Faculty Bibliography

BACKGROUND:Minoxidil is a widely used over-the-counter topical treatment for hair loss. The response rate for topical minoxidil is relatively low. Minoxidil is a pro-drug, converted to its active form, minoxidil sulfate, by SULT1A1 enzymes located in the scalp. Recently, a novel topical formula that increases the activity of SULT1A1 in hair follicles was reported. AIMS/OBJECTIVE:To evaluate any benefit of applying the SULT1A1 enzyme booster prior to daily 5% minoxidil treatment. METHODS:Male androgenic alopecia patients were recruited to a randomized blinded placebo-controlled study. Patients were randomized to receive 5% topical minoxidil plus the novel formula or minoxidil plus a sham adjuvant. Patient's hair growth was monitored using global photography over 60 days. RESULTS:Twenty-four males with androgenic alopecia (Norwood scale average 4.4, range 2-6) were randomized and completed the trial: 12 in the active arm and 12 in placebo. 75% of the subjects who used the SULT1A1 adjuvant with their daily minoxidil treatments for 60 days regrew hair versus 33% of those using the placebo adjuvant (p = 0.023). CONCLUSIONS:In a small cohort of androgenetic alopecia men, adding the SULT1A1 adjuvant to their daily minoxidil treatment regimen improved hair regrowth.

BACKGROUND:Although many hair disorders can be readily diagnosed based on their clinical appearance, their progression and response to treatment are often difficult to monitor, particularly in quantitative terms. We introduce an innovative technique utilizing a smartphone and computerized image analysis to expeditiously and automatically measure and compute hair density and diameter in patients in real time. METHODS:A smartphone equipped with a dermatoscope lens wirelessly transmits trichoscopy images to a computer for image processing. A black-and-white binary mask image representing hair and skin is produced, and the hairs are thinned into single-pixel-thick fiber skeletons. Further analysis based on these fibers allows morphometric characteristics such as hair shaft number and diameters to be computed rapidly. The hair-bearing scalps of fifty participants were imaged to assess the precision of our automated smartphone-based device in comparison with a specialized trichometry device for hair shaft density and diameter measurement. The precision and operation time of our technique relative to manual trichometry, which is commonly used by hair disorder specialists, is determined. RESULTS:An equivalence test, based on two 1-sided t tests, demonstrates statistical equivalence in hair density and diameter values between this automated technique and manual trichometry within a 20% margin. On average, this technique actively required 24 seconds of the clinician's time whereas manual trichometry necessitated 9.2 minutes. CONCLUSION/CONCLUSIONS:Automated smartphone-based trichometry is a rapid, precise, and clinically feasible technique which can significantly facilitate the assessment and monitoring of hair loss. Its use could be easily integrated into clinical practice to improve standard trichoscopy.

Cutaneous involvement of the scalp is a common manifestation of dermatomyositis (DM), occurring in up to 82% of adults with DM. Scalp DM predominantly affects women and is characterized by dermatitis, alopecia, pruritus, and/or burning. While cutaneous DM negatively impacts quality-of-life, scalp symptoms in particular are often severe, debilitating, and recalcitrant to standard DM therapies. Currently, there is a paucity of guidelines to inform management of scalp symptoms in patients with cutaneous DM. In this narrative review, we summarize the treatments utilized to manage scalp DM and highlight potential areas for future research. We identified eight studies that reported on 27 treatments focused on cutaneous DM and described outcomes on scalp symptoms. A majority of the treatments were standard therapies for cutaneous DM and resulted in no or minimal improvement in scalp symptoms. Five therapies did result in complete resolution of scalp symptoms and were recommended as potential areas of future research. These included low-dose naltrexone and platelet-rich plasma, as well as two frequent and one less common therapy for cutaneous DM respectively: intravenous immunoglobulin, rituximab, and apremilast. Though the literature was not systematically assessed in this review, these findings illustrate not only that strategies for refractory scalp DM are lacking, but also that those demonstrating potential efficacy are limited by low levels of evidence. Additional studies, especially randomized controlled trials, are needed to better inform management of scalp DM.

Lichen planopilaris is a primary lymphocytic cicatricial alopecia that commonly presents with hair loss at the vertex or parietal scalp. Patients may also have associated scalp itching, burning or tenderness. Due to scarring, hair loss is typically permanent. The main goals of treatment are reducing symptoms and preventing disease progression and further hair loss. Currently, the literature has limited evidence on treatments for this difficult condition, and most available evidence is from case reports and case series. Furthermore, the evidence shows a varied response to therapy, with frequent reports of poor response. This article reviews the diagnosis of this rare disease, summarize the currently available treatments, and provide insights and practices from alopecia experts.

Evaluation of alopecia often includes laboratory testing for ferritin, thyroid stimulating hormone, vitamin D, and zinc as previous studies have found associations between non-scarring alopecia and vitamin deficiencies. These studies are limited by small sample sizes, and subsequent analyses showed conflicting results. This study aims to explore laboratory abnormalities in non-scarring alopecia and examine whether supplementation is associated with increased hair growth. A total of 131 patients completed at least two visits by a hair specialist at NYU’s Faculty Group Practice. They had quantitative hair measurements taken at each visit and laboratory tests performed at the first visit. There were 20 (15.3%) patients with abnormal lab results. The most common vitamin deficiency was ferritin (6.5%). Forty-two (32%) patients received supplementations that specifically addressed their vitamin or hormone deficiency. Multivariate regression analysis showed that supplementation did not significantly impact hair density or diameter (P=0.73; P=0.96, respectively). Baseline hair density and diameter were positively associated with change in hair density and diameter, respectively (standardized coefficient [β] 0.57, P<0.01; β 0.61, P<0.01). The number of prescribed oral medications was negatively associated with change in hair diameter (β -6.60, P=0.04). Limitations of this study include the single-center, retrospective design and the short followup interval. However, our findings suggest that vitamin supplementation may not lead to improved outcomes in non-scarring alopecia, thus limiting the utility of laboratory testing. Additional large-scale prospective studies are needed to improve our management of alopecia. J Drugs Dermatol. 2021;20(7):807-809. doi:10.36849/JDD.5886.

BACKGROUND:The major concern regarding the use of low-dose oral minoxidil (LDOM) for the treatment of hair loss is the potential risk of systemic adverse effects. OBJECTIVE:To describe the safety of LDOM for the treatment of hair loss in a large cohort of patients. METHODS:Retrospective multicenter study of patients treated with LDOM for at least 3 months for any type of alopecia. RESULTS:A total of 1404 patients (943 women [67.2%] and 461 men [32.8%]) with a mean age of 43 years (range 8-86) were included. The dose of LDOM was titrated in 1065 patients, allowing the analysis of 2469 different cases. The most frequent adverse effect was hypertrichosis (15.1%), which led to treatment withdrawal in 14 patients (0.5%). Systemic adverse effects included lightheadedness (1.7%), fluid retention (1.3%), tachycardia (0.9%), headache (0.4%), periorbital edema (0.3%), and insomnia (0.2%), leading to drug discontinuation in 29 patients (1.2%). No life-threatening adverse effects were observed. LIMITATIONS/CONCLUSIONS:Retrospective design and lack of a control group. CONCLUSION/CONCLUSIONS:LDOM has a good safety profile as a treatment for hair loss. Systemic adverse effects were infrequent and only 1.7% of patients discontinued treatment owing to adverse effects.

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