ABSTRACT Context: Alopecia areata (AA) is one of the autoimmune diseases characterized by nonscarring hair loss. It may be associated with other autoimmune diseases. Calprotectin is a biomarker for inflammatory processes, which can trigger intracellular signaling cascades leading to the initiation of inflammatory processes. Serum and stool calprotectin were documented to be elevated in various inflammatory skin disorders like acne, psoriasis, and atopic dermatitis. Aim: The aim of the study was to evaluate serum calprotectin level in AA patients, correlating its level with disease severity and activity, and exploratory fecal calprotectin measurement in certain cases to detect if there is skin–gut axis. Settings and Design: Prospective Case–control study. Subjects and Methods: This prospective Case–control study included 33 AA patients and 30 healthy individuals as the control group. Serum calprotectin levels were measured in both patients and controls by enzyme-linked immunosorbent assay (ELISA) technique, and the severity of alopecia tool (SALT) score was done for all AA patients. Fecal calprotectin was measured by ELISA technique in the patients of AA with the highest serum levels. Statistical Analysis Used: All data were statistically analyzed using SPSS 18 for Windows (SPSS Inc., Chicago, IL, USA). Results: The results revealed that serum calprotectin level was higher in AA patients compared to controls in a statistically significant manner with P = 0.006, There was no significant correlation between calprotectin level and SALT score, P > 0.05, whereas fecal calprotectin was within normal range. Conclusion: Serum calprotectin may play a role in the pathogenesis of AA, but it cannot be used to monitor disease severity or activity.
ABSTRACT Introduction: A sudden outbreak of diffuse hair loss was reported from certain areas of Maharashtra from December 2024 to January 2025. Various possibilities, such as nutritional deficiency, toxins, and infections, were proposed as the possible etiology, both by the public and healthcare professionals. Therefore, our team visited the affected areas to assess these mysterious cases. Aim: The aim is to investigate the cause of unexplained acute hair fall in certain villages of Buldhana district in Maharashtra. Materials and Methods: The investigating team collaborated with the local administration to identify new cases of hair loss. House to house survey was done, and a total of twenty subjects (13 cases and 7 controls) were evaluated with detailed history and dermatological examination, including trichoscopy and skin biopsy. Appropriate samples from hair, scalp, serum, urine, and water sources were collected, and a complete clinical, epidemiological, biochemical, and microbiological analysis was done. Results: Anagen effluvium (AE) was noticed in 11 out of 13 (84.62%) cases. Biochemical analysis revealed significantly high selenium levels in patients’ serum (15 times higher) in cases as compared to controls. Serum levels of strontium and zinc were also found to be marginally higher in cases. Some of the random water samples demonstrated the presence of excess selenium and strontium, while no fungal elements were noticed in any of the hair samples. Conclusion: The recent outbreak of diffuse hair fall in Buldhana district of Maharashtra was due to AE, possibly related to selenium, strontium, and/or zinc excess. Further investigations are necessary to pinpoint the source of exposure.
ABSTRACT Concurrent occurrence of blaschkoid lichen planus pigmentosus (LPP) and lichen planopilaris (LPp) in a pediatric patient is exceedingly rare. We present a case of a 13-year-old female with blaschkoid LPP and LPp. The patient exhibited hyperpigmented lesions in a reticular pattern on the face, trunk, and extremities, along with alopecic patches on the scalp. Histopathological examination confirmed the diagnosis. This case highlights the importance of considering LPp as a differential diagnosis for scarring alopecia in pediatric patients, even in atypical presentations.
ABSTRACT Fox–Fordyce disease (FFD) is a rare chronic inflammatory condition of the apocrine sweat glands, primarily affecting women of reproductive age. It presents as intensely itchy follicular papules, commonly in the axillary, periareolar, and pubic regions, often mimicking other follicular dermatoses. We report the case of a 28-year-old woman with a 6-month history of itchy axillary and pubic lesions. Dermoscopy revealed brown folliculocentric rims, broken hairs, black dots, and an erythematous background. Histopathology confirmed FFD, showing perifollicular histiolymphocytic infiltrate, spongiosis, and infundibular hyperkeratosis. Topical clindamycin led to symptom improvement. This case underscores the importance of dermoscopy in diagnosing rare follicular dermatoses, expanding current knowledge on FFD’s clinical and dermoscopic features.
ABSTRACT Studies of human hair at the microscale have mainly been carried out using scanning electron microscopy and transmission electron microscopy. The development of the atomic force microscope (AFM) at the end of the 1980s enabled further research even at the nanoscale. The AFM technique does not alter the structure or composition of the hair fiber, which is why numerous attempts have been made to study hair using this technique. Initially, AFM was used for in-depth analysis of hair fiber surface morphology. Subsequently, it has become possible to study the mechanical properties of hair depending on the degree of damage or ethnicity and the influence of cosmetics. With the development of the method, hybrid AFM techniques have ensured the identification of hair structures and the study of their chemical properties. This article summarizes the available research on human hair using AFM with a focus on its application in the medical and cosmetological fields.
ABSTRACT Background: The accumulation of hard water metals in human hair has been observed. Its effects on hair health become pertinent as it is often implicated in poor hair quality. We aimed to review the relevant literature systematically and analyze the effects of hard water on (i) the deposition of hard water metals and (ii) the objective and subjective hair health. Methods: Pre-registration with PROSPERO was done. We searched PubMed, Cochrane CENTRAL, DOAJ, and EBSCOhost from inception till December 31, 2024. Human observational and experimental studies were included and meta-analyzed using a random effects model. Risk of bias was assessed using the Risk of Bias in Non-randomized Studies of Interventions I tool and the National Institute of Health quality assessment tool. The evidence was ascertained using the GRADE tool. Results: Nine studies were included. The calcium and magnesium deposition were higher by 2.07 standard deviation (SD) and 1.88 SD with hard water than with soft water. The tensile strength decreased by 0.282 SD when treated with hard water. The break stress, elastic modulus, shear modulus, combing forces, style retention, and surface irregularities increased with hard water treatment. There seems to be a positive correlation between ion deposition and the hardness of water, pH, and hair treatments. The subjective hair health is negatively impacted by hard water. Conclusion: The certainty of evidence was moderate for the decrease in tensile strength, whereas it was very low for the rest of the estimates. Hard water probably increases hair breakage due to significant deposition of calcium and magnesium ions, but more robust, real-world studies can provide a greater validation.
ABSTRACT Trichoscopy has become an essential non-invasive tool for the diagnosis of alopecia areata, demonstrating characteristic features such as yellow dots, black dots, and exclamation mark hairs. Involvement of the eyebrows may present a diagnostic challenge because the short length and small calibre of eyebrow hairs make identification of these features less conspicuous than on the scalp. In this case series of five patients with eyebrow alopecia areata, a distinctive trichoscopic pattern was observed. Small exclamation mark hairs were seen interspersed among normal eyebrow hairs in an arrangement that visually resembled small fish swimming upstream against the flow of a river. This appearance, termed the “fish against the flow sign,” results from the reversed tapering of exclamation mark hairs compared with the natural architecture of normal eyebrow hairs. Recognizing this pattern may facilitate the identification of exclamation mark hairs during trichoscopic examination and assist in the diagnosis of alopecia areata affecting the eyebrows.
ABSTRACT Male pattern baldness, or androgenetic alopecia (AGA), affects up to 80% of males by age 80. The nonsurgical gold standard topical minoxidil has limited efficacy due to variable patient response and twice-daily application requirements. Recent advances reveal that tretinoin, a topical retinoid, significantly enhances minoxidil efficacy through complementary mechanisms. This original article presents scientific evidence supporting tretinoin as an adjuvant therapy for male pattern baldness. The primary mechanism involves tretinoin’s ability to upregulate follicular sulfotransferase enzymes responsible for converting minoxidil to its active metabolite, minoxidil sulfate. Tretinoin enhances percutaneous drug absorption through modulation of stratum corneum permeability. Clinical studies demonstrate that combination therapy with 5% minoxidil and 0.01% tretinoin applied once daily provides equivalent efficacy to conventional twice-daily minoxidil monotherapy while improving patient adherence. Tretinoin can convert up to 43% of predicted minoxidil nonresponders into responders, representing a significant advancement in personalized AGA treatment. The safety profile remains favorable, with adverse effects comparable to minoxidil monotherapy. While the use of Tretinoin is not new, contemporary evidence supports the integration of tretinoin into standard minoxidil regimens with improved outcomes and patient adherence.
ABSTRACT Low-dose oral minoxidil has gained popularity as an off-label pharmacological treatment of hair loss with an alleged high safety profile. Since the original introduction of low-dose oral minoxidil for treatment of pattern hair loss by Sinclair, reported adverse effects (AEs) have been purported to be infrequent and of a minor impact, and some experts have suggested minoxidil as first line agent for treatment of alopecia. Nevertheless, as such it should be prescribed with caution and be monitored by physicians experienced and aware of the AEs of the drug and potential medicolegal issues due to its status as off label medication. Observations into the genetic basis of Cantú syndrome have identified the condition as a potassium channelopathy, corroborating the role of the sulfonylurea receptor that forms ATP-sensitive potassium channels for the hair growth promoting effect of minoxidil sulfate. The phenotype of Cantú syndrome involves a generalized terminal hair hypertrichosis, acromegaloid features, and cardiopathy including pericardial effusion. It may be inferred that the potential AEs of minoxidil represent a dose-dependent phenotypic mimicry of Cantú syndrome with interindividual variability in susceptibility, and are not idiosyncratic as formerly proposed. Indeed, besides hypertrichosis, oral minoxidil has been observed to cause pseudoacromegaly with high dose, and pericardial effusion even with low dose. Some experts advocate prescription of additional drugs to counteract the AEs of oral minoxidil. Particularly, spironolactone has found favor as a diuretic with antiandrogen activity, and more recently bicalutamide has been proposed to improve minoxidil-induced hypertrichosis in female pattern hair loss, however, minoxidil-induced hypertrichosis is by definition not androgen dependent, and bicalutamide is pregnancy category X in the USA, and pregnancy category D in Australia. Ultimately, the risk of adverse drug-related events increases with polypharmacy, especially in women and the elderly. Finally, oral minoxidil is contraindicated during pregnancy and lactation for reasons of teratogenicity and the possibility of hypertrichosis in the breastfed infant.
ABSTRACT Background: Scarring alopecia comprises a heterogeneous group of disorders, characterized by irreversible follicular destruction and permanent hair loss. This retrospective study examines the clinical characteristics and therapeutic outcomes of primary scarring alopecias managed at the National Skin Center, Singapore, from 2004 to 2020. Methods: Medical records of 300 patients diagnosed with discoid lupus erythematosus (DLE), frontal fibrosing alopecia (FFA), lichen planopilaris (LPP), folliculitis decalvans (FD), acne keloidalis (AK), dissecting cellulitis of the scalp (DCS), and pseudopelade of brocq (PoB) were reviewed. Results: Notably, classic LPP showed a disproportionately high prevalence among ethnic Indians (54.6%) compared to FFA (9.0%). This aligns with existing reports of increased lichen planus (LP) incidence in this population and suggests a stronger pathophysiological link between LPP and LP than between FFA and LP. Among lymphocytic variants (LPP, FFA, DLE, and PoB), 77.7% (212/273) of treatments achieved stabilization or improvement, with 6% showing marked improvement. Neutrophilic variants (FD, DCS) responded more favorably, with 81.5% (172/211) achieving positive outcomes, including 21.8% reporting improvement. Mixed scarring alopecia (AK) had the highest treatment response (85.5% stabilized, 26.5% improved). Isotretinoin demonstrated superior efficacy for neutrophilic alopecias compared to oral antibiotics, although the use was limited by adverse effects. FFA showed strong responses to topical corticosteroids (88.9%) and finasteride (83.3%). Systemic agents such as hydroxychloroquine and immunosuppressants improved the outcomes in severe lymphocytic cases. Conclusions: This study underscores the heterogeneity of scarring alopecias and highlights better treatment responses in neutrophilic and mixed variants. Early diagnosis and individualized therapy remain critical to optimizing patient outcomes.
ABSTRACT Context: Trichoscopy is a noninvasive diagnostic technique widely used in evaluating hair and scalp disorders. However, normative trichoscopic data for richly pigmented Africans remain limited. Aims: To describe the trichoscopic features of the healthy Nigerian scalp (Fitzpatrick skin types V and VI) and to assess the influence of age, sun exposure, and gender on these features. Settings and Design: A multicenter and cross-sectional study of 1020 healthy participants aged 5–82 years in three Nigerian states in 2023. Subjects and Methods: Trichoscopic assessment was performed across the four scalp regions (frontal, temporal, vertex, and occipital). Features evaluated included follicular openings, number of hair shafts per follicular unit, and pigmentation patterns. Data on sun exposure, hair care practices, and demographics were collected. Statistical Analysis Used: Analysis was conducted using SPSS version 26; P < 0.05 was considered significant. Results: Participants were 51.9% female, with a mean age of 28.4 ± 17.3 years. Non-sun exposure was reported in 25%. The most consistent findings were a preserved honeycomb pigment network (99.6%) and regularly distributed pinpoint white dots (99.3%). Inter-follicular scales were observed in 15.7%. Gender differences were noted in the presence of scales. Age and sun exposure had no significant impact on trichoscopic patterns. Conclusion: In individuals with Fitzpatrick skin types V and VI, preserved honeycomb pigmentation and regular pinpoint white dots are hallmark features of a healthy scalp and they are unaffected by age or sun exposure. The presence of interfollicular scales may occur in healthy individuals and is influenced by hair care practices and gender.
ABSTRACT Frontal fibrosing alopecia (FFA) represents a patterned scarring alopecia. Initially considered uncommon, its frequency has increased since its original report in 1994. While its etiology has remained obscure, attracting the attention of researchers and giving rise to speculations on its etiopathogenesis, particularly hormonal and environmental factors. In our opinion, FFA is among the currently most misunderstood trichological conditions, with speculations as to its origins so far having been rather confusing than clarifying. Specifically, FFA may have existed before 1994; the pattern of clinical disease presentation may be more specific for the condition than the underlying pathology, either lichen planopilaris, discoid lupus erythematosus, or folliculitis decalvans; so far, questionnaire-based studies in patients with FFA on the use of sunscreens and cosmetics have not been conclusive; and extension well beyond the frontal and temporal hairline to involve sexual hormones-independent areas, such as the occipital hairline, facial vellus hair, and peripheral body hair, in men specifically anterolateral leg-like alopecia, neither supports a role of sexual hormones or estrogen-like endocrine-disrupting chemicals for pathogenesis, nor a role for antiandrogens and 5alpha-reductase inhibitors for the treatment of FFA. “Failure is in a sense the highway to success, as each discovery of what is false leads us to seek earnestly after what is true” (John Keats).
Artificial intelligence (AI) is intelligence exhibited by computation, as opposed to natural human intelligence. Founded as an academic discipline in 1956, AI went through cycles of optimism, followed by periods of disappointment. The growing use of AI in our century is influencing a shift toward increased automation, data-driven decision-making, and the integration of AI systems into various areas of life, including health care. On the occasion of the European Academy of Dermatology and Venereology Spring Symposium 2024, reference was made to AI in dermatology, specifically trichology. Particularly in the domain of trichoscopy, AI's contribution to automated image analysis stands out. Due to the fairly standardized imaging and a limited amount of diagnoses, trichoscopic images have become a center of interest for automated medical image analysis and its commercial utilization. Yet, costly, multi-parameter computer-assisted trichoscopic image analysis is the least effective in medical practice. Using dermoscopy, signature patterns are seen in a range of scalp and hair conditions that have provided the foundation for diagnostic algorithms. Algorithms discourage physicians from thinking independently and with creativity. Doctors are trained to romance with technology. However, healing is replaced with treating, caring is supplanted by managing, and the art of listening is taken over by technology. The power of technology, particularly computer-based, may shake the confidence of a specialist in his initial diagnosis. Nevertheless, machines cannot replace the doctor's mind, and his thinking about what he sees and what he does not see. Ultimately, common AI mistakes are often not too different from mistakes born out of natural human error. Taking all of this into account, it does not seem wise to precociously hail an evolving technology in public without the respective experimentation and experience to back up its factual utility in our practice.
Canities subita is a rare condition characterized by sudden hair pigmentation loss. Although its etiology is under discussion, an association with alopecia areata (AA) has been proposed. We present the case of a 60-year-old male with rheumatoid arthritis who experienced abrupt hair whitening and a large bald occipital patch. Diagnosed with canities subita with concomitant AA, treatment with baricitinib led to remarkable hair repigmentation within 8 months and repopulation of the occipital patch. This case supports the link between canities subita and AA, evidenced by similar presentations. However, only a fraction of cases copresent with alopecia, suggesting alternative etiologies. Our findings suggest baricitinib as a potential treatment, particularly in AA-associated cases of canities subita. Further research is warranted to explore the efficacy and mechanisms of baricitinib in treating this condition.
