August – 2014 - SolidChennai

D
S
L
I
O
Connect
August 2014
Advisory Board
Editorial Board
President:
Dr. D. Prabhavathy MD, DD
Dr. Shwetha Rahul M.D.DVL
Dr. T.K. Anandi MD
Dr.S. Shobana MD, DD
Dr. K. N. Sarveshwari MD, DD, DNB
Dr. S. Varalakshmi DDVL
Dr. Renuka Ramakrishnan MD
Secretary:
Dr. Maya Vedamurthy MD, DD
Dr. Sindhuja M.D.DVL
Dr. Samna Pramod, DDVL
Dr. Parvathi Padmanabhan MD, DD
Board Members
Executive Board
“Society of Ladies in Dermatology”
is an initiative to bring together lady dermatologists to further academic interactions among our peers.
President’s Message:
S
O
L
I
D
A
u
g
1
4
Dear Colleagues and Fellow members of SOLID
It was once again a great pleasure to interact with all members of the group during the last meeting. We
were very fortunate to have an excellent speaker in Dr,T.K. Sumathi. who addressed us on a topic of
immense importance - Hairfall in women. The talk was informative, concise yet covered all aspects of the
topic and the speaker also drew from her vast experience ,anecdotes to highlight the various aspects of the
problem
We also had the pleasure of listening to another doyen in the field of dermatology- Prof S. Premalatha on
bringing up the girl child in the modern era. As always the topic was dealt with finesse and artistry which
has always been Madam's forte.
At this juncture I would like to highlight the fact that we are fast approaching our Anniversary .Yes Ladies
on November11 2014 we will be completing a year of successful operation. In view of this momentous
occasion we will be organising a technical training programme for education of Final year postgraduates of
various medical colleges in the latest advances in cosmetology. As part of our social conscience we will also
be conducting awareness programmes in various schools and colleges on common dermatological
problems.
Needless to say that our anniversary programme will have excellent speakers from the fields of both
Dermatology and Rheumatology speaking on topics of clinical interest.
I take this opportunity to thank each and every member of the executive committee for their unstinting
hard work and enthusiastic support which has made SOLID what it is today.
I once again warmly welcome each and every one of you to the events which are to take place in the coming
months.
Long Live Solid
Regards,
Dr Shobana S.
Editor’s Note:
Dear colleagues,
As clinicians, we must hone our diagnostic skills towards perfection.
However, skilled or knowledgeable a clinician is, or has impeccable bedside manners, without a working
diagnosis, or at least a differential diagnosis, she will flounder in therapy. Although a strong academic
foundation is power, without a systematic and orderly approach, a diagnosis may remain elusive.
Diagnosis however, is only the beginning of practice and the healing process follows.
Let us, through our academic interactions, become better diagnosticians and thence better doctors!
Warm regards,
Dr. Parvathi Padmanabhan
Hair loss
The SOLID meeting started with very crisp but informative talk by Dr. T.K. Sumathy MD, MNAMS.,
Senior Professor of Dermatology, M.S.Ramaiah Medical College & Senior Consultant MS Ramaih Memorial
Hospital, about the evaluation and management of hair loss in women.
She started with classification of hair loss in women as
I. Telogen effluvium- acute and Chronic Diffuse Telogen Hair Loss (CDTHL) and Chronic Telo
gen Effluvium (CTE).
II. Female Pattern Hair Loss (FPHL)
III. Anagen effluvium
IV. Loose anagen hair syndrome
I. Telogen Effluvium: It could be due to
•
•
•
•
•
Immediate anagen release (eg: severe illness, stress, drugs)
Delayed anagen release (eg: T.Gravidarum, Post OCP, prolonged minoxidil therapy
Immediate telogen release (short telogen)
Delayed telogen release
Short anagen syndrome- idiopathic shortening of anagen
a. Chronic Diffuse Telogen Hair Loss: This could be due to
•
•
•
•
•
•
•
Secondary to thyroid (hyper 50%)
Iron deficiency
Zinc deficiency
Chronic malnutrition
HIV
Auto immune disease
Malignancy and drugs.
Of all these, iron deficiency anemia has better outcome, which can be diagnosed by performing tests like
¾¾
¾¾
¾¾
¾¾
¾¾
Ferritin (> 70 ng/ml)
Erythrocyte Zinc Protoporphyrin Concentration and
Transferrin Saturation
Crash dieting <0.8 gm of protein
Protein< 1200 K cal/day
With drugs, hair fall starts 6-12 weeks after starting
b. Chronic Telogen Effluvium: Primary Idiopathic
‰‰
‰‰
‰‰
‰‰
‰‰
Affects middle aged women.
Shortening of anagen will be seen
Clinically short regrowing hair in fronto temporal areas
Hair pull test positive.
Before concluding CTE, CDTHL should be ruled out.
II.Female Pattern Hair Loss (FPHL)
‹‹
‹‹
‹‹
‹‹
‹‹
‹‹
‹‹
It is characterized by reduction in hair density over crown, frontal scalp but retention of hairline.
It begins any time after puberty.
Duration of anagen is dramatically shortened to few months.
Other features of hyperandrogenisim are also seen.
Clinically, it is divided into
IStage 1: Widening of midline portion
Stage 2: Christmas tree pattern of widening
Stage 3:Vertex is practically bald, however the frontal hairline is intact.
A detailed history of menstruation, signs of hyper androgenesis, whether on OCP etc., should be noted.
FPHL should be evaluated by
))Non invasive techniques like
• Questionnaire
• 60 ‘s hairs per quadrant
• Hair wash test
• Trichoscopy
• Global Photography
• Dermoscopy and
• Video Dermoscopy
))Semi invasive- trichogram
))Invasive-scalp biopsy shows
• Miniaturization of terminal hairs
• Streamers
• Telogen hair 15- 20%
• Perifollicular Lympho Histiocytic infiltration
• Fibrosis( poor progress)
))In dermoscopy, shows
• Hair with different diameters
• Brown halo at follicular ostium
• Scalp pigmentation
))Role of trichoscopy
• Hair Diameter <30 microns in Vellus hair
• Unlike AGA, 20% hair diameter variability is seen in CTE
ÍÍ Investigations
99 Standardised hair count. Third day shampoo more than 50 hair fall is Telogen Effluvium.
99 Hair pull test. In 60 hair per quadrant less than 10 hair fall is normal. More than 10 is Telogen Effluvium.
99 Trichogram and Phototrichogram. 50 to 100 hair pulled with clamp showing more than 25% Telogen
hairs is Telogen Effluvium.
99 Telogen.
99 Phototrichogram.
99 Dermoscopy. In Acute Telogen Effuvium short regrowing hair seen. In chronic Telogen Effluvium
< 20% diameter variation is seen which differentiates it from Female pattern hair loss.
99 CTE- <20% diameter variation differentiate it with FPHL
ÚÚ Lab Tests
•
•
•
•
•
•
•
•
•
Complete Blood Count (CBC)
S.Ferritin
S. Iron / TIBC
T3, T4, TSH, anti – TPO
S. testosterone
Sex Hormone Binding Globulin (SHBG)
S. Prolactin
ANA profiling
SVDRL TEST
³³ SPECIFIC TREATMENT
※※
※※
※※
※※
Diet
Iron : Maintain Serum Ferritin at 40 -70 micro g/dl
60 mg elemental iron – 3-4 times a day
If it is not improving, start 2% minoxidil.
Topical Agents
For Hair Growth
Promotion
Introduction
Hair loss is a common dermatological compliant of the patients which affects them both physically and
psychologically. Many different causes for hair loss, such as telogen effluvium and alopecia areata, androgenetic
alopecia (AGA), i.e., male pattern hair loss and female pattern hair loss exist. Of this AGA is the most prevalent
form in both men and women. Because of its considerable psychological impact many patients actively search
for new treatments.
Topical Treatments:
1. Minoxidil:
zz Minoxidil is the current standard treatment for hair loss.
zz Minoxidil is an adenosine-triphosphate-sensitive potassium channel opener reported to stimulate the
production of vascular endothelial growth factor, a possible promoter of hair growth.
zz Minoxidil prolongs duration of anagen of the hair cycle and increases miniaturized hair follicle size in
addition to its significant ability to maintain and thicken preexisting hair.
zz This treatment is life-long and stopping minoxidil will shed all minoxidil-dependent hair growth
within 4 to 6 months.
zz The recommended dosing of either 2% or 5% minoxidil solution is twice daily application of 1 ml
(25 drops) spread evenly over the entire top of the dry scalp.
zz For the 5% foam formulation, half a capful is applied twice daily on the dry scalp and left in place for
at least 4 hours.
zz To minimize the risk of hypertrichosis of the face, especially in women, hands should be washed with
warm water after application. Minoxidil has a well-established safety profile.
zz Adverse effects are very infrequent and include skin irritation, contact dermatitis, facial hypertrichosis,
scale, dryness, tachycardia, and transient increased hair shedding, which is more prominent in the first
4 weeks and results from induction of anagen from the resting phase.
This may be viewed as an indication of minoxidil’s efficacy, as such; patients should be advised to
continue with treatment even if this side effect occurs.
)) Constituents of the vehicle (e.g., propoylene glycol and minoxidil) can cause irritant contact dermatitis,
allergic contact dermatitis, or exacerbation the 5% of seborrheic dermatitis, which are more common
with solution.
)) The side effect of hypertrichosis is more frequently seen in female patients who already have hirsutism.
It mostly affects the forehead, malar areas and sides of the face, but is totally reversible with cessation
of the drug.
Minoxidil has been assigned to pregnancy category C.
))
zz
1. Prostaglandins:
Latanoprost and bimatoprost are prostaglandin analogue eye drops to stimulate eyelash growth in alopecia
areata. Erythema at the application site was observed with these prostaglandin analogues. Bimatoprost may
eventually be more effective at the right titrated concentration.
2. Fluridil:
zz Fluridil is a synthetic novel topical antiandrogen.
zz Fluridil is a highly hydrophobic, systemically non-resorbable compound that demonstrates local
tolerance and degrades into inactive metabolites without systemic antiandrogenic effects.
zz Sexual function, libido, hematology and blood chemistry values were normal over the duration of the
investigation.
zz Fluridil is being used throughout Europe but is still awaiting approval in the US.
3. Ketoconazole:
Ketoconazole is an imidazole antifungal agent known to be effective for the treatment of seborrheic
dermatitis and dandruff.
4. Spironolactone:
zz Spironolactone is an aldosterone receptor blocker that reduces enzyme activity in the biosynthesis of
testosterone
zz Female patients with AGA, topical spironolactone 1% was found to be effective in promoting hair
growth without hypotonia or hormonal disorders.
5. Melatonin:
zz Melantonin has long been known to modulate hair growth.
zz Melatonin stimulates the anagen phase of hair growth.
6. Estrogens:
zz Systemic estrogens increase production of the glycoprotein sex hormone-binding globulin (SHBG),
leading to a decrease in free testosterone.
zz More studies validate the use of topical estrogens in AGA.
7. Topical Steroids:
zz Topical steroids include fluocinolone acetonide cream, fluocinolone scalp gel, betamethasone valerate
lotion, clobetasol propionate ointment, dexamethasone in a penetration-enhancing vehicle and
halcinonide cream.
8. Intralesional corticosteroids:
zz Intralesional corticosteroids are the first-line treatment in localized conditions involving
zz <50% of the scalp. Hydrocortisone acetate (25mg/ml) and Triamcinolone acetonide (5-10mg/ml) are
commonly used.
zz Triamcinolone acetonide is administered usually in the concentration of 5mg/ml using a 0.5 inch long
30-gauge needle in multiple 0.1 ml injections approximately 1 cm apart.
9. Anthralin:
zz Dithranol (anthralin) or other irritants have been used in the treatment of alopecia areata.
zz The exact mechanism of action is unknown, but is believed to be through immunosuppressant and
anti-inflammatory properties with the generation of free radicals.
zz
zz
zz
It is used at concentrations ranging from 0.5 to 1 % for 20-30 minutes after which the scalp should be
washed with shampoos in order to avoid excessive irritant effects.
The applications are made initially every other day and later on daily.
Adverse effects include pruritus, erythema, scaling, staining of treated skin and fabrics, folliculitis,
and regional lymphadenopathy 26-27. In an open study, 25% patients with severe alopecia areata were
shown to respond positively to local applications of 0.5-1% anthralin. More placebo control studies are
needed to justify the use of anthralin in alopecia areata.
10. Topical immunotherapy:
zz Topical immunotherapy is the best documented treatment so far for severe and refractory cases of
alopecia areata.
zz Topical immunotherapy is defined as the induction and periodic elicitation of allergic contact dermatitis
by applying a potent contact allergen33.
zz In 1965, the alkylating agent triethyleneimino benzoquinone was the first topical sensitizer used to
treat cutaneous disease, but it was abandoned on account of its mutagenic potential.
zz Later nitrogen mustard, poison ivy, nickel, formalin, and primin were tried, mainly as topical
immunotherapy, for alopecia areata and warts.
zz Contact immunotherapy was introduced in 1976, by Rosenberge and Drake.
zz Later, potent contact allergens namely dinitrochlorobenzene (DNCB) and diphenylcyclopropenone
(DPCP) replaced the allergens that were used earlier33.
zz DNCB is mutagenic against Salmonella tymphimurium in the Ames test and is no longer used Neither
SADBE, nor DPCP are mutagenic. DPCP is more stable in solution and is usually the agent of choice.
11. Proanthocyanidins:
zz Proanthocyanidins extracted from grape seeds promote proliferation of hair follicle cells.
zz Copper peptides are also widely used in hair products, because they are said to inhibit the production of
dihydrotestosterone (DHT), the main cause of thinning hair, as well as enlarge hair follicles, promoting
growth.
12. Saw palmetto:
zz An extract of saw palmetto berries may block 5-alpha-reductase, an enzyme that converts testosterone
to DHT.
zz DHT is the molecule responsible for hair loss, and also is involved in the enlargement of the prostate.
zz Saw palmetto comes in several different forms, including
¾¾ Whole dried berries
¾¾ Tablets
¾¾ Liquid extracts
¾¾ Powdered capsules
13. Biotin:
zz Biotin is a naturally occurring B-vitamin (vitamin B7).
zz Biotin does not stimulate new hair growth.
zz It renews the follicles and roots of the hairs that are already growing.
zz It results in thicker, fuller & much healthier hair.
14. Revivogen:
zz This topical treatment claims to be very successful at inhibiting the 5-alpha reductase enzyme, which converts
testosterone into DHT.
15. Crinagen:
zz This topical scalp spray is noted for being completely natural.
zz It contains no alcohol and has displayed no side effects.
zz Crinagen is also equally safe for men and women.
zz The product’s two most main ingredients are Proanthocyanidins and azelaic acid.
zz The manufacture alleges that both of these ingredients reduce DHT content and nourish the scalp’s hair
follicle.
16. Tricomin:
zz Tricomin, which is used by men and women, is a topical spray that has undergone a wide variety of scientific
testing.
zz The spray’s main ingredient is copper, which has been proven to be beneficial for hair.
zz The FDA has conducted some clinical studies, with the subjects applying the treatment twice per day for 24
weeks.
zz These results were shown to be very positive.
zz Besides the spray, Tricomin is available as a shampoo and condition.
Reference:
I. Omar S. Shamsaldeen, MD1, Thamer AI Mubki, Topical Agents for Growth Promotion.
Photo Corner
S
O
L
I
D
A
u
g
1
4