Review Article a Multidisciplinary Evaluation for Advanced Supportive Care of Breast Cancer Patients.

Background: Cancer cases diagnosed each year are increasing, mainly because the population is ageing and, in part, due to early detection. This implies that there are more and more persons that receive medical anticancer therapies and that are interested in maintaining their quality of life. Many oncological treatments, including chemotherapy, immunotherapy, surgery, and radiotherapy, and combined therapy are associated with cutaneous toxicity and long-term side effects to different tissues and organs. This is particularly relevant when new therapies are used since these may cause new and unexpected side effects that may be short-lived but, in some cases, may become chronic or permanent. Patients often seek advice with their oncologists on what can be done and what cannot be done. Notably, many of the cutaneous side effects can be prevented or reduced by adequate interventions. Summary: The aim of this review is to highlight how oncological patients may benefit from a closer collaboration between specialists in different branches. We will focus on women with breast cancer since we think that they may derive a special benefit from this collaboration, but we will analyse other cancers in future papers. Key Messages: The working group was created to help the medical doctor in the prevention and management of all the adverse effects of the oncological treatments, supporting patients in this phase of their life, including nutritional assessment and dietary support.

Clinical and Trichoscopic Graded Live Visual Scale for Androgenetic Alopecia.

Introduction: Currently, the mostly used classifications of androgenetic alopecia (AGA) only provide a macroscopic and subjective description of this disorder, without evaluating trichoscopic features. Objectives: The aim of this study is to elaborate a graded live visual AGA severity scale including macroscopic and microscopic (trichoscopic) pictures, and to determine the most frequent trichoscopic characteristics associated to each grade. Methods: A retrospective observational study was conducted on 122 patients (50 females and 72 males) affected by AGA. Macroscopic and trichoscopic photographs were taken at standardized scalp points. Results: Each picture was ranked from AGA stage I to VII, according to Hamilton scale for men and Sinclair scale for women, and the most representative images of each severity degree were collected to produce a graded live visual scale. In males, 2 live visual scales, 1 for the anterior and 1 for posterior region of the scalp were created. In females, only 1 scale of the anterior region was realized. For each stage of severity, the corresponding trichoscopic parameters were statistically analyzed. Conclusions: We realized new macroscopic and trichoscopic graded live visual scales for male and female patients affected by AGA, which could help physicians in giving an objective evaluation of the disease and in better managing it.

Recommendations on trichological treatments during COVID-19 pandemic.

COVID-19 is an infectious disease caused by the novel coronavirus SARS-CoV-2, which rapidly spreads via respiratory droplets and is the cause of the current pandemic. In this alarming situation, it is a delicate matter how to visit patients safely and how to manage their chronic treatments. The aim of this paper is to examine in detail the potential impact on SARS-CoV-2 infection of treatments routinely used in trichology and to provide a useful guide for the therapeutic management of trichological patients in this new COVID-19 era.

Recurrence of alopecia areata after covid-19 vaccination: A report of three cases in Italy.

BACKGROUND: Common COVID-19 vaccines side effects are pain at the injection site, muscle pain, fever, headaches, fatigue. Possible immune-related side effects in predisposed individuals have not been established so far. MATERIALS AND METHODS: We report three cases of recurrence of alopecia areata (AA) occurred after the first dose of COVID-19 vaccine. RESULTS: All patients had previous episodes of AA with total hair regrowth and stable remission during the months preceding the vaccination. Rapid hair loss occurred 2-3 weeks after BNT162b2 mRNA (patient 1) and AZD1222/ChAdOx1 vaccine (patient 2 and 3), with widespread hair loss in two cases and a single patch of the vertex in one case, with typical trichoscopic features of AA. DISCUSSION: Both BNT162b2 mRNA and AZD1222/ChAdOx1 vaccines share the same goal of inducing the immune system, with antibodies production and Th1 cells activation with release of pro-inflammatory cytokines. Thus, in patients with pre-existing inflammatory dysregulated pathways, the interaction between the immune system and vaccines may enhance other autoimmune mechanisms. In our cases, we speculate that vaccine may have induced the hair loss focusing on components having a key role in both COVID-19 vaccination and AA pathogenesis. CONCLUSION: This report may help to collect new data concerning possible immune-related effects of vaccines. Certainly, only three cases are not sufficient to draw conclusion, thus a large-scale study is necessary. Immune-mediated side effects remain a rare event, thus the benefits of COVID-19 vaccines outweigh the risk of disease flares and we strongly recommend it in all eligible patients with AA.

Telogen Effluvium after SARS-CoV-2 Infection: A Series of Cases and Possible Pathogenetic Mechanisms.

INTRODUCTION: Physicians have largely studied the cutaneous involvement of coronavirus disease 2019 (COVID-19), but only few reports have focused on telogen effluvium (TE) as a possible sequela of COVID-19. We assessed 14 cases of hair loss occurring after SARS-CoV-2 infection using trichoscopy and trichogram to investigate patterns related to COVID-19. Furthermore, we discussed possible mechanisms involved in COVID-19 TE. CASE PRESENTATION: Fourteen individuals were referred to our post-COVID-19 dermatology office complaining acute hair loss after SARS-CoV-2 infection. Clinical evaluation included pull test, trichoscopy, and trichogram. CO-VID-19 TE occurred after a median of 2 months (range 1-3 months) following SARS-CoV-2 infection. The median duration of hair loss was 5 months (range 1-6 months). Trichoscopy showed variable but typical TE patterns. Trichogram showed different telogen/anagen ratio depending on the interval between onset of hair loss and trichological visit. DISCUSSION/CONCLUSION: Our cases showed TE between 1 and 3 months after the onset of SARS-CoV-2 infection, thus earlier than classic TE. Trichoscopic features and trichogram showed no variations from classic TE. Different pathogenetic mechanisms including pro-inflammatory cytokines and direct viral damage on the hair follicle can be hypothesized; further studies on a larger sample are needed to better understand this condition.

Alopecia areata treated with topical and systemic brevilin A: A case series.

Alopecia areata (AA) is an autoimmune T CD8 cell mediated condition clinically characterized by hair loss from single or few small patches to complete hair loss. The management of AA is challenging and all available therapies does not ensure a long-term remission. To assess the safety and efficacy of both systemic and topical brevilin A, a natural compound, in AA patients not responding to other treatments. After obtaining informed consent, we administered off-label brevilin A to 13 adult patients affected by AA, for a period ranging from 6 to 18 months. Medical records for each patient and the severity of alopecia tool (SALT) score before and after brevilin A administration were recorded. The mean SALT score of our patients was 81.03 (SD 34.9) at baseline and 75.8 (SD 37.4) after brevilin A therapy, meaning no statistically significant improvement was observed (P = .2385 Paired t test). However, three multifocal AA (MAA) patients out of four attained an improvement (75%) suggesting that brevilin A may be represent an alternative therapy in this form of AA. Authors conclude that brevilin A could represent in the future a possible effective treatment in MAA forms but further studies are required.

Clinical aspect, pathogenesis and therapy options of alopecia induced by hormonal therapy for breast cancer.

Adjuvant hormonal therapy is one of the most important treatments of hormone-receptor-positive breast cancer and includes selective estrogen receptor modulators, aromatase inhibitors, and luteinizing hormone-releasing hormone analogs. In patients receiving these drugs, a progressive recession of frontal-temporal hairlines is often observed, such as a certain grade of hair miniaturization in the same areas and the central scalp area, producing a pseudo-female androgenic alopecia, which has to be considered oncotherapy-induced alopecia. The aim of this work, is to describe the clinical aspects and pathogenesis of this type of alopecia and to analyze the different drugs which have been proposed until now. The authors concude that topical hormones should not be considered as a therapeutic approach because of their direct or indirect oncogenic potential. A therapeutic approach that could be both safe and effective is proposed.

Frontal Fibrosing Alopecia: A New Association with Lichen Sclerosus in Men.

BACKGROUND: Frontal fibrosing alopecia (FFA) is a scarring alopecia that has been reported mostly in postmenopausal women and is characterized by frontotemporal hairline. Currently, there are only a few reports about FFA in male patients. OBJECTIVE: This study sought to analyze clinical and trichoscopic features of FFA in a case series of men and to describe the main features of FFA in male patients through a review of the literature. METHODS: Male patients with clinical and trichoscopical signs of FFA, histologically confirmed, who attended to our clinic from 2014 to 2019 were included in our study. From each patient, clinical and trichoscopic data were collected. RESULTS: Eight men with an average age of 59 years were recruited. In five patients, serrated hairline recession (i.e., a "zig-zag" pattern) was present, while three presented with linear hairline recession. Also, the eyebrows (n=3 patients), sideburns (n=2 patients), and beard (n=2 patients) were involved. Surprisingly, in two patients, an association with lichen sclerosus (LS) was present. CONCLUSION: To the best of our knowledge, this is the first report of a serrated hairline recession pattern in male patients with FFA. A new association between FFA and LS in men was also found. Further studies need to establish the extent of this association and facilitate a better comprehension of the pathophysiologic mechanisms underlying these two diseases.

Dermatologic management of oncotherapy side effects: A proposed algorithm.

Since the introduction of the first chemotherapeutic regimens for the treatment of oncological disease, hundreds of drugs have been approved for cancer treatment and many more are under investigation. The development of newer drugs such as target therapies, immuno-oncotherapies, and hormonal therapies has increased in specificity with the development of smaller molecules and more selective targets. Cutaneous side effects are now well known for both standard chemotherapy and targeted therapies. The correct diagnosis and management of these effects are of vital importance both to optimize therapeutic success rates and to reduce the patient's suffering. In fact, the appearance of a cutaneous adverse event can be responsible for a reduction in drug dosage or worse its suspension. In order to achieve this objective, we propose a management algorithm, based on three different steps, before, during, and after the oncological treatments, respectively. Our proposal underlines the importance of correct skin care measures to limit or reduce the severity of side effects.

Prevention and Treatment of Chemotherapy-Induced Alopecia.

BACKGROUND: Chemotherapy-induced alopecia (CIA) is one of the most dramatic side effects of chemotherapy. Currently no guidelines are available for its prevention and treatment. Several devices and drugs are used, but results are often disappointing. AIMS: Our aim is to analyze drugs and devices proposed in the literature for prevention and treatment of CIA induced by cytotoxic drugs and to discuss the evidenced-based opinion. METHODS AND RESULTS: Scalp cooling is the only agent that has been approved by the US Food and Drug Administration for CIA prevention. Minoxidil and bimatoprost should not be used during chemotherapy administration, but they can be used after chemotherapy discontinuation to obtain greater regrowth. CONCLUSIONS: Therapy should always be modulated for the patient and no fixed protocol should be used. Trichoscopy and trichogram could be useful tools in supporting this treatment.

Efficacy of Topical Finasteride 0.5% vs 17α-Estradiol 0.05% in the Treatment of Postmenopausal Female Pattern Hair Loss: A Retrospective, Single-Blind Study of 119 Patients.

BACKGROUND AND OBJECTIVES: Female pattern hair loss (FPHL) is a common form of scalp hair loss that occurs in 38% of females. Currently, minoxidil solution is the only therapy approved by the US Food and Drug Administration, but many other treatments are used, including cyproterone acetate, spironolactone, topical 17α-estradiol, and prostaglandin analogs. Systemic finasteride has been considered a treatment option in women even though its teratogenic effects tend to limit its prescription. Recently, topical finasteride has been evaluated to limit the side effect profile of the drug. The objective of the present study is to compare retrospectively the efficacy of topical 0.05% 17α-estradiol solution and a 0.5% finasteride lotion in the treatment of FPHL. PATIENTS AND METHODS: We enrolled 119 postmenopausal female patients. The first group comprised 69 women treated with finasteride 0.5% and minoxidil 2%. The second group included 50 women treated with 17α-estradiol 0.05% and minoxidil 2%. At baseline and at 6- and 12- to 18-month follow-up, global photographs were systematically taken. Three operators blind to the prescribed treatment evaluated photographs using a 7-point scale. One-way analysis of variance and unpaired Student t tests were performed to analyze 7-point scale scores. RESULTS: The improvement was statistically significant from 6 months to 12-18 months, both for finasteride (P < 0.005) and 17α-estradiol (P < 0.05). The efficacy of topical finasteride was significantly greater than that of 17α-estradiol solution, both at the 6-month (P < 0.05) and at the 12- to 18-month follow-up (P < 0.005). In general, the highest improvement was observed after 12-18 months of treatment with topical finasteride therapy. CONCLUSIONS: Topical finasteride 0.5% in combination with minoxidil 2% could represent a valid therapeutic option for the treatment of postmenopausal FPHL, showing higher efficacy than topical 17α-estradiol with minoxidil 2% both at 6-month and 12- to 18-month follow-up.

Eosinophilic folliculitis of the scalp associated with PD-1/PDL1 inhibitors.

BACKGROUND: Immune checkpoint inhibitors are monoclonal antibodies which target immune "checkpoints" enhancing T cell-mediated cytotoxic and antitumor responses. Together to the amazing results, these drugs are associated with some peculiar adverse events called immune-related adverse events. Alopecia is one of these. It is usually reported to be clinically and histologically similar to alopecia areata. AIMS: We report a case of eosinophilic folliculitis of the scalp occurred during nivolumab therapy, its management and some pathogenetic hypotheses. PATIENT: Herein, we report the first case of eosinophilic folliculitis of the scalp occurred during nivolumab therapy, firstly appeared as a lichen planopilaris. Topical steroids and fusidic acid cream were applied with partial benefit and a scaring outcome. No discontinuation of nivolumab was required. CONCLUSION: Immune checkpoint inhibitors induced inflammatory response leads to the exposure of hair follicle antigens and a consequent loss of Immuno Privilege. We hypothesize a role of steroids in deviating a primarily lichenoid reaction toward a folliculitis.

The diagnosis of androgenetic alopecia in children: Considerations of pathophysiological plausibility.

Androgenetic alopecia (AGA), one of the most common causes of hair loss in men and women, is an infrequent cause of alopecia in children. In AGA, patients generally start noticing hair thinning after the onset of puberty due to progressive miniaturisation of the hair follicle which leads to vellus transformation of terminal hair. However, the occurrence of prepubertal AGA has rarely been reported in the literature. The pathophysiology of AGA is tightly linked to androgen hormones; prepubertal children do not usually produce significant amounts of adrenal or gonadal androgens. When it does occur, an underlying abnormality should be suspected. Secondary causes of AGA must be excluded when evaluating a patient before the appearance of puberty. Premature puberty, polycystic ovarian syndrome and other causes of hyperandrogenism can present with hair loss in an androgenetic pattern. This article reviews the normal physiology of androgen hormones and their role in the pathophysiology of childhood AGA.

Scalp infection by Candida Albicans in an immunocompetent patient: a description of a rare case.

Candida is a large genus of yeast, consisting of about 150 species, among which C.albicans is the most prevalent fungal species of the human microbiota. C. albicans is the most important fungal opportunistic pathogen that can cause infection when the host becomes debilitated or immunocompromised. We report a case of a scalp infection by C.albicans in a patient without an obvious immunocompromised state.

Chemotherapy-induced alopecia management: Clinical experience and practical advice.

BACKGROUND: Chemotherapy-induced alopecia (CIA) is probably one of the most shocking aspects for oncological patients and underestimated by physicians. Among hair loss risk factors, there are treatment-related aspects such as drug dose, administration regimen, and exposure to X-rays, but also patient-related characteristics. To the best of our knowledge, no guidelines are available about CIA management. AIMS AND METHODS: With this study, based on literature background and our clinical experience, we would like to propose a list of actions in order to estimate the risk of hair loss before starting chemotherapy and to manage this condition before, during, and after drug administration and to create a sort of practical guide for dermatologists and oncologists. RESULTS AND CONCLUSION: There is an urgent need for prospective studies to clarify the mechanistic basis of alopecia associated with these drugs and consequently to design evidence-based management strategies.