What's new in the pathophysiology of alopecia areata? the possible contribution of skin and gut microbiome in the pathogenesis of alopecia – Big opportunities, big challenges, and novel perspectives Kamila Migacz-Gruszka, Wojciech Branicki, Aleksander Obtulowicz, Magdalena Pirowska, Krystian Gruszka, Anna Wojas-Pelc International Journal of Trichology 2019 11(5):185-188 The term “microbiome” defines the collective genome of all commensal, symbiotic, and pathogenic microbes living in the human body. The composition of microbiota in the gut and skin is influenced by many factors such as the stage of life, nutrition, lifestyle, and gender. In the past few years, several scientific papers have demonstrated an implication of microbiota in many immune-mediated diseases, for example, diabetes, ulcerative colitis, and multiple sclerosis. The alterations in the proportion of gut microbiota have emerged as potential immunomodulators with the capacity to induce physiologic as well as pathologic immune responses against the human body, causing inflammation and destruction of tissues or organs. The microbiota influences the differentiation of adaptive immune cells not only in the gut but also in the skin. Alopecia areata (AA) is a dermatologic disorder which causes hair loss in most cases resistant to treatment. There are some clinical and experimental evidences indicating that AA is the demonstration of autoimmune attack against hair follicles. The factors that may implicate such an autoimmunity in AA still remain unknown. Despite more and more evidences demonstrate that human microbiome plays a key role in human health and diseases, to the best of our knowledge, no study has been conducted to analyze an implication of microbiome in the pathogenesis of AA. Undoubtedly, there is a need to performing a study which might explain the involvement of gut and skin microbiota in the unclear pathogenesis of AA and lead to alternative treatment options for numerous patients suffering from current treatment limitations.

Trichoscopic findings in normal hair and scalp in children under 17 years Jeta Y Buch, Sebastian Criton International Journal of Trichology 2019 11(5):189-198 Objective: The aim of the study is to establish normal values of measurable parameters, set the standard, and provide a framework for future reference. Materials and Methods: A total of 750 children of Malayalam speaking ethnicity with no hair or scalp diseases in anamnesis and clinical examination were included in the study. Children were divided into six age groups (neonates, infants, 1–5, 6–10, 11–14, and 15–17 years), and trichoscopy was performed in frontal, left and right temporal, vertex, crown, and occiput using Wi-Fi cordless digital dermoscope. Hair shaft, follicular opening, and perifollicular and interfollicular area were evaluated and analyzed with SPSS software. Results: Among the parameters analyzed, we observed that with 0.95 probability (95%), the terminal: vellus ratios are (26,29), (22,25), (22,26), (29,33), (25,29), and (19,24) in neonates; (11,14), (7,11), (9,13), (13,17), (12,16), and (7,12) in infants; (16,17), (10,11), (10,11), (16,18), (15,16), and (14,15) in 1–5 years; (17,18), (11), (11), (19,21), (23), and (16,17) in 6–10 years; (17,18), (9,10), (10), (19,20), (18,19), and (16,17) in 11–14 years; and (14,15), (8–9), (8,9), (15,16), (14, 16), and (13,14) in 15–17 years. Likewise, we have documented the various trichoscopic findings of different age groups. Conclusion: We propose the summary of trichoscopic patterns of different age groups with normal hair and scalp to accurately identify the abnormal.

Evaluation of the efficacy and safety of 308-nm monochromatic excimer lamp in the treatment of resistant alopecia areata Nabeel K Al Hamzawi International Journal of Trichology 2019 11(5):199-206 Context: Treatment of resistant alopecia areata (AA) can be very challenging and include many options with variable efficacy and safety profiles. The 308-nm excimer lamp has been claimed to offer an effective alternative without significant risks, though there exists a lack of guidelines in this setting. Aims: This study aimed to evaluate the efficacy and safety of the 308-nm excimer lamp in treating resistant AA in Iraqi patients. Settings and Design: A prospective interventional study. Subjects and Methods: Eighteen patients with multiple AA were enrolled in this study. All patients were treated with a 308-nm monochromatic excimer lamp, in two sessions per week for 12 weeks. The efficacy of this modality was evaluated using two methods, namely the Severity of Alopecia Tool (SALT) score and digital photographs which were taken at four points (baseline, 4 weeks, 8 weeks, and 12 weeks). The safety of the equipment was evaluated by the objective recording of adverse reactions and patient satisfaction. Follow-up continued for 6 months after treatment to assess the level of recurrence. Statistical Analysis Used: SPSS software version 23. Results: There was a statistically significant decrease in the SALT score from the baseline (range 11–30; mean 20.33 ± standard deviation [SD] 4.78) to 12 weeks (range 2–24; mean 9.11 ± SD 5.41) (P < 0.001). The overall response rate was 100%, and successful (>50%) regrowth of hair was seen in 55.5% of patients (n = 10). Younger patients responded to the treatment more than the older age group (P < 0.05). No significant side effects were recorded. Conclusions: The results suggest that 308-nm excimer light has a significant effect on resistant cases of multiple AA, with considerable safety and tolerability.

Hair and scalp disorders in children below 2 years: An unremarked sphere Balvinder Kaur Brar, Sukhmani Kaur Brar, Rajvir Kaur, Naveen Sethi International Journal of Trichology 2019 11(5):207-212 Context: Hairs contribute significantly to our appearance and are mirror to many systemic diseases. Hair and scalp disorders in children are associated with profound psychological effects arising from concerns of chronicity, severity, and contagiousness, in addition to cosmetic outline. Studies have documented children below 2 years as the most common age group affected by hair and scalp disorders in the pediatric population; however, to the best of our knowledge, none has been carried out exclusively on this age group, so far. Aims: To determine the pattern of hair and scalp disorders and their underlying etiologies in children below 2 years. Settings and Design: Observational and analytical. Subjects and Methods: Fifty consecutive patients, aged 0–24 months presenting with complaints of hair and scalp disorder, to the outpatient department of dermatology of a tertiary care hospital in North India, constituted the study population. Results: The most common disorder was seborrheic dermatitis (SD) 56%, followed by transient neonatal hair loss 22%. We also came across interesting cases of plica neuropathica (PN) 4%, trichotillomania 2%, and traction alopecia 6%, apart from a list of other disorders noted. The most common age group was 0–6 months. Conclusions: Hair and scalp disorders vary greatly with different demographic areas. In this region of the world, we came across cases of PN due to religious practices. SD was the most prevalent disorder as seen elsewhere. Trichotillomania noted in such a young child was not as a mere habit (as popularly believed), rather an act of anger. Hence, with this study, we want to emphasize the role of detailed history and examination, besides outlining the spectrum of disorders in this age group.

Apremilast in refractory alopecia areata Andrea Estébanez, Nuria Estébanez, Jose M Martín, Encarna Montesinos International Journal of Trichology 2019 11(5):213-215 Alopecia areata (AA) is a common disease characterized by nonscarring hair loss. There are no satisfactory therapies for extensive cases. Systemic immune suppressants are usually used despite their nonspecific actions and often associated side effects. Apremilast is an oral, small-molecule, inhibitor of phosphodiesterase 4 approved for the treatment of psoriasis and psoriatic arthritis. Its use in AA has shown variable results. Whereas a recent reduced clinical trial concluded a lack of efficacity, several case reports demonstrate a significant improvement. We report four cases of extensive AA successfully treated with apremilast.

Central centrifugal cicatricial alopecia following a patchy pattern: A new form of clinical presentation and a challenging diagnosis for the dermatologist Alba Gomez-Zubiaur, David Saceda-Corralo, María Dolores Velez-Velázquez, Ana Rodriguez-Villa Lario, Lidia Trasobares-Marugan International Journal of Trichology 2019 11(5):216-218 Central centrifugal cicatricial alopecia (CCCA) is included among the primary lymphocytic cicatricial alopecias. The current nomenclature of CCCA suggested by the North American Hair Research Society refers to the traditional clinical presentation pattern of this type of alopecia, which begins in the central area of the scalp and has a progressive and symmetric centrifuge evolution. However, some exceptions should be highlighted, and a new clinical variety of CCCA presenting with patches of hair loss affecting the lateral and posterior scalp has been recently described. Here, we report a new case of CCCA presenting with a patchy pattern. In addition to the fact that this new patchy presentation of CCCA is not contemplated in the current terminology, it has a difficult differential diagnosis with other alopecias that have patches as their presentation. In these cases, both the trichoscopy and the histopathology are indispensable for diagnosis that will allow a targeted treatment and avoid an unfortunate prognosis.

Alopecia areata treated with oral azathioprine: A case series Vikrant Saoji, Sandeep Kulkarni, Bhushan Madke International Journal of Trichology 2019 11(5):219-222 Alopecia areata is commonly encountered non scarring alopecia with clinical presentations ranging from localised bald patches to extensive involvement. Clinical course is variable ranging from self limiting disease to chronic relapsing and recalcitrant disease. Topical and oral corticosteroids; nonetheless being front line agents for the treatment of alopecia areata;are not advocated for long term administration due to potentially undesirable systemic side effects. Hence the need of steroid sparing immunosuppresive agents like Azathioprine is warranted which have desired therapeutic action without much systemic adverse effects. We report a case series of 4 patients of alopecia areata treated with systemic azathioprine monotherapy.

A painless, slow-growing ulcer on the scalp Fernando Garcia-Souto, Isabel Maria Coronel-Perez, Francisco Sosa-Moreno, Yessica Sanchez-Santos, Jerónimo Escudero-Ordoñez International Journal of Trichology 2019 11(5):223-225