professor and chair - sec meetings · 2019-09-29 · 157 articles on “hair loss and african...
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Amy McMichael, MD
Professor and Chair
Department of Dermatology
Wake Forest Baptist Health
Winston-Salem, NC SEC 2019
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DISCLOSURE/CONFLICTS OF INTEREST
Investigator
Allergan
Intendis
Procter & Gamble
Samumed
Casseopia
Concert
Alcaris
Incyte
Consultant
Johnson & Johnson
Procter & Gamble
Stiefel
Allergan
Bayer
Galderma
Incyte
Samumed
Aclaris
Anacor
Pfizer
Nutrafol
Bioniz
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157 articles on “hair loss and African Americans” in Pub Med from 1968 – 2019
99 articles on Central Centrifugal Cicatricial Alopecia
101 articles on Pseudofolliculitis barbae
349 Frontal fibrosing alopecia (225 articles in 2017)
4214 articles on alopecia areata
>40,000 articles on psoriasis
> 20,000 articles on atopic dermatitis
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TOP DIAGNOSES IN AFRICAN AMERICAN PATIENT VISITS TO DERMATOLOGISTSNATIONAL AMBULATORY MEDICAL CARE SURVEY 1993-2009
Diagnosis ICD-9 Code No. of Visits % of Visits
Acne 706.1 5,720,000 22.1%
Unspec. dermatitis 692.9 3,640,000 14.0%
Seb dermatitis 690.10 1,990,000 7.7%
Atopic derm 691.8 1,590,000 6.1%
Dyschromia 709.0 1,290,000 5.0%
Psoriasis 696.1 950,000 3.6%
Alopecia 704.00 920,000 3.6%
Keloid scar 701.4 830,000 3.2%
Viral warts 078.1 780,000 3.0%
Sebaceous cyst 706.2 780,000 3.0%
Davis SA, et al. J Drugs Dermatol 2012
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TOP DIAGNOSES IN AFRICAN AMERICAN PATIENT VISITS TO DERMATOLOGISTSNATIONAL AMBULATORY MEDICAL CARE SURVEY 1993-2009
Diagnosis ICD-9 Code No. of Visits % of Visits
Acne 706.1 5,720,000 22.1%
Unspec. dermatitis 692.9 3,640,000 14.0%
Seb dermatitis 690.10 1,990,000 7.7%
Atopic derm 691.8 1,590,000 6.1%
Dyschromia 709.0 1,290,000 5.0%
Psoriasis 696.1 950,000 3.6%
Alopecia 704.00 920,000 3.6%
Keloid scar 701.4 830,000 3.2%
Viral warts 078.1 780,000 3.0%
Sebaceous cyst 706.2 780,000 3.0%
Davis SA, et al. J Drugs Dermatol 2012
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CENTRAL CENTRIFUGAL SCARRING ALOPECIA EPIDEMIOLOGY
▪ Prevalence ranges from 2.7% in 604 South African women to 5.6% in 529 US women1,2
▪ Wide range of clinical severity
▪ Symptoms range from none to severe pruritus and pain
▪ Mostly women of African descent, ages 30-65
▪ Often accompanied by traction alopecia
▪ Pre-dated chemical relaxers
▪ Traction common theme1. Khumalo NP et al, BJD. 2007
2. Olsen EA et al, JAAD. 2011
3. Yolanda Lenzy, personal
communication, AAD 2016
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• Hopkins study of 447 women (0.09%) with a medical history of CCCA were identified, 62 of whom had uterine leiomyomas (ULs)• Women with CCCA have nearly 5 times increased odds of having uterine leiomyomas
compared with race-, age-, and sex-matched controls - Dina et al, JAMA Dermatol 2017
• Microarray data from 5 CCCA patients suggesting upregulation of critical genes implicated in fibroproliferative disorders in the gene expression profile of patients with CCCA – Aguh et al, JAAD 2018
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Central Scalp Alopecia
Photographic Scale
in African American Women
Olsen EA, Callender V, Sperling L,
McMichael A, Anstrom KJ, Bergfeld W,
Durden F, Roberts J, Shapiro J
and Whiting DA— Derm Therapy Vol 21, 2008
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▪ 9 patients with vertex hair breakage
▪ 8/9 with biopsy results
▪ 5 showed typical CCCA changes
▪ 1 showed advanced end-stage scarring alopecia
▪ 2 showed premature desquamation of inner root sheath (suggestive of early CCCA)
▪ Callender V, Wright D, Davis E, Sperling L Arch Dermatol2012
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Tosti and Miteva, Skin Appendage 2015 My patient
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Dermatoscopic evaluation: can be followed with treatment
Perifollicular scale and erythema activity
Significant loss of follicular openings burnt out disease
Miniaturization of hair shafts possible ability to recruit and have regrowth
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▪ 10 women with bx-proven CCCA
▪ Clinical and dermatoscopic photographs obtained from clinically active alopecic site and clinically-unaffected posterior scalp
▪ All 10 patients with histologic changes of CCCA 4 cm below clinical changes
▪ Dermatoscopic findings suggest early changes of CCCA and correlate with path
▪ Dermoscopy may be reliable, less invasive option to visualize CCCA changes
▪ Early treatment in proximal areas may reduce disease severity and improve quality of life for CCCA patients
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▪ Dlova et al, Autosomal dominant inheritance of central centrifugal cicatricial alopecia in black South Africans. JAAD, 2014;70:679-682
▪ 14 index families with 31 immediate family members
▪ Pedigree analysis suggests autosomal dominance
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▪ Collaborative study with U.S. and S. African patients and Genetics group in Israel
▪ 16 patients, identified one splice site and three heterozygous missense mutations in PADI3
▪ PADI3 encodes peptidyl arginine deiminase, type III (PADI3), an enzyme that post-translationally modifies other proteins essential to hair-shaft formation
▪ Uncombable hair syndrome shown in some cases to involve mutations in PADI3- (no alopecia)
▪ Mutations resulted in reduced PADI3 expression, abnormal intracellular localization of the protein, and decreased enzymatic activity
▪ Immunofluorescence staining showed decreased expression of PADI3 in biopsy samples of scalp skin from patients with CCCA
▪ Replication set of 42 patients was directly sequenced. Combining data sets, we found pathogenic variants in 14 out of 58 affected patients (24%).
Liron Malki et al, New England Journal of
Med, Feb 2019
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Stained with anti-PADI3 specific
antibodies
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▪ Retrospective study of patients staged at beginning and end of treatment
▪ Treatment = IL Kenalog, topical steroids, +/- minoxidil
▪ N = 15
▪ After treatment:
▪ 5/15 (33.3%) had decreased severity scores (Improved)
▪ 8/15 (53.3%) had increased severity scores (Worsened)
▪ 2/15 (13.3%) had no change in severity scores
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Discuss Genetic predisposition with patients to increase awareness +/- Biopsy for extent of inflammation/alternate diagnosis Decrease all traumatic styling methods and heat behaviors to vertex scalp
Inflammatory Stage
▪ Moisturizing anti-dandruff shampoos weekly
▪ Decrease inflammation via topical and intralesional corticosteroids
▪ IL Kenalog for 8 rounds with 5.0-7.5 mg/cc for max 3 cc/visit (q 6-8 weeks)
▪ Oral/topical antibiotics for pustular disease
▪ Push treatment until symptom free
Post-inflammatory treatment
▪ Long term topical steroids
▪ Minoxidil solution for prolongation of anagen
▪ Surgical restoration
▪ ?PRP
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Discuss Genetic predisposition with patients to increase awareness +/- Biopsy for extent of inflammation/alternate diagnosis Decrease all traumatic styling methods and heat behaviors to vertex scalp CARF – Cicatricial Alopecia Research Foundation Skin of Color Society short film (www.skinofcolorsociety.org)
Inflammatory Stage▪ Moisturizing anti-dandruff shampoos weekly
▪ Decrease inflammation via topical and intralesional corticosteroids
▪ IL Kenalog for 8 rounds with 5.0-7.5 mg/cc for max 3 cc/visit (q 6-8 weeks)
▪ Oral/topical antibiotics for pustular disease
▪ Push treatment until symptom free
Post-inflammatory treatment▪ Long term topical steroids
▪ Minoxidil solution for prolongation of anagen
▪ Surgical restoration
▪ ?PRP
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▪ Scarring alopecia difficult to treat
▪ Treatment often leads to disappointing outcomes for patients
▪ Idea is to rescue and recruit hairs that are undecided in their fate
▪ Must rescue hairs that are under inflammatory attack but have not succumbed to fibrosis
▪ Stabilization may be the outcome but may see improved density
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Pre-treatment Post-medical treatment Post-surgical treatment
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DINA Y, AGUH C. DERMATOL SURG. 2018
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NIGERIAN WOMANTREATMENT : IL KENALOG AND HAIR RESTORATION
Pretreatment Post-treatment
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Pre-treatment 3 mo/treatment
9 mo/treatment
6 mo weave in
place
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▪ Use your dermatoscope to look for early disease
▪ Discuss known genetics with CCCA patients to encourage family members to share their experience
▪ Manage traction-related hair care practices
▪ Aggressively manage anti-inflammatory treatments
▪ In post-inflammatory stage, use minoxidil (off-label) and continue topical steroids
▪ Follow these patients yearly to ensure stable disease
▪ Refer for surgical restoration in appropriate cases
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THANK YOU FOR YOUR [email protected]
North American Hair Research Society www.nahrs.org
Cicatricial Alopecia Research Foundation www.carfintl.org
National Alopecia Areata Foundation www.naaf.org