Techniques in the Evaluation and Management of Hair Diseases

Rubina Alves, Ramon Grimalt

• Publisher: CRC Press
• Year: 2021
• ISBN:
  9781000348262
• Edition: 1
• Topic: Medicine
• Subtopic: Dermatology

This book covers the aspects that will help someone starting a practice focused on hair disease or more senior practitioners needing an update on developments. World experts have here generously supplied the information needed, in an extremely practical way, to properly manage daily practice when treating hair patients.

Published in association with the Journal of Dermatological Treatment.

1

Introduction

Ramon Grimalt

Hair diseases represent a vast group of entities that affect an enormous part of the population and represent a huge amount of consultations for dermatologists and scalp surgeons.

Thirty-five years ago, when I was still a medical student, I remember that during the lesson on hair diseases during the fifth year of the degree at the University of Barcelona, our professor stated “Do not waste time on hair diseases; there is nothing to be done – look at me!” And he was pointing at his bold scalp. We all laughed and applauded his joke but the message got in, and probably most of our generation of doctors lived with the idea that hair was a problem that didn’t need attention.

With the first minoxidil commercial topical fluids from Upjohn in the early 1980s things slowly started to change. Then we entered a long barren period until 2017 when finasteride was approved by the FDA for the treatment of common baldness. After that, many new compounds, options, and techniques appeared – and even two journals devoted exclusively to the management of hair diseases are in international medical libraries (Skin Appendage Disorders, from Miami, Florida, edited by Prof. A. Tosti and Dr. D. Rigopoulos; and the International Journal of Trichology, from Chennai in India, edited by Dr. S. Murugusundram).

For this book, we started work with a list of chapter topics and the idea of covering most of the aspects that could help someone starting a practice on hair disease or would help more senior practitioners needing an update on developments. We then selected the world experts on those topics; and were extremely pleased that they all happily accepted the offer and generously donated their time and knowledge to our project.

In this book, therefore, readers will be able to find all the information needed to properly manage a daily practice when treating hair patients. We start with a “Summary of Hair Diseases” by Drs. Alessandrini, Piraccini, and Starace from Bologna, Italy, in which they cover most of the options for medical management of the most common hair diseases.

We asked Prof. Adriana Rakowska from Poland to provide her tips on the practical techniques for taking clinical pictures of patients. There is a real need to maintain good images of patients, not only for teaching purposes but also to help on patients’ follow-up. Most patients are pleased to know that we keep good digital follow-ups of their scalp problems.

The pull test and the trichogram are old techniques, which are still very useful as the first approach to treating hair-affected patients. Many young dermatologists have not been trained on this technique, and in the chapter led by Dr. Cristina Serrano Falcon, they will have the chance to learn how to perform it properly.

Since the first papers on dermoscopy for pigmentary lesions were published back in the early 1990s, many trichologists have started to use the dermatoscope for studying hair diseases. Now, dermoscopy for hair is a very useful and well-defined method for approaching hair patients; the name that was coined by Prof. Rudnicka for it is “trichoscopy.” We have decided to fill two large chapters of the book with these techniques using the most standard classification among two large groups: non-cicatricial and cicatricial forms of alopecia. We are extremely honored to have the world-recognized experts for these chapters: Drs. Bruna Duque-Estrada and Rodrigo Pirmez, as well as Anna Was´kiel-Burnat and Lidia Rudnicka.

Understanding scalp pathology is not easy, and as it can get quite bloody, many hair specialists do not commonly perform scalp biopsies. So, we asked one of the world experts on scalp pathology – Dr. Mariya Miteva – to try to make pathology an understandable technique for helping on those difficult cases. Dr. Miteva has performed a tremendous job, and this is a great chapter for all who like to consult their own preparations.

Contact therapy for alopecia areata has been used for a long time after the first article from Prof. Rudolf Happle that showed half-scalp response; I still remember Dr. Jerry Shapiro's idea of “low tolerable eczema” to decide the concentration of diphenciprone when treating alopecia areata patients. Prof. Juan Ferrando (a senior on the world of hair), together with Dr. Andrea Combalia (a new and rising star), have performed a great review on how to approach patients that would like to be treated with this old but extremely useful technique.

Giselle Martins Pinto from Brazil is a world expert on lasers. In hair research meetings in Brazil, there has been a huge discussion about the efficacy of lasers when treating hair problems. Some research shows good results; others fail to demonstrate any significant differences. In this great chapter, Drs. Martins Pinto and Damasco have taken the time to show how to perform laser and low-level laser therapy (LLLT) properly in order to satisfy patients.

Dermarollers and microneedling are also currently very popular, and in many countries patients want this type of treatment. We have been lucky that Prof. Rachita Dhurat and Dr. Daruwalla from Mumbai, India, has agreed to show us how to do it, in a very detailed chapter, with all the tips and tricks to get good results. The idea is simple; the results can be spectacular, and patients tend to love it.

No better expert could be found to write on oral minoxidil and JAK inhibitors than Prof. Rodney Sinclair from Melbourne, Australia. He has wide experience on such treatments and he and Jared Marc John have provided useful information that can be applied directly to our daily practice. The action mechanism of topical minoxidil does not differ much from the one obtained by oral minoxidil when treating common baldness, and the secondary effects, well detailed in the chapter, are minimal. JAK inhibitors are in constant evolution. Some of them have been proven to be useful for alopecia areata but with secondary effects. We believe that topical JAK inhibitors might be, in the future, a good, safe, and inexpensive way to treat patients affected by severe forms of alopecia areata.

Dr. Sergio Vaño Galván’s group from Madrid, Spain, have been working hard on obtaining consensus and evidence of new treatments for hair diseases. One of his members – Dr. David Saceda – has written a beautiful chapter on the mesotherapy options for treating hair loss. He and his colleagues have vast experience on injected dutasteride with excellent results. In this chapter, they provide the practical information, dilution, cadence, and milliliters needed to successfully start with mesotherapy options when treating patients.

Platelet-rich plasma (PRP) is an autologous blood-derived product with increased platelet concentrations as a result of centrifugation. The effects of PRP are believed to be due to platelet activation and platelet-derived growth factors (PDGFs). The treatment was initially utilized in the field of orthopedics, and PRP preparation systems currently have 510(k) medical device clearance from the United States Food and Drug Administration for the enhancement of bone graft handling properties in operative settings. PRP is becoming popular in the world and many patients ask their doctors to perform such a treatment on them. We have been extremely honored that Prof. Jerry Shapiro's team agreed to write this chapter with all the tricks and methods they use in New York to keep the population satisfied with this innovative and much-in-demand system.

There was a tendency when I started to work on hair diseases 20 years ago that dermatologists did not care about hair cosmetics – it was considered to be related to hairdressers and stylists. However, the position has moved on with facial cosmetics so that currently most dermatologists should know the minimal information to properly assess a patient’s appearance when asked. Similarly, trichologists and dermatologists interested in hair problems should now also be able to advise on helping the appearance of patients’ hair. A basic knowledge of hair cosmetics is extremely important in order to properly assess patients affected by hair diseases. The research group from Bologna, Italy, led by Dr. Bianca Maria Piraccini has provided useful and practical information in the chapter related to hair cosmetics and cosmeceuticals.

Social media has changed the way that we show ourselves to the world. And most people tend to magnify the importance of their aspect not only because we tend to give more importance to our image but also now because we show our image to more people through social media. Those unfortunate patients that suffer from difficult to treat hair problems, can cause them to dislike their own appearance, and as a result they might suffer from psychological alterations. Being qualified and competent as doctors – with the main primary objective to improve the patient's quality of life – we should in many cases also take care of the psychological alterations that might come together with hair diseases. Currently available reports in the literature suggest that male pattern baldness can be associated with significant impacts on the quality of life, often with serious psychological problems. Negative effects have been reported, which include lower self-esteem, perception of physical unattractiveness, depression, emotional distress, greater self-consciousness, anxiety, and psychosocial maladjustment; and in addition, dissatisfaction with appearance, preoccupation with hair loss, worry about other's reactions, and fear of social teasing. Prof. Antonella Tosti and Dr. Andjela Egger from Miami, Florida, have provided a comprehensive chapter on these psychological aspects of hair loss.

In 1998, Drs. Bernstein and Rassman coined the term “follicular unit extraction” (FUE), and in the last ten years the world of hair surgery has changed radically. With the onset of this new technique, many patients who would have been resistant to the idea of scalp surgery are now satisfied with the results obtained. Many dermatologists who did not have the infrastructure to perform the classical strip technique, and would have hesitated about the investment of hiring a whole team for hair surgery, are now able to perform the FUE technique without logistical concerns. Moreover, the new FUE system allows treatment to correct smaller areas that with the strip techniques were not usually approached. Furthermore, the big change in the cost of this type of intervention, together with the tourism surgery in low-cost countries, has provided a big boom in the number of patients interested in hair transplantation. In the chapter written by Dr. Bessam Farjo from Manchester, United Kingdom, useful information to better assess patients interested in hair transplantation is presented, along with how to deal with first cases for those who wish to become a hair transplantation surgeon. It is a nice and informative chapter.

The increasing amount of hair transplant patients has also obliged dermatologists who do not perform hair transplants to possess some skills in assessing the appearance of hair-transplanted patients. The evolution of hair dermoscopy – trichoscopy – has become a useful tool to better understand the normal evolution of hair-transplanted patients. The chapter from Dr. Rui Oliveira Soares is very helpful in its detailed descriptions of the tricks and tips on how to use trichoscopy in hair transplantation.

In the last chapter, before the conclusion of this book, there is a guide to starting a hair consultation service. Dr. Oscar Muñoz Moreno-Arrones and Dr. Sergio Vañó Galván have written a tool kit on how to start a hair clinic and what is needed to be successful. They have a wide reputation in Madrid, Spain, where they run a very busy and successful clinic.

We have wanted to add images (plenty of images!) for demonstrating all types of techniques; even if our book does not pretend to be an atlas, it does claim to be extremely practical and useful. The appendices under Dr. Rubina Alves reinforces this idea, complementing the book with a more detailed description of three treatments frequently performed in the consultation: platelet-rich plasma, mesotherapy with dutasteride, and intralesional corticosteroids. The aim is to show how to perform each of these techniques, with a step-by-step description, thus allowing the reader in a practical and intuitive way to move from theory to practice.

I hope you enjoy this book and all the information in it! We have done our best to make it practical and useful.

2

Summary of Hair Diseases: Cicatricial and Non-Cicatricial

Aurora Alessandrini, Bianca Maria Piraccini, and Michela Starace

Introduction

The two basic categories of alopecia are scarring and non-scarring alopecia. Non-scarring (or non-cicatricial) alopecia is more frequently seen in daily practice and can be caused by androgenetic alopecia, alopecia areata, telogen effluvium, or anagen effluvium. Scarring alopecia is rarer and is characterized by damaged hair follicles with permanent hair loss and skin scarring, such as lichen planopilaris or frontal fibrosing alopecia. In this chapter, we will deepen the most important features of these hair diseases, underlying the main differences within them (Table 2.1).

TABLE 2.1
Most Common Hair Diseases

Cicatricial Alopecias
Lymphocyte-Associated
Lichen planopilaris
Frontal fibrosing alopecia
Discoid lupus erythematosus
Central centrifugal cicatricial alopecia
Keratosis follicularis spinulosa decalvans
Neutrophil-Associated
Folliculitis decalvans
Dissecting cellulitis
Mixed Inflammatory Infiltrate
Erosive pustular dermatitis of the scalp

Non-Cicatricial Hair Diseases

Androgenetic Alopecia

Androgenetic alopecia (AGA) is the most ...

Table of contents

• Cover
• Half Title
• Series Page
• Title Page
• Copyright Page
• Contents
• Preface
• Contributors
• 1. Introduction
• 2. Summary of Hair Diseases: Cicatricial and Non-Cicatricial
• 3. Photography in Hair Diseases
• 4. Pull Test and Trichogram
• 5. Trichoscopy I: Non-Cicatricial Alopecia
• 6. Trichoscopy II: Cicatricial Alopecia
• 7. Scalp Biopsy in Hair Disorders
• 8. Topical Contact Immunotherapy in Alopecia Areata
• 9. Lasers and New Technologies in Hair Disease
• 10. Microneedling
• 11A. Emerging Oral Treatments: Oral JAK Inhibitors for Alopecia Areata
• 11B. Oral Minoxidil for Androgenetic Alopecia
• 12. Mesotherapy: Dutasteride, Minoxidil, Vitamins
• 13. Platelet-Rich Plasma
• 14. Hair Cosmetics and Cosmeceuticals
• 15. Psychological Aspects of Hair Loss
• 16. Modern Techniques in Hair Transplantation
• 17. Trichoscopy in Hair Transplantation
• 18. What You Need for a Trichology Consultation
• 19. Conclusions
• Appendix I: Platelet-Rich Plasma
• Appendix II: Mesotherapy with Dutasteride
• Appendix III: Intralesional Corticosteroids
• Index