Ingrid Herskovitz

Female Pattern Hair Loss

Context: Female pattern hair loss (FPHL) also known as female androgenetic alopecia is a common condition afflicting millions of women that can be cosmetically disrupting. Prompt diagnosis and treatment are essential for obtaining optimal outcome. This review addresses the clinical presentation of female pattern hair loss, its differential diagnosis and treatment modalities. Evidence Acquisition: A) Diffuse thinning of the crown region with preservation of the frontal hairline (Ludwig’s type) B) The “Christmas tree pattern” where the thinning is wider in the frontal scalp giving the alopecic area a triangular shaped figure resembling a christmas tree. C) Thinning associated with bitemporal recession (Hamilton type). Generally, FPHL is not associated with elevated androgens. Less commonly females with FPHL may have other skin or general signs of hyperandrogenism such as hirsutism, acne, irregular menses, infertility, galactorrhea and insulin resistance. The most common endocrinological abnormality associated with FPHL is polycystic ovarian syndrome (PCOS). Results: The most important diseases to consider in the differential diagnosis of FPHL include Chronic Telogen Effluvium (CTE), Permanent Alopecia after Chemotherapy (PAC), Alopecia Areata Incognito (AAI) and Frontal Fibrosing Alopecia (FFA). This review describes criteria for distinguishing these conditions from FPHL. Conclusions: The only approved treatment for FPHL, which is 2% topical Minoxidil, should be applied at the dosage of 1ml twice day for a minimum period of 12 months. This review will discuss off-label alternative modalities of treatment including 5-alfa reductase inhibitors, antiandrogens, estrogens, prostaglandin analogs, lasers, light treatments and hair transplantation.

Vellus hairs in the frontal scalp in early female pattern hair loss

Background: Dermoscopy of the scalp (trichoscopy) is a technique to evaluate the skin of the scalp and the hair disorders. It clinically helps to establish early female pattern hair loss (FPHL) without the need for more invasive techniques. Objectives: This work intends to demonstrate new adjunct criteria for the clinical diagnosis of FPHL by determining the number of short vellus hairs encountered in the frontal area of the scalp of female patients with FPHL. Materials and Methods: We retrospectively reviewed the trichoscopy images from 45 women affected by FPHL in initial stages, at 20 fold magnification dermoscopy at 2 cm from the hairline into the frontal area of the scalp. Results: A total of 45 patients images included had more than 20% variability at dermoscopy, criteria utilized to diagnose and included them in the study. All patients were graded as Ludwig I severity, 14 patients had frontal accentuation. The average number of vellus hairs in the frontal area at 20-fold magnification of all patients was of 12.02 vellus hair in the frontal area. When comparing the Ludwid I pattern group versus the Ludwig I with frontal accentuation pattern group there was no statistical difference between the two clinical groups. Conclusions: All 45 patients analyzed in this study were clinically diagnosed with FPHL. The number of vellus hairs in the frontal area was greater than the average found in normal subjects. Most patients (80%) with FPHL had more than or equal to seven vellus hairs per 20-fold magnification field in the frontal area, therefore we suggest that the presence of more than 6 vellus hairs in the frontal scalp at 20-fold magnification can be used as an additional criterion of FPHL.

A Review of Cellular and Acellular Matrix Products: Indications, Techniques, and Outcomes

Background: Wound healing is a dynamic process whereby cells, growth factors (GFs), and the extracellular matrix (ECM) interact to restore the architecture of damaged tissue. Chronic wounds can be difficult to treat due to the increased presence of inflammatory cells that degrade the ECM, GF, and cells necessary for wound healing to occur. Cellular and acellular matrix products can be used in the management of a variety of chronic wounds including venous, diabetic, and pressure ulcers and other conditions such as burns, epidermolysis bullosa, pyoderma gangrenosum, and surgical wounds. These matrices provide cells, GF, and other key elements that act as a scaffold and promote reepithelialization and revascularization of the wound bed. Methods: This article focuses on cellular and acellular matrix products that have been well-studied clinically with positive results in randomized clinical trials and widely available matrices for chronic nonhealing wounds. We present trial results as well as their indications, techniques, and outcomes. Results: There are a variety of matrix products available on the market. Some of these products are used to treat chronic wounds, for example, diabetic foot ulcers, venous leg ulcers, pyoderma gangrenosum, and pressure ulcers. In this review, we found that wounds of different etiologies have been treated with a variety of matrices, with successful outcomes compared with standard wound care. Conclusions: Both cellular and acellular matrix products are useful in the management of a variety of chronic wounds. These matrices provide cells, GF, and other key elements that promote reepithelialization and revascularization of the wound bed while preventing degradation of the ECM. The treatment of chronic wounds with matrix products in combination with standard wound care has been proven to aid in wound healing when added to standard of care.

Central centrifugal cicatricial alopecia: challenges and solutions

Central centrifugal cicatricial alopecia (CCCA) is the most common scarring alopecia among African American women. Data about epidemiology, etiology, genetic inheritance, and management are scarce and come from individual reports or small series. CCCA has been associated with hot combing and traumatic hair styling for years; however, studies fail to confirm it as the sole etiologic factor. It has been shown in a small series that CCCA can be inherited in an autosomal dominant fashion, with a partial penetrance and a strong modifying effect of hairstyling and sex. CCCA presents clinically as a central area of progressive irreversible hair loss that expands to the periphery. A patchy form has also been described. Dermoscopy is helpful to identify the optimal site for the biopsy, which establishes the diagnosis. Well-designed randomized controlled trials are needed to discover the optimal management. At this point, patients are advised to avoid traction and chemical treatments; topical and intralesional steroids, calcineurin inhibitors, and minoxidil can be helpful in halting the progression.

Short anagen hair syndrome

Short anagen syndrome (SAS) is a condition in which hair does not grow long. It usually perceived by parents in children around 2-4 years of age. It is a benign disease of the hair cycle. The condition is relevant from the standpoint of differential diagnosis with loose anagen syndrome. We report a case of SAS in a Hispanic 3-year-old girl.

Epidermal skin grafting.

Autologous skin grafts, such as full‐ and split‐thickness, have long been part of the reconstructive ladder as an option to close skin defects. Although they are effective in providing coverage, they require the need for a trained surgeon, use of anaesthesia and operating room and creation of a wound at the donor site. These drawbacks can be overcome with the use of epidermal skin grafts (ESGs), which can be harvested without the use of anaesthesia in an office setting and with minimal to no scarring at the donor site. ESGs consist only of the epidermal layer and have emerged as an appealing alternative to other autologous grafts for the treatment of acute and chronic wounds. In this article, we provide an overview of epidermal grafting and its role in wound management.

Minoxidil induced hypertrichosis in a 2 year-old child

We report a case of a 2 year-old male patient who developed generalized hypertrichosis after 2 months of treatment with 5% minoxidil foam for alopecia areata. This report highlights the danger of prescribing topical minoxidil to young children and the need to correctly instruct caretakers about its administration.

Statins may be associated with six‐week diabetic foot ulcer healing

Diabetic foot ulcers (DFUs) affect 1.5 million Americans annually, of which only a minority heal with standard care, and they commonly lead to amputation. To improve care, investigations are underway to better understand DFU pathogenesis and develop more effective therapies. Some currently used medications may improve healing. One small, randomized clinical trial found statins improve DFU healing. In this secondary analysis of a large multisite prospective observational cohort of 139 patients with DFUs receiving standard care, we investigated whether there was an association between 6‐week DFU wound size reduction and use of a variety of medications including alpha‐blockers, beta‐blockers, angiotensin converting enzyme inhibitors (ACEi) and statins. We found no significant (p < 0.05) association between six‐week wound reduction and use of any of the evaluated drugs; however, statins did trend toward an association (p = 0.057). This suggests a potential benefit of statins on DFU healing, and larger, targeted studies are warranted.

Reply: Alopecia areata treatment with simvastatin/ezetimibe

To the Editor: The results reported by Loi et al suggest that statins are not an effective treatment for patients with long-lasting severe alopecia areata. This is not completely surprising, as statin’s immunological mechanism of action is more directed in preventing interferonsignaling and lymphocyte activation, which are important target in acute alopecia areata. Statins were shown to prevent development of alopecia areata in a mouse model (J. J. J. unpublished data) and are useful (A. T. personal experience) in preventing relapses in patients who had hair regrowth with other treatments. A similar preventive effect of statins has recently been described in a mouse model for vitiligo. Statins offer also an adjuvant option for patients with active disease who show minimal progress on other treatments.

Comment on Yang et al. Association of statin use and reduced risk of lower-extremity amputation among patients with diabetes: A nationwide population-based cohort observation. Diabetes Care 2016;39:e54-e55

It is estimated that 2 million Americans, two-thirds of whom have diabetes mellitus (DM), are currently living with a limb amputation (1). Patients with DM are at significant risk for limb amputation, as one in four will develop a diabetic foot ulcer (DFU) over their lifetime and nearly one in six will require amputation (2). In 2009, U.S. hospital costs due to amputation exceeded