Faculty Bibliography

BACKGROUND:A systematic review failed to identify any systemic therapy used in alopecia areata (AA) where use is supported by robust evidence from high quality randomized controlled trials (RCTs). OBJECTIVE:To produce an international consensus statement on the use and utility of various treatments for AA. METHODS:Fifty hair experts from 5 continents were invited to participate in a 3 round Delphi process. Agreement >66% was considered consensus. RESULTS:In the first round, consensus was achieved in 22 of 423 (5%) questions. Following a face-to-face meeting in round 3, overall, consensus was achieved for only 130 (33%) treatment specific questions. There was greater consensus for intralesional treatment of AA 19 (68%) followed by topical treatment 25 (43%). Consensus was achieved in 45 (36%) questions pertaining to systemic therapies in AA. The categories with the least consensus were phototherapy and non-prescription therapies. LIMITATIONS/CONCLUSIONS:The study included a comprehensive list of systemic treatments for AA, but not all treatments used. CONCLUSION/CONCLUSIONS:Despite divergent opinions amongst experts, consensus was achieved on a number of pertinent questions. The concluding statement also highlights areas where expert consensus is lacking and where an international patient registry could enable further research.

A preliminary observation of high frequency of male pattern hair loss among admitted COVID-19 patients and suggest that androgen expression might be a clue to COVID-19 severity.

Racial disparities in COVID-19 infection rates and disease severity are due to a multifactorial etiology that can include socioeconomic as well as other factors. Nevertheless, genetic factors in different ethnic groups often contribute to disease severity and treatment response. In particular, the frequency of genetic variations in the androgen receptor differs by ethnicity and gender. For example, the increased prevalence of prostate cancer and androgenetic alopecia among African Americans correlates with the frequency of these variants. In this communication, we propose that androgens may be implicated in COVID-19 disease severity. As such, special attention may need to be given to African Americans infected by the SARS-CoV-2 virus. Finally, if a link to genetic variations in the androgen receptor and COVID-19 disease severity can be established, it would suggest new treatment options.

Alopecia areata (AA) is thought to be an autoimmune process. In other autoimmune diseases, the innate immune system and Toll-like receptors (TLRs) can play a significant role. Expression of TLR7, TLR9, and associated inducible genes were evaluated by quantitative PCR in peripheral blood mononuclear cells (PBMCs) from 10 healthy individuals and 19 AA patients, categorized according to disease duration, activity, and hair loss extent. Microdissected scalp biopsies from 5 patients and 4 controls were also assessed by quantitative PCR and immunohistology. TLR9 was significantly upregulated 2.37 fold in AA PBMCs. Notably, TLR9 was most significantly up regulated in patients with active AA, as shown by a positive hair pull test, compared to stable AA patients. In hair follicle bulbs from AA patients, IFNG and TLR7 exhibited statistically significant 3.85 and 2.70 fold increases in mRNA respectively. Immunohistology revealed TLR7 present in lesional follicles, while TLR9 positive cells were primarily observed peri-bulbar to AA affected hair follicles. The increased expression of TLR7 and TLR9 suggest components of the innate immune system may be active in AA pathogenesis.

Introduction/UNASSIGNED:We present 2 cases in which typically irreversible lichen planopilaris (LPP) and frontal fibrosing alopecia (FFA) showed signs of reversal. Case Presentation/UNASSIGNED:A 27-year-old Caucasian man presented with hair loss and intense pruritus on the vertex scalp for 4 years with biopsy-proven LPP and having failed multiple pharmacologic modalities. Six months after adding oral tofacitinib and later dapsone, he demonstrated reduced scalp visibility, evidence of crown and vertex hair regrowth, and elimination of itch. A 45-year-old premenopausal Hispanic woman presented with eyebrow loss for 3.75 years and hair loss for 9 months with biopsy-proven FFA. After beginning oral finasteride and hydroxychloroquine, triamcinolone injections, and topical minoxidil, she initially worsened over 11 months but subsequently improved over 6 months, demonstrating hair and eyebrow regrowth, reduction in glabella-hairline distance, and new absence of frontal hair line hyperkeratosis and inflammation. Discussion/Conclusion/UNASSIGNED:Cicatricial alopecia involves inflammation with JAK-STAT upregulation. We report a positive clinical response in LPP to tofacitinib, a JAK1/3 inhibitor, and dapsone, an anti-neutrophilic agent. FFA is believed to involve autoimmune and/or hormonal processes. Here we report a positive clinical response to androgenic and immune modulators.

BACKGROUND:Platelet rich plasma (PRP), processed from autologous peripheral blood, is used to treat androgenetic alopecia (AGA). OBJECTIVE:To determine the efficacy of PRP for hair growth promotion in AGA patients in a randomized, blinded, placebo controlled, pilot clinical trial (NCT02074943). METHODS:The efficacy of an 8 week, 5 session, PRP treatment course was determined by measuring hair density and hair caliber changes in 10 AGA affected patients. For each PRP sample, the concentrations of selected growth factors were determined using a multiplex assay system. The clinical results were then correlated to the growth factor concentrations in PRP. RESULTS:At 16 weeks, 8 weeks after the last PRP injection, treated areas exhibited increased mean hair density (+12.76%) over baseline compared to placebo (+0.99%). Mean hair caliber decreased in both treated and placebo regions (-16.22% and -19.46% respectively). Serial analysis of PRP significant variability in concentrations between patients. Overall, there was a positive correlation between GDNF concentration and hair density (p= 0.004). Trends, though not statistically significant, were also observed for FGF2 and VEGF. LIMITATIONS/CONCLUSIONS:Small sample size and lack of comparative cohorts receiving protocol variations limit confidence in the study data. CONCLUSIONS:This small pilot clinical trial suggests PRP treatment may be beneficial for AGA. However, the variable hair growth responses between patients indicate there is a significant opportunity to improve PRP therapy protocols for hair growth promotion. The variability in growth factor concentration in PRP suggests standardization of growth factors post-processing might improve hair growth responses.

INTRODUCTION: Permanent skin and nail disorders resulting from cytotoxic or endocrine agents used in early stages of breast cancer such as facial skin aging and nail changes (including nail ridging, discoloration, and onycholysis) develop in 3% and 78% of patients, respectively, however their impact on quality of life (QoL) has not been reported.
Objective(s): The CHANCE study is a prospective, longitudinal study of chemotherapy-and endocrine therapy-induced hair, skin, and nail changes in women with non-metastatic breast cancer. This preliminary analysis intends to evaluate the impact of permanent skin and nail sequelae of adjuvant breast cancer therapies on patients' QoL.
Material(s) and Method(s): A target of 500 patients in 5 treatment cohorts will be followed for 3 years using standardized clinical images and objective skin biometrics. Patient-reported outcomes are assessed through QoL questionnaires at baseline, 6 months after chemotherapy completion, or one year after initiation of endocrine therapy: Skin QoL Questionnaire (SQQ) and Nail-specific QoL Questionnaire (NQQ). Higher scores correspond to worse QoL.
Result(s): Questionnaires were completed at both baseline and follow-up by 85 of 327 enrolled patients at the time of analysis. Overall worsening of QoL was found (baseline vs. follow-up: SQQ 2.89 vs. 3.19, p=.03; NQQ fingernail module 1.08 vs. 1.33, p=.003; NQQ toenail module 1.22 vs. 1.57, p=0.008). The greatest impact on skin-related QoL occurred in patients receiving cyclophosphamide+methotrexate+5-fluorouracil and on nail-related QoL occurred in patients receiving newer combination chemotherapy regimens (e.g. taxane+trastuzumab). The greatest change in NQQ subscale score occurred in fingernail emotional and toenail symptoms subscales (baseline vs. follow-up: fingernail 1.08 vs. 1.36, p=.002; toenail 1.21 vs. 1.57, p=.002).
Conclusion(s): Adjuvant therapy used in non-metastatic breast cancer result in persistent skin and nail changes that cause a negative impact on patients' QoL. Longer-term effects of anticancer therapy on QoL will be assessed with subsequent analyses