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1.  Survivin, p53, MAC, Complement/C3, fibrinogen and HLA-ABC within hair follicles in central and centrifugal cicatricial alopecia 
Context:
Central centrifugal cicatricial alopecia (CCCA; originally entitled follicular degeneration syndrome, or hot comb alopecia) was first described in African American women utilizing hot combs and/or strong chemical hair care products.
Case Report:
A 67 year old African American female was evaluated for the presence of alopecic areas occurring on the scalp vertex, and spreading centrifugally. The alopecic lesions appeared as diffuse patches, including atrophic small areas surrounding individual hair follicles.
Patients and Methods:
Skin biopsies for hematoxylin and eosin examination, as well as for direct immunofluorescence and immunohistochemistry analyses were performed.
Results:
hematoxylin and eosin staining demonstrated histopathologic findings of premature desquamation of the inner root sheath and eccentric thinning of the follicular epithelium, supporting the diagnosis of CCCA. Direct immunofluorescence revealed strong depositions of Complement/C3, fibrinogen and kappa light chains around the hair follicles. Immunohistochemistry demonstrated increased expressions of HLA-ABC (as in African American patients with insulin independent diabetes mellitus). We also detected positive p53, bcl-2 and MAC staining in the hair follicle areas.
Conclusions:
Follicular degeneration syndrome may have an important immunological component previously not described, and multicolor immunofluorescence may be useful in establishing an early diagnosis.
doi:10.4297/najms.2011.3292
PMCID: PMC3336922  PMID: 22540101
Central centrifugal cicatricial alopecia; follicular degeneration syndrome; hot comb alopecia; survivin; p53; bcl-2; MAC; HLA-ABC; complement/C3
2.  Primary Cicatricial Alopecias: A Review of Histopathologic Findings in 38 Patients from a Clinical University Hospital in Sao Paulo, Brazil 
Clinics (Sao Paulo, Brazil)  2008;63(6):747-752.
BACKGROUND
Scarring alopecias are classified into primary and secondary types according to the initial site of inflammation. In primary scarring alopecias, the hair follicle is the main target of destruction; the term secondary cicatricial alopecia implies that follicular destruction is not the primary pathologic event.
AIMS
To review the histopathologic diagnoses of cases of cicatricial alopecia in order to classify them according to the North American Hair Research Society.
PATIENTS AND METHODS
Patients with biopsy specimens diagnosed as cicatricial alopecia seen from 2000 to 2005 at the Dermatologic Department of Hospital das Clinicas, São Paulo University Medical School had hematoxylin and eosin, Periodic acid-Schiff and Weigert stained slides reevaluated and sub-typed into different primary cicatricial alopecias.
RESULTS
Thirty-eight cases of primary cicatricial alopecias were reclassified as: chronic cutaneous lupus (17), lichen planus pilaris (4), pseudopelade of Brocq (12), folliculitis decalvans (3), dissecting folliculitis (1), and non-specific scarring alopecia (1). In our cases, the methods employed allowed an accurate diagnosis in 12 of 13 cases (92.3%) previously classified as non-specific cicatricial alopecias.
CONCLUSIONS
Even in the late, pauci or non-inflammatory phases, an approach with systematic evaluation of a constellation of criteria in routine hematoxylin and eosin stain, Periodic acid-Schiff and Weigert stain allowed for a more accurate diagnosis of cicatricial alopecias.
doi:10.1590/S1807-59322008000600007
PMCID: PMC2664273  PMID: 19060995
Cutaneous lupus erythematosus; Lichen planus pilaris; Pseudopelade of Brocq; Folliculitis decalvans; Dissecting folliculitis
3.  The Spectrum of Histopathological Lesions in Scarring Alopecia: A Prospective Study 
Introduction: The aim of the article was to study the histopathological features of various lesions of Scarring Alopecia (SA) and to classify Primary SA on the basis of the predominant type of inflammatory cell component. Scarring or cicatricial alopecias are those that are produced as a result of the malformation, damage or destruction of the pilosebaceous follicles, which are replaced by cicatricial tissue, in such a way that they cannot again produce hair.
Material and Methods: This prospective study included 32 biopsy – proven cases of SA, who had attended our hospital. Primary SA was classified according to the North American Hair Research Society. The informed consents of the subjects and the institutional ethical clearance was obtained for the study. The SPSS, version 14 software was used to analyse the data. Frequencies and percentages were used to describe the data.
Results: During the study period, 32 cases of scarring alopecia were diagnosed, of which 24 were primary SA and 8 were secondary SA. Among the primary SA, there were 23 cases of lymphocyte associated primary scarring alopecias, of which, 19 of lupus erythematosus, 3 of lichen planopilaris (LPP) and one case of non specific SA. 1 case of neutrophil associated primary scarring (folliculitis decalvans) was also noted and among the secondary SA, there were 4 cases of morphea and 1 case each of lupus vulgaris, congenital absence of skin, burn and sarcoidosis.
Conclusion: To conclude, histopathology is a dependable tool for identifying the underlying cause in scarring alopecia, which is helpful for an early diagnosis and treatment.
doi:10.7860/JCDR/2013/5138.3131
PMCID: PMC3749638  PMID: 23998068
Scarring alopecia; Lupus erythematosus; A congenital absence of the skin
4.  Alopecia: evaluation and treatment 
Hair loss is a very common complaint. Patients may describe increased shedding and diffuse or localized alopecia. The differential diagnosis of hair loss includes a number of disorders causing cicatricial or noncicatricial alopecias. This paper describes the clinical approaches and diagnostic tests that are useful in the evaluation of patients presenting with alopecia. It also reviews treatments for noncicatricial alopecias, including androgenetic alopecia, alopecia areata, and telogen effluvium, as well as cicatricial alopecias, including lichen planopilaris, its clinical variant frontal fibrosing alopecia, and discoid lupus erythematosus.
doi:10.2147/CCID.S10182
PMCID: PMC3149477  PMID: 21833160
alopecia; evaluation; treatment
5.  PSYCHOSOCIAL IMPACT OF CICATRICIAL ALOPECIAS 
Indian Journal of Dermatology  2011;56(6):684-688.
Background:
Cicatricial alopecias have a significant impact on the psychological status, quality of life, and social interaction of those suffering from it. Till date, limited or no data have been available regarding the psychosocial and quality of life aspects of cicatricial alopecias.
Aims:
To assess the psychosocial impact of cicatricial alopecias.
Materials and Methods:
Thirty patients fulfilling the criteria for cicatricial alopecia irrespective of their age and sex were included in the study. Psychosocial assessment was carried out in 23 patients who were capable of responding to the questionnaire, using an adopted and suitably modified version of Women's Androgenetic Alopecia Quality of Life Questionnaire.
Results:
We observed that 73.9% of our patients with cicatricial alopecias had moderate to severe psychosocial impact due to their hair loss. Patients of younger age group and with inactive disease, suffered from greater psychosocial impact of the disease. Patients with slight hair loss also had considerable psychological distress. The chronicity of disease duration did not seem to reduce the psychosocial impact of the disease. Both married and unmarried patients suffered equally from the psychosocial impact of the disease.
Conclusion:
The management of cicatricial alopecias needs a holistic approach. In addition to laying an emphasis on early diagnosis aided by clinco-pathological correlation, to prevent irreversible hair loss, the psychosocial impact of the disease should also be taken into consideration and addressed by the treating dermatologist.
doi:10.4103/0019-5154.91829
PMCID: PMC3276897  PMID: 22345771
Cicatricial alopecias; modified women's androgenetic alopecia quality of life questionnaire; psychosocial impact
6.  Trichoscopy update 2011 
Trichoscopy performed with a handheld dermoscope or a videodermoscope became an indispensable tool in differential diagnosis of hair and scalp diseases. Current research is focusing on trichoscopy of: 1) non-cicatricial alopecia, 2) cicatricial alopecia, 3) hair shaft disorders, and 4) inflammatory scalp diseases. This review summarizes current knowledge in these four fields of research. In all non-cicatricial alopecias presence of empty follicular openings is a common trichoscopy finding. In alopecia areata black dots and micro-exclamation mark hairs and tapered hairs correlate with disease activity, whereas yellow dots and vellus hairs correlate with disease severity. In androgenic alopecia trichoscopy shows hair shaft thickness heterogeneity, multiple thin and vellus hairs, yellow dots, perifollicular discoloration, and predominance of follicular units with only one hair. These features predominate in the frontal area. In all forms of cicatricial alopecia, trichoscopy shows milky-red or ivory-white areas lacking follicular openings. In classic lichen planopilaris trichoscopy shows perifollicular inflammation, tubular perifollicular scaling, elongated, concentric blood vessels and "classic white dots", which merge to form white areas. Frontal fibrosing alopecia shows mild perifollicular scaling. Folliculitis decalvans is characterized by tufted hairs, large follicular pustules with emerging hair shafts and perifollicular starburst pattern hyperplasia. In dissecting cellulitis characteristic findings are "3D" yellow dots imposed over dystrophic hairs, large, yellow amorphous areas and pinpoint white dots with a whitish halo. Trichoscopy is particularly useful to diagnose hair shaft abnormalities in trichorrhexis nodosa, trichorrhexis invaginata, monilethrix, pili torti, and pili annulati. The method may be also useful in diagnosing inflammatory scalp diseases. In discoid lupus erythematosus trichoscopy shows large arborizing vessels and large hyperkeratotic folliculilar yellow dots. Trichoscopy of scalp psoriasis shows regularly distributed twisted and lacelike blood vessels, whereas in seborroic dermatitis thin arborizing vessels may be observed. In tinea capitis trichoscopy shows comma, corkscrew and zigzag hairs. Examination tinea capitis may be facilitated by UV-light enhanced trichoscopy (UVET). In conclusion, trichoscopy is a non-invasive method which may be applied in differential diagnosis of most hair and scalp diseases.
doi:10.3315/jdcr.2011.1083
PMCID: PMC3241952  PMID: 22408709
alopecia; dermoscopy; hair; psoriasis; lichen planopilaris; lupus; seborheic dermatitis; trichoscopy; UV; videodermoscopy
7.  Dermoscopy findings of alopecia areata in an African-American patient 
Background
Dermoscopy has been established as an indispensable tool in the diagnosis and follow up of hair disorders. In alopecia areata, dermoscopy of active disease shows yellow dots, dystrophic hairs, as well as cadaverized (black dots) and exclamation mark hairs. Alopecia areata has been reported to occur equally among races, however, until date, there are no published data regarding dermoscopic findings in African-American patient.
Main observation
We report a case of scalp dermoscopy of alopecia areata in an African-American patient that shows a diffuse honeycomb-like pigmented network, few yellow dots and white dots.
Conclusion
This case shows that skin color may affect dermoscopic findings in alopecia areata. In our African-American patient with alopecia areata dermoscopy showed a diffuse honeycomb-like pigmented network, which was previously considered characteristic for androgenic alopecia and white dots, which were considered characteristic for cicatricial alopecia. Further studies are needed to elucidate the presence of white dots in alopecia areata.
doi:10.3315/jdcr.2008.1020
PMCID: PMC3157783  PMID: 21886714
alopecia areata; dark skin; epiluminescence microscopy; hair loss; pigmented network; scalp; trichoscopy
8.  Surgical treatment of secondary cicatricial alopecia of scalp and eyebrow 
Secondary cicatricial alopecia occurs as a result of destruction of hair follicles by scar tissue formed in the scalp and eyebrows. It is a permanent condition and regrowth of hairs in the area is not expected. The purpose of the study was to select the appropriate method for treating cicatricial alopecia. 24 patients were admitted to our hospital during the period from June 2006 to July 2007. They were suffering from acquired cicatricial alopecia affecting the scalp and the eyebrow. Their ages ranged from 6-48 years with mean age 26-25 years. They were treated surgically by total excision of the lesions with direct closure of the defect in ten cases, excision of alopecia with advancement flaps with the aid of scalp expanders in seven cases, scalp reduction through serial excision of alopecia in three cases and excision of alopecia and reconstruction of the defect by strip composite hair-bearing scalp grafts in four cases. Our results suggest there are three key factors that decide the surgical methods for treating alopecia: size, location and shape. We also discuss and evaluate the various techniques of reconstruction. Good results were obtained in 18 patients.
doi:10.4103/0970-0358.53014
PMCID: PMC2772292  PMID: 19881023
Alopecia; Secondary cicatricial; Scalp defects
9.  Trichoscopy in Alopecias: Diagnosis Simplified 
Trichoscopy is the term coined for dermoscopic imaging of the scalp and hair. This novel diagnostic technique, both simple and non-invasive, can be used as a handy bed side tool for diagnosing common hair and scalp disorders. Trichoscopic observations can be broadly grouped as hair signs, vascular patterns, pigment patterns and interfollicular patterns. In this article, we have briefly described the trichoscopic findings in the common categories of cicatricial and non-cicatricial alopecias such as androgenetic alopecia, alopecia areata, telogen effluvium, tinea capitis, trichotillomania, lichen planopilaris, discoid lupus erythematosus and hair shaft disorders. Besides diagnosing alopecia, it has the potential for obviating unnecessary biopsies and when a biopsy is still needed it is helpful in choosing an ideal biopsy site. Moreover, trichoscopy is a valuable tool for evaluating the treatment response photographically at each follow-up. The last statement here is deleted as asked.
doi:10.4103/0974-7753.130385
PMCID: PMC3999645  PMID: 24778525
Alopecia areata; androgenetic alopecia; dermoscopy; diagnosis; discoid lupus erythematosus; lichen planopilaris; telogen effluvium; tinea capitis; trichoscopy; trichotillomania
10.  Practical management of hair loss. 
Canadian Family Physician  2000;46:1469-1477.
OBJECTIVE: To describe an organized diagnostic approach for both nonscarring and scarring alopecias to help family physicians establish an accurate in-office diagnosis. To explain when ancillary laboratory workup is necessary to confirm the diagnosis. QUALITY OF EVIDENCE: Current diagnostic and therapeutic interventions for hair loss are based on randomized controlled studies, uncontrolled studies, and case series. MEDLINE was searched from January 1966 to December 1998 with the MeSH words alopecia, hair, and alopecia areata. Articles were selected on the basis of experimental design, with priority given to the most current large multicentre controlled studies. Overall global evidence for therapeutic intervention for hair loss is quite strong. MAIN MESSAGE: The most common forms of nonscarring alopecias are androgenic alopecia, telogen effluvium, and alopecia areata. Other disorders include trichotillomania, traction alopecia, tinea capitis, and hair shaft abnormalities. Scarring alopecia is caused by trauma, infections, discoid lupus erythematosus, or lichen planus. Key to establishing an accurate diagnosis is a detailed history, including medication use, systemic illnesses, endocrine dysfunction, hair-care practices, and family history. All hair-bearing sites should be examined. A 4-mm punch biopsy of the scalp is useful, particularly to diagnose scarring alopecias. Once a diagnosis has been established, specific therapy can be initiated. CONCLUSIONS: Diagnosis and management of hair loss is an interesting challenge for family physicians. An organized approach to recognizing characteristic differential features of hair loss disorders is key to diagnosis and management.
Images
PMCID: PMC2144852  PMID: 10925761
11.  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.
doi:10.5812/ijem.9860
PMCID: PMC3968982  PMID: 24719635
Polycystic Ovary Syndrome; Minoxidil; Female; Alopecia, Therapy; Alopecia, physiopathology; Androgen antagonist, Therapeutic Use
12.  Primary Idiopathic Pseudopelade of Brocq: Five Case Reports 
Pseudopelade of Brocq (PPB) is a rare, idiopathic self-limiting hair disorder resulting in progressive cicatricial alopecia primarily involving the parietal scalp and vertex. The general pathogenesis of scarring alopecias has been focused on theories of stem cell failure and sebaceous gland destruction. Acquired immunity, Borrelia infection and senescence of follicular stem cell reservoir plays suspected role. It classically presents as porcelain white hypopigmented and slightly depressed atrophic plaque. There is no standard treatment for PPB. Here, we present five cases which were labeled as primary idiopathic PPB, as on histopathology no specific changes of any cicatricial alopecia were seen.
doi:10.4103/0974-7753.136759
PMCID: PMC4124692  PMID: 25114452
Alopecia; foot print in snow; pseudopelade of Brocq
13.  Central centrifugal cicatricial alopecia severity is associated with cowhage-induced itch 
The British journal of dermatology  2013;168(2):253-256.
Summary
Background
Patients with central centrifugal cicatricial alopecia (CCCA) often suffer from varying degrees of itch, pain and burning sensations. However, the neural component of these skin sensations has not been assessed.
Objective
To conduct a comprehensive analysis of C nerve fibre function relating to itch and pain perception in patients with CCCA using thermosensory testing and experimental itch models.
Methods
Fifteen healthy African-American women and 16 African-American female patients with CCCA participated in the study and underwent quantitative computerized thermosensory testing to assess warmth and heat pain thresholds. Itch was induced using histamine iontophoresis and application of cowhage spicules, and the intensity of each itch was assessed. The association between itch intensity and CCCA severity score was examined.
Results
A positive correlation between CCCA severity score and peak itch ratings of cowhage on the lesional scalp (crown) was observed (P = 0·023, r = 0·562). Notably, the histamine peak itch rating was not found to have a significant correlation with CCCA severity score (P = 0·913). The crown also had significantly higher warmth and pain thresholds than the occiput in both healthy subjects and patients with CCCA.
Conclusions
Our results suggest a putative role for the protease-activated receptor (PAR)-2, which is activated by cowhage, in the pathogenesis of CCCA. Future studies should examine PAR-2-directed therapeutics for patients with CCCA. Examining for itch and other dysaesthesias in patients with CCCA is of vital importance to dermatologists in assessing disease severity.
doi:10.1111/bjd.12043
PMCID: PMC3659809  PMID: 22985403
14.  OA01.42. Evaluation of Therapeutic Efficacy of Ayurvedic Formulations in Patients with Alopecia areata 
Ancient Science of Life  2012;32(Suppl 1):S42.
Purpose:
Alopecia aerata is one among the most prevalent human autoimmune diseases, leading to disfiguring hair loss by the collapse of immune privilege in the hair follicle and subsequent autoimmune attack. Generally, hair loss in patches signifies alopecia areata. It typically presents a gradual or sudden loss of hair in head, eyebrows, eyelashes, nasal, ear and other areas of the body causing patches to appear. Alopecia areata or hair loss occurs in one in 1,000 people. Autoimmune-associated alopecia areata has no age boundaries and can affect even children, men and women equally. If left untreated, or if the disease does not respond to treatment, complete baldness can result in the affected area. The two major forms of Alopecia are scarring and non scarring. Highlighting the significance, a study was carried out to evaluate the therapeutic efficacy of Ayurvedic formulations in patients with Alopecia Areata.
Method:
Fifteen alopecia areata patients of either sex with varying degrees of hair loss were randomly selected for the clinical trial and were treated with Indralupta Bhasma, Malathyadi Tailam and Guduchi tablet for a period of 3-5 months. Subsequently, most of them were observed bi monthly up to a 5 months period.
Result:
Findings revealed that 8 of the15 patients with patchy progressive hair loss stabilised and showed no additional hair loss. After 3-5 months of treatment hair growth in these patients were partial or full. Of the other 7 patients with stable patchy total hair loss, four had some limited growth, two patients displayed complete growth of eyebrows and eyelashes, but had poor hair growth on scalp while one patient did not show any response.
Conclusion:
The study vividly indicated the efficacy of Ayurvedic formulations in patients with Alopecia Areata. The trial medicines too proved to be effective minimizing the patchy hair loss.
PMCID: PMC3800921
15.  Retinoid metabolism is altered in human and mouse cicatricial alopecia 
C57BL/6 mice develop dermatitis and scarring alopecia resembling human cicatricial alopecias (CA), particularly the central centrifugal cicatricial alopecia (CCCA) type. To evaluate the role of retinoids in CA, expression of retinoid metabolism components were examined in these mice with mild, moderate, or severe CA compared to hair cycle matched mice with no disease. Two feeding studies were performed with dams fed either NIH 31 diet (study 1) or AIN93G diet (study 2). Adult mice were fed AIN93M diet with 4 (recommended), 28, or 56 IU vitamin A/g diet. Feeding the AIN93M diet to adults increased CA frequency over NIH 31 fed mice. Increased follicular dystrophy was seen in study 1 and increased dermal scars in study 2 in mice fed the 28 IU diet. These results indicate that retinoid metabolism is altered in CA in C57BL/6J mice that require precise levels of dietary vitamin A. Human patients with CCCA, pseudopelade (end stage scarring), and controls with no alopecia were also studied. Many retinoid metabolism proteins were increased in mild CCCA, but were undetectable in pseudopelade. Studies to determine if these dietary alterations in retinoid metabolism seen in C57BL/6J mice are also involved in different types of human CA are needed.
doi:10.1038/jid.2012.393
PMCID: PMC3546159  PMID: 23096705
16.  Assessment of the usefulness of dihydrotestosterone in the diagnostics of patients with androgenetic alopecia 
Introduction
Androgenetic alopecia (AGA) is the most common form of hair loss. Clinically observed hair loss is due to the continuous miniaturization of affected hair follicles. Genetic factors and androgenic factors especially dihydrotestosterone (DHT), which is a testosterone tissue metabolite, play major roles in the pathogenesis of AGA. However, expert opinions about the usefulness of DHT in the diagnosis of this type of alopecia are divided.
Aim
To evaluate the usefulness of DHT level in patients with androgenetic alopecia compared with the control group.
Material and methods
The study comprised 49 subjects: 19 women and 9 men with androgenetic alopecia. The control group consisted of 17 healthy women and 4 men without hair loss.
Results
Increased serum concentrations of DHT were observed in patients with androgenetic alopecia (17 women, 5 men), but also in the control group. The differences in mean values of DHT were not significant according to the types of alopecia and the control group. Increased serum concentrations of DHT were not correlated with the advance of alopecia.
Conclusions
Dihydrotestosterone is the most influential androgen and seems to play a very important role in the pathogenesis of androgenetic alopecia. Based on the results of our study and others, the most important factors would appear to be the genetically-determined sensitivity of the follicles to DHT and their different reactions to androgen concentration.
doi:10.5114/pdia.2014.40925
PMCID: PMC4171668  PMID: 25254005
androgenetic alopecia; dihydrotestosterone; diagnostic
17.  Topical Melatonin for Treatment of Androgenetic Alopecia 
Background:
In the search for alternative agents to oral finasteride and topical minoxidil for the treatment of androgenetic alopecia (AGA), melatonin, a potent antioxidant and growth modulator, was identified as a promising candidate based on in vitro and in vivo studies.
Materials and Methods:
One pharmacodynamic study on topical application of melatonin and four clinical pre-post studies were performed in patients with androgenetic alopecia or general hair loss and evaluated by standardised questionnaires, TrichoScan, 60-second hair count test and hair pull test.
Results:
Five clinical studies showed positive effects of a topical melatonin solution in the treatment of AGA in men and women while showing good tolerability: (1) Pharmacodynamics under once-daily topical application in the evening showed no significant influence on endogenous serum melatonin levels. (2) An observational study involving 30 men and women showed a significant reduction in the degree of severity of alopecia after 30 and 90 days (P < 0.001) based on questionnaires completed by investigators and patients. (3) Using a digital software-supported epiluminescence technique (TrichoScan) in 35 men with AGA, after 3 and 6 months in 54.8% to 58.1% of the patients a significant increase of hair density of 29% and 41%, respectively was measured (M0: 123/cm2; M3: 159/cm2; M6: 173/cm2;) (P < 0,001). (4) In 60 men and women with hair loss, a significant reduction in hair loss was observed in women, while hair loss in men remained constant (P < 0.001). (5) In a large, 3-month, multi-center study with more than 1800 volunteers at 200 centers, the percentage of patients with a 2- to 3-fold positive hair-pull test decreased from 61.6% to 7.8%, while the percentage of patients with a negative hair-pull test increased from 12.2.% to 61.5% (P < 0.001). In addition, a decrease in seborrhea and seborrheic dermatitis of the scalp was observed.
Conclusions:
Since safety and tolerability in all of the studies was good, the topical application of a cosmetic melatonin solution can be considered as a treatment option in androgenetic alopecia.
doi:10.4103/0974-7753.111199
PMCID: PMC3681103  PMID: 23766606
Androgenetic alopecia; melatonin; seborrhea; seborrheic dermatitis
18.  Central centrifugal cicatricial alopecia 
Central centrifugal cicatricial alopecia is a common cause of progressive permanent apical alopecia. This unique form of alopecia includes entities previously know as “hot comb alopecia,” “follicular degeneration syndrome,” “pseudopelade” in African Americans and “central elliptical pseudopelade” in Caucasians. The etiology appears to be multifactorial and the condition occurs in all races.
doi:10.4103/2229-5178.105484
PMCID: PMC3573455  PMID: 23440368
Alopecia; central; centrifugal; cicatricial; pseudopelade
19.  Frontal Fibrosing Alopecia: Role of Dermoscopy in Differential Diagnosis 
Case Reports in Dermatology  2010;2(1):40-45.
Frontal fibrosing alopecia (FFA) is more common in postmenopausal women, but it can occur in younger women. Some authors consider FFA to be a distinct frontal variant of lichen planopilaris. From a clinical point of view, this relatively uncommon condition is characterized by progressive frontotemporal recession due to inflammatory destruction of hair follicles. Dermoscopy can be very useful, as the differential diagnosis between traction alopecia, alopecia areata, FFA and cicatricial marginal alopecia may be difficult. It is not clear whether or not treatment alters the natural history of the disease - the disease stabilized with time in most of the patients with or without continuing treatment. Here we report a case of a 50-year-old woman with FFA and discuss the relevance of dermoscopy in the differential diagnosis of this disease.
doi:10.1159/000298283
PMCID: PMC3004211  PMID: 21173926
Alopecia; Dermoscopy; Menopausal; Lichen planopilaris
20.  FOLLICULITIS ET PERIFOLLICULITIS CAPITIS ABSCEDENS ET SUFFODIENS CONTROLLED WITH A COMBINATION THERAPY: SYSTEMIC ANTIBIOSIS (METRONIDAZOLE PLUS CLINDAMYCIN), DERMATOSURGICAL APPROACH, AND HIGH-DOSE ISOTRETINOIN 
Indian Journal of Dermatology  2011;56(3):318-320.
Folliculitis et perifolliculitis capitis abscedens et suffodiens is a rare disease of unknown etiology. It is a suppurative process that involves the scalp, eventually resulting in extensive scarring and irreversible alopecia. The condition is also known as ‘acne necrotica miliaris’ or ‘Proprionibacterium’ folliculitis. Most often the disease affects men of African-American or African-Caribbean descent between 20 and 40 years of age. The clinical picture is determined by fluctuating painful fistule-forming conglomerates of abscesses in the region of the occipital scalp. The cause of scalp folliculitis is not well understood. It is generally considered to be an inflammatory reaction to components of the hair follicle, particularly the micro-organisms. These include: bacteria (especially Propionibacterium acnes, but in severe cases, also Staphylococcus aureus), Yeasts (Malassezia species) and mites (Demodex folliculorum). The initial histopathologic finding is an exclusively neutrophilic infiltration followed by a granulomatous infiltrate. The treatment of the disease is usually difficult and often disappointing. Successful treatment with isotretinoin 1 mg/kg body mass could be achieved only after regular systematic administration in the course of 3–4 months. Here we describe a patient with eruptive purulent form of the disease, which has been controlled with combination therapy: systemic antibiosis with metronidazole and clindamycin, dermatosurgical removal of single nodular formations, and isotretinoin 1 mg/kg body mass for 3–5 months.
doi:10.4103/0019-5154.82492
PMCID: PMC3132914  PMID: 21772598
Acne conglobata; Candida; isotretinoin; Spritzer; Hoffmann
21.  Dermoscopic Findings in Scalp Psoriasis and Seborrheic Dermatitis; Two New Signs; Signet Ring Vessel and Hidden Hair 
Indian Journal of Dermatology  2015;60(1):41-45.
Background:
Psoriasis and seborrheic dermatitis are both chronic erythemato-squamous dermatoses that can involve the scalp. It may be difficult to differentiate these two diseases when there is isolated scalp involvement. Recently, trichoscopy is commonly used to differentiate noncicatricial alopecias including psoriasis and seborrheic dermatitis that can lead to telogen effluvium (TE).
Objectives:
The objective of this study is to evaluate the trichoscopic figures that may help to differentiate scalp psoriasis and seborrheic dermatitis.
Materials and Methods:
Thirty one with scalp psoriasis and 112 patients with seborrheic dermatitis were enrolled. Trichoscopic examinations were performed using a videodermatoscope (MoleMax 3®). Trichoscopic findings of scalp psoriasis and seborrheic dermatitis were compared with each other, with 100 healthy individuals and with other noncicatricial alopecias including female androgenetic alopecia (FAGA) (n: 138), male androgenetic alopecia (n: 63), FAGA of male pattern (FAGA.M) (n: 5), alopecia areata (39), TE (n: 22) and trichotillomania (n: 4).
Results:
Atypical red vessels, red dots and globules (RDG), signet ring vessels (SRV), structureless red areas and hidden hairs (HH) were statistically more common in psoriasis while twisted red loops and comma vessels (CV) in seborrheic dermatitis. RDG were considered as the characteristic videodermatoscopic figure for psoriasis and arborizing red lines and CV for seborrheic dermatitis. In comparison with previous reports, our study yielded two new trichoscopic structures supporting the diagnosis of psoriasis; HH and SRV. Besides, according to our study, CV were described for the first time in seborrheic dermatitis and considered to be specific for seborrheic dermatitis.
Conclusion:
This study confirmed that trichoscopy might be useful in differentiating scalp psoriasis and seborrheic dermatitis from each other and from other noncicatricial alopecia with three trichoscopic structures as HH, SRV and CV.
doi:10.4103/0019-5154.147786
PMCID: PMC4318061  PMID: 25657395
Dermatoscopy; dermoscopy; psoriasis; seborrheic dermatitis; trichoscopy
22.  Hair Follicle Stem Cell-Specific PPARγ Deletion Causes Scarring Alopecia 
Primary cicatricial or scarring alopecias (CA) are a group of inflammatory hair disorders of unknown pathogenesis characterized by the permanent destruction of the hair follicle. The current treatment options are ineffective in controlling disease progression largely because the molecular basis for CA is not understood. Microarray analysis of the lymphocytic CA, Lichen planopilaris (LPP), compared to normal scalp biopsies identified decreased expression of genes required for lipid metabolism and peroxisome biogenesis. Immunohistochemical analysis showed progressive loss of peroxisomes, proinflammatory lipid accumulation, and infiltration of inflammatory cells followed by destruction of the pilosebaceous unit. The expression of peroxisome proliferator-activated receptor (PPAR) γ, a transcription factor that regulates these processes, is significantly decreased in LPP. Specific agonists of PPARγ are effective in inducing peroxisomal and lipid metabolic gene expression in human keratinocytes. Finally, targeted deletion of PPARγ in follicular stem cells in mice causes a skin and hair phenotype that emulates scarring alopecia. These studies suggest that PPARγ is crucial for healthy pilosebaceous units and it is the loss of this function that triggers the pathogenesis of LPP. We propose that PPARγ-targeted therapy may represent a new strategy in the treatment of these disorders.
doi:10.1038/jid.2008.369
PMCID: PMC3130601  PMID: 19052558
23.  Congenital Lipedematous Alopecia: Adding to the Differential Diagnosis of Congenital Alopecia 
Annals of Dermatology  2015;27(1):87-89.
Lipedematous alopecia is a rare condition of unknown etiology characterized by a thick boggy scalp with varying degrees of hair loss. It is usually seen in adult African-American females, and a case in a 9-year-old was the youngest patient reported thus far. We report on the appearance of this condition in two children, a 6-year-old child and a 10-year-old child. Each presented with congenital patchy hair loss on the occipital area and the left temple. A boggy hairless scalp with soft swelling was detected in both patients. Histological examination showed increased thickness of the subcutaneous fat tissue with a decrease in hair follicles. These features were consistent with a diagnosis of lipedematous alopecia. We report two cases of congenital lipedematous alopecia, which has not been reported previously. Although congenital, these distinct clinical features should be kept in mind in the diagnosis of alopecic hair loss.
doi:10.5021/ad.2015.27.1.87
PMCID: PMC4323610
Alopecia; Congenital; Edema; Scalp; Subcutaneous fat
24.  NONCICATRIZING ALOPECIAS—With Special Reference to Alopecia Areata 
California Medicine  1958;89(5):322-330.
Since the epochal work of Hamilton there has been general acceptance of the causal relationship of the male sex hormone, age and familial inheritance in development of male pattern baldness.
Some of the medicaments used in recent years may cause a diffuse loss of scalp hair. Alopecia that accompanies disease states is probably due to generalized toxemia and disturbances in metabolism. Sometimes male pattern baldness occurs in physiologic states, as exemplified by diffuse hair loss occasionally in the postpartum period.
Alopecia areata deserves a critical appraisal, since it may be evidence of underlying neuropsychotic states that need psychiatric diagnosis and treatment. The development of alopecia totalis or universalis in 50 per cent of the prepuberal cases of alopecia areata is of real significance, especially since so very few patients recover their normal scalp hair.
The conclusions reached by the authors of two articles reporting on 368 cases of alopecia areata, alopecia totalis and alopecia universalis that the evidence is overwhelming against the malfunction of the endocrine glands as the cause of alopecia areata must be considered real contributions to our understanding of this condition.
A few conditions simulate alopecia areata. Probably the ones which are seen most often are trichotillomania and patchy baldness caused by agents used in hair waving and straightening.
Our findings in 22 cases of alopecia areata of a persistent inflammatory perivascular and perifollicular infiltrate, massive plugging of the ostia, disappearance of robust hair follicles and diminution in total number of hair follicles and sometimes fibrosis are not necessarily diagnostic of alopecia areata but seem to be very definitely characteristic.
Treatment for alopecia areata is of little avail. At this time we do not recommend the general use of the corticosteroids despite the improvement of scalp appearance in the majority of instances in which the systemic administration of these hormones have been employed.
Images
PMCID: PMC1512506  PMID: 13585156
25.  Lichen Planopilaris Treated With a Peroxisome Proliferator—Activated Receptor γ Agonist 
Archives of dermatology  2009;145(12):1363-1366.
Primary cicatricial alopecias (PCAs), rare disorders that lead to permanent hair loss, have been poorly understood and are difficult to treat. Lichen planopilaris (LPP) is a prototypical PCA; patients often present with sudden onset of hair loss and clinically significant symptoms of itching, burning, and pain of the scalp. Examination reveals patchy alopecia or a more diffuse thinning of the scalp with characteristic perifollicular erythema and perifollicular scale at the margins of the areas of alopecia. Treatment typically includes use of anti-inflammatory medications; although symptomsmay improve, hair loss is often progressive.
doi:10.1001/archdermatol.2009.283
PMCID: PMC2937154  PMID: 20026843

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