Usefulness of TrichoScan professional in the evaluation of hair loss in females. Report of 180 cases

Background TrichoScan Professional is a computerized program used for digital measurement of hair growth and hair loss. The aim of our study was to undertake an evaluation with TrichoScan Professional of female patients consulting at our hospitals for hair loss. The purpose of our study was to determine whether TrichoScan was able to identify differences in hair parameters that would correlate with the pattern of alopecia or according to the age of the patients evaluated. Material and methods One hundred‐eighty women that consulted consecutively for loss of hair were included. Patients were aged between 8 and 85 years (mean age 36 years). Data including age, the number of hairs, hair density per square centimetre, anagen and telogen percentage and percentage of terminal and miniaturized hair were analysed. Results Results observed with TrichoScan were as below: number of hairs (mean 154.9; range 34–316). Hair density per square centimetre (mean 239; range 52–486). Hair in anagen phase (mean 62.4%; range 9–93%). Hair in telogen phase (mean 37.4%; range 7–91%). Terminal hair (mean 95.2%; range 82–100%). Vellus hair (mean 4.7%; range 0–17%). Pearson′s correlation test was used to measure the strength of the association of age with the rest of parameters. The statistical analysis showed a significant correlation between age and both the number of hairs and the hair density per square centimetre. However, no significant correlation between age and rest of the parameters was observed. Conclusions TrichoScan Professional may help to quantify hair density and in our sample, this was the only parameter showing a significant decrease according to age in various types of alopecia affecting the females.     

Natural progression of male pattern baldness in young men

Twenty-six men who presented with male pattern baldness (androgen-dependent alopecia), were quantitatively evaluated for scalp hair variables and compared with 13 age-matched controls. Compared to controls, significant mean differences for hair variables were found in the frontal-vertex area, while in the occipital area, a reduction in total hair density (hairs/cm2) was the only significant (P less than 0.05) finding. A large proportion (48.5%) of meaningful hair (non-vellus hair) was less than or equal to 40 mm in length, yet had diameters similar to hairs growing much longer. In controls, these hairs accounted for only 12.2% of the total population. Compared to baseline, mean values from the frontal-vertex area of subjects with androgen-dependent alopecia were significantly lower for total hair density, meaningful hair density (non-vellus hairs/cm2) and percentage of hair in the anagen growth phase, 12 and 24 months later. During this time, total hair density decreased by 6.5% after 12 months and by 11.9% after 24 months. Similarly, meaningful hair density declined at 12 months by 10.8% and by 22.7% after 24 months. No change in any hair variable was detected in controls after 12 or 24 months. Our findings suggest that medications capable of maintaining the existing hair population should be regarded as effective treatments for this condition. Left untreated androgen-dependent alopecia progressively deteriorates. The induction of non-vellus hairs less than or equal to 40 mm in length to grow longer, would substantially improve the aesthetic profile without the need to generate new hair.     

Quantitative assessment of 2% topical minoxidil in the treatment of male pattern baldness

Forty-seven men with male pattern baldness were treated in a double-blind clinical trial with topical 2% minoxidil or placebo. Twelve were randomly selected for quantitative hair measurement using the unit area trichogram and visual counting. There was no significant difference after 6 or 12 months of treatment with a 2% minoxidil solution for total hair density (THD; hair cm-2), meaningful hair density (MHD; hair greater than 40 microns in diameter greater than 30 mm in length cm-2), per cent of hair in the anagen growth phase, or the per cent of meaningful hair in the anagen growth phase. Significantly fewer hairs were recorded with the visual hair counting method, compared to values obtained from adjacent sites with the unit area trichogram. In addition, a significantly larger mean total hair count was recorded by an experienced observer, compared to an inexperienced observer. Increased pigmentation was observed within the vellus hair population of treated subjects. Our findings indicate that minoxidil appears unlikely to affect the long-term course of male pattern baldness. However, we found no significant deterioration in total hair density, or meaningful hair density in treated subjects, suggesting minoxidil may have a prophylactic effect. Further long-term studies employing the unit area trichogram are required to evaluate this finding.     

Expression of the L-fucose moiety on infrainfundibular follicular keratinocytes of terminal follicles, its decreased expression on vellus and indeterminate follicles of androgenetic alopecia, and re-expression in drug-induced hair regrowth.

The distribution of various glycoprotein molecules on the surface of follicular keratinocytes was studied with a panel of lectins with specificity for various sugar moieties on biopsy specimens from both bald/balding scalp and normal occipital scalp, of 23 patients with androgenetic alopecia as well as on biopsies of normal forearm skin of four patients. The most significant differences between bald and normal scalp biopsy were noted with Ulex europaeus agglutinin I (UEA I). We noted an increased (91.8% +/- 3.1; mean +/- SE) expression of UEA I binding sites on the infra-infundibular follicular keratinocytes in anagen terminal scalp hairs, compared to 28.5% +/- 5.2 in the indeterminate (anagen) hairs of balding scalps, and 23.2% +/- 6.3 in the anagen follicles of vellus fore-arm hairs. By contrast, the telogen hairs demonstrated minimal UEA I staining: 4.0% +/- 0.8, mean +/- SE in telogen scalp hairs, 1.8% +/- 0.5 in telogen hairs of balding scalps (0% in completely bald scalps, in which all the hairs were in the telogen phase), and 1.9% +/- 0.2 in telogen forearm hairs. The percentage of UEA I staining correlated with the length of the infra-infundibular follicles in all cases studied. In three cases of hair regrowth after hair growth promotors, the UEA I staining increased to 80.6% +/- 6.1 in anagen hairs and correlated with increased length of infra-infundibular follicles. Our data indicate that there are 1) marked differences between anagen and telogen follicles in UEA I binding to infra-infundibular follicular keratinocytes; 2) the percentage of UEA I staining reflects the size (length) of the infra-infundibular hair follicle; and 3) the anagen follicles of balding scalps (indeterminate hairs) show UEA I staining resembling that exhibited by anagen follicles of vellus hairs.     

The unit area trichogram in the assessment of androgen-dependent alopecia

The unit area trichogram was defined in the frontal and occipital areas often normal men and ten normal women and the results compared with the findings in ten male and fifteen female patients with androgenic alopecia. The epilation technique provided accurate data of normal hair density (higher than previously reported) and the phases of hair growth. The measurement of hair diameter showed that of 7603 hairs, 1241 were less than 40 μ in diameter, of which only 21 were more than 80 mm in length. Variation in the diameter of individual hair fibres was recorded. The number of hairs less than 40 μ diameter per cm² of scalp was increased in both men and women with androgenic alopecia. It was concluded that the number of hairs greater than 40 μ in diameter per cm² (meaningful density) reflected most closely the amount of hair usefully contributing to an individual's clinical appearance.     

The vellus hair follicle in acne: hair growth and sebum excretion

Summary In this study we investigated the activity of the vellus hair follicle in acne. Hair growth and sebum excretion in vellus hair follicles were measured on the forehead and back of men, and on the forehead, cheek, and back of women with acne. Hair growth was assessed by computerized image analysis (phototrichogram), and sebum excretion by computer analysis using Sebutape®.
In patients with acne, marked differences were revealed when results were compared with recent data from healthy persons. In particular, the mean growth rate of vellus hairs was higher, whereas the percentage of anagen hairs was lower, and the duration of the anagen phase shorter in patients with acne than in healthy individuals. Hair growth and sebum excretion depended significantly ( P < 0.01) on the anatomical site (forehead 414 hairs/cm², 0.053 mm/day, 34%; back 93 hairs/cm², 0.16 mm/day. 21%),
In addition, analysis of hair growth revealed significantly higher values in females than in males for (i) percentage of anagen hairs ( P >0.01), (ii) for vellus hair length ( P <0.05), and (iii) for the duration of the anagen phase ( P <0.01).
The present study demonstrates that the activity of the vellus hair follicle is influenced by acne, and vice versa, and therefore its role in the aetiopathogenesis of acne should be reconsidered.     

Finasteride increases anagen hair in men with androgenetic alopecia

BACKGROUND: The growth of scalp hair is a cyclical process of successive phases of growth (anagen) and rest (telogen). In previous clinical trials in men with androgenetic alopecia, treatment with finasteride increased scalp hair counts in a defined area (i.e. increased hair density). OBJECTIVES: The current study used a phototrichogram methodology to assess the effect of finasteride on the phases of the hair growth cycle. PATIENTS/METHODS: Two hundred and twelve men, age 18-40 years, with androgenetic alopecia were randomized to receive finasteride 1 mg daily or placebo for 48 weeks. At baseline and at 24 and 48 weeks, macrophotographs were taken to measure total and anagen hair count in a 1-cm(2) target area of the scalp. RESULTS: At baseline, mean total and anagen hair counts in the finasteride group were 200 and 124 hairs, respectively (% anagen = 62%) and the anagen to telogen ratio was 1.74 (geometric mean). In the placebo group, the respective values were 196 and 119 hairs (% anagen = 60%) and 1.57. At week 48, the finasteride group had a net improvement (mean +/- SE) compared with placebo in total and anagen hair counts of 17.3 +/- 2.5 hairs (8.3% +/- 1.4%) and 27.0 +/- 2.9 hairs (26% +/- 3.1%), respectively (P < 0.001). Furthermore, treatment with finasteride resulted in a net improvement in the anagen to telogen ratio of 47% (P < 0.001). In this study, treatment with finasteride 1 mg day(-1) for 48 weeks increased both total and anagen hair counts, and improved the anagen to telogen ratio. CONCLUSIONS: These data provide direct evidence that finasteride 1 mg daily promotes the conversion of hairs into the anagen phase. These data support that finasteride treatment results in favourable effects on hair quality that contribute to the visible improvements in hair growth observed in treated patients.     

Low dosage retinol and L-cystine combination improve alopecia of the diffuse type following long-term oral administration

In a pilot study (I) the efficacy of a new combination therapy for hair loss of the diffuse type was tested in 36 patients, followed by a double blind study with 47 patients. The daily dosage was 18,000 IE retinol, 70 mg L-cystine and 700 mg gelatin. The clinical efficacy was evaluated by standard methods, such as the preparation of trichograms and measurement of the hair density before and after treatment. The pilot study demonstrated a significant improvement, with reduction of the telogen rate by 8.3%, an increase of the anagen rate by 11%, and an increase of the hair density by 6.9%. In the double blind study (II) the trichogram showed a significant decrease of the telogen rate by 13.5% compared with pathological baseline values. There was no change in the placebo group. The lowered anagen rate of 47.2% was improved by 8%, whereas the mean value in the placebo group decreased from 47.7% to 39.9%. In addition, the percentage of dysplastic anagen hairs improved by 7.4%, as against further impairment with an increase of 26% in the placebo group. During oral therapy no systemic side-effects were detected. We conclude that long-term oral therapy with high doses of L-cystine and gelatin in combination with vitamin A may have beneficial effects on diffuse hair loss.     

The biology of hair

Hair is a product of small pits in the skin known as hair follicles. The most important feature of hair follicles is that their activity is intermittent; each active phase or anagen is succeeded by a transitional phase (catagen) and a resting phase (telogen), during which the fully formed "club hair" is retained for a period and then shed. The growth of facial, body, axillary, and pubic hair depends on androgens. Facial hair and body hair require high levels of testosterone and its conversion to 5-alpha-dihydrotestosterone. Pubic and axillary hair follicles require much lower levels of hormone, and 5-alpha-reduction appears to be unnecessary. Paradoxically, male pattern alopecia and its female equivalent also require androgen for their manifestation. The differing lengths of hair in the various regions of the body result largely from differences in the duration of anagen and only to a small extent from differences in the rates of growth. Some hair loss from the scalp can be characterized in terms of the hair growth cycle, and some involves long-term changes in the follicular architecture. Thus postfebrile and postpartum alopecias are telogen effluvia that involve shedding of club hairs, whereas drug-induced alopecia and alopecia areata involve shearing and loss of growing hairs. Male pattern baldness and female diffuse alopecia involve gradual shortening of the periods of anagen and shrinkage of the hair follicles over a long term.     

Congenital hypotrichosis due to short anagen

Two children with congenital hypotrichosis are described. Both presented with persistent short, fine hair since birth. Evidence is provided that the short hair observed in these patients is due to a short anagen phase of the hair cycle, with a normal rate of hair growth. Shortening of the anagen phase of the scalp hair cycle leads to a decrease in the maximal hair length and an increase in the number of hairs in telogen, resulting in an increase in hair shedding. Scanning electron microscopy showed a widely spaced cuticular pattern, a finding typically seen in hair of thin calibre. One patient had affected family members with an apparently autosomal dominant mode of inheritance. The disorder appears to resolve spontaneously during puberty and adulthood.     

The size and form of the medulla of human scalp hair is regulated by the hair cycle and cross-sectional size of the hair shaft

Hairs were sampled from long-haired Caucasian females, and cross-sectional measurements were performed using a rotating profile method at fixed humidity (100%). The effect of the hair cycle on medullation was investigated by examining medulla size and form along the lengths of anagen and telogen terminal hairs and also from a composite model of the entire medulla, as produced from a full cycle's growth, by amalgamating the results from the anagen and telogen hairs. The effect of hair shaft cross-sectional size on medullation has been investigated by controlling any effect of the hair cycle on terminal hairs and by use of the maximal medulla size in short, fine (vellous) hairs from the same subjects. All terminal hairs were medullated for the majority of their lengths. The presence and size of the medulla, in terminal hairs, was profoundly affected by the hair cycle. It was largest early in anagen, where the medulla minor axis, major axis and cross-sectional area represented about 26%, 23% and 7% of the corresponding whole hair shaft parameters (at 100% humidity). The medulla was virtually absent towards the end of anagen. The shape of the medulla cross-section was less elliptical than that of the whole hair shaft and was close to circular. There was no significant change in medulla shape through anagen. The form of the medulla was also affected by the hair cycle; approximately, it was continuous for the first 50% of anagen, discontinuous for the next 25% and virtually absent or absent for the final 25%. The maximal size of the medulla, as occurred in early anagen, was markedly associated with the cross-sectional size of the whole hair shaft, both within terminal hairs and between all scalp hairs. The medulla was large in terminal hairs and small or absent in very small hairs. The proportion of the whole hair shaft occupied by the medulla increased with increase in hair size and reached a maximum in terminal hairs, in which the medulla minor axis represented about 30% of the whole hair shaft minor axis. Furthermore, this proportion was constant in the terminal hairs and was not related to whole hair shaft size. Such maximal proportional medullation might represent a defining feature of terminal hairs. Variation in size of the medulla is not the cause of the previously reported cycle-dependent change in cross-sectional size of the whole hair shaft of terminal hairs.     

TrichoScan as a method to determine hair root pattern in patients with scalp psoriasis

Scalp involvement is a prominent and often the initial presentation in patients with psoriasis. Hair growth may be impaired with a hair loss and an increased telogen/anagen ratio. The aim of this study was to investigate the hair density and anagen/telogen ratio in psoriatic patients, using epiluminescence microscopy combined with digital image analysis (TrichoScan). Thirty psoriatic patients with scalp involvement and the same number of clinically healthy individuals were included in the study. For the measurement of hair density, anagen/telogen ratio and number of terminal and vellus hairs, a commercially available software TrichoScan was used. Hair density measurements did not show significant difference between patients and controls (P=0.05). The anagen ratio was significantly lower and telogen ratio significantly higher in psoriasis patients than in controls (P<0.01 both). There was no correlation between hair parameters and patient age or duration of disease. Study results support the evidence that scalp psoriasis is associated with an increased telogen/anagen ratio.     

Eficacia del tratamiento con inyecciones intradérmicas de plasma rico en plaquetas para la alopecia androgenética en varones: estudio de «antes-después»

Background and aimsPlatelet rich plasma is a source of growth factors recently introduced to treat androgenetic alopecia (AGA) with conflicting results. Our aims are to assess the efficacy of platelet rich plasma in increasing hair density in males with AGA, and to investigate a correlation between positive response and each of patient's age and type and duration of AGA.Materials & methodsThis before and after study included 30 males with no history of hair treatments for at least 3 months prior to our study. Each patient received 3 injections at one-month intervals. Scalp hair density of each subject was measured manually by a dermatoscope before and following 2 and 6 months of the first intervention. Data were compared to evaluate efficacy.ResultsHair density was increased by 19.17% following our intervention (172.46 ± 59.04 hairs/cm² before treatment to 205.53 ± 68.20 hairs/cm² after 6 months) with minimal short-term side effects. Type III vertex was the least responsive pattern and no correlation was observed between positive response and either patient's age or duration of AGA.ConclusionPlatelet rich plasma injections for men with AGA has a positive effect on hair density.     

A preliminary study of the effect of 11a-hydroxyprogesterone on the hair growth in men suffering from androgenetic alopecia

Ten male patients suffering from androgenetic alopecia were treated during one year with a lotion containing 1% 11a-hydroxyprogesterone. Eight untreated patients served as control group. The parameters used were hair root status, hair shaft diameter of anagen hair roots and number of hairs with a diameter less than 40 micron. After therapy the cranial region showed an increase in the number and mean hair shaft diameter of anagen hair roots and in the number of hair roots with a diameter less than 40 micron. The number of hair roots in catagen/telogen decreased, the number of dysplastic/dystrophic hair roots remained unchanged. After therapy the cranial region in the controls showed a decrease in number and mean hair shaft diameter of anagen roots, and in the number of dysplastic/dystrophic hair roots. There was an increase in number of hair roots in catagen/telogen and of hair roots with a diameter less than 40 micron. The results warrant the conclusion that the above mentioned therapy would seem to be effective in men suffering from androgenetic alopecia.     

A girl with loose anagen hair syndrome and uncombable, spun-glass hair

A 4-year-old girl presented with a 2-year history of scalp hair that had an odd texture, was difficult to manage, tended to "stick out" from the scalp, and was irregular in length. A hair pull test revealed that hairs could be easily and painlessly extracted. Light microscopic examination of the hair demonstrated anagen hairs with a ruffled cuticle and distorted bulb as well as an unusual undulation and grooving of the shafts. These findings are consistent with both loose anagen and uncombable hair syndromes. The occurrence of both syndromes in the same patient seems unlikely, and we propose that our patient has loose anagen hair syndrome with features resembling uncombable hair syndrome.     

The cross–sectional size and shape of human terminal scalp hair

Change in size of the hair shaft with distance from the scalp has been investigated, using a rotatory profile method of diameter measurement, in terminal human scalp hair of long–haired young Caucasian women. As the whole length of hairs having completed anagen are rarely found intact, two types of hair were investigated: those including segments produced at the onset of anagen (‘anagen hairs’), and those including segments produced at the end of anagen (‘telogen hairs’). In addition, a method of determining the cause of any size variation has been described and employed. Changes were found in the major axis of the hair cross–section, cross–sectional area and ellipticity with distance from the scalp, while the minor cross–sectional axis remained constant. It was established that these changes were the result of intrafollicular rather than extrafollicular mechanisms. Finally, a composite picture of the cross–sectional size and shape of the ‘average’ whole anagen hair of the study has been constructed. From the distal tip towards the scalp for approximately 6–8 cm, there was an abrupt increase in size, representing a starting–up phase of early anagen. Following this, the hair was at its greatest cross–sectional size and ellipticity which then progressively decreased through anagen (20% decrease for cross–sectional area and 13% for ellipticity). In contrast, the minor axis of the hair cross–section, remained constant throughout anagen. The hair was not therefore a uniformly sized cylinder. It was approximately spear–shaped, being broadened out in one plane distally where it was more elliptical. Subsequently as anagen progressed the hair shaft became smaller and more circular.     

Topical application of cyclosporin A induces rapid-remodeling of damaged anagen hair follicles produced in cyclophosphamide administered mice.

Adult C3H mice which had either anagen IV or anagen VI hair follicles were given the anti-tumor drug cyclophosphamide, and cyclosporin A or minoxidil were topically applied to the mice daily from the 4th day after cyclophosphamide administration. In the mice that had anagen IV-hair follicles, 0.5% cyclosporin A induced very thick and long hairs after 21 days of cyclophosphamide administration, while vehicle and 1% minoxidil induced sparsely visible, short hairs. In the mice which received cyclosporin A, the injured hair follicles seemed to remodel themselves into intact anagen hair follicles and restart the production of hairs, instead of shifting to telogen. In the mice that had anagen VI-hair follicles at the time of cyclophosphamide administration, complete alopecia occurred within the first 7 days in all groups. After 14 days of cyclophosphamide administration, hair regrowth was observed in both the 0.5% cyclosporin A-group and the 1% minoxidil- group with the predominant effect over the vehicle. This study shows that anagen hair follicles respond to cyclophosphamide in different ways depending on their stages (IV and VI), and that the damaged anagen IV hair follicles have the potential of remodeling themselves, which is promoted by topical cyclosporin A administration.     

Loose Anagen Hair in Hypohidrotic Ectodermal Dysplasia

We report a 4 year-old boy affected with hypohidrotic ectodermal dysplasia in whom loose anagen hair syndrome (LAHS) was suspected clinically. The diagnosis was confirmed by examination of hair by optic and scanning electron microscopy. Loose anagen hairs have not been previously described in the ectodermal dysplasias. It is possible that our patient had real LAHS or an ectodermal dysplasia with loose anagen hair as an epiphenomenon.     

'Atrophic telogen effluvium' from cytotoxic drugs and a randomized controlled trial to investigate the possible protective effect of pretreatment with a topical vitamin D analogue in humans

BACKGROUND: Hair loss from cytotoxic drugs is classically ascribed to the loss of fractured hairs (anagen effluvium). Telogen hair loss has also been described but some authors have denied any effect on the hair cycle. There are conflicting reports on a protective effect of pretreatment with a vitamin D analogue on cytotoxic drug-induced hair loss in rodents. OBJECTIVES: To investigate the process of cytotoxic hair loss and any protective effect on the hair of pretreatment with topical calcipotriol. METHODS: Breast cancer patients who were about to receive cycles of chemotherapy with cyclophosphamide 600 mg m(-2), methotrexate 40 mg m(-2) and 5-fluorouracil 600 mg m(-2) were recruited and randomized to receive calcipotriol scalp solution 50 microg mL(-1) or vehicle. The solution was applied twice daily from 4 days prior to chemotherapy and continued for 14 days in each treatment cycle. Shed, plucked and cut hairs were sampled. Absolute shed rates, the proportion of major hair types, the presence of proximal hair shaft changes, regrowth (using the new anagen hair count) and hair density were assessed. RESULTS: Ten patients receiving calcipotriol and 14 receiving vehicle completed three treatment cycles and nine from both groups completed six cycles. There was no detectable effect of calcipotriol on the proportion of patients experiencing minimal hair loss from chemotherapy, shed rates, plucked telogen and fractured hair counts, the morphology of shed and plucked hair, hair regrowth or hair density. Combining results of the treatment groups, there was a large variation in the impact of chemotherapy on hair loss, from total loss in five patients to no obvious loss in five. Excluding the latter, during chemotherapy shed telogen hairs (mean 81% of shed hairs) predominated over fractured (12%) and anagen hairs (6%) (P = 0.0002). The major pathological change was proximal hair shaft tapering, baseline mean 3% of shed hairs rising to 48% (P = 0.0005) during treatment, and there was a consequent decrease in normal telogen hairs, baseline mean 98% of all telogen hairs falling to 55% (P = 0.0005) during treatment. The pathological tapered telogen hairs had normal or small, sometimes diminutive, bulbs. Fracturing of hairs with diminutive bulbs produced typical 'exclamation mark' hairs. CONCLUSIONS: The cardinal effects of cytotoxic drugs found in this study were tapering of the proximal hair shaft and premature entry of the follicle into telogen, conflicting with the conventional view that affected hair follicles continue in anagen. There was a resulting effluvium of a mixture of tapering telogen hairs and fractured hairs. As entry into telogen is an integral part of the process, cytotoxic hair loss may be regarded as a variant of the conventional 'telogen effluvium' and we propose the term 'atrophic telogen effluvium'. There was no obvious protective effect on the hair loss of prior treatment with topical calcipotriol.     

Teloptosis, a turning point in hair shedding biorhythms

The timing regulation of the hair growth phases is quite complex. We name teloptosis the termination of the telogen phase with hair shedding. The initiation of the next anagen I phase is independent from teloptosis. Both events are triggered by distinct factors. Indeed, teloptosis is the result of the loss of adhesion between cells of the club hair and those of its epithelial envelope. Teloptosis synchronization is perceived as telogen effluvium, related or not to shortening of the anagen phase. Subtle changes leading to early or delayed teloptosis affect hair density. It is possible to distinguish two types of telogen hairs on a trichogram. Those with an epithelial sheath indicate strong binding, suggesting early telogen, whereas the absence of an epithelial sheath indicates loose binding, conveying teloptosis.