Introduction: Dermal papilla (DP) is the site of expression of various hair growth related genes. Various researches have demonstrated the underlying importance of Wnt proteins and wound growth factors in stimulating DP associated stem cells. Microneedling works by stimulation of stem cells and inducing activation of growth factors. Materials and Methods: Hundred cases of mild to moderate (III vertex or IV) androgenetic alopecia (AGA) were recruited into 2 groups. After randomization one group was offered weekly microneedling treatment with twice daily 5% minoxidil lotion (Microneedling group); other group was given only 5% minoxidil lotion. After baseline global photographs, the scalp were shaved off to ensure equal length of hair shaft in all. Hair count was done in 1 cm ² targeted fixed area (marked with tattoo) at baseline and at end of therapy (week 12). The 3 primary efficacy parameters assessed were: Change from baseline hair count at 12 weeks, patient assessment of hair growth at 12 weeks, and investigator assessment of hair growth at 12 weeks. A blinded investigators evaluated global photographic response. The response was assessed by 7- point scale. Results: (1) Hair counts - The mean change in hair count at week 12 was significantly greater for the Microneedling group compared to the Minoxidil group (91.4 vs 22.2 respectively). (2) Investigator evaluation - Forty patients in Microneedling group had +2 to +3 response on 7-point visual analogue scale, while none showed the same response in the Minoxidil group. (3) Patient evaluation - In the Microneedling group, 41 (82%) patients reported more than 50% improvement versus only 2 (4.5%) patients in the Minoxidil group. Unsatisfied patients to conventional therapy for AGA got good response with Microneedling treatment. Conclusion: Dermaroller along with Minoxidil treated group was statistically superior to Minoxidil treated group in promoting hair growth in men with AGA for all 3 primary efficacy measures of hair growth. Microneedling is a safe and a promising tool in hair stimulation and also is useful to treat hair loss refractory to Minoxidil therapy.

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Hair cosmetics are an important tool that helps to increase patient's adhesion to alopecia and scalp treatments. This article reviews the formulations and the mode of action of hair cosmetics: Shampoos, conditioners, hair straightening products, hair dyes and henna; regarding their prescription and safetiness. The dermatologist's knowledge of hair care products, their use, and their possible side effects can extend to an understanding of cosmetic resources and help dermatologists to better treat hair and scalp conditions according to the diversity of hair types and ethnicity.

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Background: Androgenetic alopecia (AGA) is the most common cause of hair loss in men with limited treatment options. Platelet-rich plasma (PRP) therapy is one of the newer treatment options in the management of AGA which has shown promising results. Aims and Objectives: This study was aimed at comparing the clinical efficacy of PRP therapy with minoxidil therapy. Materials and Methods: In the study, patients were randomized into two groups – Group A (given PRP therapy) and Group B (given minoxidil therapy). Both groups were followed up over a period of 6 months, and final analysis was done with the help of global photography, hair pull test, standardized hair growth questionnaire, patient satisfaction score; in addition, a comparison of platelet counts in PRP was done, to know that if a clinical correlation exists between platelet concentration and clinical improvement. A total of 40 patients clinically diagnosed with AGA were enrolled in the study with 20 patients in each group. Four patients from Group A (PRP) and six patients from Group B (minoxidil) could not complete the treatment for 6 months and were eventually excluded. Results: At the end of 6 months, 30 patients were evaluated to compare the efficacy of intradermal PRP and topical minoxidil therapy. On global photography, Group A (PRP) was found to have a comparatively better outcome than Group B (minoxidil). In hair pull test, hair growth questionnaire, and patient satisfaction score, Group A was found to be better than Group B. Mean platelet count at baseline was 3.07 ± 0.5 lac/mm, 3 while platelet count in final PRP prepared was 12.4 ± 1.7 lac/mm, and patients with a higher platelet count in PRP had a much better clinical improvement compared to patients with a low platelet count in PRP. Side effects with PRP therapy were minimal with better results which may improve the compliance of the patient. Conclusion: PRP therapy can be a valuable alternative to topical minoxidil therapy in the treatment of AGA.

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Premature graying of hair (PGH) is defined as graying of hair before the age of 20 years in Caucasians and before 30 years in African American population. It can severely affect the self-esteem of an individual. The exact etiopathogenesis remains unknown, although it has been associated with premature aging disorders, atopy, and autoimmune diseases. Patients, who present with PGH, should be assessed for syndromes and metabolism diseases. Hair dyes remain the main modality of the treatment for cosmetic concerns after nutritional supplementation.

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Trichoscopy is the term coined for dermoscopic imaging of the scalp and hair. This novel diagnostic technique, both simple and non-invasive, can be used as a handy bed side tool for diagnosing common hair and scalp disorders. Trichoscopic observations can be broadly grouped as hair signs, vascular patterns, pigment patterns and interfollicular patterns. In this article, we have briefly described the trichoscopic findings in the common categories of cicatricial and non-cicatricial alopecias such as androgenetic alopecia, alopecia areata, telogen effluvium, tinea capitis, trichotillomania, lichen planopilaris, discoid lupus erythematosus and hair shaft disorders. Besides diagnosing alopecia, it has the potential for obviating unnecessary biopsies and when a biopsy is still needed it is helpful in choosing an ideal biopsy site. Moreover, trichoscopy is a valuable tool for evaluating the treatment response photographically at each follow-up. The last statement here is deleted as asked.

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Alopecia areata (AA) is a complex autoimmune condition that causes nonscarring hair loss. It typically presents with sharply demarcated round patches of hair loss and may present at any age. In this article, we review the epidemiology, clinical features, pathogenesis, and new treatment options of AA, with a focus on the immunologic mechanism underlying the treatment. While traditional treatment options such as corticosteroids are moderately effective, a better understanding of the disease pathogenesis may lead to the development of new treatments that are more directed and effective against AA. Sources were gathered from PubMed, Embase, and the Cochrane database using the keywords: alopecia, alopecia areata, hair loss, trichoscopy, treatments, pathogenesis, and epidemiology.

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Conventionally, the medical focus has been either on hair loss or the condition of the scalp in terms of specific dermatological diseases. Indeed, the proximate structural arrangement of the scalp and hair leads to an interdependent relationship between the two. While protective benefits of the hair to the scalp are obvious, the role of the scalp as an incubatory environment for the preemergent hair fiber has largely been ignored. In fact, there is a wealth of observational data on specific dermatological conditions of the scalp providing evidence for the role of the scalp condition in supporting the production of healthy hair. Oxidative stress, the inability of the body to sufficiently counteract the sources of oxidation, is prevalent in many skin conditions, including normal skin aging. On the scalp, the hair appears to be impacted prior to emergence, and oxidative stress appears to play a role in premature hair loss. The scalp commensal organism, Malassezia, has been recognized to be a source of oxidative damage. Therefore, hair care products, specifically shampoos, with active Malassezia inhibitory agents, such as zinc pyrithione, tend to reduce premature hair loss, besides the known benefits in treating specific dermatologic scalp pathologies, and therefore should represent an integral part of every treatment regimen for hair loss, even in individuals not showing symptoms of scalp pathologies.

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The post-Finasteride syndrome (PFS) has been claimed to occur in men who have taken oral finasteride to treat hair loss or benign prostatic hyperplasia. While the incidence of persistent sexual, mental, and physical side effects despite quitting finasteride is unknown, and the condition is not recognized by the scientific community, individuals who suffer from PFS do present with very distinctive and homogenous symptoms. The concept has emerged from reports of nondermatologists, neuroendocrinological research, case reports, and uncontrolled studies. These have been scrutinized by hair experts who found that persistent sexual side effects were only documented in low-quality studies with a strong bias selection and a significant nocebo effect. Others totally dispute the credibility of the PFS. In any case, the PFS is a problem that has to be dealt with. Low-quality studies neither confirm nor refute the condition as a valid nosologic entity. Therefore, it is as inappropriate to dismiss the condition, as it would be to demonize finasteride for the treatment of male pattern hair loss. Whether the PFS represents a nocebo reaction or a real drug adverse event is irrelevant, while the best way to alleviate the emotional distress related to hair loss is to effectively treat the condition causing the problem. It is not sufficient to only discuss the plausibility of the PFS. There is a need for practical recommendations to include such important issues as patient selection and risk assessment, appropriate patient information, how to react in case of drug-related adverse events, issues of fertility and malignancy, management of the PFS, and alternatives, specifically the use of topical finasteride. It is the aim of this commentary to provide the respective information.

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Background: The hair whorl denotes the spiral disposition of hairs around an axis, which is determined by the follicle growing direction. Atypical variants of scalp hair patterns, identified by abnormally placed or multiple whorls, have been associated with early brain developmental disorders and several dysmorphic syndromes. Materials and Methods: A 6-month case–control, prospective monocentric study included an overall number of 557 children. A logistic regression analysis was performed to evaluate the relationship between localization, the number of scalp hair whorls, and their association with neurofibromatosis type 1 (NF1). Results: NF1 positively correlates with a frontal localization, whereas a negative association was found with a parietal whorl pattern (P < 0.001). Conclusion: Evaluation of scalp whorls gains importance in the neonatal settings and may contribute to suspect the early diagnosis of NF1, as the related National Institutes of Health diagnostic criteria cannot be usually observed at an early age.

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Madarosis is a terminology that refers to loss of eyebrows or eyelashes. This clinical sign occurs in various diseases ranging from local dermatological disorders to complex systemic diseases. Madarosis can be scarring or non-scarring depending upon the etiology. Appropriate diagnosis is essential for management. Follicular unit transplantation has been found to be a useful method of treating scarring madarosis and the procedure relevant to eyebrow and eyelash reconstruction has been discussed. A useful clinical approach to madarosis has also been included for bedside diagnosis. The literature search was conducted with Pubmed, Medline, and Google scholar using the keywords madarosis, eyebrow loss, and eyelash loss for articles from 1960 to September 2011. Relevant material was also searched in textbooks and used wherever appropriate.

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Introduction: Trichotillomania (TTM) is characterized by patchy alopecia of hair bearing areas. This is because of compulsive urge to pull the hair. Scalp is the most common site for pulling hair. Usually, patients may have only small areas of baldness, in severe forms, tonsure pattern of baldness is observed. Diagnosis is by history and clinical examination. However, it is difficult to differentiate from other causes of noncicatricial alopecia. Here, authors observed trichoscopic patterns and evaluated their importance in the diagnosis of TTM. Materials and Methods: This study was conducted in S. Nijalingappa Medical College, Bagalkot, from January 2014 to July 2014. Ten patients with clinically suspected TTM were included in the study. Informed consent was taken and ethical clearance was obtained. Dermlite3 dermoscope was used with Sony camera attachment to save the images. Histopathological examination was conducted in all the patients to confirm the diagnosis. Results: Ten patients were included in the study. Mean age of the patients was 34 years. Most common symptom was patchy loss of hair in the frontal area (100%). Common trichoscopic feature was decreased hair density and broken hairs. Trichoptilosis ("split ends") and irregular coiled hairs were seen in 80% patients. Novel diagnostic signs like black dots, flame hair, v-sign, follicular hemorrhages, were seen in 30% each. Tulip hair and hair powder were observed in 10% of patients. All patients had the noninflammatory alopecia with distorted and collapsed inner root sheath in histopathology. Conclusion: Trichotillomania is often chronic and difficult to treat. Hence, early diagnosis and treatment is necessary. Authors believe that the trichoscopy plays a vital role in the diagnosis of this condition by demonstrating specific trichoscopic patterns.

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Background: Keratosis pilaris (KP) is characterized by keratinous plugs in the follicular orifices and varying degrees of perifollicular erythema. The most accepted theory of its pathogenesis proposes defective keratinization of the follicular epithelium resulting in a keratotic infundibular plug. We decided to test this hypothesis by doing dermoscopy of patients diagnosed clinically as keratosis pilaris. Materials and Methods: Patients with a clinical diagnosis of KP seen between September 2011 and December 2011 were included in the study. A clinical history was obtained and examination and dermoscopic evaluation were performed on the lesions of KP. Results: The age of the patients ranged from 6-38 years. Sixteen patients had history of atopy. Nine had concomitant ichthyosis vulgaris. All the 25 patients were found to have coiled hair shafts within the affected follicular infundibula. The hair shafts were extracted with the help of a sterile needle and were found to retain their coiled nature. Perifollicular erythema was seen in 11 patients; perifollicular scaling in 9. Conclusion: Based on our observations and previously documented histological data of KP, we infer that KP may not be a disorder of keratinization, but caused by the circular hair shaft which ruptures the follicular epithelium leading to inflammation and abnormal follicular keratinization.

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Hypothyroidism is a common and well recognized cause of diffuse hair loss. Zinc and other trace elements such as copper and selenium are required for the synthesis of thyroid hormones, and deficiency of these can result in hypothyroidism. Conversely, thyroid hormones are essential for the absorption of zinc, and hence hypothyroidism can result in acquired zinc deficiency. The hair loss attributed to hypothyroidism may not improve with thyroxine unless zinc supplements are added, as demonstrated in our case.

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Aim: Dermatologists most frequently prescribe shampoos for the treatment of hair shed and scalp disorders. Prescription of hair care products is often focused on improving scalp hair density, whereas the over-the-counter products focus on hair damage prevention. Little is taught in medical schools about the hair cosmetics, so that the prescriptions are based only on the treatment of the scalp and usually disregards the hair fi ber health. Materials and Methods: 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. About 19.23% presented pH ≤ 5.5.(IC: 7.4-37.6%). 80.77% of all anti-dandruffs 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. 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 lower pH of shampoos may cause less frizzing for generating less negative static electricity on the fiber surface. Interestingly, only 38% of the popular brand shampoos against 75% of the salons shampoos presented a pH ≤ 5.0. 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.

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Experimental evidence supports the hypothesis that oxidative stress plays a major role in the ageing process. Reactive oxygen species are generated by a multitude of endogenous and environmental challenges. Reactive oxygen species or free radicals are highly reactive molecules that can directly damage cellular structural membranes, lipids, proteins, and DNA. The body possesses endogenous defence mechanisms, such as antioxidative enzymes and non-enzymatic antioxidative molecules, protecting it from free radicals by reducing and neutralizing them. With age, the production of free radicals increases, while the endogenous defence mechanisms decrease. This imbalance leads to the progressive damage of cellular structures, presumably resulting in the ageing phenotype. Ageing of hair manifests as decrease of melanocyte function or graying, and decrease in hair production or alopecia. There is circumstantial evidence that oxidative stress may be a pivotal mechanism contributing to hair graying and hair loss. 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 alopecia.

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Background: In the search for alternative agents to oral finasteride and topical minoxidil for the treatment of androgenetic alopecia (AGA), melatonin, a potent antioxidant and growth modulator, was identified as a promising candidate based on in vitro and in vivo studies. Materials and Methods: One pharmacodynamic study on topical application of melatonin and four clinical pre-post studies were performed in patients with androgenetic alopecia or general hair loss and evaluated by standardised questionnaires, TrichoScan, 60-second hair count test and hair pull test. Results: Five clinical studies showed positive effects of a topical melatonin solution in the treatment of AGA in men and women while showing good tolerability: (1) Pharmacodynamics under once-daily topical application in the evening showed no significant influence on endogenous serum melatonin levels. (2) An observational study involving 30 men and women showed a significant reduction in the degree of severity of alopecia after 30 and 90 days ( P < 0.001) based on questionnaires completed by investigators and patients. (3) Using a digital software-supported epiluminescence technique (TrichoScan) in 35 men with AGA, after 3 and 6 months in 54.8% to 58.1% of the patients a significant increase of hair density of 29% and 41%, respectively was measured (M0: 123/cm² M3: 159/cm² M6: 173/cm²) ( P < 0,001). (4) In 60 men and women with hair loss, a significant reduction in hair loss was observed in women, while hair loss in men remained constant ( P < 0.001). (5) In a large, 3-month, multi-center study with more than 1800 volunteers at 200 centers, the percentage of patients with a 2- to 3-fold positive hair-pull test decreased from 61.6% to 7.8%, while the percentage of patients with a negative hair-pull test increased from 12.2.% to 61.5% ( P < 0.001). In addition, a decrease in seborrhea and seborrheic dermatitis of the scalp was observed. Conclusions: Since safety and tolerability in all of the studies was good, the topical application of a cosmetic melatonin solution can be considered as a treatment option in androgenetic alopecia.

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Background: Androgenetic alopecia (AGA) 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. Objective: The aim was to evaluate the efficacy and safety of low-level laser therapy (LLLT) for AGA, either as monotherapy or as concomitant therapy with minoxidil or finasteride, in an office-based setting. Materials and Methods: Retrospective observational study of male and female patients with AGA, treated with the 655 nm-HairMax Laser Comb ^® , in an office-based setting. Efficacy was assessed with global photographic imaging. 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. Conclusions: LLLT represents a potentially effective treatment for both male and female AGA, either as monotherapy or concomitant therapy. Combination treatments with minoxidil, finasteride, and LLLT may act synergistic to enhance hair growth.

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We report a series of four patients who presented with complaints of diffuse non-scarring alopecia. They had similar clinical features of alopecia, hyperseborrhea, and distinct keratinaceous hair casts that encircled the hair shafts. Propionibacterium acnes was isolated from two of the patients' scalp, and Gram-positive, Giemsa-positive bacteria were seen in the hair follicles in the scalp biopsy of one of the patients. The patients' symptoms did not respond to standard treatment for seborrheic dermatitis, but responded to a course of systemic antibiotics targeting P. acnes. We propose a role for P. acnes colonization of the terminal hair follicles in the pathogenesis of hair casts, and possibly diffuse non-scarring alopecia. Possible mechanisms of pathogenesis are discussed with a literature review.

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Acute hair felting is a rare disorder of scalp hair. In this condition, the hair becomes twisted, entangled as a hard stony mass resembling a bird's nest. Sudden hair matting has been reported earlier in the literature after vigorous use of chemical and herbal shampoos. Plica polonica is a patchy area of hair matting occurring in due course of time in neglected hair or underlying psychiatric illness. This case is interesting as the whole scalp hair matted immediately after using coconut oil and castor oil following washing. Growing long hair and taking oil bath are cultural and religious customs in South India. The high viscosity of castor oil and long hair had contributed to sudden felting of hair. This disorder of hair is irreversible and the hair should be cut off. Acute nature of this disorder will result in a serious psychological impact on the patient and the family.

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Light microscopy of the hair forms an important bedside clinical tool for the diagnosis of various disorders affecting the hair. Hair abnormalities can be seen in the primary diseases affecting the hair or as a secondary involvement of hair in diseases affecting the scalp. Hair abnormalities also form a part of various genodermatoses and syndromes. In this review, we have briefly highlighted the light microscopic appearance of various infectious and non-infectious conditions affecting the hair.

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Clinical photography of hair disorders is an extension of photography in dermatology practice. Some points should be kept in mind while taking images of the hair and hair bearing areas in view of the reflection of light and the subsequent glare that may spoil the result. For documentation of most conditions of the hair, the same general rules of dermatological photography apply. The correct lighting is the most important aspect of clinical photography in trichology practice and can be achieved by reflected light than direct light. Special care should be taken in conditions requiring serial images to document progress/response to treatment and the most important factor in this context is consistency with respect to patient positioning, lighting, camera settings and background. Dermoscopy/trichoscopy can also be incorporated in clinical practice for image documentation.

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Alopecia, a frequently reported problem, severely impacts the quality of life of patients and is often associated with loss of confidence and low self-esteem. Several conditions such as telogen effluvium (TE), anagen effluvium, diffuse type of alopecia areata, female pattern hair loss, hair shaft abnormalities, loose anagen hair syndrome, and congenital atrichia or hypotrichosis are associated with hair loss. The actual prevalence rate of TE is not reported since most cases are subclinical in nature. Further, since women get more distressed by hair fall and promptly seek treatment, they tend to be over-represented. However, both genders can suffer from this condition if triggering factors are present. This consensus paper was developed by taking into account opinions of renowned experts in the field and is hoped to serve as an evidence-based platform for selecting efficacious and safe therapy for patients with TE. This review presents a synopsis of the key opinions of experts on all aspects of treatment and effective management of this condition.

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Background: Trichomycosis is asymptomatic bacterial infection of the axillary hairs caused by Corynebacterium sp. Objective: to bring a series of cases of trichomycosis, its clinical and microbiological experience. Materials and Methods: This report consists in a linear and observational retrospective study of 15 years of cases of trichomycosis confirmed clinically and microbiologically. Results: Fifty six confirmed cases of trichomycosis were included in this report. The majority were men 53/56 (94.6%), mean age was 32.5 years. The most commonly affected area was the axilla (92%), trichomycosis flava was the principal variant 55/56 (98.2%) and signs and symptoms associated were hyperhidrosis (87.5%), hairs' texture change (57.1%) and odor (35.7%). Bacterial concretions were observed in all cases, and the predominant causative agent in 89.3% of all cases was Corynebacterium sp. Thirty patients were included in therapeutic portion of the study, and 28 (93.3%) of them experienced a clinical and microbiological cure. Conclusion: Trichomycosis is asymptomatic, superficial infection, which primarily affects axillary hairs.

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