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The Truth About Hair Loss And Baldness Cures
Next Avenue | By Laine Bergeson
Posted: 11/08/2014 7:45 am EST Updated: 11/10/2014 2:59 pm EST
Hair loss, common for men and many women in midlife, can have profound emotional and psychological effects. So,
too, can baldness cures advertised as magical remedies.
“There’s this guy, a regular caller on my radio show, who had his head disfigured by a terrible hair transplant,” says
Spencer Kobren, founder and president of the American Hair Loss Association and author of The Bald Truth: The
First Complete Guide to Preventing and Treating Hair Loss. “He purposely became a New York City cop so he could
wear a hat.” And he refused promotions so he could remain a beat cop and keep wearing the hat.
Forty percent of hair loss sufferers are women, and the phenomenon can be particularly devastating for them. “With
men, hair loss in midlife is expected and they can still be seen as attractive,” says Kobren. “But for a woman, it is
over.”
This makes women especially vulnerable to all manner of hair loss “cures,” and the possibility of spending lots of
money, time and emotional investment on ineffective treatments.
“A lot of men are suicidal,” says David Kingsley, author of The Hair Loss Cure. “And it is very traumatic for women. It
affects their social life and their life with their spouse or partner.”
Hair loss treatment is a $3.5 billion industry — as big as the over-the-counter cold and flu market. “But about 99
percent of the treatments don’t work at all,” says Kobren.
So what triggers hair loss in midlife, what really helps and what is nothing but a gimmick?
The Causes of Hair Loss
The most effective treatment for hair loss depends on what is causing hair to fall out in the first place. There are a
variety of reasons men and women lose hair, according to Kingsley. They include:
 Heredity
 Hormones
 Stress
 Poor diet/missing nutrients
 Chemical hair styling services
 Certain medications
 Surgery or high temperature
Sometimes the cause is a combination of factors. One person may lose hair due to a mix of stress and a recent surgery
or medications. Male pattern baldness (MPB), on the other hand, is the result of the intersection of hormones and
heredity, occurring in men who have a genetic sensitivity to the hormone dihydrotestosterone (DHT).
Contrary to popular belief, notes Kingsley, genetic hair loss probably isn’t tied to your mother’s father. “The latest
research indicates girls follow mother’s father, boys follow father’s father,” says Kingsley. “But most likely, it is an
assortment from both.”
The very first step a person should take, says Sophia Emmanuel, a certified trichologist (a professional trained in all
aspects of care and treatment for the head and scalp) in New York City, is to find a dermatologist or trichologist to
help diagnose the root cause of hair loss.
Diagnosis can include blood work to test for nutrient deficiencies, scalp examination (looking at patterns and shapes
of hair loss, possibly a skin biopsy) and gathering medical, lifestyle and family information.
Once you know the cause of hair loss, you can choose targeted treatments that help maintain the hair you do have or
regrow new hair.
Hair Loss Treatments
One hair loss myth, note both Emmanuel and Kingsley, is that all hair loss is permanent. “It’s not,” says Kingsley.
When the cause is nutrient deficiency or stress, for example, the hair loss is typically temporary. In such cases, hair
growth can be encouraged by addressing the underlying problems: working to build up the body’s stores of zinc,
boosting iron levels and better managing stress — though experts note that it may take several months to see
progress.
Genetic hair loss, on the other hand, is largely permanent, as is any type of hair loss triggered by scarring on the scalp,
says Emmanuel. Scarring can be caused by chemical hair styling services or too-tight pony tails, a problem Emmanuel
sees with many African American women who are hair-loss sufferers. She adds that scarring can also be triggered by
some autoimmune disorders.
Women with genetic or autoimmune related hair loss “have very few options” for hair regrowth, says Kobren.
Minoxidil (brand name Rogaine) has been FDA-approved for women in a 2 percent concentration, but it only helps
maintain existing hair and does not promote regrowth.
Kobren encourages women interested in using minoxidil to buy it over-the-counter to save money. Lots of companies
will add minoxidil to expensive shampoos and charge top dollar, he says, when straight minoxidil is available for
much less money at regular pharmacies.
Men with genetically-driven hair loss have more options for hair regrowth, continues Kobren, thanks to a drug called
finasteride, which is marketed as Propecia by the pharmaceutical giant Merck. Finasteride works by blocking the
creation of dihydrotestosterone, which fuels male pattern baldness, and double-blind clinical trials have shown that
finasteride can noticeably thicken men’s hair.
Many men shy away from taking finasteride, however, because of the possibility of sexual side effects, including loss
of libido. And, more recently, studies have shown that those side effects may persist after discontinuation of the
medicine.
What About Surgery?
Surgery can be an effective option for men with male pattern baldness, says Kobren. The procedure’s success is
predicated on moving DHT resistant hair to areas on the scalp that previously grew DHT-sensitive hair. Because DHT
sensitivity is rarely the problem for women, they almost never gain long-term benefit from the procedure.
This is despite aggressive marketing to women, who may feel vulnerable due to hair loss, making them a susceptible
target.
Kobren says: “Surgery is often the first place women go, but I strongly advise them against it.”
Men, too, need to use caution because the success of the procedure all depends on the quality and training of the
practitioner performing it.
“The whole field of cosmetic surgery is a very dangerous place,” says Kobren, and that is especially true in the
booming hair loss market. “I know a gynecologist who promotes himself as a hair transplant specialist.”
In the wrong hands, a transplant can disfigure and further traumatize a hair loss sufferer.
Kobren founded a group, the International Alliance of Hair Restoration Surgeons (IAHRS.org), to help identify
qualified practitioners. He said the organization has received over 900 applications, but accepted just 65 people based
on the quality of their work.
He advises people interested in transplants to comb through the site for someone in their area. But Kobren cautions
that the site is just a starting point — a place to begin to do due diligence. Just because someone is listed there, says
Kobren, doesn’t make him or her the right practitioner for a particular client.
The most important thing someone interested in surgery can do, says Kobren, is homework: talk to specialists, meet
people they’ve worked on, read reviews online. This piece is critically important for success.
It is also important given the price of the surgery.
“The average surgery is about 2,000 grafts,” says Kobren, “and grafts are between $5 and $11 per graft. You can be
talking a minimum investment of $20,000.”
Other “Cures” and Myths
Kobren believes that two other emerging therapies hold promise: platlet-rich plasma therapy and laser therapy, but at
this point he doesn’t endorse either.“I haven’t seen enough clinical data yet to show that it works,” he says. Anecdotal
evidence, however, has been promising.
The vast majority of other miracle cures — like thickening shampoos or standing on your head — are nothing more
than snake oil, says Kobren. And even effective therapies can be ineffective if the treatment and the root cause don’t
align.
Kinsley highlights three other myths about hair loss:



Myth: Washing your hair every day causes hair loss. “That’s rubbish,” says Kinsley. “It doesn’t make your hair fall
out. Don’t be frightened.”
Myth: Shaving your head makes hair grow faster. “No, it doesn’t,” says Kinsley.
Myth: There is a fast solution. With some medical issues there is a quick fix, says Kinsley. “A person goes on
medicine and it’s all under control. With hair loss, it’s different. There is no one thing you can put on the scalp or
take to fix the problem.”
Eur J Cancer. 2015 May;51(7):825-32. doi: 10.1016/j.ejca.2015.01.008. Epub 2015 Mar 11.
Alopecia as surrogate marker for chemotherapy response in
patients with primary epithelial ovarian cancer: a metaanalysis of
four prospective randomised phase III trials with 5114 patients.
Sehouli J1, Fotopoulou C2, Erol E3, Richter R3, Reuss A4, Mahner S5, Lauraine EP6, Kristensen
G7, Herrstedt J8, du Bois A9, Pfisterer J10.

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

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

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1
Department of Gynecology, University of Berlin, Charite, Campus Virchow, Berlin, Germany. Electronic address:
[email protected].
2
Department of Gynecology, University of Berlin, Charite, Campus Virchow, Berlin, Germany; Ovarian Cancer Action Research
Centre, Department of Surgery and Cancer, Imperial College London, Du Cane Road, London W12 0NN, United Kingdom.
3
Department of Gynecology, University of Berlin, Charite, Campus Virchow, Berlin, Germany.
4
Coordinating Center for Clinical Trials, University Marburg, Germany.
5
Klinik und Poliklinik für Gynäkologie, Universitätsklinikum Hamburg-Eppendorf, Hamburg, Germany.
6
Group d'Investigateurs Nationaux pour l'Etude des Cancers Ovariens (GINECO) and Université Paris Descartes, Assistance
Publique-Hôpitaux de Paris, Paris, France.
7
Nordic Society of Gynaecological Oncology (NSGO) and Norwegian Radium Hospital, Oslo, Norway.
8
Department of Oncology, Odense University Hospital, 5000 Odense, Denmark.
9
Gynäkologie & Gynäkologische Onkologie, Kliniken Essen-Mitte, Essen, Germany.
10
Zentrum für Gynäkologische Onkologie, Kiel, Germany.
Abstract
PURPOSE:
Alopecia is a common side-effect of chemotherapy and affects quality of life of cancer patients. Some patients and physicians
believe that alopecia could be a surrogate marker for response to chemotherapy and impact on prognosis. However, this was never
been tested in a sufficiently large cohort of ovarian cancer patients.
PATIENTS AND METHODS:
We analysed retrospectively the meta-databank of four prospective randomised phase-III-trials with platinum- and taxane-based 1stline-chemotherapy in patients with advanced epithelial ovarian cancer (EOC) regarding the impact of alopecia overall outcome.
RESULTS:
For 4705 (92.0%) of a total of 5114 EOC-patients alopecia was documented. They had received on median six cycle platinumtaxane chemotherapy (range 0-11) with 4186 (89.0%) having completed ⩾ 6 cycles. Worst alopecia grade was 0 in 2.4%, 1 in 2.9%
and 2 in 94.7% of the patients. In a univariate analysis, including all patients, grade-0/1 alopecia was associated with significantly
lower progression free survival (PFS) and overall survival (OS) compared to grade-2 alopecia. However when assessing only those
patients who completed ⩾ 6 chemotherapy-cycles and hence eliminating the bias of lower total dose of treatment, alopecia failed to
retain any significant impact on survival in the multivariate analysis. Merely the time point of alopecia onset was an independent
prognostic factor of survival: patients who developed grade-2 alopecia up to cycle 3 had a significantly longer OS compared to
patients who experienced alopecia later during therapy (hazard ratio (HR): 1.25; 95% confidence interval (CI): 1.04-1.50).
CONCLUSIONS:
Within a large EOC-patient cohort with 1st-line platinum- and taxane-based chemotherapy early onset alopecia appears to be
significantly associated with a more favourable outcome in those patients who completed ⩾ 6 chemotherapy cycles. It remains to be
elucidated if early onset alopecia is just a surrogate marker for higher sensitivity to chemotherapy or if other biological effects are
underlying.
Copyright © 2015 Elsevier Ltd. All rights reserved.
KEYWORDS:
Association; Chemotherapy;
effectiveness
PMID: 25771433
Epithelial
ovarian
cancer;
Responds;
Survival;
Therapy
An Bras Dermatol. 2015 Mar-Apr; 90(2): 232–235.
doi: 10.1590/abd1806-4841.20153084
PMCID: PMC4371673
Alopecia secondary to anti-tumor necrosis factor-alpha therapy*
Lara Beatriz Prata Ribeiro,1 Juliana Carlos Gonçalves Rego,2 Bruna Duque Estrada,2 Paula Raso Bastos,2 Juan Manuel Piñeiro
Maceira,3 and Celso Tavares Sodré2,4
Abstract
INTRODUCTION
The increased use of biologic drugs has been revealing new adverse effects. The cutaneous reactions described include
eczema, erythema, urticaria, lupus-like syndrome and, paradoxically, psoriasis.1 The development of alopecia related to
anti-TNF is a possible although seldom reported collateral effect. In this context, alopecia areata (AA), psoriatic alopecia
and anti-TNF therapy-related alopecia are described, of which the latter mixes clinical and histopathological
characteristics of both psoriatic alopecia and AA.2
Two cases of alopecia associated with anti-TNF therapy were reported, which resulted in cutaneous psoriasiform lesions.
CASE REPORTS
Case 1
Male patient, 28 years old, affected by Crohn's disease and treated with infliximab for 3 years, presented alopecia plaques
on the scalp and erythematous-scaly lesions in the armpits, navel and perianal region for the last 2 weeks. He denied
personal or family history of psoriasis. During the physical examination, 2 alopecia plaques were found in the left parietal
region. The oldest lesion, smooth and normochromic, showed clinical and dermoscopic aspects of AA: black spots and
exclamation-mark hairs, whereas the most recent one presented erythema and desquamation (Figures 1, ,22 and and3).3).
Histopathology demonstrated extensive parakeratosis, epidermal hyperplasia, dilated dermal papillae containing tortuous
capillaries and mononuclear inflammatory infiltrate, involving all levels of intra and perifollicular structure and intense
miniaturization of hair follicles (Figure 4). Direct mycological examination was negative. Daily treatment was started with
clobetasol gel, coal tar shampoo, intralesional corticoid in monthly application on the scalp and tacrolimus 0.1% on body
lesions. Infliximab was maintained and after 3 months the desquamation disappeared and there was complete hair
regrowth and remission of cutaneous lesions.
FIGURE 1
Dermoscopy of alopecic plaque. Exclamationmark hairs in the center, vellus hairs and black spots on the edges of the
plaque (10x magnification)
FIGURE 2
Alopecic plaques in different phases of evolution. Most recent plaque with erythema and desquamation and the oldest one
normochromic and smooth
FIGURE 3
Dermoscopy of desquamative alopecic plaque. Detail of desquamation
FIGURE 4
Histopathology of alopecia plaque with desquamation (HE). Extensive parakeratosis, epidermal hyperplasia, dilated
dermal papillae containing tortuous capillaries and mononuclear inflammatory infiltrate in the interior and around
miniaturized follicular ...
Case 2
Female patient, 14 years old, had been treated with infliximab for 6 months due to Crohn's disease. After 4 months of
treatment, she presented erythematous-desquamating lesions on the body and alopecia plaques with desquamation of the
scalp. She denied personal or family history of psoriasis. At the physical examination, she presented erythematousdesquamating plaques on the trunk, armpits, pubic region, breasts, plantar regions, elbows and knees. On the scalp,
alopecia desquamating plaques were detected in the bilateral frontal and parietal region (Figure 5). Trichoscopy revealed
tortuous vessels compatible with psoriasis (Figure 6). Histopathology of the scalp revealed hyperkeratosis which extended
to the follicular ostia, small foci of parakeratosis, pronounced miniaturization with only 50% of hair terminals in anagen
and mononuclear infiltrate, discrete perivascular and multifocal intrafollicular. On the trunk a slight, irregular acanthosis
was observed with hyperkeratosis, non-confluent parakeratosis and neutrophilic aggregates in the stratum corneum.
FIGURE 5
Detail of alopecia plaques. Presence of erythema and desquamation
FIGURE 6
Dermoscopy with polarized light and interface liquid of alopecia plaque with desquamation. Areas of atrichia and thick,
tortuous capillary loops in the perifollicular region associated with balled capillary loops in the periphery of the plaque
(20x magnification) ...
Coal tar shampoo was prescribed, along with betamethasone cream on the scalp, LCD lotion 6% and mometasone on body
lesions. After 5 months, there was hair regrowth and remission of cutaneous lesions. Infliximab was maintained.
DISCUSSION
The estimated prevalence of psoriasiform eruptions during use of anti-TNFα is between 1.5 and 5%, mainly associated
with infliximab.1 One of the proposed mechanisms was blocking TNF receptors, which would increase the production of
interferon-α by plasmacytoid dendritic cells in genetically predisposed individuals. Interferon-α would become then the
cytokine responsible for activation and amplification of pathogenic T-cells.3 In a revision of psoriasis cases induced by
anti-TNF in patients with inflammatory intestinal disease, the flexural area was affected in 31% of the cases and the scalp
in 42%, although alopecia has not been described.4 Reports of psoriasis on the scalp associated with alopecia induced by
anti-TNF are rare.5,6Recently, a new kind of psoriatic alopecia / alopecia areata-like reaction secondary to anti-Tumor
Necrosis Factor-α therapy has been described based on the report of 3 alopecia cases that mixed clinical and
histopathological characteristics of AA and psoriasis.2 For this diagnosis, it would be necessary to meet the following
criteria: (1) development of psoriasiform lesions after treatment with anti-TNF, (2) absence of previous psoriasis history,
(3) alopecia plaque(s) on the scalp, (4) erythematous - desquamative plaques on the scalp and/or pustular lesions on the
scalp and (5) development of psoriasiform rash on the body after treatment.2 All patients in this report presented all of
these characteristics.
In the histopathology of alopecia induced by anti-TNF, besides classic psoriasiform epidermal changes, alterations similar
to AA ones are observed on the dermis, such as intense miniaturization, increase in catagen and telogen hairs and
peribulbar lymphocytic infiltrate in terminal hairs. Numerous plasmocytes and eosinophils were also observed.2 We
computed the following discrepancies in the histological findings of Doyle et al.: 1) The lymphocytic infiltrate was not
restricted to the peribulbar region, occupying all levels of the follicular structure. This does not invalidate AA dermal
findings, since the "swarm of bees" peribulbar lymphocytic infiltrate, typical of AA, is more often associated with the
acute phase.7 Moreover, in psoriatic alopecia there is no lymphocytic infiltrate in the peribulbar region; 2) Eosinophils and
plasmocytes were not identified in the inflammatory infiltrate.8 Eosinophils were found in 44% of the 109 cases of AA by
Peckhametal and plasmocytes are normal components of the occipital scalp area.7,9 This way, we believe that the presence
of eosinophils and plasmocytes may not be fundamental to characterize this type of alopecia.
This combination of clinical, histopathological and dermoscopic characteristics of psoriatic alopecia and AA reinforce the
diagnosis of psoriatic alopecia / alopecia areata-like reaction secondary to anti-Tumor Necrosis Factor-α therapy. The
main differential diagnoses are AA, psoriatic alopecia, pityriasis amiantacea and tinea capitis.
There is no consensus regarding maintenance or suspension of anti-TNFα in face of cutaneous reaction triggered by these
drugs. Upon revising 16 cases of AA induced by anti-TNFα, treatment was suspended in 7 cases, and only 2 presented
complete hair regrowth.10 For psoriasis induced by anti-TNFα they are usually maintained and topical treatment with
corticosteroids and vitamin D analog allow for total or partial remission of the cutaneous lesions.3 Iborra et al. recommend
the suspension of anti-TNFα when the lesions cover more than 5% of body surface, are intolerable or if that is what the
patient wishes.1 For these patients, infliximab was maintained due to the small extension of psoriasiform lesions, achieving
good clinical evolution.
The objective of this report was to demonstrate the first 2 cases described in national literature of alopecia induced by antiTNFα which fall within the category described as psoriatic alopecia / alopecia areata-like reaction secondary to antiTumor Necrosis Factor-α therapy, pointing out histopathological differences regarding the only previous publication and
emphasizing dermoscopic signs as an auxiliary diagnostic tool.
Footnotes
Conflict of Interests: none
Financial Support: none
How to cite this article: Ribeiro LBP, Rego JCG, Duque-Estrada B, Bastos RP, Maceira JMP, Sodré CT. Alopecia secondary to Anti-Tumor
Necrosis Factor-Alpha therapy. An Bras Dermatol. 2015;90(2):232-5.
*
Work performed at Instituto de Dermatologia Professor Rubem David Azulay - Santa Casa de Misericórdia do Rio de Janeiro (IDPRDASCMRJ) - Rio de Janeiro (RJ), Brazil.
References
1. Iborra M, Beltran B, Bastida G, Aguas M, Nos P. Infliximab and adalimumab-induced psoriasis in Crohn's disease: A
paradoxical side effect. J Crohns Colitis. 2011;5:157–161. [PubMed]
2. Doyle LA, Sperling LC, Baksh S, Lackey J, Thomas B, Vleugels RA, et al. Psoriatic alopecia/alopecia areata-like
reactions secondary to anti-Tumor Necrosis Factor-a Therapy: A Novel Cause of Noncicatricial Alopecia. Am J
Dermatopathol. 2011;33:161–166. [PubMed]
3. Collamer AN, Battafarano DF. Psoriatic skin lesions induced by tumor necrosis factor antagonist therapy: clinical
features and possible immunopathogenesis. Semin Arthritis Rheum. 2010;40:233–240. [PubMed]
4. Cullen G, Kroshinsky D, Cheifetz AS, Korzenik JR. Psoriasis associated with antitumor necrosis factor therapy in
inflammatory bowel disease: a new series and a review of 120 cases from the literature. Aliment Pharmacol
Ther. 2011;34:1318–1327. [PubMed]
5. Medkour F, Babai S, Chanteloup E, Buffard V, Delchier JC, Le-Louet H. Development of diffuse psoriasis with
alopecia during treatment of Crohn's disease with infliximab. Gastroenterol Clin Biol.2010;34:140–141. [PubMed]
6. Perman MJ, Lovell DJ, Denson LA, Farrell MK, Lucky AW. Five cases of anti-tumor necrosis factor alpha-induced
psoriasis presenting with severe scalp involvement in children. Pediatr Dermatol.2012;29:454–459. [PubMed]
7. Peckham SJ, Sloan SB, Elston DM. Histologic features of alopecia areata other than peribulbar lymphocytic
infiltrates. J Am Acad Dermatol. 2011;65:615–620. [PubMed]
8. Bardazzi F, Fanti PA, Orlandi C, Chieregato C, Misciali C. Psoriatic scarring alopecia: observations in four patients. Int
J Dermatol. 1999;38:765–768. [PubMed]
9. James WD, Berger TG, Elston DM. Andrews diseases of the skin. 10th ed. Philadelphia: Saunders/Elsevier; 2006.
10. Ferran M, Calvet J, Almirall M, Pujol RM, Maymó J. Alopecia areata as another immune-mediated disease developed
in patients treated with tumor necrosis factor-a blocker agents. Report of five cases and review of the literature. J Eur Acad
Dermatol Venereol. 2011;25:479–484. [PubMed]
1
Journal of Cosmetics, Dermatological Sciences and Applications, 2013, 3, 1-8
http://dx.doi.org/10.4236/jcdsa.2013.33A1001 Published Online September 2013 (http://www.scirp.org/journal/jcdsa)
Comprehensive Overview and Treatment Update on Hair
Loss
Katlein França1, Thiago Saldanha Rodrigues2, Jennifer Ledon1, Jessica Savas1, Anna Chacon1
1
Department of Dermatology & Cutaneous Surgery, University of Miami Miller School of Medicine, Miami, USA; 2Department of
Oncologic Surgery, Instituto do Câcner Doutor Arnaldo Vieira de Carvalho, São Paulo, Brazil.
Email: [email protected]
Received April 1st, 2013; revised May 3rd, 2013; accepted May 10th, 2013
Copyright © 2013 Katlein França et al. This is an open access article distributed under the Creative Commons Attribution License,
which permits unrestricted use, distribution, and reproduction in any medium, provided the original work is properly cited.
ABSTRACT
Hair loss is one of the most common complaints among all patients consulting a dermatologist and is usually associated
with severe psychological disturbances, distress and symptoms of depression. [1-3]. It can be temporary or long lasting.
Diagnosis of hair loss is based on detailed clinical history, physical exam, clinical diagnostic tests, laboratory testing,
and scalp biopsy, which may be necessary to confirm some diagnoses. This article presents an overview of the most
common clinical causes of hair loss and provides updated information on the current available therapeutic options for
these disorders.
Keywords: Hair Loss; Alopecia; Telogen Effluvium; Trichotillomania
1. Introduction
Hair loss is one of the most common complaints among
all patients consulting a dermatologist and is usually associated with severe psychological disturbances, distress
and symptoms of depression [1-3]. It can be temporary or
long lasting. Diagnosis is based on detailed clinical history, physical exam, clinical diagnostic tests, laboratory
testing, and scalp biopsy, which may be necessary to
confirm some diagnosis [4-6]. The pathophysiology of
such disorders may include infectious, nutritional, congenital, autoimmune, or environmental causes. The most
common forms of nonscarring alopecia are androgenic
alopecia, telogen effluvium, and alopecia areata. Scarring
alopecia is caused by trauma, infections, discoid lupus
erythematosus, or lichen planus. Other disorders include
trichotillomania, traction alopecia, tinea capitis, and hair
shaft abnormalities [7,8]. An adequate evaluation and
management is essential for appropriate patient care and
successful treatment [3].
This article presents an overview of the most common
clinical causes of hair loss in women and provides updated information on the current available therapeutic options for these disorders.
sis. The patient may provide information regarding the
use of medications, illnesses, recent surgeries and general
anesthesia, hormonal disease, thyroid disease, diets and
weight loss, history of important psychological distress
and family history of hair loss. The duration and location
of the hair loss should also be asked. Patients may be
referred for focal patches or more diffuse hair loss [6-8].
3. Physical Exam
Once the history of the patient is documented, the patient
should be carefully examined. First the skin of the scalp
should be examined. Note the color of the scalp, presence
and distribution of hair follicles, scaling or evidence of
scarring [8]. The hair density should also be noted if it is
normal or decreased. To evaluate the severity of hair
shedding, the “pull test” can be performed. This simple
test can determine the ongoing activity and severity of
hair loss. The physician should grab onto 20 - 30 hairs
with his/her fingers and gently pull on them. If produces
more than 10 hairs is suggestive of increased hair loss
[2,4]. A hair sample should be collected for microscopic
analysis. Light microscopy of the hair is an important
tool for several disorders affecting the scalp and hair,
including genodermatoses and other syndromes [9-11].
2. Clinical History
4. Understanding the Hair Cycle
A detailed clinical history is essential to make a diagno-
Hair follicles cycle through anagen (growth), catagen (re-
Copyright © 2013 SciRes.
JCDSA
Comprehensive Overview and Treatment Update on Hair Loss
2
gression) and telogen (resting) phases (Table 1). Understanding this process is clinically important, since the
vast majority of patients with hair disorders suffer from
an undesired alteration of hair follicle cycling [12,13].
Anagen hair loss occurs due to disorders that stop the mitotic activity of anagen follicles, such as alopecia areata
and drugs [4,14]. On the other hand, telogen hair loss
occurs due to injuries that may cause premature follicle
telogenization [4,15].
5. Alopecia
5.1. Androgenetic Alopecia
Androgenetic alopecia (AGA) is the most common form
of hair loss. When it affects women, it leads to diffuse
alopecia over the mid-frontal scalp (female pattern hair
loss) [16]. This process is a result of hair follicle miniaturization within follicular units. It represents a progressive reduction in diameter, pigmentation and length of
the hair shaft [4,17]. These miniaturized hairs are the
hallmark of AGA. Most women with AGA have normal
menses and pregnancies. 18 This disorder is induced by
androgens in genetically susceptible persons. These patients present hair follicles with increased 5α-reductase
activity and dihydrotestosterone (DHT) levels. In these
genetically susceptible hair follicles, the DHT binds to
the androgen receptor and the hormone-receptor complex,
activating the genes responsible for the transformation of
the normal hair follicle in miniaturized follicles [18,19].
The reduction in the number of terminal fibers per follicular unit will produce a diffuse alopecia [17]. The impact of androgenetic alopecia is predominantly psychological. While men anticipate age-related hair loss, the
same process in women is usually unexpected and unwelcome at any time [20,21] (Figure 1).
Association with thyroid disorders is suggested by
some authors, but alopecia is unaffected by thyroid substitution [21]. This disorder can be precipitated or worsened by conditions that induce telogen effluvium such as
postpartum telogen effluvium. If associated with hirsutism and acne, AGA can be a sign of hyperandrogenism in premenopausal women [4]. Pharmacological-containing estrogens (contraception) have a beneficial effect
on such alopecia, probably through different mechanisms:
anti-androgen effect increased and proliferative effect of
dermal papilla cells [22]. But contraceptives that contain
androgenic progestins like nortestosterone-derivates levonorgestrel may induce or worsen this condition [4,22,23].
Levonorgestrel intrauterine device has been described as
cause of hair loss [24].
5.2. Alopecia Areata
Alopecia areata (AA) is a nonscarring autoimmune, inflammatory scalp, and/or body hair loss condition [25]. It
affects up to 2% of the population and it is characterized
by patchy hair loss (Figure 2). It can affect the entire
scalp (alopecia totalis) or cause loss of all body hair
(alopecia universalis) [4,26]. Histopathology shows an
increased number of the catagen and telogen follicles and
the presence of an inflammatory lymphocytic infiltrate in
the peribulbar region [25].
Figure 1. A 55-year-old male presenting androgenetic
alopecia.
Table 1. Hair cycle phases.
The follicles produce the hair shaft. Duration ranges from
Anagen two to seven years. Up to 85% of the hair is in this phase
at one time.
Catagen
Transitional phase that lasts two to three weeks which
precedes the resting telogen phase
Telogen
Hair production is absent. Up to 15% of hair is in this
phase at one time and it can last 3 months.
Copyright © 2013 SciRes.
Figure 2. Alopecia areata in a 64-year-old female.
JCDSA
Comprehensive Overview and Treatment Update on Hair Loss
Many factors are under investigation to clarify the pathogenesis of AA. Nonspecific immune and organ-specific autoimmune reactions and genetic constitution are
possible causes [27,28].
One of the most discussed ideas is that genetically predisposed individuals present an autoimmune T cell-mediated-reaction against the hair follicle [28]. This process
may be caused by different triggering factors, such as viral infections and stress [4,29]. It can be associated with
other autoimmune disorders, such as thyroid disease [4].
The influence of psychological factors in the development, evolution and therapeutic management of alopecia areata is documented by several authors. The comorbidity of psychiatric disorders, mainly depression, generalized anxiety disorder and phobic states, is high [30,31].
Postoperative alopecia areata following surgery has
been reported after gynecologic and cardiac procedures.
Although pressure-induced ischemia is the most likely
etiological factor, a study conducted by Khalaf and colleagues showed that these patients might also present
with psychiatric comorbidities, questioning the real etiology of AA in these patients [32].
3
Figure 3. Chemotherapy induced alopecia.
5.3. Chemotherapy Induced Alopecia
Most cytotoxic anticancer chemotherapy agents induce
alopecia by ablating the rapidly dividing epithelium of
the hair follicle. The overall incidence of chemotherapyinduced hair loss is estimated to be 65% and the severity
and prevalence of this type of hair loss is related to the
selected chemotherapeutic agent and treatment protocol
[33]. Chemotherapy-induced anagen effluvium is usually
reversible, but it’s known that certain chemotherapy regimens can cause permanent alopecia. In these cases, moderate to very severe hair thinning and altered texture
may be seen when hair regrows [34]. Although it is transient, chemotherapy-induced alopecia it is often psychologically devastating, especially for women [35,36] (Figures 3 and 4).
5.4. Trichotillomania
Trichotillomania, also known as hair pulling disorder, is
an impulse-control disorder that affects at least 3.7 million people in the United States and results in marked
functional impairment [37,38]. This disease is characterized by an irresistible desire to manipulate and pull out
the hair [4]. The disorder typically onsets in childhood
either in preschool or in the preadolescent years and is up
to seven times more commonly found in the pediatric
population than in adults [39]. The disorder may begin as
a habit, similar to nail-biting or thumb-sucking [40]. On
physical examination, irregular patches of hair loss with
bizarre borders can be observed. Inside of these patches,
short and broken hairs with variable lengths are evident
Copyright © 2013 SciRes.
Figure 4. Eyebrow hair loss in a female patient undergoing
chemotherapy.
[4]. Appropriate psychoeducation and minimally invasive behavioral treatments are possible interventions for
this common disorder [41,42].
6. Telogen Effluvium
Telogen effluvium (TE) is an increased loss of normal
club hairs that occurs by a perturbation of the hair cycle
[43]. It was first described by Kligman in 1961 and his
hypothesis was that whatever the cause of hair loss, the
follicle tends to behave in a similar way, causing premature termination of anagen [43,44]. The true incidence is
unknown because many cases are subclinical [45]. Common causes of TE include iron deficiency, drugs and
stress (Table 2).
6.1. Acute Telogen Effluvium
The first description of classic telogen effluvium was an
acute onset hair loss 2 - 3 months after a triggering event
such as surgical trauma or high fever [46]. Other known
causes include drugs, stress, fever, weight loss, hypothyroidism, hyperthyroidism, and other disorders that may
cause inflammation of the scalp, such as contact dermatitis [45,47]. In cases where no cause is found, screening
for thyroid disease, antinuclear antibody and syphilis
should be performed. Acute TE does not usually produce
visible alopecia; the patient often complains that the hair
JCDSA
Comprehensive Overview and Treatment Update on Hair Loss
4
Table 2. Common causes of telogen effluvium.
Nutritional Deficiency
Stress
Fever
Drugs
Postpartum
Hypothyroidism/hyperthyroidism
Hepatic failure
Chronic renal failure
6.1.4. Postpartum
Postpartum hair loss usually starts two to four months
after delivery and may last six months to one year [55].
Although the prevalence of postpartum alopecia is not
known, it is believed to be common. Patients without nutritional deficiencies or other diseases will achieve complete recovery after an additional six to nine months, but
physicians should keep in mind that this condition can
precipitate the development of alopecia areata in predisposed patients [54,55]. The hair loss is always diffuse but
never total. Some patients may experience slower growth
with decreased hair density [55,56].
Idiopathic
6.2. Chronic Telogen Effluvium
is falling out. Daily shedding of 100 to 200 telogen hairs
can be observed in severe cases [4].
6.1.1. Nutritional Deficiency
One of the most common causes of hair loss in premenopausal women is nutritional deficiency of iron. Screening
for serum ferritin and hemoglobin should be performed
to clarify the possible cause of hair loss in this population
[48]. Iron supplementation is recommended when levels
of ferritin are below 30 ng/ml [4]. Severe protein, caloric
restriction, vitamin D deficiency, zinc deficiency and chronic starvation can also induce diffuse telogen hair loss
[49,50].
6.1.2. Stress
Evidence of the data suggests that neurotransmitters,
neurohormones, and cytokines released during the stress
response may also significantly influence the hair cycle
[51]. Arck and colleagues provided further evidence for
existence of a “brain-hair follicle axis”. This theory says
that audiogenic stress also induces significant changes in
actively growing hair follicles and promotes their transition into the involution phase [52].
6.1.3. Drugs
Hair loss can be an adverse effect of a large number of
drugs. The severity of alopecia will depend on the drug
and individual predisposition. While some drugs will
produce only hair abnormalities others will produce severe hair loss, even with appropriate dosages. Drugs affect anagen follicles by two different processes: precipitating the follicles into premature rest (telogen effluvium)
or inducing an abrupt cessation of mitotic activity in rapidly dividing hair matrix cells (anagen effluvium). Anticoagulants, retinol, interferon, antihyperlipidemic drugs
are just a few examples of drugs that can induce telogen
effluvium [52]. Hair loss from the scalp, eyebrows, and
pubic area was identified as a possible adverse effect of
most psychotropic medications. This process is usually
reversible after interruption of treatment [53].
Copyright © 2013 SciRes.
This condition is characterized by hair shedding lasting
longer than 6 months, and with a fluctuating chronic course over many years. It is idiopathic and usually a trigger
cannot be identified [2,4]. The diagnosis of chronic telogen effluvium is made by the exclusion of causes of
diffuse telogen hair loss, including androgenetic alopecia
[8]. Scalp pain and reduced hair density is commonly reported by patients.
7. Treatment
7.1. Androgenetic Alopecia
7.1.1. Topical Minoxidil
Topical Minoxidil is now the most widely recommended
treatment for androgenetic alopecia. It is available in 2%
and 5% solutions for hair loss. The 2% solution is the
only one approved by FDA for use in female patients. It
stimulates new hair growth and helps stop the loss of hair
in individuals with androgenetic alopecia (AGA) [57-59].
Side effects include a transient shedding during the first 4
months of use and contact dermatitis [60].
7.1.2. Finasteride
Finasteride is a synthetic type-2 5α-reductase inhibitor
and has been studied by several authors as a treatment for
female pattern hair loss. A review study published in
2011 shows that objective evidence of efficacy is limited,
but it may be considered as a treatment for patients who
fail topical minoxidil [61]. Finasteride is well tolerated;
however, premenopausal patients must adhere to reliable
contraception while receiving it. The dosage of 2.5
mg/daily seems to show better results when compared to
1.0 mg/daily. It is contraindicated in pregnancy, due to
known teratogenicity. For men, the dosage is 1 mg once
a daily [62].
7.2. Anti-Hormonal Therapy
Reviews suggest that anti-hormonal therapy is helpful in
treating female pattern alopecia in some women who
JCDSA
Comprehensive Overview and Treatment Update on Hair Loss
have normal hormone levels.
Spironolactone is an aldosterone antagonist employed
in clinical practice as a potassium-sparing diuretic. It
reduces adrenal androgen production and exerts competitive blockade on androgen receptors in target tissues [63].
This medication has been used off-label in female pattern
har loss for over 20 years and it has been shown to arrest
hair loss progression with a long-term safety profile. It
should not be used in pregnancy due to its teratogenic effects [64].
Cyproterone acetate is an androgen receptor blocker
with strong progestational activity and a weak glucocorticoid action. It seems to decrease hair shedding, but does
not seem to promote regrowth [65]. The dose required
for premenopausal women is 100 mg daily for 10 days of
each menstrual cycle and postmenopausal women should
use 50 mg daily continuously. Sinclair and colleagues
performed an intervention study involving eighty female
patients with FPHL to evaluate the efficacy of oral antiandrogen therapy in the management of women with
FPHL. Forty patients received spironolactone 200 mg
daily and 40 received cyproterone acetate, either 50 mg
daily or 100 mg for 10 days per month if premenopausal.
This study showed no significant difference in the results
or the trend between spironolactone and cyproterone
acetate. Thirty-five (44%) women had hair regrowth, 35
(44%) had no clear change in hair density before and
after treatment, and only 10 (12%) experienced continuing hair loss during the treatment period [66].
7.2.1. Alopecia Areata
Treatment is not mandatory considering it a benign condition. Spontaneous remissions and recurrences are common. Some therapeutic agents can be effective. This list
includes systemic, intralesional and topical steroids under
occlusion and topical immunotherapy with squaric acid
dibutylester or diphencyprone [67-69].
7.2.2. Chemotherapy Induced Alopecia
Scalp cooling is as a method of preventing hair loss during chemotherapy and it has been discussed by several
authors as an effective option [70,71]. Topical 2% minoxidil as a therapy for accelerating regrowth after chemotherapy has also proven to shorten the baldness period
[72]. Psychological support, education, and self-care strategies are important components of any management
approach [73].
7.2.3. Trichotillomania
Behavior therapy and pharmacotherapy are the most efficacious treatments for adult trichotillomania and have
shown significant reductions in hair pulling over the
short term. [74] Pharmacotherapy agents include selective serotonin inhibitors at high dosage and domipramine.
Copyright © 2013 SciRes.
5
Recent developments in pharmacotherapy have suggested that other medications such as opioid blockers,
atypical neuroleptics, and glutamate modulators hold promise as treatment for trichotillomania. [75]
7.3. Telogen Effluvium
7.3.1. Iron Supplementation
Female patients without systemic inflammation or other
underlying disorders, serum ferritin levels below or equal
to 30 ng/mL are strongly associated with telogen hair
loss [76,77]. Iron supplementation with oral iron sulphate
is recommended until a serum ferritin level of 70 ng/ml
is achieved [4].
7.3.2. Biotin Supplementation
Biotin also known as vitamin H or coenzyme R has been
shown to improve clinical appearance and combing problems in patients with uncombable hair syndrome [78]. A
study performed by Shelley and colleagues showed the
effectiveness of the biotin treatment in increasing the
root strength, in making the scaling disappear, and in
accelerating the growth rate, hence the hair became more
pliable and combable. The recommended supplementation is 5 mg daily [78].
7.3.3. Cysteine Supplementation
It is unclear whether cysteine supplements will improve
the quality of hair and the growth cycle. Available clinical data do not prove or disprove this theory. The recommended dosage is 500 mg daily.
REFERENCES
[1]
J. V. Schmitt, C. F. Ribeiro, F. H. Souza, E. B. Siqueira
and F. R. Bebber, “Hair Loss Perception and Symptoms
of Depression in Female Outpatients Attending a General
Dermatology Clinic,” Anais Brasileiros de Dermatologia,
Vol. 87, No. 3, 2012, pp. 412-417.
doi:10.1590/S0365-05962012000300010
[2]
S. B. Shrivastava, “Diffuse Hair Loss in an Adult Female:
Approach to Diagnosis and Management,” Indian Journal
of Dermatology, Venereology and Leprology, Vol. 75, No.
1, 2009, pp. 20-28. doi:10.4103/0378-6323.45215
[3]
M. B. Chartier, D. M. Hoss and J. M .Grant-Kels, “Approach to the Adult Female Patient with Diffuse Nonscarring Alopecia,” Journal of the American Academy of Dermatology, Vol. 47, No. 6, 2002, pp. 809-818.
doi:10.1067/mjd.2002.128771
[4]
A. Tosti, B. M. Piraccini, A. Sisti and B. Duque-Estrada
“Hair Loss in Women,” Minerva Ginecologica, Vol. 61,
No. 5, 2009, pp. 445-52
[5]
E. B. Hawryluk and J. C. English, “Female Adolescent
Hair Disorders,” Journal of Pediatric and Adolescent
Gynecology, Vol. 22, No. 4, 2009, pp. 271-281.
doi:10.1016/j.jpag.2009.03.007
JCDSA
Comprehensive Overview and Treatment Update on Hair Loss
6
[6]
A. L. Mounsey and S. W. Reed, “Diagnosing and Treating Hair Loss,” American Family Physician, Vol. 80, No.
4, 2009, pp. 356-362.
[7]
J. Shapiro, M. Wiseman and H. Lui “Practical Management of Hair Loss,” Canadian Family Physician, Vol. 46,
No. 7, 2000, pp. 1469-1477.
[8]
[9]
F. Mulinari-Brenner and W. F. Bergfeld, “Hair Loss: An
Overview,” Dermatology Nursing, Vol. 13, No. 4, 2001,
pp. 269-272, 277-278.
H. H. Celik, H. Tore, S. Tunali, I. Tatar and M. M. Aldur,
“Light and Scanning Electron Microscopic Examination
of Hair in Griscelli Syndrome,” Saudi Medical Journal,
Vol. 28, No. 8, 2007, pp. 1275-1277.
[10] V. V. Smith, G. Anderson, M. Malone and N. J. Sebire
“Light Microscopic Examination of Scalp Hair Samples
as an Aid in the Diagnosis of Pediatric Disorders: Retrospective Review of More Than 300 Cases from a Single
Center,” Journal of Clinical Pathology, Vol. 58, No. 12,
2005, pp. 1294-1298. doi:10.1136/jcp.2005.027581
standing,” International Journal of Dermatology, Vol. 37,
No. 8, 1998, pp. 561-566,
[21] C. Jamin, “Androgenetic Alopecia,” Annales De Dermatologie Et De Venereologie, Vol. 129, 2002, pp. 801-803.
[22] H. Zaun, “Influence of Contraceptive Hormones on Hair
Growth,” Deutsche Medizinische Wochenschrift, Vol. 103,
No. 6, 1978, p. 240.
[23] H. Zaun, “Skin Changes from Taking Hormonal Contraceptives,” Medizinische Monatsschrift für Pharmazeuten,
Vol. 4, No. 6, 1981 pp. 161-165.
[24] H. Paterson, J. Clifton, D. Miller, J. Ashton and M. Harrison-Woolrych, “Hair Loss with Use of the Levonor-gestrel Intrauterine Device,” Contraception, Vol. 76, No.
4, 2007, pp. 306-309.
doi:10.1016/j.contraception.2007.06.015
[25] D. Wasserman, D. A. Guzman-Sanchez, K. Scott and A.
McMichael, “Alopecia Areata,” International Journal of
Dermatology, Vol. 46, No. 2, 2007, pp. 121-131.
doi:10.1111/j.1365-4632.2007.03193.x
[11] K. A Adya, A.C Inamadar, A. Palit, R. Shivanna and N. S
Deshmukh, “Light Microscopy of the Hair: A Simple
Tool to ‘Untangle’ Hair Disorders,” International Journal
of Trichology, Vol. 3, No. 1, 2011, pp. 46-56.
doi:10.4103/0974-7753.82124
[26] F. M. Delamere, M. J. Sladden, H. M. Dobbins and J.
Leonardi-Bee, “Interventions for Alopecia Areata,” Cochrane Database of Systematic Reviews, No. 2, 2008, Article ID: CD004413.
doi:10.1002/14651858.CD004413.pub2
[12] R. Paus and K. Foitzik, “In Search of the ‘Hair Cycle
clock’: A Guided Tour,” Differentiation, Vol. 72, No.
9-10, 2004, pp. 489-511.
doi:10.1111/j.1432-0436.2004.07209004.x
[27] A. Gilhar and R. S. Kalish, “Alopecia Areata: A Tissue
Specific Autoimmune Disease of the Hair Follicle,” Autoimmunity Reviews, Vol. 5, No. 1, 2006, pp. 64-69.
doi:10.1016/j.autrev.2005.07.001
[13] M. Kimura-Ueki, Y. Oda, J. Oki, A. Komi-Kuramochi, E.
Honda, M. Asada, M. Suzuki and T. Imamura, “Hair Cycle Resting Phase is Regulated by Cyclic Epithelial
FGF18 Signaling,” Journal of Investigative Dermatology,
Vol. 132, No. 5, 2012, pp. 1338-1345.
doi:10.1038/jid.2011.490
[28] S. Madani and J. Shapiro, “Alopecia Areata Update,”
Journal of the American Academy of Dermatology, Vol.
42, No. 4, 2000, pp. 49-66.
[14] M. Courtois, G. Loussouarn, C. Hourseau and J. F. Grollier, “Hair Cycle and Alopecia,” Skin Pharmacology, Vol.
7, No. 1-2, 1994, pp. 84-89. doi:10.1159/000211279
[15] S. Harrison and R. Sinclair, “Telogen Effluvium,” Clinical and Experimental Dermatology, Vol. 27, No. 5, 2002,
pp. 389-395. doi:10.1046/j.1365-2230.2002.01080.x
[16] O. T. Norwood, “Incidence of Female Androgenetic Alopecia (Female Pattern Alopecia),” Dermatologic Surgery,
Vol. 27, No. 1, 2001, pp. 53-54.
doi:10.1111/j.1524-4725.2001.00124.x
[17] R. Sinclair, M. Patel, T. L. Dawson Jr., A. Yazdabadi, L.
Yip, A. Perez and N. W. Rufaut, “Hair Loss in Women:
Medical and Cosmetic Approaches to Increase Scalp Hair
Fullness,” British Journal of Dermatology, Vol. 165,
Suppl. 3, 2011, pp. 12-18.
doi:10.1111/j.1365-2133.2011.10630.x
[18] V. H. Price, “Androgenetic Alopecia in Women,” Journal
of Investigative Dermatology Symposium, Vol. 8, No. 1,
2003, pp. 24-27. doi:10.1046/j.1523-1747.2003.12168.x
[29] M. J. García-Hernández, S. Ruiz-Doblado, A. RodriguezPichardo and F. Camacho, “Alopecia Areata, Stress and
Psychiatric Disorders: A Review,” The Journal of Dermatology, Vol. 26, No. 10, 1999, pp. 625-632.
[30] S. Ruiz-Doblado, A. Carrizosa and M. J. García-Hernández, “Alopecia Areata: Psychiatric Comorbidity and
Adjustment to Illness,” International Journal of Dermatology, Vol. 42, No. 6, 2003, pp. 434-437.
doi:10.1046/j.1365-4362.2003.01340.x
[31] H. Khalaf, H. Negmi, G. Hassan, M. Al-Sebayel, “Postoperative Alopecia Areata: Is Pressure-Induced Ischemia
the Only Cause to Blame?” Transplantation Proceedings,
Vol. 36, No. 7, 2004, pp. 2158-2159.
doi:10.1016/j.transproceed.2004.08.126
[32] R. M. Trüeb, “Chemotherapy-Induced Hair Loss,” Skin
Therapy Letter, Vol. 15, No. 7, 2010, pp. 5-7.
[33] D. Gude, “Tackling Chemotherapy-Induced Alopecia,”
International Journal of Trichology, Vol. 4, No. 1, 2012,
pp. 47-48. doi:10.4103/0974-7753.96098
[19] V. K. Soni, “Androgenic Alopecia: A Counterproductive
Outcome of the Anabolic Effect of Androgens,” Medical
Hypotheses, Vol. 73, No. 3, 2009, pp. 420-426.
doi:10.1016/j.mehy.2009.03.032
[34] I. R. Kim, J. Cho, E. K. Choi, I. G. Kwon, Y. H. Sung, J.
E. Lee, S. J. Nam and J. H. Yang, “Perception, Attitudes,
Preparedness and Experience of Chemotherapy-Induced
Alopecia among Breast Cancer Patients: A Qualitative
Study,” Asian Pacific Journal of Cancer Prevention, Vol.
13, No. 4, 2012, pp. 1383-1388.
doi:10.7314/APJCP.2012.13.4.1383
[20] D. A.Whiting, “Male Pattern Hair Loss: Current Under-
[35] H. Roe, “Chemotherapy-Induced Alopecia: Advice and
Copyright © 2013 SciRes.
JCDSA
Comprehensive Overview and Treatment Update on Hair Loss
Support for Hair Loss,” British Journal of Nursing, Vol.
20, No. 10, 2011, pp. S4-S11.
[36] N. Shoenfeld, O. Rosenberg, M. Kotler and P. N. Dannon,
“Tricotillomania: Pathopsychology Theories and Treatment Possibilities,” The Israel Medical Association Journal, Vol. 14, No. 2, 2012, pp. 125-129.
[37] C. A. Flessner, V. S. Knopik and J. McGeary, “Hair Pulling Disorder (Trichotillomania): Genes, Neurobiology,
and a Model for Understanding Impulsivity and Compulsivity,” Psychiatry Research, Vol. 199, No. 3, 2012, pp.
151-158. doi:10.1016/j.psychres.2012.03.039
[38] G. Hamdan-Allen, “Trichotillomania in Childhood,” Acta
Psychiatrica Scandinavica, Vol. 83, No. 4, 1991, pp. 241243. doi:10.1111/j.1600-0447.1991.tb05532.x
[39] G. L. Hanna, “Trichotillomania and Related Disorders in
Children and Adolescents,” Child Psychiatry and Human
Development, Vol. 27, No. 4, 1997, pp. 255-268.
doi:10.1007/BF02353354
[40] M. E. Franklin, C. A. Flessner, D. W. Woods, N. J. Keuthen, J. C. Piacentini, P. Moore, et al., “The Child and
Adolescent Trichotillomania Impact Project: Descriptive
Psychopathology, Comorbidity, Functional Impairment,
and Treatment Utilization,” Journal of Developmental
and Behavioral Pediatrics, Vol. 29, No. 6, 2008, pp. 493500. doi:10.1097/DBP.0b013e31818d4328
[41] C. D. Labouliere and E. A. Storch, “Pediatric Trichotillomania: Clinical Presentation, Treatment, and Implications
for Nursing Professionals,” Journal of Pediatric Nursing,
Vol. 27, No. 3, 2012, pp. 225-232.
doi:10.1016/j.pedn.2011.01.028
[42] J. T. Headington, “Telogen Effluvium. New Concepts and
Review,” Archives of Dermatology, Vol. 129, No. 3, 1993,
pp. 356-363.
doi:10.1001/archderm.1993.01680240096017
[43] A. M. Kligman, “The Human Hair Cycle,” The Journal of
Investigative Dermatology, Vol. 33, 1959, pp. 307-316.
doi:10.1038/jid.1959.156
[44] S. Harrison and R. Sinclair, “Telogen Effluvium,” Clinical and Experimental Dermatology, Vol. 27, No. 5, 2002,
pp. 389-395. doi:10.1046/j.1365-2230.2002.01080.x
[45] A. Kligman, “Pathological Dynamics of Reversible Hair
Loss in Humans,” Archives of Dermatology, Vol. 83,
1961, pp. 175-198.
[46] A. Tosti, B. M. Piraccini and D. J. van Neste, “Telogen
Effluvium after Allergic Contact Dermatitis of the Scalp,”
Archives of Dermatology, Vol. 137, No. 2, 2001, pp. 187190.
[47] E. A. Olsen, K. B. Reed, P. B. Cacchio and L. Caudill,
“Iron Deficiency in Female Pattern Hair Loss, Chronic
Telogen Effluvium, and Control Groups,” Journal of the
American Academy of Dermatology, Vol. 63, No. 6, 2010,
pp. 991-999. doi:10.1016/j.jaad.2009.12.006
7
256-261. doi:10.3949/ccjm.68.3.256
[50] R. Paus, V. A. Botchkarev, N. V. Botchkareva, L. Mecklenburg, T. Luger and A. Slominski, “The Skin POMC
System (SPS). Leads and Lessons from the Hair Follicle,”
Annals of the New York Academy of Sciences, Vol. 885,
1999, pp. 350-363.
doi:10.1111/j.1749-6632.1999.tb08690.x
[51] P. C. Arck, B. Handjiski, E. Hagen, R. Joachim, B. F.
Klapp and R. Paus, “Indications for a ‘Brain-Hair Follicle
Axis (BHA)’: Inhibition of Keratinocyte Proliferation and
Up-Regulation of Keratinocyte Apoptosis in Telogen Hair
Follicles by Stress and Substance P,” FASEB Journal,
Vol. 15, No. 13, 2001, pp. 2536-2538.
[52] A. Tosi, C. Misciali, B. M. Piraccini, A. M. Peluso and F.
Bardazzi, “Drug-Induced Hair Loss and Hair Growth. Incidence, Management and Avoidance,” Drug Safety, Vol.
10, No. 4, 1994, pp. 310-317.
doi:10.2165/00002018-199410040-00005
[53] M. Gautam, “Alopecia Due to Psychotropic Medications,” The Annals of Pharmacotherapy, Vol. 33, No. 5,
1999, pp. 631-637. doi:10.1345/aph.18346
[54] J. H. Eastham, “Postpartum Alopecia,” The Annals of
Pharmacotherapy, Vol. 35, No. 2, 2001, pp. 255-258.
doi:10.1345/aph.10153
[55] L. Millikan, “Hirsutism, Postpartum Telogen Effluvium,
and Male Pattern Alopecia,” Journal of Cosmetic Dermatology, Vol. 5, No. 1, 2006, pp. 81-86.
doi:10.1111/j.1473-2165.2006.00229.x
[56] E. A. Olsen, F. E. Dunlap, T. Funicella, J. A. Koperski, J.
M. Swinehart, E. H. Tschen and R. J. Trancik, “A Randomized Clinical Trial of 5% Topical Minoxidil versus
2% Topical Minoxidil and Placebo in the Treatment of
Androgenetic Alopecia in Men,” Journal of the American
Academy of Dermatology, Vol. 47, No. 3, 2002, pp. 377385. doi:10.1067/mjd.2002.124088
[57] R. L. De Villez, “Androgenetic Alopecia Treated with
Topical Minoxidil,” Journal of the American Academy of
Dermatology, Vol. 16, No. 3, 1987, pp. 669-672.
doi:10.1016/S0190-9622(87)70085-1
[58] E. Arca, G. Açikgöz, H. B. Taştan, O. Köse and Z. Kurumlu, “An Open, Randomized, Comparative Study of
Oral Finasteride and 5% Topical Minoxidil in Male Androgenetic Alopecia,” Dermatology, Vol. 209, No. 2,
2004, pp. 117-125. doi:10.1159/000079595
[59] K. J. McElwee and J. S. Shapiro, “Preventing Androgenic
Alopecia,” Skin Therapy Letter, Vol. 17, No. 6, 2012, pp.
1-4.
[60] S. M. Stout and J. L. Stumpf, “Finasteride Treatment of
Hair Loss in Women,” The Annals of Pharmacotherapy,
Vol. 44, No. 6, 2010, pp. 1090-1097.
doi:10.1345/aph.1M591
[48] A. Rook and R. Dawber, “Diffuse Alopecia: Endocrine,
Metabolic and Chemical Influences on the Follicular Cycle,” Blackwell Science Publications, Oxford, 1982.
[61] M. Iorizzo, C. Vincenzi, S. Voudouris, B. M. Piraccini
and A. Tosti, “Finasteride Treatment of Female Pattern
Hair Loss,” Archives of Dermatology, Vol. 142, No. 3,
2006, pp. 298-302. doi:10.1001/archderm.142.3.298
[49] W. F. Bergfeld and F. Mulinari-Brenner, “Shedding: How
to Manage a Common Cause of Hair Loss,” Cleveland
Clinic Journal of Medicine, Vol. 68, No. 3, 2001, pp.
[62] D. Rathnayake and R. Sinclair, “Innovative Use of Spironolactone as an Antiandrogen in the Treatment of Female Pattern Hair Loss,” Dermatologic Clinics, Vol. 28,
Copyright © 2013 SciRes.
JCDSA
Comprehensive Overview and Treatment Update on Hair Loss
8
[63] D. Rathnayake and R. Sinclair, “Use of Spironolactone in
Dermatology,” Skinmed, Vol. 8, No. 6, 2010, pp. 328332.
[71] C. E. Yeager and E. A. Olsen, “Treatment of Chemotherapy-Induced Alopecia,” Dermatologic Therapy, Vol. 24,
No. 4, 2011, pp. 432-442.
doi:10.1111/j.1529-8019.2011.01430.x
[64] J. D. Peereboom-Wynia, A. H. Van der Willigen, T. Van
Joost and E. Stolz, “The Effect of Cyproterone Acetate on
Hair Roots and Hair Shaft Diameter in Androgenetic
Alopecia in Females,” Acta Dermato-Venereologica, Vol.
69, No. 5, 1989, pp. 395-398.
[72] P. J. Hesketh, D. Batchelor, M. Golant, G. H. Lyman, N.
Rhodes and D. Yardley, “Chemotherapy-Induced Alopecia: Psychosocial Impact and Therapeutic Approaches,”
Supportive Care in Cancer, Vol. 12, No. 8, 2004, pp.
543-549. doi:10.1007/s00520-003-0562-5
[65] R. Sinclair, M. Wewerinke and D. Jolley, “Treatment of
Female Pattern Hair Loss with Oral Antiandrogens,”
British Journal of Dermatology, Vol. 152, No. 3, 2005,
pp. 466-473. doi:10.1111/j.1365-2133.2005.06218.x
[73] W. E. Minichiello, R. L. O’Sullivan, D. Osgood-Hynes
and L. Baer, “Trichotillomania: Clinical Aspects and
Treatment Strategies,” Harvard Review of Psychiatry,
Vol. 1, No. 6, 1994, pp. 336-344.
doi:10.3109/10673229409017100
No. 3, 2010, pp. 611-618. doi:10.1016/j.det.2010.03.011
[66] K. H. Chang, S. Rojhirunsakool and L. J. Goldberg,
“Treatment of Severe Alopecia Areata with Intralesional
Steroid Injections,” Journal of Drugs in Dermatology,
Vol. 8, No. 10, 2009, pp. 909-912.
[67] A. Tosti, B. M. Piraccini, M. Pazzaglia and C. Vincenzi,
“Clobetasol Propionate 0.05% under Occlusion in the
Treatment of Alopecia Totalis/Universalis,” Journal of
the American Academy of Dermatology, Vol. 49, No. 1,
2003, pp. 96-98. doi:10.1067/mjd.2003.423
[74] M. E. Franklin, K. Zagrabbe and K. L. Benavides,
“Trichotillomania and Its Treatment: A Review and Recommendations,” Expert Review of Neurotherapeutics,
Vol. 11, No. 8, 2011, pp. 1165-1174.
[75] M. Moeinvaziri, P. Mansoori, K. Holakooee, Z. S. Naraghi and A. Abbasi, “Iron Status in Diffuse Telogen Hair
Loss among Women,” Acta Dermatovenerologica Croatica, Vol. 17, No. 4, 2009, pp. 279-284.
[68] R. Hoffmann and R. Happle, “Topical Immunotherapy in
Alopecia Areata. What, How, and Why?” Dermatologic
Clinics, Vol. 14, No. 4, 1996, pp. 739-744.
doi:10.1016/S0733-8635(05)70400-9
[76] D. H. Rushton, “Nutritional Factors and Hair Loss,”
Clinical and Experimental Dermatology, Vol. 27, No. 5,
2002, pp. 396-404.
doi:10.1046/j.1365-2230.2002.01076.x
[69] C. J. Van den Hurk, M. Peerbooms, L. V. van de
Poll-Franse, J. W. Nortier, J. W. Coebergh and W. P.
Breed, “Scalp Cooling for Hair Preservation and Associated Characteristics in 1411 Chemotherapy Patients—Results of the Dutch Scalp Cooling Registry,” Acta Oncologica, Vol. 51, No. 4, 2012, pp. 497-504.
doi:10.3109/0284186X.2012.658966
[77] V. Boccaletti, E. Zendri, G. Giordano, L. Gnetti and G.
De Panfilis, “Familial Uncombable Hair Syndrome: Ultrastructural Hair Study and Response to Biotin,” Pediatric Dermatology, Vol. 24, No. 3, 2007, pp. E14-E16.
doi:10.1111/j.1525-1470.2007.00385.x
[70] P. K. Auvinen, U. A. Mähönen, K. M. Soininen, P. K.
Paananen, P. H. Ranta-Koponen, I. E. Saavalainen, R. T.
Johansson, M. Duvic, et al., “The Effectiveness of a Scalp
Cooling Cap in Preventing Chemotherapy-Induced Alopecia,” Tumori, Vol. 96, No. 2, 2010, pp. 271-275.
Copyright © 2013 SciRes.
[78] W. B. Shelley and D. Shelley, “Uncombable Hair Syndrome: Observations on Response to Biotin and Occurrence in Siblings with Ectodermal Dysplasia,” Journal of
the American Academy of Dermatology, Vol. 13, No. 1,
1985, pp. 97-102. doi:10.1016/S0190-9622(85)70150-8
JCDSA
FDA-approved drug restores hair in patients with alopecia areata
Date: August 17, 2014
Source: Columbia University Medical Center
Summary:
Researchers have identified the immune cells responsible for destroying hair follicles in people with alopecia
areata, a common autoimmune disease that causes hair loss, and have tested an FDA-approved drug that
eliminated these immune cells and restored hair growth in a small number of patients.
This image shows the effect of an FDA-approved drug that restored hair growth in a research subject with alopecia areata.
Left to right: at baseline, at 3 months, and at 4 months of treatment.
Credit: Julian Mackay-Wiggan
Researchers at Columbia University Medical Center (CUMC) have identified the
immune cells responsible for destroying hair follicles in people with alopecia areata,
a common autoimmune disease that causes hair loss, and have tested an FDAapproved drug that eliminated these immune cells and restored hair growth in a
small number of patients.
The results appear in today's online issue of Nature Medicine.
In the paper, the researchers report initial results from an ongoing clinical trial of the drug, which has produced complete hair
regrowth in several patients with moderate-to-severe alopecia areata. Data from three participants appear in the current
paper; each patient experienced total hair regrowth within five months of the start of treatment.
"We've only begun testing the drug in patients, but if the drug continues to be successful and safe, it will have a dramatic
positive impact on the lives of people with this disease," said Raphael Clynes, MD, PhD, who led the research, along with
Angela M. Christiano, PhD, professor in the Departments of Dermatology and of Genetics and Development at CUMC.
Alopecia areata is a common autoimmune disease that causes disfiguring hair loss. The disease can occur at any age and
affects men and women equally. Hair is often lost in patches on the scalp, but in some patients it also causes loss of facial
and body hair. There are no known treatments that can completely restore hair, and patients with the disease experience
significant psychological stress and emotional suffering.
Scientists have known for decades that hair loss in alopecia areata occurs when cells from the immune system surround
and attack the base of the hair follicle, causing the hair to fall out and enter a dormant state. Until now, the specific type of
cell responsible for the attack had been a mystery. A major clue was uncovered four years ago in Dr. Christiano's genetic
study of more than 1,000 patients with the disease. That study suggested that a "danger signal" in the hair follicles of
patients -- not previously linked to alopecia areata -- attracts the immune cells to the follicle and sparks the attack.
The current paper describes how the team first studied mice with the disease, then tracked backward from the danger signal
to identify the specific set of T cells responsible for attacking the hair follicles. Further investigation of mouse and patient
cells revealed how the T cells are instructed to attack and identified several key immune pathways that could be targeted by
a new class of drugs, known as JAK inhibitors.
Two FDA-approved JAK inhibitors tested separately by the researchers -- ruxolitinib and tofacitinib -- were able to block
these immune pathways and stop the attack on the hair follicles. In mice with extensive hair loss from the disease, both
drugs completely restored the animals' hair within 12 weeks. Each drug's effect was also long-lasting, as the new hair
persisted for several months after stopping treatment.
Together with Julian Mackay-Wiggan, MD, MS, director of the Clinical Research Unit in the Department of Dermatology at
CUMC and a practicing dermatologist at NewYork-Presbyterian/Columbia who treats patients with multiple types of hair loss,
the researchers rapidly initiated a small open-label clinical trial of ruxolitinib -- which is FDA approved for the treatment of a
blood disorder -- in patients with moderate-to-severe alopecia areata (with more than 30 percent hair loss). In three of the
trial's early participants, ruxolitinib completely restored hair growth within four to five months of starting treatment, and the
attacking T cells disappeared from the scalp.
"We still need to do more testing to establish that ruxolitinib should be used in alopecia areata, but this is exciting news for
patients and their physicians," Dr. Clynes said. "This disease has been completely understudied -- until now, only two small
clinical trials evaluating targeted therapies in alopecia areata have been performed, largely because of the lack of
mechanistic insight into it."
"The timeline of moving from genetic findings to positive results in a clinical trial in only four years is astoundingly fast and
speaks to this team's ability to perform translational science of the highest caliber," said David Bickers, MD, the Carl Truman
Nelson Professor of Dermatology and chair of the Department of Dermatology at CUMC and dermatologist-in-chief at
NewYork-Presbyterian/Columbia. A practicing dermatologist who cares for many patients with alopecia areata himself, Dr.
Bickers said, "There are few tools in the arsenal for the treatment of alopecia areata that have any demonstrated efficacy.
This is a major step forward in improving the standard of care for patients suffering from this devastating disease."
But as Dr. Christiano knows firsthand from her own personal experience with the disease, alopecia areata is too often
dismissed as simply an appearance-altering disease. "Nothing could be further from the truth," she said. "Patients with
alopecia areata are suffering profoundly, and these findings mark a significant step forward for them. The team is fully
committed to advancing new therapies for patients with a vast unmet need."
The paper is titled, "Alopecia Areata is Driven by Cytotoxic T Lymphocytes and is Reversed by JAK Inhibition." The other
contributors are Luzhou Xing, Zhenpeng Dai, Ali Jabbari, Jane E. Cerise, Claire Higgins, Weijuan Gong, Annemieke de
Jong, Sivan Harel, Gina M. DeStefano, Lisa Rothman, Pallavi Singh, Lynn Petukhova, all at CUMC.
This work was supported in part by USPHS NIH/NIAMS R01AR056016 (to A.M.C.) and R21AR061881 (to A.M.C and R.C.),
R01CA164309 and a Shared Instrumentation Grant for the LSR II Flow Cytometer (S10RR027050) to R.C., the Columbia
University Skin Disease Research Center (P30AR044535), as well as the Locks of Love Foundation and the Alopecia
Areata Initiative. J.E.C. is supported by (T32GM082271) Medical Genetics Training Grant (to A.M.C.). A.J., C.H., S.H., and
A.D. are recipients of Career Development Awards from the Dermatology Foundation, and A.J. is also supported by the
Louis V.Gerstner, Jr. Scholars Program.
Dr. Clynes worked on this study while an associate professor in the departments of Pathology and Cell Biology, Medicine,
and Dermatology at CUMC, and a medical oncologist at NewYork-Presbyterian/Columbia. Dr. Clynes is now employed by
Bristol-Myers Squibb, which was not involved in this research.
Columbia University has filed for intellectual property protection on the treatment of alopecia areata with small-molecule JAK
inhibitors (PCT/US2011/059029 and PCT/US2013/034688).
Story Source:
The above post is reprinted from materials provided by Columbia University Medical Center. Note: Materials may be
edited for content and length.
Journal Reference:
1.
Luzhou Xing, Zhenpeng Dai, Ali Jabbari, Jane E Cerise, Claire A Higgins, Weijuan Gong, Annemieke de Jong, Sivan Harel,
Gina M DeStefano, Lisa Rothman, Pallavi Singh, Lynn Petukhova, Julian Mackay-Wiggan, Angela M Christiano, Raphael
Clynes. Alopecia areata is driven by cytotoxic T lymphocytes and is reversed by JAK inhibition. Nature Medicine,
2014; DOI: 10.1038/nm.3645
MC Med. 2015; 13: 87.
Published online 2015 Apr 20. doi: 10.1186/s12916-015-0331-6
PMCID: PMC4417286
Hair regrowth in alopecia areata patients following Stem Cell Educator therapy
Yanjia Li, Baoyong Yan, Hepeng Wang, Heng Li, Quanhai Li, Dong Zhao, Yana Chen, Ye Zhang, Wenxia Li, Jun Zhang, Shanfeng
Wang, Jie Shen, Yunxiang Li, Edward Guindi, and Yong Zhao
Abstract
Background
Alopecia areata (AA) is one of the most common T cell-mediated autoimmune skin diseases, leading to chronic and
relapsing hair loss. AA affects both children and adults of all ages and on hairs of all colors, with a prevalence rate at 2%
of the overall population without gender predilection [1]. Clinical evidence supports a high prevalence of comorbid
autoimmune conditions among individuals with AA, such as thyroid disease, type 1 diabetes mellitus, inflammatory bowel
disease, and systemic lupus erythematosus [1,2]. The quality of life in AA patients has been significantly affected by the
disappointing outcomes, side effects, and relapses with current conventional therapies, including topical and systematic
applications of immunosuppressive regimens (such as corticosteroids and cyclosporine) or immune modulators (e.g.,
dithranol and diphenylcyclopropenone (DPCP)) [1,3]. To overcome these challenges, an innovative and translational
technology is necessary to advance the current management of AA. Ideally, this clinical approach should address multiple
or all of the underlying causes of autoimmunity in AA. However, similar to all other autoimmune diseases, possible
triggers for autoimmunity in AA include genetic, epigenetic, physical, emotional, social, and environmental factors. These
complicated factors may act independently or jointly to break down the “immune privilege” of hair follicles through
different molecular and cellular mechanisms, resulting in the autoimmune destruction of hair follicles by multiple immune
cells, such as CD4+ and/or CD8+ T cells and natural killer (NK) cells [1,4-7]. Thus, a comprehensive approach is needed to
fundamentally restore the immune privilege of hair follicles and address these multiple immune dysfunctions resulting
from a variety of etiological causes.
Hair follicles are normally immune privileged sites, similar to other organ tissue systems, such as the brain, eye, and testis,
and they contribute to the regulation of homeostasis through the neuroendocrine-immune network [8,9]. Under
physiological conditions, the maintenance of the immune privilege status may include the following potential mechanisms:
a low expression or absence of major histocompatibility complex (MHC) class I antigens and MHC class I chain-related A
(MICA) molecules; a presence of functionally impaired Langerhans cells; and local expression of potent
immunosuppressants (for example, transforming growth factor beta 1 (TGF-β1) and α-melanocyte stimulating hormone
(MSH)) [5-7,10]. It is well recognized that collapse of hair follicle immune privilege leads to the onset of AA [7,11-14].
Due to the complexity of AA-related autoimmune responses and the similarity with other autoimmune diseases, clinical
therapies and trials that only target one or a few components of the autoimmune responses are likely to fail, as has been
observed in recent clinical trials for type 1 diabetes [15-17]. Successful immune therapies will likely restore the immune
balance and peripheral tolerance by a comprehensive modulation within the entire human immune system.
We have previously characterized a novel type of stem cell from human umbilical cord blood, designated a cord bloodderived multipotent stem cell (CB-SC) [18,19]. CB-SCs are phenotypically and functionally different from other types of
stem cells [20], including hematopoietic stem cells (HSCs), mesenchymal stem cells (MSCs), endothelial progenitor cells
(EPCs), and monocyte-derived stem cells [21,22]. Preclinical work demonstrated the immune modulation capability of
CB-SCs in autoimmune-caused diabetic non-obese (NOD) mice [23] as well as with autoreactive human T cells from type
1 diabetic patients [19]. Recently, we reported on the development of the Stem Cell Educator therapy utilizing cultured
CB-SCs in clinical trials for both type 1 and type 2 diabetes [20,24,25]. Clinical data demonstrated that a single treatment
with the Stem Cell Educator provided lasting reversal of autoimmunity and a rebalance of immune responses that allowed
regeneration of islet β cells and improvement of metabolic control in subjects with long-standing type 1 diabetes [20,24].
Additionally, a phase 1/2 clinical study demonstrated that Stem Cell Educator therapy can control immune dysfunction
and restore the immune balance through the modulation of monocytes/macrophages, leading to a long-lasting
improvement of insulin sensitivity and metabolic control in long-standing type 2 diabetic patients [25]. The combined
preclinical and early clinical data [19,20,23-26] raise the intriguing possibility that the Stem Cell Educator therapy may
also be useful in overcoming the autoimmunity involved in AA. Here, we explore the therapeutic potential of Stem Cell
Educator therapy in AA subjects.
Methods
Cell proliferation and ex vivo co-cultures
Human buffy coat blood units were purchased from the Blood Center of New Jersey (East Orange, NJ, USA). Human
peripheral blood-derived mononuclear cells (PBMCs) were harvested as previously described [24,25]. The PBMCs were
stimulated for 5 days with Dynabeads coupled with anti-CD3, anti-CD28, and anti-CD137 antibodies (Life Technologies,
Grand Island, NY, USA) in the presence of 50 U/ml recombinant human IL-2 (rIL-2) and 5 ng/ml recombinant human IL7 (rIL-7) (R&D Systems, Minneapolis, MN), and incubated at 37°C, in 8% CO2. The proliferation of lymphocytes was
stained and analyzed with CellTrace™ CFSE Cell Proliferation kit (Life Technologies) following the manufacturer’s
instructions. The Dynabeads were removed for flow cytometry by using DynaMag-15 (Life Technologies) according to
the manufacturer’s instructions.
To perform ex vivo studies, human cord blood units were provided by the CORD:USE Cord Blood Bank (Orlando, FL,
USA). All cord blood samples were screened for alanine aminotransferase (ALT) and pathogenic antigen antibodies
(including anti-HCV, anti-HBsAg, anti-HIV, anti-Syphilis, anti-Chlamydia, and anti-Gonorrhea Abs), and only pathogenfree cord blood units were used for isolating CB-SCs. Human cord blood-derived stem cells (CB-SCs) were generated as
previously described [24,25] with the following modifications. Cord blood mononuclear cells were plated in serum-free
culture medium (Lonza, Walkersville, MD, USA) and incubated at 37°C, in 8% CO2. After 2 to 3 weeks, CB-SCs growing
at 80-90% confluence were prepared for co-culture with allogeneic lymphocytes.
Flow cytometry
Flow cytometric analyses were performed as previously described [23]. Cells were incubated with mouse anti-human
monoclonal antibodies (mAb; Beckman Coulter, Brea, CA, USA), including APC-Alexa Fluor 750-conjugated anti-CD4
and anti-CD66b, Krome Orange-conjugated anti-CD8α, anti-CD14, and anti-CD19, phycoerythrin (PE)-conjugated antiCD8β and anti-CD123, APC-conjugated anti-CD11c, phycoerythrin-Cy7 (PE-Cy7)-conjugated anti-BTLA, R
Phycoerythrin-Cyanine 5.5 (PC5.5)-conjugated anti-PD-1, and FITC-conjugated anti-HLA-DR. FITC-conjugated mouse
anti-human CD45 mAb was purchased from BD Biosciences (San Jose, CA, USA). PE-conjugated mouse anti-human
CD270 (HVEM) mAb was purchased from BioLegend (San Diego, CA, USA). Alexa Fluor 647-conjugated rat antihuman Oct 3/4 mAb was purchased from eBioscience (San Diego, CA, USA). Cells were stained for 30 min at room
temperature and then washed with PBS prior to flow analysis. Isotype-matched mouse anti-human IgG antibodies
(Beckman Coulter) served as a negative control for all fluorescein-conjugated IgG mAb. For intracellular staining, cells
were fixed and permeabilized using a PerFix-nc kit (Beckman Coulter). After staining, cells were collected and analyzed
using a Gallios Flow Cytometer (Beckman Coulter), equipped with 3 lasers (488 nm blue, 638 red, and 405 violet lasers)
for the concurrent reading of up to 10 colors. The final data were analyzed using the Kaluza flow cytometry analysis
software (Beckman Coulter).
Patients
The AA subjects were consecutive patients receiving care through the Department of Dermatology at the First Hospital of
Hebei Medical University (Shijiazhuang, Hebei, China) who were enrolled in a phase 1/phase 2, open-label clinical trial
conducted from 29 August 2012 through 31 July 2014. With oversight from a planning committee, the principal
investigator designed the trial and received ethical approval for the clinical treatment protocol and consent from the First
Hospital of Hebei Medical University (Shijiazhuang, Hebei, China). Helsinki protocols were followed. Participants and
their parents provided written informed consent to participate in this study, and for the publication of images and details
related to the individual participants. Thirty subjects were approached for the study. The trial was conducted with nine
subjects with established AA (mean alopecic duration of 5 years) (Table 1). Patients were qualified for enrollment if they
met the Alopecia Areata Investigational Assessment Guidelines of the National Alopecia Areata Foundation (NAAF). All
subjects receiving Stem Cell Educator therapy had been treated with current standard therapy, but the treatment failed.
With at least a 3-month washout period, subjects received one treatment with the Stem Cell Educator therapy. Key
exclusion criteria included: clinical fever; clinically significant liver, kidney, or heart disease; pregnancy;
immunosuppressive medication; viral and bacterial diseases; or diseases associated with immunodeficiency; or any other
clinically significant, coexisting conditions.
Table 1
Characteristics of the AA subjects before treatment
Stem Cell Educator therapy and follow-up
Nine participants received a single treatment with the Stem Cell Educator (Tianhe Stem Cell Biotechnologies®, Jinan,
China) and follow-up studies, as described in following diagram (Figure 1).
Figure 1
Diagram of Stem Cell Educator therapy for the treatment and follow-up studies.
The preparation of CB-SC cultures and Stem Cell Educators was performed as previously described [24]. Briefly, human
cord blood units derived from healthy allogeneic donors were obtained from Maternal and Child Health Hospital (Jinan,
Shandong, China). All cord blood samples were screened for alanine aminotransferase (ALT) and pathogenic antigen
antibodies (including anti-HCV, anti-HBsAg, anti-HIV, and anti-Syphilis Abs), and only pathogen-free cord blood units
were used for isolating CB-SCs. Human CB-SCs were generated as previously described with the following modifications
[18,23]. Cord blood mononuclear cells were plated in serum-free culture medium (Lonza, Walkersville, MD) and
incubated at 37°C, in 8% CO2. After 2 to 3 weeks, CB-SCs growing at 90% confluence were prepared for clinical trial.
The endotoxin level was < 0.05 EU/ml. One Educator device was generated from one cord blood unit, and used for one
subject.
For Stem Cell Educator therapy, a 16-gauge IV needle was placed in the left (or right) median cubital vein, and the
patient’s blood was passed through a Blood Cell Separator MCS+ (Haemonetics®, Braintree, MA, USA) for 6 to 7 hours
to isolate mononuclear cells in accordance with the manufacturer’s recommended protocol. The collected mononuclear
cells were transferred into the device for exposure to allogeneic CB-SCs, and other blood components were automatically
returned to the patient. In the Stem Cell Educator, mononuclear cells separated from a patient’s blood are slowly passed
through the stacked discs of material with adherent CB-SCs. After 2 to 3 hours in the device, CB-SC-treated mononuclear
cells were returned to the patient’s circulation via a dorsal vein in the hand with physiological saline (2 to 3 ml/min).
Approximately 10,000 ml of blood was processed during the procedure resulting in approximately two repeated
educations for the lymphocyte fraction. The whole process took 8 to 9 hours. During the apheresis, some of the patients
received oral calcium gluconate solution (10%, 10 ml) to ease the tingling of the lips or toes, due to the hypocalcemia
caused by the citrate anticoagulant. They did not receive any other medications (such as antibiotics) during the course of
treatment. Patients were hospitalized for one day to monitor temperature and conduct blood count tests for adverse
reactions following treatment. Follow-up visits were scheduled 4, 12, 24, 40, 56, 84, and 112 weeks after treatment for
clinical assessments and laboratory tests. Skin biopsies of scalps were performed before the treatment and at 12 weeks
post-treatment. The time points for follow-up studies were similar for all subjects. Previous work demonstrated that
participants receiving sham therapy failed to show changes in immune modulation [24]. Thus, the main outcome measures
in the current trial were changes in hair growth and immune markers between baseline and follow-up.
Study end points
The primary study end points were feasibility and safety of the Stem Cell Educator therapy through 24 weeks posttreatment and preliminary evaluation of the efficacy of the therapy for improving hair growth in AA subjects. The
secondary study end point was preliminary evidence for efficacy of the therapy in modulating autoimmunity by flow
cytometry [24,25]. Baseline blood samples and scalp tissues by biopsy were collected prior to Stem Cell Educator therapy.
Immunohistochemistry and histology
Biopsied scalp tissues were fixed in 10% formaldehyde, embedded in paraffin, and processed for hematoxylin and eosin
(H&E) staining. To determine phenotypes of infiltrated leukocytes and released cytokines, cryosections of frozen tissues
were used. Cryosections (5 μm thick) of frozen tissues from AA subjects before and post-treatment with Stem Cell
Educator therapy were prepared using a Leica CM1850 cryostat [23]. Cryosections were immunostained with different
mAbs including FITC-conjugated anti-CD1c, anti-CD11b, anti-CD14, anti-CD83, anti-DEC205 (eBioscience), anti-TGFβ1 (BioLegend), PE-conjugated anti-TGF-β1 (BioLegend), and Alexa Fluor 488-conjugated anti-human Foxp3
(eBioscience), followed by imaging with an Olympus IX71 inverted microscope. The fluorescence intensity was measured
by using the ImageJ 1.46 software.
Statistical analysis
An intention-to-treat approach was used, with nine patients undergoing Stem Cell Educator therapy. All patients were
included in safety analyses. The primary efficacy end points were hair regrowth and the change in immune markers
between baseline and follow-up. Statistical analyses of data were performed using the two-tailed Student’s t-test to
determine statistical significance. Values were given as mean ± SD (standard deviation).
Results
Suppressed proliferation of antigen-specific T cells by co-culture with CB-SCs
The expansion of antigen-specific autoreactive T cells is the critical step leading to the destruction of tissues in
autoimmune diseases. Recently, mouse and human data have demonstrated that CD8+NKG2D+ effector T cells function as
a key mediator in the pathogenesis of AA [27]. To explore the therapeutic potential of CB-SC in AA,
CD8+NKG2D+ effector T cells from human peripheral blood mononuclear cells (PBMC) were activated and expanded
with Dynabeads coupled with anti-CD3, anti-CD28, and anti-CD137 mAb in the presence of IL-2 and IL-7. After ex
vivo expansion with this mAb combination for 5 days, there were large numbers of cell clusters with different sizes
floating in the supernatant (Figure 2A, left panel), suggestive of significant cell proliferation. However, this phenomenon
was not evident in the presence of CB-SCs (Figure 2A, right panel). Flow cytometry revealed that 52% of lymphocytes
proliferated in response to costimulation with this combination of mAb molecules and growth factors (Figure 2B, middle
panel). By contrast, there were only 13% of lymphocytes proliferating after co-culture with CB-SCs (Figure 2B, right
panel). Triple color staining demonstrated that 25% of CD8+NKG2D+ T cells were proliferated upon costimulation in the
absence of CB-SCs. Notably, the percentage of proliferating CD8+NKG2D+ T cells was reduced to 5% following coculture with CB-SCs. Further multi-color flow cytometry indicated that the percentage of CD8+NKG2D+ T cells was
decreased from 25.6% ± 0.43% to 13.87% ± 3.43% in the presence of CB-SCs (Figure 2C, left panels) P = 0.04).
Additionally, we examined the expression of coinhibitory molecules on CD8+NKG2D+ T cells, such as BTLA (B and T
lymphocyte attenuator) and PD-1 (programmed death-1 receptor). Results confirmed that co-culture with CB-SCs
increased the percentage of CD8+NKG2D+BTLA+PD-1+ T cells from 69% to 91%. Their mean fluorescence intensity
(MFI) also increased after co-culture with CB-SCs (Figure 2C, right panels). These data demonstrated that CB-SCs could
markedly suppress the proliferation of CD8+NKG2D+ T cells and up-regulate the expression of coinhibitory molecules on
those cells. This finding supports the clinical-translational potential of CB-SCs in AA subjects.
Figure 2
Ex vivo studies of the immune modulation of CB-SCs on T cells. (A)Phase contrast microscopy shows the formation of
cell clusters in human peripheral blood-derived lymphocytes that were activated with Dynabeads coupled with anti-CD3,
anti-CD28, and anti-CD137 ...
Expression of herpesvirus entry mediator (HVEM, CD270) on CB-SCs
Human CB-SCs mediate immune modulation through the release of soluble factors (for example, nitric oxide and TGF-β1)
and the expression of surface molecules such as PD-L1 (programmed death-1 ligand) [19,20,28]. To investigate additional
potential molecular mechanisms underlying the immune modulation, we also found that CB-SCs strongly displayed the
surface molecule HVEM (Figure 3A), the ligand of BTLA. Triple color staining confirmed the co-expression of HVEM on
CB-SCs positive with molecular markers of leukocyte common antigen CD45+ and embryonic transcription factor
Oct3/4+ (Figure 3B).To further substantiate that HVEM may be a mechanism of immune modulation by CB-SCs, flow
cytometry also demonstrated the expression of BTLA and PD-1 on most immune cells, including CD4+ and CD8β+ T cells,
CD19+ B cells, CD14+ monocytes, CD11c+ myeloid dendritic cells (mDCs), CD123+ plasmacytoid dendritic cells (pDCs),
and CD66b+ granulocytes (Figure 3C). There were about 40-80% BTLA+PD-1+cells in each subpopulation of immune cells
(Figure 3D). These data suggest that CB-SCs may display a broad spectrum of modulatory capacity on immune cells via
HVEM/BTLA and PD-L1/PD-1 signaling pathways.
Figure 3
Flow cytometry analysis. (A) Expression of HVEM on CB-SCs. Isotype-matched IgG served as control. (B) Expression of
+
+
HVEM on the gated CD45 Oct3/4 CB-SCs. (C) Expression of BTLA and PD-1 on peripheral blood-derived immune
cells. (D) The percentage of ...
Hair regrowth in alopecia areata subjects
Nine AA subjects received one treatment with Stem Cell Educator therapy and completed the study. All patients tolerated
the procedure well, without any significant adverse events during the course of treatment. Their baseline clinical
characteristics are described in Table 1. No participants experienced any significant adverse events during the course of
treatment and the 2-year follow-up period. At 4 weeks post-treatment with Stem Cell Educator therapy, there was hair
regrowth in subjects with patchy AA and alopecia totalis (Figure 4). There were short vellus hairs on the scalp of patients
with AA universalis (3/4) at the 12-week follow-up. Two participants (one having alopecia totalis and another having
multiple patches of AA) achieved complete hair regrowth at 12 weeks and 16 weeks, post-treatment, respectively, and
remained completely recovered with no relapse after 2 years (Figure 4). Patients (3/4) with alopecia universalis exhibited
regrowth of eyebrows and eyelashes at the 12-week follow-up. Notably, the regrowth of eyebrows and a mustache
occurred in a 17-year-old boy affected by severe alopecia universalis since he was 1 year old. Additionally, one of nine
subjects with nail pitting also improved, as indicated by the reduction of the number and the cavity of nail pitting at 4
weeks after receiving Stem Cell Educator therapy. All of these improvements were maintained throughout the final
follow-up at 2 years. Of nine AA subjects, only one participant with alopecia universalis failed to show a response to the
Stem Cell Educator therapy, possibly due to a previous long-term therapy with oral prednisone. Overall, the proof-ofconcept data demonstrated the therapeutic potential of Stem Cell Educator therapy for the treatment of AA subjects.
Figure 4
Regrowth of hair following Stem Cell Educator therapy. A subject with severe AA (patient 4 in Table 1) achieved
complete hair regrowth at 12 weeks follow-up after receiving Stem Cell Educator therapy and maintained regrowth
through the last follow-up ...
Systematic immune modulation after receiving Stem Cell Educator therapy
To explore the immune modulation of Stem Cell Educator therapy in AA subjects, we examined changes in the percentage
of regulatory T cells (Treg) in their peripheral blood by using the specific intracellular marker, FoxP3. Flow cytometry
revealed that the percentage of FoxP3+ Treg at 4 weeks was unchanged from the baseline (1.69% ± 1.02 versus
1.38% ± 0.85, P = 0.49). This result suggested that the immune modulation via Stem Cell Educator therapy in AA subjects
may act through a different mechanism than induction of Treg. TGF-β1, one of the best-characterized cytokines
contributing to the induction of peripheral immune tolerance [29], also plays a crucial role in modulating the normal
cycling of hair follicles [30]. Flow cytometry demonstrated a marked increase in TGF-β1 expression by blood
mononuclear cells 4 weeks after receiving Stem Cell Educator therapy (P = 0.015, Figure 5A). Additionally, participants
exhibited significant up-regulation of Th2 cytokines IL-4 and IL-5 expression at the 4-week follow-up (P = 0.012
and P = 0.022, respectively, Figure 5A). Expression of IL-13 was also significantly increased in 6/9 participants
(3.69 ± 3.27 versus 15.55 ± 7.48, P = 0.005). No changes were observed in the level of Th1 cytokine IL-12 (P = 0.24,
Figure 5A). Thus, these data suggested that the up-regulation of Th2 cell responses may suppress the Th1 cell-mediated
autoimmune response in AA subjects [1,4,31] via associated cytokines [32]. The Stem Cell Educator therapy may shift the
balance towards Th2-mediated immune responses, leading to the clinical efficacy in AA subjects.
Figure 5
Immune modulation of Stem Cell Educator therapy. Patient lymphocytes were isolated from peripheral blood by FicollHypaque technique (γ = 1.077) for flow cytometric analyses in AA patients at baseline and 4 weeks after Stem Cell ...
The costimulatory molecule, CD28, functions as a key signal leading to Th2 cell differentiation and activation [33-36]. To
determine changes in expression of costimulatory molecules, we examined lymphocytes for their levels of CD28 and
inducible costimulator (ICOS). Flow cytometry demonstrated that the expression of CD28 was markedly increased in 8/9
participants 4 weeks after Stem Cell Educator therapy (P = 0.013, Figure 5B), but levels of ICOS were unchanged in all
participants (P = 0.84, Figure 5B). Therefore, the up-regulation of CD28 expression, together with the increase of IL-4
production in AA subjects, can provide critical signals that shift the differentiation of human CD4+ T cells into Th2 cells
[36] and attenuate Th1 cell responses.
Formation of a “ring of TGF-β1” leading to local immune modulation and restoration of immune privilege of hair
follicles after Stem Cell Educator therapy
To clarify the molecular and cellular mechanism underlying the regrowth of hairs and the immune modulation, we
performed immunohistochemistry on fresh tissues via the biopsy of alopecic lesions from subjects after receiving Stem
Cell Educator therapy. The histology of the alopecic lesions demonstrated a dense, perifollicular lymphocytic infiltration
around anagen hair follicles. Twelve weeks after receiving Stem Cell Educator therapy, histological examination revealed
the restoration of hair follicle architecture and the disappearance of the substantial perifollicular infiltration of
lymphocytes. Additionally, horizontal sections confirmed an increase in the density of total hair follicles in these
participants with alopecia totalis.
TGF-β1 is a pleiotropic growth factor that plays a key role not only in the induction of local immune tolerance [29], but
also in the regulation of cycling of hair follicles via the inhibition of keratinocyte proliferation and the induction of
apoptosis [30,37,38]. Previous works demonstrated that TGF-β1 contributed to the therapeutic efficacy of Stem Cell
Educator therapy in both autoimmune-caused diabetic NOD mice [23] and diabetic patients [24,25]. Notably, in addition
to the up-regulation of TGF-β1 expression in the peripheral blood mononuclear cells (Figure 5A), immunohistochemistry
demonstrated that the level of TGF-β1 expression post-treatment (21.78 ± 0.27) was much higher than that of baseline
before treatment (5.14 ± 0.01, P = 3.14337E-14), specifically at the proximal anagen hair follicle (Figure 5C, middle
panel). The expression of TGF-β1 formed a cycle around the hair follicles (Figure 5C, bottom panel), similar to the “ring
of TGF-β1” that we observed in a previous study [23]. It suggested that this unique feature of TGF-β1 distribution may
contribute to reconstitution of the immune privilege of hair follicles and protect the regenerated hair follicles against
further destruction by autoimmune cells. HE staining further demonstrated the reduction of immune cell infiltration and
restoration of normal architecture of the hair follicles (Figure 5D).
To elucidate the major origin of the TGF-β1 production involved in the formation of the “ring of TGF-β1,” we performed
double immunostaining in biopsied tissues by using the markers of monocyte/macrophage (CD14 and CD11b),
Langerhans/dendritic cells (CD83 and DEC205), myeloid dendritic cells (CD1c), and Treg FoxP3, respectively. There
were a few CD14+ monocytes/CD11b+ macrophages, Langerhans/dendritic cells (positive with CD83, DEC 205, or CD1c),
and FoxP3+ Treg cells distributed in the dermal tissues. Double immunostaining showed weak staining for TGF-β1 in
these immune cells, indicating that these immune cells were not the major source of TGF-β1. Notably, we found that there
was a strong expression of TGF-β1 in the proximal root sheath of hair follicles of participants after receiving Stem Cell
Educator therapy (Figure 5C, bottom panels) relative to the baseline level (Figure 5C, top panel). These data suggested
that keratinocytes were recovered after receiving Stem Cell Educator therapy and became the major TGF-β1-producing
cells leading to the restoration of immune privilege and the induction of immune tolerance in hair follicles. The molecular
mechanisms underlying the up-regulation of TGF-β1 in keratinocytes need to be clarified in future studies.
Go to:
Discussion
AA is a devastating autoimmune disease that affects patients’ daily lives. Immune dysfunction of AA subjects is
complicated, not only localizing in hair follicles, but also having effects outside of hair follicles with the development of
other autoimmune diseases. Overcoming the autoimmunity represents one of the key hurdles in the treatment of AA.
Systematic applications of immunosuppressive regimens usually yield significant side effects. Localized therapies have
been widely utilized in clinic, including intralesional injections of glucocorticoids and the use of topical sensitizers
through the induction of contact allergy (for example, dithranol and diphenylcyclopropenone), as well as topical
corticosteroids and minoxidil [1,3,39]. To date, although a multitude of therapeutic options exist, neither local treatments
nor systematic approaches can provide a cure for AA subjects [1,39]. Current clinical proof-of-concept data reveal the
safety and efficacy of the Stem Cell Educator therapy approach in the treatment of AA subjects, as demonstrated by
clinical outcomes in hair regrowth. This finding opens up a new avenue for AA clinical treatment by using the
comprehensive immune modulation induced by Stem Cell Educator therapy. Because this disorder affects children of all
hair colors [1], it is important to highlight that pediatric apheresis presents unique challenges due to children’s low body
weight (<40 kg) and height (<140 cm) and the difficulties in vascular access and clinical monitoring. To overcome these
technical hurdles and improve the safety in pediatric apheresis, alternative approaches should be considered for the
treatment of pediatric AA subjects such as the application of a different apheresis machine with low extracorporeal blood
volume, blood priming, and femoral vein catheterization.
AA is characterized as a T cell-mediated autoimmune disease, and CD8+ T cells seem to dominate the response. They may
recognize the MHC class I-restricted melanogenesis-associated autoantigens and/or anagen-associated hair follicle
autoantigens and thereby mediate the destruction of hair follicles [1,14]. More recently, CD8β+NKG2D+ T cells have been
characterized as a major player leading to the autoimmune destruction of hair follicles [27]. Therefore, it is essential to
attenuate these effector CD8+ T cells through the induction of peripheral immune tolerance to these self-antigens. Notably,
we found that co-culture with CB-SCs could suppress the proliferation of activated CD8β+NKG2D+ T cells and reduce
their percentage. Up-regulation of the expression of coinhibitory molecules BTLA and PD-1 on CD8β+NKG2D+ T cells
may further attenuate their cytotoxic effects. The current study confirmed the expression of BTLA ligand HVEM on CBSCs. Previous work demonstrated that the strong expression of programmed death-1 ligand (PD-L1) on CB-SCs
contributed to the immune modulation of CD8 T cells [28]. Thus, CB-SCs may directly modulate CD8β+NKG2D+ T cells
through the PD-1/PD-L1 and BTLA/HVEM pathways.
Additionally, CB-SCs strongly express the autoimmune regulator (Aire) [24] transcription factor. Aire proteins are usually
found in thymic medullary epithelial cells, which play a central role in T cell development and the induction of immune
tolerance by mediating ectopic expression of peripheral self-antigens and mediating the deletion of autoreactive T cells
[40,41]. Knockdown of Aire protein expression resulted in a reduction of PD-L1 expression on CB-SCs. Thus, we
hypothesize that, in a way, the Stem Cell Educator therapy may function as “an artificial thymus” that circulates a patient’s
blood through a blood cell separator [20], briefly allows interactions between T cells and other immune cells with CBSCs in vitro, induces immune tolerance through the actions of Aire [24], expression of PD-L1 and HVEM, the release of
soluble factors (nitric oxide and TGF-β1), and cell-cell contacting mechanisms [20,28], returns the educated autologous
lymphocytes to the patient’s circulation, and achieves immune balance and homeostasis in these AA subjects. Of interest,
apheresis only withdraws approximately 10-15% of all lymphocytes, and since many pathogenic immune cells likely
remain in the hair follicles and the connective tissue sheath which fail to enter into the blood circulation during the
apheresis procedure, many autoimmune cells escape direct interaction with the CB-SCs. This would suggest that some of
the cells altered by direct encounter with CB-SC can spread the tolerance systemically. Additionally, due to the short life
span of most lymphocytes, subjects with severe AA may need additional treatments, perhaps at 3- to 6-month intervals, to
improve the efficacy and possibly prevent the relapse of disease. To improve the clinical efficacy of Stem Cell Educator
therapy, the sooner treatment with this therapy begins after diagnosis, the higher the chance of rescuing hair follicles and
finding a cure for AA.
Animal and clinical studies demonstrated that both CD4+ Th1 cells and CD8+ T cells are required for the pathogenesis of
AA [1,4,42]. Up-regulation of Th1 cytokines in AA subjects, not Th2 cytokines, exacerbates the autoimmune destruction
[31,43,44]. Kubo and colleagues reported that there was a positive correlation between the severity of the alopecia and the
increase of Th1 cells, inversely proportional to the number of IL-4-producing Th2 cells [45]. Therefore, the promotion of
Th2 immune responses has been proposed to be beneficial for the treatment of AA patients [1,4]. The current study
demonstrated that Th2 response-associated cytokines such as IL-4, IL-5, and IL-13 in these AA subjects were markedly
increased after receiving Stem Cell Educator therapy. Additionally, CD28, one of the major costimulatory molecules
contributing to the differentiation of Th2 cells [33-36], was up-regulated after Stem Cell Educator therapy. Thus, the
combination of CD28 + IL-4 can provide key signals facilitating naïve or memory CD4+ T cells and giving rise to Th2
cells via the activation of mutagen-activated protein (MAP) kinas and extracellular signal-regulated kinas (ERK) signaling
pathways [36]. Consequently, these Th2 cells and their cytokines may antagonize Th1 cell functions and counterbalance
their AA-related autoimmune responses [32].
Collapse of immune privilege in hair follicles is the major cause of pathogenesis in AA. Due to constitutively low or
absent expression of MHC class I antigen in the proximal hair follicle epithelium, hair follicles may initially be attacked
by NK cells through NK cell function-activating receptors NKG2D and NKG2C [5,46]. Thus, attenuating NK cells is also
necessary to reestablish the immune privilege and fundamentally advance the clinical outcomes for the treatment of AA.
Notably, current data provide evidence for the up-regulation of TGF-β1 production in peripheral blood mononuclear cells,
as well as the formation of a “ring of TGF-β1” in hair follicles of AA subjects after receiving Stem Cell Educator therapy.
TGF-β1 can significantly suppress the proliferation and activity of NK cells [47], in addition to its effects on CD4+ and
CD8+ T cells [29]. Thus, TGF-β1 may play a key role in the restoration of immune privilege of hair follicles and the
induction of local immune tolerance.
It is also well known that TGF-β1 is a pleiotropic growth factor that plays a key role in the production and remodeling of
the extracellular matrix [48]. Animal studies show that TGF-β1 acts as an essential factor contributing to the regulation of
cycling and remodeling of hair follicles via the inhibition of keratinocyte proliferation and induction of apoptosis
[30,37,38], as well as one of the key niche factors that regulate melanocyte stem cell immaturity and quiescence in the
bulge area of hair follicles [49]. Previous work demonstrated that the formation of a “ring of TGF-β1” around pancreatic
islets may protect the newly regenerated islet β cells against infiltrating lymphocytes and macrophages [23], providing a
safe environment for promotion of regeneration of pancreatic islet β cells in long-standing type 1 diabetic patients [20,24].
Thus, the formation of a “ring of TGF-β1” may not only protect hair follicles through the restoration of immune privilege,
but may also lead to the activation of epithelial hair follicle stem cells and hair regrowth. Additional molecular and cellular
mechanisms underlying the Stem Cell Educator therapy in humans can be further explored by studying easily accessible
and abundant hair follicles. Thus, clinical success in AA by the Stem Cell Educator therapy approach may open up new
avenues for the treatment of other autoimmune diseases.
Conclusions
AA is one of the most common skin autoimmune diseases, significantly affecting the life quality of patients. The current
phase 1/phase 2 study demonstrates the safety and feasibility of Stem Cell Educator therapy in the treatment of AA
subjects. Findings from this trial provide visible evidence that Stem Cell Educator therapy can control the autoimmunity
and lead to hair regrowth.
Acknowledgments
This clinical trial was supported by the China Jinan 5150 Program, Jinan High-Tech Development Zone. We are grateful
to Mr. Ajay Plodder and Bartech for generous funding support via the HackensackUMC Foundation. The sponsors had no
role in conception, design, or conduct of the study; collection, management, analysis, or interpretation of the data; or
preparation, review, or approval of the manuscript. The researchers worked independently of the funders. We are grateful
to Dr. Robert Korngold for his helpful discussions and review of this manuscript.
Abbreviations
AA
alopecia areata
AIRE
autoimmune regulator
BTLA
B and T lymphocyte attenuator
CB-SC cord blood-derived multipotent stem cell
CD
cluster differentiation antigen
CFSE
carboxyfluorescein succinimidyl ester
DC
dendritic cell
ICOS
inducible costimulator
IL-4
interleukin-4
IL-5
interleukin-5
IL-12
interleukin-12
IL-13
interleukin-13
NOD
non-obese diabetes
PD-1
programmed death-1 receptor
TGF-β1 transforming growth factor β1
Th
helper T cells
Treg
regulatory T cells
Footnotes
Competing interests
Dr. Zhao (YZ), inventor of this technology, led the clinical study, and has an investment and a fiduciary role in Tianhe Stem Cell
Biotechnologies Inc. (licensed this technology from the University of Illinois at Chicago). YeZ, WL, SW, JS, and YuL are employees of Tianhe
Stem Cell Biotechnologies Inc. who might have an interest in the submitted work. All other authors (YaL, BY, HW, HL, QL, DZ, YC, JZ, and
EG) have no financial interests that may be relevant to the submitted work.
Authors’ contributions
YZ and YaL designed the trial and analyzed the data. YZ drafted the manuscript and obtained the funding. HW and HL collected data. BY,
QL, DZ, YC, YeZ, WL, SW, JS, JZ, YuL, and EG provided administrative, technical, or material support. All authors had full access to all the
data and take responsibility for the integrity of the data and the accuracy of the data analysis. All authors read and approved the final
manuscript.
Contributor Information
Yanjia Li, Email: [email protected].
Baoyong Yan, Email: [email protected].
Hepeng Wang, Email: [email protected].
Heng Li, Email: [email protected].
Quanhai Li, Email: [email protected].
Dong Zhao, Email: [email protected].
Yana Chen, Email: [email protected].
Ye Zhang, Email: [email protected].
Wenxia Li, Email: [email protected].
Jun Zhang, Email: [email protected].
Shanfeng Wang, Email: [email protected].
Jie Shen, Email: [email protected].
Yunxiang Li, Email: [email protected].
Edward Guindi, Email: [email protected].
Yong Zhao, Email: [email protected].
References
A,
Etzioni
A,
Paus
R.
Alopecia
1. Gilhar
10.1056/NEJMra1103442. [PubMed] [Cross Ref]
areata. N
Engl
J
Med. 2012;366:1515–25.
doi:
2. Huang KP, Mullangi S, Guo Y, Qureshi AA. Autoimmune, atopic, and mental health comorbid conditions associated
with
alopecia
areata
in
the
United
States. JAMA
Dermatol. 2013;149:789–94.
doi:
10.1001/jamadermatol.2013.3049. [PubMed] [Cross Ref]
3. Galan-Gutierrez M, Rodriguez-Bujaldon A, Moreno-Gimenez JC. Update on the treatment of alopecia areata. Actas
Dermosifiliogr. 2009;100:266–76. doi: 10.1016/S0001-7310(09)70820-8. [PubMed][Cross Ref]
4. Gilhar A, Landau M, Assy B, Shalaginov R, Serafimovich S, Kalish RS. Mediation of alopecia areata by cooperation
between CD4+ and CD8+ T lymphocytes: transfer to human scalp explants on Prkdc(scid) mice.Arch
Dermatol. 2002;138:916–22. doi: 10.1001/archderm.138.7.916. [PubMed] [Cross Ref]
5. Ito T, Ito N, Saatoff M, Hashizume H, Fukamizu H, Nickoloff BJ, et al. Maintenance of hair follicle immune privilege
is
linked
to
prevention
of
NK
cell
attack. J
Invest
Dermatol. 2008;128:1196–206.
doi:
10.1038/sj.jid.5701183. [PubMed] [Cross Ref]
6. Ito T, Meyer KC, Ito N, Paus R. Immune privilege and the skin. Curr Dir Autoimmun. 2008;10:27–52. doi:
10.1159/000131412. [PubMed] [Cross Ref]
7. Paus R, Ito N, Takigawa M, Ito T. The hair follicle and immune privilege. J Investig Dermatol Symp Proc.2003;8:188–
94. doi: 10.1046/j.1087-0024.2003.00807.x. [PubMed] [Cross Ref]
8. Ito N, Ito T, Betterman A, Paus R. The human hair bulb is a source and target of CRH. J Invest
Dermatol.2004;122:235–7. doi: 10.1046/j.1523-1747.2003.22145.x. [PubMed] [Cross Ref]
9. Ito N, Ito T, Kromminga A, Bettermann A, Takigawa M, Kees F, et al. Human hair follicles display a functional
equivalent of the hypothalamic-pituitary-adrenal axis and synthesize cortisol. FASEB J.2005;19:1332–4. [PubMed]
10. Ito T, Ito N, Bettermann A, Tokura Y, Takigawa M, Paus R. Collapse and restoration of MHC class-I-dependent
immune privilege: exploiting the human hair follicle as a model. Am J Pathol. 2004;164:623–34. doi: 10.1016/S00029440(10)63151-3. [PMC free article] [PubMed] [Cross Ref]
11. Gilhar A, Ullmann Y, Berkutzki T, Assy B, Kalish RS. Autoimmune hair loss (alopecia areata) transferred by T
lymphocytes to human scalp explants on SCID mice. J Clin Invest. 1998;101:62–7. doi: 10.1172/JCI551. [PMC free
article] [PubMed] [Cross Ref]
12. Gilhar A, Paus R, Kalish RS. Lymphocytes, neuropeptides, and genes involved in alopecia areata. J Clin
Invest. 2007;117:2019–27. doi: 10.1172/JCI31942. [PMC free article] [PubMed] [Cross Ref]
13. McElwee KJ, Freyschmidt-Paul P, Hoffmann R, Kissling S, Hummel S, Vitacolonna M, et al. Transfer of CD8(+) cells
induces localized hair loss whereas CD4(+)/CD25(-) cells promote systemic alopecia areata and CD4(+)/CD25(+) cells
blockade disease onset in the C3H/HeJ mouse model. J Invest Dermatol.2005;124:947–57. doi: 10.1111/j.0022202X.2005.23692.x. [PubMed] [Cross Ref]
14. Paus
R,
Nickoloff
BJ,
Ito
T.
10.1016/j.it.2004.09.014. [PubMed] [Cross Ref]
A
‘hairy’
privilege. Trends
Immunol. 2005;26:32–40.
doi:
15. Bach JF. Anti-CD3 antibodies for type 1 diabetes: beyond expectations. Lancet. 2011;378:459–60. doi:
10.1016/S0140-6736(11)60980-X. [PubMed] [Cross Ref]
16. Mathieu C, Gillard P. Arresting type 1 diabetes after diagnosis: GAD is not enough. Lancet.2011;378:291–2. doi:
10.1016/S0140-6736(11)60978-1. [PubMed] [Cross Ref]
17. Wherrett DK, Bundy B, Becker DJ, DiMeglio LA, Gitelman SE, Goland R, et al. Antigen-based therapy with glutamic
acid decarboxylase (GAD) vaccine in patients with recent-onset type 1 diabetes: a randomised double-blind
trial. Lancet. 2011;378:319–27. doi: 10.1016/S0140-6736(11)60895-7. [PMC free article][PubMed] [Cross Ref]
18. Zhao Y, Wang H, Mazzone T. Identification of stem cells from human umbilical cord blood with embryonic and
hematopoietic characteristics. Exp Cell Res. 2006;312:2454–64. doi: 10.1016/j.yexcr.2006.04.008. [PubMed] [Cross Ref]
19. Zhao Y, Mazzone T. Human cord blood stem cells and the journey to a cure for type 1 diabetes.Autoimmun
Rev. 2010;10:103–7. doi: 10.1016/j.autrev.2010.08.011. [PubMed] [Cross Ref]
20. Zhao Y. Stem cell educator therapy and induction of immune balance. Curr Diab Rep. 2012;12:517–23. doi:
10.1007/s11892-012-0308-1. [PubMed] [Cross Ref]
21. Zhao Y, Glesne D, Huberman E. A human peripheral blood monocyte-derived subset acts as pluripotent stem
cells. Proc Natl Acad Sci U S A. 2003;100:2426–31. doi: 10.1073/pnas.0536882100.[PMC free article] [PubMed] [Cross
Ref]
22. Zhao Y, Mazzone T. Human umbilical cord blood-derived f-macrophages retain pluripotentiality after thrombopoietin
expansion. Exp Cell Res. 2005;310:311–8. doi: 10.1016/j.yexcr.2005.08.004. [PubMed][Cross Ref]
23. Zhao Y, Lin B, Darflinger R, Zhang Y, Holterman MJ, Skidgel RA. Human cord blood stem cell-modulated regulatory
T lymphocytes reverse the autoimmune-caused type 1 diabetes in nonobese diabetic (NOD) mice. PLoS One. 2009;4 doi:
10.1371/journal.pone.0004226. [PMC free article] [PubMed][Cross Ref]
24. Zhao Y, Jiang Z, Zhao T, Ye M, Hu C, Yin Z, et al. Reversal of type 1 diabetes via islet beta cell regeneration
following immune modulation by cord blood-derived multipotent stem cells. BMC Med.2012;10:3. doi: 10.1186/17417015-10-3. [PMC free article] [PubMed] [Cross Ref]
25. Zhao Y, Jiang Z, Zhao T, Ye M, Hu C, Zhou H, et al. Targeting insulin resistance in type 2 diabetes via immune
modulation of cord blood-derived multipotent stem cells (CB-SCs) in stem cell educator therapy: phase I/II clinical
trial. BMC Med. 2013;11:160. doi: 10.1186/1741-7015-11-160. [PMC free article][PubMed] [Cross Ref]
26. Zhao Y, Jiang Z, Guo C. New hope for type 2 diabetics: Targeting insulin resistance through the immune modulation
of stem cells. Autoimmun Rev. 2011;11:137–42. doi: 10.1016/j.autrev.2011.09.003. [PubMed][Cross Ref]
27. Xing L, Dai Z, Jabbari A, Cerise JE, Higgins CA, Gong W, et al. Alopecia areata is driven by cytotoxic T lymphocytes
and is reversed by JAK inhibition. Nat Med. 2014;20:1043–9. doi: 10.1038/nm.3645.[PMC free article] [PubMed] [Cross
Ref]
28. Zhao Y, Huang Z, Qi M, Lazzarini P, Mazzone T. Immune regulation of T lymphocyte by a newly characterized
human
umbilical
cord
blood
stem
cell. Immunol
Lett. 2007;108:78–87.
doi:
10.1016/j.imlet.2006.10.007. [PubMed] [Cross Ref]
29. Li MO, Flavell RA. TGF-beta: a master of all
10.1016/j.cell.2008.07.025. [PMC free article] [PubMed] [Cross Ref]
T
cell
trades. Cell. 2008;134:392–404.
doi:
30. Foitzik K, Lindner G, Mueller-Roever S, Maurer M, Botchkareva N, Botchkarev V, et al. Control of murine hair
follicle regression (catagen) by TGF-beta1 in vivo. FASEB J. 2000;14:752–60. [PubMed]
31. Gilhar A, Landau M, Assy B, Ullmann Y, Shalaginov R, Serafimovich S, et al. Transfer of alopecia areata in the
human scalp graft/Prkdc(scid) (SCID) mouse system is characterized by a TH1 response. Clin Immunol. 2003;106:181–7.
doi: 10.1016/S1521-6616(02)00042-6. [PubMed] [Cross Ref]
32. Skapenko A, Niedobitek GU, Kalden JR, Lipsky PE, Schulze-Koops H. Generation and regulation of human Th1biased immune responses in vivo: a critical role for IL-4 and IL-10. J Immunol. 2004;172:6427–34. doi:
10.4049/jimmunol.172.10.6427. [PubMed] [Cross Ref]
33. Webb LM, Feldmann M. Critical role of CD28/B7 costimulation in the development of human Th2 cytokineproducing cells. Blood. 1995;86:3479–86. [PubMed]
34. King CL, Stupi RJ, Craighead N, June CH, Thyphronitis G. CD28 activation promotes Th2 subset differentiation by
human CD4+ cells. Eur J Immunol. 1995;25:587–95. doi: 10.1002/eji.1830250242.[PubMed] [Cross Ref]
35. Rulifson IC, Sperling AI, Fields PE, Fitch FW, Bluestone JA. CD28 costimulation promotes the production of Th2
cytokines. J Immunol. 1997;158:658–65. [PubMed]
36. Skapenko A, Lipsky PE, Kraetsch HG, Kalden JR, Schulze-Koops H. Antigen-independent Th2 cell differentiation by
stimulation of CD28: regulation via IL-4 gene expression and mutagen-activated protein kinas activation. J
Immunol. 2001;166:4283–92. doi: 10.4049/jimmunol.166.7.4283. [PubMed] [Cross Ref]
37. Soma T, Dohrmann CE, Hibino T, Raftery LA. Profile of transforming growth factor-beta responses during the murine
hair cycle. J Invest Dermatol. 2003;121:969–75. doi: 10.1046/j.1523-1747.2003.12516.x.[PubMed] [Cross Ref]
38. Welker P, Foitzik K, Bulfone-Paus S, Henz BM, Paus R. Hair cycle-dependent changes in the gene expression and
protein content of transforming factor beta 1 and beta 3 in murine skin. Arch Dermatol Res.1997;289:554–7. doi:
10.1007/s004030050239. [PubMed] [Cross Ref]
39. Shapiro J. Current treatment of alopecia areata. J Investig Dermatol Symp Proc. 2013;16:S42–4. doi:
10.1038/jidsymp.2013.14. [PubMed] [Cross Ref]
40. Metzger TC, Anderson MS. Control of central and peripheral tolerance by Aire. Immunol Rev.2011;241:89–103. doi:
10.1111/j.1600-065X.2011.01008.x. [PMC free article] [PubMed] [Cross Ref]
D.
Benoist
C:
Aire. Annu
Rev
41. Mathis
10.1146/annurev.immunol.25.022106.141532. [PubMed] [Cross Ref]
Immunol. 2009;27:287–312.
doi:
42. Ito T, Hashizume H, Shimauchi T, Funakoshi A, Ito N, Fukamizu H, et al. CXCL10 produced from hair follicles
induces Th1 and Tc1 cell infiltration in the acute phase of alopecia areata followed by sustained Tc1 accumulation in the
chronic phase. J Dermatol Sci. 2012;69:140–7. doi: 10.1016/j.jdermsci.2012.12.003.[PubMed] [Cross Ref]
43. Barahmani N, Lopez A, Babu D, Hernandez M, Donley SE, Duvic M. Serum T helper 1 cytokine levels are greater in
patients with alopecia areata regardless of severity or atopy. Clin Exp Dermatol. 2010;35:409–16. doi: 10.1111/j.13652230.2009.03523.x. [PubMed] [Cross Ref]
44. Katagiri K, Arakawa S, Hatano Y. In vivo levels of IL-4, IL-10, TGF-beta1 and IFN-gamma mRNA of the peripheral
blood mononuclear cells in patients with alopecia areata in comparison to those in patients with atopic dermatitis. Arch
Dermatol Res. 2007;298:397–401. doi: 10.1007/s00403-006-0700-2. [PubMed][Cross Ref]
45. Kubo R, Nakamura M, Tokura Y. Alopecia universalis following two sequential traffic accidents: possible association
with increased Th1 and Th17 cells and decreased Th2 cells. J UOEH. 2011;33:313–7.[PubMed]
46. Lanier LL, Corliss B, Wu J, Phillips JH. Association of DAP12 with activating CD94/NKG2C NK cell
receptors. Immunity. 1998;8:693–701. doi: 10.1016/S1074-7613(00)80574-9. [PubMed] [Cross Ref]
47. Bellone G, Aste-Amezaga M, Trinchieri G, Rodeck U. Regulation of NK cell functions by TGF-beta 1.J
Immunol. 1995;155:1066–73. [PubMed]
48. Schmierer B, Hill CS. TGFbeta-SMAD signal transduction: molecular specificity and functional flexibility. Nat Rev
Mol Cell Biol. 2007;8:970–82. doi: 10.1038/nrm2297. [PubMed] [Cross Ref]
49. Nishimura EK, Suzuki M, Igras V, Du J, Lonning S, Miyachi Y, et al. Key roles for transforming growth factor beta in
melanocyte stem cell maintenance. Cell Stem Cell. 2010;6:130–40. doi: 10.1016/j.stem.2009.12.010. [PMC free
article] [PubMed] [Cross Ref]
Prostate. 2015 Mar 1;75(4):415-23. doi: 10.1002/pros.22927. Epub 2014 Dec 9.
Male pattern baldness in relation to prostate cancer risks: an
analysis in the VITamins and lifestyle (VITAL) cohort study.
Zhou CK1, Littman AJ, Levine PH, Hoffman HJ, Cleary SD, White E, Cook MB.
Author information

1
Division of Cancer Epidemiology and Genetics, National Cancer Institute, National Institutes of Health, Maryland; Department of
Epidemiology and Biostatistics, George Washington University, Washington, District of Columbia.
Abstract
BACKGROUND:
Male pattern baldness and prostate cancer may share common pathophysiological mechanisms in terms of advancing age,
heritability, and endogenous hormones. Results from previous epidemiologic studies are inconsistent. Therefore, we investigated
the association of prostate cancer risks with male pattern baldness at age 30 years, age 45 years, and baseline (median age = 60.5
years) in the VITamins And Lifestyle (VITAL) cohort study.
METHODS:
We included 32,583 men who were aged 50-76 years and without prior cancer diagnosis (excluding non-melanoma skin cancer) at
the start of follow-up. First primary incident prostate cancers were ascertained via linkage to the western Washington Surveillance,
Epidemiology, and End Results (SEER) program. Hazard ratios (HRs) and 95% confidence intervals (95% CIs) were estimated
using Cox proportional hazards regressions with adjustment for potential confounders.
RESULTS:
During follow-up (median = 9 years), 2,306 incident prostate cancers were diagnosed. Male pattern baldness at age 30 years, age
45 years, and baseline were not statistically significantly associated with overall or subtypes of prostate cancer.
CONCLUSION:
This study did not provide support for the hypothesis that male pattern baldness may be a marker for subsequent prostate cancer.
Previous evidence indicates that a distinct class of frontal with vertex balding may be associated with increased risk of aggressive
prostate cancer, but all such balding classes were captured as a single exposure category by the VITAL cohort questionnaire.
Prostate 75:415-423, 2015. © 2014 Wiley Periodicals, Inc.
© 2014 Wiley Periodicals, Inc.
KEYWORDS:
androgen; cohort study; male pattern baldness; prostate cancer
PMID: 25492530
PMCID: PMC4293210
EBioMedicine
Volume 2, Issue 4, April 2015, Pages 351–355
Original Article
Reversal of Alopecia Areata Following Treatment With the JAK1/2 Inhibitor
Baricitinib
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Ali Jabbaria, 1,
Zhenpeng Daia, 1,
Luzhou Xingb, 1,
Jane E. Cerisea,
Yuval Ramotc,
Yackov Berkund,
Gina A. Montealegre Sancheze,
Raphaela Goldbach-Manskye,
Angela M. Christianoa, f, , 2, ,
Raphael Clynesa, b, g, 2,
Abraham Zlotogorskic, , 2,
a
Department of Dermatology, Columbia University, New York, NY, USA
Department of Pathology, Columbia University, New York, NY, USA
c
Department of Dermatology, Hadassah-Hebrew University Medical Center, Jerusalem, Israel
d
Department of Pediatrics, Hadassah-Hebrew University Medical Center, Jerusalem, Israel
e
Translational Autoinflammatory Disease Section, NIAMS, NIH, Bethesda, MD, USA.
f
Department of Genetics & Development, Columbia University, New York, NY, USA
g
Department of Medicine, Columbia University, New York, NY, USA
Received 21 January 2015, Revised 20 February 2015, Accepted 24 February 2015, Available online 26 February 2015
b
Abstract
Background
Alopecia areata (AA) is an autoimmune disease resulting in hair loss with devastating psychosocial
consequences. Despite its high prevalence, there are no FDA-approved treatments for AA. Prior studies have
identified a prominent interferon signature in AA, which signals through JAK molecules.
Methods
A patient with AA was enrolled in a clinical trial to examine the efficacy of baricitinib, a JAK1/2 inhibitor, to treat
concomitant CANDLE syndrome. In vivo, preclinical studies were conducted using the C3H/HeJ AA mouse
model to assess the mechanism of clinical improvement by baricitinib.
Findings
The patient exhibited a striking improvement of his AA on baricitinib over several months.In vivo studies using
the C3H/HeJ mouse model demonstrated a strong correlation between resolution of the interferon signature
and clinical improvement during baricitinib treatment.
Interpretation
Baricitinib may be an effective treatment for AA and warrants further investigation in clinical trials.
Keywords
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Alopecia areata;
Interferon gamma;
JAK inhibitor;
CANDLE syndrome;
Autoimmune disease;
Baricitinib;
Gene expression profiling;
Autoinflammatory
1. Introduction
Alopecia areata (AA) is a polygenic autoimmune disease that results in hair loss that ranges in presentation
from circular patches on the scalp that can often undergo spontaneous resolution to complete hair loss that
may persist for life. There are currently no FDA-approved treatments for AA, and treatment regimens for
patients with severe disease are empiric and frequently unsatisfactory. Recent work in human subjects has
identified several genes underlying AA (Petukhova et al., 2010 and Betz et al., 2015), as well as a prominent
interferon (IFN) signature in the AA scalp (Xing et al., 2014), inviting trials targeting this pathway for treatment
purposes.
Chronic atypical neutrophilic dermatosis with lipodystrophy and elevated temperature (CANDLE) syndrome
(OMIM 256040) is a monogenic autoinflammatory syndrome that was initially described in 2010 (Torrelo et al.,
2010). Patients present within the first six months of life with recurrent episodes of fever, periocular erythema
and edema, annular violaceous plaques (Supplementary Fig. 1) and lipodystrophy (Torrelo et al., 2010,Ramot
et al., 2011 and Liu et al., 2012). Alopecia is not reported as a part of the CANDLE phenotype or other
immunoproteasome-related disorders (Torrelo et al., 2010, Agarwal et al., 2010 and Arima et al., 2011).
Mutations have been discovered in PSMB8, whose gene product is a component of the immunoproteasome, in
some, but not all patients, with CANDLE syndrome ( Liu et al., 2012). There are currently no well-established
treatments for this rare orphan disease. Whole genome expression analysis of peripheral blood mononuclear
cells identified the IFN pathway as being highly dysregulated in these patients ( Liu et al., 2012), establishing a
possible target for the development of new treatments.
AA and CANDLE syndrome are both characterized by prominent IFN signatures, albeit as a result of different
genetic mechanisms. Type I and type II IFNs signal through cell surface receptors that initially activate JAK
kinases, specifically JAK1 and either TYK2 or JAK2, respectively. Small molecule JAK inhibitors have been
developed and are currently available for myelofibrosis (Verstovsek et al., 2010) and rheumatoid arthritis (RA)
(Fleischmann et al., 2012). This class of drugs offers the convenience of being orally bioavailable when
compared with biologic inhibitors of IFNs, which require parenteral administration. Here, we describe a patient
enrolled in a clinical trial of baricitinib, an oral JAK inhibitor with relative selectivity for JAK1 and JAK2, for
CANDLE syndrome who experienced dramatic resolution of his AA.
A 17-year-old man with chronic long-standing AA was enrolled in a clinical trial examining the efficacy of
baricitinib for a proposed IFN mediated autoinflammatory syndrome, CANDLE syndrome (NCT01724580). The
diagnosis of CANDLE syndrome was based on the typical clinical features of widespread annular violaceous
skin lesions and the multisystemic inflammatory characteristics (Ramot et al., 2011) and had been confirmed by
finding a homozygous mutation in PSMB8 ( Liu et al., 2012). Prior to the trial, he had been treated for CANDLE
syndrome with two courses of intravenous pulses of methylprednisolone and oral methotrexate (10 mg/week).
At the time of study initiation, he had been taking oral prednisone at a dose of 12 mg/day.
The patient suffered from a chronic patch-type AA for seven years, which involved mainly his occipital scalp.
He had been treated with dithranol cream and minoxidil in the past without improvement of his alopecia. In the
time preceding his enrollment in the trial, the patient experienced progression of his disease to an ophiasis
pattern, a form of AA that is usually recalcitrant to treatment (Finner, 2011), despite being on an
immunosuppressive regimen for CANDLE syndrome.
2. Methods
2.1. Clinical Studies
Due to the observation that increased STAT-1 phosphorylation and a strong IFN response signature are
observed in CANDLE patients (Liu et al., 2012), a treatment trial with the JAK 1/2 inhibitor baricitinib was
initiated at the National Institutes of Health (NCT01724580). The patient was enrolled in this study and started
to receive once-daily oral baricitinib in September 2012, initially at a dose of 7 mg daily and 6 months later at
7 mg in the morning and 4 mg in the evening, with gradual tapering of oral corticosteroids to 3 mg daily.
Informed consent was provided by the patient and his guardians. All forms and protocol were approved by the
NIDDK/NIAMS IRB, and the study number on clinicaltrials.gov is NCT01724580.
2.2. Animal Studies
We performed three sets of in vivo experiments to determine the mechanistic basis for treatment response of
AA with baricitinib. Baricitinib was obtained from MedKoo Biosciences (Chapel Hill, NC). The C3H/HeJ graftrecipient mouse model of AA was used for these experiments. C3H/HeJ mice spontaneously develop alopecia
at a rate of 10–20% by 6–18 months of age. C3H/HeJ mice that receive skin grafts of alopecic skin from donor
alopecic C3H/HeJ mice develop the disease 95–100% of the time by 10 weeks post-transplant. Using the
C3H/HeJ grafted mouse model of AA, we first conducted experiments to prevent onset of disease by
administering baricitinib at the time of grafting. Briefly, alopecic skin from a C3H/HeJ mouse that spontaneously
developed hair loss was grafted onto 8–10 week old C3H/HeJ mice free of disease. At the time of grafting, an
osmotic pump (Alzet) that administered approximately 0.7 mg/day of baricitinib or placebo was implanted.
Osmotic pumps were changed monthly.
A time-to-event survival analysis for interval censored data was performed. The survival and interval packages
in R were used to perform log-rank tests. The hypothesis that the survival distributions are equal in the (n = 10)
baricitinib-treated mice and (n = 10) placebo-treated mice is rejected at the 5% level using Sun's score to
perform an exact log-rank two-sample test with the p-value of 0.0035.
We then conducted treatment experiments in the setting of established AA in mice, using both systemic
delivery and topical delivery of baricitinib. C3H/HeJ recipients of alopecic C3H/HeJ mouse skin were aged at
least an additional 12 weeks to allow for near complete alopecia prior to either implantation of osmotic pumps
or topical treatment. Osmotic pump administration was conducted in a similar manner as for the prevention
experiments. For topical treatment experiments, vehicle control or 0.5% baricitinib was applied topically daily.
For these experiments, the R package nparLD was used to test the hypothesis that there exists a treatment by
time interaction. A F1–LD–F1 design was employed. The hypothesis of no interaction, i.e., parallel time profiles,
is rejected at the 5% level using both the Wald-type statistic and the ANOVA-type statistic with the p-values of
5.80 × 10− 22 and 3.74 × 10− 15, respectively, for the baricitinib-treated (n = 8) and placebo-treated (n = 8) groups.
At the indicated time points, skin samples were taken for the purposes of immunohistochemical staining and
microscopy, immune infiltrate extraction and flow cytometric analysis, and/or RNA expression studies (see
Supplementary Materials and methods). Microarray data were deposited in Gene Expression Omnibus with
accession number GSE61555.
3. Results
3.1. Clinical Response to Baricitinib
Soon after starting baricitinib treatment, there was a remarkable improvement in the patient's AA, regressing to
only a single patch of hair loss on his occipital scalp three months after starting baricitinib treatment (Fig. 1).
There was a steady regrowth of hair on this single patch, until he had complete resolution of hair loss nine
months after starting treatment (Fig. 1). With continued baricitinib treatment, his hair regrowth persisted. Today,
under baricitinib treatment, the patient has complete hair growth on his scalp, with no signs of recurrence of
AA.
Fig. 1.
Clinical response to baricitinib in CANDLE patient with AA.
Scalp photos of the CANDLE patient with AA prior to and during treatment with baricitinib. Timeline showing the
approximate dates that photographs were taken and period in which the patient was being treated with baricitinib.
Figure options
3.2. Resolution of the IFN Signature
Intrigued by the rapid improvement in his AA, we evaluated the effect of baricitinib in a mouse model of AA and
conducted mechanistic studies to understand the action of baricitinib. We conducted three sets of in
vivo experiments to investigate the mechanisms of action of baricitinib for AA. C3H/HeJ grafted alopecic mice
were treated with systemically administered baricitinib or vehicle/placebo control either prior to (Supplementary
Fig. 2) or following the establishment of alopecia (Supplementary Fig. 3). Furthermore, C3H/HeJ grafted
alopecic mice were treated with a topical formulation of baricitinib or vehicle control after the mice developed
alopecia ( Fig. 2). In all three cases, hair growth was consistently observed in baricitinib-treated mice,
compared with no clinical evidence of hair regrowth in vehicle control treated mice ( Fig. 2 and Supplementary
Figs. 2 and 3). Skin biopsies were taken 12 weeks after the start of treatment and assessed for immune cell
infiltration and loss of immune privilege. Baricitinib treated mice exhibited substantially reduced inflammation as
assessed by H&E staining, reduced CD8 infiltration, and reduced MHC class I and class II expression when
compared with vehicle-control treated mice ( Fig. 2). CD8+NKG2D+ cells, critical effectors of disease in murine
and human AA, were greatly diminished in baricitinib treated mice compared with vehicle control treated mice
( Fig. 2).
Fig. 2.
Treatment of AA in C3H/HeJ mouse model.
C3H/HeJ graft recipient mice were treated with topical baricitinib or vehicle control after disease establishment. A,
Photographs were taken at 12 weeks post-treatment. B, Graph of hair regrowth index in each group over time. C, Skin
sections were taken at baseline and at 12 weeks post-treatment and stained with H&E or with antibodies to CD8, MHC
class I, MHC class II, or ICAM-1. D, Frequency of CD8+NKG2D+cells in treated skin.
To define the molecular response to baricitinib, we performed gene expression profiling of treated skin in both
the prevention and treatment models. Our previous studies defined an Alopecia Areata Disease Activity Index
(ALADIN) biomarker for response to treatment (Xing et al., 2014), which monitors three distinct gene
expression signatures, one of which is the IFN response. In all three contexts, we observed rapid normalization
of the IFN gene expression signature in response to baricitinib (Fig. 3 and Supplementary Figs. 2 and 3). Both
the IFN and cytotoxic T lymphocyte (CTL) components of the ALADIN strongly discriminated between
effectively treated mice and mice that did not exhibit disease resolution.
Fig. 3.
Normalization of IFN signature in baricitinib treated skin.
A, Expression of indicated genes in skin and, B, ALADIN score plots, from C3H/HeJ grafted mice treated with topical
baricitinib or vehicle control administered after the establishment of disease demonstrating resolution of IFN and CTL
scores with baricitinib treatment only. Yellow, control treatment at week 0; orange, control treatment at week 12; red,
baricitinib treatment at week 0; purple, baricitinib treatment at week 12.
4. Discussion
In this study, we report a dramatic clinical response to the JAK inhibitor baricitinib in a patient with longstanding
AA. We further define the mechanism of response to baricitinib and resolution of the IFN gene expression
signature in the AA mouse model. Recently, three independent studies reported similar clinical responses to
JAK inhibitors in patients with AA. We recently showed that the JAK inhibitor ruxolitinib, which also has relative
selectivity for JAK1 and JAK2 and is currently approved for myelofibrosis, reversed disease in three AA
patients in an open-label clinical trial of oral drug in moderate-to-severe disease (Xing et al., 2014). Secondly, a
single patient with alopecia universalis and psoriasis was treated orally with tofacitinib, an FDA approved JAK
inhibitor with higher affinity to JAK3, and also showed a clinical response (Craiglow and King, 2014). Lastly, a
patient with essential thrombocythemia and alopecia universalis was treated with ruxolitinib and exhibited
striking and near-complete hair regrowth after 10 months of treatment (Pieri et al., 2015). Our previous studies
using both ruxolitinib and tofacitinib in the C3H/HeJ mouse model of AA demonstrated the molecular
underpinnings of the response and resolution of the disease at the cellular and molecular levels (Xing et al.,
2014).
Small molecule JAK inhibitors offer several advantages when compared with a therapeutic strategy centered
on targeting cytokines with biologics. First, small molecule JAK inhibitors have oral bioavailability, making them
more attractive to patients and likely increasing adherence. Second, JAK inhibitors inhibit multiple pathogenic
pathways simultaneously, including both type I and type II IFN receptor pathways, both of which appear to be
active in AA (Xing et al., 2014, Freyschmidt Paul et al., 2006 and Ghoreishi et al., 2010). Notably, small
molecule JAK inhibitors may be developed into a topical form in the future, with two published studies
examining the efficacy of a topical JAK inhibitor for the treatment of psoriasis (Ports et al., 2013 and Punwani et
al., 2012). A topical JAK inhibitor may decrease the risk/benefit profile of this class of drugs. Clinical trials
examining the efficacy of baricitinib in the context of the compassionate use protocol for CANDLE syndrome as
well as for RA are currently underway. Results from a phase IIb clinical trial for baricitinib in RA have been
released showing a statistically significant improvement in ACR20 between baricitinib treatment and placebo
(Genovese et al., 2012), and phase III trials are currently underway for this indication. AA may represent
another potential indication for which baricitinib may be tested in the future. Taken together, the recent reports
of dramatic responses to treatment using JAK inhibitors invite broader clinical exploration of the utility of these
agents in AA.
Contributors
AJ, ZD, LX, AMC, RC and AZ contributed to the conception and design of the study. AJ, ZD, LX, YR, YB, GMS,
RG-M, and AZ contributed to data collection. AJ, ZD, LX, JEC, YR, YB, GMS, RG-M, AMC, RC, and AZ
analyzed and interpreted the data. AJ, AMC, and AZ drafted the report, which was critically revised for
important intellectual content by RG-M and RC. All authors approved the final version of the report.
Declaration of Interests
All authors declare no competing interests.
Acknowledgments
We are grateful to the Locks of Love Foundation and the Alopecia Areata Initiative for their support of this work.
This work was also supported in part by USPHS NIH/NIAMSR01AR056016 (to AMC) and R21AR061881 (to
AMC and RC), a Shared Instrumentation Grant for the LSR II Flow Cytometer (S10RR027050) to RC,
the Columbia University Skin Disease Research Center (P30AR044535), the NIAMS IRP program (RGM,
GMS), The Authority for Research and Development, Hebrew University of Jerusalem (to AZ), and a Young
Clinician's Grant, Hadassah-Hebrew University Medical Center (to YR). JEC is supported by T32GM082271
Medical Genetics Training Grant (issued to AMC). AJ is the recipient of a Career Development Award from the
Dermatology Foundation and the Louis V. Gerstner, Jr. Scholars Program.
References
1.
o
o
o
Agarwal et al., 2010
A.K. Agarwal, C. Xing, G.N. DeMartino, et al.
PSMB8 encoding the β5i proteasome subunit is mutated in joint contractures, muscle atrophy, microcytic anemia, and
panniculitis-induced lipodystrophy syndrome
o
Am. J. Hum. Genet., 87 (2010), pp. 866–872
o
o
o
Arima et al., 2011
K. Arima, A. Kinoshita, H. Mishima, et al.
Proteasome assembly defect due to a proteasome subunit beta type 8 (PSMB8) mutation causes the autoinflammatory
disorder, Nakajo–Nishimura syndrome
o
Proc. Natl. Acad. Sci. U. S. A., 108 (2011), pp. 14914–14919
o
o
o
Betz et al., 2015
o
Nat. Commun., 6 (2015), p. 5966 http://dx.doi.org/10.1038/ncomms6966
o
o
o
Craiglow and King, 2014
o
J. Investig. Dermatol., 134 (2014), pp. 2988–2990
o
o
o
Finner, 2011
o
Dermatol. Ther., 24 (2011), pp. 348–354
o
o
o
Fleischmann et al., 2012
o
N. Engl. J. Med., 367 (2012), pp. 495–507
o
o
o
Freyschmidt Paul et al., 2006
o
Br. J. Dermatol., 155 (2006), pp. 515–521
o
o
Genovese et al., 2012
2.
R.C. Betz, L. Petukhova, S. Ripke, et al.
Genome-wide meta-analysis in alopecia areata resolves HLA associations and reveals two new susceptibility loci
3.
B.G. Craiglow, B.A. King
Killing two birds with one stone: oral tofacitinib reverses alopecia universalis in a patient with plaque psoriasis
4.
A.M. Finner
Alopecia areata: clinical presentation, diagnosis, and unusual cases
5.
R. Fleischmann, J. Kremer, J. Cush, et al.
Placebo-controlled trial of tofacitinib monotherapy in rheumatoid arthritis
6.
P. Freyschmidt Paul, K.J. McElwee, R. Hoffmann, et al.
Interferon‐γ‐deficient mice are resistant to the development of alopecia areata
7.
M.C. Genovese, E. Keystone, P. Taylor, et al.
o
24-Week results of a blinded phase 2b dose-ranging study of baricitinib, an oral Janus kinase 1/Januse kinase 2
inhibitor, in combination with traditional disease modifying antirheumatic drugs in patients with rheumatoid arthritis
o
64 (2012), pp. S1049–S1050
o
o
o
Ghoreishi et al., 2010
o
Br. J. Dermatol., 163 (2010), pp. 57–62
o
o
o
Liu et al., 2012
8.
M. Ghoreishi, M. Martinka, J.P. Dutz
Type 1 interferon signature in the scalp lesions of alopecia areata
9.
Y. Liu, Y. Ramot, A. Torrelo, et al.
Mutations in proteasome subunit β type 8 cause chronic atypical neutrophilic dermatosis with lipodystrophy and
elevated temperature with evidence of genetic and phenotypic heterogeneity
o
Arthritis Rheum., 64 (2012), pp. 895–907
o
o
o
Petukhova et al., 2010
o
Nature, 466 (2010), pp. 113–117
o
o
o
Pieri et al., 2015
o
Am. J. Hematol., 90 (2015), pp. 82–83
o
o
o
Ports et al., 2013
10.
L. Petukhova, M. Duvic, M. Hordinsky, et al.
Genome-wide association study in alopecia areata implicates both innate and adaptive immunity
11.
L. Pieri, P. Guglielmelli, A.M. Vannucchi
Ruxolitinib-induced reversal of alopecia universalis in a patient with essential thrombocythemia
12.
W.C. Ports, S. Khan, S. Lan, et al.
A randomized phase 2a efficacy and safety trial of the topical Janus kinase inhibitor tofacitinib in the treatment of
chronic plaque psoriasis
o
Br. J. Dermatol., 169 (2013), pp. 137–145
o
o
o
Punwani et al., 2012
o
J. Am. Acad. Dermatol., 67 (2012), pp. 658–664
13.
N. Punwani, P. Scherle, R. Flores, et al.
Preliminary clinical activity of a topical JAK1/2 inhibitor in the treatment of psoriasis
14.
o
o
o
Ramot et al., 2011
o
Pediatr. Dermatol., 28 (2011), pp. 538–541
o
o
o
Torrelo et al., 2010
o
J. Am. Acad. Dermatol., 62 (2010), pp. 489–495
o
o
o
Verstovsek et al., 2010
o
N. Engl. J. Med., 363 (2010), pp. 1117–1127
o
o
o
Xing et al., 2014
o
Nat. Med., 20 (2014), pp. 1043–1049
Y. Ramot, T. Czarnowicki, A. Maly, P. Navon Elkan, A. Zlotogorski
Chronic atypical neutrophilic dermatosis with lipodystrophy and elevated temperature syndrome: a case report
15.
A. Torrelo, S. Patel, I. Colmenero, et al.
Chronic atypical neutrophilic dermatosis with lipodystrophy and elevated temperature (CANDLE) syndrome
16.
S. Verstovsek, H. Kantarjian, R.A. Mesa, et al.
Safety and efficacy of INCB018424, a JAK1 and JAK2 inhibitor, in myelofibrosis
17.
L. Xing, Z. Dai, A. Jabbari, et al.
Alopecia areata is driven by cytotoxic T lymphocytes and is reversed by JAK inhibition
Correspondence to: A.M. Christiano, Department of Dermatology, Columbia University, College of Physicians &
Surgeons, 1150 St. Nicholas Ave., 3rd Floor, New York, NY 10032, USA.
Correspondence to: A. Zlotogorski, Department of Dermatology, Hadassah-Hebrew University Medical Center, Jerusalem
9112001, Israel.
1
These authors contributed equally to this work.
2
These authors jointly directed this work.
Copyright © 2015 Published by Elsevier B.V.
Understanding images: microRNAs contribute to hair loss and follicle
regression
Posted: June 16, 2015
Author: Zhengquan Yu, State Key Laboratories for Agrobiotechnology, College of Biological Sciences,
China Agricultural University, Beijing, China
PLOS Genetics May Issue Image. Immunoflorscent staining of hair follicles. Image Credit: Yuan and colleagues
Up to 60% of men experience some degree of hair loss in their lifetime. However, despite its prevalence, efficient treatment
for hair loss is lacking. One of the key distinguishing features of hair follicles in baldness-affected areas is premature
regression. This leads to shorter hairs and excessive hair fallout. This month’s cover image features actively growing hair
follicles with prominent layers of the outer root sheath surrounding the hair shaft cortex. In this issue of PLOS Genetics, we
describe an essential role for a highly conserved microRNA, miR-22, in regulating the regression of mouse hair follicles. New
insights into the mechanism of premature hair growth regression in mice enrich our understanding of the pathogenesis of
hair loss.
The basics of hair loss
Because hair loss results from the premature termination of the follicle’s growth phase, it is essential to understand in more
detail the mechanism underlying normal hair regeneration. During the active phase of the hair growth cycle, stem cell
activity sustains an actively dividing population of epithelial cells at the base of the follicle called matrix cells. As progeny of
the matrix cells move upward from the follicle base (or bulb), they differentiate into a hardened hair shaft, which emerges
above the skin surface. Fully differentiated hair shafts consist of dead, but mechanically sound and highly cross-linked,
keratin-filled cells. After a period of active hair shaft production, follicles activate an involution program, during which a
large portion of epithelial cells die, and the remaining stem cells are reduced to a tight cluster underneath the skin surface.
These follicles then remain dormant for some time; however, they can undergo activation and restart active hair shaft
production.
Hair loss. Image credit: Aida. CC BY 3.0. Licence.
The growth, regression, and resting phases together constitute the hair growth cycle, and this cycling can be influenced by a
variety of local and systemic signaling factors. Consequently defects in hair cycling can arise from changes in the normal
signaling milieu due to disease, aging, or injury. Commonly, in humans, scalp hair follicles enter resting phase prematurely,
and hairs shafts become shorter and fall out, resulting in visible baldness. Therefore, identifying new signaling regulators of
hair follicle regression will provide a better understanding of the hair loss pathogenesis mechanism and will likely identify
novel therapeutic targets.
miR-22 induction causes premature hair loss by promoting follicle involution
Immunoflorescence of hair follicle. Image credit: Yuan and colleagues.
To test the function of miR-22, we generated a genetic tool to induce miR-22 overexpression in mouse hair follicles, and
interestingly, found that increasing miR-22 results in hair loss in mice due to the premature regression of actively growing
follicles. Surprisingly, our data reveal that the expression of over 50 distinct keratin genes are markedly reduced by miR22 and that silencing of keratin-mediated hair shaft assembly by miR-22is a prerequisite for follicle regression. At the
molecular level, we found that miR-22 directly represses multiple transcription factors, includingDlx3 and Foxn1, which
positively regulate the expression of keratin genes.
Hair loss in mice. Image credit: Yuan and colleagues.
Indeed, deletion of Dlx3or Foxn1 closely resembles the hair loss phenotype caused bymiR-22 induction. Thus, by
suppressing Dlx3- andFoxn1-dependent keratin expression, miR-22 is sufficient to terminate hair differentiation. In
addition, miR-22contributes to follicle regression by repressing proliferation of hair stem cells and promoting their death.
Collectively, miR-22 emerges as a key regulator of follicle transition from the growth to regression phase. There are
hundreds of microRNAs expressed in a hair follicle [2], but most of them are not well studied. Our findings of the essential
role of miR-22 highlight the importance of determining the combinatorial effects of the microRNA regulatory network in
hair cycling.
Implications of findings
In the future, our findings are likely to benefit human hair loss research efforts. Androgenic alopecia, where premature
regression of scalp hair follicles is induced by increasing androgen levels, is the most common hair loss disorder in humans.
Interestingly, it has been reported that miR-22 is strongly induced in the liver in response to testosterone treatment [3,4].
Our unpublished data show that two binding sites for an androgen receptor are located in the promoter of both human and
mouse miR-22. These findings support the hypothesis that miR-22 functions in the pathogenesis of Androgenic Alopecia,
warranting future studies of miR-22 inhibitors as potential anti-hair loss drugs.
1.
2.
3.
4.
Lee J, Tumbar T (2012) Hairy tale of signaling in hair follicle development and cycling. Semin Cell Dev Biol 23: 906916.
Mardaryev AN, Ahmed MI, Vlahov NV, Fessing MY, Gill JH, et al. (2010) Micro-RNA-31 controls hair cycle-associated
changes in gene expression programs of the skin and hair follicle. FASEB J 24: 3869-3881.
Delic D, Grosser C, Dkhil M, Al-Quraishy S, Wunderlich F (2010) Testosterone-induced upregulation of miRNAs in the
female mouse liver. Steroids 75: 998-1004.
Wang WL, Chatterjee N, Chittur SV, Welsh J, Tenniswood MP (2011) Effects of 1alpha,25 dihydroxyvitamin D3 and
testosterone on miRNA and mRNA expression in LNCaP cells. Mol Cancer 10: 58.