Hair disorders

Hair loss in women: From diagnosis to treatment

Rui Oliveira Soares (Portugal)

Women’s hair loss is frequent and, in many cases, quality of life is highly impaired. Trichoscopy is the most useful tool for a quick diagnosis; it helps to distinguish between cicatricial and non-cicatricial alopecia by detecting presence or absence of follicular openings.

Anisotriquia (hairs with different thickness) is considered the hallmark of androgenetic alopecia (AGA), the most common form of hair loss in women.

In most countries, the only approved treatment for female androgenetic alopecia (FAGA) is topical minoxidil. Unfortunately, this approach is not enough to achieve results in many patients. Thus, the use of oral minoxidil (0,25-1,5mg/day), anti-androgens (finasteride, dutasteride, flutamide, bicalutamide) and spironolactone (diuretic with anti-androgen action) are very common worldwide.

The use of PRP, micro-needling and lasers for the treatment of FAGA is also common. However, these treatments are very expensive in the long-term and the results are disappointing when compared with the pharmacological approach. In fact, they could be considered as complementary treatments.

Management of chronic folliculitis of the scalp

Ralph Trüeb (Switzerland)

Scalp folliculitis is an inflammatory disorder of the hair follicles in the scalp that is characterized by usually small, very itchy pustules, often most troublesome on the marginal hairline. There may be only a small number of lesions, or numerous, that are hard to leave alone due to itch, often becoming sore and crusted.

The cause of scalp folliculitis is heterogeneous. It is generally considered to be an inflammatory reaction to components of the hair follicle, particularly the micro-organisms, either commensal or pathogenic. These include: bacteria, especially Cutibacterium acnes, but in severe cases, also Staphylococcus aureus and gram-negative bacteria, yeasts (Malassezia species), and mites (Demodex folliculorum).

Superficial folliculitis of the scalp or ostiofolliculitis is a common type of scalp folliculitis that is marked by itchy, white, pus-filled bumps. It occurs when hair follicles become infected with bacteria, usually Staphylococcus aureus. Gram-negative folliculitis sometimes develops in patients receiving long-term antibiotic therapy.

Acne necrotica is a more severe form of scalp folliculitis also known as acne varioliformis. Larger follicular papules become inflamed, then develop blackened crusts, finally leaving permanent pox-like scars.

Folliculitis decalvans is a chronic and recurrent condition that usually presents in the central scalp area with crusted areas and grouped follicular pustules at the hair-bearing margin and centrifugal progression resulting in scarring alopecia. Invariably, pathogenic strains of Staph. aureus can be detected.

Treatment of scalp folliculitis depends on the nosology and severity of the condition. The scalp affected by folliculitis should be washed with a mild normal shampoo as often as desired. Antidandruff shampoos containing antifungal agents such as ketoconazole or ciclopirox are sometimes helpful. Medications include: topical antibiotics (e.g. fusidic acid creme, clindamycin solution, or erythromycin solution), topical steroid lotions or creams, oral antibiotics and oral isotretinoin. Subcutaneous adalimumab may be effective in refractory cases of dissecting cellulitis of the scalp. Scalp reduction surgery with expander may be performed with success in widespread folliculitis decalvans with scarring.

Alopecia areata: JAK inhibitors and beyond

Julien Seneschal (France)

Alopecia Areata is an acquired, chronic, non-scarring hair disorder, affecting 0.5-2% of the general population worldwide. Multiple mechanisms are involved in the disease, namely genetic predisposition, environmental triggers, impaired hair growth, and altered inflammatory and immune responses.

Recent progress in the understanding of immune patho-mechanisms opens interesting perspectives for innovative treatment strategies. Several strategies have been tested with controversial results. However, the proof of concept in humans of targeting the IFNγ /Th1 pathway and the JAK signaling pathway led to the development of several topical and oral JAK inhibitors in this disease with high unmet needs.

This review covers novel immune mechanisms of the disease and promising therapeutic approaches including JAK inhibitors and other immunomodulating agents already tested in clinical trials and/or under development.

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