Poonkiat Suchonwanit, MD - Mahidol University...ALOPECIA NON-SCARRING SCARRING DIFFUSE FOCAL -- Male...

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Poonkiat Suchonwanit, MD Hair and Scalp Disorders Unit Division of Dermatology Department of Medicine Ramathibodi Hospital

Transcript of Poonkiat Suchonwanit, MD - Mahidol University...ALOPECIA NON-SCARRING SCARRING DIFFUSE FOCAL -- Male...

Page 1: Poonkiat Suchonwanit, MD - Mahidol University...ALOPECIA NON-SCARRING SCARRING DIFFUSE FOCAL -- Male androgenetic alopecia - Female pattern hair loss PATTERN >100 hairs/day •Telogen

Poonkiat Suchonwanit, MD Hair and Scalp Disorders Unit

Division of Dermatology Department of Medicine

Ramathibodi Hospital

Page 2: Poonkiat Suchonwanit, MD - Mahidol University...ALOPECIA NON-SCARRING SCARRING DIFFUSE FOCAL -- Male androgenetic alopecia - Female pattern hair loss PATTERN >100 hairs/day •Telogen

Hair loss

Excessive hair growth

Hair haft abnormalities Hair color

Page 3: Poonkiat Suchonwanit, MD - Mahidol University...ALOPECIA NON-SCARRING SCARRING DIFFUSE FOCAL -- Male androgenetic alopecia - Female pattern hair loss PATTERN >100 hairs/day •Telogen
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Anagen Catagen Telogen

Page 5: Poonkiat Suchonwanit, MD - Mahidol University...ALOPECIA NON-SCARRING SCARRING DIFFUSE FOCAL -- Male androgenetic alopecia - Female pattern hair loss PATTERN >100 hairs/day •Telogen

80-90% 2-6 years

<1% 1-2 weeks

10-15% 1-3 months

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Phase Duration Amount

Anagen 1000 90,000 (90%)

Telogen 100 10,000 (10%)

Total 100,000

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>100

>200

Not wash

Wash

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Hair loss or hair thinning? Number of hair shedding? Characteristics? Duration? Life event? Symptom to indicate systemic disease? Family history?

Page 9: Poonkiat Suchonwanit, MD - Mahidol University...ALOPECIA NON-SCARRING SCARRING DIFFUSE FOCAL -- Male androgenetic alopecia - Female pattern hair loss PATTERN >100 hairs/day •Telogen
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Inspection

Distribution

Scalp lesions

Hair pull test

Tug test

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Distribution of hair loss

Localized

Diffuse

Pattern

Hair shape: exclamation, tufted, fragility Scarring or non-scarring

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Scarring alopecia should be concerned

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Non-scarring alopecia

Scarring alopecia

Permanent hair loss

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Nail Oral cavity: mucosa, teeth Conjunctiva Thyroid gland Genitalia Other skin lesions

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ALOPECIA

SCARRING NON-SCARRING

DIFFUSE FOCAL

- Male androgenetic alopecia

- Female pattern hair loss

PATTERN

>100 hairs/day

•Telogen Effluvium

•Anagen Effluvium

•Alopecia Areata

•Trichotillomania

•Hair shaft defects

- Alopecia Areata

- Trichotillomania

- Hair shaft defects

- Congenital hair loss

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ALOPECIA

SCARRING NON-SCARRING

- Lichen planopilaris

- Lupus erythematosus

- Pseudopelade of Brocq

- Folliculitis decalvans

- Dissecting cellulitis of the scalp

- Morphea

- Trauma

- Tumor

- Infections

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Reaction to physical or

mental stressors, drugs 3-6 mo. after inciting event

Resolve after cause removed

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Loss of anagen hairs Usually broken off > shed Cause

Radiation therapy

Systemic chemotherapy

TOXIC agents

Severe protein malnutrition

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Regrowth rapidly after stop chemotherapy High-dose busulfan -> permanent alopecia

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Lymphocyte

accumulation

Hair shaft

thinning

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DDx in sexually active period

Moth-eaten

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Alopecia totalis (AT)

Alopecia universalis (AU)

Page 32: Poonkiat Suchonwanit, MD - Mahidol University...ALOPECIA NON-SCARRING SCARRING DIFFUSE FOCAL -- Male androgenetic alopecia - Female pattern hair loss PATTERN >100 hairs/day •Telogen

Nail:

pitting, trachyonychia, onychomadesis

Page 33: Poonkiat Suchonwanit, MD - Mahidol University...ALOPECIA NON-SCARRING SCARRING DIFFUSE FOCAL -- Male androgenetic alopecia - Female pattern hair loss PATTERN >100 hairs/day •Telogen

Atopy Autoimmune thyroid disease Down syndrome Vitiligo Autoimmune polyendocrinopathy syndrome type I Type I diabetes (relative of AA pt.) SLE (Taiwan)

Page 34: Poonkiat Suchonwanit, MD - Mahidol University...ALOPECIA NON-SCARRING SCARRING DIFFUSE FOCAL -- Male androgenetic alopecia - Female pattern hair loss PATTERN >100 hairs/day •Telogen
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Spontaneous remission (80% in 1 yr) Relapse is common Poor prognostic factor:

Location (ophiasis pattern)

Age of onset: childhood

Association of atopy

Duration of hair loss (>1 yr)

Loss of body hair

Nail involvement

Positive family history

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Bizarre shapes , irregular border

Hairs of varying length

Page 38: Poonkiat Suchonwanit, MD - Mahidol University...ALOPECIA NON-SCARRING SCARRING DIFFUSE FOCAL -- Male androgenetic alopecia - Female pattern hair loss PATTERN >100 hairs/day •Telogen

Cognitive behavioral therapy : Most effective Rx

Psychotropic drug :

1st line: Clomipramine, SSRI (fluoxetine, sertaline)

NAC

Page 39: Poonkiat Suchonwanit, MD - Mahidol University...ALOPECIA NON-SCARRING SCARRING DIFFUSE FOCAL -- Male androgenetic alopecia - Female pattern hair loss PATTERN >100 hairs/day •Telogen

Male androgenetic alopecia

Female pattern hair loss

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5 alpha reductase enzyme

Key enzyme

Testosterone -> DHT

Page 43: Poonkiat Suchonwanit, MD - Mahidol University...ALOPECIA NON-SCARRING SCARRING DIFFUSE FOCAL -- Male androgenetic alopecia - Female pattern hair loss PATTERN >100 hairs/day •Telogen

Dermatologic Therapy, 2008,314-28.

Randall: paradoxical effect of androgen

Miniaturization Shortening of anagen duration Increased percentage of telogen

Page 44: Poonkiat Suchonwanit, MD - Mahidol University...ALOPECIA NON-SCARRING SCARRING DIFFUSE FOCAL -- Male androgenetic alopecia - Female pattern hair loss PATTERN >100 hairs/day •Telogen
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Topical only (solution or foam) 5% in male, 2-5% in female Twice daily Mechanism?

Unknown

Side effect

Allergic contact dermatitis: propylene glycol

Irritant contact dermatitis: alcohol

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Page 47: Poonkiat Suchonwanit, MD - Mahidol University...ALOPECIA NON-SCARRING SCARRING DIFFUSE FOCAL -- Male androgenetic alopecia - Female pattern hair loss PATTERN >100 hairs/day •Telogen

Type II 5 - reductase inhibitor 1 mg/day (Propecia) ½ AD or ¼ OD (Proscar) Sexual adverse effect Reduction incidence of prostate CA but small

increase high grade prostate CA

Page 48: Poonkiat Suchonwanit, MD - Mahidol University...ALOPECIA NON-SCARRING SCARRING DIFFUSE FOCAL -- Male androgenetic alopecia - Female pattern hair loss PATTERN >100 hairs/day •Telogen

Hair follicles

Page 49: Poonkiat Suchonwanit, MD - Mahidol University...ALOPECIA NON-SCARRING SCARRING DIFFUSE FOCAL -- Male androgenetic alopecia - Female pattern hair loss PATTERN >100 hairs/day •Telogen

Type I & II 5 - reductase inhibitor More potent & more half life time Efficacy -> in research

Evidence of mark decrease DHT level

Evidence of improve AGA

Current use in BPH

Page 50: Poonkiat Suchonwanit, MD - Mahidol University...ALOPECIA NON-SCARRING SCARRING DIFFUSE FOCAL -- Male androgenetic alopecia - Female pattern hair loss PATTERN >100 hairs/day •Telogen
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Teratogenic effect

Feminization in male fetus

No risk to a male fetus in a pregnant partner

Page 52: Poonkiat Suchonwanit, MD - Mahidol University...ALOPECIA NON-SCARRING SCARRING DIFFUSE FOCAL -- Male androgenetic alopecia - Female pattern hair loss PATTERN >100 hairs/day •Telogen
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Characteristics Permanent destruction of the hair follicle

Irreversible damage to hair follicle stem cell

Effacement of follicular orifices

Page 54: Poonkiat Suchonwanit, MD - Mahidol University...ALOPECIA NON-SCARRING SCARRING DIFFUSE FOCAL -- Male androgenetic alopecia - Female pattern hair loss PATTERN >100 hairs/day •Telogen

telangiectasia

pigmentary change, central atrophy round, scaly- adherent scales, follicular plugging

Page 55: Poonkiat Suchonwanit, MD - Mahidol University...ALOPECIA NON-SCARRING SCARRING DIFFUSE FOCAL -- Male androgenetic alopecia - Female pattern hair loss PATTERN >100 hairs/day •Telogen

Risks to develop SLE

1. Widespread DLE below the neck

2. Non-specific lesions

▪ Alopecia

▪ Vasculitis

3. ANA positive high titer

4. Lymphocytopenia

Page 56: Poonkiat Suchonwanit, MD - Mahidol University...ALOPECIA NON-SCARRING SCARRING DIFFUSE FOCAL -- Male androgenetic alopecia - Female pattern hair loss PATTERN >100 hairs/day •Telogen

Topical therapy - Sunscreen - Potent topical/intralesional steroid Systemic therapy - Antimalarial drugs - Methotrexate - Dapsone - Thalidomide

Page 57: Poonkiat Suchonwanit, MD - Mahidol University...ALOPECIA NON-SCARRING SCARRING DIFFUSE FOCAL -- Male androgenetic alopecia - Female pattern hair loss PATTERN >100 hairs/day •Telogen

Lichen planus of the

scalp

Evidence of lichen planus elsewhere

Screening for HCV

Page 58: Poonkiat Suchonwanit, MD - Mahidol University...ALOPECIA NON-SCARRING SCARRING DIFFUSE FOCAL -- Male androgenetic alopecia - Female pattern hair loss PATTERN >100 hairs/day •Telogen

Lichen planus

Wickham striae

Page 59: Poonkiat Suchonwanit, MD - Mahidol University...ALOPECIA NON-SCARRING SCARRING DIFFUSE FOCAL -- Male androgenetic alopecia - Female pattern hair loss PATTERN >100 hairs/day •Telogen

Reticulated whitish patch

Page 60: Poonkiat Suchonwanit, MD - Mahidol University...ALOPECIA NON-SCARRING SCARRING DIFFUSE FOCAL -- Male androgenetic alopecia - Female pattern hair loss PATTERN >100 hairs/day •Telogen

Pterygium nail

Twenty nails dystrophy

Page 61: Poonkiat Suchonwanit, MD - Mahidol University...ALOPECIA NON-SCARRING SCARRING DIFFUSE FOCAL -- Male androgenetic alopecia - Female pattern hair loss PATTERN >100 hairs/day •Telogen

Mild to moderate LPP (<10%) - Intralesional steroid (+/- topical steroid)

- Oral steroid for rapid progressive

Severe LPP (>10%) - Hydroxychloroquine - Cyclosporine

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Contour Surface Color Periungual Detachment

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Clubbing

Koilonychia

Over curvature

Page 66: Poonkiat Suchonwanit, MD - Mahidol University...ALOPECIA NON-SCARRING SCARRING DIFFUSE FOCAL -- Male androgenetic alopecia - Female pattern hair loss PATTERN >100 hairs/day •Telogen

Intrathoracic disorder Hypertrophic pulmonary osteoarthropathy

Pachydermoperiostosis Secondary lung carcinoma

Page 67: Poonkiat Suchonwanit, MD - Mahidol University...ALOPECIA NON-SCARRING SCARRING DIFFUSE FOCAL -- Male androgenetic alopecia - Female pattern hair loss PATTERN >100 hairs/day •Telogen

Spoon nail Physiologic in early infancy Iron deficiency

Page 68: Poonkiat Suchonwanit, MD - Mahidol University...ALOPECIA NON-SCARRING SCARRING DIFFUSE FOCAL -- Male androgenetic alopecia - Female pattern hair loss PATTERN >100 hairs/day •Telogen

Over curvature

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Beau’s line

Pits

Trachyonychia

Page 70: Poonkiat Suchonwanit, MD - Mahidol University...ALOPECIA NON-SCARRING SCARRING DIFFUSE FOCAL -- Male androgenetic alopecia - Female pattern hair loss PATTERN >100 hairs/day •Telogen

Transverse depression of nail plate Occur after illnesses

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Alopecia areata Shallow regular pitting

Page 73: Poonkiat Suchonwanit, MD - Mahidol University...ALOPECIA NON-SCARRING SCARRING DIFFUSE FOCAL -- Male androgenetic alopecia - Female pattern hair loss PATTERN >100 hairs/day •Telogen

Twenty nail dystrophy

Page 74: Poonkiat Suchonwanit, MD - Mahidol University...ALOPECIA NON-SCARRING SCARRING DIFFUSE FOCAL -- Male androgenetic alopecia - Female pattern hair loss PATTERN >100 hairs/day •Telogen

Leukonychia True leukonychia

Apparent leukonychia

Chromonychia

Page 75: Poonkiat Suchonwanit, MD - Mahidol University...ALOPECIA NON-SCARRING SCARRING DIFFUSE FOCAL -- Male androgenetic alopecia - Female pattern hair loss PATTERN >100 hairs/day •Telogen

True leukonychia

Transverse: systemic disorder

Punctate: manicure

Longitudinal

Apparent leukonychia

Terry’s nail

Half and half nail

Muehrcke’s nail

Page 76: Poonkiat Suchonwanit, MD - Mahidol University...ALOPECIA NON-SCARRING SCARRING DIFFUSE FOCAL -- Male androgenetic alopecia - Female pattern hair loss PATTERN >100 hairs/day •Telogen
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Associated with

Cirrhosis of the liver

Chronic congestive heart failure

Adult-onset diabetes mellitus

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Two parts showing a sharp demarcation Uremic patients

Page 80: Poonkiat Suchonwanit, MD - Mahidol University...ALOPECIA NON-SCARRING SCARRING DIFFUSE FOCAL -- Male androgenetic alopecia - Female pattern hair loss PATTERN >100 hairs/day •Telogen

Paired, narrow white bands parallel the lunula in the nail bed

Associated with

Hypoalbuminemia

Following chemotherapy

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Extension of pigmentation onto the nail folds is a classic sign of subungual melanoma

Page 85: Poonkiat Suchonwanit, MD - Mahidol University...ALOPECIA NON-SCARRING SCARRING DIFFUSE FOCAL -- Male androgenetic alopecia - Female pattern hair loss PATTERN >100 hairs/day •Telogen

Pseudomonas nail infection

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Acute paronychia

Chronic paronychia

Dorsal pterygium Gradual shortening of proximal nail groove

Ventral pterygium

Obliterating distal nail groove

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Onychomadesis

Nail shedding

Onycholysis

Detached distal or lateral attachment

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Environmental Exposures, irritants,

water, photo onycholysis

Primary skin disorder Psoriasis

Infection Candidas, dermatophytes

Drugs Tetracyclines

Metabolic/systemic disorder Hyperthyroidism

Tumor Subungual exostoses, SCC

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4 types

Page 101: Poonkiat Suchonwanit, MD - Mahidol University...ALOPECIA NON-SCARRING SCARRING DIFFUSE FOCAL -- Male androgenetic alopecia - Female pattern hair loss PATTERN >100 hairs/day •Telogen
Page 102: Poonkiat Suchonwanit, MD - Mahidol University...ALOPECIA NON-SCARRING SCARRING DIFFUSE FOCAL -- Male androgenetic alopecia - Female pattern hair loss PATTERN >100 hairs/day •Telogen
Page 103: Poonkiat Suchonwanit, MD - Mahidol University...ALOPECIA NON-SCARRING SCARRING DIFFUSE FOCAL -- Male androgenetic alopecia - Female pattern hair loss PATTERN >100 hairs/day •Telogen
Page 104: Poonkiat Suchonwanit, MD - Mahidol University...ALOPECIA NON-SCARRING SCARRING DIFFUSE FOCAL -- Male androgenetic alopecia - Female pattern hair loss PATTERN >100 hairs/day •Telogen

Systemic antifungal drug: azole group, terbinafine

Onychomycosis of toenails

Oral itraconazole

▪ 200 mg PO BID for 1 week, then 3 weeks without treatment, repeated for a total of 4-6 pulses of therapy

Onychomycosis of fingernails

Oral itraconazole

▪ 200 mg PO BID for 1 week, then 3 weeks without treatment, then 200 mg PO BID for 1 week (2-4 pulses)

Page 105: Poonkiat Suchonwanit, MD - Mahidol University...ALOPECIA NON-SCARRING SCARRING DIFFUSE FOCAL -- Male androgenetic alopecia - Female pattern hair loss PATTERN >100 hairs/day •Telogen

Hairtransplantationin male-pattern alopecia

Hairtransplantationin male-pattern alopecia

Alopecia in the Primary Care Setting - American College of ... · Androgenetic Alopecia (Female pattern hair loss) No recession of the hairline except possibly the triangles Wider

Alopecia in the Primary Care Setting - American College of ... · Androgenetic Alopecia (Female pattern hair loss) No recession of the hairline except possibly the triangles Wider

Scarring Alopecia: Diagnostic Challenges S063...Melissa Piliang, MD Scarring Alopecia Diagnostic Challenges DISCLOSURES I do not have any relevant relationships with industry. Investigator

Scarring Alopecia: Diagnostic Challenges S063...Melissa Piliang, MD Scarring Alopecia Diagnostic Challenges DISCLOSURES I do not have any relevant relationships with industry. Investigator

Blistering, Papulosquamous, Connective Tissue and Alopecia · Differentiating Routine Alopecia…pearls •Telogen effluvium non-scarring diffuse hair loss, normal scalp, last 1 to

Blistering, Papulosquamous, Connective Tissue and Alopecia · Differentiating Routine Alopecia…pearls •Telogen effluvium non-scarring diffuse hair loss, normal scalp, last 1 to

A Case of Hair Regrowth in a Patient with Complete ... · Female pattern hair loss, also known as female androgenetic alopecia, is a non-scarring progressive thinning of hair [2].

A Case of Hair Regrowth in a Patient with Complete ... · Female pattern hair loss, also known as female androgenetic alopecia, is a non-scarring progressive thinning of hair [2].

Lichen Planopilaris and Low-Level Light Therapy: Four Case ... · scarring alopecia that causes inflammation of the scalp and the eventual destruction of hair ... in 2016 with history

Lichen Planopilaris and Low-Level Light Therapy: Four Case ... · scarring alopecia that causes inflammation of the scalp and the eventual destruction of hair ... in 2016 with history

You’ve Got This: New Patient Hair Loss...•Non-scarring loss of axillary and pubic hair CCCA •Central Centrifugal Cicatricial Alopecia (CCCA) •Scarring hair loss common in black

You’ve Got This: New Patient Hair Loss...•Non-scarring loss of axillary and pubic hair CCCA •Central Centrifugal Cicatricial Alopecia (CCCA) •Scarring hair loss common in black

ALOPECIA - Autoimmune · Alopecia areata is an autoimmune disease, chronic in nature, with a pattern of relapsing immune-mediated inflammation of the hair follicles. This inflammatory

ALOPECIA - Autoimmune · Alopecia areata is an autoimmune disease, chronic in nature, with a pattern of relapsing immune-mediated inflammation of the hair follicles. This inflammatory

Adrenal androgenic female-pattern alopecia: sex hormones ...

Adrenal androgenic female-pattern alopecia: sex hormones ...

Updates in Lichen Planopilaris & Frontal Fibrosing ... F028 - Lenzy... · *Karnik P, et al. Hair follicle stem cell-specific PPARgamma deletion causes scarring alopecia. JID 2009

Updates in Lichen Planopilaris & Frontal Fibrosing ... F028 - Lenzy... · *Karnik P, et al. Hair follicle stem cell-specific PPARgamma deletion causes scarring alopecia. JID 2009

Australia Alopecia Areata Foundation Inc. Alopecia Areata ... · iYS life changing . Australia Alopecia Areata Foundation Inc. Alopecia Areata iYS life changing . Author: Tracy Hoare

Australia Alopecia Areata Foundation Inc. Alopecia Areata ... · iYS life changing . Australia Alopecia Areata Foundation Inc. Alopecia Areata iYS life changing . Author: Tracy Hoare

Pattern Alopecia during Hormonal Anticancer Therapy in ...

Pattern Alopecia during Hormonal Anticancer Therapy in ...

The usefulness of dermoscopy in canine pattern alopecia: a ... · Results – Dermoscopic findings in canine pattern alopecia were hair shaft thinning, circle hairs and follicular

The usefulness of dermoscopy in canine pattern alopecia: a ... · Results – Dermoscopic findings in canine pattern alopecia were hair shaft thinning, circle hairs and follicular

Efficacy of non‐surgical treatments for androgenetic alopecia: a … · 22 hours ago · Androgenetic alopecia, or male/female pattern baldness, is the most common type of progressive

Efficacy of non‐surgical treatments for androgenetic alopecia: a … · 22 hours ago · Androgenetic alopecia, or male/female pattern baldness, is the most common type of progressive

The AutoimmuneBasis of Alopecia Areata: A ...immunology-allergy.org/JournalPapers/AlopeciaAutoimmuneMechanisms...Alopecia areata (AA) is a common, non-scarring dermatologic condition

The AutoimmuneBasis of Alopecia Areata: A ...immunology-allergy.org/JournalPapers/AlopeciaAutoimmuneMechanisms...Alopecia areata (AA) is a common, non-scarring dermatologic condition

Hairlossin children - BMJ · Other causes of scarring alopecia include ... irritation is not a prerequisite for hair regrowth withdithranol. ... Children who pull their hair are relatively

Hairlossin children - BMJ · Other causes of scarring alopecia include ... irritation is not a prerequisite for hair regrowth withdithranol. ... Children who pull their hair are relatively

JAK inhibition in the treatment of alopecia areata – a ......scarring hair loss and nail dystrophy. Current treatment options for AA are limited and often yield unsatisfactory results.

JAK inhibition in the treatment of alopecia areata – a ......scarring hair loss and nail dystrophy. Current treatment options for AA are limited and often yield unsatisfactory results.

Alopecia areata

Alopecia areata

Presentación de PowerPoint - AAD Highlights · • Alopecia areata: JAK inhibitors, new peptides under development (BNZ-1) • Scarring alopecias: low-dose naltrexone for LPP •

Presentación de PowerPoint - AAD Highlights · • Alopecia areata: JAK inhibitors, new peptides under development (BNZ-1) • Scarring alopecias: low-dose naltrexone for LPP •

Dr Z. Shahmoradi Dermatologist. Synonyms Male pattern hair loss (MPHL) Male pattern baldness (MPB) Androgenetic alopecia (AGA) Common baldness.

Dr Z. Shahmoradi Dermatologist. Synonyms Male pattern hair loss (MPHL) Male pattern baldness (MPB) Androgenetic alopecia (AGA) Common baldness.