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Background: Folliculitis decalvans (FD) is a rare primary neutrophilic scarring alopecia whose etiology has not been completely elucidated yet. Objective: To determine if the follicular microbiota residing in FD-affected hair follicles had a distinct microbiological signature and if an aberrant immune response was present in the pathogenesis of FD. Methods: We conducted a cross-sectional study of ten patients affected by FD. Trichoscopy-guided follicular biopsies were taken from affected and healthy scalp to identify the follicular microbiome using next-generation sequencing. We searched for microbiological biomarkers of FD-affected follicles using the linear discriminant analysis (LDA) effect size (LEfSe) tool. Additionally, peripheral blood mononuclear cells were obtained, and their cytokine production was quantified after incubation with pathogen-associated molecular patterns isolated from patients’ biopsies and compared with healthy controls. Results: β-diversity analysis showed statistically significant differences regarding bacteria comparing follicular microbiota of healthy and FD-affected hairs. Ruminococcaceae, Agathobacter sp., Tyzzerella sp. and Bacteriodales vadin HA21 family were good predictors of disease status. IL-10, TNF-α and IL-6 levels were significantly decreased in patients after incubation with various strains of bacteria compared with controls. Conclusion: FD hair follicles have a specific heterogenous follicular bacterial microbiota signature. Additionally, these patients seem to have an impaired immunological response.

Background Frontal fibrosing alopecia (FFA) has become one of the most common causes of cicatricial alopecia worldwide. However, there is a lack of clear aetiology and robust clinical trial evidence for the efficacy and safety of agents currently used for treatment. Objectives To enable data to be collected worldwide on FFA using common criteria and assessment methods. Methods A multicentre, international group of experts in hair loss was convened by email to create consensus recommendations for clinical trials. Consensus was defined at > 90% agreement on each recommended part of these guidelines. Results Standardized diagnostic criteria, severity rating, staging, and investigator and patient assessment of scalp hair loss and other clinical features of FFA were created. Conclusions These guidelines should allow the collection of reliable aggregate data on FFA and advance efforts in both clinical and basic research to close knowledge gaps in this condition.

It is estimated that chemotherapy-induced alopecia (CIA) occurs in 65% of chemotherapeutic patients. Forty-seven percent of cancer patients consider hair loss to be the most traumatic aspect of therapy. CIA can be anticipated, depending on the regimen used, and doctors should be aware of the treatments that can minimize it. Careful evaluation before chemotherapy treatment should be performed, and trichoscopy may be useful. Dermatologists do not generally evaluate postchemotherapy alopecia. However, there is an increasing number of reports of permanent chemotherapy-induced alopecia, and these patients require treatment.

Background The major concern regarding the use of low-dose oral minoxidil (LDOM) for the treatment of hair loss is the potential risk of systemic adverse effects. Objective To describe the safety of LDOM for the treatment of hair loss in a large cohort of patients. Methods Retrospective multicenter study of patients treated with LDOM for at least 3 months for any type of alopecia. Results A total of 1404 patients (943 women [67.2%] and 461 men [32.8%]) with a mean age of 43 years (range 8-86) were included. The dose of LDOM was titrated in 1065 patients, allowing the analysis of 2469 different cases. The most frequent adverse effect was hypertrichosis (15.1%), which led to treatment withdrawal in 14 patients (0.5%). Systemic adverse effects included lightheadedness (1.7%), fluid retention (1.3%), tachycardia (0.9%), headache (0.4%), periorbital edema (0.3%), and insomnia (0.2%), leading to drug discontinuation in 29 patients (1.2%). No life-threatening adverse effects were observed. Limitations Retrospective design and lack of a control group. Conclusion LDOM has a good safety profile as a treatment for hair loss. Systemic adverse effects were infrequent and only 1.7% of patients discontinued treatment owing to adverse effects.

Background Dutasteride has been proposed as an effective therapy for frontal fibrosing alopecia (FFA). Objectives We sought to describe the therapeutic response to dutasteride and the most effective dosage in FFA compared with other therapeutic options or no treatment. Methods This was a retrospective observational study including patients with FFA with a minimum follow-up of 12 months. Therapeutic response was evaluated according to the stabilization of the hairline recession. Results A total of 224 patients (222 females) with a median follow-up of 24 months (range 12-108 months) were included. The stabilization rate for the frontal, right, and left temporal regions after 12 months was 62%, 64%, and 62% in the dutasteride group (n = 148), 60%, 35%, and 35% with other systemic therapies (n = 20), and 30%, 41%, and 38% without systemic treatment (n = 56; P = .000, .006, and .006, respectively). Stabilization showed a statistically significant association with an increasing dose of dutasteride (88%, 91%, and 84% with a weekly treatment of 5 or 7 doses of 0.5 mg [n = 32], P Limitations Limitations included the observational and retrospective design. Conclusions Oral dutasteride was the most effective therapy with a dose-dependent response for FFA in real clinical practice compared with other systemic therapies or no systemic treatment.

5-alpha inhibitors are an effective treatment for androgenetic alopecia. Mesotherapy with dutasteride has been proposed as an effective method to improve hair loss and reducing systemic absorption.The main objective was to describe the safety profile of mesotherapy with dutasteride in real clinical practice in a large cohort of patients with androgenetic alopecia. A secondary aim was to describe the effectiveness of this treatment.A multicentric retrospective study was designed. Patients treated with at least 6 months of follow-up were included in the study. Side effects and response to the treatment were analyzed.A total of 541 patients were included. The commonest approach during the first year was to perform the treatment every 3 months. Response to the mesotherapy in monotherapy could be assessed in 86 patients (15.9%) after one year. Most of them presented clinical improvement, being a marked improvement in 33 patients (38.4%). Pain was the most frequent side effect of the treatment (246 patients, 45.5%). No serious or sexual adverse events were detected.Mesotherapy with dutasteride was effective in male and female hair loss in real clinical practice. Side effects related to the treatment were mild and self-limited. This therapy may be an effective option for select patients wishing to avoid oral treatment. J Drugs Dermatol. 2022;21(7):742-747. doi:10.36849/JDD.6610.

Cutaneous manifestations in patients with COVID-19 infection are being increasingly reported. Several patterns have been described since the initial report by Recalcati,1 including erythematous maculo-papular,1 urticarial,1,2 chickenpox-like,1,3 purpuric peri-flexural,4 transient livedo reticularis,5 and acro-ischemic or chilblain-like lesions.6,7 Herein we report the observation a new pattern with erythema multiforme-like lesions in 4 hospitalized patients with COVID-19 infection. All of them were women, and the mean age was 66.75 years (range 58 - 77). The mean time period between the onset of COVID-19 symptoms to the appearance of cutaneous lesions was 19.5 days (range 16 - 24). One patient developed the skin rash during hospitalization. The remaining 3 patients had been previously discharged after clinical, analytical and radiologic improvement, and negativization of COVID-19 PCR test. These 3 patients returned to the Emergency department consulting for skin rashes 6, 7 and 4 days after discharge, respectively. Laboratory tests at the time of skin lesions showed worsening of one or more parameters, compared to those at the time of discharge (CRP, D-dimer and lymphocyte count). However, none of the patients presented recurrence of clinical symptoms of COVID-19. Microbiological studies were performed in 2 patients, excluding other infectious diseases (Table 1). In all patients, skin lesions begun as erythematous papules in upper trunk, that progressively turned to erythemato-violaceous patches with a dusky center, and a pseudo-vesicle in the middle. Typical target lesions were observed in two patients. Lesions were markedly coalescing in the back, and then spread to the face and limbs within 1 week, without involvement of palms and soles (Figure 1). Three patient had their oral cavity examined, showing palatal macules and petechiae. Histological examination was similar in all patients, revealing a normal basket-weave stratum corneum, and mild to moderate spongiosis in epidermis. The dermis showed dilated vessels filled with neutrophils, extravasation of red blood cells, and lymphocytic perivascular and interstitial infiltrate. Basal vacuolar changes with interface dermatitis was observed in 1 patient, and lymphocytic exocytosis in another (Figure 2). All patients were treated with systemic corticosteroids with progressive resolution of the skin lesions within 2-3 weeks. We are facing challenging times in Dermatology. New information and cutaneous manifestations possibly related to COVID-19 are emerging every day. Further studies are needed to evaluate whether these lesions are associated with the virus, the drug intake or any other conditions. Erythema multiforme (EM) is linked to infectious agents in 90% of the cases, while drug-associated EM is reported in less than 10% of cases. Herpes simplex virus (HSV) and Mycoplasma pneumoniae are the main agents, but other viruses have been reported, such as Adenovirus, Coxsackie, Parvovirus B19.8 We suggest that this EM-like or target-like exanthem might be another pattern of exanthem associated with COVID-19 infection. Recent articles also report targetoid lesions in exanthems of patients with COVID-19 infection.9,10 In addition, the presence of pseudo-vesicles and enanthem are two clues that suggest an infectious cause rather than a drug reaction. However, we cannot positively exclude the involvement of the various drugs administered to the patients. This is a first observation that will require further investigations.

Topical immunotherapy with dyphencyprone (DPCP) is widely used in patients with alopecia areata (AA). It can produce a contact dermatitis that is believed to decrease Th1 response, predominant in AA. It has been shown that imiquimod (IMQ), a topical immunomodulator drug, can produce sensitization to DPCP in patients that do not show signs of contact dermatitis when exposed to DPCP. Nevertheless, there is no evidence as to whether it can improve DPCP efficacy in already sensitized patients. We present a series of 9 patients, (7 females [77%] and 2 males [22%]) with a mean age of 38.4 years (range, 19-60 years), successfully sensitized to DPCP, that were treated with a combination of DPCP and IMQ. The mean SALT (Severity of Alopecia Tool) score before adding IMQ was 43.3 (range, 10-60), and the mean number of months of DPCP use prior to the addition of IMQ was 6.8 (range 0-10). After adding IMQ to their DPCP treatment, 77% of the patients had further improvement, with a mean SALT reduction of 13.3 (range, [-50] - 40), and a mean duration of response of 5.2 months. No adverse effects were reported. According to this data, we believe that the combination of DPCP and IMQ can be a promising way of improving the efficacy of contact immunotherapy in AA, and requires further study.

Frontal fibrosing alopecia (FFA) is a scarring alopecia that affects the frontotemporal hairline. Clinically, it may develop with cutaneous hypopigmentation of the affected areas, which has been associated with a reduction in the epidermal melanocyte count. In trichoscopy, peripilar white halos can be observed, which have been associated with fibrosis in other scarring alopecias.To evaluate the trichoscopic, histopathological and immunohistochemical characteristics of the peripilar white halos in FFA patients.We conducted a descriptive cross-sectional study that included 12 patients with FFA presenting peripilar white halos. Two 2-mm punch trichoscopy-guided biopsies were performed in all patients, one fragment for vertical section and another for horizontal section. The vertical sections were stained with Fontana-Mason and Melan-A.On trichoscopic examination, peripilar white halos ≤ 1 mm in size were observed on the affected scalp. In vertical sections, a reduction in basal melanin pigmentation and a decrease in the melanocyte count in the upper segment of the hair follicle were observed with Fontana-Masson staining and Melan-A immunostaining, respectively.The small sample size and absence of a control group.This study shows follicular melanocyte involvement in FFA, and this finding may be associated with the peripilar white halos observed in trichoscopy.

O prazer por desvendar o novo, compartilhar conhecimento e experiências já adquiridos e, especialmente, o amor genuíno pela docência serviram de combustível na criação desta obra, a qual, mais do que proporcionar informação médica atual e de excelência, visa trazer a experiência de grandes nomes da tricologia dos cenários nacional e internacional, para que o aprendizado seja suave, duradouro e pautado em um misto de evidências científicas e prática diária.

Importance A recent expert consensus exercise emphasized the importance of developing a global network of patient registries for alopecia areata to redress the paucity of comparable, real-world data regarding the effectiveness and safety of existing and emerging therapies for alopecia areata. Objective To generate core domains and domain items for a global network of alopecia areata patient registries. Evidence Review Sixty-six participants, representing physicians, patient organizations, scientists, the pharmaceutical industry, and pharmacoeconomic experts, participated in a 3-round eDelphi process, culminating in a face-to-face meeting at the World Congress of Dermatology, Milan, Italy, June 14, 2019. Findings Ninety-two core data items, across 25 domains, achieved consensus agreement. Twenty further noncore items were retained to facilitate data harmonization in centers that wish to record them. Broad representation across multiple stakeholder groups was sought; however, the opinion of physicians was overrepresented. Conclusions and Relevance This study identifies the domains and domain items required to develop a global network of alopecia areata registries. These domains will facilitate a standardized approach that will enable the recording of a comprehensive, comparable data set required to oversee the introduction of new therapies and harness real-world evidence from existing therapies at a time when the alopecia areata treatment paradigm is being radically and positively disrupted. Reuse of similar, existing frameworks in atopic dermatitis, produced by the Treatment of Atopic Eczema (TREAT) Registry Taskforce, increases the potential to reuse existing resources, creates opportunities for comparison of data across dermatology subspecialty disease areas, and supports the concept of data harmonization.

Severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2) has been recently linked to dermatologic manifestations and is thought to affect more severely patients with androgenetic alopecia. We designed a prospective multicentric study which enrolled patients from March to August of 2020 with acute telogen effluvium (ATE) that had a prior SARS-CoV-2 infection confirmed either by serological tests (e.g. detection of serum antibodies against the virus via enzyme-linked immunosorbent assays (ELISA)) or detection of viral RNA using real-time reverse transcription polymerase chain reaction (RT-PCR).

Acknowledgement: “This Protocol of a Cochrane Review was published in the Cochrane Database of Systematic Reviews 2020, Issue 9. Cochrane Protocols and Reviews are regularly updated as new evidence emerges and in response to feedback, and the Cochrane Database of Systematic Reviews should be consulted for the most recent version of the Protocol.'

Background: In 2017, we carried out a cross-sectional study with the aim of describing androgenic alopecia (AGA) prescription habits among dermatologists who practice in Spain. Three years later, we repeated this study with the aim of describing the current situation and comparing it with previous data. Material and Methods: Descriptive cross-sectional study using online questionnaires autocompleted by dermatologists working in Spain. Results: The responses of 243 dermatologists were analyzed. The most common treatments prescribed for MAGA were topical minoxidil (100%), oral finasteride (92.6%), oral dutasteride (75.7%), and oral minoxidil (50.6%). For premenopausal female AGA (FAGA), the most common treatments were topical minoxidil (99%), oral contraceptives (75%), nutricosmetics (71%), and oral minoxidil (67.9%). Lastly, the most common treatments prescribed in patients with postmenopausal FAGA were topical minoxidil (99.2%), oral finasteride (79%), oral durasteride (71.6%), and oral minoxidil (63%). Conclusions: In conclusion, AGA is the most frequent alopecia in the trichology clinic. The most common treatments prescribed in male AGA (MAGA) and postmenopausal FAGA were topical minoxidil and oral finasteride, while in premenopausal FAGA, topical minoxidil, oral contraceptives, and nutricosmetics were most commonly prescribed. In the past three years, oral dutasteride and oral minoxidil have increased drastically among the most prescribed therapies for MAGA, premenopausal FAGA, and postmenopausal FAGA.

This cohort study assesses the association of inflammatory symptoms with the progression of hair loss in women with frontal fibrosing alopecia.

Background Folliculitis decalvans (FD) is a rare neutrophilic cicatricial alopecia that poses a therapeutic challenge. Objectives To describe the therapeutic response in a large number of cases of FD with long-term follow-up and analyze potential prognostic factors associated with severity of form and with a better therapeutic response. Methods This multicenter prospective study included patients with FD who had a minimum of 5 years of follow-up. Severity was assessed by the maximum diameter of the cicatricial area. Therapeutic response was evaluated according to stabilization of the size of the cicatricial areas and the improvement in clinical symptoms. Results A total of 60 patients (37 men [61.7%] and 23 women [38.3%]) with a mean age of 40 years were included. Earlier age of onset (P = .01) was statistically associated with severity of form. Treatment with rifampicin and clindamycin, tetracyclines, and intralesional steroids was the most effective. No statistically significant prognostic factors predicting a better therapeutic response were found. Limitations Because FD is a rare disease, the main limitation was the sample size. Conclusions An earlier age of onset was associated with the severe form of the disease. The proposed specific therapeutic protocol can be a very useful tool in clinical dermatologic practice.

Background Frontal fibrosing alopecia (FFA) is a chronic cicatricial alopecia with an increasing incidence and unknown aetiology. Aim To identify possible environmental and hormonal factors related to FFA. Methods We conducted a multicentre case-control study paired by sex and age, and recruited 664 women (335 cases and 329 controls) and 106 men (20 cases and 86 controls). Study subjects completed an exhaustive questionnaire enquiring about pharmacological, environmental, hormonal, social, job exposure, lifestyle, drugs and diet factors to which they were exposed at least 5 years prior to the onset of the disease. Results For women, there was a statistical association between alopecia and history of pregnancy (OR = 1.6; 95% CI 1.06-2.41), use of facial sunscreen (OR = 1.6; 95% CI 1.06-2.41) and hormone replacement therapy (HRT) (OR = 1.76; 95% CI 1.11-2.8) or raloxifene (no controls exposed therefore OR was not calculated), exposure to alkylphenolic compounds (OR = 1.48; 95% CI 1.05-2.08), and presence of rosacea (OR = 1.91; 95% CI 1.07-3.39), lichen planus pigmentosus (LPP) (OR = 5.14; 95% CI 1.11-23.6) or hypothyroidism (OR = 1.73; 95% CI 1.11-2.69). For men, there was a statistical association between alopecia and use of facial sunscreens (OR = 11.6; 95% CI 1.7-80.9) or antiageing creams (OR = 1.84; 95% CI 1.04-3.23). Conclusions FFA seems to be associated with hormonal exposure (pregnancy, HRT and raloxifene), comorbidities (hypothyroidism, LPP and rosacea) and environmental factors (facial sunscreens, antiageing creams and occupational exposure). Further research is required to analyse the exact mechanism in which these environmental factors participate in the development of this alopecia.

Resumen Introduccion A pesar de que los unicos farmacos con indicacion aprobada en nuestro pais para la alopecia androgenica (AGA) son minoxidil topico y finasterida oral, es comun la utilizacion de numerosas terapias fuera de indicacion, provocando una gran variabilidad en el manejo de estos pacientes. El objetivo principal de este trabajo fue describir los habitos de prescripcion de los dermatologos en Espana en AGA masculina (MAGA) y AGA femenina (FAGA). Material y metodos Estudio descriptivo transversal mediante cuestionarios digitales autocumplimentados por dermatologos que ejercen en territorio espanol. Resultados Se incluyeron las respuestas de un total de 241 dermatologos. En MAGA los tratamientos mas utilizados fueron en este orden: minoxidil topico (98%), finasterida oral (96%), nutricosmeticos (44%), finasterida topica (37%), dutasterida oral (33%), plasma rico en plaquetas (14%) y laser de baja potencia (8%). En FAGA premenopausica: minoxidil topico (98%), anticonceptivos orales (81%), nutricosmeticos (72%), acetato de ciproterona (58%), finasterida oral (39%), finasterida topica (39%), espironolactona (27%), plasma rico en plaquetas (20%), dutasterida oral (20%), flutamida oral (18%) y laser de baja potencia (7%). En FAGA posmenopausica: minoxidil topico (98%), finasterida oral (84%), nutricosmeticos (68%), finasterida topica (50%), dutasterida oral (35%), plasma rico en plaquetas (21%), espironolactona (16%), acetato de ciproterona (16%), flutamida oral (9%) y laser de baja potencia (9%). Como limitaciones de nuestro estudio, no se incluyeron terapias novedosas para AGA como minoxidil oral o microinyecciones de dutasterida. Conclusiones Los agentes terapeuticos mas utilizados en MAGA y FAGA posmenopausica por los dermatologos en Espana fueron minoxidil topico, finasterida oral y nutricosmeticos, mientras que en FAGA premenopausica fueron minoxidil topico, anticonceptivos orales y nutricosmeticos.

Background Topical minoxidil and oral finasteride are the only drugs approved for the treatment of androgenetic alopecia (AGA) in Spain. However, the management of this condition is highly variable because numerous treatments are used off-label. The main aim of this study was to describe the prescribing habits of dermatologists in Spain for male AGA (MAGA) and female AGA (FAGA). Material and methods Descriptive cross-sectional study using online questionnaires completed by dermatologists working in Spain. Results The responses of 241 dermatologists were analyzed. The most common treatments prescribed for MAGA were minoxidil (98%), oral finasteride (96%), nutricosmetics (44%), topical finasteride (37%), oral dutasteride (33%), platelet-rich plasma (14%), and low-level laser therapy (8%). For premenopausal FAGA, the most common treatments were topical minoxidil (98%), oral contraceptives (81%), nutricosmetics (72%), cyproterone acetate (58%), oral finasteride (39%), topical finasteride (39%), spironolactone (27%), platelet-rich plasma (20%), oral dutasteride (20%), oral flutamide (18%), and low-level laser therapy (7%). Finally, for postmenopausal FAGA, the most common treatments prescribed were topical minoxidil (98%), oral finasteride (84%), nutricosmetics (68%), topical finasteride (50%), oral dutasteride (35%), platelet-rich plasma (21%), spironolactone (16%), cyproterone acetate (16%), oral flutamide (9%), and low-level laser therapy (9%). A limitation of our study is that we did not analyze novel AGA treatments such as oral minoxidil and dutasteride mesotherapy. Conclusions The most common treatments prescribed for AGA by dermatologists in Spain are topical minoxidil, oral finasteride, and nutricosmetics for MAGA and postmenopausal FAGA and topical minoxidil, oral contraceptives, and nutricosmetics for premenopausal FAGA.