A recent study published in the Journal of Cutaneous Medicine and Surgery describes the use of oral methotrexate as monotherapy for severe alopecia areata. Alopecia areata is a common autoimmune condition where the immune system attacks the hair, making it fall out in patches or occasionally in a diffuse pattern. Typical therapies include topical, intralesional, and systemic steroids, topical minoxidil, and topical immunotherapies. More recently, phosphodiesterase-4 inhibitors and JAK inhibitors have had some success but long-term safety has not yet been established.
Methotrexate has been used for many skin disorders for decades and has been recently proven to inhibit the JAK/STAT pathway, which is believed to play a significant role in the pathophysiology of alopecia areata. A meta-analysis in 2019 concluded that methotrexate has reasonable effectiveness in patients with severe alopecia areata. This recently published retrospective study looked at 15 patients with severe alopecia area who had failed standard therapies. 13 out of 15 patients (86.7%) improved on methotrexate monotherapy. Some patients had >70% improvement on methotrexate.
This study is valuable because it provides further evidence that methotrexate is another therapeutic tool we can use for the treatment of severe alopecia areata while we await further studies on the long-term efficacy and safety of newer drugs such as JAK inhibitors.
A recent study published in Dermatologic Surgery in May of 2021 compared different types of follicular unit extraction (FUE) graft injuries to see if there was any difference in survival. This was a mouse study where human follicles were transplanted into mouse recipients. In the study, they compared three types of follicular unit injury: paring, fracture, and bulb injury.
Paring refers to laceration of the outer root sheath or dermal sheath of the hair follicle whereas fracture refers to separation of the follicle into two or more pieces. In this study, the authors found that survival rates in the fracture group was the worst (18%). The survival rate in the paring and bulb injury groups was better than those in the fracture group but still significantly lower than the intact group.
This study demonstrates how important it is that hair transplant teams be aware of the need to preserve the integrity of hair transplant grafts, including the bulbs, dermal sheath, and outer root sheath as this can have an adverse effect of the results of the hair transplant procedure.
Frontal fibrosing alopecia (FFA) is an increasingly common cause of hair loss not just in North America but in many parts of the world. It is a type of scarring alopecia characterized by frontotemporal hair loss, as well as hair loss of the eyebrows in many cases. As it is a type of scarring hair loss, the hair loss is permanent and our treatments are focused on preventing disease progression.
There is no definitive cause for this hair disorder but many speculate that exogenous products may be causing this condition. One of the possible culprits may be sunscreens as several case-control studies suggest this may be a factor. A recent study published in the Journal of the American Academy of Dermatology found possible associations of frontal fibrosing alopecia with long-term use of facial moisturizers, ordinary (non-dermatologic) soap, and formalin hair straighteners. Interestingly, sunscreen use was not associated with FFA in this study, and smoking and anti-residue shampoos were found to be protective.
Although there is no absolute consensus on whether or not sunscreens are a culprit, this study does continue to support the possibility that topical products may be responsible for eliciting an inflammatory reaction causing hair loss. It might help explain why anti-residue/clarifying shampoos may be protective against this condition.
More research will need to be done to clarify the impact of exogenous agents on this type of scarring alopecia.
Cranwell WC, Sinclair R. Sunscreen and facial skincare products in frontal fibrosing alopecia: a case-control study.Br J Dermatol. 2019; 180: 943-944
This is a common situation where a woman comes into our office presenting with female pattern hair loss. It is often a question as to whether or not bloodwork is necessary to see if androgen excess is responsible for the hair loss.
A recent review article in the Journal of the American Academy of Dermatology 2021 looked at androgen-mediated skin disease and came up with an algorithm for when bloodwork or ovarian ultrasounds are necessary when investigating women with androgen mediated skin disorders.
The authors indicated if the woman presents with female pattern hair loss (FPHL) alone then no further bloodwork or investigation is required. However, if the woman has more than 1 androgen-mediated skin disorder (e.g. acne, FPHL, hirsutism) or has FPHL and menstrual irregularities or evidence of virilization, then bloodwork is recommended to rule out an underlying problem.
This algorithm clarifies the situations in which further investigation is necessary in the evaluation of FPHL.
A recent article published in the Journal of the American Academy of Dermatology outlined some of the world experts consensus opinions of therapeutic options for alopecia areata. Topical and intralesional corticosteroids were the most common treatments used for this problem, although other topicals such as calcineurin inhibitors, prostaglandin analogues like Latisse, minoxidil, and DPC were acknowledged to be useful in some situations.
With respect to systemic therapy, oral corticosteroids can sometimes be used although steroid-sparing agents would probably be preferred for chronic alopecia areata. If used, oral steroids generally require a taper over more than 12 weeks. Some of the steroid sparing agents mentioned include cyclosporine and methotrexate, as well as JAK inhibitors.
The main problem with platelet rich plasma (PRP) studies is that there are so many different ways of preparing PRP that it is difficult to assess the effectiveness of PRP as a whole. One practitioner may prepare the PRP differently from another or the method of injecting may be different from one another.
Despite this, this study is important because it provides further real evidence that PRP for androgenic alopecia in women is helpful. This study was performed by the Mayo Clinic and was published in Dermatologic Surgery 2020.
This was a randomized, controlled pilot study and patients were treated with either PRP followed by minoxidil after an 8 week washout period, or with minoxidil followed by PRP. The hair was analyzed using a TrichoScan device and looked at hair count, vellus hair density, terminal hair density, and cumulative thickness. The patients were also asked how they felt about the benefit or lack of benefit from treatment with minoxidil and PRP.
The study showed there was a definite improvement from PRP, although the study also suggests that minoxidil may have been slightly more effective in these patients. Interestingly, the patient’s subjective opinions about PRP vs. minoxidil was that PRP was more effective than minoxidil. Lastly, the authors noted there may be a combination effect from the two treatments.
Further studies are needed but this provides more objective evidence that PRP is effective for female pattern hair loss.
A Randomized, Controlled Pilot Trial Comparing Platelet–RichPlasma to Topical Minoxidil Foam for Treatment of Androgenic Alopecia in Women. Bruce AJ, Pincelli TP, Heckman MG, Desmond CM, Arthurs JR, Diehl NN, Douglass EJ, Bruce CJ, Shapiro SA. Dermatol Surg. 2020 Jun;46(6):826-832
In a recent post, we discussed the use of topical finasteride (Propecia) and went through the benefits and limitations of this agent. A recent study published by Haber et al. in the Hair Transplant Forum International looked at 762 men (663 on oral finasteride and 99 not on oral finasteride) and assessed whether or not they experienced any sexual dysfunction. The short answer seems to be that there was no evidence of increased sexual dysfunction in this study, which supports a previous systematic review of the literature that also did not show any evidence of increased sexual dysfunction from the use of oral finasteride.
Based on these studies, it seems that we can be even more confident about the lack of sexual side effects from the use of oral Propecia in male pattern hair loss. We will therefore continue to prescribe Propecia in the management of male pattern hair loss.
There are many different types of punch designs and some of them offer advantages over previous designs. At the most recent International Society of Hair Restoration Surgery 2020 conference, Dr. Nakatsui came across several new advances that he is eager to implement. One new advance is a new punch design that incorporates a hexagonal blunt portion of the punch shaft that uses vibration to help release the follicular unit from the surrounding tissue. As well, it has tiny grooves cut into the distal shaft. These changes, while they may appear subtle, should allow us to produce better grafts with even lower transection rates. Our dermatologist, Dr. Nakatsui, is really looking forward to incorporating this new advance into our FUE hair transplant procedures!
Dr. Nakatsui also came across several other hair transplantation advances that are very intriguing and will add these to our hair transplant blog in the near future.
The first study on topical finasteride was done in 1997 and showed a decrease in rate of hair loss at 6 months.
In 2009, another study compared topical finasteride to oral finasteride. This study was a double blind, randomized clinical trial. Both topical and oral led to increased hair counts, although the increase occurred 1 month earlier with oral finasteride. Another difference between the two groups was that the size of the area of hair loss decreased by the fourth month of treatment in the oral finasteride group, whereas there was no significant change in the topical group.
In 2018, Lee et al. reviewed 7 studies that looked at the use of topical finasteride for the treatment of pattern hair loss in men and women. They looked at several concentrations, including finasteride 0.005%, 0.25%, and 1%. The good news is that they all showed some efficacy with limited systemic effects. Overall, topical 0.25% finasteride solution applied once a day seemed to be the most effective. The downside is that topical finasteride did cause some scalp irritation in some participants, which could be a limiting factor for some patients. It is not clear if the irritation came from the finasteride itself or from one of the other components in the solution.
In a study by Ramos et al in 2019, oral minoxidil was investigated as an alternative therapy for female pattern hair loss. In the study, which was a 24 week, randomized, open study design, they compared 1 mg oral minoxidil to 5% topical minoxidil used for 24 weeks. The authors found that the increase in density with both treatments was very similar and there was no statistically significant difference.
Oral minoxidil was well tolerated and had very few side effects. Some of the reported adverse events included mild hypertrichosis in 27% of participants and increased mean resting heart rate.
Oral minoxidil at a dose of 1 mg daily may be an option, particularly in women who cannot tolerate topical minoxidil. However, this medication should probably be avoided in patients with pre-existing cardiac disease for the moment until it has been further evaluated.