Tofacitinib for children & teens with Alopecia Areata

Tofacitinib for children & teens with Alopecia Areata

Some of the most difficult forms of alopecia areata to treat are those occurring in children. 
Treatments used for children with alopecia areata are typically similar to those used in adults with even more attention and concern placed on safety.

Recently, we have seen adults with alopecia areata get improvement with tofacitinib (also marketed under the name Xeljanz)

The question  then arises: Would tofacitinib help children? 

A recent study now proves that it does. Craiglow and colleagues from Yale published a study looking at 13 children age 12-18 with alopecia areata. 9 of them (69%) improved confirming that this drug is beneficial in children. 

The next question that is raised is what age to we draw the cut off and tell parents that their children they are too young for this medication. If 12 years old is acceptable, what about an 10 year old with alopecia areata? What about a 6 year old? What about a 2 year old? I think it's clear that most would agree some cut off exists, but what is it? That is where careful discussion with parents are so important. There is no universal right or wrong answer. There is no universal age cut off. For some the answer is no and for others it may be yes.

REFERENCE
Craiglow BG, et al. Tofacitinib for the treatment of alopecia areata and variants in adolescents.J Am Acad Dermatol. 2016 Nov 2

Platelet Rich Plasma (PRP)

PRP: Treating Alopecia Areata

How does PRP compare to minoxidil in the treatment of the autoimmune condition alopecia areata?

Researchers from Egypt studied the effect of PRP, minoxidil and placebo in 90 patients with alopecia areata. 
Patients with alopecia areata grew hair faster than patients receiving minoxidil. The authors conclusions were that PRP was more effective than minoxidil for patients with alopecia areata.

Reference
Platelets rich plasma versus minoxidil 5% in treatment of alopecia areata: A trichoscopic evaluation.
El Taieb MA, et al. Dermatol Ther. 2016.

Arrector Pili Muscle (APM)

Arrector Pili Muscle (APM)

The arrector pili muscle (APM) is not as well known as other muscles like the biceps, triceps or quadriceps. The APM is a small muscle attached to every hair. When it contracts, the result is goose pimples! It has been thought that the APM does not have any active role in any of the various mechanisms of hair loss and more or less acts as a ‘bystander.’ In new model of how balding develops, Australian dermatologist Rodney Sinclair and colleagues propose a model for understanding androgenetic alopecia. They propose that the APM has a key role in the decision of a hair follicle to ultimately "miniaturize" or get skinnier during the course of AGA.

By observing how miniaturization occurs within follicular units – the authors propose that by maintaining attachment to the APM, some hair follicles are prevented from proceeding down the pathway of permanent miniaturization.

Like all models, this proposal sets the stage for further exploration. The APM has perhaps been ignored for too long and may have a more important role than we ever imagined.

Reference
Sinclair R, Torkamani N and Jones L. Androgenetic alopecia: new insights into the pathogenesis and mechanisms of hair loss. F1000Res. 2015 Aug 19;4 (F1000 Faculty Rev):585

Sebaceous Glands (SB)

Sebaceous Glands

It takes a lot of coordination by many cell types to finally produce a healthy hair fiber. One particular participant is the sebaceous glands (also called the oil glands). The sebaceous glands secrete an oily substance to help lubricate the hair follicle. The substance also has anti-microbial and antibacterial properties to help prevent the hair follicle from becoming infected.

Without sebaceous glands, a hair follicle can't form properly. Mice engineered in the lab that have abnormal sebaceous glands develop a scarring alopecia (scarring hair loss condition) which teaches us just how important these structures really are.

The sebaceous glands get bigger in patients with genetic hair loss and this can often be seen in their biopsies. The sebaceous glands get smaller and then disappear altogether in patients with scarring hair loss (scarring alopecias) and this phenomenon can always be seen in their biopsies.

Dermal Papilla (DP)

Dermal Papilla

It takes a great deal of coordination by many cell types to finally produce a healthy hair fiber. Let me tell you about one participant - the dermal papilla.

The dermal papilla is found at the bottom of the hair follicle. It is composed of a group of very specialized cells known as fibroblasts.

The dermal papilla is a key control centre for the hair follicle. It tells another group of cells known as the "hair matrix" exactly what to do in order to make a hair fiber.

The more active and bigger the dermal papilla, the bigger and wider the hair follicle that will be produced. 
The dermal papilla has the potential to form new hairs when transplanted into other areas of the skin and are therefore said to be "trichogenic" (hair forming).

One day, it may be possible to take a patient's skin and expand the number of dermal papilla cells they have and inject them back into their scalp. This could lead to an endless supply of hairs.

Preparing a Scalp Biopsy

What happens when a scalp biopsy is sent to a pathologist

Typically a 4 mm diameter cylindrical core sample is obtained from the patient. The tissue is allowed to bathe in formalin to fix it before being cut into very thin slices (4-5 micrometer thick), mounted onto a microscope slide and then stained with a special pink/purple stain known as hematoxylin and eosin. Once the biopsy specimen is stained, it is presented to the pathologist for interpretation. A formal report is then sent to the dermatologist.

Finasteride

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Scalp Psoriasis

Scalp Psoriasis in Children

Psoriasis is an immunological skin disease, affecting 2-3 % of adults. Studies have suggested that 1 out of every 200 children have psoriasis.

Most psoriasis in children affects the body (plaque and guttate psoriasis) and the folds (inverse and diaper) but the scalp is a fairly common site as well. Girls tend to be slightly more affected than boys. Most children are healthy, however obesity is found in 25 %.

This photo shows a typical presentation of the red, scaly areas of scalp psoriasis. These areas are frequently itchy and bleeding is not uncommon (as shown here).

Alopecia Areata on the eyebrows

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Alopecia Areata on the eyebrows

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Spironolactone vs Finasteride

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Why won't my hair grow long?

Hair won't grow long- what are the reasons?

Many individuals with hair loss claim that their hair has stopped growing and hasn't grown in months. This is actually not a possibility. Hair MUST grow and can not sit in the scalp for months and months stagnant. What is happening is either the hair is breaking off, coming off, or not growing long anymore due to shortened growth cycles. 

My hair just won't grow! A look at possible reasons.

1. Androgenetic alopecia (AGA) 

For women with AGA, the growth cycle become shorter and hairs become thinner. Hair that once grew for 3-4 years and down to the mid back now only grow for 1-2 years and down to the shoulders. The impression to the individual is that it is not growing anymore. 

2. Hair breakage from heat, dyes and chemicals

Heat, dyes, chemicals can cause hair breakage. Hair breaks from the shaft rather than the root. Small short pieces of hair are found. This cases a phenomenon called trichorrhexis nods. The impression to the individual is that it is not growing anymore. 

3. Telogen effluvium (TE)

Telogen effluvium refers to hair shedding. Stress, thyroid problems, low iron, crash diets and medications all cause shedding. Similar to AGA (above), the hair cycles are shorter and shorter hairs are produced. The impression to the individual is that it is not growing anymore. 

4.  Adult onset loose anlagen syndrome. 

This is an uncommon condition in adults where the hair does not stay rooted in the scalp properly. In essence the glue that holds hair in place in the scalp is faulty. The impression to the individual is that it is not growing anymore. 

Aromatherapy for Alopecia Areata: A Look at the Evidence

Aromatherapy: Does it really help alopecia areata?

Aromatherapy refers to the use of aromatic plant-based essential oils for massage into the scalp. A well conducted study from almost 2 decades ago showed benefit of aromatherapy in the treatment of the autoimmune disease alopecia areata.

Dr Hays and colleagues set out to investigate the efficacy of aromatherapy in the treatment of patients with alopecia areata. They conducted a randomized, double-blind, controlled trial over 7 months.

86 patients diagnosed as having alopecia areata were divided into 2 groups. The active aromatherapy group massaged essential oils (thyme, rosemary, lavender, and cedarwood) in a mixture of carrier oils (jojoba and grapeseed) into their scalp daily. The control group used only carrier oils for their massage.

Remarkably, 19 of 43 patients in the aromatherapy group (44%) showed improvement compared with just 6 (15%) of 41 patients in the control group.

This remarkable study suggested a benefit for essential oils for some individuals with alopecia areata.

I advise patients to rub the following essential oil mixture on their scalp: 1 ml lavender, 1 mL thyme, 1 mL rosemary, 1 mL cedarwood oil in 100 mL jojoba. These are rubbed daily on the scalp.

Reference
Hay IC, et al. Randomized trial of aromatherapy. Successful treatment for alopecia areata. Randomized controlled trial. Arch Dermatol. 1998.

Hair loss after bleaching

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Hair loss after bleaching

What is the normal post op course after a hair transplant?

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Do any dietary supplements help prevent Propecia side effects?

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Skin depressions in patients with alopecia areata

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What is the cause?

What is the root cause of my hair loss?

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Root cause of hair loss

Is PRP considered 'anti-inflammatory"?

Does PRP stop inflammation?

Is platelet rich plasma (PRP) considered "anti-inflammatory"? and if so - which inflammatory scalp conditions can it be used in?

Platelet rich plasma (PRP) procedures are short 1 hour procedures. They involve taking a patient's blood (generally about 30-120 mL) and spinning in down in a centrifuge type machine to obtain "PRP". From 120 mL of "whole blood", we usually obtain about 3-6 mL of concentrated PRP.

PRP has potential anti-inflammatory properties

PRP has potential anti-inflammatory properties. Studies in the joints and tendons of humans and animals have shown that a protein known as hepatocyte growth factor (HGF) may be responsible for the anti-inflammatory effects. Furthermore studies have shown that PRP can impair the ability of blood cells known as monocytes to differentiate into dendritic cells and activate the immune system.

PRP can sometime create inflammation

Other studies have shown that the white blood cells and neutrophils in PRP can be "pro-inflammatory" in some cases (rather than inhibiting inflammation) so we have a ways to go to understand all the effects of PRP!

We have had an interest in understanding PRP and whether it helps a range of hair loss conditions. For the autoimmune condition alopecia areata, we have published already that PRP can benefit some patients but not everyone. Whether PRP also helps inflammatory scarring alopecias is unknown but something we are very much interested in.

Reference

Bendinelli P, et al. Molecular basis of anti-inflammatory action of platelet-rich plasma on human chondrocytes: mechanisms of NF-κB inhibition via HGF.  J Cell Physiol. 2010.

Papait A, et al.Allogeneic platelet-rich plasma affects monocyte differentiation to dendritic cells causing an anti-inflammatory microenvironment putatively fostering the wound healing.  J Tissue Eng Regen Med. 2016.

Elevated DHEAS- Is it causing me to lose hair?

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