Consensus on Trichology Treatments from a Panel of Experts

Treatment advancements for trichology, or hair disorders, have not been recently evaluated and therefore lack consensus on their safety and efficacy. A steering committee of dermatologists renowned for their expertise in trichology conducted a literature review from the past 5 years and provided 2 recommendations per area of trichology treatment. They invited trichology experts from 10 different countries to participate as panelists in a 2-step modified Delphi questionnaire measuring how much panelists agreed with the steering committee’s recommendations. The level of agreement for a consensus was set at 80%. They published their results as guidelines for clinical practice in the Journal of The European Academy of Dermatology and Venereology.

Non-cicatricial alopecia

• Oral minoxidil 5 mg daily is a therapeutic option for men with androgenetic alopecia.
  • Assess for cardiovascular complications since oral minoxidil is also used to treat hypertension.
  • Lower doses of 2.5 mg daily or less can be considered for patients with comorbidities or mild alopecia.
• Oral bicalutamide must be considered in female pattern hair loss then other approved treatment options have failed.
  • Monitor liver enzymes every 3 to 4 months since mild hypertransaminasaemia is the most frequent adverse effect.
  • Women of childbearing age must maintain contraceptive measures during treatment and for 2 months post-treatment.
• Mesotherapy with dutasteride is a useful treatment for androgenetic alopecia patients. A protocol should be established, as current studies vary in therapeutic regimens.
  • Dutasteride 0.5 mg daily is safe and effective for male pattern hair loss.
• Systemic therapy is advisable for moderate to severe alopecia areata due to its association with systemic activation of the immune system.

Cicatricial alopecia

• It is controversial whether patients with frontal fibrosing alopecia who are worsening despite treatment may benefit from reducing the use of sunscreens.
• Platelet-rich plasma can be used as an adjunctive anti-inflammatory treatment for patients with lichen planopilaris.

Trichoscopy

• Every patient treated for hair loss should have a trichoscopy examination performed by the physician at least once throughout the treatment process
• In cases of chronic telogen effluvium associated with trichoscopical inflammatory signs (yellow dots, perifollicular erythema or hyperkeratosis, etc.), a trichoscopy-guided biopsy should be recommended since telogen hair loss can occur in other types of hair or systemic disorders.
• Recently described diffuse variants of lichenoid alopecias should be considered in the differential diagnosis of patients complaining of scalp pruritus. In these patients, a trichoscopy-guided biopsy is recommended.
  • Fibrosing alopecia in a pattern distribution (FAPD) and lichen planopilaris diffuse pattern (LPPDP) may be associated with scalp pruritis. As these types of alopecia can be easily confused with other dermatologic issues, a trichoscopy-guided biopsy is recommended for a definitive diagnosis.

Scalp pruritis

• In case of alopecias associated with scalp dysesthesia, naltrexone represents a promising option in patients unresponsive to conventional treatments.
  • Low-dose naltrexone (1-5 mg) is a potential alternative to standard treatment for scalp pruritis.

Microbiome and scalp: seborrheic dermatitis, alopecia areata, and psoriasis

• Balance between bacteria and yeast might lead to a healthy skin. Further studies are needed in this area.
• Mild forms of scalp psoriasis could also be related to the type and quantity of bacteria living in our skin.
  • Some studies have found a relative imbalance of Streptococcus, Staphylococcus and Malassezia in patients with psoriasis compared to those with healthy skin.

Hair transplantation

• Hair transplant should be considered in some cases of frontal fibrosing alopecia (FFA).
  • Hair transplants should only be considered in some selected cases of FFA after discussing the expected results and durability of the transplanted hairs with the patient.

Hair ageing

• Among hair disorders, hair ageing is an entity of its own requiring specific patient education and management.
  • Hair ageing and androgenic alopecia are commonly confused.
• Experimental evidence supports the need for clinical studies to assess whether antioxidants could be a supportive measure for individuals suffering from clinical signs of hair ageing.

 Evidence-based hair cosmetics

• An innovative generation of in vitro models is needed to closely reproduce native hair follicle by using long-term organ culture and tissue engineering. They will be useful to better understand hair follicle biology and to improve alopecia treatment before clinical trials in patients.
• The identification of active ingredients that specifically target both intra- and extra-follicle signaling pathways (Wnt/B catenin pathway, microcirculation, growth factors, cytokines, hormones, and enzymes) could help improve hair loss treatment.
• Nutritional deficiencies should be corrected by diet supplementation or nutricosmetics to improve telogen effluvium.
  • Studies have shown that patients with alopecia have low levels of ferritin, iron, Vitamin D or zinc, but more well-designed clinical trials are needed on the role of micronutrients in hair loss.
• Patients with telogen effluvium could benefit from oral iron supplementation in order to reach ferritin levels greater than 40 µ/L.
  • Although the role of vitamin and mineral supplementation in telogen effluvium is controversial, many dermatologists routinely prescribe oral iron supplements, and the panelists agreed to continue recommending this practice.
• Topical dermo-cosmetic formulations may improve hair loss by using specific active ingredients targeting the hair follicle, but also help to improve the quality of life of patients. Robust clinical trials are needed to evaluate the efficacy of these products.

Limitations of this study include that the recommendations were not based on an exhaustive systematic review, the Delphi technique only provides qualitative results, and most panelists (69%) were Spanish, which may not be representative of the specialist population.

Disclosure: Several study authors declared affiliations with biotech, pharmaceutical, and/or device companies. Please see the original reference for a full list of authors’ disclosures. 

Reference

Meyer-Gonzalez T, Bacqueville D, Grimalt R, et al. Current controversies in trichology: a European expert consensus statement. J Eur Acad Dermatol Venereol. 2021;35 Suppl 2:3-11. doi:10.1111/jdv.17601