Aline Donati

Alopecia Areata: An Evidence-Based Treatment Update

BackgroundThere is no cure for alopecia areata, nor is there any universally proven therapy that induces and sustains remission. Treatment choices are frequently based on disease duration, extent, and activity as well as the age of the patient.ObjectiveOur objective was to review all randomized controlled studies on the treatment of alopecia areata.MethodsWe performed a search in the biomedical literature database PubMed, and used the terms ‘alopecia areata treatment’ and article type ‘randomized controlled trials’.ResultsFollowing this algorithm, we reviewed, analyzed, and reported on 29 trials that examined the efficacy of anthralin, antidepressants, biologics, calcineurin inhibitors, corticosteroids (topical and systemic), minoxidil, prostaglandin analogs, sensitizers, and a miscellaneous group of topical and oral drugs with less scientific evidence (aromatherapy, photodynamic therapy, azelaic acid, garlic gel, bexarotene, triiodothyronine, inosiplex, and total glucosides of paeony).ConclusionUsing the American College of Physicians Guideline grading system, our assessment is that the majority of published randomized controlled studies of alopecia areata are only of moderate quality. A number of treatments were found to be effective, for example, topical and oral corticosteroids and the sensitizing agents diphenylcyclopropenone and dinitrochlorobenzene; however, most studies had major limitations that hinder the interpretation of these results.

Glabellar red dots in frontal fibrosing alopecia: a further clinical sign of vellus follicle involvement

DEAR EDITOR, Frontal fibrosing alopecia (FFA) was first described by Kossard as a variant of lichen planopilaris (LPP) that affects mainly postmenopausal women. A progressive frontal or frontotemporal symmetric band of alopecia is the usual presentation, with eyebrows commonly involved. Reports of hair loss at other areas such as limbs and axillary and pubic regions with involvement of terminal, intermediate and vellus hair follicles in any stage of the hair cycle, from anagen to telogen, have expanded the spectrum of the disease, suggesting that FFA is, in fact, a generalized skin condition. Involvement of facial vellus hair follicles in FFA was first described by Donati et al. Unlike the noninflammatory hair loss resulting from vellus involvement at other body sites, affected facial vellus hair follicles were associated with skin surface changes, namely, facial papules. We describe three patients with FFA with a clinical feature that has not been previously reported: the presence of numerous follicular red dots (FRD) in the forehead. All patients were white women (age range 57–67 years) with disease duration ranging from 3 to 5 years. None of them was currently receiving any treatment for this condition. On examination, apart from clinical signs such as frontotemporal recession of the hairline, we noticed FRD that could be restricted to the glabellar zone as seen in two patients (Fig. 1a,c), but that could also be perceived more extensively in the forehead (one patient, Fig. 1b). In two subjects, FRD were associated with follicular keratosis (Fig. 1a). In order to correlate clinical and pathological features, punch biopsies from areas presenting the FRD pattern were obtained from two patients. Both specimens showed perifollicular lichenoid lymphocytic inflammatory infiltrate involving vellus hairs, histological features suggestive of vellus hair follicle involvement by LPP (Fig. 2). We also performed a retrospective evaluation of clinical images of 69 patients with FFA, which revealed three other female patients with the FRD pattern present in the glabellar region. FRD were first described by Tosti et al. as a trichoscopic feature of active discoid lupus erythematosus (DLE) of the scalp and its presence associated with better prognosis. It has been suggested that the overlying atrophic epidermis of DLE lesions would allow the visualization of the rich vascular net that naturally envelops the normal hair follicle. FRD in DLE lesions would therefore represent still viable hair follicles responsible for the better chance of hair regrowth reported in those patients. FRD have also been described in the eyebrows of patients with FFA. Even though no histopathological correlation was made by the

Clinical and dermoscopic features of lichen planus pigmentosus in 37 patients with frontal fibrosing alopecia.

DEAR EDITOR, The coexistence of frontal fibrosing alopecia (FFA) and lichen planus pigmentosus (LPPigm), an uncommon macular variant of lichen planus, was first reported by Dlova in 2013 in South African patients. Herein, we report 37 patients with such an association, describe the clinical and dermoscopic features of facial LPPigm and compare our findings with previously published data. In total, 37 patients aged 34–79 years were included [36 women (30 postmenopausal, six premenopausal) and one man]; 33 had skin phototype IV or higher (hispanics and people of African descent) and three had skin phototype III. All patients presented with frontotemporal hair loss; three (8%) had the recently described pseudo ‘fringe sign’. Facial papules were noted in 16 (43%), eyebrow involvement in 36 (97%) and body hair loss in 27 (73%). All patients presented with facial hyperpigmentation, which we classified as diffuse in 25 (67%), reticulated in eight (22%) and comprised of multiple pigmented macules in four (11%) (Fig. 1a–c). In 14 (38%), neck involvement was also prominent. In 19 patients, LPPigm preceded FFA presentation, in five it followed diagnosis of FFA, in one patient FFA and LPPigm were diagnosed simultaneously and in 12 patients precise disease onset was unable to be confirmed. Punch biopsies were performed in 14 patients, confirming a clinical diagnosis of LPPigm, which showed an interface dermatitis pattern and/or pigment incontinence, occasionally involving hair follicles and eccrine glands (Fig. 1d–f). Epidermal atrophy and discrete perivascular lymphocytic infiltrate were commonly observed. Dermoscopy and photographic documentation of facial lesions were performed in all cases using either Fotofinder Dermoscope (nonpolarized; Teachscreen Software, Bad Birnbach, Germany), Fotofinder Handyscope (Teachscreen Software) or DermLite Foto II Pro (3Gen, San Juan Capistrano, CA, U.S.A.) attached to a Canon EOS T3i camera (polarized; Canon, Tokyo, Japan). The photographs were analysed by all authors and four distinct patterns of pigmentation were identified: (i) pseudonetwork (n = 24); (ii) dotted pattern (n = 8); (iii) speckled blue–grey dots (n = 13); and (iv) blue–grey dots arranged in circles (n = 7) (Fig. 1g–k), with 14 (38%) patients showing more then one pattern. Additionally, rhomboidal structures were noted in five patients with a pseudonetwork pattern and asymmetry of follicular openings in one (Fig. 1l, m). There was no correlation between the clinical type of pigmentation and one specific dermoscopic pigmentation pattern. Vascular alterations were assessed in 25 cases, and 12 presented focal erythema or telangiectasias and three diffuse erythema (Fig. 1g–i). Twenty-four patients presented complete or partial loss of facial vellus hair. In accordance with the initial description and later reports, coexistence of FFA and LPPigm in our series was observed mostly in dark-skinned patients (89%). Most of our patients were postmenopausal; only 17% were premenopausal. This differs from the series of Dlova, which included 64% premenopausal patients, but is similar to the recently published large series of patients with FFA. In the same study by Dlova, LPPigm preceded hair loss in all patients and was considered as a herald sign of FFA. A clear history of LPPigm preceding FFA was present in only 19 (51%) of our patients. However, considering that early signs of FFA and LPPigm can go unnoticed in patients, and a possible recall bias, we consider assessment of the predictive status of LPPigm as a harbinger of FFA to be hampered in the present study. The blue–grey hue observed through dermoscopy can be justified by the depth of the pigment present in the dermis, and has been described in lesions of lichen planus pigmentosus inversus. Speckled blue–grey dots and the pseudonetwork patterns possibly correlate with a more prominent interfollicular interface dermatitis; the former resulting from scattered foci of inflammation with melanophages, and the latter from a broader damage to the epidermal basal cell layer. Demonstration of eccrine and follicular involvement in biopsy specimens supports that the dotted pattern and circles result from damage to those structures, respectively. Blue–grey or brown perifollicular pigmentation in facial macules resembling LPPigm have been recently reported in patients with FFA and might correspond to the circles observed in our patients. Loss of facial vellus hairs also results from hair follicle involvement and has been previously described in FFA. Vascular changes might be found in the context of an inflammatory process and epidermal atrophy might have facilitated their visualization by dermoscopy. Clinically, the differential diagnosis of LPPigm should be established with a heterogeneous group of disorders causing facial hyperpigmentation, such as exogenous ochronosis, melasma, Riehl’s melanosis and ashy dermatosis. Hydroxychloroquine-induced hyperpigmentation should also be

Alopecia areata incognita

Alopecia areata incognita, also known as diffuse alopeciaareata, is a rare form of alopecia areata described pre-dominantly in young women. In cases of alopecia areataincognita, the typical patchy distribution of hair loss inclassical alopecia areata is absent, but abrupt and intensehair loss is characteristic. While the clinical picturepresented by this disease closely resembles that of telogeneffluvium, specific clinical and dermoscopic findings ofalopecia areata are invariably present along the diseasecourse.

Psoriatic scarring alopecia

Psoriasis is a relatively frequent inflammatory dermatosis. Scarring alopecia due to scalp psoriasis was first reported in 1972, but few reports have been written since then, showing that this is a very rare complication of a common disorder. We report a young Brazilian woman with longstanding scalp psoriasis, which progressed to scaring alopecia.

Efeitos colaterais cutâneos de quimioterapia com taxanos: O ponto de vista do dermatologista

Chemotherapy with taxanes has recently become part of the treatment for many advanced neoplastic diseases, specially breast and lung cancer. Their main noncutaneous adverse reactions include neutropenia and mucositis, which eventually lead to drug discontinuation. Cutaneous adverse reactions are frequent and significantly interfere with the patients quality of life. Treatments are poorly effective, but special recommendations may improve symptoms and prevent relapses requiring drug rechallenge.

Frontal fibrosing alopecia and sunscreens: cause or consequence?

1 Ahnlide I, Zalaudek I, Nilsson F et al. Preoperative prediction of histopathological outcome in basal cell carcinoma: flat surface and multiple small erosions predict superficial basal cell carcinoma in lighter skin types. Br J Dermatol 2016; 175:751–61. 2 Menzies SW, Westerhoff K, Rabinovitz H et al. Surface microscopy of pigmented basal cell carcinoma. Arch Dermatol 2000; 136:1012–6. 3 Altamura D, Menzies SW, Argenziano G et al. Dermatoscopy of basal cell carcinoma: morphologic variability of global and local features and accuracy of diagnosis. J Am Acad Dermatol 2010; 62:67–75. 4 Lallas A, Apalla Z, Argenziano G et al. The dermatoscopic universe of basal cell carcinoma. Dermatol Pract Concept 2014; 4:11–24. 5 Lallas A, Argenziano G, Zendri E et al. Update on non-melanoma skin cancer and the value of dermoscopy in its diagnosis and treatment monitoring. Expert Rev Anticancer Ther 2013; 13:541–58. 6 Pan Y, Chamberlain AJ, Bailey M et al. Dermatoscopy aids in the diagnosis of the solitary red scaly patch or plaque – features distinguishing superficial basal cell carcinoma, intraepidermal carcinoma, and psoriasis. J Am Acad Dermatol 2008; 59:268–74. 7 Lallas A, Tzellos T, Kyrgidis A et al. Accuracy of dermoscopic criteria for discriminating superficial from other subtypes of basal cell carcinoma. J Am Acad Dermatol 2014; 70:303–11. 8 Apalla Z, Lallas A, Tzellos T et al. Applicability of dermoscopy for evaluation of patients’ response to nonablative therapies for the treatment of superficial basal cell carcinoma. Br J Dermatol 2014; 170:809–15. 9 Lallas A, Apalla Z, Ioannides D et al. Dermoscopy in the diagnosis and management of basal cell carcinoma. Future Oncol 2015; 11:2975–84. 10 Telfer NR, Colver GB, Morton CA; British Association of Dermatologists. Guidelines for the management of basal cell carcinoma. Br J Dermatol 2008; 159:35–48. 11 Lallas A, Argenziano G, Kyrgidis A et al. Dermoscopy uncovers clinically undetectable pigmentation in basal cell carcinoma. Br J Dermatol 2014; 170:192–5.

Videodermoscopy does not enhance diagnosis of scalp contact dermatitis due to topical minoxidil.

Background: Videodermoscopy (VD) is a noninvasive diagnostic tool that provides useful information for the differential diagnosis of scalp disorders. Objectives: The aim of this study was to investigate if dermoscopy may help the clinician in the diagnosis of contact dermatitis of the scalp. Materials and Methods: We analyzed the dermoscopic images taken from 7 patients with contact dermatitis due to topical minoxidil, 6 patients complaining of intense scalp itching during treatment with topical minoxidil but with negative patch tests and 19 controls. The following dermoscopic patterns described for scalp diseases were evaluated: Vascular patterns (simple loops, twisted loops and arborizing lines), follicular/perifollicular patterns (yellow dots, empty ostia, white dots, peripilar signs), white scales, yellow scales, follicular plugging, hair diameter diversity, honeycomb pattern and short regrowing hairs. Findings were graded from 0-4, according to severity in 20-fold magnifications. Statistical analysis included univariate analysis and Chi-square test by SPSS version 12. Results: There were no statistical differences in the analysis of the vascular patterns and scales between the 3 groups. Conclusions: We were not able to detect dermoscopic features that can help the clinician in distinguishing scalp contact dermatitis due to topical minoxidil from other conditions that cause severe scalp itching. In particular, minoxidil contact dermatitis does not produce increase or alterations in the morphology of the scalp vessels or significant scalp scaling when evaluated with dermoscopy.

Patchy traction alopecia mimicking Areata

Acute traction alopecia is a diagnostic challenge when the external factor is not suspected or admitted. We report two female patients with non-scarring patchy alopecia resulting from traction of video-electroencephalogram electrodes in which the clinical diagnosis of alopecia areata was suspected. Associated diffuse hair disorders might be implicated in these cases. The correct diagnosis of traction alopecia is important in order to avoid unnecessary treatments.

Trichostasis spinulosa of the scalp mimicking Alopecia Areata black dots

Alopecia areata is a common autoimmune disorder that leads to nonscarring hair loss. Black dots, also called comedo-like cadaver hairs, can be found in almost 50% of alopecia areata patients and indicate disease activity. Trichostasis spinulosa is a follicular disorder resulting from the retention of numerous hairs surrounded by a keratinous sheath in dilated follicles. Trichostasis spinulosa is a relatively common but underdiagnosed disorder of hair follicles. Here, we describe a man with alopecia areata of the eyebrows, androgenetic alopecia and trichostasis spinulosa at the vertex and show how dermoscopy can be useful in distinguishing black dots from Trichostasis spinulosa lesions.