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.

Anagen effluvium (AE) is a hair growth disorder that occurs due to a disturbance in the hair follicle cycling. The most common cause of AE is alopecia areata (AA). Autoimmune diseases like AA may develop after drug reaction with eosinophilia and systemic symptoms (DRESS) syndrome and are usually long-standing conditions. We report the case of a 17-year-old woman who developed a severe and abrupt AE after DRESS syndrome with a full and rapid recovery after two months of topical minoxidil.

Introduction: Frontal Fibrosing Alopecia (FFA) and Fibrosing Alopecia in a Pattern Distribution (FAPD) are two distinct entities of cicatricial pattern hair loss that share histological features of perifollicular lichenoid inflammation associated with concentric fibrosis. Although the pathophysiology of FFA and FAPD are still unknown, recently published reports of familial cases indicate a possible genetic correlation. Case Presentation: We report 6 cases of familial alopecia composed of mothers and daughters: five with FFA and one with FAPD. We describe clinical, trichoscopy and histological correlation in cases of familial alopecia. Conclusions: These cases of mother and daughter disease association suggest a potential benefit of and role for performing systematic scalp examinations of all first-degree relatives of patients with pattern cicatricial alopecia.

Introduction: The prevalence of frontal fibrosing alopecia (FFA) is increasing worldwide, though the pathogenesis remains unknown. Anecdotal reports describe alopecia occurring in an FFA pattern following facial surgical procedures, but this potential link remains unexplored. Objective: The objective of this study is to determine if a significant association exists between the diagnosis of FFA and a history of facial and scalp surgical procedures. Methods: This retrospective study comparing data from frontal alopecia patients to controls was conducted at a tertiary medical center. Additionally, a literature review was conducted on scarring alopecias occurring from scalp procedures. Results: Fifty percent of frontal alopecia patients (n = 54) reported a history of facial surgical procedures compared to 9.8% of controls (n = 51) (OR: 7.8 [95% CI: 2.77–25.98, p < 0.001]). Although no significant differences were observed in current daily facial sunscreen use, sunscreen use prior to alopecia onset was significantly higher in frontal alopecia (p = 0.295; p = 0.021). Sunscreen use was not a significant modifier in the association between frontal alopecia and facial surgical procedures (p = 0.89). Conclusions: A significant association exists between frontal alopecia clinically consistent with FFA and a history of facial surgery, the nature of which is unclear. The role of sunscreen use and frontal alopecia development in this setting needs to be better elucidated.

Background and Objectives One of the challenges in developing effective hair loss therapies is the lack of reliable methods to monitor treatment response or alopecia progression. In this study, we propose the use of optical coherence tomography (OCT) and automated deep learning to non-invasively evaluate hair and follicle counts that may be used to monitor the success of hair growth therapy more accurately and efficiently. Study Design/Materials and Methods We collected 70 OCT scans from 14 patients with alopecia and trained a convolutional neural network (CNN) to automatically count all follicles present in the scans. The model is based on a dual approach of both detecting hair follicles and estimating the local hair density in order to give accurate counts even for cases where two or more adjacent hairs are in close proximity to each other. Results We evaluate our system on 70 OCT manually labeled scans taken at different scalp locations from 14 patients, with 20 of those redundantly labeled by two human expert OCT operators. When comparing the individual human predictions and considering the exact locations of hair and follicle predictions, we find that the two human raters disagree with each other on approximately 22% of hairs and follicles. Overall, the deep learning (DL) system predicts the number of follicles with an error rate of 11.8% and the number of hairs with an error rate of 18.7% on average on the 70 scans. The OCT system can capture one scalp location in three seconds, and the DL model can make all predictions in less than a second after processing the scan, which takes half a minute using an unoptimized implementation. Conclusion This approach is well-positioned to become the standard for non-invasive evaluation of hair growth treatment progress in patients, saving significant amounts of time and effort compared with manual evaluation. Lasers Surg. Med. (c) 2020 Wiley Periodicals, Inc.

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.

To the Editor: Recent evidence suggests that there are notable differences in the presentation of psoriasis between ethno-racial groups, with the Latino population often presenting to physicians with more severe psoriasis1 and increased body surface area (BSA).2 However, the specific clinical characteristics, such as the distribution of severity and BSA, in Latino patients remain unspecified. Additionally, there is a scarcity of Latino patients enrolled in psoriasis clinical trials and a clear lack of data on the relationship between psoriasis and comorbidities in this population.

Medical professionals that treat patients with alopecia usually lack knowledge about hair cosmetics. Trichologists focus on hair cycling and growth problems and not on the hair shaft integrity. This may lead to abandon of the use of the prescribed treatment, such as topical minoxidil or to inadequate traumatic grooming habits that may jeopardize hair follicle health. Shampoos, hair dyes, and hair-straightening products may alter hair fiber structure, remove lipids, and elude protein. Hair procedures such as hair dying and straightening have side effects and health concerns, especially for pregnant women or sensitive hair and scalp patients. Hair breakage, follicle traction, frizz, contact dermatitis, and mutagenicity are possible side effects of hair cosmetics misuse. The proper use of hair care products may help to increase patients' adherence to alopecia treatments and avoid health problems related to inadequate application of hair cosmetics and procedures.

BACKGROUND Periorbital hyperpigmentation (POH) is an aesthetic concern for patients. Etiologies of the condition include pigmentary, structural, vascular, and mixed causes. OBJECTIVE To systematically review the current literature for treatment of POH. METHODS A systematic literature review was performed on PubMed. Search terms included "infraorbital dark circles," "dark circles," "periorbital hyperpigmentation," "idiopathic hyperchromia AND orbital," "under-eye circles," "ICHOR (idiopathic cutaneous hyperchromia of the orbital region)," "dark circles" AND "treatment," and "filler" AND "dark circles." RESULTS A total of 39 studies were included. Effective treatments for POH include lasers, topical creams and serums, fillers, chemical peels, carboxytherapy, plasma-rich platelet injections, blepharoplasty, and normobaric oxygen. CONCLUSION Soft tissue fillers and autologous fat grafting are most effective in treating dark circles due to volume loss. Blepharoplasty surgery is best when excessive skin laxity is the underlying cause. Various topical creams and chemical peels are useful in treating pigment-based POH, whereas lasers are mildly to moderately beneficial for both vascular and pigment types. Given the scarcity of high-quality evidence supporting these results, recommendations should be interpreted selectively. Additional randomized clinical trials studying POH will be helpful.

Background and ObjectivesTechnological advances in medicine have brought about many novel skin imaging devices. This review aims to evaluate the scientific evidence supporting the use of noninvasive optical imaging techniques to aid in the diagnosis and prognosis of inflammatory skin diseases.Study Design/Materials and MethodsPubMed and Scopus were searched in September 2020 according to PRISMA guidelines for articles using reflectance confocal microscopy (RCM), optical coherence tomography (OCT), and multiphoton microscopy (MPM) in inflammatory skin diseases, excluding studies monitoring treatment efficacy.ResultsAt the time of the study, there were 66 articles that addressed the utilization of noninvasive imaging in interface, spongiotic, psoriasiform, vesiculobullous, and fibrosing/sclerosing inflammatory skin dermatoses: RCM was utilized in 46, OCT in 16, and MPM in 5 articles. RCM was most investigated in psoriasiform dermatoses, whereas OCT and MPM were both most investigated in spongiotic dermatoses, including atopic dermatitis and allergic contact dermatitis.ConclusionsThere is preliminary evidence to support the diagnostic potential of noninvasive optical imaging techniques in inflammatory skin diseases. Improvements in the devices and further correlation with histology will help broaden their utility. Additional studies are needed to determine the parameters for diagnostic features, disease differentiation, and staging of inflammatory skin conditions. Lasers Surg. Med. © 2021 Wiley Periodicals LLC

Funding sources: none. Conflicts of interest: the authors declare they have no conflicts of interest. Dear Editor, Frontal fibrosing alopecia (FFA) and fibrosing alopecia in a pattern distribution (FAPD) are forms of primary cicatricial alopecia, classified as subtypes of lichen planopilaris.1, 2 FAPD and FFA may present with clinical overlap and similar histopathological and dermoscopic features.1 Parietal scalp involvement with frontal hairline recession can obscure the clinical delineation between FAPD and FFA. The aim of this study was to establish whether FAPD can be differentiated from FFA by histopathological analysis. We conducted a cross‐sectional analysis of biopsies from 43 women, all with a previous classical diagnosis of FAPD or FFA.1–4 All samples had horizontal sections in haematoxylin and eosin stain. Anisotrichia (hair fibre diversity) was present only in patients with FAPD. Twenty‐one histopathological markers were critically compared and contrasted. Analysis of nonparametrically distributed data was performed using the Mann–Whitney U‐test, and Person’s χ2‐test was used to measure association. The research complied with Good Clinical Practice guidelines and was approved by an institutional review board.

Alopecia areata (AA) is an autoimmune hair loss condition that is difficult to treat and frequently disruptive to the psychosocial well-being of patients. Platelet-rich plasma (PRP) is an innovative therapy that provides concentrated GFs that impart anti-inflammatory effects. Optical coherence tomography (OCT) is a noninvasive imaging modality with the potential for providing quantitative monitoring of AA response to PRP. Our objective is to share our experience using OCT to monitor the therapeutic progress of patients with AA treated with PRP. Two patients with patchy AA and one with alopecia universalis were treated with PRP three times at 6-week intervals as part of a larger clinical trial. Patients were followed from baseline to week 24 with OCT imaging. OCT demonstrates an increase in hair density associated with improvement in inflammation at week 24. Conversely, the patient with alopecia universalis did not experience any significant change in follicular activity. This case series exemplifies the potential of PRP in inflammatory regulation as well as hair regrowth in patchy AA, whereas there is no notable advantage in alopecia universalis. Our findings add evidence on the possible value of OCT in quantitatively assessing hair growth progress throughout a treatment course.

Lichen planus pigmentosus is a rare variant of classic lichen planus that most commonly affects Fitzpatrick skin phototype III to VI.1,2 The coexistence of lichen planus pigmentosus and frontal fibrosing alopecia (FFA) was first described by Dlova.3,4 In this work we studied lichen planus pigmentosus in female patients with cicatricial alopecia and defined clinical, dermoscopic and histopathological features related to this diagnosis.

Background and Objective Early diagnosis and treatment of hair loss disorders is vital in providing patients with improved psychological outcomes. Non-invasive imaging with optical coherence tomography (OCT) may be useful in characterizing and managing alopecia. Despite expanding clinical applications of OCT in dermatology, guidelines demonstratingin vivofeatures of normal and alopecic scalp images remain scant. This pilot study aims to provide an atlas of OCT findings of healthy and alopecia subjects, explore diagnostic quantitative endpoints of alopecia, and compare epidermal thickness and follicular density between scalp regions. Study Design/Materials and Methods A total of 32 patients (19-76 years old) were enrolled in the study, including healthy patients (n = 6), and patients with scarring alopecia (n = 12) or non-scarring alopecia (n = 14). An in-line fiber-based swept source OCT was used to image five scalp locations at baseline and 6-month visits. Three investigators evaluated each image for gross features, epidermal thickness, and follicular density. Results Only data from baseline imaging analysis is discussed in this manuscript. Qualitative differences of OCT images are identified in sample images from healthy scalp and each subtype of alopecia studied. Scarring alopecia is characterized by significantly increased epidermal thickness (average Image J pixel units 32 +/- 2 compared with non-scarring alopecia [average 28 +/- 3] and control [average 27 +/- 3]) (P = 0.022) and decreased follicle count (average 35 +/- 5 in a 5 x 7 mm(2)area compared with control (50 +/- 3) and non-scarring patients (47 +/- 6)) (P = 0.0052). Scalp location had no impact on epidermal thickness (P = 0.861) or follicular density (P = 0.15). Conclusion OCT holds promise as a non-invasive technique to further characterize and objectively measure alopecia. Larger sample sizes and longitudinal data are needed to improve reliability and determine if additional distinction between alopecia subtypes and treatment monitoring is possible. Lasers Surg. Med. (c) 2020 Wiley Periodicals, Inc.

Hidradenitis suppurativa (HS) is a systemic recalcitrant inflammatory condition characterized by debilitating lesions with high morbidity. Its known association with obesity and smoking indicate correlation with other environmental factors, such as diet, suggesting a larger role for lifestyle modifications in disease treatment. This study seeks to assess the contribution of weight loss and dietary intake in HS management. A primary literature search was conducted using PubMed, Web of Science, and CINAHL in November 2018 to include association and intervention studies on the influence of diet and weight on HS. Twenty‐five articles were included. Meta‐analysis of nine case–control studies across Asia, Europe, and the United States showed that HS patients are four times more likely to be obese compared to the general population; random effects pooled odds ratio 4.022 (2.667–6.065), P < 0.001. Five articles assessed weight‐loss interventions and revealed mixed findings. The remaining articles included three association studies on micronutrient levels, eight dietary intervention studies, and one article analyzing both micronutrient association and dietary intervention. Included articles in this systematic review reveal that low serum zinc and vitamin D levels are associated with increased lesion count in HS. Supplementation of zinc, vitamin D, vitamin B12, or exclusion of dairy or brewer’s yeast can be effective in partial or complete lesion resolution. Reviewed data show that weight loss from bariatric surgery may lead to HS improvement but often results in more severe malnutrition that worsens or even leads to new onset HS post bariatric surgery. Future reporting is needed to conclusively determine the role of diet in HS.

Introduction: Frontal fibrosing alopecia (FFA) is characterized by scarring hair loss of the frontal hairline. Despite an increasing prevalence of FFA worldwide, the exact pathogenic mechanism remains unknown. Anecdotal reports describe alopecia occurring in an FFA pattern following facial surgical procedures, but this potential link remains unexplored.

Background: Alopecia areata (AA) is caused by autoimmune attack of the hair follicle. The exact pathogenesis is unknown, but hypotheses include innate immunity imbalance, environmental exposures, genetic predisposition, and possibly the microbiome. The objective of this study was to characterize the skin and gut microbiome of AA patients, and compare microbial composition to healthy individuals. Methods: This was a pilot, case-control study. Scalp and fecal microbiome samples were collected from 25 AA patients, and 25 age, gender, and race-matched healthy controls in Southern California with no significant difference in demographic characteristics. After library preparation and identification of bacterial and fungal taxonomy, multivariant analysis was performed to compare AA and healthy microbiomes. Results: The AA scalp microbiome was significant for decreased Clostridia and Malasseziomycetes, and the gut microbiome was significant for decreased Bacteroidia and increased Bacilli (p<0.05) compared to healthy controls. Conclusions: The composition of the AA bacterial and fungal, scalp and gut microbiome is significantly different than healthy individuals. Future directions include using this data to characterize microbial changes associated with AA patient diet, relating to disease severity, and predicting disease progression, prognosis and/or therapeutic response.

While isotretinoin has been the gold-standard of therapy for severe acne since its approval in 1982, its anti-inflammatory properties makes it a potentially applicable and versatile therapy for a wide variety of dermatologic conditions yet to be explored. This systematic review comprehensively recounts the success of oral isotretinoin in non-acne cutaneous diseases and provide insight into future directions of isotretinoin utility. A systematic literature review was performed using PubMed. Search terms included “isotretinoin” OR “accutane” AND “skin” OR “dermatology” OR “hair” OR “nails” OR “rosacea” OR “psoriasis” OR “pityriasis rubra pilaris” OR “condyloma acuminata” OR “granuloma annulare” OR “darier’s disease” OR “non-melanoma skin cancer” OR “frontal fibrosing alopecia” OR “cutaneous lupus erythematosus” OR “hidradenitis suppurativa” OR “photodamaged skin” OR “skin aging” OR “wart” OR “flat warts” OR “plane warts” OR “lichen planus” OR “dissecting cellulitis” OR “folliculitis decalvans” OR “sebaceous hyperplasia” OR “cutaneous t-cell lymphoma” OR “mycosis fungoides.” A total of 169 studies discuss the use of oral isotretinoin for 16 non-acne dermatologic conditions, the most common being non-melanoma skin cancers (0.2–8.2 mg/kg/day), cutaneous T-cell lymphomas (0.5–2 mg/kg/day), and rosacea (0.22–1 mg/kg/day). Inflammatory conditions such as rosacea, granuloma annulare, and hidradenitis suppurativa benefit from lower oral isotretinoin dosage of 0.3–1 mg/kg/day, whereas, hyperkeratotic diseases such as psoriasis and pityriasis rubra pilaris, consistently respond better to higher dosages of up to 2–4 mg/kg/day for lesion clearance. Recurrence of disease following discontinuation of isotretinoin have been reported for rosacea, psoriasis, granuloma annulare, Darier’s disease, dissecting cellulitis, and non-melanoma skin cancers. Disease exacerbation was reported in some patients with hidradenitis suppurativa. Off-label isotretinoin is an effective treatment choice for dermatological conditions beyond acne. Further prospective, randomized human trials are needed to clarify when and how to prescribe off-label isotretinoin for maximum efficacy and safety.

Background: Chemotherapy-induced alopecia (CIA) is a common adverse effect of chemotherapy. 8% of patients consider declining chemotherapy due to CIA risk.Objective: To determin whether cancer patients who are actively receiving chemotherapy are interested in preventing or treating CJA.Materials and Methods: This is a survey-based, cross-sectional study of cancer patients undergoing chemotherapy infusion at a tertiary medical center. Data including demographics, cancer diagnosis, medical literacy, quality of life, hair quality satisfaction, and costs patients were willing to accrue for CIA prevention/treatment were gathered.Results: Sixty-two adults were enrolled, mostly 55 to 64 years of age, female (72.6%), and White (63.8%). Many patients were diagnosed with malignancies associated with a high rate of morbidity-mortality including ovarian, lung and pancreatic. In our cohort, all patients would not decline cancer treatment based on CIA risk. 94.6% of patients were unwilling to risk cancer recurrence, 80.9% additional side effects, 55.8% extra time outside of infusion and 47.9% to pay out-of-pocket for CIA prevention/treatment.Conclusions: Patients with high cancer disease burden will not decline current treatment due to CIA risk. In addition, they are not willing to sustain additional discomfort, cost or time to prevent or treat CIA.