An appraisal of laboratory models of androgenetic alopecia: A systematic review.

Background: Androgenetic alopecia (AGA) is the most common form of non-scarring alopecia in humans. Several studies have used different laboratory models to study the pathogenesis and interventions for AGA. These study models have proved beneficial and have led to the approval of two drugs. However, the need to build on existing knowledge remains by examining the relevance of study models to the disease. Objective: We sought to appraise laboratory or pre-clinical models of AGA. Method: We searched through databases (PubMed, ScienceDirect, Web of Science, World CAT, Scopus and Google Scholar) for articles on AGA-related studies from 1942 to March 2019 with a focus on study models. Results: The search rendered 101 studies after screening and deduplication. Several studies (70) used in vitro models, mostly consisting of two-dimensional monolayer cells for experiments involving the characterization of androgen and 5-alpha reductase (5AR) and inhibition thereof, the effects of dihydrotestosterone (DHT) and biomarker(s) of AGA. Twenty-seven studies used in vivo models of mice and monkeys to investigate DHT synthesis, the expression and inhibition of 5AR and hair growth. Only four studies used AGA-related or healthy excisional/punch biopsy explants as ex vivo models to study the action of 5AR inhibitors and AGA-associated genes. No study used three-dimensional [3-D] organoids or organotypic human skin culture models. Conclusion: We recommend clinically relevant laboratory models like human or patient-derived 3-D organoids or organotypic skin in AGA-related studies. These models are closer to human scalp tissue and minimize the use of laboratory animals and could ultimately facilitate novel therapeutics.

Investigating hair zinc concentrations in children with and without atopic dermatitis.

BACKGROUND: Atopic dermatitis (AD) is a common chronic inflammatory skin condition that disproportionately affects children and is associated with reduced quality of life. Zinc deficiency may contribute to the pathogenesis of AD because zinc plays a role in epidermal barrier integrity and the immune system. Systematic review evidence suggests that low zinc is associated with AD, but limitations of included studies support further investigation. OBJECTIVES: To investigate hair zinc concentrations in children with AD v. healthy controls in a low- to middle-income country setting. METHODS: One hundred and five children aged 1 - 12 yea-rs participated in a frequency-matched for age case-control study. The outcome variable, AD, was confirmed by a clinician and corroborated using the UK Working Party criteria. The primary predictor, long-term average zinc concentration, was determined by measuring hair zinc using inductively coupled mass spectrometry. Baseline demographic characteristics, anthropometry and measures of socioeconomic status were included in our logistic regression analysis. Subgroup analysis was performed where interaction terms suggested effect modification. RESULTS: Using data from the overall sample, population median hair zinc was not significantly different between children with AD and healthy controls. However, subgroup analysis suggested a clinically and statistically significant difference in median zinc between children with AD (175.35 µg/g) and healthy controls (206.4 µg/g) in the older age group (5 - 12 years) (p=0.01). In this age group, multivariable logistic regression analysis also found significantly decreased hair zinc concentrations in AD (odds ratio 0.83; 95% confidence interval 0.66 - 0.96; p=0.046). CONCLUSIONS: The inverse association between zinc status and AD in children aged 5 - 12 years in our setting is consistent with the international literature. The clinical importance of decreased zinc levels in AD is not yet known. Further investigation into relevant underlying mechanisms seems warranted given the global reach of AD, its effect on quality of life, and the low cost of potential zinc-based interventions.

The pH of lye and no-lye hair relaxers, including those advertised for children, is at levels that are corrosive to the skin.

BACKGROUND: Hair relaxers are used by up to 70% of females of black African ancestry. Occupational safety regulations list a pH ≥10.5 as irritant and a pH ≥11.50 as corrosive to the skin. OBJECTIVES: To determine the pH of all relaxers sold on the South African market and whether it is lower in no-lye relaxers and those marketed for children. METHODS: Relaxers were purchased from retailers in Cape Town, but more than half (54%) of the 39 brands tested were international. The pH was determined using a benchtop pH meter with an electrode for emulsions. Three pH readings were done over 3 consecutive days for each sample, and the average was used for data analysis. Differences between relaxers were analysed using Kruskal-Wallis, Wilcoxon rank-sum (Mann-Whitney) and two-sample t-tests (p<0.05). RESULTS: The median pH of all relaxers (calcium hydroxide, lithium hydroxide and sodium hydroxide) was 12.36 (interquartile range 12.10 - 12.62). The active ingredient was sodium hydroxide (lye or caustic soda) in 63% of the total of 121 relaxers (6/76 (7.9%) of these marketed for children). Lithium hydroxide and calcium hydroxide (no-lye) relaxers comprised 17% and 20%, respectively. No difference in pH was found between relaxers marketed for adults and those for children (sodium hydroxide p=0.2703, lithium hydroxide p=0.6787 and calcium hydroxide p=0.1048) or between lye (sodium hydroxide) and no-lye (calcium hydroxide) relaxers (p=0.2740). Furthermore, 64/70 (91%) of sodium hydroxide relaxers for adults and 4/6 (67%) of those for children were sold packaged without a neutralising shampoo. CONCLUSIONS: The pH of all the relaxers tested was at levels deemed corrosive to the skin and may contribute to the high prevalence of alopecia in females with afro-textured hair. A review of permissible safe pH levels for cosmetic use is warranted.

Zinc and atopic dermatitis: a systematic review and meta-analysis.

Zinc plays a central role in skin integrity via barrier and immune mechanisms and may also be relevant in the pathogenesis of atopic dermatitis (AD). However, little is known about the relationship between zinc and AD. We performed a systematic review to determine (i) the association between zinc levels or zinc deficiency and AD and (ii) the efficacy of oral zinc supplementation in the treatment of AD. We searched PubMed, Scopus, Web of Science and article references for observational studies on zinc levels or zinc deficiency in participants with AD vs. controls and for randomized control trials (RCTs) on zinc supplementation in AD. For observational studies, we calculated pooled standardized mean differences (SMDs) or odds ratios (ORs) along with 95% confidence intervals (CIs) using a random effects model. We included 14 observational studies and two RCTs. The pooled SMD demonstrated significantly lower serum (SMD 0.66, 95% CI 0.21-1.10, P = 0.004), hair (SMD 0.95, 95% CI 0.38-1.52, P = 0.001) and erythrocyte (SMD 0.95, 95% CI 0.38-1.52, P = 0.001) zinc levels in participants with AD compared to controls. Pooled unadjusted data from three studies showed a non-significant increased odds of AD in those with zinc deficiency compared with those without zinc deficiency (OR = 1.50, 95% CI 0.71-3.16, P = 0.28). One RCT of oral zinc supplementation among AD patients with zinc deficiency showed improvement in extent and severity of AD, while another RCT among all AD patients showed no significant improvement. All the studies were of low or moderate quality. We conclude that low serum, hair and erythrocyte zinc levels are associated with AD. However, the poor quality of included studies makes interpretation of these results problematic. High-quality observational studies are needed to confirm the association between low zinc levels and AD, and RCTs are required to evaluate the merit of zinc supplementation for the treatment or prevention of AD.

Blood and virus detection on barber clippers.

BACKGROUND: Bleeding from the popular clean-shave 'chiskop' haircut was recently reported as prevalent in South Africa (SA), a country with 6.9 million HIV-infected people. OBJECTIVES: To investigate the prevalence of barber hair clipper contamination with blood and HIV and hepatitis B viruses. METHODS: Fifty barbers from three townships in Cape Town, SA, were invited to participate. One clipper from each barber was collected immediately after it had been used for a clean-shave haircut. Each clipper was rinsed with phosphate-buffered saline and then submerged in viral medium. The polymerase chain reaction (PCR) was used to identify the blood-specific RNA marker haemoglobin beta (HBB), hepatitis B virus (HBV) and HIV. RESULTS: The clean-shave haircut was the most common haircut requested by clients (78%). Of the clippers collected, 42% were positive for HBB, confirming detection of blood, none were positive for HIV, and 4 (8%) were positive for HBV. Two clippers (clippers 16 and 20) were positive on qualitative HBV PCR. HBV DNA from clipper 16 clustered with genotype A sequences from SA, India, Brazil and Martinique, while clipper 20 clustered with SA genotype D sequences. The clipper 20 sequence was identical to a subtype D sequence (GenBank accession AY233291) from Gauteng, SA. CONCLUSIONS: This study confirms that there is significant contamination of barber hair clippers with blood and blood-borne viruses. Hepatitis B was detected with enough DNA copies to pose a risk of transmitting infection. Although HIV was not detected in this small study, the risk of transmission should be quantified. Further studies to investigate barber clipper sterilisation practices and whether the clean-shave hairstyle is an independent risk factor for HIV, HBV and hepatitis C virus infections are warranted. Public education on individual clipper ownership (as is the case with a toothbrush) should be advocated for clean-shave and blade-fade haircuts.

Determinants of hair cortisol concentration in children: A systematic review.

BACKGROUND: Several factors are known contribute to hair cortisol concentration (HCC) in adults. However, there is less research on determinants of HCC in children and adolescents. HCC is a valuable tool for medical research pertaining to the hypothalamic-pituitary-adrenal (HPA) axis. This review aims to assess the extent to which established determinants of HCC in adults have been consistently reported in children (birth - 18 years) and to identify determinants of HCC specific to this age group. METHODS: Eligible studies were identified, selected and appraised as per PRISMA-P guidelines and as detailed in our systematic review protocol, registered on PROSPERO (registration number CRD42017056220). In view of contrasting methods and measures, a meta-analysis could not be done but a qualitative synthesis was performed. RESULTS: Thirty-six studies were included in the analysis. Higher HCC is associated with male sex and anthropometry, particularly increased body mass index and waist circumference. There is preliminary evidence to suggest that socio-economic status is inversely related to child HCC, particularly with reference to caregiver education and income. Of note, most of the studies analysing socio-economic variables were performed in relatively equal societies. Hair wash frequency and use of hair products and treatments do not affect HCC when proximal segments of hair are used. There is conflicting evidence regarding the relationship between HCC and age in children and adolescents. Further investigation is required to better delineate if and how the following are associated with HCC in children: hair colour, hair type, exposure to trauma and stressors, psychiatric illness, atopic illness, steroid use (including topical and inhaled steroids) and perinatal variables. CONCLUSIONS: Sex and anthropometry are potential confounders and should be considered for adjustment in hair cortisol research. Hair wash frequency and use of hair products and treatments are not important confounders when proximal hair segments are used. A better understanding of HCC in children in relation to exposure to trauma and stressors is required before it can be used as a biomarker, particularly in terms of vulnerable developmental stages, definition and measurement of stress, and temporal relationship to stressors. Age, SES and other correlates also warrant further investigation.

Blood and virus detection on barber clippers

Background. Bleeding from the popular clean-shave 'chiskop' haircut was recently reported as prevalent in South Africa (SA), a country with 6.9 million HIV-infected people.Objectives. To investigate the prevalence of barber hair clipper contamination with blood and HIV and hepatitis B viruses.Methods. Fifty barbers from three townships in Cape Town, SA, were invited to participate. One clipper from each barber was collected immediately after it had been used for a clean-shave haircut. Each clipper was rinsed with phosphate-buffered saline and then submerged in viral medium. The polymerase chain reaction (PCR) was used to identify the blood-specific RNA marker haemoglobin beta (HBB), hepatitis B virus (HBV) and HIV.Results. The clean-shave haircut was the most common haircut requested by clients (78%). Of the clippers collected, 42% were positive for HBB, confirming detection of blood, none were positive for HIV, and 4 (8%) were positive for HBV. Two clippers (clippers 16 and 20) were positive on qualitative HBV PCR. HBV DNA from clipper 16 clustered with genotype A sequences from SA, India, Brazil and Martinique, while clipper 20 clustered with SA genotype D sequences. The clipper 20 sequence was identical to a subtype D sequence (GenBank accession AY233291) from Gauteng, SA.Conclusions. This study confirms that there is significant contamination of barber hair clippers with blood and blood-borne viruses. Hepatitis B was detected with enough DNA copies to pose a risk of transmitting infection. Although HIV was not detected in this small study, the risk of transmission should be quantified. Further studies to investigate barber clipper sterilisation practices and whether the clean-shave hairstyle is an independent risk factor for HIV, HBV and hepatitis C virus infections are warranted. Public education on individual clipper ownership (as is the case with a toothbrush) should be advocated for clean-shave and blade-fade haircuts

Double Morphology: Tertiary Syphilis and Acquired Immunodeficiency Syndrome-A Rare Association.

BACKGROUND: Human immunodeficiency virus (HIV) and Treponema pallidum coinfection is relatively common and accounts for about 25% of primary and secondary syphilis. Tertiary syphilis in HIV-uninfected and HIV-infected patients is vanishingly rare. This is most likely due to early treatment of cases of primary and secondary syphilis. There is rapid progression to tertiary syphilis in HIV-infected patients. CASE PRESENTATION: A 49-year-old woman diagnosed with HIV Type 1 infection and cluster of differentiation 4 (CD4) count of 482 presented with a four-week history of multiple crusted plaques, nodules, and ulcers on her face, arms, and abdomen. Her past history revealed red painful eyes six months prior to this presentation. She had generalized lymphadenopathy, no alopecia, and no palmar-plantar or mucosal lesions. There were no features suggestive of secondary syphilis. Neurological examination was normal. Her rapid plasma reagin test was positive to a titer of 64. She was treated with Penicillin G 20 mu IVI daily for 2 weeks. CONCLUSION: Penicillin remains the treatment of choice in syphilitic infected HIV negative and HIV-infected individuals. In neurosyphilis, the dose of Penicillin GIVI is 18-24 mu daily for 10-14 days. This case report demonstrates the importance of excluding syphilis in any HIV-infected patient.

Higher concentrations of dithranol appear to induce hair growth even in severe alopecia areata.

Alopecia areata (AA) is the commonest autoimmune cause of non-scarring alopecia. Topical treatments including corticosteroids and irritants maybe beneficial. Studies report variable hair regrowth with dithranol (anthralin) but all used low concentrations (0.1-1.25%) and inconsistent measurements of AA severity. We report retrospective data (2005-2014) of 102 patients who had failed ultra-potent topical steroids and were referred to a specialist hair clinic for treatment with dithranol up to 3%. The severity of alopecia areata tool was used and participants graded as mild (<25%), moderate (>25 to 75%), and severe (>75%) hair loss. Compared with baseline any and at-least 50% hair regrowth [72%, 68%, 50% and 61.5%, 48.4%, 37.5%, in mild, moderate and severe AA respectively] occurred in all groups (median treatment duration 12 months). Twenty-nine patients (28.4%) were discharged with complete regrowth; with no difference in proportions in severity groups (33.3%, 29%, and 21.9%) but in the period to discharge [7.9, 6.3, and 29.4 months (p-values <.05)] for mild, moderate, and severe AA. Treatment trials of 12 months with dithranol at higher concentrations may be an option in patients who failed potent topical or intra-lesional steroids) regardless of AA severity. Randomized trials (of less staining formulations) of dithranol are warranted.

Geometric classification of scalp hair for valid drug testing, 6 more reliable than 8 hair curl groups.

INTRODUCTION: Curly hair is reported to contain higher lipid content than straight hair, which may influence incorporation of lipid soluble drugs. The use of race to describe hair curl variation (Asian, Caucasian and African) is unscientific yet common in medical literature (including reports of drug levels in hair). This study investigated the reliability of a geometric classification of hair (based on 3 measurements: the curve diameter, curl index and number of waves). MATERIALS AND METHODS: After ethical approval and informed consent, proximal virgin (6cm) hair sampled from the vertex of scalp in 48 healthy volunteers were evaluated. Three raters each scored hairs from 48 volunteers at two occasions each for the 8 and 6-group classifications. One rater applied the 6-group classification to 80 additional volunteers in order to further confirm the reliability of this system. The Kappa statistic was used to assess intra and inter rater agreement. RESULTS: Each rater classified 480 hairs on each occasion. No rater classified any volunteer's 10 hairs into the same group; the most frequently occurring group was used for analysis. The inter-rater agreement was poor for the 8-groups (k = 0.418) but improved for the 6-groups (k = 0.671). The intra-rater agreement also improved (k = 0.444 to 0.648 versus 0.599 to 0.836) for 6-groups; that for the one evaluator for all volunteers was good (k = 0.754). CONCLUSIONS: Although small, this is the first study to test the reliability of a geometric classification. The 6-group method is more reliable. However, a digital classification system is likely to reduce operator error. A reliable objective classification of human hair curl is long overdue, particularly with the increasing use of hair as a testing substrate for treatment compliance in Medicine.

Primary cutaneous malignancies in the Northern Cape Province of South Africa: A retrospective histopathological review.

BACKGROUND: Excessive sun exposure and a high prevalence of HIV increase skin cancer risk in South Africa (SA). OBJECTIVE: To describe the nature and extent of skin cancers presenting in the public and private health sectors of the Northern Cape Province of SA. METHODS: A retrospective analysis of histologically confirmed new primary cutaneous malignancies from 1 January 2008 to 31 December 2012 was conducted using public and private health sector databases. Types, quantity and distribution of common invasive malignancies by population group, age, gender, anatomical site and health sector were explored. One-year cumulative incidence was calculated and logistic regression models were used to analyse incidence and melanoma thickness trends. RESULTS: A total of 4 270 biopsies (13 cutaneous malignancies) were identified. The commonest was squamous cell carcinoma (SCC), followed by basal cell carcinoma, Kaposi's sarcoma (KS), cutaneous malignant melanoma (CMM) and basosquamous carcinoma, in descending order. The odds of a white male developing SCC increased by 8% each year (odds ratio (OR) 1.08, 95% confidence interval (CI) 1.01 - 1.15; p=0.022), while the odds of a black male developing SCC and KS decreased by 9% (OR 0.91, 95% CI 0.84 - 0.99; p=0.033) and 18% (OR 0.82, 95% CI 0.70 - 0.97; p=0.022), respectively, each year. SCC and CMM were diagnosed at more advanced stages in the public than in the private healthcare sector. CMM is being detected earlier, as indicated by low-stage depth increasing by 72% annually (OR 1.72, 95% CI 1.04 - 3.01; p=0.042). CONCLUSIONS: Results suggest that reported skin cancer patterns are changing. There is a need for further research and equitable appropriation of financial resources and effort towards developing primary skin cancer prevention initiatives in SA.

Combinations of potent topical steroids, mercury and hydroquinone are common in internationally manufactured skin-lightening products: a spectroscopic study.

BACKGROUND: The topical steroids betamethasone (BM) and clobetasol propionate (CP) are illegal in cosmetics. Hydroquinone (HQ) and mercury (Hg) are either illegal or allowed only in limited concentrations (2% and 1 ppm, respectively). AIM: To investigate active ingredients and countries of origin of popular skin-lightening products available in Cape Town, South Africa. METHODS: In total, 29 products were examined; of these, 22 products were purchased from informal vendors, and 2 products (out of a total of 29) were purchased over the counter. HQ, Hg(2+) and steroids were quantified by high-performance liquid chromatography-ultraviolet spectrophotometry, inductively coupled plasma-mass spectrometry and liquid chromatography-mass spectrometry, respectively. RESULTS: Of the 29 products, 22 (75.9%), all imported and bought from informal vendors, contained illegal or banned ingredients: 13 (44.8%) contained steroids (9 CP, 4 BM), 12 (41.4%) contained Hg (30-2300 ppm), and 11 (37.9%) contained HQ. Sequentially, the products originated from Italy (27.3%, n = 6), India (22.7%, n = 5), the Democratic Republic of Congo (DRC) (22.7%, n = 5), Cote d'Ivoire (9.1%, n = 2), USA (9.1%, n = 2), UK (4.5%, n = 1) and France (4.5%, n = 1). Two products, one from India and one from the DRC, contained all four ingredients (HQ, Hg, BM, CP). Of the 12 products containing Hg, 10 also contained HQ and/or a steroid, yet none listed Hg as an ingredient. A significant proportion of the steroid-containing products (76.9%) also contained at least one other skin-lightening agent. Not all internationally available products were tested, which is a limitation of the study. CONCLUSION: In spite of a European Union ban on skin lighteners, a third of the products tested were from Europe. Combinations of Hg and ultrapotent steroids were prominent. International law enforcement and random testing is needed to encourage industry compliance and help protect consumers.

Affordable moisturisers are effective in atopic eczema: A randomised controlled trial.

BACKGROUND: Many patients depend on moisturisers issued by public health services in the management of atopic dermatitis (AD). METHODS: In a randomised controlled trial of patients with mild to moderate AD, aged 1-12 years, study 1 compared aqueous cream v. liquid paraffin (fragrance-free baby oil) as a soap substitute, all patients using emulsifying ointment as moisturiser, and study 2 compared four moisturisers, emulsifying ointment, cetomacrogol, white petroleum jelly and glycerine/petroleum (proportion 1:2; 'the 1:2 moisturiser'), all using fragrance-free baby oil as soap substitute. Assessments were one quality of life and three AD severity scores, at baseline and weeks 4, 8 and 12. Differences were compared using repeated measures of analysis of variance. RESULTS: In both studies (120 children randomised, 20 in each group of the two trials) disease severity scores declined with time. The only significant difference was in one AD severity score (SCORing Atopic Dermatitis) in study 1, both at baseline and over time (p=0.042 and p=0.022). The groups did not differ with regard to topical steroid use or side-effects. Itching from baby oil applied as soap was reported by four patients in the two studies, the petroleum jelly group had more dropouts than the 1:2 moisturiser group, although this was not statistically significant, and 110 patients (91.7%) completed the trial. CONCLUSIONS: The small sample limits generalisability, but the duration was longer than in most AD moisturiser studies. Fragrance-free baby oil is an effective soap substitute that may be better tolerated (if irritation occurs) as a bath additive. The home-made 1:2 moisturiser may be preferable to white petroleum jelly, but both are equivalent to cetomacrogol and emulsifying ointment. Use of accessible moisturisers could reduce the cost of managing mild to moderate AD.

Invisible bleeding from clean-shave haircuts: detection with blood specific RNA markers.

BACKGROUND: 'Haircut-associated bleeding' is a newly recognized entity that affects at least a quarter of African men who wear shiny clean-shave ('chiskop') haircuts. AIM: This pilot study aimed to elucidate whether invisible haircut-associated bleeding was detectable using blood specific RNA markers (16 participants, 5 with unknown HIV status) and whether surface virus could be detected using PCR from scalp swabs (of 11 known HIV-positive participants). METHODS: Haircuts were performed professionally and scalps examined by a dermatologist to exclude injury. Serum samples for viral loads were also collected at the same time. RESULTS: In all, 6/16 (37%) samples tested positive (>100 relative fluorescent units) for hemoglobin beta and albumin, confirming evidence of blood; of these, only 1/11 was HIV-positive but had an undetectable serum viral load. No surface HIV was detected from any scalp samples. CONCLUSIONS: This study confirms the entity of haircut-associated bleeding but goes further to show for the first time that invisible bleeding from clean-shave haircuts is also common. Both a high serum viral load and evidence of bleeding should ideally be present prior to surface HIV detection. Future investigations for potential HIV (and hepatitis B) transmission through clean-shave haircuts are warranted but should not delay public education for disease prevention.

Health risks of the clean-shave chiskop haircut.

The clean-shave haircut known locally as the chiskop is rare among females but popular with black South African men, who are also predisposed to folliculitis keloidalis nuchae (FKN) (keloids on the back of the head). During a previous study, participants described an unexpected symptom of haircut-associated bleeding. As this is not a widely recognised entity, we conducted the present study at an HIV clinic servicing the same population, with the objective of comparing the prevalences of haircut-associated bleeding and FKN in 390 HIV-positive subjects with published data for Langa (Western Cape, South Africa). The results for HIV-positive participants were similar to the population data, but in both groups the prevalence of haircut-associated bleeding (24.5% v. 32%; p=0.17) was much higher than that of FKN (10.2% v. 10.5%), suggesting that the hairstyle increases the risk of bleeding even in people with healthy scalps without folliculitis. This study does not (and was not intended to) prove a higher HIV prevalence in chiskop wearers or in FKN sufferers, but it confirms a history of haircut-associated bleeding in at least a quarter of our male study participants. The risk of transmission of blood-borne infection via haircuts is likely to be low, but requires formal quantification. Public education on adequate sterilisation of barber equipment between haircuts and promotion of individual hair-clipper ownership for chiskop clients should not be delayed. Depilatory creams formulated for African hair offer a non-mechanical means of achieving clean-shave hairstyles.

The adapted classification of male pattern hair loss improves reliability.

BACKGROUND: The Hamilton-Norwood classification (HNC) is used to assess the severity of pattern hair loss (PHL). Conflicting associations between PHL and cardiovascular disease (CVD) have been reported from studies that used different methods to assess alopecia severity. No classification including the HNC has been validated for population studies. We aimed to simplify the HNC, produce the adapted HNC and test its reliability for use in population studies. METHODS: Identifying vertex alopecia as distinct allowed for a simpler alignment of alopecia figures where scores 4V and 5V in the adapted HNC replace IV and V in the original HNC. The two classifications were to be used by twelve of our staff (secretaries, nurses, dermatology trainees and dermatologists) to evaluate 16 men with PHL. Observer agreement was estimated using intraclass correlation coefficient (ICC) and a percentage method duplicated from the recent basic and specific (BASP) classification. RESULTS: The ICC improved with the adapted HNC when assessed by both the nurses/secretaries (from 0.47 to 0.61) and dermatology residents/consultants (from 0.68 to 0.76). Agreement using the BASP percentage method for dermatologists was 62-69% for the original and 93-100% for the adapted HNC. CONCLUSIONS: The adapted HNC increased reliability at various staff levels, making it suitable for epidemiological studies; its use in future studies could help elucidate the association between PHL and CVD.