Nonpharmacological treatment approach in trichotillomania (hair‐pulling disorder)

Trichotillomania (TTM) is a fairly common psychodermatological disorder. This is characterized by recurrent urges to pull hair from hair‐containing parts of the body and produces bald patches on scalp. Besides scalp, eye lashes, eyebrows, and pubic area may be involved. Clinically two types are recognized, the automatic and focused types. Currently, this is classified into obsessive‐ and compulsive‐related disorder. Most common psychiatric manifestations include anxiety, depression, and low self‐esteem. It has bimodal distribution in children and adolescents and adults. No recognized treatment is available. Pharmacological treatment is based on limited trials and case reports. Psychotherapies are mainstay of treatment. This review mainly focuses on evidence‐based psychotherapeutic techniques used in the treatment of TTM.     

Trichotillomania

Trichotillomania (TTM) is an impulse disorder, in which patients chronically pull hair from the scalp and/or other sites. Very early onset of hair pulling in children under the age of 6 may be more benign and self-limiting than the more common syndrome of late childhood onset hair pulling. While far more women and adolescent girls appear for treatment, survey studies suggest chronic hair pulling also occurs in males. Diagnosis may be complicated by patient and family denial or ignorance of the hair pulling; accurate scalp examination and biopsy can be critical. Classic scalp biopsies for TTM feature trichomalacia, pigment clumps, peribulbar hemorrhage and hair canal pigment casts, and lack lymphocytic infiltrates seen in alopecia areata. Treatment is difficult: the tricyclic antidepressant clomipramine is the most promising agent, although many patients find it difficult to tolerate at adequate dosages, and treatment response may not be maintained over the long term. More benign medications have not demonstrated efficacy in controlled studies. Augmentation with topical preparations or psychotropic medications may be helpful for patients experiencing limited efficacy or relapse. Specialized psychotherapy, known as habit reversal training, is highly recommended; however, the treatment is intensive and highly specialized. Skilled therapists are difficult to locate.     

Isolated hair loss on the eyebrow: five cases with trichoscopic features

Alopecia areta (AA) and trichotillomania (TTM) are common causes for hair loss on the eyebrows. Yellow dots, vellus hairs, anisotrichosis, empty follicular openings, and black dots were observed in the present study’s patients with AA. Split hairs, question mark hairs, broken hairs, flame hairs, black dots, hairs with different lengths, and hemorrhagic areas were found in the patients with TTM. Trichoscopy is a very useful and helpful technic in distinguishing AA and TTM on the eyebrows.     

Characterization of hair follicle antigens targeted by the anti-hair follicle immune response

Alopecia areata is a common disfiguring hair loss disorder that primarily affects the hair follicle as it enters the prolonged growth phase called anagen. The last few years have yielded an explosion of more rigorously obtained data on the etiology and pathogenesis of this disorder. While a consensus is rapidly building in support of an autoimmune pathogenesis, there are still several enigmatic issues to be resolved. These include the possibility that alopecia areata is really a multientity disorder with causes that are multifactorial. This will have important implications for the research scientist's search for the jigsaw puzzle's largest missing piece--the identification of the target autoantigen(s). There is now much evidence that autoimmune diseases with both T and B cell components have shared target autoantigens/epitopes. It is likely that alopecia areata is similar, as there is now very strong evidence for the generation of autoantibodies as well as autoreactive T cells to hair follicles in the pathogenesis of this disease. The following brief review outlines the progress we have made over the last five to ten years in the characterization of hair follicle antigens targeted by antibodies in alopecia areata. Results of these studies now show that the elicitation of antibodies to hair follicle-specific proteins is a highly conserved phenomenon in all affected species studied to date. Candidate autoantigens that have been identified include the 44/46 kDa hair-specific keratin (expressed in the precortical zone of anagen hair follicles) and trichohyalin (an important intermediate filament-associated protein) expressed in the inner root sheath of the growing hair follicle. Moreover, there is evidence that anti-hair follicle antibodies are modulated during the disease process, can occur before clinically detectable hair loss, and may be reduced in titer during successful treatment. Preliminary data from passive transfer experiments suggest that in some species these antibodies may disrupt hair cycling. We are currently applying a more molecular approach (e.g., cDNA library screening) to identify hair follicle antigens truly associated with the onset of the disorder.     

Hair and systemic disease.

Hair loss (alopecia) occurs as a manifestation of numerous systemic diseases, but usually can be categorized into one of five general groups: telogen effluvium, anagen arrest, follicular destruction, hair miniaturization, and hair shaft defects. An excess of hair also can be evidence of internal disease, and there are two general categories of increased hair density: hypertrichosis and hirsutism. The basic categories of hair disease and the systemic conditions associated with them are discussed. The history, physical examination, and histopathologic data usually are sufficient to categorize the form of hair disorder and may provide a clue to the nature of the underlying systemic disease.     

Histopathological insights into hair loss in Cronkhite–Canada syndrome: Diffuse anagen‐telogen conversion precedes clinical hair loss progression

Cronkhite–Canada syndrome (CCS) is a rare disorder characterised by gastrointestinal polyposis and ectodermal changes, represented by extensive alopecia. Detailed histopathological investigations of alopecic lesions in two female CCS patients with severe hair loss revealed a marked increase in telogen hair follicles with no sign of loss or of the minaturisation or atrophy of hair follicle structures and the absence of inflammatory change, despite severe inflammation in the gastrointestinal tract. These findings suggested that hair regrowth can be expected without systemic corticosteroids, if they are not necessary for treatment of the gastrointestinal tract, and that anagen‐telogen transition is an early event preceding clinical hair loss in CCS.     

Alopecia areata: Clinical presentation, diagnosis, and unusual cases

Alopecia areata (AA) is a nonscarring hair loss disorder with a 2% lifetime risk. Most patients are below 30 years old. Clinical types include patchy AA, AA reticularis, diffuse AA, AA ophiasis, AA sisiapho, and perinevoid AA. Besides scalp and body hair, the eyebrows, eyelashes, and nails can be affected. The disorder may be circumscribed, total (scalp hair loss), and universal (loss of all hairs). Atopy, autoimmune thyroid disease, and vitiligo are more commonly associated. The course of the disease is unpredictable. However, early, long‐lasting, and severe cases have a less favorable prognosis. The clinical diagnosis is made by the aspect of hairless patches with a normal skin and preserved follicular ostia. Exclamations mark hairs and a positive pull test signal activity. Dermoscopy may reveal yellow dots. White hairs may be spared; initial regrowth may also be nonpigmented. The differential diagnosis includes trichotillomania, scarring alopecia, and other nonscarring hair loss disorders such as tinea capitis and syphilis.     

Trichostasis spinulosa of the scalp mimicking Alopecia Areata black dots

Alopecia areata is a common autoimmune disorder that leads to nonscarring hair loss. Black dots, also called comedo-like cadaver hairs, can be found in almost 50% of alopecia areata patients and indicate disease activity. Trichostasis spinulosa is a follicular disorder resulting from the retention of numerous hairs surrounded by a keratinous sheath in dilated follicles. Trichostasis spinulosa is a relatively common but underdiagnosed disorder of hair follicles. Here, we describe a man with alopecia areata of the eyebrows, androgenetic alopecia and trichostasis spinulosa at the vertex and show how dermoscopy can be useful in distinguishing black dots from Trichostasis spinulosa lesions.     

A practical, algorithmic approach to diagnosing hair shaft disorders

The hair shaft is a unique structure composed of an inner cortex and a protective outer cuticle. Any defects in this normal structure due to genetics or the environment can lead to variations in physical properties. Thus one should suspect a hair shaft disorder if a patient presents with an abnormality or change in hair texture, appearance, manageability or ability to grow hair long. A key feature of the clinical evaluation is to determine whether there is hair breakage (increased fragility) by looking for broken hairs and performing a tug test. Once this determination is made, an algorithmic approach can be used to narrow the differential diagnosis: hair shaft disorders with and without fragility. A hair mount along with other directed questions and examination will almost always allow the clinician to make an in-office diagnosis. Common case scenarios, photographs, and practical tips are provided to illustrate the use of this algorithmic approach in the diagnosis of hair shaft disorders. We have also included a summary of the molecular defects where known, which can be helpful in providing a correlation with clinical findings, in counseling patients, and potentially offering treatment options.     

Pseudofolliculitis cutis: a vexing disorder of hair growth

Pseudofolliculitis cutis (PFC) is a troublesome and potentially disfiguring cutaneous disorder characterized by a chronic inflammatory response to ingrown hair. Despite a simple precipitating stimulus, ingrown hair, PFC has a relatively complex aetiology that can involve grooming practices, hair type, genetic predisposition and medication history. Curly hair and a single‐nucleotide substitution in the gene encoding keratin 75 may act synergistically to increase the risk for developing this condition. PFC is most common in men of sub‐Saharan African lineage, but can occur in men and women of many different ethnicities, particularly in body areas where hair is coarse, abundant and subject to traumatic removal. Treatment options for PFC can be divided into three main categories: modifying hair removal practices, managing symptoms with medication, and long‐term hair removal with laser therapy. Laser hair removal is safe and effective in most skin types and has become increasingly popular among dermatologists in the treatment of PFC. However, it is imperative that the laser system and parameters are specifically matched to the patient's skin type.     

Loose anagen hair syndrome: a familial case with fetal hair in meconium

INTRODUCTION: Loose anagen hair syndrome is a recently described hair disorder. We report a familial case. CASE REPORT: Two sisters were examined, 4 years-old and 8 months old, from a consanguineous marriage. At birth, they presented diffuse alopecia of the scalp; the meconium contained black and silky hair. Clinical examination noted the short, fine hair with easy and painless uprooting. No clinical associated symptoms were observed. The trichogram showed 70 p. 100 of anagen hair and 30 p. 100 of telogen hairs. DISCUSSION: Our familial case is original by this clinical symptom: discharge of probably dystrophic foetal hair in the meconium. Loose anagen hair is characterised by easily pluckable hair. The trichogram confirms the diagnostic. It is composed of anagen hairs (80 to 100 p. 100) devoid of sheaths. The loose anagen hair is usually isolated, but associations have been reported. It may occur in families. The precise pathogenesis and treatment of this hair disorder are not known.     

甲氨蝶呤是否能有效安全地维持全秃患者的头发再生? 一个经过严格评价议题

Alopecia areata (AA) is a common disorder causing hair loss, which can range from patches, to complete hair loss on the scalp (alopecia totalis), or involving all hair‐bearing sites (alopecia universalis). It can cause anxiety, depression and low self‐esteem. Treatment can be difficult – there are several options but they don't always work and can have unwanted side effects. Hair can in fact regrow without any treatment. The aim of this study was to assess the current evidence regarding use of a drug called methotrexate for getting hair to regrow, and then remain, in people with alopecia. The authors looked at 13 studies comprising 226 patients with alopecia varying from 30% hair loss to alopecia universalis at the start. Methotrexate was usually given with drugs called systemic corticosteroids to start hair regrowth rather than regrowth maintenance. Regrowth, defined as anything from 50% to complete regrowth, was reported in 20‐90% of patients. Relapse (meaning hair re‐grew but then fell out again) occurred in 20‐80%, with variable regrowth on retreatment. Unwanted side effects ranged from 7‐60%. The authors found insufficient evidence to conclude whether methotrexate is useful for maintaining regrowth in extensive alopecia areata. They found some evidence to suggest that hair regrowth may be started by methotrexate when used in combination with systemic corticosteroids, but it was difficult to say which of the treatments this was due to, or if the hair was going to regrow anyway. Further trials are needed.     

Evaluation of cutaneous body image dissatisfaction in the dermatology patient

Cutaneous body image (CBI), defined as the individual's mental representation of his or her skin, hair, and nails, is an important clinical factor in dermatologic disorders and often the primary consideration in deciding whether to proceed with cosmetic procedures or institute treatment in some skin disorders such as acne. CBI is a highly subjective construct that can be significantly confounded by cultural, psychosocial, and psychiatric factors. Assessment of CBI in the dermatology patient is best accomplished using a biopsychosocial model that involves (1) evaluation of concerns about the appearance of the skin, hair, and nails, (2) assessment of comorbid body image pathologies, especially body dysmorphic disorder, and (3) assessment of other psychiatric comorbidities such as major depressive disorder that can confound the presentation of the CBI complaint. Depending on the psychiatric comobidities, an assessment of suicide risk may have to be done, and if necessary, a referral made to a mental health professional. The clinician should consider the patient's developmental stage (eg, body image concerns are likely to be much greater in the adolescent patient independent of his or her dermatologic disorder) and sociocultural background (eg, a desire for lighter skin in some ethnic groups), factors that can also have a major effect on CBI.     

Localized trichorrhexis nodosa

Trichorrhexis nodosa is a disorder of the hair shaft in which there is a distinctive response to injury. The hair is fragile and on examination regularly spaced pale nodelike'swellings may be observed. It may affect tiormal hair following excessive or repeated trauma, or may occur after minimal trauma if there is an inherent defect in keratin synthesis causing abnormally brittle hair. The diagnosis can be readily made clinically and confirmed microscopically. Treatment is aimed at reducing trauma.¹² We describe a case of localized trichorrhexis nodosa in a patient with otherwise apparently nonnal hair.     

Histopathology of hypotrichosis with juvenile macular dystrophy

Hypotrichosis with juvenile macular dystrophy (HJMD) (MIM 601553) is a rare disorder characterized by the paucity of hair and progressive macular degeneration leading to blindness. We have recently shown that mutations in the CDH3 gene encoding P-cadherin are the proximal cause of HJMD. The present study was performed to establish the histopathology of this disorder. 4 mm punch scalp biopsies from 6 HJMD patients aged 9 to 21 years were studied. All patients had a homozygous missense mutation resulting in a single amino acid substitution at position 503 of P-cadherin amino acid sequence (R503H). The total number of hair follicles varied between 6 and 14 per histologic section. More catagen-telogen hair follicles were observed in five cases, and an increased ratio of vellus hair follicles to terminal hair follicles was observed in two cases. There were no signs of inflammation or scarring. Thus, the most frequent histologic abnormality in HJMD resembles chronic telogen effluvium. This suggests that absence of functional P-cadherin interferes with normal hair cycle.     

Alopecia areata: autoimmune basis of hair loss

Alopecia areata (AA) is a heterogeneous disease characterized by nonscarring hair loss on the scalp or any hair-bearing surface. A wide range of clinical presentations can occur -- from a single patch of hair loss to complete loss of hair on the scalp (alopecia totalis) or the entire body (alopecia universalis). Particularly in severe or chronic cases, AA may cause considerable psychological and emotional distress for affected individuals. The estimated lifetime risk of developing AA is 1.7%. While the precise etiology of this common disorder has not been elucidated, a substantial body of evidence suggests that AA is an organ-specific, autoimmune disease, targeted to hair follicles. However, the antigenic target(s), mechanisms, and consequences of autoimmune attack in AA have yet to be determined. Here, we critically explore the evidence supporting the hypothesis that AA is an autoimmune disease and propose specific pathways by which self-directed immune responses are generated.     

Female pattern hair loss and its relationship to permanent/cicatricial alopecia: a new perspective

Female pattern hair loss (FPHL) is a common hair disorder of the central scalp. The clinical change in hair density, related to a change in the hair cycle and miniaturization of the hair follicle, is generally considered to be potentially reversible. However, there is now evidence of a permanent hair loss that develops in a subset of women with FPHL. The presence of a perifollicular lymphohistiocytic infiltrate and fibrosis is seen without follicular drop-out in biopsies of women with FPHL and with a notable follicular drop-out in a cicatricial form of this condition (heretofore called cicatricial pattern hair loss) as well as in fibrosing alopecia in a pattern distribution, currently classified as a subset of lichen planopilaris. The potential relationship of these conditions as well as frontal fibrosing alopecia and central centrifugal cicatricial alopecia, two other conditions of permanent hair loss seen primary in women, is discussed.     

Uncombable hair and atopic dermatitis in a case of tricho‐dento‐osseous syndrome

The tricho‐dento‐osseous syndrome is a rare genetic disorder due to a mutation in the DLX3 gene on chromosome 17q21. It can affect hair, teeth, bone and nails, causing phenotypic variability. We report on an 8‐year‐old girl with tricho‐dento‐osseous syndrome, who presented in our allergy center with severe atopic dermatitis. Additional clinical findings included light, kinky hair reminiscent of pili trianguli et canaliculi (uncombable hair), enamel hypoplasia and enlarged pulp chambers of the molar teeth (tau‐rodontism). A genetic investigation revealed a de‐novo mutation in the DLX3 gene on chromosome 17q21. Electron microscopic examination of the curly hair showed a flattened hair shaft with longitudinal grooves.     

Marie Unna hereditary hypotrichosis: report of a Chinese family and evidence for genetic heterogeneity

Marie Unna hereditary hypotrichosis (MUHH) is a rare autosomal dominant disorder with progressive hair loss starting in early childhood and aggravating at puberty. Several studies have mapped the MUHH gene to chromosome 8p21. Here we report a Chinese MUHH family with variable phenotypes. All affected individuals have anomalies affecting both hair density and hair shafts. Major clinical characteristics, disease history and histological examination support the diagnosis of MUHH, but the features of scarring in this kindred are modest and none of the patients have vertex hair loss, which is in contrast with typical MUHH. We now report genotyping and linkage analysis using 11 polymorphic microsatellite markers spanning the MUHH locus at 8p. Two-point linkage analysis using these markers revealed significant exclusion of this locus (log of the odds scores < - 2) at Theta = 0 indicating that there is a range of clinical presentations in MUHH, and that more than one genetic locus is responsible for the disorder.     

Clinical evaluation of a novel fractional radiofrequency device for hair growth: Fractional radiofrequency for hair growth stimulation

AGA is a common disorder. Different treatments are available to prevent hair loss and achieve hair growth with variable results. The purpose of the present study was to evaluate the efficacy and safety of a novel fractional radiofrequency (RF) device (HairLux, Innogen Technologies Ltd., Yokneam, Israel), to prevent hair loss and induce hair growth. Twenty‐five patients received 10 fractional RF treatments every 2 weeks, and were followed up 2 months after the last treatment. All patients were evaluated by global photography. In 10 patients, blinded manual hair counts were performed. Patients demonstrated less hair shedding, fuller hair, and faster hair growth. There was an average increase of 31.6% in hair density (based on hair counts) and 18% increase in hair shaft thickness. All subjects tolerated the treatments well. The HairLux device is effective and safe for hair growth stimulation in AGA. Ten treatment sessions are recommended to maximize results.