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Background: Tyrosinase is the rate-limiting enzyme of melanogenesis and thus an ideal inhibitory target for treating hyperpigmentation. There are many commercially available tyrosinase inhibitors with limited clinical efficacy. A recent screen of 50,000 compounds found isobutylamido thiazolyl resorcinol (ITR) to be the most potent inhibitor of human tyrosinase., Objective: To summarize the current evidence on the efficacy and adverse effects of ITR in treating hyperpigmentation., Methods: A literature search was conducted using PubMed and Google Scholar databases in June 2022. Fourteen clinical studies investigating the use of topical ITR in hyperpigmentation treatment or prevention were identified., Results: Most studies (n=13) investigated topical ITR as a treatment, while only one investigated ITR as a preventative measure against hyperpigmentation. All studies (n=14) found ITR to provide statistically significant improvements to hyperpigmentation conditions, including facial hyperpigmentation (n=3), melasma (n=5), post-inflammatory hyperpigmentation (PIH) (n=3), and UV-induced hyperpigmentation (n=3). Evidence suggests that the effective dosage and duration of topical ITR appears to be 0.1% to 0.2% ITR 2 to 4 times daily for 12 to 24 weeks. Successful prevention of UVB-induced hyperpigmentation has been seen following twice-daily topical ITR application for 3 weeks (P<0.001)., Conclusion: Topical ITR can significantly reduce hyperpigmentation, however, the evidence for its use is limited. Further investigation is warranted to identify the optimal dosage and application schedule of ITR, as well as compare the efficacy of ITR vs hydroquinone to determine if ITR is superior to the current standard of care. J Drugs Dermatol. 2024;23(11):986-991.  doi:10.36849/JDD.7985.

Objective: Scalp inflammation and alopecia are distressing conditions for which patients regularly present to dermatology. Although some diagnoses can be made clinically, others require biopsy, which carries the risk of pain, infection, bleeding, and scarring. This review examines the existing literature regarding noninvasive in vivo imaging techniques and their evidence and utility in evaluating scalp pathology, with a focus on the diagnostics of hair conditions., Methods: A systematic literature search was conducted using the Preferred Reporting Items for Systematic Reviews and Meta-Analyses (PRISMA) guidelines without timeframe restrictions. The PubMed and Clarivate (Web of Science) databases were searched using the terms ("imaging" OR "in-vivo imaging" OR "non-invasive imaging" OR "non-invasive in vivo imaging" "imaging," "in-vivo imaging) AND ("human scalp disorders" OR "scalp" OR "hair loss" OR "alopecia"). Peer-reviewed randomized control trials (RCTs), prospective studies, retrospective studies, and case series or reports discussing in vivo imaging of the scalp published before 2022 were selected., Results: Forty-two studies were included and discussed; modalities included laser devices (n = 27), ultrasound (US) (n = 13), infrared thermography (n = 1), skin capacitance imaging (SCI), and ultraviolet light-enhanced visualization (ULEV) (n = 1). The most common laser devices used were reflectance confocal microscopy (RCM), multiphoton microscopy (MPM), and optical coherence tomography (OCT). US techniques included high-frequency US (HFUS) and US biomicroscopy (UBM)., Conclusion: Quality imaging of the scalp in the setting of alopecic, neoplastic, and inflammatory diseases is highly sought after. Many of these noninvasive imaging techniques show promise, each with individual advantages and disadvantages in imaging-specific conditions. Ultimately, noninvasive imaging techniques may be used to optimize patient management and minimize morbidity associated with scalp biopsies., (© 2024 The Author(s). Lasers in Surgery and Medicine published by Wiley Periodicals LLC.)

Background: Alopecia areata (AA) is a hair loss disorder that can seriously impact quality of life. Janus kinase (JAK) inhibitors, including deuruxolitinib, have previously demonstrated significant hair regrowth in AA., Objective: The Phase 3 THRIVE-AA1 randomized, double-blinded, placebo-controlled trial (NCT04518995) evaluated the safety and efficacy of the oral JAK1/JAK2 inhibitor deuruxolitinib in adult patients with AA., Methods: Patients aged 18-65 years with ≥50% hair loss were randomized to deuruxolitinib 8 mg twice daily, deuruxolitinib 12 mg twice daily, or placebo for 24 weeks. The primary end point was the percentage of patients achieving a Severity of Alopecia Tool score ≤20. A key secondary end point was the percentage of satisfaction of hair patient-reported outcome responders., Results: Significantly higher proportions of patients taking deuruxolitinib met the primary end point (8 mg 29.6%; 12 mg 41.5% versus placebo 0.8%). Both deuruxolitinib doses achieved significant improvements in all secondary end points versus placebo, including satisfaction of hair patient-reported outcome (8 mg 42.1%; 12 mg 53.0% versus placebo 4.7%). Most treatment-emergent adverse events were mild or moderate, consistent with other oral JAK inhibitors., Limitations: Further studies are required to understand longer-term safety, efficacy, and impact of treatment cessation., Conclusion: Both doses of deuruxolitinib were effective for hair regrowth. Patient satisfaction aligned with hair growth., Competing Interests: Conflicts of interest Dr King has served on advisory boards and/or is a consultant and/or is a clinical trial investigator for AbbVie, AltruBio Inc, Almirall, AnaptysBio, Arena Pharmaceuticals, Bioniz Therapeutics, Bristol Myers Squibb, CoNCERT Pharmaceuticals (subsequently acquired by Sun Pharmaceutical Industries Limited), Equillium, Horizon Therapeutics, Eli Lilly, Incyte Corp., Janssen Pharmaceuticals, LEO Pharma, Otsuka/Visterra Inc, Pfizer, Regeneron, Sanofi Genzyme, Sun Pharmaceutical Industries Limited, TWi Biotechnology Inc, and Viela Bio Inc; also served on speaker bureaus for AbbVie, Incyte, Eli Lilly, Pfizer, Regeneron, and Sanofi Genzyme and is a scientific advisor for BiologicsMD. Dr Senna has been a speaker for Eli Lilly and Pfizer and a principal investigator and/or received research funding from Follica, Eli Lilly, CoNCERT Pharmaceuticals (subsequently acquired by Sun Pharmaceutical Industries Limited), Santiste Medical, and LEO Pharma; has also served on scientific advisory boards and/or been a consultant for Eli Lilly, Follica, L'Oreal, Kintor, and Pfizer, and is on the board of directors/medical advisory board for the National Alopecia Areata Foundation, Scarring Alopecia Foundation, and the American Hair Research Society. Dr Mesinkovska has been an advisor for CoNCERT Pharmaceuticals (subsequently acquired by Sun Pharmaceutical Industries Limited), Eli Lilly, and Pfizer, a principal investigator for AbbVie, Arcutis Biotherapeutics, Bristol Myers Squibb, CoNCERT Pharmaceuticals (subsequently acquired by Sun Pharmaceutical Industries Limited), Eli Lilly, and Pfizer and a speaker for Eli Lilly. Dr Lynde has been a speaker and/or consultant for AbbVie, Amgen, Aralez, Arcutis, Bausch Health, Bayer, Boehringer Ingelheim, Bristol Myers Squibb, Celgene, Cipher, Dermavant, Devonian, Eli Lilly, Fresenius Kabi, Galderma, GSK, Incyte, Innovaderm, Intega Skin, Janssen, Kyowa Kirin, La Roche Posay, LEO Pharma, L'Oreal, Medexus, MedX, Merck, Novartis, P&G, Pediapharm, Pfizer, Regeneron, Roche, Sanofi Genzyme, Sandoz, Sentrex, Sun Pharmaceutical Industries Limited, TEVA, Tribute, UCB, Viatris, and Volo Health; and has also been a principal investigator for AbbVie, Acelyrin, Akros, Altius, Amgen, Aralez, Arcutis, Avillion, Bausch Health, Bayer, Boehringer Ingelheim, Bristol Myers Squibb, Celgene, Celltrion, Cipher, CoNCERT Pharmaceuticals (subsequently acquired by Sun Pharmaceutical Industries Limited), Dermavant, Devonian, Eli Lilly, Evelo, Galderma, GSK, Incyte, Innovaderm, Intega Skin, Janssen, Kyowa Kirin, La Roche Posay, LEO Pharma, L'Oreal, Medexus, MedX, Merck, MoonLake, Novartis, P&G, Pediapharm, Pfizer, Regeneron, Roche, Sanofi Genzyme, Sandoz, Sentrex, Sun Pharmaceutical Industries Limited, TEVA, Tribute, UCB, Valeant, Viatris, and Volo Health. Dr Zirwas has been an investigator and/or speaker and/or consultant for AbbVie, Acrotech, Aldeyra, Advanced Derm Solutions, All Free Clear/Sun, Amgen, Anaptys Bio, Apogee, Arcutis, Bausch and Lomb, Biocon, Bristol Myers Squibb, Cara, Castle Biosciences, CoNCERT Pharmaceuticals (subsequently acquired by Sun Pharmaceutical Industries Limited), Connect Biopharma, Dermavant, Edessa Biotech, EPI Health, Evelo, Galderma, Genentech/Novartis, Incyte, Janssen, L'Oreal, LEO Pharma, Level-Ex, Eli Lilly, LUUM, Nimbus, Oculus, Peloton, Pfizer, Regeneron/Sanofi, Trevi, Trifecta, and UCB; has also been an advisor for Vial and is part owner of AsepticMD. Dr Maari has served on advisory boards and/or is a consultant and/or is a clinical trial investigator for AbbVie, Almirall, AnaptysBio, Arena Pharmaceuticals, Bristol Myers Squibb, CoNCERT Pharmaceuticals (subsequently acquired by Sun Pharmaceutical Industries Limited), Horizon Therapeutics, Eli Lilly, Incyte Corp., Janssen Pharmaceuticals, LEO Pharma, Pfizer, Regeneron, Sanofi Genzyme, Sun Pharmaceutical Industries Limited, Valeant, Dermavant, Novartis, Amgen, and UCB. Dr Prajapati has been an advisor, consultant, and/or speaker for AbbVie, Actelion, Amgen, Aralez, Arcutis, Aspen, Bausch Health, BioScript Solutions, Boehringer Ingelheim, Bristol Myers Squibb, Canadian Psoriasis Network, Celgene, Cipher, CoNCERT Pharmaceuticals (subsequently acquired by Sun Pharmaceutical Industries Limited), CorEvitas, Eczema Society of Canada, Eli Lilly, Galderma, GlaxoSmithKline, Homeocan, Incyte, Janssen, LEO Pharma, Medexus, Novartis, Pediapharm, Pfizer, Sanofi Genzyme, Sun Pharmaceutical Industries Limited, Tribute, UCB, and Valeant; investigator for AbbVie, AnaptysBio, Arcutis, Arena, Bausch Health, Boehringer Ingelheim, Bristol Myers Squibb, Celgene, CoNCERT Pharmaceuticals (subsequently acquired by Sun Pharmaceutical Industries Limited), CorEvitas, Dermavant, Dermira, Eli Lilly, Galderma, Incyte, Janssen, LEO Pharma, Nimbus Lakshmi, Novartis, Pfizer, RAPT Therapeutics, Regeneron, Reistone, Sanofi Genzyme, Takeda, and UCB; received grants from AbbVie, Bausch Health, Janssen, LEO Pharma, Novartis, and Sanofi Genzyme. Dr Sapra has been a principal investigator, consultant, or speaker for AbbVie, Amgen, Arcutis, Avillion, Bausch Health, Boehringer Ingelheim, Bristol Myers Squibb, Celgene, CoNCERT Pharmaceuticals (subsequently acquired by Sun Pharmaceutical Industries Limited), Dermavant, Eli Lilly, Galderma, GSK, Incyte, Innovaderm, Janssen, LEO Pharma, Merz, Novartis, Pfizer, Pulse Biosciences, Regeneron, Roche, Sanofi, UCB, and Valeant. Dr Brzewski has been a principal investigator and/or consultant for AbbVie, Acelyrin, Alvotech Swiss, Amgen, BenevolentAI, Bioeq GmbH, Biogen, Celltrion, CoNCERT Pharmaceuticals (subsequently acquired by Sun Pharmaceutical Industries Limited), Eli Lilly, Horizon Therapeutics, Janssen, LEO Pharma, Pfizer, Regeneron, and Samsung Bioepis. Dr Osman has been an advisor for AbbVie, Affibody, Allergan, Amgen, AnaptysBio, Arcutis, Aurigene, Botanix, Castle Biosciences, Chemocentryx, CoNCERT Pharmaceuticals (subsequently acquired by Sun Pharmaceutical Industries Limited), Dermavant, DS Biopharma, Eli Lilly, Foamix Pharmaceuticals, Galderma, Janssen, Incyte, LEO Pharma, Reistone, Sun Pharmaceutical Industries Limited, and Valeant. Dr Hanna has been an advisory board member, principal investigator, investigator, speaker, and/or consultant for AbbVie, Akros, Allergan, Altius Healthcare, Amgen, Aralez, Arcutis, Bausch Health, Biopharma, Boehringer Ingelheim, Bristol Myers Squibb, Celgene, Coherus, CoNCERT Pharmaceuticals (subsequently acquired by Sun Pharmaceutical Industries Limited), Cutanea, Dermira, Galapagos, Galderma, Glenmark, Incyte, Janssen, LEO Pharma, Lilly, Lumenis, Merz, Novartis, Pediapharma, Pfizer, Prollenium, Regeneron, Revanesse, Reistone, Sandoz, Sanofi, Sun Pharma, and UCB. Dr Wiseman has been a principal investigator, consultant, advisor, or speaker for Acelyrin, AbbVie (previously Abbott), Akros, Amgen, Arcutis, Asana BioSciences, AstraZeneca, Bausch Health, Bristol Myers Squibb, CoNCERT Pharmaceuticals (subsequently acquired by Sun Pharmaceutical Industries Limited), Celgene, Dermavant, Dermira, Dice, Eli Lilly, Evelo, Galderma, Glenmark, Incyte, Janssen, LEO Pharma A/S, L'Oreal, Merck Frosst Canada, Moonlake, Novartis, Pfizer, Principia, PRCL Research, Regeneron, Sanofi, Takeda, Timber. Drs Hamilton and Cassella are employees of Sun Pharmaceutical Industries, Inc., (Copyright © 2024 American Academy of Dermatology, Inc. Published by Elsevier Inc. All rights reserved.)

Competing Interests: Conflicts of interest None disclosed.

Importance: Baricitinib has demonstrated efficacy for treating severe alopecia areata in adults. There is currently limited information about the need for continuous therapy after achieving scalp hair regrowth., Objective: To report results from the randomized withdrawal period of the BRAVE-AA1 trial., Design, Setting, and Participants: BRAVE-AA1 was a randomized, placebo-controlled, phase 3 randomized clinical trial with a treatment withdrawal substudy that was conducted at 70 centers in 3 countries beginning in March 2019. It included 654 adults with severe alopecia areata (AA) (Severity of Alopecia Tool [SALT] score ≥50) who were randomized 3:2:2 to receive treatment with baricitinib, 4 mg; baricitinib, 2 mg; or placebo. Data were analyzed in August 2023., Intervention: At week 52, 154 patients who were responders (SALT score ≤20) were rerandomized 3:1 to continue to take their current dose of baricitinib or transition to placebo (randomized withdrawal). Responders randomized to placebo who experienced a loss of treatment benefit (>20-point worsening in SALT score) at any time after week 52 were retreated with their original baricitinib dose., Main Outcome and Measures: The proportion of patients who lost treatment benefit through week 152 and the proportion of patients who recaptured response after retreatment. The last observation carried forward was used to impute missing or censored data., Results: Of 654 patients who received treatment, the mean (SD) age was 37.1 (13.0) years, and there were 383 women (58.6%). At week 52, 10 of 39 responders taking baricitinib, 2 mg, and 30 of 115 responders taking baricitinib, 4 mg, were rerandomized to placebo. At 4 and 8 weeks of treatment withdrawal, 0% and 10% to 11% of patients, respectively, lost treatment benefit regardless of dose. At week 152, 80% of patients had lost benefit compared with 7% for those who continued baricitinib therapy for both dose groups. Within the follow-up observation periods, 5 of 8 patients taking 2 mg (63%) and 21 of 24 patients taking 4 mg (87.5%) recaptured a SALT score of 20 or less response after retreatment., Conclusions and Relevance: Severe AA is a chronic, relapsing condition, and this randomized clinical trial found that withdrawal of therapy for a patient population with severe AA who had achieved meaningful hair regrowth after 1 year of treatment with baricitinib resulted in loss of benefit for almost all patients, indicating that continued therapy is required to maintain hair regrowth., Trial Registration: ClinicalTrials.gov Identifier: NCT03570749.

Background: Minoxidil is an anti-hypertensive vasodilator increasingly used off-label for the treatment of alopecia. It is associated with an increased risk of pericardial effusions, with recent reports even in patients on low-dose oral minoxidil (LDOM) therapy., Objective: To evaluate whether LDOM is associated with increased prevalence of pericardial effusions in patients with alopecia., Methods: In this cross-sectional study, point-of-care ultrasound was used to screen alopecia patients at dermatology appointments. Scans were evaluated by two independent cardiologists for the presence and size of effusions. The prevalence of effusions was compared between patients on LDOM therapy and patients not on minoxidil therapy., Results: A total of 100 patients were evaluated for pericardial effusion: 51 LDOM patients and 49 control patients. The two groups were similar in terms of age (53.7 vs 54.1; P=0.91), sex (86% vs 73% female; P=0.14), and race. Small pericardial effusions (<1 cm) were identified in 5.8% of LDOM patients and 6% of control patients (P=1), none of which were symptomatic., Limitations: This is a small, cross-sectional study with limitations on speculation of causality in confirmed cases., Conclusion: We did not find evidence of increased prevalence of pericardial effusions in a small group of alopecia patients on LDOM. J Drugs Dermatol. 2024;23(9):725-728. doi:10.36849/JDD.8029.

Competing Interests: Conflicts of interest Dr Min is on the advisory boards of Horizon and BMS, and is an investigator for Amgen, BI, BMS, and Priovant. The authors Arora, Kincaid, Sharma, and Mesinkovska have no conflicts of interest to declare.

Background: The ALLEGRO phase 2a and 2b/3 studies demonstrated that ritlecitinib, an oral JAK3/TEC family kinase inhibitor, is efficacious at doses of ≥ 30 mg in patients aged ≥ 12 years with alopecia areata (AA)., Objective: The objective of this study was to evaluate the safety of ritlecitinib in an integrated analysis of four studies in AA., Methods: Two cohorts were analyzed: a placebo-controlled and an all-exposure cohort. Proportions and study size-adjusted incidence rates (IRs) of adverse events (AEs) of interest and laboratory abnormalities are reported., Results: In the placebo-controlled cohort (n = 881; median exposure: 169 days), the proportion of ritlecitinib-treated patients with AEs was 70.2-75.4% across doses versus 69.5% in the placebo group; serious AEs occurred in 0-3.2% versus 1.9% for the placebo. A total of 19 patients permanently discontinued due to AEs (5 while receiving the placebo). In the all-exposure cohort (n = 1294), median ritlecitinib exposure was 624 days [2091.7 total patient-years (PY)]. AEs were reported in 1094 patients (84.5%) and serious AEs in 57 (4.4%); 78 (6.0%) permanently discontinued due to AEs. The most common AEs were headache (17.7%; 11.9/100 PY), severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2) positive test (15.5%; 9.8/100 PY), and nasopharyngitis (12.4%; 8.2/100 PY). There were two deaths (breast cancer and acute respiratory failure/cardiorespiratory arrest). Proportions (IRs) were < 0.1% (0.05/100 PY) for opportunistic infections, 1.5% (0.9/100 PY) for herpes zoster, 0.5% (0.3/100 PY) for malignancies (excluding nonmelanoma skin cancer), and 0.2% (0.1/100 PY) for major adverse cardiovascular events., Conclusions: Ritlecitinib is well tolerated with an acceptable safety profile up to 24 months in patients aged ≥ 12 years with AA (video abstract and graphical plain language summary available)., Trial Registries: ClinicalTrials.gov: NCT02974868 (date of registration: 11/29/2016), NCT04517864 (08/18/2020), NCT03732807 (11/07/2018), and NCT04006457 (07/05/2019)., (© 2024. The Author(s).)

Importance: Current measures of alopecia areata (AA) severity, such as the Severity of Alopecia Tool score, do not adequately capture overall disease impact., Objective: To explore factors associated with AA severity beyond scalp hair loss, and to support the development of the Alopecia Areata Severity and Morbidity Index (ASAMI)., Evidence Review: A total of 74 hair and scalp disorder specialists from multiple continents were invited to participate in an eDelphi project consisting of 3 survey rounds. The first 2 sessions took place via a text-based web application following the Delphi study design. The final round took place virtually among participants via video conferencing software on April 30, 2022., Findings: Of all invited experts, 64 completed the first survey round (global representation: Africa [4.7%], Asia [9.4%], Australia [14.1%], Europe [43.8%], North America [23.4%], and South America [4.7%]; health care setting: public [20.3%], private [28.1%], and both [51.6%]). A total of 58 specialists completed the second round, and 42 participated in the final video conference meeting. Overall, consensus was achieved in 96 of 107 questions. Several factors, independent of the Severity of Alopecia Tool score, were identified as potentially worsening AA severity outcomes. These factors included a disease duration of 12 months or more, 3 or more relapses, inadequate response to topical or systemic treatments, rapid disease progression, difficulty in cosmetically concealing hair loss, facial hair involvement (eyebrows, eyelashes, and/or beard), nail involvement, impaired quality of life, and a history of anxiety, depression, or suicidal ideation due to or exacerbated by AA. Consensus was reached that the Alopecia Areata Investigator Global Assessment scale adequately classified the severity of scalp hair loss., Conclusions and Relevance: This eDelphi survey study, with consensus among global experts, identified various determinants of AA severity, encompassing not only scalp hair loss but also other outcomes. These findings are expected to facilitate the development of a multicomponent severity tool that endeavors to competently measure disease impact. The findings are also anticipated to aid in identifying candidates for current and emerging systemic treatments. Future research must incorporate the perspectives of patients and the public to assign weight to the domains recognized in this project as associated with AA severity.

Background: The study aimed to compare barriers perceived by medical students and resident physicians identifying as of underrepresented groups in medicine (UIM) and/or as sexual and gender minorities (SGM) to individuals not identifying with these groups, especially for trainees with an interest in dermatology., Methods: Cross-sectional survey of medical students and resident physicians based in the United States from February 2021 to July 2021, with subgroup analysis of trainees with interest in dermatology., Findings: Among trainees interested in dermatology, the most notable barriers for the UIM group were 1) lack of home program in specialty/fellowship of interest (4.71&plusmn;1.73); 2) lack of connections/networking opportunities (4.14&plusmn;1.29); 3) lack of opportunity to obtain AOA membership (4.00&plusmn;1.96); 4) obtaining mentorship (4.00&plusmn;1.47); and lack of diversity in specialty/fellowship of interest (3.93&plusmn;1.14)., Conclusions and Relevance: Increasing focused mentorship programs and fostering environments that embrace diversity are key to reducing perceived barriers for minority candidates. J Drugs Dermatol. 2023;22(12):1210-1215. doi:10.36849/JDD.7528R1.

Competing Interests: Conflicts of interest Dr Mesinkovska has served as an adviser and speaker for Lilly, Pfizer, and Concert as well as a board member of the American Hair Research Society and former Chief Scientific Officer for the National Alopecia Areata Foundation. The other authors have no potential conflict of interest to disclose.

Female genital mutilation (FGM) is a common cultural practice, which involves the partial or complete removal of the external female genitalia. With increasing immigration from regions where the practice is endemic, there has been a growing prevalence of FGM in the United States and other developed nations. However, most medical professionals lack the baseline knowledge regarding FGM and its associated health complications. Given this increasing trend, dermatologists should anticipate an increasing number of patients with a history of FGM in their practice. While some of the obstetric, gynecologic, and psychologic consequences of FGM have been well-reported, the dermatologic findings are less characterized. Thus, this review article aims to provide dermatologists with a fundamental understanding of the prevalence, cultural significance, and health implications of FGM with a focus on the associated dermatological findings and provides recommendations on how dermatologists can address this sensitive matter., Competing Interests: None disclosed., (© 2024 Published by Elsevier Inc. on behalf of the American Academy of Dermatology, Inc.)

What Is This Summary About?: This is a summary of the results of the ALLEGRO phase 2b/3 clinical trial, originally published in The Lancet . ALLEGRO-2b/3 looked at how well and safely the study medicine, ritlecitinib, works in treating people with alopecia areata ('AA' for short). The immune system protects your body from outside invaders such as bacteria and viruses. AA is an autoimmune disease, meaning a disease in which one's immune system attacks healthy cells of the body by mistake. In AA, the immune system attacks hair follicles, causing hair to fall out. AA causes hair loss ranging from small bald patches to complete hair loss on the scalp, face, and/or body. Ritlecitinib is a medicine taken as a pill every day, by mouth, that is approved for the treatment of severe AA. It blocks processes that are known to play a role in causing hair loss in patients with AA., What Were the Results of the Study?: Adults and adolescents (12 years and older) took part in the ALLEGRO-2b/3 study. They either took ritlecitinib for 48 weeks or took a placebo (a pill with no medicine) for 24 weeks. Participants taking placebo later switched to taking ritlecitinib for 24 weeks. The study showed that participants taking ritlecitinib had more hair regrowth on their scalp after 24 weeks than those taking the placebo. Hair regrowth was also seen on the eyebrows and eyelashes in participants taking ritlecitinib. Hair regrowth continued to improve to week 48 with continued ritlecitinib treatment. In addition, more participants taking ritlecitinib reported that their AA had 'moderately' or 'greatly' improved after 24 weeks than those taking the placebo. Similar numbers of participants taking ritlecitinib or placebo had side effects after 24 weeks. Most side effects were mild or moderate., What Do the Results of the Study Mean?: Ritlecitinib was an effective and well-tolerated treatment over 48 weeks for people with AA. Clinical Trial Registration: NCT03732807 (phase 2b/3 ALLEGRO study).

Competing Interests: Conflicts of interest None disclosed.

Competing Interests: Conflicts of interest None disclosed.

Background: Radiofrequency (RF) devices are being increasingly used for cosmetic dermatology applications. Recent studies have reported an apparent dualistic nature of RF devices for hair, causing either removal or growth depending on the modality of RF., Materials and Methods: PubMed/MEDLINE and Web of Science searches were conducted in July 2022 according to PRISMA guidelines for studies discussing RF technology in hair applications ( n = 19)., Results: The majority of studies describe the utility of RF devices in removal of unwanted hair ( n = 15). Bipolar RF has been used in combination with intense pulsed light for effective long-term removal of body and facial hair. The chromophore-independent method of energy delivery in RF makes it a viable add-on therapy for treating lighter colored hair and darker Fitzpatrick skin types. Monopolar RF is used for eyelash removal in patients with trichiasis. In contrast, fractional RF has been used to stimulate hair growth in patients with alopecia areata and androgenetic alopecia., Conclusions: Preliminary evidence supports the use of bipolar and monopolar RF devices for hair removal, while fractional RF appears to be an emerging technology for hair growth. Additional studies are needed to investigate the efficacy, mechanisms, and parameters of radiofrequency devices for various hair applications., Competing Interests: The authors have no conflicts of interest to disclose., (Copyright © 2023 by S. Karger AG, Basel.)

Introduction: Alopecia areata is a heterogenous, immune-mediated hair loss disorder that can affect any hair-bearing site on the body. Despite being one of the most prevalent autoimmune skin diseases, treatments have historically been limited to off-label medications that have demonstrated limited efficacy, especially in more severe forms of disease. Thus, there has long been an unmet need for rigorously studied therapeutics in alopecia areata., Areas Covered: Janus kinase inhibitors have proven to be an effective class of drugs for treating several inflammatory disorders. One such drug, baricitinib, has recently demonstrated significant hair regrowth in phase 2 and 3 alopecia areata trials. It has since become the first systemic therapy approved for treating severe alopecia areata. This review examines the role of Janus kinase pathways in alopecia areata's pathogenesis and the safety and efficacy of baricitinib for treating severe alopecia areata., Expert Opinion: The approval of baricitinib for treating severe alopecia areata marks a major milestone in the disease's history. While baricitinib has proven to be efficacious for this indication and has demonstrated an overall good safety profile, patients' individual risk factors for serious adverse events should be assessed during shared decision-making with patients before initiating treatment.

Background: Alopecia areata is characterised by non-scarring loss of scalp, face, or body hair. We investigated the efficacy and safety of ritlecitinib, an oral, selective dual JAK3/TEC family kinase inhibitor, in patients with alopecia areata., Methods: In this randomised, double-blind, multicentre, phase 2b-3 trial done at 118 sites in 18 countries, patients aged 12 years and older with alopecia areata and at least 50% scalp hair loss were randomly assigned to oral ritlecitinib or placebo once-daily for 24 weeks, with or without a 4-week loading dose (50 mg, 30 mg, 10 mg, 200 mg loading dose followed by 50 mg, or 200 mg loading dose followed by 30 mg), followed by a 24-week extension period during which ritlecitinib groups continued their assigned doses and patients initially assigned to placebo switched to ritlecitinib 50 mg or 200 mg loading dose followed by 50 mg. Randomisation was done by use of an interactive response system and was stratified by baseline disease severity and age. The sponsor, patients, and investigators were masked to treatment, and all patients received the same number of tablets to maintain masking. The primary endpoint was Severity of Alopecia Tool (SALT) score 20 or less at week 24. The primary endpoint was assessed in all assigned patients, regardless of whether they received treatment. This study was registered with ClinicalTrials.gov, NCT03732807., Findings: Between Dec 3, 2018, and June 24, 2021, 1097 patients were screened and 718 were randomly assigned to receive ritlecitinib 200 mg + 50 mg (n=132), 200 mg + 30 mg (n=130), 50 mg (n=130), 30 mg (n=132), 10 mg (n=63), placebo to 50 mg (n=66), or placebo to 200 mg + 50 mg (n=65). 446 (62%) of 718 patients were female and 272 (38%) were male. 488 (68%) were White, 186 (26%) were Asian, and 27 (4%) were Black or African American. Of 718 patients randomly assigned, 104 patients discontinued treatment (34 withdrew, 19 adverse events [AEs], 12 physician decision, 12 lack of efficacy, 13 lost to follow up, five rolled over to long-term study transfer, four pregnancies, two protocol deviations, one declined to attend follow-up due to COVID-19, one attended last visit very late due to COVID-19, and one non-compliance). At week 24, 38 (31%) of 124 patients in the ritlecitinib 200 mg + 50 mg group, 27 (22%) of 121 patients in the 200 mg + 30 mg group, 29 (23%) of 124 patients in the 50 mg group, 17 (14%) of 119 patients in the 30 mg group, and two (2%) of 130 patients in the placebo group had a response based on SALT score 20 or less. The difference in response rate based on SALT score 20 or less between the placebo and the ritlecitinib 200 mg + 50 mg group was 29·1% (95% CI 21·2-37·9; p<0·0001), 20·8% (13·7-29·2; p<0·0001) for the 200 mg + 30 mg group, 21·9% (14·7-30·2; p<0·0001) for the 50 mg group, and 12·8% (6·7-20·4; p=0·0002) for the 30 mg group. Up to week 48 and including the follow-up period, AEs had been reported in 108 (82%) of 131 patients in the ritlecitinib 200 mg + 50 mg group, 105 (81%) of 129 patients in the 200 mg + 30 mg group, 110 (85%) of 130 patients in the 50 mg group, 106 (80%) of 132 patients in the 30 mg group, 47 (76%) of 62 patients in the 10 mg group, 54 (83%) of 65 patients placebo to ritlecitinib 200 mg + 50 mg in the extension period, and 57 (86%) of 66 patients in the placebo to 50 mg group. The incidence of each AE was similar between groups, and there were no deaths., Interpretation: Ritlecitinib was effective and well tolerated in patients aged 12 years and older with alopecia areata. Ritlecitinib might be a suitable treatment option for alopecia areata in patients who are candidates for systemic therapy., Funding: Pfizer., Competing Interests: Declaration of interests BK served on advisory boards or was a consultant or clinical trial investigator for AbbVie, AltruBio, Almirall, AnaptysBio, Arena Pharmaceuticals, Bioniz Therapeutics, BMS, Concert Pharmaceuticals, Equillium, Horizon Therapeutics, Eli Lilly, Incyte, Janssen Pharmaceuticals, LEO Pharma, Otsuka/Visterra, Pfizer, Regeneron, Sanofi Genzyme, TWi Biotechnology, and Viela Bio. BK is on speaker bureaus for AbbVie, Incyte, Eli Lilly, Pfizer, Regeneron, and Sanofi Genzyme. WGH was a scientific advisor or clinical study investigator for Beiersdorf/Eucerin, BioNOOX, Eucerin, Galderma, GSK, Janssen, Johnson & Johnson, Pfizer, and Sanofi. JCS was scientific advisor or consultant for AbbVie, LEO Pharma, Novartis, Sandoz, Sanofi Genzyme, Trevi, and Viofor; speaker for AbbVie, Eli Lilly, Janssen-Cilag, LEO Pharma, and Sanofi Genzyme; and investigator for AbbVie, Amgen, BMS, Galderma, Galapagos, Incyte, InfraRx, Janssen-Cilag, Menlo Therapeutics, Merck, Novartis, Pfizer, Regeneron, Trevi, and UCB. JS was a consultant or clinical study investigator for 30 Madison, Eirion, Eli Lilly, Pfizer, and Regenlab; and stockholder of 30 Madison. CL was speaker or consultant for AbbVie, Altius, Amgen, Aralez, Arcutis, Bausch Health, Bayer, Boehringer Ingelheim, BMS, Celgene, Cipher, Dermavant, Eli Lilly, Fresenius Kabi, GSK, Innovaderm, Intega Skin, Janssen, Kyowa, La Roche Posay, LEO Pharma, L'Oreal, Medexus, Merck, P&G, Pediapharm, Regeneron, Roche, Sanofi Genzyme, Sentrex, TEVA, Tribute, UCB, Valeant, and Viatris; and principal investigator for AbbVie, Amgen, Aralez, Arcutis, Bausch Health, Bayer, Boehringer Ingelheim, BMS, Celgene, Cipher, Dermavant, Eli Lilly, GSK, Innovaderm, Janssen, Kyowa, LEO Pharma, L'Oreal, Merck, Pediapharm, Regeneron, Roche, Sanofi Genzyme, Tribute, UCB, and Valeant. NAM provided professional services for AbbVie, Arena Pharmaceuticals, BMS, Concert Pharmaceuticals, Eli Lilly, La Roche Posay, and Pfizer. RS provided professional services to Aerotech, AbbVie, AstraZeneca, Akesobio, Amgen, Arcutis, Arena, Ascend, Bayer, BMS, Boehringer Ingelheim, Celgene, Coherus BioSciences, Connect, Cutanea, Dermira, Eli Lilly, Galderma, GSK, Janssen, LEO Pharma, MedImmune, Merck, MSD, Novartis, Oncobiologics, Pfizer, Regeneron, Reistone, Roche, Samson Clinical, Sanofi, Sun Pharma, and UCB. SHZ, LN, DW, AF, DM, VP, and RW are employees of and own stock in Pfizer. RF was an employee of and owned stock in Pfizer at the time of this study. XZ declares no competing interests., (Copyright © 2023 Elsevier Ltd. All rights reserved.)

Competing Interests: Conflicts of interest None disclosed.

Hair lipid composition varies by ethnic hair type and by hair layer. Lipids in the cuticle, cortex, and medulla of the hair shaft provide a protective barrier to environmental and chemical damage, prevent hair breakage and desorption, and affect the elastic and tensile properties of hair. The aim of this systematic review is to provide an overview of the lipid composition and ethnic differences of human hair, effects of external damage on lipid content and properties, and changes in hair lipid composition associated with disease states. PubMed/MEDLINE was searched up to March 2021 according to PRISMA guidelines for articles discussing the lipid content of human hair and effects of physical, chemical, or environmental damage, and disease. Fifty-nine articles investigating the lipid content of hair were included for review. Lipids affect fluid permeability, hydration, strength, and texture of ethnic hair fibers. Lipid loss is accelerated by hair-damaging treatments such as bleach, dye, perm, straightening, and surfactant use, and sun and aging processes, leading to dehydrated, breakable, disordered, and dull hair. Diseases including acne, alopecia, and breast, gastric, prostate, lung, and rectal cancers display elevated hair lipid levels. Lipids are vital in protection against damage and maintenance of healthy hair. Further studies are needed to investigate the effects of lipids on the structural properties of ethnic hair, and changes in hair lipid composition with various dermatologic and systemic diseases., (© 2022 the International Society of Dermatology.)

Complete scalp hair loss can be a source of distress for affected children and their families. In addition to infectious and trauma-related causes of hair loss, infants and children may present with total scalp alopecia arising from a range of genetic predispositions. Our objective with this review was to identify the common genetic conditions in children with complete scalp alopecia. The PubMed Database was reviewed for all articles from 1962 to 2019 containing the search terms related to genetic alopecia. The conditions with at least five reported cases in the literature were considered for the inclusion. All clinical trials, retrospective studies, and cases on human subjects and written in English were included. Six genetic conditions related to complete scalp alopecia were included in this review. The most common genetic conditions associated with total scalp hair loss include: alopecia totalis/Alopecia universalis (AU), atrichia with papular lesions, AU congenita, hereditary Vitamin D-resistant rickets type IIA, alopecia with mental retardation, and pure hair and nail ectodermal dysplasia. In children presenting with total scalp hair loss, a myriad of genetic and environmental factors may be the underlying cause. Increased awareness of potential genetic conditions associated with total scalp hair loss may assist in diagnosis, with improved the prognosis for the children., Competing Interests: There are no conflicts of interest., (Copyright: © 2023 International Journal of Trichology.)

Background: Microfocused ultrasound with visualization (MFU-V) and calcium hydroxylapatite (CaHA) filler are modalities for improving skin laxity. Their use in combination on body sites other than the face is expanding., Objective: To investigate the effectiveness and safety of combination MFU-V and dilute CaHA (dCaHA) for lower anterior thigh and knee laxity over 12 and 24 weeks., Methods: Twenty women (40-71 years) with moderate to severe laxity of the anterior thigh and knee were enrolled in this split-body trial. Subjects received dual-depth (3.0mm, 1.5mm) or triple-depth MFU-V (4.5mm, 3.0mm, 1.5mm) to the inferior anterior thigh (127-381 lines) along with dCaHA (1:1 normal saline) injection (0.5-3mL). Clinical effectiveness was monitored using photography, qualitative clinician and subject assessments, and quantitative analysis of skin topography by three-dimensional imaging and dermal thickness by optical coherence tomography., Results: At 12 and 24 weeks, the treated thigh and knee experienced significant improvement in qualitative clinician scales ( p <0.01), with subjective improvement on photography and subject-reported assessments; no significant changes were noted by quantitative measures. Adverse events were reported in 68 percent of patients, including mild bruising (n=12) and swelling (n=10)., Conclusion: Combining MFU-V and dCaHA is safe and results in clinical improvement of anterior thigh and knee laxity., Competing Interests: DISCLOSURES: Funding and research product was provided by Merz North America, Inc., (Copyright © 2023. Matrix Medical Communications. All rights reserved.)

Recurrence of DRESS syndrome is poorly characterized, and dermatologists must be prepared to predict, identify, and manage patients after treatment of the initial presentation. In this study, a primary literature search was conducted using PubMed, capturing all articles recording cases of DRESS syndrome recurrence. Forty-two articles were included for review comprising a total of 60 patients. The average age of patients was 46.3 years and time to recurrence was 123 days. Recurrent episodes presented more frequently with a higher fever and eosinophil absolute peak. Relapse was most often attributed to the introduction of a new medication (n = 18). Of the 17 cases in which outcome data were available, the survival rate of those experiencing recurrence was 71%. Viral reactivation with HHV-6 and organ involvement of the liver were frequently recorded complications. In essence, viral reactivation, severe internal organ involvement, and hematological abnormalities all portended a poorer prognosis in those experiencing DRESS syndrome recurrence. An adequate course of treatment should be maintained until clinical and laboratory parameters normalize, with a slow taper to minimize the likelihood of relapse in those most at risk., (© 2021. The Author(s), under exclusive licence to Springer-Verlag GmbH Germany, part of Springer Nature.)

Objective: We sought to evaluate the impact of the coronavirus-19 (COVID-19) pandemic on sun-seeking and sun-safe behaviors., Methods: We conducted an online, cross-sectional, population-based survey., Results: In total, 1,001 respondents participated in the survey and reported being exposed to 12 or more hours of sunlight (i.e., direct and indirect ultraviolet light, and blue light) each day. Participants self-reported a net increase in all types of light exposure since the onset of the COVID-19 pandemic, especially to blue light (+38%). Notably, while the effects of direct sunlight were well known among survey respondents, they were less aware of the potential damaging impact of indirect sunlight and blue light., Limitations: As the survey was only conducted among residents of the United States, results might not be generalizable to all geographical regions., Conclusion: Social outreach strategies are required to improve sun-safe behaviors. Future behavioral interventions should encourage the implementation of broad-spectrum sun protection., Competing Interests: DISCLOSURES: The authors received honorarium fees from La Roche-Posay (L’Oréal, USA)., (Copyright © 2022. Matrix Medical Communications. All rights reserved.)

Competing Interests: Conflicts of interest None disclosed.

Abstract: Hair products are commonly used to maintain hair health or cosmesis. Products applied to the scalp and hair contain multiple active and inactive ingredients that can potentially cause irritant and/or allergic contact dermatitis. The objectives of this study were to identify and to discuss the most common allergens in scalp and hair applied products causing scalp allergic contact dermatitis (ACD). A PubMed search identified 99 studies, with 3185 patients and 31 categories of scalp products. Hair products reportedly associated with scalp ACD were hair dyes (41%), shampoos (28%), and conditioners (22%). The most commonly reported patch test-positive allergens were p -phenylenediamine (23%), nickel (15%), fragrance mix (13%), balsam of Peru (10%), cocamidopropyl betaine/3-dimethylaminopropylamine (7%), and methylchloroisothiazolinone/methylisothiazolinone (6%). Common symptoms and signs include eczematous lesions, pruritus, and a burning sensation. Medical practitioners should be aware of causative agents to provide appropriate patient education, counseling, and/or treatment., Competing Interests: The authors have no funding or conflicts of interest to declare., (Copyright © 2022 American Contact Dermatitis Society. All Rights Reserved.)

Background: Alopecia areata is an autoimmune condition characterized by rapid hair loss in the scalp, eyebrows, and eyelashes, for which treatments are limited. Baricitinib, an oral, selective, reversible inhibitor of Janus kinases 1 and 2, may interrupt cytokine signaling implicated in the pathogenesis of alopecia areata., Methods: We conducted two randomized, placebo-controlled, phase 3 trials (BRAVE-AA1 and BRAVE-AA2) involving adults with severe alopecia areata with a Severity of Alopecia Tool (SALT) score of 50 or higher (range, 0 [no scalp hair loss] to 100 [complete scalp hair loss]). Patients were randomly assigned in a 3:2:2 ratio to receive once-daily baricitinib at a dose of 4 mg, baricitinib at a dose of 2 mg, or placebo. The primary outcome was a SALT score of 20 or less at week 36., Results: We enrolled 654 patients in the BRAVE-AA1 trial and 546 in the BRAVE-AA2 trial. The estimated percentage of patients with a SALT score of 20 or less at week 36 was 38.8% with 4-mg baricitinib, 22.8% with 2-mg baricitinib, and 6.2% with placebo in BRAVE-AA1 and 35.9%, 19.4%, and 3.3%, respectively, in BRAVE-AA2. In BRAVE-AA1, the difference between 4-mg baricitinib and placebo was 32.6 percentage points (95% confidence interval [CI], 25.6 to 39.5), and the difference between 2-mg baricitinib and placebo was 16.6 percentage points (95% CI, 9.5 to 23.8) (P<0.001 for each dose vs. placebo). In BRAVE-AA2, the corresponding values were 32.6 percentage points (95% CI, 25.6 to 39.6) and 16.1 percentage points (95% CI, 9.1 to 23.2) (P<0.001 for each dose vs. placebo). Secondary outcomes for baricitinib at a dose of 4 mg but not at a dose of 2 mg generally favored baricitinib over placebo. Acne, elevated levels of creatine kinase, and increased levels of low- and high-density lipoprotein cholesterol were more common with baricitinib than with placebo., Conclusions: In two phase 3 trials involving patients with severe alopecia areata, oral baricitinib was superior to placebo with respect to hair regrowth at 36 weeks. Longer trials are required to assess the efficacy and safety of baricitinib for alopecia areata. (Funded by Eli Lilly under license from Incyte; BRAVE-AA1 and BRAVE-AA2 ClinicalTrials.gov numbers, NCT03570749 and NCT03899259.)., (Copyright © 2022 Massachusetts Medical Society.)