Solam Lee

Management of alopecia areata: Updates and algorithmic approach

Alopecia areata is a chronic, recurrent and non‐scarring alopecia. The prognoses of patients are very diverse. The larger the area of hair loss, the poorer the treatment response and greater the probability of chronic disease progression. Numerous treatments have been introduced, but curative treatments have yet to be established. The long‐term efficacy of the current treatments is minimal, and the therapeutic response varies widely. Recent clinical trials have attempted to apply therapeutic metrics, such as the Severity of Alopecia Tool, and many have been designed as randomized controlled studies, enabling a more precise evaluation of existing treatments. There have been updates in practice, efficacy or indications of therapeutics that have been previously used. Moreover, the use of novel treatments such as biologics has recently been introduced. Commonly, the most important factor in determining the treatment modality for alopecia areata has been the extent of hair loss. However, if the disease activity is high and likely to progress, combination therapy with adjuvant modalities will be more desirable. This review will discuss the therapeutic effects of existing and newly‐introduced treatments based on their quantity, quality of evidence and expected complications. In addition, an algorithmic approach to management of alopecia areata is proposed according to clinical subtype, severity, onset and activity of the disease.

Efficacy of topical diphenylcyclopropenone maintenance treatment for patients with alopecia areata: A retrospective study

Disease stabilization, % (n) Yes 70.7 (65) No 29.3 (27) Time to stabilization, months Average (range) 10.4 (1-72) Intralesional treatment, % (n) Triamcinolone acetonide 71.7 (66) Systemic treatments, % (n) Hydroxychloroquine 34.8 (32) Antibiotics: doxycycline, tetracycline, or minocycline 70.7 (65) Methotrexate 4.3 (4) Spironolactone 2.2 (2) Finasteride/dutasteride 26.1 (24) Mycophenolate mofetil 3.2 (3) Pioglitazone 6.5 (6) Systemic prednisone 2.2 (2) Topical treatments, % (n) Tacrolimus, 0.3% (in Cetaphil cleanser) 41.3 (38) Clobetasol propionate, 0.05% lotion or foam and betamethasone dipropionate, 0.05% lotion 23.9 (22)

Subclinical sensitization with diphenylcyclopropenone is sufficient for the treatment of alopecia areata: Retrospective analysis of 159 cases

Background Contact immunotherapy with diphenylcyclopropenone (DPCP) is presently considered the treatment of choice for extensive alopecia areata. However, a major concern with contact immunotherapy is that it causes various adverse effects (AEs) that contribute to discontinuation of treatment. Objective We investigated whether a modified DPCP treatment protocol can promote hair regrowth with fewer AEs. Methods All patients were sensitized with 0.1% DPCP and began treatment with 0.01% DPCP. Thereafter, the DPCP concentration was slowly increased according to the treatment response and AEs. This was a retrospective review of DPCP treatment with modified protocols in 159 patients with alopecia areata. Results Of the 159 patients, 46 (28.9%) showed a complete response and 59 (37.1%) showed a partial response. No patients had AEs after sensitization. During the treatment, only 3 patients (1.9%) showed severe AEs, and 55 showed moderate AEs; however, all were well controlled with antihistamines alone or antihistamines and medium‐potency topical steroids. There was no association between treatment response and AEs. Limitations Sample size, subject composition, and the retrospective study design represent potential limitations. Conclusion A modified DPCP treatment protocol with subclinical sensitization could induce a favorable therapeutic response and result in fewer AEs.

Therapeutic Efficacy of a Combination Therapy of Topical 17α-Estradiol and Topical Minoxidil on Female Pattern Hair Loss: A Noncomparative, Retrospective Evaluation

Background A variety of agents have been used to treat female pattern hair loss (FPHL), including topical minoxidil, topical 17α-estradiol, oral anti-androgen agents, and mineral supplements. Compared with these single agent regimens, combination therapies could be a better therapeutic option in expectation of superior treatment outcome. Objective This study was designed to determine the efficacy of a combination therapy consisting of topical 0.025% 17α-estradiol and 3% minoxidil in Korean patients with FPHL. Methods Therapeutic efficacy was evaluated in 34 women who applied topical 0.025% 17α-estradiol and 3% minoxidil once daily for more than 6 months. Phototrichogram analysis was performed before and after therapy. The efficacy was evaluated with respect to total hair count, hair caliber (as assessed by phototrichogram analysis), and photographic assessment. Results Total hair count and hair caliber both increased from baseline to 6 months in patients treated with the combination therapy of topical 0.025% 17α-estradiol and 3% minoxidil (p<0.001). Photographic assessment also revealed significant disease improvement, thus supporting the therapeutic efficacy. Conclusion A combination therapy consisting of topical 0.025% 17α-estradiol and 3% minoxidil can be tried as an effective treatment for FPHL.

Differences in Genetic Variations Between Treatable and Recalcitrant Atopic Dermatitis in Korean

Purpose Variations in barrier- or immune response-related genes are closely related to the development of atopic dermatitis (AD). This study was designed to identify genetic variations and clinical features to predict ‘recalcitrant AD.’ Methods AD patients were classified as treatable and recalcitrant. Treatable AD patients showed satisfactory clinical improvement with basic and topical treatments. Recalcitrant AD patients used systemic immune-suppressants for over 4 weeks as they had not shown clinical improvement with basic and topical treatments. The frequency of gene variations in barrier- (FLG 3321delA, FLG K4022X, KLK7, SPINK 1156, SPINK 1188, SPINK 2475) and immune response- (DEFB1, KDR, IL-5RA, IL-9, and IL-12RB1a, b) related genes were compared between each AD group and the controls. Results Of all, 249 treatable AD and 32 recalcitrant AD were identified. Heterozygous mutations (Hetero) in KLK7 was more frequent in recalcitrant AD patients than treatable AD, without statistical significance. Hetero in DEFB1 was more frequent in treatable AD patients. However, no other significant genetic differences between treatable and recalcitrant AD was observed. Instead, higher initial Eczema Area Severity Index (EASI) score, serum immunoglobulin E (IgE) level, allergen specific IgE for house dust mites, and family history of atopic diseases were associated with recalcitrant AD with statistical significance. Conclusions According to our study, no genetic variation to predict recalcitrant AD was identified, suggesting that clinical manifestation, rather than genetic variations of AD patients is more likely to be an important factor in predicting the prognosis of AD. Further large-scale studies on the correlation between genetic variation and recalcitrant AD are needed.

Home-based contact immunotherapy with diphenylcyclopropenone for alopecia areata is as effective and safe as clinic-based treatment in patients with stable disease: A retrospective study of 40 patients

context of appropriate and essential medical care, the treatment of AA satisfies the definition of medical necessity and is merited, by objective measures, in the same way that treatment of other chronic dermatoses, such as atopic dermatitis and psoriasis, is merited. Lastly, Skindex-16 is not specific to AA and might not be the ideal instrument for assessing patient satisfaction with treatment. Assessment with AA-specific instruments, such as the AA Quality-ofLife Index, might be more appropriate. Because patient-reported outcomes are becoming increasingly important in clinical trials, instruments that effectively assess the psychosocial impact of AA are necessary.

Almost Unilateral Focal Dermal Hypoplasia

Focal dermal hypoplasia, caused by mutations in PORCN, is an X-linked ectodermal dysplasia, also known as Goltz syndrome. Only seven cases of unilateral or almost unilateral focal dermal hypoplasia have been reported in the English literature and there have been no previously reported cases in the Republic of Korea. A 19-year-old female presented with scalp defects, skin lesions on the right leg and the right trunk, and syndactyly of the right fourth and fifth toes. Cutaneous examination revealed multiple atrophic plaques and a brown and yellow mass with fat herniation and telangiectasia that was mostly located on the lower right leg. She had syndactyly on the right foot and the scalp lesion appeared to be an atrophic, membranous, fibrotic alopecic scar. A biopsy of the calf revealed upper dermal extension of fat cells, dermal atrophy, and loss of dermal collagen. A diagnosis of almost unilateral focal dermal hypoplasia was made on the basis of physical and histologic findings. Henceforth, the patient was referred to a plastic surgeon and an orthopedics department to repair her syndactyly.

Comorbidities in alopecia areata: A systematic review and meta-analysis

BACKGROUND Alopecia areata (AA) may be associated with various systemic diseases according to several studies. OBJECTIVE To identify prevalent and incident diseases in patients with AA and quantify their prevalence and odds and hazard ratios compared with those in controls without AA. METHODS A systematic review of the studies published before February 28, 2018, was performed by using the MEDLINE, Embase, Web of Science, and Cochrane Library databases. Observational studies on prevalent or incident diseases in patients with AA were included, whereas studies limited to pediatrics or providing only laboratory results or continuous data were excluded. The inverse variance method with a random-effects model was used for meta-analyses. RESULTS A total of 87 studies were analyzed. Atopic diseases, metabolic syndrome, Helicobacter pylori infection, lupus erythematosus, iron deficiency anemia, thyroid diseases, psychiatric diseases, vitamin D deficiency, and audiologic and ophthalmic abnormalities were more prevalent in patients with AA. Patients with AA had a higher risk of developing autoimmune diseases. LIMITATIONS Some diseases were investigated by an insufficient number of studies to be meta-analyzed. Meta-analysis of incident diseases was not performed owing to the limited availability of cohort studies. CONCLUSION AA is associated with various systemic and psychiatric diseases. Physicians are encouraged to evaluate and manage potential comorbid conditions to achieve better outcomes.

Liponeurofibroma: Clinicopathological features and histogenesis

A neurofibroma is a common cutaneous benign tumor of neural origin. Various histological variants have been reported. Recently, sporadic reports of fatty variants have been reported but their clinicopathological features have not been well studied. The purpose of this study was to examine liponeurofibroma, and to report the distinctive clinicopathological features and histogenesis in comparison with the classic form. A retrospective study was performed on 130 cases. Immunohistochemical staining was performed for S100, factor VIIIa, perilipin and vascular endothelial growth factor. Massons trichrome stain was also used. Intratumoral adipocytes were examined with transmission electron microscopy. Thirty‐two (24.6%) cases were classified as liponeurofibroma on microscopic examination. This variant was more common in patients with neurofibromatosis type 1, older age and female sex. The most prevalent location was the head and neck. Intratumoral fat deposits showed differences in morphology and size compared with subcutaneous fat on light microscopy. Neurofibromatosis type 1 had the highest odds of fatty change in liponeurofibroma. In sporadic cases, fatty change can be caused by senescence, chronic injury, or tissue hypoxia secondary to internal or external stimuli. Further investigation is needed to identify the pathomechanism of fatty change in various cutaneous neoplasms, including neurofibroma.

Variation in male sex hormone levels among the pattern subtypes of hair loss in patients with androgenetic alopecia

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