Describe the key data for the management of onychomycosis with a focus on topical treatment options

Identify patients for the management of onychomycosis

Discuss strategies to optimize care for patients with onychomycosis 

Targeting Onychomycosis with Topicals: Treat to Terminate: Online CME Activity

Hair and Nails

THURSDAY, Nov. 21, 2024 (HealthDay News) -- Consensus has been reached for 76 items relating to low-dose oral minoxidil (LDOM) treatment for patients with hair loss, according to a statement published online Nov. 20 in JAMA Dermatology.Yagiz Matthew Akiska, from the George Washington University School of Medicine &amp; Health Sciences in Washington, D.C., and colleagues created an expert consensus statement for LDOM prescribing for patients with hair loss. Forty-three hair loss specialist dermatologists from 12 countries participated in a modified Delphi process, which started with 180 items in the first round. Seventy-six items achieved consensus, which was reached if at least 70 percent agreed or strongly agreed. The authors noted that these items included diagnoses for which LDOM may provide direct or supportive benefit, indications for LDOM versus topical minoxidil, dosing for adults and adolescents, contraindications, precautions, baseline evaluation, monitoring, adjunctive therapy, and specialty consultation. Consensus was not achieved for pediatric use and dosing items for children younger than 12 years or for LDOM titration protocols."This consensus statement contributes substantially to the current understanding of LDOM prescribing for patients with hair loss, providing a solid foundation for clinical practice," the authors write. "These consensus recommendations serve as a crucial reference for dermatologists treating patients with hair loss, offering best-practice insights into LDOM prescribing until further data emerge."Several authors disclosed ties to the pharmaceutical, skin care, and medical technology industries.<a target="_blank" rel="noopener noreferrer" href="https://jamanetwork.com/journals/jamadermatology/article-abstract/2826573">Abstract/Full Text (subscription or payment may be required)</a>

Seventy-six items achieved consensus, including indications for LDOM versus topical minoxidil, dosing for adults and teens, contraindications

Consensus Statement Issued for Low-Dose Oral Minoxidil for Hair Loss

WEDNESDAY, Sept. 25, 2024 -- The robotic hair technology ARTAS is effective and safe for selecting hair follicular units (FUs) and harvesting hair for treatment of male androgenetic alopecia (AGA), according to a study published online Sept. 19 in the Journal of Cosmetic Dermatology.Yifei Zhu, from the Shanghai Institute of Dermatology at Fudan University, and colleagues compared efficacy and safety between the ARTAS system and follicular unit excision (FUE) for treatment of male AGA. The study enrolled 13 Chinese male patients with Norwood-Hamilton II to IV AGA aged 25 to 35 years. For each patient, the donor site was randomly divided into left and right regions, one of which received ARTAS and the other FUE. The yield, transection, and discard rates of hair FUs were compared for both sides.The researchers found that the total yield rate was lower on the ARTAS side versus the FUE side (82.05 versus 90.03 percent), but the difference was not significant. The total discard rate was significantly higher on the ARTAS side (10.71 versus 5.46 percent), while the total transection rate was lower, but not significantly so (13.17 versus 13.96 percent). There were no significant differences noted in patient satisfaction. During or after all surgeries, there were no side effects or complications reported."While the yield rate is lower in ARTAS (not statistically significant), the transection rate is lower," the authors write. "Clinically, this means that follicles once successfully harvested by ARTAS have a higher chance to be of higher quality compared to FUE counterparts."

Total yield rate lower, but not significantly so, on ARTAS side, and total transection rate also lower

Robotic Hair Transplant Technology ARTAS Found to Be Safe, Effective

MONDAY, May 20, 2024 (HealthDay News) -- Individuals with BRCA1-associated protein (BAP1) have a high rate of nail abnormalities consistent with onychopapillomas, according to a study published online May 17 in JAMA Dermatology to coincide the annual meeting of the Society for Investigative Dermatology, held from May 15 to 18 in Dallas.Alexandra Lebensohn, from the National Institutes of Health in Bethesda, Maryland, and colleagues examined the prevalence of nail abnormalities in individuals with pathogenic germline variants in BAP1 in a prospective cohort study. Data were included for 47 participants, aged 13 to 72 years, from 35 families.The researchers found that 41 patients (87.2 percent) had nail abnormalities, including leukonychia, splinter hemorrhage, onychoschizia, and distal nail hyperkeratosis. Overall, 39 patients (83.0 percent) had clinical findings consistent with onychopapilloma, including 35 of 40 individuals aged 30 years or older (87.5 percent). Five patients underwent nail bed biopsy, which was consistent with onychopapilloma. In nearly all patients with nail involvement (38 of 39 [97.4 percent]), polydactylous involvement with onychopapillomas was detected."Given the uncertain biologic potential of the nail lesions, clinical photography and periodic observation is prudent to monitor lesions, and patients should be advised to return for reevaluation if a significant change occurs in the nail or nail pain develops," the authors write.<a target="_blank" rel="noopener noreferrer" href="https://jamanetwork.com/journals/jamadermatology/fullarticle/2819036">Abstract/Full Text</a>

Almost all patients with nail involvement had polydactylous involvement with onychopapillomas

Individuals With BAP1 Have High Rate of Nail Abnormalities

MONDAY, Dec. 11, 2023 (HealthDay News) -- An educational intervention targeted at barbers substantially increases knowledge regarding the causes, prevention, and treatment of pseudofolliculitis barbae (PFB), according to a research letter published online Dec. 6 in JAMA Dermatology.Xavier Rice, M.D., from the University of Texas Medical Branch in Galveston, and colleagues evaluated the effectiveness of an educational intervention as a pilot for allyship between barbers and dermatologists to address gaps in PFB care. Forty barbers were surveyed before and after an intervention, which included a comprehensive educational pamphlet on the recognition, cause, prevention, and treatment of PFB, as well as common myths and home remedies.The researchers found that before the intervention, there was near unanimous participant understanding (97.5 percent) that Black men were the group most affected by PFB and that severe forms of PFB should be evaluated by a physician. Yet, only 30 percent of barbers correctly identified the PFB photograph in the pretest survey compared with 97.5 percent in the posttest survey. In the posttest survey, 92.5 percent of barbers recognized laser hair removal as the most effective treatment for PFB, versus only 5 percent pretest."Educating barbers on dermatologic conditions that disproportionately affect Black males and establishing referral services between barbers and dermatologists could serve as plausible interventions," the authors write.

Educational intervention successfully increased barbers’ knowledge of causes, prevention, and treatment

Barbers Can Partner With Dermatologists to Augment Pseudofolliculitis Barbae Care

WEDNESDAY, Dec. 13, 2023 -- For patients with nail unit cutaneous squamous cell carcinoma (cSCC), Mohs micrographic surgery (MMS) results in a localized recurrence rate (LRR) of 1.7 percent, according to a research letter published online Dec. 1 in the Journal of the American Academy of Dermatology.Surya A. Veerabagu, M.D., from the University of New Mexico in Albuquerque, and colleagues reported LRRs for the largest single-institutional cohort of MMS-treated nail unit cSCC. Cases included invasive and in situ cSCC (cSCCis) localized to the nail unit; 101 patients with 117 distinct nail unit cSCC and cSCCis were included in the analysis.The researchers found that during a mean follow-up of 2.5 years, the LRR was 1.7 percent (2/117). Dermatologists identified both local recurrences, which occurred in immunocompromised transplant recipients (bone marrow and renal). The Kaplan-Meier LRRs at one and five years were 1.00 and 2.12 percent, respectively. Reconstructions were performed by a Mohs surgeon and plastic surgeon in 53.8 and 46.2 percent of cases, respectively. Full-thickness skin graft, second intention healing, and amputation with local volar flap were the most common reconstructions (34.2, 27.4, and 17.1 percent, respectively). For patients undergoing amputation, MMS helped ascertain soft tissue and/or bony involvement, which aided with the decision to perform partial or full amputation; LRR in this subgroup was 0 percent."This large retrospective cohort supports the growing use of MMS to lower LRR for nail unit cSCC," the authors write.

Kaplan-Meier localized recurrence rate at one and five years 1.00 and 2.12 percent in cohort of MMS-treated patients

Mohs Linked to Low Recurrence in Nail Unit Squamous Cell Carcinoma

In a study published online Aug. 31 in
 
 JAMA Dermatology
 
 , the authors expand the genotypic spectrum of uncombable hair syndrome (UHS) and identify pathogenic variants in
 
 PADI3
 
 ,
 
 TCHH
 
 , and
 
 TGM3.
 




 F. Buket Basmanav, Ph.D., from the University of Bonn in Germany, and colleagues examined the genetic spectrum of UHS in a cohort study including 107 unrelated index patients with a suspected diagnosis of UHS and their family members who were recruited worldwide from January 2013 to December 2021.




 The researchers found that in 80 of 107 index patients (74.8 percent) who carried biallelic pathogenic variants in
 
 PADI3
 
 ,
 
 TGM3
 
 , or
 
 TCHH
 
 (i.e., genes that encode functionally related hair shaft proteins), the genetic characteristics were established. The molecular genetic findings from 11 of these patients have already been published. The UHS phenotype was associated with pathogenic variants in
 
 PADI3
 
 in 76 patients (71.0 percent). Of the 152 variant
 
 PADI3
 
 alleles, 73 and 57 (48.0 and 37.5 percent) were accounted for by the two most commonly observed variants. Two individuals harbored variants in
 
 TGM3
 
 , and pathogenic variants in
 
 TCHH
 
 were seen in two others. A founder effect was suggested in haplotype analyses for the four most commonly observed pathogenic variants in the
 
 PADI3
 
 gene.




 "This cohort study extends and gives an overview of the genetic variant spectrum of UHS based on molecular genetic analyses of the largest worldwide collective of affected individuals, to our knowledge," the authors write. "Formerly, a diagnosis of UHS could only be made by physical examination of the patient and confirmed by microscopical examination of the hair shaft. The discovery of pathogenic variants in
 
 PADI3
 
 ,
 
 TCHH
 
 , and
 
 TGM3
 
 may open a new avenue for clinicians and affected individuals by introducing molecular diagnostics for UHS."




 One author disclosed financial ties to the pharmaceutical industry.




 <a class="rm-stats-tracked" href="https://jamanetwork.com/journals/jamadermatology" target="_blank">
 Abstract/Full Text (subscription or payment may be required)
 </a>

Genetic Spectrum of Uncombable Hair Syndrome Described

Congenital and congenital-type nail matrix nevi (NMN) have clinical and dermatoscopic features similar to those observed in adult subungual melanoma, according to a study published in the September issue of the
 
 Journal of the American Association of Dermatology
 
 .




 Félix Pham, M.D., from Centre Hospitalier Lyon Sud in France, and colleagues describe the initial clinical and dermatoscopic features of NMN appearing at birth or after birth but before age 5 years (congenital and congenital-type, respectively) using data collected from 102 hospitals or private medical offices across 30 countries from 2009 to 2019.




 The researchers identified 69 congenital and 161 congenital-type NMNs. An irregular pattern of longitudinal microlines (64 percent) was displayed by congenital and congenital-type NMN, reminiscent of subungual melanoma in adults. The distal fibrillar pattern was present in 27.8 percent of patients, which was encountered more frequently in congenital than in congenital-type NMN. Compared with congenital-type NMN, congenital NMN more frequently displayed a periungual pigmentation and Hutchinson's sign.




 "Further studies of the cohort will focus on the evolutive characteristics of these lesions and hopefully will help us to better define management guidelines," the authors write.




 <a class="rm-stats-tracked" href="https://www.jaad.org/article/S0190-9622(22)00158-X/fulltext" target="_blank">
 Abstract/Full Text (subscription or payment may be required)
 </a>

Congenital and congenital-type nail matrix nevi predominantly display irregular pattern of longitudinal microlines

Features of Congenital Nail Matrix Nevi Similar to Adult Subungual Melanoma

About half of postmenopausal women experience female pattern hair loss (FPHL), according to a study published online Feb. 14 in
 
 Menopause
 
 .




 Sukanya Chaikittisilpa, M.D., from Chulalongkorn University and King Chulalongkorn Memorial Hospital in Bangkok, Thailand, and colleagues assessed the prevalence of FPHL in healthy postmenopausal women. The analysis included 178 postmenopausal women (aged 50 to 65 years).




 The researchers found that the prevalence of FPHL was 52.2 percent. FPHL severity, as measured by Ludwig classification, was 73.2 percent for grade I, 22.6 percent for grade II, and 4.3 percent for grade III. Age, time since menopause, and body mass index (BMI) were all significantly associated with FPHL, but when adjusting for age and family history of FPHL, only BMI ≥25 kg/m
 
 2
 
 was significantly associated with FPHL (adjusted odds ratio, 2.65).




 "Female pattern hair loss was prevalent and associated with lower self-esteem in healthy postmenopausal women in this small cross-sectional study," Stephanie Faubion, M.D., medical director of the North American Menopause Society, said in a statement. "A better understanding of the mechanisms responsible for this common type of hair loss in women may lead to more effective preventive strategies and treatment options."




 <a class="rm-stats-tracked" href="https://journals.lww.com/menopausejournal/Abstract/9000/Prevalence_of_female_pattern_hair_loss_in.96812.aspx" target="_blank">
 Abstract/Full Text (subscription or payment may be required)
 </a>








 <a href="https://consumer.healthday.com/u/physiciansbriefingstaff">
 <img alt="HealthDay" src="https://assets.rbl.ms/23636171/origin.png" style="max-width: 150px;"/>
 </a>

Female Pattern Hair Loss Common During Menopause Transition

In episode 22 of Cutaneous Miscellaneous, our host, Nicholas Brownstone, MD, speaks with Hannah Kopelman, DO, a fellowship-trained physician in hair loss disorders and the host of the popular Derm Club podcast.

In episode 22 of Cutaneous Miscellaneous, our host, Nicholas Brownstone, MD, speaks with Hannah Kopelman, DO, a fellowship-trained physician in hair loss disorders and the host of the popular Derm Club podcast. The episode focuses on hair loss. Dr Brownstone and Dr Kopelman discuss board review tips, keys to diagnosis, counseling pearls, treatment options, and many other high-yield pearls for the following nonscarring and scarring hair diseases: androgenetic alopecia, telogen effluvium, alopecia areata, lichen planopilaris/front fibrosing alopecia, and central centrifugal cicatricial alopecia.&nbsp; This is a great episode to help review important board review facts on hair loss while providing clinical tips you can start using in the clinic tomorrow for patients with hair loss.&nbsp; <a target="_blank" rel="noopener noreferrer" href="https://dermsquared.com/resources/biologics-and-jak-charts">Click this link to access the JAK Inhibitors Quick Reference Sheet</a>, which includes key information (eg, dosage and lab monitoring) on the FDA-approved JAK inhibitors for the treatment of alopecia areata. &nbsp;Cutaneous Miscellaneous Boards Booster!In this new feature, we’ll put your knowledge to the test with high-yield board review questions written by dermatology residents and fellows and sourced from key resources like Bolognia’s Dermatology, Andrews’ Dermatology, and Alikhan’s Review of Dermatology. These quiz questions will test your skills on the board review topic that’s discussed in each episode.<a target="_blank" rel="noopener noreferrer" href="https://www.research.net/r/P5HRMXK?Email=[Email_value]"> Click here to get begin</a>.

Hannah Kopelman, DO

Cutaneous Miscellaneous Podcast

Hair Loss Hotline 

In Episode 5 of&nbsp;Cutaneous Miscellaneous, our host Nicholas Brownstone, MD, talks with Dawn L. Sammons, DO, Program Director at Ohio Health Dermatology Residency.&nbsp; The episode begins with board review prep on hair loss. The following disorders are discussed: androgenetic alopecia, alopecia areata, CCCA, and lichen planopilaris. &nbsp;

Sponsored by: <a target="_blank" rel="noopener noreferrer" href="https://castletestinfo.com/"><img style="height:auto;margin-left:10px;max-width:250px;" src="https://fchealth-assets.s3.amazonaws.com/castle-fc-podcast-page.png" alt=""></a> In Episode 5 of&nbsp;Cutaneous Miscellaneous, our host Nicholas Brownstone, MD, talks with Dawn L. Sammons, DO, Program Director at Ohio Health Dermatology Residency.&nbsp; The episode begins with board review prep on hair loss. The following disorders are discussed: androgenetic alopecia, alopecia areata, CCCA, and lichen planopilaris. &nbsp; The remainder of the episode discusses how to learn and teach as a dermatology resident effectively. For junior dermatology residents, Dr. Sammons gives tips on absorbing the vast amount of information required when starting a dermatology residency. She specifically discusses successful learning methods and how to best integrate academic knowledge with clinical skills. For senior residents, Dr. Brownstone asks Dr. Sammons how they can best teach and mentor junior dermatology residents and medical students and how to give effective feedback. The episode ends with a few pointers on teaching patients about their diagnoses.&nbsp; The learning and teaching tips offered in this episode are useful for all 3 years of dermatology residency and beyond!

Learning and Teaching as a Dermatology Resident

In this episode of Derms &amp; Conditions, James Q. Del Rosso, DO gleans up-to-date practical information on hair loss from Natasha Mesinkovska, MD, PhD, based on her extensive clinical and research experience in&nbsp;this area of dermatology.

In this episode of Derms &amp; Conditions, James Q. Del Rosso, DO gleans up-to-date practical information on hair loss from Natasha Mesinkovska, MD, PhD, based on her extensive clinical and research experience in this area of dermatology. Several entities and challenges are discussed with tips on both diagnosis and management.&nbsp; The latter half focuses on alopecia areata, including its relationships to both atopy and autoimmune disease. The episode concludes with how Dr. Mesinkovska integrates oral JAK inhibitors into her management plan. This discussion is loaded with pearls! FINANCIAL DISCLOSURES: James Q. Del Rosso, DO CONSULTANT/ADVISOR Abbvie, Aclaris, Almirall, Amgen, Arcutis, Bausch Health (Ortho Dermatology), BioFrontera, BioPharmX, Bristol-Myers-Squibb, Cassiopea, Dermata, Dermavant, Encore, EPI Health, Evommune, Ferndale, Galderma, Incyte, JEM Health, Leo Pharma, La Roche Posay, Lilly (Dermira), MC2, Novan, Pfizer, Regeneron, Sanofi-Genzyme, SolGel, Sonoma (IntraDerm), Sun Pharma, Trevi, UCB, Verrica, Vyne (Foamix; Menlo) SPEAKER BUREAU Aclaris, Almirall, Amgen, Arcutis, Bausch Health (Ortho Dermatology), EPI Health, Ferndale, Galderma, Genentech, JEM Health, Leo Pharma, La Roche Posay, Lilly (Dermira), Pfizer, Regeneron, Sanofi-Genzyme, Sun Pharma, UCB, Verrica, Vyne (Foamix; Menlo) RESEARCH INVESTIGATOR Aclaris, Almirall, Amgen, Anaptys Bio, Arcutis, Athenex, Bausch Health (Ortho Dermatology), BioPharmX, Biorasi, Botanix, Brickell, Cara Therapeutics, Cassiopea, Dermavant, EPI Health, Ferndale, Galderma, Incyte, Leo Pharma, Lilly (Dermira), Novan, Pfizer, Ralexar, Regeneron, SolGel, Sun Pharma, UCB, Verrica, Vyne (Foamix; Menlo).

Derms and Conditions Podcast

Tying Up The Loose Ends With Managing Hair Loss: Practical Advice That Will Help Right Now

In this episode, James Del Rosso, DO and Dawn Sammons, DO discuss&nbsp;frequently&nbsp;encountered clinical challenges in everyday practice with patients including chronic hair loss in women, application of topical lovastatin and cholesterol for&nbsp;Porokeratosis, and more.

In this episode, James Del Rosso, DO and Dawn Sammons, DO discuss&nbsp;frequently&nbsp;encountered clinical challenges in everyday practice with patients including chronic hair loss in women, application of topical lovastatin and cholesterol for&nbsp;Porokeratosis, and more. 
Financial Disclosures:
James Del Rosso, DO:
CONSULTANT/ADVISOR Abbvie, Aclaris, Almirall, Amgen, Arcutis, Bausch Health (Ortho Dermatology), BioFrontera, BioPharmX, Bristol-Myers-Squibb, Cassiopea, Dermata, Dermavant, Encore, EPI Health, Evommune, Ferndale, Galderma, Incyte, JEM Health, Leo Pharma, La Roche Posay, Lilly (Dermira), MC2, Novan, Pfizer, Regeneron, Sanofi-Genzyme, SolGel, Sonoma (IntraDerm), Sun Pharma, Trevi, UCB, Verrica, Vyne (Foamix; Menlo)
SPEAKER BUREAU Aclaris, Almirall, Amgen, Arcutis, Bausch Health (Ortho Dermatology), EPI Health, Ferndale, Galderma, Genentech, JEM Health, Leo Pharma, La Roche Posay, Lilly (Dermira), Pfizer, Regeneron, Sanofi-Genzyme, Sun Pharma, UCB, Verrica, Vyne (Foamix; Menlo)
RESEARCH INVESTIGATOR Aclaris, Almirall, Amgen, Anaptys Bio, Arcutis, Athenex, Bausch Health (Ortho Dermatology), BioPharmX, Biorasi, Botanix, Brickell, Cara Therapeutics, Cassiopea, Dermavant, EPI Health, Ferndale, Galderma, Incyte, Leo Pharma, Lilly (Dermira), Novan, Pfizer, Ralexar, Regeneron, SolGel, Sun Pharma, UCB, Verrica, Vyne (Foamix; Menlo). Dawn Sammons, DO:
CONSULTANT/ADVISOR Abbvie, Novartis Pfizer,&nbsp;Lilly, UCB.
SPEAKER BUREAU Abbvie, Novartis Pfizer,&nbsp;Lilly, OrthDermatologics, Sun, Amgen, Janssen.

Untangling Common Challenges in Clinical Practice: Tips You Can Use Right Now with Dawn Sammons, DO

Bridging the Gaps in Nail Disorder Management: New Approaches for Dermatologists 

In this episode of Topical Conversations, Dr Jasmine Rana, Clinical Assistant Professor and Director of the Nail Disorders Clinic at Stanford Dermatology, discusses her recent publication, “<a target="_blank" rel="noopener noreferrer" href="https://jamanetwork.com/journals/jamadermatology/article-abstract/2817885">Nails as Dynamic, Not Static, Entities—Rethinking the Approach to Nail Disorders</a>,” reviewing the practice gaps that exist for nail diseases and offering a few practical takeaways to improve nail disease management.&nbsp;Nail disorders are dynamic&nbsp;Dr Rana emphasizes that nail disorders are not static entities. Instead, they are dynamic, influenced by various coexisting factors that affect nail health. She notes that it is the responsibility of the health care provider to piece these factors together. A key example is diagnosing nail fungus, or onychomycosis. While fungus may be present, it is also crucial to identify other structural influences such as bunions, hammer toes, arthritis, nerve dysfunction, and nail psoriasis, since these factors influence treatment approaches and patient counseling.&nbsp;Recognizing cognitive biases&nbsp;Dr Rana also notes the importance of health care providers recognizing cognitive biases. Many dermatologists are not trained to recognize or treat podiatric disorders; similarly, podiatrists may not be trained to recognize nail psoriasis or conditions like nail lichen planus. Recognizing and addressing these biases can improve diagnosis and treatment.&nbsp;Improving nail disease management&nbsp;Dr Rana emphasizes that nails do not belong neatly to one medical specialty, making interdisciplinary approaches essential for optimal care. She suggests considering interdisciplinary nail clinics staffed by dermatologists, podiatrists, radiologists, vascular doctors, and orthopedic surgeons to provide an opportunity to offer holistic, high-value care.&nbsp;Practical takeaways&nbsp;Acknowledging that establishing interdisciplinary clinics is challenging, Dr Rana proposes a few practical strategies to improve nail disease management:&nbsp;<ul><li>Separate visits for nail concerns: Scheduling separate visits for nail concerns can reduce the stress of addressing multiple issues in one visit, leading to better diagnosis and recognition of nail conditions.&nbsp;</li><li>Championing nail disease in large practices: In large group practices, identifying a specialist with an interest in nail disease can help champion educational initiatives and facilitate referral pathways, promoting cross-specialty collaboration.&nbsp;</li></ul>By implementing these strategies, health care providers can enhance the diagnosis and treatment of nail disorders, ultimately leading to improved patient outcomes.

PRP and Exosomes Hair and Aesthetics

Dr Glynis Ablon kicked off our last full day in Miami with an in-depth discussion of 2 popular treatments in hair aesthetics: platelet-rich plasma (PRP) and exosomes. Both PRP and exosomes can act as adjunct treatments to other procedures including with each other. Differentiating between the 2, PRP is an autologous blood component that harnesses the secretory prowess of activated platelets, specifically the alpha-granules they release, which contain growth factors and various other cytokines involved in angiogenesis, remodeling, coagulation, and inflammation. After extraction, PRP remains stable for about 4 hours. Notably, the FDA does not classify PRP as a human cellular/tissue product, and all systems require a 510(k) clearance to be sold.&nbsp; Exosomes, on the other hand, are endogenous nanoparticles released by stem cells to create phenotypic change via growth factors to enhance healing and collagen synthesis, miRNA to regulate gene expression, and cytokine to invigorate cells. Since they include mRNA and miRNA, they have effects long after that of cytokines and growth factors alone. &nbsp; Exosomes can come purified, which are frozen and contain intact active exosomes, as well as lyophilized in a powder that requires reconstitution, or suspended in a cream. We await studies to demonstrate the integrity of lyophilized exosomes, but they are appealing to consumers in a variety of skin care products. Exosomes also are present in small numbers in PRP and in some plants, though plant-derived exosomes will not bind to human-derived cell receptors and thus efficacy may be limited. Other concerns regarding exosomes include the limited quality control measures, stem-cell sourcing, and the scalability of the extensive and expensive purification process. There also isn’t a set standard for treatment frequency. Unfortunately, as of now, there are few clinical trials involving exosomes related to dermatology, but that may change in 2024.&nbsp;

Nonsurgical Treatment of Hair Loss in 2024

Gary Goldenberg, MD, focused on regenerative techniques in this up-to-date lecture on nonsurgical treatment of hair loss. He started with platelet-rich plasma (PRP), which harnesses the power of platelet products including growth factors, chemokines, and cytokines to promote cell differentiation and proliferation. Specifically, platelet-derived, vascular endothelial, fibroblast, epidermal, insulin-like, and connective tissue growth factors are responsible for these benefits, which explain this treatment’s usefulness in the treatment of androgenetic alopecia. PRP promotes anagen-associated angiogenesis and neovascularization, dermal papilla cell proliferation, and anti-apoptotic effects. The anagen phase of the hair cycle is extended as dermal papilla cells are protected from premature breakdown. Both dosing at 3 monthly sessions with subsequent injections 3 months later or 2 sessions every 3 months lead to statistically significant increases in hair count, though another trial sponsored by a PRP system manufacturer did show increased hair density with monthly injections compared to quarterly. Further, PRP can be effectively used as an adjunct treatment to many other treatments including microneedling and minoxidil.&nbsp; He moved on to discuss exosomes which are vesicles for intercellular communication, and beyond growth factors, enzymes, and chemokines, also contain mRNA and miRNA. In and of themselves, exosomes could be good or bad, but those used in dermatology are often derived from mesenchymal stem cells, conveying messages to develop into various connective tissues supporting regenerative functions. In hair loss, in addition to the benefits from growth factors and chemokines given by PRP, exosomes also promote hair matrix cell proliferation to revitalize degenerative follicles. Other examples of multipotent stem cells sources are umbilical cord blood and adipose tissue. However, the number of multipotent stem cells present in adipose tissue depends on host factors such as age and general health. Harnessing these cells for hair loss could be in the form of inducing the generation of CK19 positive cells and hairlike structures from mesenchymal stem cells. There are a few small trials that have used adipose-derived stem cells for alopecia, but larger randomized controlled trials are needed.

How do you counsel patients on their skincare regimen?

Oftentimes I'm shocked when I see a patient and that patient has seen a dermatologist in the past and has never been counseled on a skincare routine. I think it's basic dermatologic care to counsel our patients on what skincare routine they should be using. Personally, I like to keep it simple. I use the kiss principle. So what do I tell patients to use? I tell them to get a cleanser so they can wash their face morning at night. A moisturizer with sunscreen, that's a must every morning, 365 days a year, a nighttime moisturizer and a retinol. I think if you use those four or five products, that really gets you there 99%. Once patients are used to that routine, you want to layer something on top, you want to add another product or two, that's fine, but you got to get them used to at least having the very basic, which I think in most cases is actually enough if.

What are your options for treating scars in your practice?

You. Treatment of scars can be very challenging, not only for us as practitioners, but also for our patients. When I see a patient with a scar, whether it's a keloid or a surgical scar, the first thing that I do is counsel the patients of the fact that it's impossible to make that scar look like normal skin. One of my mentors in residency used to say that you can't walk through fresh snow without leaving footprints, and once there's a scar, it's there forever. The only thing that we can do is make it look better. In my practice, I really like using the combination of intralesional corticosteroids, if it's a hypertrophic scar or keloid, in combination with laser microneedling with plateletrich plasma, and perhaps a scar revision in the scenario that the scar is a traumatic scar, and cutting it out and revising it and giving a patient a nice lion scar would look better. But again, going back to the basics, make sure you counsel your patients, use the tools at your disposal, and really think about combining all those tools to make the scar look as good as it can.

How do you personalize a patient's skincare routine?

You. I think it's very important that we're specific in recommendations of skincare, and we base those exactly on the patient that's sitting in front of us. Essentially, there are three types of skin that we have to be concerned with. There's dry skin, there's oily skin and combination skin. And you can't give the same products to every patient that has different skin types. So I think it's very important that patients with oily skin, for example, they may need a stronger retinol or maybe a cleanser with salicylic acid, whereas patients with dry skin, that maybe it's eczema prone skin, those patients get more of a moisturizing skincare routine. Not to say that they couldn't use a retinol. We just need to kind of be careful starting it. And for patients with combination skin, I think that's the most challenging. You really may need to use different products in different areas of their skin. So make sure you're customizing your routine, your skincare routine, to the patient's skin type so that not everyone is walking out with exactly same routine.

What is your therapeutic algorithm for treating patients with hair loss?

You. When I see a patient with hair loss and we start discussing therapies, what I explain to the patients is that you really have to do everything in order to optimize your results. And that includes a variety of treatments, including things like supplements and vitamins, including some lifestyle modification, including oral medications, perhaps spernolactone, or even oral minoxidil. It includes topical minoxidil with or without other additives, because you can't have minoxidil compounded with other products, shampoos to strengthen the hair and increase the hair strength so that it's not breaking, because hair breakage in a patient with hair loss can result in appearance of thinner hair. And then there are procedures such as plateletrich plasma injections, as well as other regenerative therapy. And in my practice, since I'm not a hair transplant surgeon, what I tell patients is my job is to try to keep them away from the hair transplant surgeon as much as I can. But when we can't, we certainly discuss that option and offer it. And I think that some of the laser devices are also very helpful. These are things that patients can do in the privacy of their own home. And I think putting all of those things together will optimize your treatment for your patients with hair loss. Thank.

What is the role of nutrition in dermatology?

You. I think nutrition is very important when it comes to counseling patients with dermatologic conditions. One of the most common questions that I get in the office is, doctor, is this condition caused by something that I'm eating or something that I'm not eating? And I follow very, very simple steps when I counsel patients about nutrition. Cut out white sugar, white flour, and dairy. I think those most foods are proinflammatory, and we have pretty good evidence for that. Patients should be counseled to be on a diet that's full of lean proteins, complex carbohydrates, and fruits and vegetables. Keep it simple. Stick to those things. Your patients will thank you. And I think it would really help their inflammatory conditions.

How do you counsel patients with hair loss on their results?

You. Counseling patients with any condition is very important, but I think it's even more so when you're dealing with hair loss. When I see patients with hair loss, it's very important to separate two types of results. One is stopping the hair loss itself. I think patients are very distraught when their hair is coming out, whether it's telogen effluvium or sudden onset of androgenetic alopecia. So just stopping that hair loss process I think is a big win. And then the second part of the process of treatment is trying to regrow some of that hair. And we talk about that when we discuss topical therapies, procedures such as injecting plateletrich plasma or other regenerative therapies or even using oral medications. So set the right expectations from the beginning. Make sure patients understand the difference between stopping the hair loss process versus actually growing hair. And I think with this particular condition, it's very important that you discuss the expectations and set those from the first visit.

Is hair recoverable in pattern hair loss?

You as long as you still have fine or intermediate hairs present, you can oftentimes use medications or other modalities to prolong the antigen time of those hairs. So to understand that, you have to kind of understand what's happening in pattern hair loss. In pattern hair loss, the antigen phase is shortening, so the hair stays on the head less time. So instead of staying on the head five years, it might stay on the head six months or a year or however long it is. But it's shortened and it doesn't have time enough to thicken, increase in diameter and provide density. So if you can use a medication such as oral or topical minoxidil that prolongs antigen and the hair stays on the head longer, it gets larger in diameter and it starts to contribute to density. So in that case, we're not really reversing hair loss such that we're bringing hairs back that weren't there. We're just sort of pushing the hair growth in the opposite direction. Instead of getting smaller, it's getting larger, and therefore your density looks better and the hair looks fuller. So if you're lucky enough to respond to one of the topical, oral, or Prp type injections, then yes, that's going to happen and you're going to have what looks like a reversed hair loss process, but it's really just prolonging of antigen.

How often do you recommend shampooing with seborrheic dermatitis?

You to, that's going to be different depending on the hair type and how you wear your hair. So for african american patients who have sebric dermatitis, especially women, generally, they're not going to wash their hair any more than once weekly. And probably they're going to be, on an average, about every two weeks. So when you have sebric dermatitis, I recommend once weekly because I think that if you can keep your scalp cleansed and minimize the oils that build up and also use a good antidandruff shampoo to the scalp once a week, that helps to take down the itching and the buildup of the scaling, et cetera. So once weekly would be my recommendation at the very least for women of color, for those who can wash their hair every day, and if they don't wash their hair, they get the greasies. You can certainly wash your hair every day. Generally, I recommend that you use anti dandruff shampoos, especially prescription ones, only about three times a week, two to three times a week. So I wouldn't keep using those. They're very harsh on the hair shaft. So I do recommend putting the shampoo on the scalp and using your nice moisturizing shampoo on the hair. So it really does depend on hair type and what your hair style is going to be. But I think that you want to make sure that it makes sense for the patient, because if you tell someone who's an african american woman who wears her hair in a relaxed style to wash her hair every day, she won't follow any of your recommendations. So you really have to know what the hair care practices are before you give that information.

How do you discuss PRP for hair loss with your patients?

PRP or plateletrich plasma has been a mainstay of treatment for androgenetic alopecia and even telogen effluvium in my practice for about six to seven years. One of the objections that patients have to using this treatment is the expense associated due to the fact that it is a chronic treatment. I simply explain to patients that treating hair loss with PRP is no different than any other lifestyle modification, no different than a nutritional or dietary change or going to the gym. When you go to the gym, everything looks the way it should. You stop going, you get back to your baseline. So if your patient has a success with PRP initially, they do need to continue with those treatments. My treatment algorithm is to do once monthly injections for three months, take a three month pause, and then reassess the patient. If the patient is happy and it's a success. We continue with yearly injections twice a year, up to four times a year in some patients. Now, every now and again, somebody will need a booster if they have a new medication or telogen affluvium that's coming through and that's also okay. But the chronicity of the treatment is very important to explain from the get go. So your patients understand that this treatment is for them for as long as they care about their hair loss.

What are your thoughts and dosage of finasteride for androgenetic alopecia in post-menopausal women?

You. Finasteride for treatment of androgenic alopecia is one of my favorite tools. I tend to use it for postmenopausal women in a 2.5 milligram dosage, and sometimes I go up to a five milligram dosage depending on tolerance and any potential side effects. I think it is likely an underused tool, but it's definitely something I have in my armor. Material. When people, when we work them up for other forms of hair loss and we really see that it's mostly androgenic, I feel comfortable using it and usually start at that 2.5 milligram dosage.

Do patients need to be maintained on PRP therapy? If so, how often?

I recommend a series of three treatments, separated out every four to six weeks, and then I have them do one touch up treatment yearly after your last treatment. So you would come in a year after your series for that one touch up.

Can you address potential long term side effects from finasteride after discontinuation?

You. Mostly, we've seen that long term finasteride after discontinuation does not have any long term side effects. The main ones that we get asked about or that have been reported in some recent studies are potential sexual side effects in men. But from what we've seen, the risk of this is incredibly, incredibly low, less than 1% in some studies, 0.1% percent. I do talk people through it, particularly men, but women as well as one of the risks, and that there are some studies that, as I mentioned, show long term issues. But I feel comfortable prescribing finasteride in both men and women and through the process.

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