Alopecia is one of the side effects of chemotherapy that patients fear most; to the point that, just for that reason, up to 14% of women refuse chemotherapy. In fact, chemotherapy drugs destroy cancer rapidly growing cells, but do not spare other rapidly growing cells, including hair keratinocytes. In temporary alopecia, full regrowth is, however, possible. Within 96 h, DNA is repaired and hair bulb structures are restored [1], and within 3–6 months, new hairs are visible [2]. In 65% of patients, they acquire temporary different features, including curliness in 35% of cases [3]. Permanent or persistent alopecia (PA) is another possible outcome. High-dose busulfan and cyclophosphamide regimens, but breast cancer protocols as well, often including taxanes, are reported to cause it [4]. Almost constantly, all hairy areas are involved. The severest forms occur in up to 10% of cases and seem to be associated with regulatory variants in the ABCB1 gene [5]. The literature on the topic is remarkably vast and well documented but fails to answer an intriguing question: why do only some of the treated patients lose their hair, no matter the quality and dosage of the drug? The issue is quite complicated possibly because most of the researchers are not fully aware of the multifaceted aspects of trichology. Dermatologists as well often fail to deliver reliable data, as Tosti et al. [6] properly pointed out. According to Tallon et al. [7], for example, the histopathology of PA does not reveal any inflammatory sign, while scarring alopecias have been described [2] quite probably resulting from inflammation, and trichodynia [8], which may depend on peribulbar inflammation, has been reported in up to 87% of cases [9].

The progressive reduction of the number of terminal hairs and the simultaneous increase in the number of vellus hairs (hair miniaturization) are the current explanation of human baldness. In a 2.5-year study on 43 male subjects with androgenetic alopecia (AGA), we found that oral finasteride augmented the total number of hairs by 55%, but failed to decrease the prevalence of vellus hairs. While our data may explain why, in AGA, hairs become progressively softer and combable, they cannot explain why areas of hair rarefaction develop. We propose that the longer duration and higher frequency of kenogen hairs are the real mechanism through which the scalp hairs rarefy.

Polymorphous light eruption (PLE) is the commonest immuno-mediated photodermatosis. It occurs after solar or artificial UV-light exposure and affects only the sun-exposed areas with preference of the V-area of the chest, of arms and forearms, legs, upper part of the back, and rarely the face. The lesions are itching or burning, and vary morphologically from erythema to papules, vesico-papules and occasionally blisters, plaques, sometimes erythema multiforme-like, insect bite-like wheals and purpura. The clinical manifestations befall within a few hours to days from light exposure, last a few days, and subside in about a week without sequelae. Its diagnosis is based on history, morphology and phototests. PLE is considered as a delayed hypersensitivity response to newly UV induced, but still unidentified, antigen(s). Usually, MED is normal, but the provocative phototests with UVA or UVB reproduce the spontaneous lesions in about 50% of the patients. Broad spectrum sunscreens and antioxidants, photohardening with PUVA or narrow band UVB may be beneficial to prevent the disease. Therapy is based mainly on topical or systemic corticosteroids.

In women, hair loss may entail severe psychological disturbance. Hence, diagnosis needs to be assisted by a quantitative assessment. In this chapter, two simple but useful noninvasive methods are described. The pull test should be used first in any patient complaining of hair loss and indicates the severity of the disorder. The procedure consists in dipping the fingers into the scalp hair, in four different areas, and in counting the hairs that remain entrapped. Normally, only telogen hairs are shed and, in the adults, their number does not exceed four to five for the whole scalp. The hair number and the morphology of the hair roots suggest the diagnosis of non-scarring or scarring alopecias. The wash test (modified) consists in washing the hairs in a basin after refraining from shampooing for 5 days. All hairs collected on the basin floor (properly covered with a gauze) are counted and divided into hair shorter and longer than 3 cm. The former are considered vellus hairs. The global number of shed hairs indicate the severity of hair loss (telogen effluvium when >100), while the percentage of vellus hairs indicates the severity of androgenetic alopecia. The method permits to diagnose the association of telogen effluvium with androgenetic alopecia and to establish which of the two disorders is more severe and requires to be treated first. Though the two methods demand to be performed according to a strict standardized procedure, they are simple, cheap, noninvasive, and useful in the office.

Contrary to the classical view of the hair cycle, in which telogen is the resting phase that precedes the release of the hair shaft, another phase has been introduced, exogen. Exogen is the phase wherein the processes for the release of the hair shaft are initiated and successfully executed. Exogen ends when the shaft is liberated. Accordingly, human hairs would be preferably released not with telogen but with exogen roots. To better understand this somehow revolutionary point and what occurs in telogen effluvium (TE) and in androgenetic alopecia (AGA), we undertook a morphological study. We examined 25 women of comparable age by collecting shedding hairs by the Modified Wash Test under stringent diagnostic criteria. Eight patients were “normal”, 5 had AGA, 9 TE, and 3 had a TE+AGA overlap. Hair roots were divided into early telogen, full telogen, and exogen. Exogens accounted, in normal women, for 2.6% of all hairs, for 5.2% in AGA, for 6.6% in TE, and for 2.3% in TE+AGA, without any significant difference. Our exogen prevalence (2.6%) did not vary in patients with AGA and TE. Therefore, the pathogenetic role of exogen in AGA and TE seems negligible.

Background In clinical trichology, reference values are often arbitrary. The difficulty in setting them up depends mostly on the presence of the androgenetic alopecia (AGA) genotype in subjects with clinically unapparent forms. Prepubertal children, who lack 5 alpha-reductase (a real indicator of the AGA phenotype), might provide reference values independent from AGA. We verified whether the vertex/occiput ratios (V/O) of hair density and the V/O of hair diameter are suitable parameters.Methods In sixty 4-10-year-old Caucasian children, we measured the ratio between the hair density at the vertex and the occiput. The same was done for the diameter.Results The V/O of density averaged 1.07 +/- 0.17 and the V/O of diameter 1.02 +/- 0.11.Conclusions Taking the mean +/- 2SD as normal values, our "normal" V/O of density ranged between 0.73 and 1.41 and our "normal" V/0 of diameter between 0.8 and 1.24. People with lower ratios would have, therefore, AGA with 95% of probability. Moreover, we found that hair shedding using the hair pull test and the modified wash test come to 1-2 hairs/day.

The clinical diagnosis of hair diseases should be supported by objective techniques. In fact many methods are able to make advantage in some genetic syndromes with the aid of the microscope or to assess the severity of hair loss, or to distinguish a true disease from a visionary complaint of the patient. More commonly qualitative and quantitative methods are useful to distinguish androgenetic alopecia from telogen effluvium, or to recognize mild and initial cicatricial alopecias or the association of different forms of hair diseases. It is mandatory however the importance of the standardization of these technique in addition to identification of the normal values. Other techniques are essential to monitoring the effect of therapies for hair growth. Some of these methods are classified in non-invasive (pull test, wash test, daily count, phototrichogram), semi-invasive (trichogram and unit area trichogram) and invasive (biopsy).

The reliability of the methods currently used for diagnosing hair loss is ill defined. We studied 41 subjects complaining of hair loss, including androgenetic alopecia and telogen effluvium, and compared the results obtained with the modified wash test (MWT) and TrichoScan (R). Data were analysed statistically with the t-test and the Cohen statistic. The concordance between the clinical diagnosis and that of MWT (5% cut-off) was fair (=0.32) and that between clinical diagnosis and TrichoScan (R) was still fair though less satisfactory (=0.22). Only in 17 patients (41%) were the MWT and TrichoScan (R) diagnoses concordant. MWT was better in general and especially at detecting telogen effluvium (TE) (29% vs 19%). In conclusion, the clinical observation should be assisted by MWT and dermoscopy, leaving the biopsy for very difficult cases. TrichoScan (R) is less useful and may be even misleading in TE.

The reliability of the methods currently used for diagnosing hair loss is ill defined. We studied 41 subjects complaining of hair loss, including androgenetic alopecia and telogen effluvium, and compared the results obtained with the modified wash test (MWT) and TrichoScan®. Data were analysed statistically with the t‐test and the Cohen κ statistic. The concordance between the clinical diagnosis and that of MWT (5% cut‐off) was fair (κ = 0.32) and that between clinical diagnosis and TrichoScan® was still fair though less satisfactory (κ = 0.22). Only in 17 patients (41%) were the MWT and TrichoScan® diagnoses concordant. MWT was better in general and especially at detecting telogen effluvium (TE) (29% vs 19%). In conclusion, the clinical observation should be assisted by MWT and dermoscopy, leaving the biopsy for very difficult cases. TrichoScan® is less useful and may be even misleading in TE.

Androgenetic alopecia (AGA) is the most common acquired non scarring alopecia in humans caused by androgen hormones in the setting of a genetic predisposition. Usually AGA starts after puberty, but recently it has been observed also in adolescents. Their mean age was 13 years with a slight prevalence in males. The premature AGA may be caused by environmental, alimentary (meat and milk) or cosmetics overexposure to sexual hormones or to endocrine disrupters (EDs). EDs are "exogenous substances that interfere with the synthesis, secretion, transport, binding, action, or elimination of natural hormones in the body causing adverse effects to human health" and they are able bind to the steroid hormone receptors. Early onset AGA may be linked to the well known phenomenon of early puberty caused in some cases by hormones contained in food or by environmental chemicals. Therefore it is likely that the EDs may play a role also in the pathogenesis of early-onset AGA.

BACKGROUND/PURPOSE:Polymorphous light eruption (PLE) heterogeneity has been postulated, but the existence of benign summer light eruption (BSLE) is controversial. We studied the prevalence of the clinical patterns, criteria distinguishing BSLE from PLE, and diagnostic usefulness of phototest.METHODS:Five Italian Photodermatology Centres recruited retrospectively 346 patients with typical clinical history and/or presentation of PLE. Age, gender, skin type, family history and presence of atopy were considered. UVA and UVB MEDs and provocative phototests with UVA and UVB were obtained with a standardized procedure. Photopatch tests were applied according to the IRCDG rules. ANA were assessed by indirect immunofluorescence.RESULTS:Four criteria (predominance of women, shorter latency, uninvolvement of the face and absence of relapse during summer) identified BSLE in only 6.1% of cases. All had positive phototests, mostly with UVA. Uninvolvement of face, short latency and no seasonal relapses identified 11.7% patients, mostly with positive phototests to UVA. Short latency and no seasonal relapses in women identified 11.2% patients. Uninvolvement of face and no seasonal relapses in women identified 8.1% of patients. Uninvolvement of face and short latency in women identified 17.6% of patients.CONCLUSION:Criteria diagnosed BSLE in only a minority of patients, who were positive at phototesting, mostly with UVA.

AIM:The aim of this paper was to find a simple method to evaluate reliably diagnosis and severity of androgenetic alopecia (AGA) and telogen effluvium (TE).METHODS:We adopted the modified wash test (MWT), which accomplishes such task through assessing the number of shed hair and the vellus percentage. To evaluate its reliability, 25 subjects were submitted to MWT once a week for 4 consecutive weeks according to the procedure published elsewhere. The data were analysed by the intraclass correlation coefficient and ROC curves.RESULTS:The subjects were diagnosed as having TE (7 subjects), AGA (6 subjects), AGA+TE (4 subjects) and normal subjects (8 patients). An almost perfect reliability was found in AGA group for both total hair and vellus hair percentage, and in normal and TE groups for vellus hair count. Good reliability were found in all other cases, but in the total hair count in normal subjects in which it was only moderate. The areas under the ROC curve showed a sensitivity and specificity ranging from 50% to 100%.CONCLUSION:MWT can be employed with confidence in the office. It is simple, non-invasive and non-expensive and helps to distinguish TE from AGA, to identify cases of association TE+AGA, to assess the severity of the three conditions and, in TE+AGA association, to select which one is the most important and should be treated first. Possible biases and drawbacks are discussed.

Contact DermatitisVolume 63, Issue 3 p. 172-174 Consort allergic contact dermatitis caused by ketoprofen in a tango dancer Rosella Gallo, Corresponding Author Rosella Gallo Section of Dermatology – Di.S.E.M., University of Genoa, Genoa, ItalyDr Rosella GalloSection of Dermatology – Di.S.E.MUniversity of GenoaViale Benedetto XV 716132 GenoaItalyTel: +390103538433Fax: +390103538401e-mail: rs.gallo@unige.itSearch for more papers by this authorStefania Paolino, Stefania Paolino Section of Dermatology – Di.S.E.M., University of Genoa, Genoa, ItalySearch for more papers by this authorGuarrera Marcella, Guarrera Marcella Section of Dermatology – Di.S.E.M., University of Genoa, Genoa, ItalySearch for more papers by this authorAurora Parodi, Aurora Parodi Section of Dermatology – Di.S.E.M., University of Genoa, Genoa, ItalySearch for more papers by this author Rosella Gallo, Corresponding Author Rosella Gallo Section of Dermatology – Di.S.E.M., University of Genoa, Genoa, ItalyDr Rosella GalloSection of Dermatology – Di.S.E.MUniversity of GenoaViale Benedetto XV 716132 GenoaItalyTel: +390103538433Fax: +390103538401e-mail: rs.gallo@unige.itSearch for more papers by this authorStefania Paolino, Stefania Paolino Section of Dermatology – Di.S.E.M., University of Genoa, Genoa, ItalySearch for more papers by this authorGuarrera Marcella, Guarrera Marcella Section of Dermatology – Di.S.E.M., University of Genoa, Genoa, ItalySearch for more papers by this authorAurora Parodi, Aurora Parodi Section of Dermatology – Di.S.E.M., University of Genoa, Genoa, ItalySearch for more papers by this author First published: 03 August 2010 https://doi.org/10.1111/j.1600-0536.2010.01765.xCitations: 10 Conflicts of interest: The authors have declared no conflicts. Read the full textAboutPDF ToolsRequest permissionExport citationAdd to favoritesTrack citation ShareShare Give accessShare full text accessShare full-text accessPlease review our Terms and Conditions of Use and check box below to share full-text version of article.I have read and accept the Wiley Online Library Terms and Conditions of UseShareable LinkUse the link below to share a full-text version of this article with your friends and colleagues. Learn more.Copy URL Share a linkShare onFacebookTwitterLinkedInRedditWechat Citing Literature Volume63, Issue3September 2010Pages 172-174 RelatedInformation

well. A total of 31 tissue biopsies were collected in which the clinical differential included androgenic alopecia. The results came from six physicians in private practice and four physicians in academic practice. When scarring or inflammatory scalp disease was in the differential with androgenic alopecia (16 cases), the biopsy report showed scar or inflammatory cell infiltrate in 68% (11 cases). When scarring or inflammatory scalp disease was not in the differential (15 cases), the biopsy report showed scar or inflammatory cell infiltrate was noted in 46% (7 cases) (Fig. 1). The results highlight a potential challenge in alopecia and the reliance on pattern recognition for diagnosis. Scarring alopecia presentation in classic-pattern of non-scarring alopecia is not a well recognized or often discussed topic in the literature. The results show that although androgenic alopecia may have a classic clinical pattern, a significant number of occult inflammatory and scarring scalp processes may also mimic this pattern. This occurs with enough frequency that we question the possibility of making this diagnosis solely on clinical criteria. In androgenic alopecia, patients are rarely biopsied, as exemplified by our small sample size. However, these results show that when a biopsy is preformed, the clinical suspicion warranting the biopsy was verified in almost half the cases. Ultimately, we must also consider variables not controlled for in this study, such as reliance on the clinical skills of the physician. The limitation of samples to ACGME programme trained dermatologists was one way to control for clinical inexperience ⁄ training. Another limitation is that it may be possible to have had signs of inflammation on clinical exam that were not mentioned on the differential. However, it is our experience that when an inflammatory process (or other known aetiology) is expected, it is mentioned in the differential as was noted in almost half the samples. Ultimately, the need for more detailed analysis and study of these androgenic alopecia mimics is needed. We must also realize not all clinical androgenic alopecia is automatically only androgenic alopecia, and overlaps may exist. An increased awareness of the possible underlying inflammatory or scaring process can prove critical to early intervention with minimization, reversal or even prevention of potentially permanent alopecia. The continued need for research in this area is further underlined by the morbidity of this disease process.

© 2008 The Authors JEADV 2009, 23, 702–738 Journal compilation © 2008 European Academy of Dermatology and Venereology are deposited in the dermal papillae or at the dermo-epidermal junction, which leads to the typical granular immunofluorescence staining.2,3 Digital petechiae are a rare finding in adult dermatitis herpetiformis patients, but have been reported in about 64% of symptomatic children with dermatitis herpetiformis.4 Very rarely, purpuric lesions on the fingertips are the only sign of dermatitis herpetiformis.5,6 Differential diagnosis of palmar petechial lesions also includes trauma-induced haemorrhage, haemorrhagic Darier’s disease and subacute bacterial endocarditis. Diagnosis is made upon the clinical context, laboratory investigations and histology. However, biopsy specimens of palmar petechiae may reveal intense haemorrhage in the upper dermis that may overlay the typical histological signs of dermatitis herpetiformis. Therefore, direct immunofluorescence is of great importance since granular IgA deposits in the dermal papillae are diagnostic of dermatitis herpetiformis. In contrast, linear IgA deposition at the dermoepidermal junction occurs in dermatitis herpetiformis and linear IgA dermatosis. In these cases, detection of circulating antibodies against gliadin and transglutaminases confirms the diagnosis of dermatitis herpetiformis. A gluten-free diet should be recommended to the majority of dermatitis herpetiformis patients, and dietary compliance may be monitored by serological analysis of anti-transglutaminase antibody titres.7 A prompt improvement of skin lesions and pruritus in dermatitis herpetiformis patients is achieved with dapsone (diaminodiphenyl sulphone) treatment. Our patient was in excellent general health, but gastroesophageal reflux, duodenal biopsy and serological profiles were suggestive of celiac disease. Acid regurgitation and dyspepsia are common symptoms of celiac disease, although the pathophysiological mechanisms remain to be clarified. However, as reported recently, adherence to a gluten-free diet reduces reflux symptoms in the majority of celiac disease patients and prevents recurrence after withdrawal of proton-pump inhibitor treatment.8 Furthermore, a strict gluten-free diet reduces the risk of enteropathy-associated T-cell lymphoma.9 In conclusion, physicians should be aware of minimal symptoms of dermatitis herpetiformis and celiac disease. In oligosymptomatic cases, a mere dietary treatment may be sufficient.

Background.  Sun sensitivity is one of the predictors of melanoma risk, together with other individual characteristics such as skin and eye colour and number of naevi. However, it is unclear how best to measure sun sensitivity in order to quantify the individual risk of melanoma.

Background: Hamilton-Norwood scale (HNS) has been largely used to assess clinically the severity of androgenetic alopecia (AGA), especially for therapeutical trials and even to establish its association with important diseases such as ischemic heart disease and prostate cancer. Objective : To study HNS reproducibility in the hands of dermatologists and dermatology residents. Materials and Methods: Seven dermatologists and 16 residents in dermatology classified 43 photographs of male heads with different degrees of AGA. In a second study, 8 appraisers (3 dermatologists and 5 residents in dermatology) examined 56 pictures with the same procedure and repeated the observation 3 months later. In the first study, the inter-rater agreement was estimated by calculating an intra-class correlation coefficient (ICC). In the second study, for intra-rater repeatability, each rater's scores from session 1 were paired with his/her scores for the same subjects in session 2, and the ordinary least products linear regression was calculated. Results: In the first study, the concordance of appraisers was unsatisfactory (ICC = 0.63-0.68)]. In the second study, repeatability was poor, without any significant difference between dermatologists and dermatology residents. Comment: Reliability of HNS is unsatisfactory even in the hands of expert appraisers. To obtain better reliability, the number of classes should be reduced, but with such reduction HNS would be usable to classify patients only in a broad way.