International Journal of Trichology International Journal of Trichology
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ABSTRACT
Year : 2014  |  Volume : 6  |  Issue : 3  |  Page : 113-139  

Oral Presentation


Date of Web Publication18-Aug-2014

Correspondence Address:
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Source of Support: None, Conflict of Interest: None


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How to cite this article:
. Oral Presentation. Int J Trichol 2014;6:113-39

How to cite this URL:
. Oral Presentation. Int J Trichol [serial online] 2014 [cited 2019 Nov 22];6:113-39. Available from: http://www.ijtrichology.com/text.asp?2014/6/3/113/139085

Root of the Future

O 1

Hair Follicle - Root of the Future - Clinical Research, Implications and Advances Ulrike


Blume Peytavi

Clinical Research Center for Hair and Skin Science, Department of Dermatology and Allergy, Charité-Universitätsmedizin, Berlin, Germany

The human hair follicle, an highly developed biological autonomous machinery with individual self-renewing capacities, produces keratin fibers possessing an incredible symbolic power for attractiveness, strength, gender definition, as well as emotional and physical well-being. Creating and maintaining life-long beautiful hair, which is easy to grow or eliminate, pigment or depigment, newly create or replace, is the key interest to anyone interested and involved in hair research and management of patients with hair loss, alopecia or excessive hair growth. Advances in understanding hair follicle physiology, hair growth and cycling, hair genetics, innovative diagnostic techniques, hair care, hair removal and restoration have significantly contributed to an improvement in patient care and management. Today, the pilosebaceous unit is exemplary in successful translational research with the human being still remaining the best model to study and investigate hair cycling and growth behaviour. Advances in the field of stem cell biology have led to direct clinical impact in projects of hair follicle neogenesis and hair transplantation. Targeted follicular delivery, using the unique role of hair follicle pathways in percutaneous penetration with drug delivery systems, has opened a new dimension in the development of hair growth therapeutics and adjacent indications such as transfollicular vaccination strategies. Advances in experimental and clinical research enable us today to offer our patient innovative diagnostic tools and new testing devices and procedures. These in turn enable us today to validate and quantify efficiently new candidate molecules for treating hair disorders. Trichology today incorporates evidence-based guidelines established for the management of androgenetic alopecia, alopecia areata and hirsutism.

Hair Style and Life style

O 2

Because They are Worth it


P. D. Yesudian

Consultant Dermatologist, Betsi Cadwaladr University Health Board, Consultant Dermatologist, Royal Liverpool University Dental Hospital, Liverpool, UK

In January 2014, Lino Carbosiero, a hairdresser based in central London shot into the limelight after being awarded an MBE in the New Year's Honours List. He is, after all, the barber of David Cameron, our incumbent Prime Minister, arguably the most important man in our country. He has been recognised for changing the Prime Minister's side-parting from right to left, perhaps subconsciously reflecting the Tory Party's political lean in that direction, or simply a sly attempt at hiding a receding hairline. Mr. Cameron's coiffure has been a persistent talking point since his election in 2010, having been accused of visiting various stylists and trichologists in the past, but perhaps there's a good reason for his ͳ90 haircut: William Haque and Iain Duncan Smith, both bald, have the unfortunate honour of being only two of the three Conservative Party leaders since 1922 who were not elected as Prime Minister, the other being Michael Howard, who hasn't exactly got a full head of hair. A look back at history would emphasise the importance of hairstyles for those in a position of power. In Greek mythology, King Midas' enlisted a barber in an attempt to hide his donkey's ears. Similar, King Lowry Lynch of Ireland would have his hair styled once a year according to an old Irish myth, in order to hide his horses' ears. In order to keep the secret, the barber would be executed immediately once the job was done. Marie Antoinette (1755-1793) has been described as the Queen of the coiffure who had set the trend for hairstyles being regarded as status symbols. Benjamin Disraeli (1804-1881), who twice served as the Prime Minister, wore his hair characteristically in ringlets and David Lloyd George (1863-1945) had bardic locks whilst Harold Macmillan (1894-1986) had wavey hair with side peaks. More recently, files from the National Archives revealed that the late Iron Lady, Baroness Thatcher (1925-2013) had 118 hair appointments in 1984 alone. Hillary Clinton, potentially the first female US President in 2016, recently debuted her new "bangs" which seemingly attracted more attention than the actual inauguration of New York City's latest mayor, Bill de Blasio. Like Dumbledore's Elder Wand, a barber's scissors hold magical powers: A hairstyle can become a trademark, a clean cut may help to win and election, whilst an unwise choice would generate unwanted publicity. So perhaps the next time we see patients concerned about hair loss, we should remind ourselves that all our attempts at establishing hair regrowth, is because they're worth it!

O 3

Curly Hairs - Cumbersome or Cuddlesome


Maria Fernanda Reis Gavazzoni Dias

Institute of Dermatology, Rio de Janeiro, Brazil

Curly hair presents variation of diameter at several points along the thread, less water content, and an ellipsoid shape. Hair fibers present torsions at many regions along the thread, while Caucasian hair has a cylindrical cross-section. The small angle of the waves of very curly hair makes it more susceptible to breakage, when mechanically worked, making curly hair more difficult to comb without provoking frizz. African hair, curly and wavy hair are more prone to have dryer hair fiber. Sebaceous glands of curly and very curly hair are frequently less active, when compared with the Caucasian ones, and they produce low amounts of sebum. As the fiber is extremely sensible and prone to breakage it is not unusual that curly and straightened hair do not achieve long length and breaks during the growing process. The use of conditioners and leave-on products decrease interfiber friction making hair easier to comb. The use of anti-dundruff shampoos can make hair more difficult to comb. Less flyaway is achievable by lubricating the fiber surface and decreasing static charge. Grooming a non lubrified hair may lead to hair breakage. Abrasion and friction are impactant factors that causes hair damage by protein loss. The use of conditioners with oils and silicones are important to minimize the rubbing and friction of the cuticle cells for chemical treated hair and after the use of anti-dundruff shampoos. Very curly has less density than Caucasian hair. People with curly and very curly hair may experience some feeling of hair loss after performing a hair straightening procedure because when the hair loses volume, the scalp may be exposed because of the lower number of hair follicles. Curly, very curly and wavy hair are frequently submitted to hair straightening techniques. Official hair straighteners are called chemical relaxers and the effect of hair straightening is permanent. Alkaline straighteners are: Sodium hydroxide ("lye-relaxer), lithium hydroxide, calcium hydroxide or a combination of these ingredients such as guanidine carbonate and calcium hydroxide (no-lye relaxers). Disulfide bonds are cleaved using an alkaline reducing agent. Hair is sensitive to pH value changes and alkaline solutions swell the fibers and open the cuticle scales. This can make the hair susceptible to friction, lowering its resistance and strength. Ammonium Thioglycolate is another "no-lye" relaxer. It is a chemical reducing agent which selectively weakens the hair's cystine bonds instead of disrupting the entire protein. If a hot iron is aplied during the process, the permanent straightening can be achieved. This is the basis of the process called "japonese hair straightening or thermal reconditioning". Thioglycolate causes less protein loss than hydroxides. Hydroxides and thioglycolate are incompatible with each other. Also, both are incompatible with bleached hair. The "Brazilian Keratin Treatment - BKT", was based on a home-made formaldehyde or glutaraldehyde formulation. Both substances are mutagenic and a cancer hazard and therefore forbiden by law. But still, every salon in Brazil keep using the BKT. The ingredients used today are based on formaldehyde-releasers such as methilene glycol or glyoxylic acid. Both substances are capable of releasing formaldehyde when heated during blow-dry and hot iron application. Many possible side effects can occur with the use of BKT. Hair care products and procedures are extremely important for women with curly hair. Dermatologists may help these patients with good advice about the proper use of hair cosmetics and hair straightening techniques.

O 4

Matting Hair - An Evolutionary Enigma


Vijay Zawar

Consultant Dermatologist, Nashik, Maharashtra, India

Spontaneous entanglement, of scalp hair, also known as plica polonica or plica neuropathica, is an enigmatic disorder. Various etiological factors have been implicated including alarming reaction following shampoo or hair conditioners, disturbed psyche, improper personal hygiene, systemic or topical medications, local infections and eczematous states. Yet there are patients in whom exact etiology is unclear. There are various old and new concepts in the etiological factors.

O 5

Hair's Response to Restless Mind


Abhay Mani Martin

Department of Dermatology, Baby Memorial Hospital, Calicut, India

Hair is a sensor of stress. The neuro-endocrine system is actively functional in the hair follicle. With clinical observations and cases, we highlight the intricate correlation between stressful events and follicular origins of disease. The cases include examination related stress which led to alternate bands of graying akin to the Pohl-Pinkus lines, the flag sign of kwashiorkor and follicular origin of nummular eczema.

Best off the Bench

O 6

What is in the Pipeline with Cell Therapy for Androgenetic Alopecia?


Jerry Shapiro

Hair and Scalp Disorders Clinical Professor, University of British Columbia, Department of Dermatology and Skin Science, Vancouver, Canada Adjunct Professor, New York University Langone Medical Center, Department of Dermatology, New York, USA

The US FDA defines somatic cell therapy as the administration of autologous, allogeneic, or xenogeneic non-germ cells-excluding blood products for transfusion-which have been manipulated or processed and propagated, expanded, selected ex vivo, or drug-treated. Recent advances in epithelial stem cell biology have resulted in the isolation of hair follicle stem cells, which generate hair follicles when injected into immunodeficient mice. These isolated hair follicle epithelial stem cells must be combined with 'inductive' dermal cells to produce new hair follicles. The advent of techniques for cultivating inductive dermal cells and competent epithelial stem cells creates the opportunity to bioengineer hair follicles for the treatment of hair loss. However there are a few limitations. The novel development of dermal cup sheath cells may remove the obstacles in cell therapy for hair regeneration.

O 7

Research Progress in Hair Follicle Cell Culture


Desmond J. Tobin

Centre for Skin Sciences, School of Life Sciences, University of Bradford, Bradford, West Yorkshire, BD7 1DP, Great Britain.

It has long been the biologist's desire to study mammalian cells without variations in systemic homeostasis and free of experimental stresses on the intact animal. In pursuit of this, cell and tissue culture technology has advanced hugely from the early cultivation of tissue fragments to today's exacting strategies needed to grow fastidious cell types like neurons and melanocytes. Despite its unique accessibility, successful cultivation of the skin's major cell populations however, has been a relatively recent development. Keratinocyte culture strategies only emerged in the early 1970's, while successful epidermal melanocytes cultures were described only in 1982. Hair biologists were quick to adapt these culture protocols to histologically similar cells in the hair follicle. Successful culture of individual cell populations from defined follicular components was first demonstrated for keratinocytes of the outer root sheath using plucked human anagen hair follicles (1981). The cultivation of specialized fibroblast-like cells of the rat vibrissa papilla was published in the same year (1981) and human dermal papilla cells a little later (1984). The close anatomic relationship between the dermal papilla and connective tissue sheath spurred efforts to grow dermal sheath fibroblasts (1986) and this was followed by the successful cultivation of matrix epithelial cells from the anagen bulb (1993). I reported the long-term cultivation of follicular melanocytes was reported two years later (1995). Attempts to cultivate epithelial stem cells purportedly located in or close to the bulge continue with only limited success. A major step forward in hair follicle cell culture was the development of methods to growth the intact anagen VI human scalp hair follicles in organ culture for up to 8 days (1991) to allow study of the interaction of the individual cell systems. In this talk I will provide an overview on the cultivation of each of the major follicular cell types, discussing both the practical issues involved and the possible applications of this research.

O 8

Follicular Targeting and Hair as a portal Of Novel Drug Delivery


Ulrike Blume-Peytavi, Annika Vogt

Clinical Research Center for Hair and Skin Science, Department of Dermatology and Allergy, Charité-Universitätsmedizin, Berlin, Germany.

Today, the pilosebaceous unit is exemplary in successful translational research with the human being still remaining the best model to study and investigate hair cycling and growth behaviour. Targeted follicular delivery, using the unique role of hair follicle pathways in percutaneous penetration with drug delivery systems, has opened a new dimension in the development of hair growth therapeutics and adjacent indications such as transfollicular vaccination strategies. The transfollicular administration of pharmacologically active molecules is of current therapeutic interest, not only with regard to delivery to specific sites but also to different types of hair follicles (terminal and vellus HF). In vellus hair follicles topically applied 1.5 µm and 0.75 µm microparticles aggregated in the follicular infundibulum without penetration into the skin ("Macro-Targeting" of the human vellus hair follicle). Microparticles of this size may be used as drug carrier systems to create depots in the follicular duct ("Macro-Targeting" of the human vellus hair follicle). Nanoparticles e.g. 40 nm particles, in contrast, penetrate deep into human vellus hair follicles ("Micro-Targeting" of the human vellus hair follicle). Thus, nanoparticles are able to aggregate in hair follicle openings and to penetrate along the follicular duct; they are promising carrier systems for interfollicular application and transfollicular drug delivery. The importance of selective follicular targeting is increasingly evident in the development of future therapeutic strategies, especially for disorders such as seborrhoea, seborrhoic dermatitis, acne, hypertrichosis and laser epilation. In the past, the role of the hair follicle for skin penetration and barrier function was considered relatively minor. However, in the light of recent findings and considerably improved understanding of skin physiology, advances have been made in the delivery to specific sites of the hair follicle. Hair follicles are the preferred pathways for specific molecules and formulations, which pass faster into these shunts than through the stratum corneum. Hair follicle density, follicular orifice size, surface of the infundibulum, and the relation between hair follicle growth activity and sebum secretion rate ("open and closed follicles"), in combination with follicular targeting using microspheres, permit us to selectively penetrate distinct structures of the hair follicle

Breaking the Myths and Establishing Facts

O 9

Post Finasteride Syndrome: Myth or Reality?


Ralph M. Trüeb,

Center for Dermatology and Hair Diseases, Bahnhofplatz 1A, CH-8304 Zurich-Wallisellen, Switzerland

The post-finasteride syndrome has been claimed to occur in men who have taken oral finasteride to treat either hair loss or benign prostatic hyperplasia. Reported symptoms include: loss of libido, erectile dysfunction, reduction in penis size, penile curvature or reduced sensation, gynecomastia, muscle atrophy, cognitive impairment, severely dry skin, and depression. The condition allegedly may have a life-altering impact on sufferers and their families, such as job loss and the break-up of romantic relationships or marriages, while also being linked to suicides. As yet, the condition is not recognized by the scientific community, although individuals who suffer from the syndrome do present with very distinctive and relatively homogenous symptoms. While the incidence of persistent sexual, mental, and physical side effects which continue despite quitting finasteride is unknown, it is likely that over 1'000 men worldwide are experiencing the effects. This estimate is based on the number of registered users o the Internet forum www.propeciahelp.com. Persistent neurological effects from other drugs are well recognized, such as tardive dyskinesia related to the use of phenothiazines for treatment of chronic schizophrenia. The mechanisms of irreversible tardive dyskinesias from phenothiazines may be similar to the mechanisms underlying the persistent side effects of finasteride. There is a growing body of scientific evidence from studies in rodents, that finasteride may reduce the concentration of several neuroactive steroids important for neurogenesis and neuronal survival. In rats treated with the phenothiazine haloperidol to induce orofacial dyskinesias, co-administration of progesterone prevented this side effect, while pre-treatment of the rats with finasteride reversed this protective effect, demonstrating an important role of the progesterone pathway and its metabolites. Up to date there is no predictive factors for the risk of development of post-finasteride syndrome and no known treatment for the disorder. For the time being, as a general rule: (1) Refrain from prescribing oral finasteride to a patient with a personal history of depression, sexual dysfunction, or fertility problems (2) When fertility is an issue, may consider performing a sperm count before and during treatment with oral finasteride. (3) In any case of adverse effects, stop oral finasteride treatment. (4) In all men 45 and over, perform PSA before, after starting therapy with oral finasteride, and thereafter on twice yearly basis. The level should drop by ca. 50% upon initiation of therapy. In case of increase > 0.4 ng/ml per year, refer to urologist to check prostate condition. (5) For men who choose regular prostate-cancer screening, the use of oral finasteride meaningfully reduces the risk of prostate cancer.

Hair Density Recovery: New Insights in Hair Growth Biology - L'Oreal Research

O 10

The Niche of Human Hair Follicle Stem Cells: A Specific Environment


Michelle Rathman-Josserand, Bruno A.Bernard*, Namita Misra

L'Oreal Research and Innovation, India, L'Oréal Research and Innovation, Clichy, France

Human hair follicles undergo, in a stochastic manner, a succession of different phases including a growth phase (anagen), a degradation phase (catagen), a resting phase (telogen) and a neomorphogenesis phase (neogen). Of particular interest is the neogen phase during which all hair follicle compartments are regenerated from local reservoirs of stem cells. Both functional and immunohistological studies suggested the existence of at least two pools of pluripotent cells in human hair follicle, one located in the upper ORS, the other one in the lower ORS. The upper and lower reservoirs of K19+ cells are however not identical. The upper compartment mainly contains K15+/ K19+/ a6 hi / MCSP+/ CD200+ cells, facing a 4C3-CS epitope-enriched CTS, while the lower compartment mainly contains K19+/ a6 hi / CD29+/ CD271+/ MCSP+/ CD34+ cells located in a hypoxic environment as revealed by GLUT-1 and ACIX expression, and facing a 7D4-CS and HepSS-1 epitopes-enriched CTS. To investigate the potential impact of hypoxic environment on hair follicle stem and early progenitor cell populations, we measured the colony forming efficiency (CFE) of keratinocytes derived from the Outer Root Sheath (ORS) of human follicles, cultured under normoxic or hypoxic conditions. Although the absolute number of clones was not statistically different for the two conditions, cell density and differentiation were reduced under hypoxic culturing conditions, suggesting maintenance of cell immaturity. Based on these results, we hypothesized that induction of hypoxia signaling may be important in maintaining hair follicle stem cell functionality. Hypoxia signaling is mediated by the hypoxia-inducible transcription factor HIF1, the a subunit of which is degraded in an oxygen-dependent manner through prolyl-4-hydroxylase (P4H)-mediated hydroxylation. A potent P4H competitive inhibitor, named Stemoxydine, was tested for its ability to induce hypoxia-like signaling. Transcriptomic studies show that treatment of hair follicles with Stemoxydine in normoxic conditions modifies the expression of a panel of genes in the same manner as culturing under hypoxic conditions. In addition, when ORS-derived hair follicle cells were grown in normoxic conditions with Stemoxydine, CFE and clone morphology were similar to those observed in hypoxic conditions. These results suggest that hypoxia may be an important regulator of stem/progenitor cells function in the human hair follicle. We hypothesize that molecules that mimic hypoxic signaling, such as Stemoxydine, may figure as new approach to sustain hair growth and cycling.

O 11

Stemoxydine, a Hair Kenogen Phase Shortener, Leading to Increased Hair Density


Pascal Reygagne

Centre de santé Sabouraud, Saint Louis Hospital, Paris, France

Hair kenogen phase, as the latency period required for a new hair growth to engage contributes in part to decreased hair density, a hallmark of androgenetic alopecia. In vitro findings on a new compound, a potent prolyl 4 hydroxylase competitive inhibitor, Stemoxydine®, led us to assess, in vivo, its potential in shortening the hair kenogen phase, through three vehicle-controlled protocols.Three double-blind and randomized clinical studies were conducted on healthy male subjects aged 18-55 with AGA Grade III to IV:

1) Two intra-individual studies on 16 and 23 men, respectively with 5 days a week product application.

2) One inter-individual study on 100 men with daily application.

Stemoxydine® 5% hydro-alcoholic lotion was assessed versus vehicle using the phototrichogram technique (PTG).

In the three studies, after 3 month treatment, the results showed a significant increase in hair density with Stemoxydine® 5% versus vehicle, without any difference in telogen percentage.

1a) Stemoxydine®+ 4.5% versus control -0.3% (p = 0.04)

1b) Stemoxydine® + 11% versus control + 7% (p = 0.029)

2) Stemoxydine® + 8% versus control + 4% (p = 0.036)

Additionally, a significant decrease (p = 0.02) in the percentage of hair in kenogen phase was found in study 1.b) where a PTG follow-up was monthly performed. No skin intolerance was recorded in any of these 3 studies. This converging data suggests that, in AGA, Stemoxydine® could act as a hair kenogen phase shortener, leading to an increase in visible scalp hair density.

Cicatricial Alopecias

O 12

Scarring Alopecias: Going a Step Further


Ralph M. Trüeb

Center for Dermatology and Hair Diseases, Bahnhofplatz 1A, CH-8304 Zurich-Wallisellen, Switzerland

The scarring alopecias represent a diverse group of disorders that cause permanent destruction of the pilosebaceous unit and irreversible hair loss, characterized by: visible loss of follicular ostia, and destruction of the hair follicle on histopathologic examination. Loss of follicular orifices in an area of alopecia points to an irreversible loss of hair, either due to permanent damage to essential parts of the hair follicle or destruction of the entire hair follicle. Although the scarring alopecias represent the cause of alopecia in a minority of patients, the irreversibility and possible important cosmetic consequences of scarring alopecia demand special diagnostic attention in order to promptly attain a precise diagnosis and specific treatment. Scarring alopecias pose both a diagnostic and therapeutic challenge to the practitioner. Accurate diagnosis based on a careful patient history, clinical examination, microbiological studies, and scalp biopsy is a prerequisite to therapy. Problems related to the treatment of the scarring alopecias include: patient's delay, when irreversible scarring has already occurred. Since the causes are mostly unknown, therapy has remained empiric and non-specific. Published data on recommended therapies have usually low levels of evidence. Ultimately, the goal of therapy is mostly to halt further progression. With expanding technologies for dissecting the immunologic and molecular basis, there is hope for a deeper understanding of the underlying pathogenesis and novel therapeutic interventions. Among these, currently, microarray analysis is used to identify disease associated gene expression patterns with the aims of further clarification of nosologic classifications and development of targeted therapies of the scarring alopecia. Ultimately, where end-stage fibrosis is established, combination with surgical treatment, such as scalp reduction plasty and autologous hair transplantation, and prosthetic help are taken into consideration.

O 13

Cicatricial Alopecias: What I do?


Jerry Shapiro

Hair and Scalp Disorders Clinical Professor, University of British Columbia, Department of Dermatology and Skin Science, Vancouver, Canada, Adjunct Professor, New York University Langone Medical Center, Department of Dermatology, New York, USA

Cicatricial alopecias are considered as Trichological emergencies. Treatment is dependent on astute diagnosis. Diagnosis is clinical and histopathological. Treatments with tetracyclines, antimalarials, immunosuppressants combined with intralesional and aggressive topical therapy may thwart the spread of this condition.

O 14

Accumulation of Sterol Intermediates Disrupt Immune Prevalence in Hair Follicle and Initiates Permanent Hair Loss


S. Parameswara Panicker 1],[ 2 , M. C. Consolo 2 and P. Karnik 2

1
Departments of Zoology, University of Kerala, Thiruvananthapuram, 2 Dermatology, Univ Hosp Case Medical Center and Case Western Reserve Univ, Cleveland, OH

Primary Cicatricial Alopecia (PCA) is a group of rare inflammatory disorders of the pilosebaceous unit that cause scarring and permanent hair loss. The affected hair follicles fail to re-grow because of destructive inflammatory changes in the permanent portion of the hair follicle where the sebaceous gland and stem cells of the bulge are located. Little is known about the etiology and pathogenesis of PCA, but biopsy study reveals different forms of inflammatory infiltrates. Depending on the cell infiltrate into the active PCA is classified into lymphocytic, neutrophilic, or mixed. Exogenous factors like UV radiation, and bacterial infections are the main pathogenic reason for PCA. Autoimmune mediated mechanisms are proposed but a specific auto-antigen is not identified. The signals that initiate an inflammatory attack on hair follicles in PCA are not identified properly. Studies have shown that PPARγ, a transcription factor that integrates lipogenic and inflammatory signals, in the pathogenesis of PCA. However, it is unknown what triggers the inflammatory response in these disorders, whether the inflammation is a primary or secondary event in disease pathogenesis, and whether the inflammatory reaction reflects an autoimmune process. This study proposes that the cholesterol biosynthetic pathway is altered in the hair follicles of PCA patients. Treatment of hair follicle cells with BM15766, a cholesterol biosynthesis inhibitor, or 7-dehydrocholesterol (7-DHC), a sterol precursor, up regulated certain genes related to inflammation. Topical treatment of mouse skin with 7-DHC or BM15766 inhibits hair growth, causes follicular plugging and induces the infiltration of inflammatory cells into the perifollicular region. Our study demonstrate that changes in cholesterol biosynthesis pathway within hair follicle cells trigger an innate immune response that is associated with the induction of innate and pro- inflammatory chemokine genes.

Tricho-Pathology

O 15

The Quintessential Tricho Pathologist in Scarring Alopecias


Asha Kubba

Department of Dermato-Pathology, Delhi Dermatology Group, New Delhi, India

Diagnosis of alopecia is best done on histo-pathologic evaluation of scalp biopsy in conjunction with clinical presentation. It allows one, to differentiate clinically similar entities to arrive at a definitive diagnosis. Scarring alopecia is characterized by inflammation and loss of hair follicles, resulting in irreversible scarring type of alopecia. Based on the type of inflammatory infiltrate, alopecias are classified as lymphocyte associated; such as lupus erythematosus and lichen plano pilaris. Neutrophil associated pathology are seen in folliculitis decalvans and dissecting folliculitis. This presentation will focus on the histopathologic features of scarring alopecia with focus on two most common entities namely, discoid lupus erythematosus and lichen plano pilaris. Compare and contrast the features that help distinguish the two entities. Neutrophilic scarring alopecia will be discussed briefly.

O 16

Tricho-pathology in Non Scarring Alopecias - When to do, Where to do and what to expect?


Meenakshi Batrani

Department of Dermato-Pathology, Delhi Dermatology Group, New Delhi, India

Primary alopecias are divided into two groups i.e. scarring and non scarring. The term non scarring alopecia includes a heterogeneous group of disorders characterized by the preservation of follicular stem cells and henceforth, the potential for regrowth. The common disorders included in this category are alopecia areata; androgenetic alopecia; telogen effluvium; trichotillomania and traction alopecia. In cases where clinical diagnosis is questionable, the scalp biopsy is considered as the gold standard to distinguish non scarring alopecia from scarring alopecia as well as to differentiate between various causes of non scarring alopecia. The site of biopsy, type of biopsy and method of sectioning are crucial for adequate evaluation of alopecia. The various non scarring alopecias have overlapping histopathological features and therefore the interpretation of scalp biopsy is challenging. Histopathological picture in alopecia areata varies with the stage of the disease. In the absence of the classic peribulbar inflammation, it is difficult to distinguish it from other non scarring alopecia. The semiquantitative analysis of transverse sections with regard to follicular density, terminal to vellus hair ratio and percentage of telogen hairs along with assessment of morphological alterations such as trichomalacia are required for the diagnosis. The histopathological aspects of non scarring alopecias with particular emphasis on distinction of alopecia areata in the absence of classic peribulbar inflammation will be discussed.

Insulin Resistance and its Impact on Hair

O 17

Basics of Insulin Resistance and its Profile in a Dermatology Clinic in India


Raj Kubba

Department of Dermatology, Delhi Dermatology Group, New Delhi, India

Insulin Resistance (IR) has emerged, in recent years, as the single most important comorbidity and disease modifier not only in Dermatology but across all medical specialities. To know it, to master it, is nothing short of a compulsion. IR is defined as defective insulin stimulation of glucose uptake by skeletal muscle, subcutaneous fat, liver, and endothelial cells resulting in compensatory hyperinsulinemia which is intermittent (acute) in the initial phase, and progressively evolves to become persistent (chronic) in due course. Insulin is a potent mitogen, next only to IGF-1, with which it shares binding receptors [IGF-1 is capable of binding to IR-A and insulin binds to IGF-1R] and collaborates in inducing and determining tissue growth. Hyperinsulinemia is the instigator of Metabolic Syndrome (MS) which in turn includes T2DM, Hypertension, dyslipidemia (low HDL, elevated triglycerides), hyperuricemia, thyroid dysfunction, fatty liver, enhanced risk of coronary artery disease, disorders of fibrinolysis, disturbed immune system (autoimmune diseases, atopy), high BMI, PCOS in women, Acne, etc. IR is strongly expressed in skin and that aids early recognition and offers opportunity for early and timely intervention. The best known skin marker of IR is acanthosis nigricans (AN) which makes an early appearance sometimes in the prepubertal phase. Acrochordons are another recognized clue to IR and appear somewhat later. Benign cutaneous hyperplasias, namely, DPN's, syringomata, ephelides/ lentigines, eruptive melanocytic nevi, have recently been proposed as skin signs of IR. In the skin, IR individuals suffer worsening of skin color, erosion of beauty (dark circles, shaded chin and forehead), batwing melanosis (aka pigment demarcation lines), seborrhoea, hypertrichosis, Malassezia overcolonization, and several patterns of hair loss. IR is the commonest explanation for SAHA in women and APAAN in men. IR is validated by documenting disturbed glucose tolerance. More specifically by assaying fasting and postprandial sugar and fasting and postprandial insulin. The gold standard of establishing IR is HOMA-IR (homeostasis model assessment for insulin resistance) which is a computer derived formula (FBS X F. Insulin 405) and a value of 4.5 or greater denotes IR. However, in the early evolving phase of IR HOMA-IR values are subdiagnostic and clinical laboratory correlations are called for. Recognition of concomitant IR permits broader therapeutic approaches and justifies emphasis on diet and lifestyle modifications. Metformin is a key drug in the management of IR associated skin diseases including patterned hair loss.

O 18

APAAN Syndrome


Ifneela Meraj

Department of Dermatology, Delhi Dermatology Group, New Delhi, India

APAAN syndrome - acronym for Acne, Patterned Alopecia, Acanthosis Nigricans. APAAN syndrome is a counterpart of SAHA in females. It is commonly observed in Indian men starting as early as adolescence. Clinically, besides acne, these patients have Ludwig type of male pattern baldness, patterned or diffuse Acanthosis nigricans, and hyperinsulinemia (acute and chronic). We are analysing a cohort of young male patients with patterned alopecia increasingly presenting to our clinic. These patients also have associated acne of variable severity and acanthosis nigricans of variable degree. They are carefully examined and thoroughly investigated for insulin resistance and comorbidities. Findings of clinical examination and laboratory investigations are recorded in detail on a pre designed data sheet. Photographic records are maintained. A careful clinical laboratory correlation is made to arrive at a diagnosis and design a treatment plan that is individualised for each patient. An improved therapeutic outcome has been noted in these patients when treatment is administered for insulin resistance and other comorbidities identified during evaluation.

O 19

Management of Insulin Resistance in Patterned Hair Loss


Latika Arya

Department of Dermatology, Delhi Dermatology Group, New Delhi, India

Several studies have shown significant association of hyperinsulinaemia and insulin-resistance-associated disorders such as obesity, hypertension, and dyslipidaemia in individuals with early Patterned Hair Loss (earlier k.a. Androgenetic Alopecia), supporting the hypothesis that PHL is a clinical marker of insulin resistance. Hence the importance of lifestyle modification, with low glycaemic diet, regular exercise and weight management, cannot be overemphasized while treating PHL. In cases of documented insulin resistance /metabolic syndrome, particularly if those patients fail to modify their lifestyles, an insulin sensitizer needs to be instituted. Metformin is the oldest and still the most commonly used insulin sensitizer. Not only does Metformin increase the success rate of conventional hair loss management (Minoxidil, Finasteride) and convert non - responders into responders, but also reduces the risk and complications of cardiovascular disease and type 2 diabetes mellitus later in life. In few cases of Metformin intolerance, PPAR-gamma receptor agonist, Pioglitazone may be employed selectively. Addition of other insulin sensitisers like alpha -lipoic acid, inositol. N-acetyl cysteine, adds power to the treatment. DHT inhibitors Finasteride and Dutasteride slow the progression of hair loss and increase hair growth. Minoxidil is the only topical medication approved for PHL, however recently topical peptides and stemoxydine have been introduced, albeit with very preliminary evidence. Thus management of PHL involves choosing logically and adequately from the menu of available therapeutic agents, based on the etiopathogenesis, with an individualized approach.

Does Water Really Matter in Making Hair Better? and the Trichotillometer

O 20

Scanning Microscopy and the Tensile Strength of Hair Treated by Hard and Soft Water


Gowtham

Department of Dermatology, PSG Institute of Medical Sciences, Coimbatore, India

Background: Hardness of water is determined by the amount of calcium carbonate(CaCO3) and magnesium sulphate(MgSO4) dissolved in it. Hardness of water used for washing hair may damage the hair. Objectives: The objective of this study is to observe the surface changes due to hard water usage and compare the thickness of hair between hard and soft water treated samples. Methods: 10 -15 strands of hair of length 15-20 cm which was lost during combing was obtained from 15 healthy female volunteers. Each hair sample was cut into two equal halves to obtain two sets per volunteer. Each hair sample was wrapped around a glass rod. One set of 15 hair samples was washed with hard water and the other set was washed with distilled water for 10 minutes on alternate days and air dried. This procedure was carried out for 30 days. The surface of hair treated in hard and soft water was examined under a scanning electron microscope. Results: The CaCO3 and MgSO4 content of hard and distilled water samples used were determined as 212.5 ppm of CaCO3 and 10 ppm of CaCO3 respectively. The mean calcium deposition in hard and distilled water treated hair was determined as 0.804 and 0.26 respectively. The mean Magnesium deposition in hard and distilled water treated hair was determined as 0.34 and 0.078 respectively. The mean thickness of hair treated in hard water and distilled water were 72.78 and 78.14 respectively. Conclusion: The surface of hard water treated hair has a abrasive and ruffled appearance with higher mineral deposition and decreased thickness when compared with the surface of distilled water treated hair.

O 21

Innovation of a Cost Effective Hand Held Trichotillometer (To Replace Instron) in the Determination of Force Required to Pluck the Hair from the Scalp Manually


Chakravarthy R. Srinivas

Professor and Head, Department of Dermatology, PSG Institute of Medical Sciences and research, Coimbatore, India

Evaluation of hair loss includes trichogram to determine the anagen and telogen ration. It has been observed that the anagen hair is difficult to pluck than telogen hair. This can be easily explained. This study was undertaken to determine the hair plucking force of anagen and telogen hair over the frontal, parietal, vertex and occipital area of scalp using INSTRON equipment in south Indian textile research association (SITRA). Since INSTRON is an heavy duty equipment, a hand held trichotillometer was designed to determine the plucking force. The assembling of hand held trichotillometer was done with the help of Dr. Sasidharan Nair, Professor and head of the Basic sciences department at PSG institutes of Technology, Coimbatore. A spring balance with the markings was used to measure the force required to pluck the hair. The hand held spring balance was suitably modified to determine the force required to pluck the hair.

O 22

Practical Use of Hand Held Trichotillometer in Assessing the Plucking Force in Volunteers


Kumaresan Muthuvel

Department of Dermatology, PSG Institute of Medical Sciences and research, Coimbatore, India

Hair loss is a common problem encountered either due to pathological causes or nutritional deficiencies. Trichotillometer is a device that is used to determine the force required to pluck the hair. Trichotillometer is not available commercially. Aim: To determine the epilation force (EF) required to pluck the anagen hair and telogen hair from four regions (frontal, vertex, occipital and parietal) of the scalp. Methods: Thirty healthy volunteers who did not complain of hair loss were studied. The EF required to pluck hair from 4 regions (frontal, vertex, occipital and parietal) on each volunteer was determined using the customized hand held trichotillometer. Ten hair was plucked from each site.The root of the plucked hair was examined under microscope to determine whether the follicle plucked was in the anagen or telogen phase. Subsequently the mean force required to pluck the anagen hair and telogen hair from each area was calculated. Results: A total of 30 volunteers were included in the study among them fifteen were males and 1 5 were females. The mean EF required to pluck the anagen hair was 73.30 gms and telogen hair was 41.46gms. In male the mean EF required to pluck the hair anagen hair was 76.18gms and telogen hair was 42.34 gms. In female the mean EF required to pluck the hair was 55.46gms for anagen hair and telogen hair was 40.12gms. Conclusion: Greater force was required to epilate the anagen hair than the telogen hairs on all the areas of scalp and greater force was required to epilate the anagen and telogen hairs in males than the females.

Novel Therapeutic Avenues

O 23

Treating Hair Loss beyond Evidence Based Medicine


Ralph M. Trüeb

Center for Dermatology and Hair Diseases, Bahnhofplatz 1A, CH-8304 Zurich-Wallisellen, Switzerland.

Evidence-based medicine (EBM) aims to apply the best available evidence gained from the scientific method to clinical decision making. It seeks to assess the strength of the evidence of risks and benefits of treatments and diagnostic tests. Using techniques from science, engineering and statistics, such as the systematic review of medical literature, meta-analysis, risk-benefit analysis, and randomized controlled trials (RCTs), EBM aims for the ideal that healthcare professionals should make conscientious, explicit, and judicious use of current best evidence in their everyday practice. As EBM guidelines on hair loss are rare, a European consensus group was recently constituted to develop guidelines for treatment of androgenetic alopecia. The European consensus group conducted a systematic literature review in Medline, Embase and Cochrane databases. The guideline revealed excellent evidence levels for the therapeutic use of topical minoxidil and oral finasteride, low evidence levels for hormonal treatments (in women), and insufficient respectively lacking evidence for a broad panel of miscellaneous treatments available claiming effectiveness for treatment of male or female androgenetic alopecia. Although EBM is becoming regarded as the gold standard for clinical practice, there are a number of limitations of its use. The limited success of evidence based therapies points to a more important complexity of hair loss. Moreover, EBM guidelines do not remove the problem of extrapolation to different patient populations or longer timeframes, and certain groups have been under-researched, such as people with co-morbid diseases. Therefore, one must remain open-minded for the possibility of a multitude of cause-relationships underlying hair loss, and for the possibility of combined treatments and multitargeted approaches to enhance hair growth and quality. The scientific rationale for such an approach is given, but there is a need for studies to establish increase of efficacy of combination regimens for treatment of hair loss. Finally, EBM recognizes that many aspects of health care depend on individual factors such as quality- and value-of-life judgments, which are only partially subject to scientific methods. EBP, however, seeks to clarify those parts of medical practice that are in principle subject to scientific methods and to apply these methods to ensure the best prediction of outcomes in medical treatment, even as debate continues about which outcomes are desirable. Ultimately, knowledge gained from clinical research does not directly answer the primary clinical question of what is best for the patient at hand and suggests that EBM should not discount the value of clinical experience. Thus, good medical practice means integrating individual clinical expertise with the best available external clinical evidence from EBM.

O 24

Newer Insights in the Pathogenesis of Pattern Hair Loss Paving Way for Newer Therapeutic Interventions


S. Murugusundram

Founder and Medical Director, Chennai Skin Foundation and Yesudian Research Institute, Chennai, India.

Androgenetic alopecia is a genetically predetermined, androgen dependent progressive thinning of scalp hair which follows a unique pattern. Male pattern hair loss is predominantly androgen dependent, partly genetic, triggered by hair follicle micro Inflammation and recently proposed to be mainly due to hair cycle alterations (Paus & Cotsarelis 1999). Hair cycle alterations play a major role in the causation of female pattern hair loss. Apart from the stable active steady-state (Anagen), stable dormant steady state (Telogen), active involution process (Catagen) there exist new phases of hair cycle such as Exogen (Stenn, 2005) during which proteases actively release the fibre (Higgins et al., 2011) Kenogen (Rebora et al., 2002) where the empty follicle has not yet triggered a new morphogenetic process (Courtois et al., 1994) and Neogen during which active neo-morphogenesis takes place (Bruno Bernard, 2012) During telogen, a competition between inducers and inhibitors controls the hair regrowth onset (Plikus, 2012). A strong expression of "bone morphogenic protein" (BMP) (Botchkarev et al., 2001) & "fibroblast growth factor-18" (FGF-18) (Kimura-Ueki et al., 2012) characterizes a telogen refractory period, preventing any neo-morphogenetic process to take place. The progressive increase of noggin, a BMP antagonist, Wnt ligands, Activators of the b-catenin pathway and TGF-b2 (Oshimori & Fuchs, 2012) trigger the transition of telogen follicle from refractory to permissive state and, in synergy with increased FGF-7 production from the dermal papilla (DP) (Greco et al., 2009), the onset of a new cycle. These observations pave a new therapeutic avenue for hair growth.

O 25

Darkening of Hair by bFGF Derived Decapeptide


Ramaiah Abburi

India

The basic fibroblast growth factor derived deca peptide was originally developed to treat vitiligo. It was approved by the drug controller general (India) as a drug to treat vitiligo in 2001. During the clinical trials on this drug it was observed that many vitiligo patches also had white hair. It was observed that the topical application of deca peptide lotion not only repigmented the vitiligo patches but at the same time repigmented white hair. It then occurred to us that this can in effect be used for treating premature white hair and our patent applications for the darkening of hair by the deca peptide was granted by the Australian patent office as well as by US patent office. The rationale how it could repigment white hair will be presented in this lecture.

Award Papers

O 26

PRP as Monotherapy in Androgenetic Alopecia: A Pilot Study


Aditya Mahajan, Kiran Godse, Sharmila Patil

Department of Dermatology Dr. D Y Patil Hospital and Research Center, Nerul, Navi Mumbai

Background: Autologous platelet-rich plasma (PRP) has attracted attention in various medical fields however; there is a lot of controversy regarding the use and technique of PRP in androgenetic alopecia (AGA). Objective: To assess the effects of PRP in AGA in 12 patients, who have not been on any modality of treatment before or during the study duration. Methods: Out of the 12 patients, 9 patients were treated with activated PRP and 3 with non-activated PRP. 20 cc of blood was collected in each patient and double spinning method was used for centrifugation. The platelet poor plasma was discarded and activation of PRP was done (in 9 patients). Procedure was repeated every 2 weeks for 2 months and clinical photographs were taken at baseline and every month for 6 months. Efficacy was evaluated by scalp target area hair counts and patient and investigator assessments of change in scalp coverage and benefit of treatment. Results: Subjective improvement was seen in all the patients, all of them felt there was complete stoppage of hair fall and new hair growth. However on assessing the photographs, there was clinical improvement in only 1 patient. Hair shaft diameter was minimally increased in 5/12 patients. Rest of the patients showed no effect. Conclusions: Subjective improvement is more than objective improvement in PRP. It can cause increase in hair shaft diameter however new hair growth is minimal or absent. Hence it should be used only as an adjuvant for therapy of hair fall.

O 27

Langerhans Cell Histiocytosis - Scalp Involvement in Children: A Lead to Timely Diagnosis


Ramkumar Ramamoorthy*, Arathi Srinivasan**, T. Ravikumar***

*Department of Pediatric Dermatology, ** Department of Pediatric Hematology and Oncology, *** Department of Pediatrics, Kanchi Kamakoti Child Trust Hospital, Chennai, India

Aim: Langerhans Cell Histiocytosis (LCH) is a disease with varying clinical presentation. We present a case series of six children with multisystem LCH, in whom scalp involvement was the most constant feature. Material and Methods: Out of 15 children who presented to us with LCH in the period from March 2013 to march 2014, we included five who had involvement of the scalp. All of them had multisystem LCH. The diagnosis of LCH was made as per recommendations of histiocyte-society (writing group) i.e., on the basis of skin biopsy and immuno-histo-chemistry (scalp biopsy in 3 out of 6 biopsies). We recorded the presenting features and the clinical clues which lead us to consider LCH in the differential diagnosis. Results: Final diagnosis was based on scalp biopsy findings in two of the cases in whom scalp involvement is the predominant feature, in one of them who had cholangitis, the liver biopsy was not contributory, The other had occipital bone involvement. Scalp biopsy was useful assessing activity of the disease in one of the children in whom the response to chemotherapy was inadequate. Conclusion: Dermato-trichologists play an important role in establishing the diagnosis of LCH at an early stage. Early diagnosis of LCH requires high index of suspicion and interdisciplinary dialogue.

O 28

Premature Androgenetic Alopecia in Men: Phenotypic Equivalent of PCOS


Sarita Sanke, Ramchander, Taru Garg, Pravesh Yadav, Anju Jain

Department of Dermatology, Lady Hardinge Medical College, New Delhi, India

Aims and Objectives: Premature androgenetic alopecia (AGA) in men is frequently reported as phenotypic equivalent of polycystic ovarian syndrome (PCOS) in women. The study was conducted to study the hormonal profile of men with premature AGA and to see if it resembles the profile of women with PCOS. Material and Methods: 57 men with premature AGA (grade III or more on modified Norwood-Hamilton scale) were taken as subjects. The serum concentrations of LH, FSH, Prolactin, Testosterone, DHEAS, SHBG and Insulin were measured. Insulin resistance (IR) and Free androgen index (FAI) were calculated. These were compared with age and sex matched controls. Statistical analyses were performed using student's t- test for cases and controls. Results: The cases showed significantly increased mean LH, DHEAS, Testosterone, Prolactin and decreased FSH and SHBG as compared to controls. The mean FAI and LH/FSH ratio was also increased. However, IR was not significantly present. Conclusion: The hormonal profile of men with premature AGA resembles the hormonal profile of women with PCOS. Thus, premature AGA in men can be considered as phenotypic equivalent of PCOS in women. These men are implicated to develop the complications associated with PCOS like obesity, metabolic syndrome, IR, cardiovascular diseases and infertility. They should be warned against them and appropriate steps can be guided to prevent the same. In our subjects, subclinical IR may be present, which might develop with increasing age. Large scale Cohort studies should be done to follow them up.

O 29

Dermoscopic Patterns in Indian Discoid Lupus Erythematosus - Correlation with Duration of Disease and Severity Index


M. Saritha, Nishant Ghodake Bapu, Laxmisha Chandrashekar, D. M. Thappa

Department of Dermatology, JIPMER, Puducherry, India.

Introduction and Objectives: Dermascopic patterns of DLE have recently been described in literature. A time- wise correlation of certain dermascopic features with the disease has been proposed. There is no literature on dermascopic features seen in Indian/Asian patients with DLE and on the correlation of these features with CLASI score. We aimed to study the dermascopic features of DLE in Indian patients and correlation of the features with the duration and severity of disease. Materials and Methods: The study was designed as an observational study. All consenting patients of DLE coming to dermatology OPD of a tertiary care centre in South India over a period of 6 months were evaluated by dermoscopy. Demographic details, duration and location of plaques and CLASI scores were collected. Data was tabulated and analyzed using Graph Pad In Stat software. The difference in CLASI scores and duration of disease were analyzed using non- parametric tests. Results: A total of twenty six plaques from 12 patients were evaluated by dermoscopy. Hair follicle effacement (n = 20) was the commonest feature followed by patchy pigmentation (n = 18), telangiectasia (n = 13), perifollicular pigmentation (n = 13) and perifollicular scaling (n = 10).There was significant difference in disease activity (CLASI) in patients with perifollicular scale and telangiectasia compared to patients without the above features. There was significant difference in duration of disease among patients with and without follicular red dots. Conclusions: Pigmentary changes are more commonly seen in Indian patients with DLE. Hyperkeratotic perifollicular scale and telangiectasia may be associated with active disease.

O 30

Trichoscopic/Tricho-pathologic Correlations of White and Yellow Dots in Non-cicatricial Alopecia


M. S. Sukesh, Rachita Dhurat

Mumbai, India

Introduction: Yellow dots are 0.8-1mm, round, polycyclic, yellow/whitish-yellow, perifollicular structures. White dots are tiny, 0.2-0.3mm, circular, inter-follicular structures. Their clinical relevance such as discrepancy of larger size of yellow dot despite minute size of pilosebaceous duct and presence of white dots on both normal and affected scalp is not yet elucidated. Aims: To evaluate clinical significance and histopathological correlation of dots (yellow/white) and to reason out how a minute pilosebaceous duct represent larger yellow dot on scalp. Methodology: 260 cases{androgenetic alopecia[AGA](n-151), alopecia areata[AA](n-44), acute telogen effluvium(n-25), trichotillomania(n-20), tinea capitis(n-18)} and 40 normal individuals(control group) were assessed dermascopically. Then a multistep systematic approach for histopathological correlation was performed.

1. Macrophographs of 4mm tissue containing yellow dots, sectioned horizontally at dermo-epidermal junction were matched with histopathological microphotograph (H&E & oil-red O) with help of a circumferential nick.

2. 1 mm punch was passed through 2 yellow dots intoto for vertical and horizontal sectioning.

3. Similar analysis was done for white dots.

Results: Yellow dots were noted only in scalp area in AA(81%) and AGA(19%) and was noted significantly higher in patients(20.38%) than in normal volunteers(5 %)(p value-0.019).White dots were distributed on both scalp and non-scalp areas in both patients and normal individuals(99.1% and 100% respectively)(p -0.95).Multistep histopathological analysis revealed yellow dots to be sebum present at the infundibular openings of pilosebaceous ducts giving an 'umbrella effect' with the duct representing handle and the dot representing upper widened canopy. White dots correlated with eccrine duct openings. Conclusions: Yellow dots are of pathological significance. White dots which represent the eccrine duct openings are of no clinical significance. This is the only study which explores the discrepancy of larger size of yellow dot despite minute size of pilosebaceous duct.

Tricho Surgery

O 31

Benefits of Cyclical Nutrient Therapy for Hair Loss


Rajesh Rajput

Mumbai, India

Introduction: The recessive Androgenetic Alopecia gene has variable expression, influenced by, lifestyle, stress, nutrition and scalp condition. Hair loss is multi factorial but we are trying to treat all causes with Finasteride. Finasteride works by preventing damage to the follicle. However, we can also grow hair by strengthening the hair roots and stimulating growth. Clinically DHT levels are not high in higher grades of baldness. Follicles are becoming weak from onslaught of pollution, food additives, artificial flavors, preservatives, taste makers, hormones, pesticides, agents used to increase yield of foods, meat and milk. New damage is detected through Endocrine Disrupting Chemicals EDCs. These factors also disrupt the regulation of hair growth cycles. These factors with nutritional deficiencies weaken the hair follicles making them more sensitive to DHT. Our clinical study shows we can make the follicles strong enough to withstand the onslaught and achieve regrowth by using antioxidants, nutritional correction and minoxidil. Results are seen within 2-4 months, significantly shorter period compared to other therapies. Indian Institutes have detected nutritional deficiencies which justify use of vitamins. Terms like 'Hidden Hunger' by Indian National Science Academy and Adult Micronutrient Quality Index by Agharkar Research Institute, highlight the seriousness of nutrition. Zinc deficiency is another neglected cause for hair loss. Results: Improvement started within 2 months and progressed every 2 months. Hair density improved by 49% at 4 months, 65% at 8 months and 79% at 12 months. Hair caliber improved by 50% at 4 months, 93% at 8 months and 125% at 12 months.

O 32

Choice is Yours: How to Choose the Right Patient, Right Method and Right Advice


Kuldeep Saxena

India

The most important goal of surgical hair replacement is to reestablish the aesthetic balance that was lost in the balding process. MPB is progressive throughout the life, it is important to place hair in a pattern that looks age appropriate. Recommendation of selecting patients for HTP vary from surgeon to surgeon and one textbook to another. There are so many factors categorized that affect the planning and selection of the patient for HTP. However we have observed that Age and donor recipient area ratio are by far the most important factors. Apart from it patients preferences, their medical and psychological state and hair characteristics also important while selecting the patients for hair restoration. Experienced team performing hair transplants regularly can plan mega sessions but beginners should select patients for short cases so that they can gradually gain confidence for large session. Apart from selection of patients, selection of right technique for Donar area harvesting plays equally important role. Donar area harvesting by strip surgical method (FUT) remain gold standard but minimal invasive method of graft harvesting follicular unit extraction (FUE) also attract more and more physician to enter into this field. Selection of right method of hair restoration not only depend on surgeon capability but patients preference also. Non Scalp harvest is gaining popularity among the patients & physician especially in a advance degree of baldness with compromised scalp donar area. With the invention of Non scalp donar harvesting we will be able to select even Norwood type VII Androgenetic alopecia.

Conclusion: Many years of experience at hair surgery has brought us to a point that successful outcome of hair restoration always depend on Right Patients, Right Method and Right advice to the Patients. Unlike other Dermatosurgical procedure hair restoration procedure is having huge learning curve If you are entering to this world's most demanding cosmetic field prepare to face challenges, now choice is yours.

O 33

Female Pattern Hair Loss Etiology, Recent Trends in Medical and Surgical Management


Narendra Patwardhsan

Pune, India

O 34

How to Set up Tricho Surgery Practice - Pre Requisites and Appropriate Training


Sanjiv Vasa

Ahmedabad, India

O 35

Revision Hair Transplant by Fue or Body Hair Transplant


Kapil Dua

India

O 36

Pen is Mightier than the Sword - follow up Care of Your Patients After ht


Sandeep Sattur

Mumbai, India

Current Management and Update

O 37

Managing FPHL- from Minoxidil to Androgen Blockade What Works?

Rachita Dhurat,

Professor and Head, Department of Dermatology, LTM Medical College, LTMG Hospital, Mumbai, India

There are various novel modalities for treatment in female pattern hair loss (FPHL). Topical 2% Minoxidil is the only FDA approved product for use in FPHL. There are studies which show that topical 5% minoxidil once a day application is superior than 2% minoxidil twice a day, which makes women more compliant to therapy with minoxidil. According to Cochrane review the efficacy of topical minoxidil is upto 60%, which means 40% women go bald despite on therapy. Various antiandrogens such as spironolactone, Drospirenone, Cyproterone acetate, finasteride, flutamide and bicalutamide have been tried with variable success.

Flutamide is potent antiandrogen, acting via androgen receptor antagonism. The recent report on use of low dose flutamide i.e. 62mg has been advocated for FPHL. Spironolactone in doses of 100-200 mg has been used. Menstrual break through bleeding is major concern side effect of spironolactone. There is scarcity of data on efficacy of 2mg Cyproterone acetate in FPHL. In view of fear about liver toxicity of flutamide, side effect of spironolactone, most clinicians prefer to use finasteride 2.5 or 5 mg for treatment of FPHL. Recent reports of use of PRP and microneedling in pattern hair loss has gained popularity among clinicians. Use & efficacy of antiandrogens in women with FPHL contradicts its non androgenic etiopathogenesis.

O 38

Management of Madarosis


Karthikeyan Kaliaperumal,

Professor and Head, Department of Dermatology, Sri Manakula Vinayagar Medical College and Hospital, Puducherry, India

Madarosis is a clinical sign that occurs in various diseases ranging from local dermatological disorders to complex systemic diseases. Management of madarosis primarily depends upon treatment of the predisposing disorder. For this, madarosis can be broadly classified as scarring and non-scarring. In non-scarring madarosis, generally regrowth of hair occurs after treatment of the primary disorder. In cases of scarring madarosis, the treatment options are varied from cosmetic camouflage to follicular unit transplant.

O 39

Seborrhoea - Current Management and Update


Frederick Manuel

Chennai, India

Tricho Immunology

O 40

Alopecia Areata: What I do?


Jerry Shapiro

Hair and Scalp Disorders Clinical Professor, University of British Columbia Department of Dermatology and Skin Science, Vancouver, Canada Adjunct Professor, New York University Langone Medical Center, Department of Dermatology, New York, USA

Alopecia areata especially severe and recurrent always poses a challenge to the Dermato-trichologist. Topical and intra-lesional steroids, topical immunotherapy, anthralin, and phototherapy are the mainstay of treatments. A tiered algorithmic approach which will enable the physician to frame the treatment in a structured manner is handy and successful.

O 41

Research Progress in Alopecia Areata


Desmond J. Tobin

Centre for Skin Sciences, School of Life Sciences, University of Bradford, Bradford, West Yorkshire, BD7 1DP, Great Britain

Much of the recent progress in alopecia areata (AA) has focused on understanding ts presumptive autoimmune status. However, in the absence of knowing the identity of the precipitating antigen(s), this final determination of the etiology of this condition is not yet possible. While research from human skin and from the well-characterized C3H/HeJ mouse model for AA has clearly shown that this is an immune-mediate (most probably a cytotoxic T cell) condition, underpinned by a complex genetics, AA remains more distinct from other skin immune-mediated or autoimmune diseases than may have been expected. Indeed, the failure of biologic treatments that work well in psoriasis for example, highlight the need to avoid over-simplifying interpretations of the apparent similarities between immune-mediate dermatoses. This immune response has also been re-examined in the context of a proposed immune privilege collapse in AA, suggesting that while a cure for AA pay not be tractable, the reestablishment of immune privilege in the anagen hair follicle could help to treat this psychologically-debilitating condition. My lab has recently identified the inner root sheath protein, trichohyalin, as a potential target antigen in AA, and we and others are working to study potential links between this protein or its associated motifs, and immune responses in AA. The current understanding of the pathogenesis of AA promises the potential for effective treatments.

Treating theTough

O 42

The Difficult Hair Loss Patient: Taking the Challenge


Ralph M. Trüeb. MD,

Center for Dermatology and Hair Diseases, Bahnhofplatz 1A 8304 Zurich-Wallisellen, Switzerland

Few dermatologic complaints carry as much emotional overtones as hair loss. Adding to the patient's worry may be frustrating experiences with physicians, who trivialize hair loss. A detailed patient history, physical examination, and few pertinent screening blood tests usually establish a specific diagnosis. Once the diagnosis is certain, treatment appropriate for that diagnosis is likely to control the problem. Treatment options are available, though limited, in terms of indications and efficacy. Communication is an important component of patient care. For a successful encounter at an office visit, one needs to be sure that the patient's key concerns have been addressed. Physicians should recognize that alopecia goes well beyond the simple physical aspects of hair loss. Patients' psychological reactions to hair loss are less related to physicians' ratings than to patients' own perceptions. Some patients have difficulties adjusting to hair loss. The best way to alleviate the emotional distress is to eliminate the hair disease that is causing it. Success depends both on comprehension of the underlying pathology, and on unpatronizing sympathy from the part of the physician. Ultimately, patients need to be educated about the basics of the hair cycle, and why considerable patience is required for effective cosmetic recovery. Ultimately, treatment outcome relies on patient compliance. Rather than being the patient's failure, patient non-compliance results from failure of the physician to ensure confidence and motivation. Finally, patients with hypochondriacal, body dysmorphic, somatoform, or personality disorders remain difficult to manage. The physician should be careful not to be judgmental or scolding because this may rapidly close down communication. The influence of the prescribing physician should be kept in mind, since inspiring confidence versus skepticism and fear clearly impacts the outcome of treatment. Sometimes the patient gains therapeutic benefit just from venting concerns in a safe environment with a caring physician.

O 43

En Coup de Sabre - An Evidence Based Approach to Management


Paul Devakar Yesudian

Consultant Dermatologist, Betsi Cadwaladr University Health Board, Consultant Dermatologist, Royal Liverpool University Dental Hospital, Liverpool, UK

Morphea, otherwise called localised scleroderma, is a difficult condition to treat. It is an inflammatory condition of the skin that primarily affects the dermis but can extend to the subcutaneous fat as well. Linear morphea of the face (en coup de sabre) is commonly unilateral, occupying a paramedian location. As it is an uncommon condition, reviews of evidence-based therapies are rare. Improvements are difficult to define and clinical remission may not correlate with the visible changes to the patient. In this lecture, randomised controlled trials of treatment with calcitriol, narrowband UVB, low dose UVA1, topical tacrolimus, oral methotrexate, prednisolone and interferon γ will be discussed. Retrospective reviews, case series and case reports on the use of mycophenolate mofetil, methotrexate with pulsed IVmethylprednisolone, PUVA, PDT, d-penicillamine, imiquimod, ciclosporin and photopheresis will also be analyzed.

Best of Evidence and Experience

O 44

Pattern Hair Loss: Treatment of Men and Women


Jerry Shapiro

Hair and Scalp Disorders Clinical Professor, University of British, Columbia, Department of Dermatology and Skin Science, Vancouver, Canada Adjunct Professor, New York University Langone Medical Center, Department of Dermatology, New York, USA

Topical minoxidil solution or foam and antiandrogens are the mainstay of medical therapy. Platelet rich plasma and micro-needling may also prove to be effective.

Canities and Hair Ageing

O 45

Is Hair Graying (Canities) Inevitable and Irreversible? A Research Update


Desmond J. Tobin

Centre for Skin Sciences, School of Life Sciences, University of Bradford, Bradford, West Yorkshire, BD7 1DP, Great Britain

Like other complex tissue systems composed of several histologically-distinct cell lineages, the hair follicle is prone to broadly similar underlying processes that determine the functional longevity of organs and tissues. The hair follicle is somewhat unusual however, in that some of its interactive cell systems appear to be non-essential for overall hair follicle survival. For example the melanocyte can be lost without too much negative consequence to hair fiber production. Indeed, strikingly gray and white hair follicles may paradoxically grow hair even more vigorously than their pigmented predecessors. Much of the recent research has focused on both the oxidative stress that appears to increase with aging and to which the hair follicle melanocytes appears especially sensitive, and the fate of hair follicle melanocyte stem cell capacity. Moreover, despite their common cutaneous origin hair follicle melanocytes appear to be more sensitive to aging influences than melanocytes in the epidermis, as evidenced by the slow loss of pigment tone with age in the epidermis contrasting with the marked dilution of hair color in canities. This is likely to reflect significant differences in the epidermal and follicular melanocyte microenvironments. Not only is there tight coupling of follicular pigmentation to the hair growth cycle, but there are also differences in stem cell niche capacity, niche exposure, and perhaps in the overriding effects of a dominant inheritance. The hair follicle may provide richer information in this context, as the life-histories of its various sub-populations of follicular melanocytes is very diverse. Pre-proliferative, proliferative, differentiated, terminally-differentiated and 'senescent' melanocytes all co-exist in the same growing hair follicle. This talk will focus on the life history of the human scalp hair follicle pigmentary unit, to gain insight into the how aging may affect hair melanocyte behavior.

O 46

Hair Ageing and Anti ageing


Ralph M. Trüeb

Center for Dermatology and Hair Diseases, Bahnhofplatz 1A, CH-8304 Zurich-Wallisellen, Switzerland

The appearance of hair plays an important role in people's overall physical appearance and self-perception. With today's increasing life-expectations, the desire to look youthful plays a bigger role than ever. The hair care industry has become aware of this and is delivering active products directed towards meeting this consumer demand. Besides the aesthetic problem of aging hair and its management, the study of hair aging focuses on the biological problem of hair aging, in terms of microscopic, biochemical and molecular changes. The discovery of pharmacological targets and the development of safe and effective drugs indicate strategies also of the drug industry. Hair aging comprises weathering of the hair shaft, decrease of melanocyte function, and decrease in hair production. The scalp is subject to intrinsic and extrinsic aging. Intrinsic factors are related to individual genetic and epigenetic mechanisms with interindividual variations: Prototypes are familial premature graying, and androgenetic alopecia. Extrinsic factors include UV-R and smoking. Experimental evidence supports the hypothesis that oxidative stress plays a role in hair aging. Reactive oxygen species are highly reactive molecules that can directly damage cellular structural membranes, lipids, proteins, and DNA. Currently available pharmacologic treatment modalities with proven efficacy for treatment of androgenetic alopecia are minoxidil and finasteride. Topical anti-aging compounds include photoprotectors and antioxidants. New insights into the role and prevention of oxidative stress could open new strategies for intervention and reversal of the hair graying process and age-dependent hair loss. Finally, topical liposome targeting for melanins, genes, and proteins selectively to hair follicles, the role of hair follicle stem cell types, and biogenineering the hair follicle are currently under investigation for maintenance of healthy and beautiful hair in the young and old.

Paediatric Trichology

O 47

Hair Loss in Children


Ulrike Blume-Peytavi

Department of Dermatology and Allergy, Clinical Research Center for Hair and Skin Science, Charité-Universitätsmedizin Berlin, Berlin, Germany.

The differential diagnosis of hair loss and alopecia in childhood presents a difficult task for the pediatrician and dermatologist. Hair loss in children may be a leading symptom of (i) genetic or (ii) non-genetic diseases, or (iii) sign of a psychological conflict. Hair shaft abnormalities with or without associated defects, alopecia areata and trichotillomania are the most frequent causes of hair loss and alopecia in young children, whereas alopecia areata and androgen effluvium are more frequently observed in adolescents. Classification of hair loss in childhood can be based on age at onset, clinical appearance including hair loss pattern, and associated symptoms. The diagnostic procedures in order to characterize and to classify hair loss and alopecia demands careful evaluation of the patient's as well as the family's history, evaluation of mental and growth development, and a complete clinical examination, including hair loss pattern, nail, sweat gland, teeth and mucocutaneous involvement. An overview on selected diagnostic procedures and typical clinical findings, which permit the identification and classification of the underlying causes of hair loss, will be provided as a guideline for differential evaluation of hair loss in children and adolescents.

O 48

When do You Suspect Geno-trichoses and What can you do?


Arun C Inamadar

Professor and Head, Department of Dermatology, India

O 49

Hypotrichosis in Children: A 10-year-experience-based Approach


Jayakar Thomas

Professor and Head, Department of Skin and STD, Sree Balaji Medical College and Hospital, Chennai, India


Hypotrichosis in children can cause psychological stress to the parent and patient alike. It can be classified into congenital and acquired. Commonly encountered causes of this in children (tinea capitis, alopecia areata, traction alopecia and trichotillomania) are reversible if diagnosed early. Special note should be made of the extent and type of alopecia (scarring or nonscarring), any hair shaft anomalies and signs of inflammation. Diagnostic evaluation includes a bewildering array of age-old simple bedside tests (e.g., potassium hydroxide wet mount preparation) to state-of-the art accurate instruments (e.g., trichoscan). Systemic antifungal therapy is required for tinea capitis. Topical and systemic immunomodulators are currently being employed for treating alopecia areata. A holistic approach would include not just therapeutic intervention but also an active search for associated nutritional defects, underlying psychosocial disturbances and behavioural problems, the latter two requiring counselling and behaviour therapy. Children with permanent hair loss may need surgical hair transplantation or prosthesis. This presentation also includes a 10-year analytical study of 2560 children with hypotrichosis.

Ferritin - Fallacies and Facts

O 50

Evaluation of Iron Deficiency in Hair Loss and its Correlation


Sandeep Sattur

Mumbai, India

Minoxidil: Mile Stones and Main Stay

O 51

Androgenetic Alopecia: The Evidence Based Approach and What's New in Minoxidil Research?


Ulrike Blume-Peytavi

Department of Dermatology and Allergy, Clinical Research Center for Hair and Skin Science, Charité - Universitätsmedizin Berlin, Germany

Androgenetic alopecia (AGA) is the most common form of alopecia in men and women. Among men, approximately 80% over 70 years of age, in women ca. 40% > 50 years experience some degree of hair loss. In men androgenetic alopecia is an androgen-dependent trait, with recession of the frontal hair line, mainly in a triangular pattern, later followed by a vertex thinning, whereas in women typically a centroparietal hair thinning can be observed. At present, the only clinically validated medication approved for increasing hair density in AGA are in men systemic finasteride 1 mg/d and 5% minoxidil topical solution (MTS) or foam and 2% minoxidil topical solution in women. According to current evidence and consensus based guidelines (Blumeyer et al JDDG 2011) Oral finasteride 1 mg a day [Evidence level (EL) 1] is recommended to improve or to prevent progression of AGA in male patients above 18 years with mild to moderate AGA (Hamilton-Norwood IIv-V). The response to treatment should be assessed at 6 months, although in some men it may not become evident until 12 months. If successful, treatment needs to be continued to maintain efficacy. For greater efficacy the combination of oral finasteride 1 mg, 1x/d and topical Minoxidil 2% to 5% solution, 2x/d can be considered. Another 5 a-reductase inhibitor Dutasteride can be considered at 0.5 mg/d to improve or to prevent progression of AGA in male patients above 18 years with mild to moderate AGA (Hamilton-Norwood IIv-V). However, quality controlled clinical trials comparing dutasteride 0.5 mg to finasteride 1 mg are needed. Topical minoxidil 5% solution 1 ml twice daily [EL 1] is recommended to improve or to prevent progression of AGA in male patients above 18 years with mild to moderate AGA (Hamilton-Norwood IIv-V). There is not enough data to recommend the 5% minoxidil foam instead of the 5% solution. However, 5% topical foam formulation has proved to be non-inferior to the solution. Hair transplantation (EL 4) is a therapeutic option with non-progressive AGA. Especially follicular unit transplantation (FUT) can be considered in male and female patients with sufficient donor hair. In men it is suggested by the guideline to combine follicular unit transplantation (FUT) with finasteride 1 mg daily to achieve a better clinical outcome. The non-evidence based approach for patients with AGA is as important as the evidence based one. Expertise in basic psychosomatic care and an empathetic approach to the fears and concerns of the patients as well as practical advice for the daily management of hair loss should be integrated as separate elements in the management of AGA; in most cases they are gratefully welcomed by the patients. The effectiveness of hair growth promoting agents, especially minoxidil and finasteride in male AGA has been demonstrated in a large number of randomized controlled trials (RCTs) in the vertex with high evidence; but there is no hair growth product with proven effectiveness in fronto-temporal AGA. In clinical experts' perception minoxidil effectively induces hair growth in the fronto-temporal area but evidence needs to be established. We conducted a randomized, phase 3 study comparing the efficacy and safety of once-daily 5% MTF (50mg/day) versus twice-daily 2% MTS (40mg/day) in women with AGA. 113 women with AGA were randomized to 24 weeks of treatment with 5% MTF or 2% MTS. The primary efficacy parameter was change from baseline in nonvellus target area hair count (TAHC) at week 24. Secondary end points included change in nonvellus target area hair width (TAHW), overall efficacy by global photographic review (GPR), adverse events, and subjects' assessment of product aesthetics. After 24 weeks, women randomized to 5% MTF once daily showed non-inferior TAHC and TAHW and experienced greater, but non-significant, improvements in TAHC, TAHW, and overall efficacy by GPR than those randomized to 2% MTS twice daily. 5% MTF was significantly superior to 2% MTS in subjects' agreement with "the treatment does not interfere with styling my hair" (P =.001). Once-daily 5% MTF is non-inferior and as effective for stimulating hair growth as twice-daily 2% MTS in women with AGA and is associated with several aesthetic and practical advantages. We performed in 70 men with moderate stage of AGA a double-blind randomized placebo-controlled investigator initiated clinical study evaluating the effect of 5% minoxidil topical foam (MTF) BID on hair growth, especially on TAHC and TAHW at the frontotemporal area and compared these hair growth characteristics to those obtained at the vertex. Fronto-temporal and vertex target area non-vellus hair count (TAHC) and target area cumulative non-vellus hair width (TAHW) showed similar responses to 5%MTF with significant increases up to week 16 compared to baseline (p < 0.001). At week 16 and 24, TAHW shows a positive change from baseline in both regions with a similar increase in TAHC but without being statistically significant. At 24 weeks users of 5%MTF rated a significant improvement in scalp coverage for fronto-temporal (p = 0.016) and vertex area (p = 0.027). This is the first study demonstrating efficacy of 5%MTF BID in the frontotemporal region in men affected by moderate stages of AGA with comparable 24 weeks treatment response in fronto-temporal and vertex areas. This first evidence has direct clinical implications and is important for counseling our patients in daily practice.

O 52

Importance of Vehicle in Minoxidil Formulations in Improving the Outcome


S. Murugusundram

Founder and Medical Director, Chennai Skin Foundation and Yesudian Research Institute, Chennai, India

The compliance and efficacy of topical minoxidil depends largely on the vehicle. More than 10% of topical minoxidil users develop hypersensitivity to the propylene glycol vehicle although hypersensitivity to minoxidil per se also exists but very rare. Unfortunately minoxidil dissolves only in an alcohol based vehicle. Several efforts have been made to improvise the vehicle with many innovations. But still the mystery continues. Formulations containing less of alcohol and more of aqueous base have significantly reduced the hypersensitivity. Topical low potent steroid solutions, non irritant solvents and newer agents have been proposed to reduce the hypersensitivity.

Hair care

O 53

Shampoos, Conditioners, Hair Damage and pH in Shampoos: "Myth and Reality"


Maria Fernanda Reis Gavazzoni Dias

Institute of Dermatology, Rio de Janeiro, Brasil

Hair is an integrated system with a peculiar chemical and physical behavior. It is a complex structure of several morphological components that act as a unit. The exposure to repeated rough washing, unprotected drying, friction actions, sunlight and alkaline chemical treatments lead to a decrease in the lipid content of the cell surface changing it from the state of hydrophobicity to a more hydrophilic, negatively charged surface. The hydrophobicity of the hair is possible thanks to the 18-MEA lipid layer. Removal of this covalently linked fatty acid renders the fibre hydrophilic. When the hair is extremely weathered and chemically treated, there may be scaling of the cuticle layers, removal of the 18-MEA and cuticle crack. If the cuticle is removed, the exposure of the cortex and further cortex damage may lead to hair fiber fracture. The use of hair cosmetics may restore hair cuticle damage and prevent hair breakage by reducing friction and water pick up. Shampoos are typically composed of 10 to 30 ingredients. The products are grouped into: (1) Cleansing agents; (2) additives that contribute to the stability and comfort of the product; (3) conditioning agents, intended to impart softness and gloss, to reduce flyaway and to enhance disentangling facility, and (4) special care ingredients, designated to treat specific problems, such as dandruff and greasy hair. Surfactants are cleaning agents that substituted soap. They act through the weakening of the physicochemical adherence forces that bind impurities and residues to the hair. Surfactants dissolve these impurities, preventing them from binding to the shaft or the scalp. Recently, dermatologists are being questioned by their patients if low-pH shampoos are better for their hair. There is no established definition of what a low-pH shampoo. The authors considered a low-pH to be a pH ≤ 5.5. In this work, we review the current literature about the mode of action of a low-pH shampoo regarding the hair shaft's health and analyze the pH of 123 shampoos of international brands. Results: All shampoo pH values ranged from 3.5 to 9.0. 38, 21% of all 123 shampoos presented a pH ≤ 5.5 (IC: 29.9-47%) and 61.78% presented a pH > 5.5. 26 anti-dandruff shampoos were analyzed. 19.23% presented pH ≤ 5.5. (IC: 7.4-37.6%). 80.77% of all anti-dundruffs shampoos presented a pH >5.5. The dermatological shampoo group (n = 19) presented 42.10% with pH ≤5.5 (IC: 21.8-64.6%), and 57.90% with pH >5.5 (Table 4). Among the commercial (popular) products (n = 96), 34.37% presented pH ≤ 5.5 (IC: 25.4-44.3%) and 65.62% presented pH > 5.5. 15 professional products (used in hair salons) were analyzed, of which 75% had a pH ≤ 5.5 (IC: 18-65, 4%), and 25% had a pH > 5.5. 100% of the children's shampoos presented a pH >5.5. Conclusions: Alkaline pH may increase the negative electrical charge of the hair fiber surface and therefore, increase friction between the fibers. This may lead to cuticle damage and fiber breakage. It is a reality and not a myth that low-pH shampoos may cause less frizzing for generating less negative static electricity on the fiber surface. Interestingly, 38% of the popular brands shampoos and 75% of the salons shampoos, are low-pH shampoos. Pediatric shampoos had the pH of 7.0 because of the "no-tear' concept. There is no standardized value for the final pH. The authors believe that it is important to reveal the pH value on the shampoo label but studies are needed to establish the best pH range for both the scalp and the hair fiber's health.

O 54

Science and Technology Behind Hair Cosmetics


Punit Saraogi Paliram

Mumbai, India

Today cosmetic hair care is dominated by cosmetic chemists - who are constantly finding and incorporating new ingredients and technologies in their products & by the marketing team which finds innovative claims and ingredients to attract more consumers to use their product. Some ingredients are added only to support marketing and make the product sound and look exciting to consumers. In the evolving market today, there is so much of scientific research and technology that goes behind the introduction of a hair care product like a shampoo that we see innovative claims all the time. This leaves the consumer perplexed and spoilt for choice. It is no surprise that patients expect us to help them decipher the marketing frills and build a routine hair care regimen. Also for all our patients on any kind of hair & scalp disease, it is very important that along with drugs we advice them about regular hair care to complement the medications that they are using. It is important for us as treating dermatologists to understand the basics of hair cosmetics. Hair care cosmetics act primarily on the hair shaft. The primary function of a shampoo is to provide basic hair and scalp hygiene. A modern day shampoo may have 10 to 30 ingredients and it can take months to years from planning phase to the final introduction of a product that is available on the shelf for purchase. Conditioners contain fatty alcohols, cationic surfactants, polymers and silicones. They may also contain protein hydrolysates, vitamins, mineral or vegetable oils and other natural extracts.

Quiz for Every One

O 55
"Patch in a Pattern"


Ameet Dandale, Rachita Dhurat, Jill Chitalia, Sujit Shanshanwal, Smita Ghate

Department of Dermatology, Lokmanya Tilak Municipal General Hospital, Sion Hospital, Mumbai, India

A 25yr old married woman presented with linear circumscribed pattern of hair loss over the vertex since 1 year. On examination, circumscribed alopecia was present on vertex simulating Christmas tree pattern of FPHL. Hair pull test was positive. Eyebrows were also affected. Trichoscopy showed uneven broken off hair with few twisted hair.

What is Your Diagnosis?

O 56
"From a Different Land"


Bebisha Joseph, Aswathy Umesh, Priya Ashok, Anuji P. Supran, V. S. Anju, R. Lakshmy

Department of Dermatology and Venereology, Government Medical College, Thiruvananthapuram, India

A 2 year old girl presented with absence of hair growth over the right side of frontal region of scalp since birth. She also had history of skin outgrowths near her right eye, seizures and delayed developmental milestones. She is the first child of a non-consanguineous marriage. On examination, there was a single well defined area of alopecia with smooth surface and absent follicular openings over the right frontal and parietal area of scalp. Multiple soft papules and small plaques were present near medial and lateral canthus of right eye, right eyebrow, and right side of the angle of mouth. Right eye showed conjunctival congestion with corneal opacity. MRI Brain showed atrophy of cerebral hemisphere with pachygyria and schizencephaly.USG brain showed dilated right lateral ventricles. Histopathological examination of a soft papule near the right eye showed features suggestive of fibrous and lipomatous proliferation.

What is Your Diagnosis?

O 57

Look at My Hair! Let Me Know Who I Am


Krishnakanth M

Department of Dermatology, Sri Ramachandra University, Porur, Chennai, India

A 13 year male child born of consanguinous marriage presented with dry skin, easy pluckability and dry hair since birth. Antenatal and birth history was normal. Developmental delay and photosensitivity were present. On general examination the child had short stature, elfin like facies with prematurely aged appearance, short, brittle hair, icthyotic skin over both the lower limbs and trunk, hyper-keratotic fissuring of palms & soles and dystrophic changes of finger nails. Dental caries was present. Undescended testis on the left side was observed. Hair shaft under polarising light microscopy showed alternating bands.

What is Your Diagnosis?

O 58

Hair and Nail - Something New


B. S. Kumara Lakshmanan, S. Keerthi, G. Rajesh Kumar, K. Karthikeyan

Department of Dermatology, Venereology and Leprology, Sri Manakula Vinayagar Medical College and Hospital, Puducherry, India

A 9 year old boy was referred with sparseness and easy breakage of hairs throughout the body and nails changes since birth along with recent development of asymptomatic papules over eyebrows, arms and forearms and lowers legs. No symptoms of hypo or hyperhidrosis were present. Similar history of hair and nail changes was present in his father. On examination, he had brittle, coarse, lightly pigmented scalp hair with normal density, sparseness of hair over rest of the body with lateral madarosis, and multiple follicular papules over eyebrows and arms. Pterygium changes were present in all twenty nails. Teeth were normal. Trichoscopic examination showed frayed cuticle of scalp hair. Systemic examination and blood investigations were normal.

What is Your Diagnosis?

O 59

Shock Heads!


Manjot Marwah

Department of Dermatology, National Hair Clinic, Himachal Pradesh, India

Two different patients, 4 year old boy and a 6 year old girl, presented with sudden roughness of hair since 2 months. Parents of both complained of hair being uncombable. Both patients had no similar family history. Trichoscopy showed transverse ridges, cuticle damage and 180 degree twists in hair shaft occasionally.

Clipped hair from patient's scalp was thread in the plastic tubing of a vein flow. On heating the tube, there was shrinkage and on cooling the melted plastic had fixed the hair shafts. Then multiple cross sections were cut and examined. This was compared with cross section from a normal control. Triangular and oval hair shafts cross sections were seen in the patient's hair.

What is Your Diagnosis?

O 60
"It Grows But Goes"


Manjot Marwah

Department of Dermatology, National Hair Clinic, Himachal Pradesh, India

A 19 year old girl presented with hair that does not grow, since childhood. She had decrease in density of hair on scalp and eyebrows, and painless pluckability of hair. Physical examination confirmed the history. Diffuse alopecia with rough and sticky hair was noted on entire scalp. There was partial loss of eyebrows too. Hair pull test was done on scalp and eyebrows. It confirmed the painless and easy pluckability of hair however the hair was not fragile. Trichogram of plucked hair showed 100 % anagen hair with a ruffled appearance of cuticle (floppy sock appearance). The hair shaft was at an acute angle to the hair bulb giving a "mouse tail appearance". Occasional transverse ridges were seen in the hair.Histopathology showed clefting between IRS and ORS and, ORS and fibrous sheath devoid of any inflammation.

What is Your Diagnosis?

O 61

It's Scary Under the Scar


Namrata C Manjunath

Department of Dermatology, KIMS, Bangalore, India

A 50 yr old female patient presented with multiple painful swelling on the scalp since 9 months. These swellings were associated with loss of hair. Physical examination revealed well defined circular plaque of scarring alopecia, hard in consistency and tender on palpation. The skin overlying it was not free from the swelling and showed crusting. She diagnosed to have invasive ductal carcinoma of right breast 10years ago and was treated completely.

What is Your Diagnosis?

O 62

Baby with a Tiny Black Ball


Ramkumar Ramamoorthy 1 , V. V. Varadarajan 2

1 Dept of Pediatric Dermatology, Kanchi Kamakoti Childs Trust Hospital, 2 Head of Department of Paediatrics, Soorya Hospital, India

An otherwise healthy two year old girl was initially noticed to develop a pigmented patch over her right thigh at around one year of age. Her parents consulted a general practitioner, who made a a clinical diagnosis of congenital melanocytic naevus and reassured them. However four months ago, she developed hair growth and a nodular thickening over a portion of this patch. This lesion was unusually hard to feel. We performed an incisional skin biopsy to rule out the possibility of malignant transformation of congenital melanocytic naevus. But the histopathology was a surprise.

What is Your Diagnosis?

O 63

Papular, Not So Popular


Rashmi Singh, V. Senthil, B. K. Aarthi, A. Ramesh, V. Anandan

Government Stanley Medical College, Chennai, India

A 3 year old boy born out of consanguineous marriage came with progressive diffuse loss of hair from scalp and eyebrows since the age of 4 months, and multiple skin coloured lesions over the scalp since past 6 months, which gradually increased in number. Lesions were asymptomatic and no associated family history could be elicited. Teeth, nail and bone were normal. On examination, there was diffuse loss of hair follicles with skin and white coloured papules over the scalp, which on histological examination showed keratin filled cyst.

What is Your Diagnosis?

O 64

Brothers with Boils


Santhiya A. Vadhana, P. Nirmaladevi, K. Punithavathy, Judith S. Joy, K. Dhanalakshmi, P. Kalyanakumar, A. Seeniammal, Mahakrishnan

Department of Dermato Venereo Leprology, Govt Tirunelveli Medical College, Tirunelveli, India

26 and 22 years old male siblings, presented with multiple painless abscesses over the scalp and cervical regions of one month duration. Elder sibling continued to have scalp follicular lesions and multiple abscesses over the right temporal, occipital, retroauricular region, acute suppurative otitis media and maxillary-sinusitis. His eosinophil count was very high. The younger sibling had progressive scarring alopecia over the beard, eyebrows but no scalp involvement except for abscesses. He also had lung abscesses, bronchiectasis, enlarged cervical lymph nodes with necrotic areas in left submandibular, parotid, upper deep cervical nodes. His eosinophil count and serum Immunoglobulin E were high.

What is Your Diagnosis?

O 65

Mom, Where's My Skin and Hair


M. Saranya

Department of Dermatology, Sri Manakula Vinayagar Medical College and Hospital, Puducherry, India

One month old male child presented with ulcer on the scalp since birth. The child was born out of non consanguineous marriage and by normal vaginal delivery. There was no history of any birth trauma. At birth he had a singular ulcer over the vertex of the scalp and no lesions elsewhere. Examination revealed crusted erosion over the vertex of the scalp with depression and loss of hair over the plaque and surrounding area of depigmentation that measured about 4.3cm in diameter. On palpation, the plaque was soft and there was a defect in the underlying skull.

What is Your Diagnosis?

O 66

Wanna Fly, Come with Me!


R. Sudha

Department of Dermatology, Sri Ramachandra University, Porur, Chennai, India

A Two year old child presented with matted hair and foul smelling discharge of the scalp for the past three months. History of intermittent fever and application of some medicated lotion over the scalp was present. On examination of the scalp we found matted hair, multiple boggy swelling with sinuses discharging Sero-sanguinous fluid. Cervical lymphadenopathy was present.

What is Your Diagnosis?

O 67

Hey, Thumbs Up, God Gave Jewels for My Hair


Vivek Shah, Tharini G K, Manoharan K

Department of Dermatology, Madras Medical College, Chennai, India

A 2 month old female child born of second degree consanguineous marriage was brought with complaints of absence of hair over the scalp, eyebrows and body since birth. History of normal sweating was present but dentition had not erupted. Examination revealed absence of hair from the scalp, eyebrows and body with presence of hair over eyelashes. The child also had a hypoplastic thumb on the right side with normal nails. Trichoscopy revealed presence of numerous empty follicles, small broken hairs, black dots and hair with uniform nodal dilatations with intermittent constrictions at which there was shaft breakage.

What is Your Diagnosis?

O 68

Not So Old, Why Am I Bald


Vivek Shah, Madhu R, Nirmala S, Janaki C, Manoharan K

Department of Dermatology, Madras Medical College, Chennai, India

A 30 years old female presented with asymptomatic progressive loss of hair along the frontal recession of one year duration. There was no history of loss of eye brow hair. Examination showed atrophic shiny zone of alopecia with few papules over the fronto - temporal areas. Trichoscopy revealed loss of hair follicles in an ivory-white background with atrophy. Histopathology showed a few atrophic follicles with mononuclear infiltrate around hair follicles, sweat glands & arrectores pilorum muscle and fibroblastic proliferation & fibrosis around the hair follicle & arrectores pilorum muscle.

What is Your Diagnosis?

Trichosurgery

O 69

Difficulties in Extraction and Implantation in FUE Hair Transplantation: Modifications and Solutions


Avitus John Raakesh Prasad

Department Dermatology, S. P. Derma Center, Madurai, India

Follicular Unit Extraction (FUE) technique in hair transplantation has gained momentum and has become a viable procedure in a dermatologist clinic. The procedure needs a minimum space and just 3-5 trained assistants to perform the procedure. This presentation will discuss on the difficulties faced while extraction process and how to successfully extract intact viable follicular units. A detailed explanation of different ways and method of punching and extraction will be shown in animation for a better understanding. The process of implantation differs from FUT by the use of Choi or modified Choi implanters. There are some common mistakes while implanting using implanters in FU Implantation which will be discussed and along with rectifying and overcoming them. This presentation reviews the difficulties which a beginner will face in extraction and implantation, a step by step process avoiding pitfalls, Tips and tricks to encourage the young dermatologists to feel confident while performing FUE HT.

O 70

Complications of Hair Restoration Surgery- A Retrospective Study


Eswari.L, Divya Gorur, T. N. Revathy, Nataraj H V, S. Sacchidanand

Department of Dermatology, Bangalore Medical College and Research Institute, Bangalore, India

Background: Hair restoration surgery is a very tedious procedure which can give great results and at the same time can land up in various complications. They can be intra operative, early or late complications. Objectives: To analyse the complications involved following hair transplantation surgery. Material and Methods: In our study we did a retrospective analysis of all patients who underwent hair transplantation procedures from 2010 to 2014 in Victoria Hospital, BMCRI, and recorded the various complications, which included both early and late consequences. Results: 225 patients, all males, who underwent either Follicular unit transplantation or Follicular unit extraction for androgenetic alopecia were included in the study. Enlarged donor scar, folliculitis of the recipient area, hypertrophic scar in the donor area, hiccups, papular swellings in the recipient area, severe head ache, numbness in the donor area were the adverse events recorded most frequently. Conclusions: Proper selection of cases, counseling, good surgical skills, dedicated performance, and a good follow up and postoperative care, go a long way in preventing and decreasing the rate of surgical complications in hair restoration surgery.

O 71

Hair Transplantation by FUE in Advanced Baldness


Kavish Chouhan

Dermaclinix, New Delhi, India

FUE method is considered to be a very time consuming method and most surgeons do not dare to do Mega session (>2500 FU) & Giga session (>3000 FU) with FUE but in recent times with advancement in equipments and skill now it is possible to do not only mega but even Giga session with FUE. Now even in advanced baldness it is possible to do hair transplantation by FUE alone leading to better cosmetic result in donor area as it will avoid a wide linear scar.Cases with advanced baldness usually require 4000-7000 Follicular units for a decent coverage. In a case with average hair density of scalp we can extract~25-35% of Follicular units from permanent zone which comes to 2500-3500(6000-10000 hairs), 1000-1500 FU can be extracted from beard and rest can be compensated from body hairs. We have to maintain very high extraction rate of ~1000-1500 FU/hour while maintaining transaction rate of 3000 FU) in a single day with FUE alone. For graft number >3500 (10, 000 hairs) we implant in 2-3 days. Planning of recipient area: To achieve natural looks with the limited number of grafts available we plan a mature looking hairline having higher mid frontal point with some parieto temporal recession. This conserves a significant no. of grafts which can be used to cover more area. Good quality scalp hairs are used to design the frontal area while coarse beard hairs are used in mid frontal area and vertex. Body hairs are used in to increase the density in area just behind hairline zone. Achieving adequate density in recipient area: We usually try to achieve a density of ~30-40 FU/cm2 in frontal area decreasing to 25-30 in mid frontal and vertex. As usual single haired follicular units are used in hairline zone. Graft survival: To achieve out of body time <3 hours for follicles we generally divide the transplant into 2-4 sub sessions of 2-3 hours each in each we extract & implant 1000-1500 FU. Graft implantation is done simultaneously along with extraction using "NO TOUCH to Root" technique in which FU is not handled from lower 1/3rd throughout the procedure. Graft extraction speed and transaction rate: To do such large cases extraction rate of ~1000-1500 FU/hour maintaining transaction rate of <5% is required this can be achieved by motorized FUE using sharp punches in continuous mode.

O 72

Benefits of Combining FUE and Micro-needling - Manjot Marwah


Manjot Marwah

Department of Dematology, National Hair Clinic, Hamirpur, Himachal Pradesh, India

Fue is now widely accepted as a preferred modality of hair transplant surgery and microneedling has recently got scientific evidence regarding its efficacy in hair loss and hair thinning. We conducted a study evaluating the efficacy of both these modalities in combination. Material and Methods: 32 patients with androgenic alopecia willing to undergo FUE surgery and microneedling were taken in the study. Extraction of grafts was performed with James Harris SAFE SCRIBE machine and implantation with VASA implanters. Microneedling was started in 2 weeks and repeated every week till 12 weeks. It was done with a 1mm dermaroller. Additionally 5% minoxidil lotion and 1mg tablet of finesteride was started on all patients daily. These patients were followed up every 3 months for assessing the hair regrowth. Evaluation was done via global photography in the patients. Follow up was maintained for 1 year in all patients. Results: 31 patients showed reduction in baldness and significant hair growth which was regarded as 'good' and 1 patient showed good result at 7 months. Conclusion: Studies in past have proven that post hair transplant 60% hair growth is seen in 6 months and keeps increasing in 1 year. Our studies has shown a faster response in the hair growth and faster healing, with a combination of FUE & microneedling. Microneedling helped to stimulate the stem cells and hair growth factors and also loosen and facilitate faster crust removal.

O 73

Incision Counting Device (ICD)- A Innovative Device


Ravi Kant Bhushan

Bushan FUE HT Center, Bhiwani, Haryana, India

The Incision Counting Device (ICD) allows the physician to accurately maintain the incision count during recipient site preparation. This new medical instrument is used by three hair restoration surgeon dr cole (United States), dr talizi (ireland) and dr ravi kant bhushan(India). The ICD features an LED display that maintains a 12 digit count of recipient site preparation with clear female voice and 3 different tips with depth control for pre-cut blades (CTS 1.00 mm to 1.30 mm in 0.05 mm increments), needles (18G, 19G, 20G or 21G), or our twin blade cartridge depending upon your preferred method of recipient site preparation. This revolutionary device is ergonomic With other methods., graft site preparation produces a crunching sound that often makes the patient feel uncomfortable and nervous. The I CD device makes an audible beep with each incision(clear female voice in hindi and english) and mask the patient's awareness of the sound produced by graft site preparation. With this new, automated technology, the physician can now communicate freely with the patient, which help to reduce patient anxiety. With the ICD, the physician communicate openly with his staff as well during the procedure. Improved communication is of course beneficial to everyone. The ICD eliminates the need for a technician to be focused upon counting during graft site preparation. This frees your staff from counting grafts to cutting grafts, thus making your team more efficient overall. Finally, as most hair transplant procedures are billed on a per graft basis, the incision count accuracy of the ICD is an effective way to eliminate counting errors and promote improved billing accuracy. In conclusion, the ICD offers many advantages to both patients and physicians. our device is much better, innovative, easy to use, cheaper than other.

O 74

Survival of Hair Grafts in Coup de Sabre


Ravi Kant Bhushan

Bushan FUE HT Center, Bhiwani, Haryana, India

Background: Treatment of coup de sabre must remain conservative until the disease is no longer in an active state. When activity has ceased, some operative intervention is safe and effective for the correction of deformity. While hair transplantation showed high survival rates for the correction of cicatricial alopecia, it has one case yet been reported to be performed for the correction of coup de sabre. Objective: To examine the therapeutic possibility of hair transplantation for the correction of coup de sabre. Methods: Follicular units consisting of two to three hairs from the patient's occipital scalp & single hair graft from beard were transplanted. Results: Seven -month follow-up studies showed an 86.5% survival rate of the transplanted hairs. Conclusion: When coup de sabre is no longer in an active state, hair transplantation is a useful method for cosmetic improvement of the alopecia

O 75

Follicular Transection Rates in Follicular unit Extraction (F.U.E) Method


Sandeep Mahapatra

Bangalore, India

Background: Follicular Unit Extraction (F.U.E) has been developed as one type of follicular unit transplantation surgery; a widely accepted hair restoration technique with advantages like small donor area scar, faster healing and slender graft harvest without extra surrounding tissue. Aims and Objectives: To determine complete and partial transection rates of follicular units in Follicular Unit Extraction (F.U.E.) method and techniques employed to minimize them. Material and Methods: Fifty cases were selected for the study, out of which, eight cases were of previous FUT surgery and ten cases were of previous FUE surgery. Two sites of (3×3 cm2) from central part of scalp donor area and two sites of (3×3 cm2) from lateral part of scalp donor area from both sides were selected. Manual punch sizes varying from 0.8mm - 1.00 mm were used. 100 punch excision for follicular units were made on each selected site and grafts were extracted with forceps. Complete and partial transection of follicular units were determined by microscopic evaluation and average transection rates were calculated. FOX test was employed and each case was graded accordingly. Results: Average complete transection rates were noted less (8%) as compared to average partial transection rates (16%). 18 cases were of FOX Grade 1, 14 cases were of Grade 2, 12 cases were of Grade 3, 3 cases each of Grade 4 and Grade 5 respectively. P values were found to be statistically very significant when both partial and complete transaction rates were compared with individual FOX grades. Variations in transection rates occurred because of donor scalp condition, follicular anatomy variability among indivuals, quality and size of punch used, methods employed to score the epidermis and also dependent upon operating surgeon's expertise. Conclusion: Transection rates in FUE method, needs to be minimized by adapting newer techniques to achieve better yield and outcomes. More studies are required to validate these observations.

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Follicular Body Hair Transplant (BHT) - One Step Ahead


Sunil Mishra

India

Hair transplantation is an accepted technique of restoring hairs on bald scalp. Extraction technique has evolved from 4mm punch extraction by Dr. Orentreich in 1950 to follicular unit transplantation (FUT) i.e. strip method in 1990's to the most recent method of Follicular Unit Extraction (FUE) by less than 1mm punches. In all these techniques hairs from occipital 'safe zone area' is removed and implanted in the frontal or mid scalp with the principal of donor dominance. Over past few years there has been increase in patients of younger age group with extensive alopecia of grade 5 onwards, thereby limiting the availability of donor hair in the safe zone of occipital scalp. Body hairs can be used as an alternative source of hair in such cases. Also body hair transplant is a boon to patients suffering from severe cicatricial alopecia where medical management is incapable of re-growing the hairs. A special technique to determine the feasibility of a BHT is the Torso Donor Index (TDI) which takes 5 criteria into account, i.e. hair density must be above 40 FUs per cm΂, similarity between the body and head hair, number of FUs with 2 - 3 hair follicles, size of the donor area and length of the body hair. When the Torso Donor Index is less than 4, the patient is deemed unsuitable for a body hair transplant. Patients with a score of 8 or more have more body hair than head hair suitable as donor material and are therefore suitable candidates for a body hair transplant. Body hair has been shown to grow longer when transplanted to scalp, as a result of the influence of scalp dermis on the transplanted hair, referred to as recipient influence or recipient co-dominance.

O 77

Comparative Study of Follicular Unit Extraction in Different Ethnic Groups with 0.9 mm and 1.0 mm Punches


Viral Desai

Mumbai, India

Introduction: There are reports suggesting that use of smaller caliber punches (less than 1.0mm) in FUE produce fine, intact hair follicles while leaving the donor without visible scars. Conversely, some reports indicate that smaller caliber punches lead to more transected follicles and thus affect the result of the transplant. Objective: To compare the effect of 0.9mm and 1.0mm caliber punches in terms of transection rates across across ethnicities (European and Indian). Material and Methods: Two groups (one European and one Indian) of 30 randomly selected patients were created. For each patient, 2 areas of equal size were marked in the central part of the donor area. The same doctor punched a specific number of hair follicles from each space with 0.9mm and 1.0 mm punches respectively and extracted hair follicles. The assistant counted the intact hair follicles and the hair per follicle ratio of each specific area. Results: In Indian patients, the 0.9mm punch caused significantly more transactions and corresponding reduction in the ratio of hairs per follicle as compared to the 1.0mm punch. In European patients, the transection rate with both calibers was the same. The ratio of hairs per follicle varies, but does not seem to be affected significantly by the 0.9mm punch.

It seems finer caliber punches work better with Europeans because of the thinner diameter of European hair

Interesting Clinical Studies - Most Practical to the Dermato-Trichologist

O 78

Early Onset Male Androgenetic Alopecia and Cardiovascular Risk Factors: A Case Control Study


Ann Mary Jose, Rajashekar T S, Raghavendra B N

Department of Dermatology, Sri Devaraj Urs Medical College, Kolar, India

The aim was to conduct a case control study to determine if early onset male androgenetic alopecia (AGA), is associated with certain cardiovascular risk factors and determine whether the pattern of male baldness can act as a marker for cardiovascular risk. In this case control study, 57 male patients with AGA who were aged from 18-35 years were taken as cases and 42 men with a normal hair status aged from 18-35 years were enrolled as controls. In the cases, the AGA was graded by two independent observers. For both cases and controls, cardiovascular risk factors, were assessed from history (exercise, smoking, family history), as well as investigations like carotid intima-media thickness, ECG and measurements of the components of the metabolic syndrome. A Student t-test done to compare quantitative variables of the components of the metabolic syndrome showed a significant difference between the two groups, in abdominal circumference (p = 0.001), BMI (p = 0.002), Blood pressure (Systolic, p = 0.02; diastolic, p = 0.001), and cholesterol (p = 0.001). LDL differences were also significant (p = 0.0006). A chi-square test done for qualitative variables showed a significant difference between the groups for chest pain (p = 0.046) and ECG changes (p = 0.02). A spearman correlation coefficient, shows a very strong correlation between the pattern of baldness with abnormal lipid profile (p = 0.9) and abnormal waist:hip ratio (p = 0.9), and strong correlation with abnormal abdominal circumference (p = 0.8) and hypertension (p = 0.8). In conclusion, the study shows that certain cardiovascular parameters do have a correlation with the pattern of baldness, and certain variables that determine cardiovascular risk factors are significantly higher in the AGA group compared to age matched controls.

O 79

Concordance between Trichoscopic and Histopathological Features of Scarring Alopecia - A Retrospective Observational Study


Binod Kumar Thakur, Shikha

Department of Dermatology and STD, North Eastern Indira Gandhi Regional Institute of Medical sciences, Shillong, India

Introduction: Alopecias can be broadly classified into non-cicatricial and cicatricial forms. The cicatricial alopecia could be primary or secondary. In primary cicatricial alopecias, the hair follicle is the primary target of destruction. The histopathological examination is helpful in diagnostic evaluation of cicatricial alopecia. The trichoscopic examination of the scalp is a non-invasive technique which aids in differential diagnosis of hair loss.

Aim and objectives: The purpose of this research study is to retrospectively analyse the clinical, trichoscopic and histopathological characteristics of scarring alopecia and to find out the concordance between trichoscopic and histopathological features. Methods: The clinical, trichoscopic and histopathological features of primary cicatricial alopecia patients, who attended Dermatology OPD from March 2013 to April 2014, were analyzed retrospectively. The concordance between trichoscopic and histopathological characteristics of scarring alopecia was also analysed. The study was approved by Institutional ethic committee. Results: A total of 16 patients of primary scarring alopecia presented to us in one year i.e. April, 2013 to March, 2014. The male: female ratio was 2.2:1. There were 8 patients of lichen plano pilaris, 3 of discoid lupus erythematosus, 2 of pseudopelede of Brocq and one each of frontal fibrosing alopecia, dissecting cellulitis of scalp and folliculitis decalvans. Trichoscopic features were consistent with the histopathological features in 93.75% of the patients. Conclusion: There is high concordance of trichoscopic and histopathological finding in cicatricial alopecia. Trichoscopy can serve as quick method of diagnosis of cicatricial alopecia even in early lesion and may obviate the necessity of scalp biopsy.

O 80

Efficacy of Superficial Topical Cryotherapy with Liquid Nitrogen in Alopecia Areata


Jaskanwal kaur, Mahajan B B

Department of Dermatology, GGS Medical College, Mohali, India

Aims and Objectives: A number of therapeutic modalities have been used for the treatment of alopecia areata with varying success. The present study has been undertaken to evaluate the efficacy of superficial topical cryotherpy with liquid Nitrogen in alopecia areata. Materials and Methods: Forty patients of both sexes between age of five to sixty years having minimum two patches of alopecia on any part of the body were enrolled for the study. In addition to routine investigations the hair was examined microscopically for exclamation mark hair and to rule out fungal infection. ANA, thyroid function test and viral markers were also done. Cotton tipped applicator dipped in liquid nitrogen is applied on the involved area and repeated so as to complete two freeze thaw cycles of two seconds each. This procedure was repeated every week for 4 weeks. All the patients were followed up weekly for upto 12 weeks subjectively, objectively and photographic evaluation was done. Results: At the end of 12 weeks, out of 40 patients, 25 (62.5%) patients showed complete hair growth, 10 (25%) patients had 75% hair growth, 2 (5%) patients had < 50% hair growth and only 3 (7.5%) patients didn't respond at all. Conclusion: Superficial topical cryotherapy with liquid nitrogen is an effective and safe therapeutic modality in alopecia areata without any side effects.

O 81

Trichoscopy to Obviate Biopsy in Childhood Alopecias


Jaya Pathak, Rajendran S C

Department of Dermatology, Vydehi Institute of Medical Sciences and Research Centre, Bangalore, India

Aim: To explore the utility of Trichoscopy in the examination and diagnosis of various childhood hair loss disorders. Differentiate scarring from Non-scarring alopecia. Enable dermatologists to make fast diagnoses of childhood alopecias. Materials and Methods: 15 clinically difficult to diagnose childhood alopecias were included in the study. Provisional diagnosis was established clinically and confirmed by trichoscopy in doubtful cases, avoiding the need for scalp biopsy in children. trichoscopic examination was performed by a polarized-light handheld trichoscope with a 10-fold magnification. The images were obtained by a digital camera with a 5-fold optical zoom. Results: The trichoscopic patterns of circular hairs, dirty dots, epidermal scale, and pustules showed no significance. The following features were significantly more common, or observed solely, in particular types of alopecia: Yellow dots, black dots, tapering hairs, and broken hairs in alopecia areata; absence of follicular openings, tufted hairs, white dots, follicular hyperkeratosis, red dots, honeycomb pigment pattern, pink-white appearance, crusts, and pustules in primary cicatricial alopecias. Conclusion: We suggest that a polarized-light handheld trichoscope attached to a digital camera provides a practical and useful aid for the clinical diagnosis of childhood alopecias.

O 82

Association between AGA and Cardiovascular Risk Factors - Is there a Common Path?


Leelavathy B, Eshwari, Aishwarya, Shwetha, Shruthi

Department of Dermatology, Bangalore Medical college and RI, Bangalore, India

Background: In Androgenetic alopecia (AGA), androgens induce miniaturization of hair follicles in genetically predisposed for baldness. The known association between AGA and cardiovascular risk factors raises questions of common pathogenetic mechanisms of these disorders. Aim: To study the association of Insulin resistance (IR) and metabolic syndrome (MS) in early onset AGA in young males Material and Methods: A case control study with 30 participants in each group. Males between 18 and 35 years of age were included in the study. Participants in the cases group had AGA greater than Hamilton stage 3. Blood pressure, anthropometry, fasting insulin, glucose levels in blood, lipid profile, total, free testosterone and thyroid stimulating hormone were investigated for all participants. Insulin resistance was calculated using HOMA-IR and metabolic syndrome criteria devised by National Cholesterol Education Program Adult Treatment Panel III NCEP ATP III. Results: Cases had higher mean diastolic blood pressure and more frequent family history of AGA than controls. Total and free testosterone levels were significantly more in participants with AGA than controls. There was no significant difference in Insulin resistance and Metabolic syndrome criteria between the cases and controls but the prevalence of IR and MS increased with the severity of AGA. Conclusion: More studies are required in order to objectively clarify whether early AGA can be attributed to dyslipidemia due to androgens, IR alone, or MS due to IR. In the present study we could not establish a clear cut role of IR or MS, though the testosterones were significantly higher in the AGA participants suggesting the role of androgens.

O 83

Comparative Study of Histopathology and Trichoscopic findings in Diagnosis of Alopecia Areata


Rafiya Fatima

Department of Dermatology, PES Institute of Medical Sciences, Kuppam, India

Introduction: Trichoscopy which is non invasive can be used for diagnosis and follow up of Alopecia areata. This study is done to know various findings in Alopecia areata and its significance in diagnosis as compared to histopathology. Methodology: 50 Patients with classical clinical features of Alopecia areata are selected. History followed by Trichoscopy and later skin biopsy were done. Results were analyzed and compared. Results: All 50 patients showed trichoscopic features suggestive of AA, while 49 of them had histopathological features suggestive of AA. In all patients histopathological features were co-relating well with corresponding trichoscopic features. Discussion: Trichoscope is a non invasive, diagnostic tool which visualizes subtle clinical patterns of skin lesion and sub surface skin structures not usually visible to unaided eye. Characteristic trichoscopic findings of AA include: black dots, tapering hairs, broken hairs, yellow dots, and clustered short vellus hairs (shorter than 10 mm) in the areas of hair loss. Black dots, yellow dots, and short vellus hairs correlate with the severity of disease, and black dots, tapering hairs, broken hairs, and short vellus hairs correlate with disease activity. For diagnosis, yellow dots and short vellus hairs are the most sensitive markers, and black dots, tapering hairs, and broken hairs are the most specific markers. Conclusion: Thus, this study proves that Trichoscopy is as efficient as Histopathology in diagnosis of AA. Further, it can be used to record the information (provides high resolution quality images) and compare them on follow up and to assess prognosis. By allowing rapid, detailed, and non-invasive observation of the skin and hair involved, Trichoscopy may obviate the need for skin biopsy which is invasive.

O 84

Role of Iron and Vitamin B12 in Female Patients with Diffuse Hair Loss


Rajvi Patel

Department of Skin and V.D, B.J. Medical College, Civil Hospital, Ahmedabad, India

Introduction: Diffuse hair loss is a very common concern for which patients consult dermatologist. It reduces the quality of life due to severe emotional distress and can lead to personal as well as social problems. Wide variety of physiological factors, emotional stresses, nutritional deficiencies, and endocrine imbalances can interrupt the normal hair cycle triggering diffuse hair loss. Laboratory investigations are invaluable aid in detecting causes like iron deficiency anaemia, vitamin deficiency which all can lead to diffuse hair loss. Aim: To study the role of iron &vit B12 level in female patients with diffuse hair loss. Methodology: The study was conducted during period of Dec 2012 - Dec 2013. 50 female patients in age group of 15-45 years having complaint of either thinning of hair (reduced density), increased shedding of hair or reduction in growth rate were included in the study. Detailed history including duration, history of acute febrile illness, chronic medical or surgical illness, endocrine abnormality was taken in each patient. Patients having female pattern hair loss, endocrine abnormality, anagen effluvium were excluded. Trichoscopy and trichogram were done at every visit. Serum ferretin and vit B12 level was done in each patient at day 0, 90, 120. Patients whose S.ferritin (n-50-200 mcg/l) and vit B12 (n-200-1000 ng/l) value was below normal level were treated subsequently. Analysis in clinical improvement was done at 3 monthly intervals after treatment based on physician evaluation of the serial photographic documentation. Results: Seventy eight percentage of patients (39/50) were having S.ferritin below normal level (<50 mcg/l) & fourty six percentage of patients (23/50) having vit.B12 below normal level(<200ng/l).After giving treatment in forms of iron tablets &Vit B12 injections for 3 months, improvement was seen in hair density & hair thickness.(p < 0.5) Conclusion: As iron &vit b12 have vital role in hair growth, every female patient with complaint of diffuse hair loss should be investigated for S.ferritin & Vit.B12 level.

O 85

Trichoscopy - An Indian Experience - Study of 100 Cases


Satish Udare

Skin and Aesthetic Clinic, Navi Mumbai, India

Trichoscopy is a quick in-office technique, which has become a standard procedure in differential diagnosis of hair loss. Hand held dermascope (Dermlite II Pro HR; 3GEN LLC, San Juan Capistrano, CA, USA) was used. We present our experience in 100 patients with hair loss. There were 71 females and 29 males, ages from 5years to 75years. Cases ranged from alopecia areata, male and female pattern hair loss, telogen effluvium, scarring alopecia, trichotillomania, tinea capitis, with some cases of hair shaft disorders such as wooly hair, trichorrhexis nododsa etc.… Trichoscopic abnormalities included broken hairs, coiled hairs, short hairs with trichoptilosis, upright re-growing hairs, exclamation mark hairs, tapered hairs, flame hairs, tulip hairs, v-sign, hair powder, hook hairs, amorphous hair residues, black dots, yellow dots, yellow dots with black peppering, re-growing pigtail hairs (circular or oval), hypo/depigmented vellus hairs, comma hairs, corkscrew hairs, zig-zag hairs, no hairs in field of view. Some scalp abnormalities and infestations are also observed. Yellow dots are not that common in alopecia areata in our case series. Trichoscopy does give additional clues in alopecia and it is a useful tool in Dermato-trichologist's armamentarium. IIn some instances it may obviate the need for scalp biopsies.

O 86

Prognostic Value of Trichoscopy in Alopecia Areata


Satish Udare

Skin and Aesthetic Clinic, Navi Mumbai, India

Alopecia areata (AA) is a common disorder causing considerable mental trauma and poor quality of life.The prognosis and treatment outcomes are unpredictable. Trichoscopy definitely gives additional clues to dermatologist in diagnosing the disease. We planned a study the assistance of trichoscope in the clinical outcome of AA.The presence or absence and number of ''exclamation-point hair'', ''cadaveric hair'' (black dots), and ''yellow dots'' gave information for active and progressive disease or remission of disease. The number was compared at centre and at the periphery of the patch. The presence of thin and non pigmented ''vellus hair'' within the patch, transformation of vellus into terminal hair appearing as increased proximal shaft thickness and pigmentation (reverse exclamation mark hair) are characteristic of remitting disease indicative of a response to treatment. Absence of these signs and reticular pigmentation were indicative of poorer prognosis.

O 87

The Role Of Iron Deficiency And Vitamin D in Females with Diffuse Hair Loss: A Case Control Study


Sindhu P S

Department of Dermatology, Care Institute of Medical Sciences, Hyderabad, India

Background: Hair loss is a common problem and the treatment is usually expensive and unsatisfactory. Before going in for expensive investigations and treatments, looking out for simple causes like iron and vitamin D deficiency might lessen the burden on the patient. So in our study we tried to correlate the role of iron and vitamin D deficiency in females with diffuse hair loss. Materials and Methods: A total of 125 female patients in child bearing age group attending our out - patient department at CARE Institute of Medical Sciences from may 2012 till may 2013 were included in the study after obtaining consent from the patient and ethics committee approval. Out of 125 study subjects 105 subjects with history of hair loss were included as cases and 20 subjects with complains other than hair loss were included as controls. Detailed history was taken and clinical examination was done on enrolled patients. A panel of blood tests that included complete blood picture with ESR, serum ferritin, total iron binding capacity, 25 OH vitamin D and thyroid profile was performed for all patients and controls. Telogen effluvium and female pattern hair loss were diagnosed on clinical grounds. Results : Our study showed a positive correlation between iron deficiency, low vitamin D levels and hair loss. Low levels of serum ferritin and vitamin D were significantly associated with cases when compared with controls. Conclusion : From the present study it can be concluded that iron and vitamin D deficiency may be playing a significant role in women with diffuse hair loss and hence serum ferritin, hemoglobin and vitamin D levels must be included in the regular panel of tests for hair loss. In our country where nutritional anemia is widely prevalent, testing for iron deficiency may be more relevant. In addition to correcting the hormonal imbalances in FPHL supplementing for iron and vitamin D deficiencies should also be looked into.

O 88

A Study of Blood Parameters (Haemoglobin, Serum Iron, Serum Ferritin, Serum Calcium, Serum B12 Levels) in Premature Graying of Hair


Sonal M Patel, Umesh Karia, Bela J. Shah

Department of Dermatology, B.J. Medical college, Ahmedabad, India

Introduction: Hair pigmentation is one of the most conspicuous phenotypes in humans ranging from black, brown, and blonde to red. Premature graying of hair occurs more commonly without any underlying pathology but is said to be inherited in autosomal dominant pattern. Reduction in melanogenically active melanocytes in the hair bulb of gray anagen hair follicles with resultant pigment loss is central to the pathogenesis of graying. Premature graying has been shown to be associated with a few of the autoimmune disorders. A role for environmental factors and nutritional deficiencies has also been postulated. However, to date the exact etiology of premature graying has not been established. Aim: The objective of our study was to correlate levels of various blood parameters in premature graying of hair. Materials and Methods: A total 50 cases of premature greying of hair in the age group 10- 25 yrs were selected. Detailed history and examination was done. We investigated cases for various blood parameters such as Hemoglobin, serum ferritin, serum calcium, serum iron, and serum B12 levels. An informed consent was taken from all the patients. Result: Among the various laboratory parameters S. Ca, S. Ferritin and S. B12 were low in patients with premature graying of hair. Levels of S.calcium and S. ferritin were significantly low. Conclusion: According to our study S. Ca and S. Ferritin may play a role in premature graying of hair.

O 89

Trichoscopy in Trichotillomania


Sujana L, Balchandra S Ankad, Savitha L Beergouder

Department of Dermatology, S Nijalingappa Medical College, Bagalkot, India

Aim: Trichotillomania is morbid craving to pull out hair, usually diagnosed by history and clinical examination. At times, it's difficult to differentiate it from other causes of non cicatricial alopecia. Trichoscopy shows specific patterns in various hair diseases and in trichotillomania as well. Hence trichoscopy aids in finding various patterns which help in early diagnosis of this condition. Materials and Methods: This study is conducted in S. Nijalingappa medical college, Bagalkot from Dec 2013 to April 2014. Hand held polarized dermoscope with Sony camera attachment was used to evaluate patients with trichotillomania. Informed consent taken from patients and ethical clearance obtained from the ethics committee of our institute. Histopathological examination confirmed clinical diagnosis. Data collected were analyzed and tabulated in Microsoft excel sheet. The results are presented in proportions and percentages. Results: Ten patients(female-9, male-1)with clinically suspected trichotillomania and age ranging from 13years to 55years were assessed. Most common symptom was patchy loss of hair over the scalp especially in frontal area and one patient had tonsure pattern of hair loss. Four patients agreed knowingly pulling of hair and one patient gave history of trichophagia. Most common trichoscopic features observed in all patients were decreased hair density and hairs broken at different lengths. Short hair with trichoptilosis (\"split ends\"), irregular coiled hairs, upright regrowing hairs, black dots, flame hair, v-sign, tulip hair and hair powder. Conclusion: Trichoscopy demonstrates specific patterns in trichotillomania. Hence, it can be utilized as a diagnostic tool in diagnosis of trichotillomania adding one more armamentarium for Dermato trichologist.

Trichodiagnostics

O 90

How to Evaluate Hair Loss in Women?


Jerry Shapiro

Hair and Scalp Disorders Clinical Professor, University of British Columbia Department of Dermatology and Skin Science, Vancouver, Canada Adjunct Professor, New York University Langone Medical Center, Department of Dermatology, New York, USA

A thorough history and meticulous scalp examination is mandatory in evaluating scalp hair loss in women. The questions that are specific to reveal the diagnosis and what is important to look for will be discussed.

O 91

Algorithm for the Diagnosis and Treatment of Diffuse Hair Loss

Lutz Gerhard


Hair and Nail Research, Bonn, Germany

Diffuse hair loss affects mostly women and seldom men. Possible causes and diseases which induce diffuse hair loss can be very different, e. g. dermatological and internal diseases, endocrinological disorders, deficiency of iron, zinc or biotin, side effects of drugs etc. As only therapeutic options specific to the diagnosed disorders are the key to success, a structured proceeding and an evidence based diagnostics are absolutely necessary. The anamnesis should include beginning and duration as well as possible seasonal variations of hair loss. To exclude drug induced hair loss all actual medicine and that taken in the last 4 months have to be proofed for disturbing hair growth. In most cases only scalp hair is involved. Typical is a diffuse shedding of the scalp hair in the central and parietal areas. In men mostly iron and zinc deficiency as well as side effects of drugs are causative, while in women also endocrinological disorders have to be taken into account. Therefore endocrinological diagnostics in women should include beside basal TSH and Prolactin also FSH, Estradiol, Testosterone, Androstenedione and DHEAS. The gynecological parameters should be estimated in the follicular phase of the menstrual cycle and in case of oral contraceptives at the end of the monthly pill pause. The presentation summarizes 22 years of experience in the management of diffuse hair loss and discusses the relevance of diagnostic results for therapeutic strategies.

O 92

Trichoscopy as Non - Invasive Tool in Diagnosing Non Cicatricial Alopecia


Rachita Dhurat

Professor and Head, Department of Dermatology, LTM Medical College, LTMG Hospital, Mumbai 400022, India

Trichoscopy is evolving as an indispensible aid to a dermatologist by providing valuables clues on trichoscopy of the scalp and hair. Trichoscopy presents a bridging tool between clinical and histological diagnosis. It is useful to distinguish congenital atrichia from other forms of childhood hair loss such as alopecia areata universalis. There are a set of women who present with the chronic hair loss without any discernible reduction in hair density over the crown. Such early forms are often overlooked and clinical evaluation may not be adequate to make the right diagnosis. Trichoscopy has been widely used as a diagnostic as well as a prognostic tool to measure anisotrichosis in cases of overt androgenetic alopecia and female pattern hair loss and distinguish them from telogen effluvium. Trichoscopy is found to be 75% sensitive and 61.54% specific in diagnosing early FPHL It can be used to distinguish female pattern hair loss from diffuse and subtotal alopecia areata as well as trichotillmonia from alopecia areata which can have similar clinical presentations. Trichoscopy also helps prognostically by monitoring response in patients of alopecia areata. It is also useful in diagnosing infections conditions like non-inflammatory tinea capitis, seborrheic dermatitis, piedra and pediculosis. Trichoscopy represents a valuable noninvasive and low-cost technique, still underutilized, to rapidly differentiate clinically frequent hair disorders.

O 93

Histopathological Diagnoses of Alopecias


Sujay Khandpur

Professor, Department of Dermatology and Venereology, AIIMS, New Delhi, India

Introduction: Alopecias produce tremendous psychosocial impact in the affected individual. While this is true for all forms of cosmetically disturbing hair loss, the situation is more aggravated in cicatricial alopecias. We often encounter situations in our OPD where patients present with overlapping features not only between various causes of non-cicatricial and cicatricial alopecias but also between the two main alopecia forms. Under such circumstances, scalp biopsies for diagnostic confirmation are resorted to. Transverse sections on scalp biopsies carry the advantage over vertical sections in evaluating all follicles, determining hair follicle density, morphology, number of miniaturized follicles and anagen to telogen ratio. Aim: To diagnose non-cicatricial and cicatricial alopecias on transverse sections of scalp biopsy specimens. Materials and Methods: In patients with various types of alopecia, 4mm punch biopsies of the scalp are performed and the tissue is subjected to transverse sections, making sure that sections are obtained at all levels of the hair follicle. They are stained with hematoxylin & eosin stain and verhoff Von Gieson, wherever necessary. Control samples from occipital area of consenting androgenetic alopecia cases have been taken for comparison. Histopathological features in common causes of non-cicatricial alopecia (male and female AGA, alopecia areata, telogen effluvium, trichotillomania) and cicatricial alopecia (LP, DLE, folliculitis decalvans) have been assessed. Results: On quantitative and morphometric assessment of hair follicles, histopathology can categorically differentiate trichotillomania from other causes of non-scarring alopecia, majority of AGA can also be differentiated from AA, but TE yields no pathological features. Differentiation between different causes of scarring alopecia can also be made based on condition of follicles, type, quantity and site of inflammatory infiltrate, type and location of scarring and other ancillary features. Conclusion: Histopathological evaluation on transverse sections of scalp biopsies is a useful modality for diagnosis of alopecias. It should be incorporated into the diagnostic armamentarium of every dermatologist.

The Nexus

O 94

Hair and the Gut


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Consultant Dermatologist, Betsi Cadwaladr University Health Board, Consultant Dermatologist, Royal Liverpool University Dental Hospital, Liverpool, UK

Coeliac disease or gluten sensitive enteropathy is a genetic condition that has manifestations not only in the gut, but can also affect the skin. Dermatitis herpetiformis is the classical skin association with celiac disease, but there is evidence that other dermatoses may also be linked with it. Aphthous stomatitis, eczema, psoriasis, and alopecia areata have been noted in patients with coeliac disease. More recently, there have been reports of a new entity called non-coeliac gluten sensitivity, which could present with numerous systemic manifestations, including skin changes. Hair loss has been reported with this entity. A better understanding of this new disorder would help dermatologists treat their patients in a more holistic manner.

O 95

Hair and the Nail


Archana Singhal

Department of Dermatology, University College of Medical Sciences, University of Delhi, Delhi, India

Disorders of the cutis, more often than not, involve the appendages. Collateral affection of the skin, hair and nails is emblematic of common dermatoses (e.g. psoriasis, alopecia areata) as well as rare cutaneous conditions such as geno-dermatoses. The similar embryonic origin, microanatomy, and proclivity of hair and nails to concomitant involvement in skin diseases, behooves a succinct exploration of their 'nexus'. Since the appreciation of basic similarities between the nail unit and hair follicle as early as the 20th century, histo-chemical analysis have firmly established that both these appendages are derived from primitive epidermis and represent innovative products of epithelial reduplication containing keratinous fibrils embedded in a sulfur-rich matrix. Anatomical similarity of hair shaft and nail plate lies in their being 'dead' structures composed of terminally differentiated and highly compacted keratinocytes; trichocytes and onychocytes. The shared keratins between the two structures translates into, a genetic mutation in one keratin resulting in concurrent phenotypic manifestations. It is not surprising that both of these appendages are affected simultaneously in various congenital and hereditary anomalies, infective disorders (especially fungal), and acquired auto-immune conditions such as psoriasis, alopecia areata and lichen planus, amongst others. Although the nail does not undergo the cyclical phases of hair growth, the changes in the morphology or growth pattern of either or both of them act as a window to the diagnosis of metabolic and nutritional disorders! Last, but not the least, owing to their visual prominence, both these structures entail crucial psychosocial, cultural and sexual signaling functions for the human species. Indeed, hair and nail cosmetology have evolved as a specialty to be mastered. In conclusion, it is compelling for an astute dermatologist to be aware of this indisputable nexus between the hair and nail for optimizing patient outcomes, medical as well as cosmetic.

O 96

Hair and the Teeth


Pratibha Ramani

Professor and Head, Department Of Oral And Maxillofacial Pathology, Saveetha Dental College, Chennai, India

Teeth, hair and nails are ectodermally derived structures which is the outermost layer of cell in embryonic development and contributes to the formation of many parts of the body. A large group of inherited disorders are characterised by a primary defect in hair, teeth, nails or sweat gland function, in addition to another abnormalities in a tissue of ectodermal origin. A highlight on classification of etiology of the diseases of the ectodermally derived structures provides a clue for the diagnosis and the treatment for the same.Of note, the diagnosis of such diseases is not always easy to make, especially in a neonates and adults in whom characteristics such as tooth defects and other abnormalities are not necessarily evident. It is vital to closely monitor patients with defects in ectodermal derivatives as it can aid in better treatment strategies for the affected individuals.This talk primarily focuses on diagnosis of diseases on the basis of genetic, acquired, infectious, autoimmune, endocrine manifestations, neoplasms and miscellaneous disorders which has teeth and hair manifestations.

Hair and Laser

O 97

Hypertrichosis and Hirsutism: Diagnostic and therapeutic Recommendation


Ulrike Blume-Peytavi

Department of Dermatology and Allergy, Clinical Research Center for Hair and Skin Science, Charité-Universitätsmedizin Berlin, Germany

Clinical presentation of excessive hair growth may range from mild hypertrichosis to extensive hirsutism and may have devastating consequences with impact on self image and femininity. Hirsutism is usually the result of an underlying adrenal, ovarian or central endocrine abnormality mainly due to PCOS but may also be idiopathic, drug induced or rarely due to androgen-secreting neoplasm. Our current knowledge on PCOS related hirsutism clearly shows us that the dermatological signs may be part of underlying metabolic syndrome with serious long time sequelae. Today modern management of hirsutism implies the control of hormonal dysbalances and to improve the cosmetic appearance, thereby positively affecting the patient's quality of life. Today, monotherapy with oral contraceptives that have antiandrogenic activity is recommended as a first line treatment for hirsutism. Combining an OCP with an antiandrogen is recommended if clinical improvement of hirsutism is insufficient after 6-9 months' monotherapy. The primary goal of hirsutism treatment is to achieve central or peripheral androgen suppression using 3 main groups of drugs: Inhibitors of androgen production, peripheral androgen blockers and insulin-sensitising agents. In addition, dermatological treatment options for hirsutism range from classical epilation techniques (e.g. wax, razor, depilatory creams) over topical use of enzyme inhibitors. The latter, eflornithine cream, slows the rate of hair growth and can also be combined with other depilation techniques such as laserepilation.

The aim of medical treatment of hirsutism is to rectify any causal hormonal balance, slow down or stop excessive hair growth and improve the cosmetic appearance of hirsutism, thereby positively affecting the patient's quality of life.

O 98

Epilation to E lase and Beyond…


Rajetha Dami Setty

Department of Dermatology, Oliva Advanced Hair and Skin Clinic, Hyderabad, India

Laser hair reduction (LHR) has evolved from a treatment modality for hirsutism to a grooming ritual in 'normal' women and increasingly, men, who no longer want visible body hair. Shift to long wave lengths, longer pulse widths and better cooling mechanisms in the latter part of the twentieth century made laser hair reduction a safe option for those with coloured skin. The latter part of the next decade witnessed the entry of "painless" in motion hair reduction technologies, notably "Super Hair Removal (SHR)" from Alma lasers which used low peak power but high cumulative energies. In addition to giving a less painful hair reduction experience, the in-motion devices overcame the problem of skip areas and burns caused by overlap or inappropriately high fluences or low pulse pulse widths. They had an advantage over conventional hair reduction machines in tackling fine hair. However, delivering appropriate cumulative energies in a uniform manner to body parts of different shapes and sizes is operator dependent and leads to highly variable results varying from poor to excellent hair reduction. Introduction of large hand-pieces enabled with vacuum to cut down time spent in the laser room while drawing the target closer to the laser beam and dispersing the epidermal melanin (Lumenis, Milesman) and re-entry of alexandrite laser have added a new dimension to LHR. Modified fourth generation IPLs have become safer, albeit more expensive. The talk aims to provide clarity in choosing a LHR technology and optimizing the ones the delegates possess.

O 99

Low Level Lasers as Monotherapy in Androgenetic Alopecia


Maria Fernanda Gavazzoni, Andréia Munck,0 1 Ralph M Trüeb 2

1 Institute of Dermatology, Rio de Janeiro, Brasil, 2 Center for Dermatology and Hair Diseases, Switzerland

Introduction: Androgenetic alopecia is the most common form of hair loss in men and in women. Currently, minoxidil and finasteride are the treatments with the highest levels of medical evidence, but patients who exhibit intolerance or poor response to these treatments are in need of additional treatment modalities. The use of low levels of visible or near infrared light for reducing pain, inflammation and edema, promoting healing of wounds, deeper tissues and nerves, and preventing cell death and tissue damage has been known for over forty years since the invention of lasers. Eventually, LLLT has been developed for treatment of androgenetic alopecia. The HairMax Laser Comb® has originally been tested in a company-sponsored study on male subjects with the claim of significant increase in mean terminal hair density when compared to a sham device. Three possible molecular mechanisms of the LLLT to promote hair growth are discussed. The first possible mechanism involves photons absorption by the mitochondria, increasing in ATP production, activation of transcription factors, such as NF-κB and induction of gene transcription products. The second possible mechanism involves photo-releasing of low doses of nitric oxide. The third mechanism would be the activation of transcription factors by LLLT and upregulation of protective anti-apoptotic proteins. Materials and Methods: To evaluate the efficacy of the 655 nm-HairMax Laser Comb® either as monotherapy or as concomitant therapy for treatment of male and female androgenetic alopecia, we performed a retrospective observational study of global photographic assessments of patients in an office-based setting. Results: Of 32 patients (21 female, 11 male), 8 showed significant, 20 moderate, and 4 no improvement. Improvement was seen both with monotherapy and with concomitant therapy. Improvement was observed as early as 3 months and was sustained up to a maximum observation time of 24 months. No adverse reactions were reported. Conclusion: We conclude that LLLT represents a potentially effective treatment for both male and female androgenetic alopecia, either as monotherapy or concomitant therapy. Combination treatments with minoxidil, finasteride, and LLLT may act synergistic to enhance hair growth.

New Epidemics and Novel Strategies

O 100

Red scalp, Trichodynia and Scalp Burn Out - New Therapeutic Strategies


Ralph M. Trüeb

Center for Dermatology and Hair Diseases, Switzerland

Red scalp was originally reported by Thestrup-Pedersen and Hjorth and commented by Moschella as 'diffuse red scalp disease which can also be itchy and burning, is nonresponsive to therapy including topical steroids or antiseborrhoeic therapy'. Rebora et al proposed the term trichodynia for discomfort of the scalp. The conditions seem to be related. Since Willimann and Trüeb found a correlation of scalp telangiectasia with presence of scalp discomfort, an analogy was proposed to the observation that patients with telangiectactic rosacea respond more frequently with stinging sensations to topical application of 5% lactic acid on the cheeks than patients with papulopustular rosacea or normal controls. Eventually, the observation of red scalp with clinical and histopathologic findings consistent with rosacea suggest that a subset of patients represent a rosacea-like dermatosis. The cause of trichodynia remains obscure. The most prevalent speculations are: Perifollicular inflammation, increased expression of neuropeptide substance P, and underlying psychiatric disorders. These findings suggest that blood vessels are of importance in stinging sensations, and a connection exists between sensory or subjective irritation and cutaneous vascular reactivity. Substance P represents an important mediator of nociception and neurogenic inflammation, and exerts a vasodilatatory effect. By the virtue of their bidirectional effects on the neuroendocrine and immune systems, neuropeptides represent key players in the interaction between the central nervous system and the skin immune and microvascular system. Such mechanisms would explain the noxious effects of external stimuli and emotional distress on cutaneous nociception through release of neuropeptides. Finally, the burnout syndrome is defined as a condition of emotional exhaustion with reduced capacity, that is understood to represent a development line starting with enthusiastic idealism and leading through frustrating experiences to disillusionment, psychosomatic disorders, depression, and aggression. Just as the syndrome is not recognized to represent a true medical condition by the scientific community, but is rather defined as a coping problem in ICD-10, we encounter individuals in daily clinical practice with an analogous patient's career with regard to the condition of the scalp, which represents rather a question of problem solving than a specific dermatologic condition. Therapy includes: Avoidance of UVR exposure and of topical overtreatment, and use of topical witch hazel (hamamelis Virginiana)as shampoo and/or tonic, in refractory cases oral tetracyclines, and tricyclic antidepressants may be added. Efficacy of oral substance P antagonists (aprepitant) has not been convincing. Ultimately, treatment with botulinum toxin (BTX) seems a rational approach, since BTX decreases the mechanical sensitivity of nociceptors and inhibits neurogenic vasodilation through inhibition of sensory neuropeptide release.

O 101

Frontal Fibrosing Alopecia: A New Epidemic


Jerry Shapiro

Hair and Scalp Disorders Clinical Professor, University of British Columbia Department of Dermatology and Skin Science, Vancouver, Canada Adjunct Professor, New York University Langone Medical Center, Department of Dermatology, New York, USA

A silent epidemic of frontal fibrosing alopecia is brewing almost world wide. My approach to the treatment will be discussed as a tiered approach.






 

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