JAAD Online

Antiandrogenic drugs, a therapeutic option for frontal fibrosing alopecia patients

Lichen planopilaris (LPP) and frontal fibrosing alopecia (FFA) are primary, lymphocytic cicatricial hair loss disorders. These model epithelial stem cell (SC) diseases are thought to result from a CD8⁺ T-cell‒dominated immune attack on the hair follicle (HF) SC niche (bulge) after the latter has lost its immune privilege (IP) for as yet unknown reasons. This induces both apoptosis and pathological epithelial‒mesenchymal transition in epithelial SCs, thus depletes the bulge, causes fibrosis, and ultimately abrogates the HFs’ capacity to regenerate. In this paper, we synthesize recent progress in LPP and FFA pathobiology research, integrate our limited current understanding of the roles that genetic, hormonal, environmental, and other factors may play, and define major open questions. We propose that LPP and FFA share a common initial pathobiology, which then bifurcates into two distinct clinical phenotypes, with macrophages possibly playing a key role in phenotype determination. As particularly promising translational research avenues toward direly needed progress in the management of these disfiguring, deeply distressful cicatricial alopecia variants, we advocate to focus on the development of bulge IP and epithelial SC protectants such as, for example, topically effective, HF‒penetrating and immunoinhibitory preparations that contain tacrolimus, peroxisome proliferator–activated receptor-γ, and/or CB1 agonists.

Lichen planopilaris and frontal fibrosing alopecia are primary scarring alopecias where diagnosis can be suggested by clinical and trichoscopy features, especially in the early stages, but scalp biopsy is the standard exam for definitive diagnosis. Frontal fibrosing alopecia is considered a variant of lichen planopilaris, as the histopathological findings are similar, with a perifollicular lymphohistiocytic infiltrate, sometimes with a lichenoid pattern. A thorough clinical examination, trichoscopy and photographic documentation are essential to assess the evolution and therapeutic response. To date, there are no validated treatments or guidelines for these diseases, but there are recommendations that vary with the individual characteristics of each patient. This article presents a comprehensive review of the literature, including an update on topics related to the diagnosis, follow-up, histopathological aspects and available treatments for lichen planopilaris and frontal fibrosing alopecia, highlighting their similarities, differences and peculiarities.

The treatment of hair loss is an important part of clinical dermatology given the prevalence of the problem and great impact on patients’ quality of life. Many new treatments have been introduced in recent years. This review summarizes the main ones in 4 groups: a) For androgenetic alopecia, we discuss new excipients for oral minoxidil, dutasteride, and finasteride as well as new forms of application; prostaglandin agonists and antagonists; low-level laser therapy; and regenerative medicine with Wnt signaling activators and stem cell therapy. b) For alopecia areata, Janus kinase inhibitors are reviewed. c) For frontal fibrosing alopecia, we discuss the use of antiandrogens and, for some patients, pioglitazone. d) Finally, we mention new robotic devices for hair transplant procedures and techniques for optimal follicular unit extraction.

La tricología ocupa un área importante dentro de la práctica asistencial de los dermatólogos por la frecuencia de las diferentes tricosis y por el gran impacto que producen en la calidad de vida de los pacientes. Durante los últimos años hemos comprobado la incorporación de muchas novedades terapéuticas en tricología. El objetivo de la presente revisión es resumir de una forma práctica las principales novedades terapéuticas tricológicas, agrupándolas en 4 apartados: a) alopecia androgénica: nuevos excipientes de minoxidil, dutasterida y finasterida oral y nuevas formas de aplicación de estos antiandrógenos, agonistas y antagonistas de las prostaglandinas, láser de baja potencia y medicina regenerativa —activadores de la vía Wnt y terapia con células madre—; b) alopecia areata: fármacos anti-JAK; c) alopecia frontal fibrosante: antiandrógenos y, en algunos pacientes, pioglitazonas, y d) trasplante capilar: nuevos dispositivos tecnológicos y nuevas técnicas de extracción para optimizar la reserva de unidades foliculares.

The treatment of hair loss is an important part of clinical dermatology given the prevalence of the problem and great impact on patients’ quality of life. Many new treatments have been introduced in recent years. This review summarizes the main ones in 4 groups: a) For androgenetic alopecia, we discuss new excipients for oral minoxidil, dutasteride, and finasteride as well as new forms of application; prostaglandin agonists and antagonists; low-level laser therapy; and regenerative medicine with Wnt signaling activators and stem cell therapy. b) For alopecia areata, Janus kinase inhibitors are reviewed. c) For frontal fibrosing alopecia, we discuss the use of antiandrogens and, for some patients, pioglitazone. d) Finally, we mention new robotic devices for hair transplant procedures and techniques for optimal follicular unit extraction.

La tricología ocupa un área importante dentro de la práctica asistencial de los dermatólogos por la frecuencia de las diferentes tricosis y por el gran impacto que producen en la calidad de vida de los pacientes. Durante los últimos años hemos comprobado la incorporación de muchas novedades terapéuticas en tricología. El objetivo de la presente revisión es resumir de una forma práctica las principales novedades terapéuticas tricológicas, agrupándolas en 4 apartados: a) alopecia androgénica: nuevos excipientes de minoxidil, dutasterida y finasterida oral y nuevas formas de aplicación de estos antiandrógenos, agonistas y antagonistas de las prostaglandinas, láser de baja potencia y medicina regenerativa —activadores de la vía Wnt y terapia con células madre—; b) alopecia areata: fármacos anti-JAK; c) alopecia frontal fibrosante: antiandrógenos y, en algunos pacientes, pioglitazonas, y d) trasplante capilar: nuevos dispositivos tecnológicos y nuevas técnicas de extracción para optimizar la reserva de unidades foliculares.

La alopecia frontal fibrosante (AFF) es una alopecia cicatricial caracterizada por el retroceso de la línea de implantación del pelo, asociada a alopecia de cejas. Habitualmente afecta a mujeres en edad posmenopáusica, siendo mucho menos prevalente en varones.

Describir las características clínicas de la AFF en los hombres estudiados y compararlos con los datos recogidos en la literatura.

Se realizó un estudio descriptivo de los varones diagnosticados de AFF en nuestro Servicio, desde enero del 2010 hasta diciembre del 2015. Se recogieron los datos demográficos, las características clínicas y los tratamientos realizados.

Se reclutó a 12 pacientes. La edad media fue de 75 años. La alopecia fue el motivo de consulta únicamente en 4 pacientes. El retroceso medio de la línea de implantación del pelo fue de 3 cm. Las pápulas faciales estaban presentes en el 50% de los hombres, el 83% presentaba alopecia de cejas, extremidades y alopecia androgenética (AGA). El eritema y la hiperqueratosis folicular se veían en el 66% de los casos y solo el 25% refería prurito. El tratamiento más frecuentemente utilizado consistió en corticoide tópico en 8 pacientes (66%), asociado a minoxidil tópico en 4 de ellos (33%).

Según los datos obtenidos en nuestra serie, las pápulas faciales, la AGA y la afectación del vello corporal son más frecuentes en los hombres con AFF que en las mujeres. Por otra parte, a diferencia de los casos de AFF en varones descritos en la literatura, la edad media es mayor en nuestra serie, lo que podría explicar la mayor incidencia de AGA asociada y que la mayoría consulte por otro motivo.

Frontal fibrosing alopecia (FFA) is a scarring disease in which the hairline recedes and the eyebrows can be affected. Usually seen in postmenopausal women, FFA is much less common in men.

To describe the clinical characteristics of FFA in a case series of men and compare this series to those reported in the literature.

Men with FFA being treated in our dermatology department from January 2010 to December 2015 were included prospectively for this descriptive study. We collected patient information and clinical and treatment characteristics.

Twelve men (mean age, 75 years) were recruited. Alopecia was the reason for seeking medical care in only 4 cases. The hairline had receded 3 cm on average. Half the patients had facial papules, and 83% had androgenetic alopecia or hair loss on eyebrows or extremities. Follicular hyperkeratosis and erythema were present in 66%, and only 25% of the men reported pruritus. The most commonly prescribed treatments were topical: corticosteroids in 8 patients (66%) and minoxidil in 4 (33%).

Facial papules, androgenetic alopecia, and loss of body hair are more often observed in men with FFA than in women. The men in this series were older on average than in other FFA case series in the literature, possibly accounting for the higher prevalence of associated androgenetic alopecia and the fact that most of these men were seeking care for conditions other than hair loss.