma. Additionally, the ongoing revolution in alopecia treatment with oral low-dose minoxidil will be spotlighted, including the circumstances under which media attention has contributed to the growing interest in oral minoxidil prescriptions.

Dupilumab for the treatment of alopecia areata in pediatric patients with atopic dermatitis: A scoping review.

Our study aims to synthesize existing evidence of dupilumab for alopecia areata (AA) in pediatric patients with atopic dermatitis (AD). We searched MEDLINE and Embase on March 1, 2024, using keywords related to AD, AA, dupilumab, and pediatric patient populations per PRISMA-ScR guidelines. A mean SALT score reduction of 42.6 following dupilumab treatment (p < .01) over an average of 3.21 months, and a mean reduction of Investigator Global Assessment (IGA) levels of 2.14 units (p < .01) demonstrates the efficacy of dupilumab in pediatric AA when there is concurrent AD. Our findings in combination with dupilumab's favorable safety profile in pediatric AD makes it an appealing option for AA treatment, however, a greater understanding of the underlying mechanisms, optimal pediatric patient selection criteria, long-term efficacy, and safety profile of dupilumab in this context is warranted.

Genetic association between asthma and alopecia areata: A two-sample Mendelian randomization study.

BACKGROUND: Many patients with asthma experience alopecia areata (AA) in their lives. However, it is unclear whether asthma causes or results from AA. Our objective was to investigate the genetic causal relationship between asthma and AA. METHODS: Two-sample Mendelian randomization (MR) was used to assess the causal relationship between asthma and AA based on the largest publicly available genome-wide association study summary statistics. Androgenetic alopecia (AGA) and cicatricial alopecia (CA) were chosen as the control groups for AA. The main estimates were obtained using inverse variance weighting meta-analysis (IVW), Mendelian randomization-Egger (MR-Egger), maximum likelihood estimation, and the weighted median. Sensitivity analyses were conducted using Cochran's Q test, MR-Egger, and leave-one-out methods. Lastly, we conducted a reverse MR analysis to evaluate the possibility of reverse causation. RESULTS: Genetically, asthma is associated with an increased risk of AA, while the association between genetically predicted AGA or CA and asthma was negative. The risk of AA increased by 1.86 times in patients with asthma under the IVW method (OR = 1.86, 95% CI = 1.31-2.629, p < 0.001). The reverse MR analysis did not find evidence supporting reverse causality from three phenotypes of alopecia to asthma. Sensitivity analyses yielded consistent causal estimates. CONCLUSION: This study suggests that asthma is causally associated with AA. The findings deepen our understanding of the role of asthma in the pathology of AA, which emphasizes the potential for opening a new vista for the prevention and diagnosis of AA.

Sonographic comparison of subcutaneous fat layer thickness in the scalp area in patients with androgenetic alopecia compared to healthy individuals: Cross-sectional.

INTRODUCTION: Androgenetic alopecia (AGA) is one of the most common alopecia among men and women worldwide. It is a nonscarring alopecia that has a characterized pattern. In female pattern AGA, the hairline is stable but general thinning occurs most notably in the frontal region. In male-pattern AGA, the hairline is receding and the thinning is most notable in the frontotemporal region. AGA has a complex pathogenesis and relation of subcutaneous fat in the scalp region and the miniaturization of terminal hair follicles is vague. In this study, subcutaneous fat in the frontal scalp an important region for AGA is compared to the occipital scalp that is spared in AGA. METHOD: Our study is a cross-sectional study that has four groups. Male patient, female patient, male control, female control. Every group has 15 individuals. All of the people in the study are those referred to Rasoul Akram's dermatology clinic. The severity of alopecia is classified by Norwood scaling for male pattern AGA and Ludwig scaling for female pattern AGA. Subcutaneous tissue in the frontal and occipital regions is measured by ultrasonography. For evaluating the effect of aging on subcutaneous fat thickness, we subdivided any group into more than 40 years old and between 20 and 40 years old and compared these two subgroups. RESULTS: The mean age of the three groups of male patient, female patient, and female control is 40 y/o and the mean age of male control is 41 y/o. The mean subcutaneous fat layer thickness in frontal region in male patients group is 6.0 mm (more than 40 y/o = 6.6 mm, between 20 and 40 y/o = 5.5 mm), in female patients group 5.1 mm (more than 40 y/o = 5.7 mm, between 20 and 40 y/o = 4.6 mm), in the male control group is 4.4 mm (more than 40 y/o = 4.7 mm, between 20 and 40 y/o = 4 mm) and in the female control group is 4.1 mm (more than 40 y/o = 4.5 mm, between 20 and 40 y/o = 3.6 mm). The mean subcutaneous fat layer thickness in the occipital region in the male patient's group is 6.4 mm (more than 40 y/o = 6.7 mm, between 20 and 40 y/o = 6 mm), in the female patient's group 6.1 mm (more than 40 y/o = 6.5 mm, between 20 and 40 y/o = 5.7 mm), in the male control group is 6.3 mm (more than 40 y/o = 6.8 mm, between 20 and 40 y/o = 5.7 mm) and in the female control group is 6.2 mm (more than 40 y/o = 6.6 mm, between 20 and 40 y/o = 5.8 mm). CONCLUSION: This study demonstrates that the subcutaneous fat layer in the frontal region in both males and females is thicker in AGA patients than healthy group and the more severe the AGA, the thicker is subcutaneous layer in the frontal region. In the male patients group, the subcutaneous fat layer in the frontal region is thicker than in the female patients group but in the male and female control groups is not so different. The subcutaneous fat layer in the occipital region is thicker in older individuals in both patients and control groups but is not different when compared to AGA patients and control individuals.

Alopecia areata following COVID-19 vaccine: a systematic review.

BACKGROUND: To date, multiple cases of adverse reactions to COVID-19 vaccines have been reported worldwide. Alopecia areata (AA) is an uncommon type of adverse reaction reported in some articles and has a significant social and psychological impact on patients. Our study aimed to review the AA and COVID-19 vaccine literature. METHODS: This systematic review was conducted by searching for articles on AA following COVID-19 vaccines in international databases such as Embase, MEDLINE, PubMed, Web of Knowledge, and Ovid from December 2019 to December 30, 2023. We included studies that provided data for AA patients following COVID-19 vaccination with at least one dose. Data on sex, age, country/region of origin, vaccine type, days between vaccination and symptom presentation, manifestations of AA, trichoscopy and histopathological findings, treatment, and outcomes were included. RESULTS: In total, 579 explored studies were identified and assessed, and 25 articles with a total of 51 patients were included in the review. Twenty-seven (52.9%) patients developed new-onset AA following receiving the COVID-19 vaccine, and AA recurrence or exacerbation occurred after receiving the COVID-19 vaccine in 24 (47.1%) patients with preexisting disease. Five vaccines were reported to cause AA in all cases. The Pfizer vaccine (45.1%) was the most frequently reported, followed by the ChAdOx1 nCoV-19 vaccine (27.5%), Moderna mRNA-1273 (19.6%), Sinopharm (3.9%) and SinoVac (3.9%). AA occurred most frequently within one month after the 1st dose, and then, the incidence decreased gradually with time. Topical or systemic corticosteroids were used in 38 patients. Eleven patients were treated with a Janus Kinase inhibitor (jakinib) inhibitor, eight with tofacitinib, and three with an unspecified jakinib. However, 3 of the 11 patients experienced exacerbations after treatment. CONCLUSION: AA after COVID-19 vaccination is rare, and physicians should be aware of this phenomenon to improve early diagnosis and appropriate treatment.

Topical Minoxidil Overdose in a Young Man With Androgenetic Alopecia: A Case Report.

Minoxidil is an effective and relatively safe topical drug that is used to treat androgenetic alopecia and other types of alopecia. This active ingredient is used in dermatology as a hair growth stimulant; however, the use of solutions containing minoxidil can be accompanied by a variety of cardiovascular systemic side effects. In this case report, we describe the case of a 23-year-old man who presented with complaints of dizziness, blurred vision, general malaise, fatigue, and feeling pre-syncopal while standing after applying large amounts of topical minoxidil solution for three days in a row. Other potential causes of the presenting condition were excluded. The symptoms quickly resolved after the discontinuation of minoxidil. No other treatment was used apart from minoxidil withdrawal.

Small molecule agents against alopecia: Potential targets and related pathways.

Alopecia has emerged as a global concern, extending beyond the middle-aged and elderly population and increasingly affecting younger individuals. Despite its growing prevalence, the treatment options and effective drugs for alopecia remain limited due to the incomplete understanding of its underlying mechanisms. Therefore, it is urgent to explore the pathogenesis of alopecia and discover novel and safer therapeutic agents. This review provided an overview of the prevailing clinical disorders of alopecia, and the key pathways and targets involved in hair growth process. Additionally, it discusses FDA-approved drugs and clinical candidates for the treatment of alopecia, and explores small molecule compounds with anti-alopecia potential in the drug discovery phase. These endeavors are expected to provide researchers with valuable scientific insights and practical information for anti-alopecia drug discovery.

Coexistent frontal fibrosing alopecia with ophiasis pattern alopecia areata in a young female: A case report and review of the literature.

This study highlights the possibility of coexistent Frontal Fibrosing Alopecia and ophiasis pattern Alopecia Areata especially in young females which is a rare manifestation. A concomitant shared pathophysiology is suspected to underlie this association.

Botanical extract combined with minoxidil improve hidrotic ectodermal dysplasia caused by p.G11R mutations: a case report.

PURPOSE: We aim to explore a potential treatment strategy for hair loss. MATERIALS AND METHODS: A male 6-year-old child was diagnosed with hidrotic ectodermal dysplasia 2 (HED2) caused by GJB6 (p.G11R) mutations. He presented at our clinic with diffuse thinning and fine and brittle hair since birth. Additionally, the child exhibited abnormal development of teeth, fingernails, and toenails. The condition of the child's hair had not improved significantly with age. He was treated with botanical extracts combined with Minoxidil. RESULTS: After one and a half months of treatment, the patient showed remarkable hair growth. CONCLUSIONS: Our team has previously used botanical extracts in combination for the treatment of autosomal recessive wooly hair in children. In the present case, treatment with botanical extract combined with minoxidil was found to be equally efficacious. This case report provides valuable information for future studies on the use of botanical extracts in treating hair loss, as well as a safe and effective potential treatment strategy for children with congenital alopecia.

A New Method for the Follow-Up of Patients with Alopecia Areata.

Background: Teledermatology is the application of information and telecommunication technologies in the field of dermatology to provide remote care services based on the exchange of clinical information within a network of professionals or between professionals and patients. Tele-trichoscopy is a non-invasive, inexpensive, and easy-to-use method that applies the principle of surface microscopy at different magnifications. Alopecia areata is a non-scarring alopecia with a chronic evolution, which often needs a close follow-up. Objectives: The aim of our work was to analyze the possible benefits of telemedicine for the follow-up of patients with alopecia areata. Materials and Methods: We enrolled patients with alopecia areata, identified during the first trichological evaluation, and we divided the patients into two groups. One group was provided with the devices necessary for a telemedicine follow-up. The other group had a conventional follow-up. The total follow-up time was one year. All of the patients' photos were blindly evaluated by a team of expert dermatologists who were asked to indicate the quality of the images. The photos were also evaluated to identify disease markers. During the follow-up period, questionnaires were administered to both groups of patients to assess the quality of the visit, the level of patient satisfaction, and to identify any issues encountered by the patients. Results: There was a high degree of concordance between the images obtained by outpatient trichoscopy and those obtained by telemedicine. The satisfaction levels were the same between the patients followed via telemedicine and those seen in the outpatient clinic. Conclusions: Telemedicine applied to trichology using trichoscopy was proven to be a valid system for managing the follow-up of patients suffering from chronic recurrent scalp diseases and, above all, for maintaining continuity of care.

Progress of clinical research on fractional laser treatment of androgenetic alopecia: A review article.

BACKGROUND: Androgenetic alopecia (AGA) is a prevalent form of hair loss that affects both men and women, severely impacting patients' quality of life. Traditional treatments include oral medications, topical medications, and hair transplantation, but these methods have certain side effects and limitations. How to safely effectively and maximally promote hair growth has been a key issue in the treatment of AGA. In recent years, fractionated laser therapy, as a noninvasive method, has gradually gained attention due to its minimally invasive and highly effective nature. AIMS: In this paper, we summarized the studies related to fractional laser treatment of AGA in the past 15 years, and discussed its therapeutic mechanism, clinical effect, future development direction, and advantages and disadvantages compared with traditional treatment methods in the treatment of AGA. METHODS: An extensive literature search was conducted using PubMed, Google, Google Scholar, Embase, and Scopus. All available articles studying fractional laser treatment of AGA were compiled in March 2024. Titles and abstracts were then screened for relevance and thoroughly examined for patient clinical outcomes. Prospective clinical trials, retrospective chart reviews, case series, and individual case reports were included in the literature review. CONCLUSIONS: Fractional laser treatment of AGA showed remarkable efficacy and high safety. Compared with traditional treatments, fractional laser has the advantages of minimally invasive, quick recovery, fewer side effects, and a wide range of population applicability, providing an effective treatment option for AGA patients. Further large-scale clinical studies will help optimize the laser parameters and treatment settings to improve the therapeutic effect.

Is autologous platelet-rich plasma capable of increasing hair density in patients with androgenic alopecia? A systematic review and meta-analysis of randomized clinical trials⋆.

FUNDAMENTALS: Platelet-rich plasma (PRP) has been progressively more used in androgenetic alopecia (AGA). OBJECTIVES: The authors aimed to evaluate PRP efficacy compared to placebo in AGA. METHODS: A comprehensive search was conducted across seven databases, until 01/04/2023. Randomized clinical trials focusing on AGA and PRP use to increase hair density were included. Patients aged between 15 and 63 years, diagnosed with AGA characterized by Norwood I‒VII and Ludwig I‒III scales, were included. Studies with a sample size <10, lacking PRP processing method, focusing on complementary therapies or other alopecias, were excluded. The authors conducted subgroup analysis for activator, spin method, study design, risk of bias, and gender. Meta-regression was conducted for activator, spin method, design, and gender. The authors used GRADEpro to assess evidence certainty and the RoB-2 tool for risk of bias. Asymmetry was measured through a Funnel plot followed by Egger's test. The protocol was registered at PROSPERO (CRD42023407334). RESULTS: The authors screened 555 registers and included fourteen studies involving 431 patients for qualitative synthesis, with 13 studies included in the meta-analysis. Meta-analysis demonstrated a mean difference of 27.55 hairs/cm2 and 95% CI (14.04; 41.06), I2 = 95.99%, p < 0.05. Hair diameter meta-analysis presented a mean difference of 2.02 µm, 95% CI (-0.85 µm; 4.88 µm), and I2 = 77.11% (p = 0.02). That is, low quality evidence. LIMITATIONS OF THE STUDY: Studies were highly heterogeneous, of low quality, and presented evident publication bias. CONCLUSIONS: Highly heterogeneous studies with publication bias suggest PRP effectively increases hair density in AGA, so further high-quality randomized clinical trials are recommended to strengthen the evidence.

The correlation between corona virus disease 2019 and alopecia areata: a literature review.

Corona virus disease 2019(COVID-19) is one of the most serious respiratory pandemic diseases threatening human health for centuries. Alopecia areata (AA) is a sudden patchy hair loss, an autoimmune disease, which seriously affects the image and mental health of patients. Evidence shows that the risk of autoimmune diseases significantly increases after COVID-19, and is positively correlated with the severity, with a significant increase in the risk of alopecia in those over 40 years old. The relationship between COVID-19 and AA has become a hot topic of current research. Strengthening the research on the correlation between COVID-19 and AA can help to identify and protect susceptible populations at an early stage. This article reviews the research progress on the epidemiological background of COVID-19 and AA, the situation and possible mechanisms of AA induced by COVID-19 or COVID-19 vaccination, and potential treatment methods.

Application of multi-omics techniques to androgenetic alopecia: Current status and perspectives.

The rapid advancement of sequencing technologies has enabled the generation of vast datasets, allowing for the in-depth analysis of sequencing data. This analysis has facilitated the validation of novel pathogenesis hypotheses for understanding and treating diseases through ex vivo and in vivo experiments. Androgenetic alopecia (AGA), a common hair loss disorder, has been a key focus of investigators attempting to uncover its underlying mechanisms. Abnormal changes in mRNA, proteins, and metabolites have been identified in individuals with AGA, and future developments in sequencing technologies may reveal new biomarkers for AGA. By integrating multiple omics analysis datasets such as genomics, transcriptomics, proteomics, and metabolomics-along with clinical phenotype data-we can achieve a comprehensive understanding of the molecular underpinnings of AGA. This review summarizes the data-mining studies conducted on various omics analysis datasets as related to AGA that have been adopted to interpret the biological data obtained from different omics layers. We herein discuss the challenges of integrative omics analyses, and suggest that collaborative multi-omics studies can enhance the understanding of the complete pathomechanism(s) of AGA by focusing on the interaction networks comprising DNA, RNA, proteins, and metabolites.

iTRAQ-based quantitative proteomics revealing the therapeutic mechanism of a medicinal and edible formula YH0618 in reducing doxorubicin-induced alopecia by targeting keratins and TGF-ß/Smad3 pathway.

YH0618, a medicinal and edible formulation, has demonstrated the potential to alleviate doxorubicin-induced alopecia in animal studies and clinical trials. However, the mechanisms underlying its therapeutic effects remain unexplored. The objective of this study was to ascertain possible therapeutic targets of YH0618 in the treatment of doxorubicin-induced alopecia. The assessment of hair loss was conducted through the measurement of the proportion of the affected area and the examination of skin histology. Isobaric tags for relative and absolute quantification (iTRAQ) in quantitative proteomics was employed to discern proteins that exhibited variable expressions. The major proteins associated with doxorubicin-induced alopecia were identified using gene ontology (GO) and Kyoto Encyclopedia of Genes and Genomes (KEGG) pathway analysis. The interaction network of the differentially expressed proteins was constructed using the STRING database and the Python software. The study analyzed a total of 3894 proteins extracted from the skin tissue of mice. Doxorubicin treatment resulted in the upregulation of 18 distinct proteins, whereas one differential protein was found to be downregulated. The above effects were reinstated after the administration of the YH0618 therapy. The bioinformatic study revealed that the identified proteins exhibited enrichment in many biological processes, including staphylococcus aureus infection, estrogen signaling route, pyruvate metabolism, chemical carcinogenesis, and PPAR signaling pathway. The results of Western blot revealed that the levels of keratin 81 (Krt81), keratin 34 (Krt34), keratin 33a (Krt33a), and Sma and MAD-related protein 3 (Smad3) were upregulated in response to doxorubicin treatment, and were attenuated by the administration of YH0618. These four proteins are likely to correlate with DOX-induced alopecia and serve as promising therapeutic targets for YH0618. This work presents significant insights and empirical evidence for comprehending the process underlying chemotherapy-induced alopecia, paving the way for exploring innovative therapeutic or preventive strategies employing herbal items.

Association Between Natural Hair Color, Race, and Alopecia.

INTRODUCTION: Limited epidemiologic data has suggested direct associations between hair pigment, race, and incidence of alopecia areata (AA). Here, we examine the relationship between natural hair color, race, and the lifetime risk alopecia. METHODS: In this case-control study, we included UK Biobank patients of all races and self-reported hair color with diagnoses of AA, androgenetic alopecia (AGA), or scarring alopecia (SA). Multivariable logistic regression was used to detect differences in lifetime risk. RESULTS: Findings reveal a significantly increased risk of AA among individuals with black hair compared to dark brown hair (OR 1.71 [95% CI 1.22-2.38], p < 0.001). Those with red or blonde hair showed a decreased risk of AA (0.74 [0.56-0.97]; 0.62 [0.41-0.95], p < 0.05). No racial differences in AA prevalence were observed among individuals with black hair. CONCLUSIONS: Darker hair colors may be associated with a higher risk of AA, lighter hair colors with a lower risk, and differences in hair color could contribute to previously noted racial variations in AA incidence, potentially influencing dermatologists' perspectives on the disease's epidemiology.

Baricitinib as a treatment for myasthenia gravis: A case report.

Myasthenia gravis (MG) is an autoimmune disease that targets neuromuscular junctions. While immunotherapy remains the cornerstone of treatment, the effects of Janus kinase (JAK) inhibitors on MG remain underexplored. In this report, we describe the case of a 58-year-old woman with ocular myasthenia gravis who received treatment with the JAK inhibitor, baricitinib for alopecia areata. The patient presented with left eyelid ptosis and an inadequate response to steroids and pyridostigmine, along with symptoms of alopecia areata. Following diagnosis, we initiated a treatment regimen consisting of baricitinib for six months. After initiation of baricitinib, we observed a complete resolution of the patient's MG symptoms, accompanied by hair regrowth, even when steroids were tapered and pyridostigmine was discontinued. Furthermore, the titer of the anti-acetylcholine receptor antibody was decreased. This report represents the first reported case of anti-acetylcholine receptor antibody-positive MG that was successfully treated through the inhibition of JAK activity.

Hair loss and endocrine dermatosis on horses raised in a Mimosa pudica var. unijuga-invaded area.

A Mimosa pudica var. unijuga-associated toxicity affecting horses occurred in Araguari, Triângulo Mineiro, Southeast Brazil. Affected horses had gradual hair loss of the mane and tail and endocrine dermatosis after grazing for three months during the dry season on a paddock invaded by the plant. The main histological lesions include compact ortho-keratotic hyperkeratosis and numerous flame follicles. Toxicological analysis by HPLC-UV demonstrated 0.8 mg/g of mimosine in the leaves.