5‐Alpha reductase inhibitors in androgenetic alopecia: Shifting paradigms,current concepts,comparative efficacy,and safety

Androgenetic alopecia (AGA) is a multifactorial disease that carries a significant psychological burden with it. Dihydrotestosterone, the main pathogenic androgen in AGA, is produced by conversion of testosterone, which is catalyzed by the 5‐alpha reductase (5‐AR) isoenzyme family. Finasteride and dutasteride are inhibitors of these enzymes. Finasteride, which is a single receptor 5‐alpha reductase inhibitor (5‐ARI), acts by blocking dihydrotestosterone (DHT). Dutasteride, a dual receptor DHT blocker, has a higher potency than its predecessor, finasteride. This review corroborates the evidence of superiority of dutasteride over finasteride, and its comparable safety profile concerning fertility, teratogenicity, neurotoxicity, and hepatotoxicity.     

《EAU男性下尿路症状诊治指南(2012年版)》解读

欧洲泌尿外科学会(The European Association of Urology,EAU)2012年发表了新的《EAU男性下尿路症状诊治指南(2012年版)》(以下简称《指南》)。在下尿路症(Male Lower Urinary Tract Symptoms,LUTS)的评估、治疗、随访等方面做了论述。本文对《指南》的解读,旨在帮助全科医生和不熟悉LUTS治疗的医生正确诊断和治疗该病。     

Are phosphodiesterase type 5 inhibitors effective for the management of lower urinary symptoms suggestive of benign prostatic hyperplasia?

AIM: To review the efficacy of phosphodiesterase type 5 inhibitors(PDE5-Is) in lower urinary tract symptoms(LUTS) suggestive of benign prostate hyperplasia(LUTS/BPH). METHODS: A comprehensive research was conducted to identify all publications relating to benign prostate hyperplasia and treatment with sildenafil, vardenafil and tadalafil. To assess the efficacy, the changes in total international prostate symptom score(IPSS), IPSS subscore including voiding, storage and quality of life(Qo L), Benign prostatic hyperplasia Impact Index(BII), maximum urinary flow rate(Qmax) and the International Index of Erectile Function(IIEF) were extracted. A meta-analytical technique was used for the analysis of integrated data from the included studies to evaluate the mean difference in the results. RESULTS: Total IPSS score, IIEF and BII showed a significant improvement in trials in which LUTS/BPH with or without erectile dysfunction(ED) were compared with the placebo. For LUTS/BPH, the mean differences of total IPSS score, IIEF and BII are-2.17, 4.88 and-0.43, P 0.00001, respectively. For LUTS/BPH with comorbid ED, the mean difference are-1.97, 4.54 and-0.52, P 0.00001, respectively. PDE5-Is appear to improve IPSS storage, voiding and Qo L subscore(mean difference =-0.71,-1.23 and-0.33, P 0.00001, respectively). Although four doses of tadalafil(2.5, 5, 10 and 20 mg) failed to reach significance in Qmax(mean difference = 0.22, P = 0.10), the 5 mg dose of tadalafil significantly improved the Qmax(mean difference = 0.33, P = 0.03).CONCLUSION: PED5-Is demonstrated efficacy for improving LUTS in BPH patients with or without ED and could be considered to be the first line treatment for LUTS/BPH.     

新型冠状病毒感染肺炎防控期间良性前列腺增生诊疗工作指南

新型冠状病毒肺炎(COVID-19)在我国已被列为乙类传染病,并按照甲类传染病管理。此外,COVID-19疫情也被世界卫生组织宣布为全球大流行。良性前列腺增生(BPH)引起的下尿路症状(LUTS)是老年男性最常见的临床症状之一。大多数LUTS/BPH老年患者常伴有基础疾病,更易感染新型冠状病毒。在抗击COVID-19疫情的斗争中,提高LUTS/BPH患者的医疗保障水平,加强LUTS/BPH患者的互联网医疗、门诊和住院管理具有十分重要的意义。为了进一步提高LUTS/BPH临床实践的相关性和有效性,根据国家卫生健康委员会的指导方案和最新的临床研究成果,我们编写了LUTS/BPH在预防和控制COVID-19流行中的诊断和治疗指南,供泌尿外科医务人员参考。     

Controversies in the treatment of androgenetic alopecia: The history of finasteride

Male androgenetic alopecia (AGA) affects up to 60% of men by the age of 50. Currently, there are only two approved drugs for the treatment of male AGA: topical minoxidil and oral finasteride. Topical minoxidil is readily available over the counter and has a well‐established safety record. However, following 24 weeks of treatment, less than 40% of men respond to the drug. Additionally, due to the topical route of administration, compliance with minoxidil remains low. In contrast, oral finasteride, a 5‐alpha reductase inhibitor, demonstrated efficacy in arresting hair loss in more than 80% of patients following 12 months of treatment. However, controversy surrounding potential adverse sexual side effects has negatively affected public perception of the drug and may significantly reduce the number of patients that can benefit from the drug.     

Phosphodiesterase inhibitors for treatment of voiding dysfunction: An overview of experimental and clinical evidence

Recently,the focus of the origin of lower urinary tract symptoms(LUTS)has change from the prostate to the bladder.Regardless of the underlying mechanism associated with the origin of LUTS,alpha-blockers continue to be the most common medicine prescribed to treat LUTS due to benign prostatic obstruction(BPO).The newest class of drug introduced to treat LUTS/BPO is phosphodiesterase inhibitors(PDEi)and the aim of this study was to review the role of PDEi in the treatment of LUTS/BPO.In this review,the first evidence was evaluated based on epidemiological studies followed by randomized clinical trials which provide evidence on the administration of PDEi in patients with LUTS/BPO.Experimental studies were also assessed to tentatively elucidate the association between LUTS and erectile dysfunction,and to elucidate the underlying mechanism.There is still controversy regarding the administration of PDEi due to the fear of detrusorimpairment,response to acute administration,and the effects of PDEi combined with alpha-blockers.Following this review,we conclude that treatment of BPO/LUTS with PDEi is beneficial,based on experimental studies,strong evidence and the large number of randomized clinical trials confirming their efficiency.     

The evolving relationship of erectile dysfunction and lower urinary tract symptoms

Previously viewed as independent processes, erectile dysfunction (ED) and lower urinary tract symptoms (LUTS) frequently co-associate and significantly influence the overall quality of life of men. Analysis of historical and emerging literature, using some of the Bradford Hill criteria, argues for a causal link between the two disease processes. Four mechanisms are proposed to explain the relationship between ED and LUTS. Understanding this relationship is crucial for several reasons: 1) additional information on risk factors for either disease could be important for patient screening; 2) the pool of affected men is increasing, given the age demographics in many societies; 3) sexual problems related to LUTS are not necessarily limited to ED; and 4) many medical or surgical treatments for one disorder affect the other.     

下尿路症状与勃起功能障碍相关性分析

目的研究分析下尿路症状(lower urinary tract symptoms,LUTS)与勃起功能障碍的相关性。方法选取2017年1月至2018年1月诸暨巿中心医院诊治的80例LUTS患者为研究对象。按照患者年龄,将其分为三组:50岁~59岁组,30例患者;60岁~69岁组,30例患者;70岁以上组,20例患者。对三组患者进行勃起功能障碍评分(IIEF-5)和前列腺评分(IPSS),分析患者的勃起功能障碍与LUTS的关联。结果比较三组患者的IPSS评分及其严重程度可知,患者的IPSS评分和LUTS均与患者的年龄增长呈正相关,三组数据差异均具有统计学意义(均P<0.05);比较三组患者的IIEF-5评分和勃起功能障碍发病率可知,患者的IIEF-5评分和勃起功能障碍发病率与患者的年龄增长呈正相关,三组数据差异均具有统计学意义(均P<0.05);比较三种不同严重程度患者的IIEF-5评分和勃起功能障碍发病率可知,患者的IIEF-5评分和勃起功能障碍发病率与患者的LUTS严重程度呈正相关,三种数据差异均具有统计学意义(均P<0.05)。结论患者的下尿路症状和患者的勃起功能障碍均与患者的年龄呈正相关,且患者勃起功能障碍与患者下尿路症状的严重程度呈正相关,下尿路症状是患者勃起功能障碍的危险因素。     

Rasche Abheilung von akralen Ulzera bei systemischer Sklerodermie unter Sildenafil

Acral ulcers in patients with progressive systemic sclerosis (PSS) are often recalcitrant to therapy. Sildenafil, an inhibitor of phosphodiesterase-5, dilates small arteries by increasing endothelial cGMP. Oral administration of sildenafil to a 35-year-old white male patient suffering from incapacitating PSS with severe pulmonary arterial hypertension and acral ulcers induced a clinically significant reduction in dyspnea and increase in walking distance within one week as well as complete and long-lasting healing of all ulcers within five weeks. This case demonstrates the efficacy of sildenafil in the treatment of scleroderma-associated refractory acral ulcers.     

Perceived relationships between severity of psoriasis symptoms,gender, stigmatization and quality of life

Background Psoriasis is a skin disease with negative physical, psychological and social repercussions for those affected, but we still lack knowledge of how somatic and non‐somatic factors directly and indirectly combine to affect patients’ quality of life (QoL). Objectives This study seeks a better understanding of the relations between symptom severity, discomfort, stigmatization, gender and QoL among psoriasis patients. Methods The sample comprised 381 psoriasis patients in inpatient care. Symptom severity and discomfort were measured subjectively with single items. Stigmatization was measured with the Questionnaire on Experience with Skin Complaints. QoL was measured using the Dermatology Life Quality Index (DLQI) and the Short Form‐8 Health Survey (SF‐8). Results Symptom severity was associated with higher discomfort, stigmatization and lower skin‐related QoL. Symptom severity correlated weakly with more general aspects of QoL as measured by the SF‐8. Men and women reported different experiences with discomfort, stigmatization and mental aspects of QoL (SF‐8 mental component summary score). Some stigmatization parameters function as mediating variables between symptom severity and QoL. Conclusions Our findings suggest that the effect of stigmatization on skin‐related QoL is driven by symptom severity and stigmatization combined, whereas its effect on mental health is driven mostly by stigmatization alone. Further, although women and men experience the social impact of psoriasis differently, the effect of stigmatization on QoL is similar for both genders.     

疏肝益阳胶囊联合盐酸坦索罗辛治疗BPH/LUTS合并ED的临床观察

目的:探讨疏肝益阳胶囊联合盐酸坦索罗辛缓释胶囊治疗肝郁肾虚兼血瘀型前列腺良性增生/下尿路症状(BPH/LUTS)合并勃起功能障碍(ED)的临床疗效。方法:将60例确诊为肝郁肾虚兼血瘀型BPH/LUTS合并ED的患者,随机分为试验组和对照组,每组各30例。试验组采用疏肝益阳胶囊联合盐酸坦索罗辛进行治疗,对照组用盐酸坦索罗辛进行治疗。治疗时间均为8周。采用国际前列腺症状评分(IPSS)、生活质量评价(QOL)、国际勃起功能指数(IIEF-5)、综合医院焦虑抑郁表(HAD)、每月的成功性交频率及停药3个月后复发率来比较两组的疗效。结果:两组患者治疗4周后的IPSS、QOL均比治疗前提高(P0.01);试验组治疗4周后IPSS、QOL、HAD、IIEF-5及性交频率优于对照组(P0.01);试验组停药3月后的复发率低于对照组(P0.05)。结论:疏肝益阳胶囊联合盐酸坦索罗辛可以有效治疗肝郁肾虚兼血瘀型BPH/LUTS合并ED患者,提高下尿路症状的疗效,改善焦虑症状,减少复发率。     

Quality of Life Assessment in Male Patients with Androgenetic Alopecia: Result of a Prospective, Multicenter Study

Background

Androgenetic alopecia (AGA) is a common hair loss disease with genetic predisposition among men and women, and it may commence at any age after puberty. It may significantly affect a variety of psychological and social aspects of one''s life and the individual''s overall quality of life (QoL).

Objective

This study aimed to investigate the QoL of AGA patients and discover the factors that can influence the QoL of AGA patients, including previous experience in non-medical hair care, reasons for hospital visits, age, duration, and the severity of AGA.

Methods

A total of 998 male patients with AGA were interviewed, using the Hair Specific Skindex-29 to evaluate the QoL of AGA patients.

Results

The results of the Hair Specific Skindex-29 on patients with AGA were as follows: symptom scale: 26.3±19.5, function scale: 24.0±20.1, emotion scale: 32.1±21.8, and global score: 27.3±19.1. According to this assessment, QoL was more damaged if the patient had severe alopecia, a longer duration of AGA, younger age, had received previous non-medical hair care, and visited the hospital for AGA treatment.

Conclusion

This study showed that AGA could harmfully affect the patients'' QoL. These findings indicate that dermatologists should address these QoL issues when treating patients with alopecia.     

男性更年期综合征及雄激素的增龄性变化

本文探讨了男性更年期综合征的相关问题。提出男性更年期的根据是,50岁以上的部分男性可以出现与女性更年期综合征相似的临床症状。男性更年期出现增龄性雄激素的变化,以及性激素结合球蛋白的增龄性升高,雄性激素分泌紊乱,出现不同程度的心理、躯体及性功能的相关症状。应正确认识和面对男性更年期,并提供必要的医学干预服务,以提高男性更年期生活质量。     

Illness perceptions, coping and quality of life in patients with alopecia

Background  Alopecia can have substantial psychological consequences, but there has been no research looking at patients' beliefs about their condition nor how they relate to quality of life (QoL).
Objectives  To investigate the relationships between illness perceptions, coping and QoL in patients with alopecia.
Methods  The study employed a cross-sectional design. In total, 214 individuals with alopecia were recruited from four internet support groups. There were 171 women and 43 men (mean age 35 years). Participants completed an online questionnaire comprising the Revised Illness Perception Questionnaire, the Dermatology Life Quality Index and the brief COPE.
Results  The findings indicate several areas in which alopecia impacted on individuals' QoL, particularly in relation to symptoms and feelings. Women reported poorer QoL compared with men. Impaired QoL was associated with a strong illness identity, beliefs in the serious consequences of alopecia and strong emotional representations. Hierarchical multiple regressions indicated that illness perceptions accounted for 35% of the variance in QoL after controlling for demographic and disease factors, with coping adding a further 7% to the regression model.
Conclusions  Although alopecia is not a life-threatening condition, it can impair QoL by negatively impacting on self-awareness. The strong relationships found between patients' beliefs about their condition and QoL suggests that health professionals should recognize the psychological impact of alopecia and address negative beliefs and emotions surrounding the condition in treatment programmes.     

Understanding patient and physician perceptions of male androgenetic alopecia treatments in Asia–Pacific and Latin America

This survey aimed to explore patient and physician attitudes towards male androgenetic alopecia (AGA), satisfaction with currently available male AGA treatments and investigate the factors affecting treatment choice. The survey was carried out in five countries (Japan, South Korea, Taiwan, Mexico and Brazil) between November and December 2015 using a standard market research methodology. Questionnaires were completed by patients with male AGA or hair loss/thinning and practicing physicians who were responsible for prescribing AGA treatment. In total, 835 patients and 338 physicians completed the questionnaire. Overall, 37.6% of patients reported satisfaction with the treatments they had used. The highest patient satisfaction was reported for 5‐alpha‐reductase inhibitors (53.9% of patients satisfied). In all countries, physicians were more likely than patients to think that male AGA has a major impact on patient confidence (89.3% vs 70.4%, respectively). There was agreement by physicians and patients that male AGA patients who are involved in their treatment decisions have better outcomes. Patients who were satisfied with AGA treatments were more likely to have the level of involvement they desired in treatment decisions (69.1% of satisfied patients) than dissatisfied patients (56.4% of dissatisfied patients). This survey provides valuable insights into the attitudes of patients and physicians in Asia and Latin America about male AGA and its treatments. The survey identified areas of disconnect between physicians and patients regarding the impact of male AGA, treatment consultations and the importance of treatment attributes. It also highlights the need for physicians to spend sufficient time with patients discussing AGA treatment approaches.     

经尿道等离子电切术治疗高龄前列腺增生症的临床观察

目的:观察经尿道双极等离子电切术(Bipolar Plasmakinetic Transurethral Resection of Prostate,PK-TURP)治疗高龄前列腺增生症患者的安全性和疗效。方法:选取80岁以上急性尿潴留患者58例,经影像学和尿动力学检查证实前列腺增生是引起患者急性尿潴留的主要原因。应用PK-TURP对患者实施微创经尿道前列腺切除术。记录出血量、输血量、并发症、手术时间、膀胱冲洗时间、留置尿管时间、住院时间以及切除的前列腺标本重量。术后随访2年,根据急性尿潴留有无复发、国际前列腺症状评分(international prostate symptom scores,IPSS)、生活质量评分(quality of life,QoL)、残余尿量(postvoid residual urine,PVRU)、最大尿流率(maximal urine flow rates,Qmax)评价疗效。结果:58例高龄患者均安全地完成了手术,术中、术后没有出现严重的并发症。所有患者术后拔除尿管后均恢复自控排尿,随访2年内没有再次发生急性尿潴留,IPSS、QoL、PVRU、Qmax较术前均有明显改善(P<0.05)。结论:PK-TURP是治疗高龄前列腺增生症安全、有效的方法。     

Metabolic syndrome and lower urinary tract symptoms

Recently,clinical and epidemiologic data indicating the involvement of metabolic syndrome(Met S)in the pathogenesis and progression of lower urinary tract symptom(LUTS)/benign prostatic hyperplasia(BPH)are reported.This review evaluates the reports on the influence of MetS in the development and progression of LUTS/BPH,and discusses possible clinical implications for the management and treatment of this disease.Recent studies on the epidemiological relationship between MetS and LUTS hypothesize that MetS may be associated with an overactivity of the autonomic nervous system for which hyperinsulinemia,a key element of the Met S,might be responsible.An alternative explanation is that LUTS are associated with chronic ischemia of pelvis resulting from atherosclerotic changes in blood vessels,which leads the production of reactive oxygen species,which can damage the bladder detrusor.Control of autonomic nervous system overactivity and control of chronic bladder ischemia have potential as new targets for LUTS treatment.Studies suggest an association of Met S with LUTS/BPH,although further research is needed to understand how MetS influences LUTS/BPH.Met S should be considered a new domain in basic and clinical research in patients with LUTS/BPH and as a target for treatment.     

Combination of skin,joint and quality of life outcomes with etanercept in psoriasis and psoriatic arthritis in the PRESTA trial

Background Psoriasis and psoriatic arthritis (PsA) affect skin, and/or joints and quality of life (QoL). Objective To better assess the success in multiple attributes in subjects with both active psoriasis and PsA, the objective was to quantify the proportion of those who achieved substantial improvement in a composite measure of skin symptoms, joint manifestations, and QoL, on one of two treatment regimens. Methods Subjects (n = 752) with psoriasis and PsA (mean age: 46.5 years, 62.9% male) received etanercept (ETN) 50 mg twice weekly (BIW; n = 379) or 50 mg weekly (QW; n = 373) for 12 weeks, followed by open‐label ETN 50 mg QW for 12 weeks. Skin and joint symptoms and QoL were assessed using psoriasis area and severity index (PASI), American College of Rheumatology criteria (ACR) and Euro‐QoL (EQ‐5D), respectively. Results By week 24, 30.6% and 25.8% of subjects receiving ETN 50 mg BIW/QW and ETN 50 mg QW/QW, respectively (P = 0.198) achieved the composite measure of efficacy for skin plus joints plus QoL (PASI 75 + ACR 50 + EQ‐5D VAS >82). Conclusion At 24 weeks, 25.8–30.6% met the triad of rigorous efficacy outcomes. Evaluation of treatment efficacy should address the multiple components of this disease complex; therefore it may be important to consider this composite measure in future trials.     

Acne in the male resistant to isotretinoin and responsibility of androgens: 9 cases, therapeutic implications

INTRODUCTION: Treatment failures with isotretinoin in female patients are frequently related to endocrinological dysfunctions. Such a concept has never been discussed in male patients. CASE REPORTS: An extensive endocrinological work-up has been performed in nine male patients who presented with an acne refractory to conventional treatment and to isotretinoin. Adrenal dysfunction was found in four patients and isolated 5-alpha reductase hyperactivity in 2 cases. Three work-ups were normal. A suppressive treatment in three patients with adrenal dysfunction provided immediate efficacy. COMMENTS: These results would provide insight into the mechanism of refractory acne in men.     

Underreported use of palliative care and patient‐reported outcome measures to address reduced quality of life in patients with calciphylaxis: a systematic review

Calciphylaxis is associated with significant morbidity and mortality. Palliative care (PC) is a subspecialty that treats the pain and stress of serious illness. To assess whether the role of quality of life (QoL) indices, patient‐reported outcome measures and PC have been studied in patients with calciphylaxis, we performed a systematic literature review. Several databases were searched from inception to October 2016 according to modified Preferred Reporting Items for Systematic Reviews and Meta‐Analyses criteria. We searched for papers on calciphylaxis that mentioned the symptoms and supportive needs of patients, QoL or outcome measures to report symptom severity, and the involvement of PC. Twelve papers met the inclusion criteria. Reported patient symptoms included pain, skin lesion resolution and pruritus, with the first being the most frequently reported. Four papers measured pain using a previously verified patient‐reported outcome measure, including the Visual Analogue Scale. One paper used a verified QoL measure, the Dermatology Quality of Life Index. No tool was used consistently. Eight papers reported the use of hospice care or PC in the treatment of calciphylaxis. No outcome measure was used to prompt PC involvement. Overall, QoL indices, patient‐reported outcome measures and PC are underreported in the treatment of calciphylaxis. PC may be a resource to assist in symptom management and adaptive coping strategies for patients from the onset of disease.