Andrew J. G. McDonagh

Epidemiology and genetics of alopecia areata

Summary The frequency of alopecia areata and observed patterns of heritability are in keeping with a polygenic inheritance model but the genetics of alopecia areata is still poorly understood. The role of environmental factors in triggering disease initiation or exacerbation remains almost entirely speculative. Using the candidate gene approach, three susceptibility/severity factors have been identified. HLA alleles were the first to show a strong association with alopecia areata and some DQB and DR alleles have been demonstrated to confer a high risk for disease by both case–control and family‐based studies. Interleukin (IL)‐1 cluster genes, mainly the IL‐1 receptor antagonist, show a strong association with disease severity in alopecia areata and a number of other autoimmune and inflammatory diseases. Finally, the association of alopecia areata with Downs syndrome, the high frequency of alopecia areata in autoimmune polyglandular syndrome type I due to mutations of the autoimmune regulator (AIRE) gene on chromosome 21q22.3 and the finding of association with MX1, another gene in the Downs syndrome region of chromosome 21 indicate this area of the genome as a promising target for future‐family based investigations. The role of individual genes of the MHC, IL‐1 cluster or chromosome 21q22.3 is difficult to establish and further genetic and functional investigations are needed to confirm their involvement in the pathogenesis of alopecia areata.

British Association of Dermatologists' guidelines for the management of alopecia areata 2012

The guidelines have been revised and updated in accordance with a predetermined scope, based on that used in the 2003 guidelines. Recommendations in these guidelines supersede those in the 2003 guidelines. The objectives of the guidelines are to provide up-to-date recommendations for the manage- ment of alopecia areata in adults and children and a summary of the evidence base.Rosalind.Woodworth@utas.edu.au

Nickel sensitivity: the influence of ear piercing and atopy

In a group of 612 consecutive patients undergoing routine patch tests for suspected allergic contact dermatitis, more than four‐fifths of the 364 women had had their ears pierced, over half gave a history of cutaneous reactions to metallic jewellery and almost one‐third were sensitive to nickel. The increase in the frequency of nickel sensitivity in women with pierced ears compared to those with unpierced ears was highly significant (P < 0.001). In men, nickel sensitivity was much less frequent; occupational factors were often implicated and few cases were related to ear piercing. Jewellery dermatitis was more frequent in atopic than non‐atopic women but atopy did not appear to influence the propensity for developing nickel sensitivity in either sex. Ear piercing seems to induce nickel allergy which may result in lifelong morbidity and difficulty in employment. Jewellery suppliers should be encouraged to provide nickel‐free earrings to reduce the frequency of this apparently avoidable problem.

Concerns over confidentiality may deter adolescents from consulting their doctors. A qualitative exploration

Objectives: Young people who are concerned that consultations may not remain confidential are reluctant to consult their doctors, especially about sensitive issues. This study sought to identify issues and concerns of adolescents, and their parents, in relation to confidentiality and teenagers’ personal health information. Setting: Recruitment was conducted in paediatric dermatology and general surgery outpatient clinics, and on general surgery paediatric wards. Interviews were conducted in subjects’ own homes. Methods: Semistructured interviews were used for this exploratory qualitative study. Interviews were carried out with 11 young women and nine young men aged 14–17. Parents of 18 of the young people were interviewed separately. Transcripts of tape recorded interviews provided the basis for a framework analysis. Results: Young women were more concerned than young men, and older teenagers more concerned than younger teenagers, about people other than their general practitioner (GP) having access to their health information. Young people with little experience of the healthcare system were less happy than those with greater knowledge of the National Health Service (NHS) for non-medical staff to access their health information. As they grow older, adolescents become increasingly concerned that their health information should remain confidential. Conclusion: Young people’s willingness to be open in consultations could be enhanced by doctors taking time to explain to them that their discussion is completely confidential. Alternatively, if for any reason confidentiality cannot be assured, doctors should explain why.

HLA and ICAM‐1 expression in alopecia areata in vivo and in vitro: the role of cytokines

To investigate the hypothesis that aberrant HLA and adhesion molecule expression in alopecia areata (AA) are secondary to local release of interferon‐gamma (IFN‐γ) or other cytokines. we have studied HLA ABC. ‐DQ. ‐DR and ICAM‐1 expression by immunohistochemistry, and compared patterns of expression in lesional tissue sections with those observed in hair follicles maintained in short‐term organ culture, both from normal individuals and non‐lesional sites in AA patients. The organ cultures were supplemented with IFN‐γ, tumour necrosis factor‐alpha (TNE‐α), and granulocyte‐macrophage colony stimulating factor (GM‐CSE). in a range of doses.

White sponge naevus successfully treated with topical tetracycline

Four patients with white sponge naevus of the oral mucosa each showed a dramatic improvement in symptoms with the use of topical tetracycline. This effect may depend on antimicrobial activity but the exact mechanism remains uncertain.

The autoimmune regulator gene (AIRE) is strongly associated with vitiligo

Background  Vitiligo is an autoimmune disorder that occurs with greatly increased frequency in the rare recessive autoimmune polyendocrinopathy–candidiasis–ectodermal dystrophy syndrome (APECED) caused by mutations of the autoimmune regulator (AIRE) gene on chromosome 21q22·3. We have previously detected an association between alopecia areata and single nucleotide polymorphisms (SNPs) in the AIRE gene.

Quantification of allergic and irritant patch test reactions using laser-Doppler flowmetry and erythema index

The laser‐Doppler blood flow and erythema index were assessed in 16 patch test reactuibs caysed by irritants (1% aq. Sodium lauryl sulphate and 1%aq. Benzalkonium chloride) and in 13 varied allergic reactions, at 2 or 4 days. Both irritant and allergic responses produced satistically significant increases in laser‐Doppler flow index and erythema index compared to control sites (p<0.05 or less, using the Wilcoxon rank‐sum test). A disproportionately greater increase in erythema index than in laser‐Doppler flow was seen in mild irritant reactions, compared to allergic, though the two could no be reliably distinguished by these tests. 2 non‐allergic nickel sulphate sites produced an increase in both blood flow and erythema without any clinical change. Petrolatum alone produced no significant change in either measurement. The laser‐Doppler flow showed an overall correlation with the erythema index (product moment method: r=0.55. p<0.001), but there was little correlation between these indices and patch test reactivity as judged clinically by conventional scoring. Generally, allergic and irritant patch test reactions could not be differentiated on the basis of laser‐Doppler flow index for mild irritant responses warrants further study in other irritant models.

Frontal fibrosing alopecia: possible association with leave-on facial skin care products and sunscreens; a questionnaire study†

Since its first description in 1994, frontal fibrosing alopecia (FFA) has become increasingly common, suggesting that environmental factors are involved in the aetiology.

Hair darkening in porphyria cutanea tarda.

Summary Repigmentation of grey hair is rare, but has been described in several clinical settings. It has most often been reported as a postinflammatory effect, but several drugs, chronic arsenic exposure and coeliac disease have also been cited in addition to darkening as a spontaneous phenomenon. We report two patients with sustained repigmentation of the hair in association with porphyria cutanea tarda. The mechanism for this repigmentation remains elusive, but presumably involves recruitment of outer root sheath melanocytes, which are then activated to form functional hair bulb melanocytes.