Faculty Bibliography

BACKGROUND:Topical minoxidil is the only US FDA-approved drug for the treatment of female pattern hair loss (FPHL). While the safety profile of topical minoxidil is excellent, the efficacy of minoxidil in hair growth is extremely low. A recent survey of 8000 people observed that only 4% of hair loss patients using an over-the-counter minoxidil were very satisfied with their results. In contrast, in clinical studies with an intervening physician, approximately 30%-40% of patients demonstrate an appreciable benefit. Compliance with topical drug regimens is often a major obstacle, limiting their effectiveness. Topical minoxidil leaves a greasy residue on the hair, which is especially problematic for women who do not wash their hair daily. AIMS/OBJECTIVE:We set out to develop an "After Minoxidil" companion spray to minoxidil that removes residual minoxidil from the hair, where it is not needed, yet leaves minoxidil on the scalp where it is required. We hypothesized that improving the cosmetic properties of minoxidil would improve patient compliance with the drug and subsequently improve clinical outcomes. METHODS:A cohort of 20 FPHL patients was recruited to use the novel "After Minoxidil" spray and report changes in hair quality on a Likert scale. RESULTS:In our cohort of FPHL patients, the novel "After Minoxidil" spray restored ease of styling and reduced greasiness to preminoxidil level in 65% and 85% of subjects, respectively. The average reduction in perceived greasiness was 78%. Importantly, 70% of subjects interviewed stated they would likely continue to use the minoxidil and "After Minoxidil" treatment regimen for 6 months, vs 0% willing to use minoxidil alone. CONCLUSION/CONCLUSIONS:The novel "After Minoxidil" spray improved ease of hair styling and reduced greasiness following application of topical minoxidil; thus, the novel "After Minoxidil" spray may help improve drug compliance and efficacy.

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.

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

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.