Vol. 28. No. 1


Hair and nails share important anatomical and immunologic
similarities and often are simultaneously involved in a
number of congenital and acquired disorders. This issue of Seminars
in Cutaneous Medicine and Surgery provides an update on
management and treatment of a number of hair or nail disorders
that I believe are of great interest for clinicians not only because
they are commonly encountered but also because there is very
little evidence-based information about their optimal management.
I invited the most important European experts in the field
of hair and nails to select the topic of their greatest interest to
review and offer our readers their personal experience-based
contributions on management.
Although our prominent European colleagues do not need
introduction to our readers, the special focus of the articles in
this issue may benefit from my “setting the stage” for them. Dr.
Camacho from Spain dedicated most of his personal research
career to the field of androgen-dependent disorders in women,
and his article gives a new prospective to the field as he elucidates
different subsets of hair loss in women and discusses his personal
experience with a number of experimental treatments targeted to
these specific subsets of androgen-dependent hair loss disorders
in women. Drs. Assouly and Regaygne direct a special hair consultation
unit at the Saint Louis Hospital in Paris and examine an
extraordinary number of patients with different hair conditions.
Their contribution on the diagnosis and treatment of lichen planopilaris
is based on their considerable personal experience.
This contribution is of great value as they are the first to use
objective methods, such as trichoscan, to judge response to the
treatment of cicatricial alopecia. For our next contribution to
distressful hair disorders, we turn to Dr. Messenger from the UK,
who has been working on alopecia areata for many years and
provides an evidence based review of the possible treatments. We
offer a unique contribution from Dr. Trueb from Switzerland,
who discusses chemotherapy alopecia, an important clinical
problem that is only rarely considered in the dermatological
literature. Advances in understanding pathophysiology of hair
loss from chemotherapy may provide better treatment options in
the near future. Finally, Dr Blume Peytavi and colleagues from
Germany provide an overview of the techniques that allow us to
evaluate the response to treatments in patients with hair disorders.
In my opinion, the continued development of the field
requires the use of objective evaluation systems by all doctors
involved in the treatment of hair disorders.
The distinguished clinicians contributing to disorders of the
nail unit consider a wide spectrum of topics. Dr. De Berker from
the UK presents his personal experience on treatment of psoriasis
of the nails and reviews topical and systemic treatments, including
the new biological agents that can be used in the management
of these patients. Dr. Abimelec from France provides our readers
very practical information on instruments and techniques that
based upon his own personal experience he recommends to obtain
the best surgical results. Dr. Richert and colleagues from
Belgium, who are leading experts on the usage of medical imaging
for the diagnosis of subungual tumors and on nail pathology,
review recent techniques to help doctors in the clinical diagnosis
of infective and neoplastic disorders of the nails.
I personally chose to discuss the problems that dermatologists
still face in the management of nail pigmentation and in the early
diagnosis of melanoma of the nail unit. International nail experts
really think that there is an urgent necessity to provide guidelines
in this important field. Therefore, we started an International
Study Group on Melanonychia with the objective of providing
evidence based information to clinicians dealing with nail pigmentation.
The group was started in San Paulo in September
2007 (Fig. 1) and meets twice a year at the American Academy of
Dermatology and at the European Academy of Dermatology and
Venereology meetings. We have 30 members, including clini-
cians and pathologists. We welcome any doctor who might be
interested in joining the group to provide his/her expertise.
I enjoyed working on this issue of the Journal and especially
appreciated the comments and the suggestions of Dr. June Robinson,
who is the editor of this issue and really made helpful
suggestions to improve the content and the style of all the articles.
I really hope that the readers will find the information useful
in their daily management of patients with hair and nail disorders.

Lichen Planopilaris: Update on Diagnosis and Treatment

Pascal Reygagne, MD | Philippe Assouly, MD

Lichen planopilaris (LPP), a follicular form of lichen planus, is a rare inflammatory lymphocyte
mediated disorder. Although the physiopathology is unclear, an autoimmune etiology is generally
accepted. Women are affected more than men, and the typical age of onset is between
40 and 60 years. LLP is a primary cicatricial alopecia whose diagnosis is supported in the early
stage by both clinical and histopathological findings. Within the margins of the expanding areas
of perifollicular violaceous erythema and acuminate keratotic plugs, the histology can show the
lichenoid perifollicular inflammation. LPP can be subdivided into 3 variants: classic LPP, frontal
fibrosing alopecia (FFA), and Lassueur Graham-Little Piccardi syndrome. With the exception of
FFA, the hairless patches of the scalp can be unique or can occur in multiples and can present
with a reticular pattern or as large areas of scarring. This condition can have major psychological
consequences for the affected patients. The therapeutic management often is quite
challenging, as relapses are common after local or systemic treatments. Further research is
needed on the pathogenesis, and randomized controlled trials of treatment with scientific
evaluation of the results are necessary to appreciate the proposed treatment.
Semin Cutan Med Surg 28:3-10 © 2009 Elsevier Inc. All rights reserved.


Chemotherapy-Induced Alopecia

Ralph M. Trüeb, MD

Few dermatologic conditions carry as much emotional distress as chemotherapy-induced
alopecia (CIA). The prerequisite for successful development of strategies for CIA prevention is
the understanding of the pathobiology of CIA. The incidence and severity of CIA are variable
and related to the particular chemotherapeutic protocol. CIA is traditionally categorized as
acute diffuse hair loss caused by dystrophic anagen effluvium; however, CIA presents with
different clinical patterns of hair loss. When an arrest of mitotic activity occurs, obviously
numerous and interacting factors influence the shedding pattern. The major approach to
minimize CIA is by scalp cooling. Unfortunately, most published data on scalp cooling are of
poor quality. Several experimental approaches to the development of pharmacologic agents are
under evaluation and include drug-specific antibodies, hair growth cycle modifiers, cytokines
and growth factors, antioxidants, inhibitors of apoptosis, and cell-cycle and proliferation modifiers.
Ultimately, the protection should be selective to the hair follicle; for example, topical
application, such that the anticancer efficacy of chemotherapy is not hampered. Among the few
agents that have been evaluated so far in humans, AS101 and minoxidil were able to reduce the
severity or shorten the duration of CIA, but could not prevent CIA.
Semin Cutan Med Surg 28:11-14 © 2009 Published by Elsevier Inc.


Alopecia Areata: Evidence-Based Treatments

Andrew G. Messenger | Seema Garg

Alopecia areata is a common condition causing nonscarring hair loss. It may be patchy,
involve the entire scalp (alopecia totalis) or whole body (alopecia universalis). Patients may
recover spontaneously but the disorder can follow a course of recurrent relapses or result
in persistent hair loss. Alopecia areata can cause great psychological distress, and the
most important aspect of management is counseling the patient about the unpredictable
nature and course of the condition as well as the available effective treatments, with details
of their side effects. Although many treatments have been shown to stimulate hair growth
in alopecia areata, there are limited data on their long-term efficacy and impact on quality
of life. We review the evidence for the following commonly used treatments: corticosteroids
(topical, intralesional, and systemic), topical sensitizers (diphenylcyclopropenone), psoralen
and ultraviolet A phototherapy (PUVA), minoxidil and dithranol.
Semin Cutan Med Surg 28:15-18 © 2009 Elsevier Inc. All rights reserved.


Hair Loss in Women

Francisco M. Camacho-Martínez

Female pattern hair loss (FPHL) is a clinical problem that is becoming more common in
women. Female alopecia with androgen increase is called female androgenetic alopecia
(FAGA) and without androgen increase is called female pattern hair loss. The clinical
picture of typical FAGA begins with a specific “diffuse loss of hair from the parietal or
frontovertical areas with an intact frontal hairline.” Ludwig called this process “rarefaction.”
In Ludwig’s classification of hair loss in women, progressive type of FAGA, 3 patterns
were described: grade I or minimal, grade II or moderate, and grade III or severe. Ludwig
also described female androgenetic alopecia with male pattern (FAGA.M) that should be
subclassified according to Ebling’s or Hamilton-Norwood’s classification. FAGA.M may be
present in 4 conditions: persistent adrenarche syndrome, alopecia caused by an adrenal or
an ovarian tumor, posthysterectomy, and as an involutive alopecia. A more recent classification
(Olsen’s classification of FPHL) proposes 2 types: early- and late-onset with or
without excess of androgens in each. The diagnosis of FPHL is made by clinical history,
clinical examination, wash test, dermoscopy, trichoscan, trichograms and laboratory test,
especially androgenic determinations. Topical treatment of FPHL is with minoxidil, 2-5%
twice daily. When FPHL is associated with high levels of androgens, systemic antiandrogenic
therapy is needed. Persistent adrenarche syndrome (adrenal SAHA) and alopecia of
adrenal hyperandrogenism is treated with adrenal suppression and antiandrogens. Adrenal
suppression is achieved with glucocorticosteroids. Antiandrogens therapy includes cyproterone
acetate, drospirenone, spironolactone, flutamide, and finasteride. Excess release of
ovarian androgens (ovarian SAHA) and alopecia of ovarian hyperandrogenism is treated
with ovarian suppression and antiandrogens. Ovarian suppression includes the use of
contraceptives containing an estrogen, ethinylestradiol, and a progestogen. Antiandrogens
such as cyproterone acetate, always accompanied by tricyclic contraceptives, are the best
choice of antiandrogens to use in patients with FPHL. Gonadotropin-releasing hormone
agonists such as leuprolide acetate suppress pituitary and gonadal function through a
reduction in luteinizing hormone and follicle-stimulating hormone levels. Subsequently,
ovarian steroid levels also will be reduced, especially in patients with polycystic ovary
syndrome. When polycystic ovary syndrome is associated with insulin resistance, metformin
must be considered as treatment. Hyperprolactinemic SAHA and alopecia of pituitary
hyperandrogenism should be treated with bromocriptine or cabergoline. Postmenopausal
alopecia, with previous high levels of androgens or with prostatic-specific antigen
greater than 0.04 ng/mL, improves with finasteride or dutasteride. Although we do not
know the reason, postmenopausal alopecia in normoandrogenic women also improves with
finasteride or dutasteride at a dose of 2.5 mg per day. Dermatocosmetic concealment with
a hairpiece, hair prosthesis as extensions, or partial hairpieces can be useful. Lastly, weight
loss undoubtedly improves hair loss in hyperandrogenic women.
Semin Cutan Med Surg 28:19-32 © 2009 Elsevier Inc. All rights reserved.


Diagnosis of Hair Disorders

Kathrin Hillmann, MD | Ulrike Blume-Peytavi, MD, PhD

Hair disorders include hair loss, increased hair growth, and hair structure defects with
increased breakage, as well as unacceptable cosmetic appearance, such as reduced shine,
strength, curliness, and elasticity. It is the task of the dermatologist to choose the right
diagnostic tool depending on the suspected clinical diagnosis. Moreover, certain tools are
best suited for diagnosis in private practice, whereas others can only be used to monitor
hair growth under treatment in clinical studies. The techniques can be classified as either
invasive (eg, biopsies in scarring alopecia), semi-invasive (trichogram, unit area trichogram),
or noninvasive (eg, global hair counts, phototrichogram, electron microscopy,
laser scanning microscopy) methods. Further, one must differentiate between subjective
and objective techniques. For the practicing dermatologist, body and scalp hair distribution
by use of different grading systems, the hair pull test, and dermoscopy belong in the
category of basic diagnostic tools. Basic techniques may be extended by computerassisted
phototrichogram and, in selected cases, by use of the trichogram and/or scalp
biopsies. For research purposes optical coherent tomography, electron microscopy, biochemical
methods, atomic force microscopy, and confocal laser scanning microscopy are
optional tools. For clinical studies global photographs (global expert panel), hair weighing,
phototrichogram, and different clinical scoring systems have proven to be objective tools
for documentation and evaluation of hair growth and hair quality.
Semin Cutan Med Surg 28:33-38 © 2009 Elsevier Inc. All rights reserved.