Publications by authors named "Paradi Mirmirani"

55 Publications

A Global eDelphi Exercise to Identify Core Domains and Domain Items for the Development of a Global Registry of Alopecia Areata Disease Severity and Treatment Safety (GRASS).

JAMA Dermatol 2021 Mar 3. Epub 2021 Mar 3.

Sinclair Dermatology, Melbourne, Australia.

Importance: A recent expert consensus exercise emphasized the importance of developing a global network of patient registries for alopecia areata to redress the paucity of comparable, real-world data regarding the effectiveness and safety of existing and emerging therapies for alopecia areata.

Objective: To generate core domains and domain items for a global network of alopecia areata patient registries.

Evidence Review: Sixty-six participants, representing physicians, patient organizations, scientists, the pharmaceutical industry, and pharmacoeconomic experts, participated in a 3-round eDelphi process, culminating in a face-to-face meeting at the World Congress of Dermatology, Milan, Italy, June 14, 2019.

Findings: Ninety-two core data items, across 25 domains, achieved consensus agreement. Twenty further noncore items were retained to facilitate data harmonization in centers that wish to record them. Broad representation across multiple stakeholder groups was sought; however, the opinion of physicians was overrepresented.

Conclusions And Relevance: This study identifies the domains and domain items required to develop a global network of alopecia areata registries. These domains will facilitate a standardized approach that will enable the recording of a comprehensive, comparable data set required to oversee the introduction of new therapies and harness real-world evidence from existing therapies at a time when the alopecia areata treatment paradigm is being radically and positively disrupted. Reuse of similar, existing frameworks in atopic dermatitis, produced by the Treatment of Atopic Eczema (TREAT) Registry Taskforce, increases the potential to reuse existing resources, creates opportunities for comparison of data across dermatology subspecialty disease areas, and supports the concept of data harmonization.
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http://dx.doi.org/10.1001/jamadermatol.2020.5839DOI Listing
March 2021

Diagnosis and Treatment of Nonscarring Hair Loss in Primary Care in 2021.

JAMA 2021 Mar;325(9):878-879

Department of Dermatology, University of California, San Francisco.

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http://dx.doi.org/10.1001/jama.2020.19313DOI Listing
March 2021

Cutaneous manifestations of COVID-19: a systematic review and analysis of individual patient-level data.

Dermatol Online J 2020 Dec 15;26(12). Epub 2020 Dec 15.

Department of Dermatology, The Permanente Medical Group, South Sacramento, CA Department of Dermatology, University of California, Davis, CA.

Distinctive patterns in the cutaneous manifestations of COVID-19 have been recently reported. We conducted a systematic review to identify case reports and case series characterizing cutaneous manifestations of confirmed COVID-19. Key demographic and clinical data from each case were extracted and analyzed. The primary outcome measure was risk factor analysis of skin related outcomes for severe COVID-19 disease. Seventy-one case reports and series comprising 144 cases of cutaneous involvement in COVID-19 were included. The most frequently occurring morphologies were: morbilliform (30.6%), varicelliform (18.8%), urticarial (13.2%), chilblains-like (12.5%), and acro-ischemic (9%). The median age of patients was 51 years (mean: 45.9, range: 0 to 91). Patients with chilblains-like eruptions had lower frequencies of extracutaneous COVID-19 symptoms (5/18, 27.8%, P<0.05) and were less likely to have severe COVID-19 disease (2/18, 11%, 95% CI 1.4% to 34.7%, P=0.02). Patients with livedoid and acro-ischemic morphologies had severe COVID-19 more frequently than those with other morphologies (17/21, 81%, 95% CI 58.0% to 94.5%, P<0.0001). The most frequently observed cutaneous manifestations of COVID-19 (morbilliform, varicelliform, and urticarial) are well-described patterns of viral exanthems. However, chilblains-like, livedoid, and acro-ischemic morphologies are not traditionally associated with viral infections and were significantly associated with severity of COVID-19 disease.
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December 2020

Frontal fibrosing alopecia with involvement of the central hair part: distribution of hair loss corresponding to areas of sunscreen application.

Dermatol Online J 2020 Nov 15;26(11). Epub 2020 Nov 15.

Department of Dermatology, The Permanente Medical Group, Vallejo, CA Department of Dermatology, University of California, San Francisco, San Francisco, CA Department of Dermatology, Case Western Reserve University, Cleveland, OH.

Frontal fibrosing alopecia (FFA) typically presents with band-like scarring alopecia in the frontal and temporal hairline along with eyebrow loss. Although this type of hair loss is being seen with increased frequency worldwide, the etiology of the condition is unknown. Studies have suggested a potential environmental role with moisturizers and sunscreens being possible triggers. Herein, we present a 42-year-old woman with a biopsy-proven diagnosis of frontal fibrosing alopecia. In addition to the typical pattern, she also had a striking linear patch of hair loss along her central part. This was an area where she regularly applied sunscreen for many years. Although a causative role for sunscreen ingredients in the development of FFA has not been proven, the evidence accumulated thus far, including our suggestive case, substantiates the need for further study. Additionally, increasing awareness of this potential effect leading to appropriate counseling regarding cessation of possible triggers may be critical for the prevention of further hair loss.
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November 2020

Burden of Illness in Alopecia Areata: A Cross-Sectional Online Survey Study.

J Investig Dermatol Symp Proc 2020 11;20(1):S62-S68

Concert Pharmaceuticals, Lexington, Massachusetts, USA.

Previous QOL and disease burden studies have not captured all relevant aspects of living with alopecia areata (AA). To better understand the burden and everyday experience of living with moderate-to-severe AA, a cross-sectional, online, quantitative-qualitative survey was developed to assess symptoms, relationships, productivity, treatments, and financial burden. Adult patients were recruited from the National Alopecia Areata Foundation database. Data were analyzed descriptively. A total of 216 patients completed the survey. Most were female (83%), aged ≥45 years (59%), and white (78%). Nearly 2 of 3 respondents (62%) made different major life decisions (regarding relationships, education, or career) owing to AA. Most respondents (85%) stated coping with AA as a daily challenge, citing mental health issues, concealing hair loss, and others' reactions; 47% reported anxiety and/or depression. Many patients (75%) persistently concealed hair loss (mean time spent, 10.3 h/wk). Treatment discontinuation was common owing to lack of efficacy, side effects, and cost. Associated expenditures included buying wigs or hairpieces and psychotherapy (mean ∼$2,000/y each). Survey respondents comprised a self-selected sample, which may not reflect the entire population. The impact of AA extends beyond cosmetic concerns and carries a considerable psychosocial burden. Efficacious, less burdensome AA treatments are needed to regrow hair and alleviate psychosocial sequelae.
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http://dx.doi.org/10.1016/j.jisp.2020.05.007DOI Listing
November 2020

It's time to stop calling our office staff "the girls".

Authors:
Paradi Mirmirani

Int J Womens Dermatol 2020 Sep 13;6(4):346-347. Epub 2020 Apr 13.

Department of Dermatology, The Permanente Medical Group, Vallejo, CA, United States.

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http://dx.doi.org/10.1016/j.ijwd.2020.04.003DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC7522806PMC
September 2020

The Alopecia Areata Consensus of Experts (ACE) Study PART II: Results of an International Expert Opinion on Diagnosis and Laboratory Evaluation for Alopecia Areata.

J Am Acad Dermatol 2020 Sep 11. Epub 2020 Sep 11.

Sinclair Dermatology 2 Wellington Parade, East Melbourne, Victoria 3002, Australia.

Background: We previously reported The Alopecia Areata Consensus of Experts (ACE) Study: Results of an International Expert Opinion on Treatments for Alopecia Areata (AA).

Objective: To report the results of the ACE international expert opinion on diagnosis and laboratory evaluation for AA.

Methods: Fifty hair experts from 5 continents were invited to participate in a 3 round Delphi process. Consensus threshold was set at >66%.

Results: Of 148 questions, expert consensus was achieved in 82 (55%) questions. Following round 1 consensus was achieved in 10 of 148 (7%) questions. Round 2 achieved consensus in 47 of 77 questions (61%). The final face-to-face achieved consensus in 25 of 32 (78%) questions. Consensus was greatest for laboratory evaluation (12 of 14 (86%) questions), followed by diagnosis (11 of 14 (79%) questions) of AA. Overall, etiopathogenesis achieved the least category consensus (31 of 68 (46%) questions).

Limitations: The study had low representation from Africa, South America and Asia.

Conclusion: There is expert consensus on aspects of epidemiology, etiopathogenesis, clinical features, diagnosis, laboratory evaluation and prognostic indicators of AA. The study also highlights areas where future clinical research could be directed to address unresolved hypotheses in AA patient care.
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http://dx.doi.org/10.1016/j.jaad.2020.09.028DOI Listing
September 2020

Gram-negative infections in patients with folliculitis decalvans: a subset of patients requiring alternative treatment.

Dermatol Online J 2020 Feb 15;26(2). Epub 2020 Feb 15.

Department of Dermatology, Kaiser-Permanente Northern California, Stockton, CA.

Background Folliculitis decalvans is a neutrophilic cicatricial alopecia whose etiology remains unknown. It is frequently associated with staphylococcal infections. We aimed to determine the rate of gram-negative infections in patients with folliculitis decalvans. Methods A retrospective chart review was performed of patients with biopsy-proven folliculitis decalvans seen at a tertiary hair referral center. The results of bacterial cultures were evaluated. Subjects were determined to have no infection, gram-positive infections, gram-negative infections, or mixed infections. Results Thirty-nine subjects were included in the study. Ninety-three cultures were performed. The majority of cultures were positive for staphylococci. Eleven patients (28%) had gram-negative infections of the scalp. Gram-negative infections comprised one-third of all cultures (33%). Conclusion We present the largest cohort of folliculitis decalvans patients with gram-negative infections, suggesting the need for routine bacterial cultures in patients who are not responsive to standard anti-staphylococcal antibiotics. Awareness of the incidence of these infections may lead to better therapeutic outcomes.
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February 2020

The Alopecia Areata Consensus of Experts (ACE) study: Results of an international expert opinion on treatments for alopecia areata.

J Am Acad Dermatol 2020 Jul 9;83(1):123-130. Epub 2020 Mar 9.

Sinclair Dermatology, East Melbourne, Melbourne, Australia. Electronic address:

Background: A systematic review failed to identify any systemic therapy used in alopecia areata (AA) where use is supported by robust evidence from high-quality randomized controlled trials.

Objective: To produce an international consensus statement on the use and utility of various treatments for AA.

Methods: Fifty hair experts from 5 continents were invited to participate in a 3-round Delphi process. Agreement of 66% or greater was considered consensus.

Results: In the first round, consensus was achieved in 22 of 423 (5%) questions. After a face-to-face meeting in round 3, overall, consensus was achieved for only 130 (33%) treatment-specific questions. There was greater consensus for intralesional treatment of AA (19 [68%]) followed by topical treatment (25 [43%]). Consensus was achieved in 45 (36%) questions pertaining to systemic therapies in AA. The categories with the least consensus were phototherapy and nonprescription therapies.

Limitations: The study included a comprehensive list of systemic treatments for AA but not all treatments used.

Conclusion: Despite divergent opinions among experts, consensus was achieved on a number of pertinent questions. The concluding statement also highlights areas where expert consensus is lacking and where an international patient registry could enable further research.
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http://dx.doi.org/10.1016/j.jaad.2020.03.004DOI Listing
July 2020

Frontal Fibrosing Alopecia: An Emerging Epidemic.

Skin Appendage Disord 2019 Feb 19;5(2):90-93. Epub 2018 Jun 19.

Division of Dermatology, Department of Medicine, University of Alberta, Edmonton, Alberta, Canada.

Since the initial description of frontal fibrosing alopecia (FFA) in 1994, increasingly more cases of FFA have been reported in literature. Although clear epidemiologic data on the incidence and prevalence of FFA is not available, it is intriguing to consider whether FFA should be labeled as an emerging epidemic. A medline trend analysis as well as literature review using keywords "alopecia," "hair loss," and "cicatrical" were performed. Medline trend analysis of published FFA papers from 1905 to 2016 showed that the number of publications referenced in Medline increased from 1 (0.229%) in 1994 to 44 (3.5%) in 2016. The number of patients per published cohort also increased dramatically since the first report of FFA. Over the time period of January 2006-2016, our multi hair-referral centers collaboration study also showed a significant increase in new diagnoses of FFA. At this juncture, the cause for the rapid rise in cases is one of speculation. It is plausible that a cumulative environmental or toxic factor may trigger hair loss in FFA. Once perhaps a "rare type" of cicatricial alopecia, FFA is now being seen in a frequency in excess of what is expected, thus suggestive of an emerging epidemic.
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http://dx.doi.org/10.1159/000489793DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC6388564PMC
February 2019

Erosive Pustular Dermatosis: A Manifestation of Immunosenescence A Report of 8 Cases.

Skin Appendage Disord 2018 Aug 25;4(3):180-186. Epub 2017 Nov 25.

The Permanente Medical Group, Vallejo, CA.

Erosive pustular dermatosis (EPD) is a rare condition of the scalp and legs that is marked by crusted erosions or superficial ulcerations that may result in scarring alopecia and chronic wounds. The condition predominantly affects elderly female as compared to male patients. Its pathogenesis remains poorly understood. The majority of the cases in the literature are from the United Kingdom and continental Europe. In this series, we present 8 North American patients with EPD of the scalp, one of whom also had involvement of the legs and another with the involvement of the face. All our patients were advanced in age and had a predisposition to chronic actinic damage, which are common characteristics of EPD previously reported in the literature. We hypothesize that immunosenescence leads to an aberrant immune response to wound healing and, along with other factors such as a loss of the normal epidermal barrier, ultraviolet damage, and hormonal factors, may contribute to the development of this condition.
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http://dx.doi.org/10.1159/000484488DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC6120385PMC
August 2018

Understanding and Addressing Hair Disorders in Transgender Individuals.

Am J Clin Dermatol 2018 Aug;19(4):517-527

Department of Dermatology, The Permanente Medical Group, 975 Sereno Drive, Vallejo, CA, 94589, USA.

In the United States, an increasing number of individuals are identifying as transgender. Males at birth who identify as females are called male-to-female (MTF) transgender individuals or trans women, and females at birth who identify as males are called female-to-male (FTM) transgender individuals or trans men. The transgender patient population possess unique health concerns disparate from those of the general populace. Exogenous hormone therapy for transgender patients leads to changes in the distribution and pattern of hair growth. Exogenous testosterone can lead to male pattern hair loss and hirsutism, while estrogen therapy usually results in decreased facial and body hair growth and density. A thorough understanding of the hormonal treatments that may be used in transgender individuals as well the unique and complex biologic characteristics of the hair follicle is required for appropriate diagnosis, counseling and treatment of patients. The aim of this article is to provide a framework for understanding hair disorders in transgender individuals and effective treatment options.
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http://dx.doi.org/10.1007/s40257-018-0343-zDOI Listing
August 2018

Vitamin D Deficiency in an Alopecia Referral Clinic During a 3-Month Period: The Need to Pursue Systemic Screening.

Skinmed 2017;15(5):339-341. Epub 2017 Oct 1.

Dermatology Department, Kaiser Permanente Health Network, Vallejo, CA.

Alopecia is typically viewed as a localized process, and comorbidities are not usually analyzed. The authors examine the prevalence of vitamin D deficiency among patients attending an alopecia clinic during a 3-month period. The data showed that 79% of patients had vitamin D deficiency, and the average value of low vitamin D was 19.1 mg/mL in patients. Vitamin D levels have not been examined extensively in skin disorders, and it is not clear whether vitamin D levels are correlative or causative in alopecia. The co-occurrence of both findings at such a dramatic level suggests the need for evaluation of this laboratory value in the alopecia population.
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July 2019

Objective outcome measures: Collecting meaningful data on alopecia areata.

J Am Acad Dermatol 2018 Sep 8;79(3):470-478.e3. Epub 2017 Nov 8.

University of Minnesota, Minneapolis, Minnesota.

Background: Although alopecia areata is a common disorder, it has no US Food and Drug Administration-approved treatment and evidence-based therapeutic data are lacking.

Objective: To develop guidelines for the diagnosis, evaluation, assessment, response criteria, and end points for alopecia areata.

Methods: Literature review and expert opinion of a group of dermatologists specializing in hair disorders.

Results: Standardized methods of assessing and tracking hair loss and growth, including new scoring techniques, response criteria, and end points in alopecia areata are presented.

Limitations: The additional time to perform the assessments is the primary limitation to use of the methodology in clinical practice.

Conclusion: Use of these measures will facilitate collection of standardized outcome data on therapeutic agents used in alopecia areata both in clinical practice and in clinical trials.
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http://dx.doi.org/10.1016/j.jaad.2017.10.048DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC7450487PMC
September 2018

An analysis of gene expression data involving examination of signaling pathways activation reveals new insights into the mechanism of action of minoxidil topical foam in men with androgenetic alopecia.

Cell Cycle 2017 8;16(17):1578-1584. Epub 2017 Jun 8.

g Insilico Medicine, Inc., Emerging Technology Centers , Johns Hopkins University at Eastern , Baltimore , MD , USA.

Androgenetic alopecia is the most common form of hair loss. Minoxidil has been approved for the treatment of hair loss, however its mechanism of action is still not fully clarified. In this study, we aimed to elucidate the effects of 5% minoxidil topical foam on gene expression and activation of signaling pathways in vertex and frontal scalp of men with androgenetic alopecia. We identified regional variations in gene expression and perturbed signaling pathways using in silico Pathway Activation Network Decomposition Analysis (iPANDA) before and after treatment with minoxidil. Vertex and frontal scalp of patients showed a generally similar response to minoxidil. Both scalp regions showed upregulation of genes that encode keratin associated proteins and downregulation of ILK, Akt, and MAPK signaling pathways after minoxidil treatment. Our results provide new insights into the mechanism of action of minoxidil topical foam in men with androgenetic alopecia.
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http://dx.doi.org/10.1080/15384101.2017.1327492DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC5587030PMC
May 2018

Hormones and clocks: do they disrupt the locks? Fluctuating estrogen levels during menopausal transition may influence clock genes and trigger chronic telogen effluvium.

Authors:
Paradi Mirmirani

Dermatol Online J 2016 May 15;22(5). Epub 2016 May 15.

Departments of Dermatology: The Permanente Medical Group (Vallejo, CA), University of California, San Francisco, Case Western Reserve University.

Chronic telogen effluvium describes the clinical condition noted mostly in middle-aged women of increased, diffuse scalp hair shedding that is prolonged and often presents with a fluctuating course that may continue for years but does not lead to visible hair thinning. Despite its description almost 20 years ago, the underlying pathologic cause of CTE is yet to be identified. However the culmination of research in the field of hair biology and the burgeoning field of chronobiology may lead to exciting breakthroughs in our understanding of CTE. In this paper the current literature on CTE is reviewed and a hypothesis is put forth that CTE may be triggered by hormonal fluctuations and alterations in circadian control genes.
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May 2016

Cocking the eyebrows to find the missing hairline in frontal fibrosing alopecia: A useful clinical maneuver.

J Am Acad Dermatol 2016 Aug;75(2):e63-4

Department of Dermatology, University of California, San Francisco, California.

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http://dx.doi.org/10.1016/j.jaad.2015.12.054DOI Listing
August 2016

Age-related hair changes in men: mechanisms and management of alopecia and graying.

Authors:
Paradi Mirmirani

Maturitas 2015 Jan 23;80(1):58-62. Epub 2014 Oct 23.

Department of Dermatology, The Permanente Medical Group, Vallejo, CA, United States; Department of Dermatology, University of California, San Francisco, San Francisco, CA, United States; Department of Dermatology, Case Western Reserve University, Cleveland, OH, United States. Electronic address:

The appearance of human scalp hair is often tied to perceptions of youth and virility, especially in men. Hair loss, or alopecia and hair graying are commonly associated with advancing age and are frequently a source for emotional distress and anxiety. Our understanding of the complex molecular signals and mechanisms that regulate and influence the hair follicle has expanded in recent years. By harnessing this understanding we are poised to address the esthetic concerns of aging hair. Additionally, changes in the hair follicle may be a reflection of systemic senescent signals, thus because of its accessibility, the hair follicle may serve as an important research tool in gerontology. In this review, the most current knowledge and research regarding mechanisms of androgenetic alopecia, senescent alopecia, and graying are discussed, as are extrinsic factors that may contribute to hair changes with age. Evidence based management strategies for treatment of age-related hair changes are also reviewed.
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http://dx.doi.org/10.1016/j.maturitas.2014.10.008DOI Listing
January 2015

Two birds that exclude each other: the Renbök phenomenon.

Authors:
Paradi Mirmirani

J Invest Dermatol 2015 Apr 28;135(4):1180. Epub 2014 Nov 28.

The Permanente Medical Group, Vallejo, California, USA; Department of Dermatology, Case Western Reserve University, Cleveland, Ohio, USA; Department of Dermatology, University of California, San Francisco, San Francisco, California, USA. Electronic address:

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http://dx.doi.org/10.1038/jid.2014.509DOI Listing
April 2015

The impact of obesity on the folliculosebaceous unit.

J Am Acad Dermatol 2014 Sep;71(3):584-5

Kaiser Permanente Division of Research, Oakland, California.

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http://dx.doi.org/10.1016/j.jaad.2014.03.057DOI Listing
September 2014

Traction alopecia: how to translate study data for public education--closing the KAP gap?

Dermatol Clin 2014 Apr 22;32(2):153-61. Epub 2014 Jan 22.

Division of Dermatology Ward G23, Groote Schuur Hospital Main Road Observatory and the University of Cape Town, Western Province 7925, South Africa. Electronic address:

Traction alopecia (TA) affects up to 32% of women and 22% of high school girls with Afro-textured hair but can start in the preschool years. Traction induces inflammation and follicle damage. The risk of TA increases with symptomatic traction and combined hairstyles. To influence the practice of hairdressers and at risk individuals and help narrow the knowledge, attitudes, and practices (KAP) gap, scientific data should be translated into simple messages like "tolerate pain from a hairstyle and risk hair loss" and "no braids or weaves on relaxed hair". With appropriate education and public awareness, TA could potentially be eradicated.
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http://dx.doi.org/10.1016/j.det.2013.12.003DOI Listing
April 2014

Skin disorders associated with obesity in children and adolescents: a population-based study.

Pediatr Dermatol 2014 Mar-Apr;31(2):183-90. Epub 2013 Dec 13.

Permanente Medical Group, Vallejo, California; Case Western Reserve University, Cleveland, Ohio; University of California at San Francisco, San Francisco, California.

Obesity in children is a major public health concern in the United States. The objectives of the current study were to determine the prevalence of various groups of cutaneous disorders in obese children and adolescents and to compare the use of dermatology services in obese subjects with that those with a normal body mass index (BMI). This was a retrospective, population-based study at the Kaiser Permanente Northern California Managed Healthcare System. The main outcome measures were the relative risk of cutaneous disorders associated with insulin resistance, androgen excess, bacterial infection, fungal infection, viral infection, inflammation, mechanical changes, and other skin conditions (hidradenitis, hyperhidrosis) in three weight groups (normal, overweight, obese) and the number of dermatology visits. A total of 248,775 subjects were included. Bivariate analyses showed a higher proportion of insulin resistance disorders, bacterial infection, fungal infection, inflammatory disorders, mechanical changes, and other skin conditions in obese subjects than in subjects with a normal BMI (p < 0.001). Disorders of androgen excess and viral infection were significantly less common in obese subjects (p < 0.001). Obese subjects had significantly lower odds of having at least one dermatology encounter than subjects with a normal BMI (odds ratio = 0.92, 95% confidence interval 0.88, 0.96, p = 0.003). Early onset obesity is associated with cutaneous disorders characterized by hyperproliferation, inflammation, bacterial and fungal infection, and mechanical changes but lower rates of disorders of androgen excess and viral infection. The use of dermatology services was not greater in obese patients. Heightened recognition and further analysis of adipose tissue as an endocrine organ that is capable of affecting the skin is warranted.
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http://dx.doi.org/10.1111/pde.12271DOI Listing
January 2015

Epidemiologic trends in pediatric tinea capitis: a population-based study from Kaiser Permanente Northern California.

J Am Acad Dermatol 2013 Dec 3;69(6):916-21. Epub 2013 Oct 3.

Permanente Medical Group, Vallejo, California; Case Western Reserve University, Cleveland, Ohio; University of California, San Francisco, California. Electronic address:

Background: Epidemic levels of tinea capitis (TC) have previously been reported in children.

Objective: We sought to determine new epidemiologic trends for TC among northern California children from 1998 through 2007.

Methods: Annual incidence of TC was based on diagnosis code or first-time antifungal prescriptions in all children up to age 15 years at Kaiser Permanente Northern California.

Results: An average of 672,373 children/y met the inclusion criteria. Trend analyses showed decreases in TC by diagnosis code and by prescriptions (73.7% and 23.7%, respectively). Girls had lower incidence rates than boys by diagnosis (111.9 vs 146.4, P < .001 for 1998, and 27.9 vs 39.9, P < .001 for 2007). African Americans had the highest incidence rates by diagnosis (447.3 in 1998 and 184.1 in 2007) compared with other ethnic groups. Trichophyton tonsurans was the predominant organism (89.4% of all positive fungal cultures in 1998 and 91.8% in 2007). Prescriptions for griseofulvin declined, whereas the prescriptions for other antifungals increased.

Limitations: This was a retrospective study.

Conclusions: In this cohort, there was a significant decrease in incidence of TC over the study period. Trichophyton tonsurans continued to be the predominant organism. These trends may be a result of improved education, recognition, diagnosis, and treatment of TC and increased use of new oral antifungals.
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http://dx.doi.org/10.1016/j.jaad.2013.08.031DOI Listing
December 2013

Elastin staining patterns in primary cicatricial alopecia.

J Am Acad Dermatol 2013 Nov 10;69(5):776-782. Epub 2013 Sep 10.

Department of Dermatology, Kaiser Permanente Medical Group, Vallejo, California.

Background: Most biopsy specimens of cicatricial (scarring) alopecia can be readily subclassified as lymphocytic versus neutrophilic, but specific diagnosis remains difficult, particularly when a late stage of the disease is sampled.

Objective: We sought to document patterns of scarring highlighted by elastic tissue staining in primary cicatricial alopecia.

Methods: We documented Verhoeff elastic van Gieson staining patterns in 58 routinely embedded (vertical) biopsy specimens of cicatricial alopecia. Patterns of fibrosis included perifollicular (wedge-shaped vs broad tree trunk-shaped) and diffuse. The patterns were compared against the diagnosis obtained by independent expert clinical review, including central centrifugal cicatricial alopecia (CCCA), lichen planopilaris, traction alopecia, frontal fibrosing alopecia, discoid lupus erythematosus, and tufted folliculitis.

Results: Wedge-shaped perifollicular fibrosis was seen in lichen planopilaris but also in CCCA. Broad tree trunk-shaped perifollicular fibrosis was most commonly encountered in CCCA.

Limitations: The retrospective nature of the study precluded temporal staging of the disease process.

Conclusions: Patterns of fibrosis highlighted by elastin staining in primary cicatricial alopecia appear to be disease specific. Superficial wedge-shaped perifollicular fibrosis is associated with but may not be specific for lichen planopilaris. Broad tree trunk-like perifollicular fibrosis is specific for CCCA but not present in many cases. Elastin staining represents a useful ancillary study for the evaluation of late-stage scarring alopecia in routinely oriented punch biopsy specimens.
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http://dx.doi.org/10.1016/j.jaad.2013.07.018DOI Listing
November 2013

Transversely sectioned biopsies in the diagnosis of end-stage traction alopecia.

Dermatol Online J 2013 Apr 15;19(4):11. Epub 2013 Apr 15.

Division of Dermatology, University of Toronto; Hair Club Medical Group; Cleveland Clinic, Canada.

The pathogenesis of scarring alopecia in African American women remains poorly understood. Furthermore, the overlapping clinical and histological features present diagnostic challenges. The diagnosis of end stage traction alopecia secondary to traumatic hair styling practices can sometimes present particular challenges. We present a young African American woman with a scarring alopecia. As we describe, a scalp biopsy processed by transverse sections enabled rapid diagnosis and presented advantages over a biopsy processed with vertical sections.
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April 2013

Microarray analysis of androgenetic and senescent alopecia: comparison of gene expression shows two distinct profiles.

J Dermatol Sci 2013 Nov 9;72(2):183-6. Epub 2013 Jul 9.

Department of Dermatology, University Hospitals Case Medical Center and Case Western Reserve University, Cleveland, OH, United States. Electronic address:

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http://dx.doi.org/10.1016/j.jdermsci.2013.06.017DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC4164265PMC
November 2013

Investigating the effects of metabolic dysregulation on hair follicles: a comparison of HIV-infected women with and without central lipohypertrophy.

Int J Dermatol 2014 Oct 20;53(10):e443-8. Epub 2013 Jun 20.

Department of Dermatology, The Permanente Medical Group, Vallejo, CA, USA.

Background: Normal lipid metabolism and functioning of the peroxisome proliferator-activated receptor gamma (PPAR-gamma) in the sebaceous gland is critical to maintaining a normal hair follicle. Human immunodeficiency virus (HIV) infection affects lipid metabolism; some have hypothesized a link between PPAR-gamma function and lipodystrophy in HIV infection. Our objective was to determine whether lipodystrophy is associated with altered hair characteristics in HIV-infected women from the Women's Interagency HIV Study.

Methods: Hair characteristics and scalp inflammation were assessed by an interviewer-administered questionnaire. Central lipohypertrophy and peripheral lipoatrophy were defined by self-report of moderate to severe fat gain in central body sites and fat loss in peripheral body sites, respectively confirmed by clinical examination. Additional covariates considered in the analyses included demographics, behavioral characteristics, medical history, and HIV-related factors.

Results: There were 1037 women with data on all study variables; 76 women reported central lipohypertrophy, while only four women reported lipoatrophy. Women with central lipohypertrophy were more likely to be older, had a self-reported history of injection drug use, statin medication use, diabetes, elevated cholesterol, and have self-reported less hair and shorter eyelashes. After adjustment for age, central lipohypertrophy was associated with shorter eyelashes (OR 2.3; 95% CI 1.4-3.8).

Conclusions: Central lipohypertrophy was not associated with change in scalp hair texture or scalp inflammation in this cohort. Rather, we found an association between central lipohypertrophy and shorter eyelash length. This finding may be explained by an influence of prostaglandin E2 mediators on eyelash follicles.
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http://dx.doi.org/10.1111/ijd.12044DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC3785560PMC
October 2014

Managing hair loss in midlife women.

Authors:
Paradi Mirmirani

Maturitas 2013 Feb 24;74(2):119-22. Epub 2012 Nov 24.

Department of Dermatology, The Permanente Medical Group, Vallejo, CA 94589, United States.

Hair is considered one of the most defining aspects of human appearance. Hair loss, or alopecia in women is often met with significant emotional distress and anxiety. In midlife, women may encounter various hormonal and age-related physiologic changes that can lead to alterations in hair texture and growth. The most significant hormonal alteration is the onset of menopause in which there is a cessation of ovarian estrogen production. This decrease in estrogen is known to have deleterious effects on the skin and cutaneous appendages. As our understanding of the molecular and hormonal controls on the hair follicle has grown, there has been increased interest in the various modulators of hair growth, including the potential role of estrogen. Further study of hair changes in midlife women provides an important opportunity for identification of the complex regulation of hair growth as well as identification of treatment targets that may specifically benefit women. In this review, management of hair loss in midlife women is discussed with a focus on three most commonly encountered clinical conditions: female pattern hair loss, hair shaft alterations due to hair care, and telogen effluvium.
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http://dx.doi.org/10.1016/j.maturitas.2012.10.020DOI Listing
February 2013

Sterol intermediates of cholesterol biosynthesis inhibit hair growth and trigger an innate immune response in cicatricial alopecia.

PLoS One 2012 7;7(6):e38449. Epub 2012 Jun 7.

Department of Dermatology, University Hospitals Case Medical Center, Case Western Reserve University, Cleveland, Ohio, United States of America.

Primary cicatricial alopecia (PCA) is a group of inflammatory hair disorders that cause scarring and permanent hair loss. Previous studies have implicated PPARγ, a transcription factor that integrates lipogenic and inflammatory signals, in the pathogenesis of PCA. However, it is unknown what triggers the inflammatory response in these disorders, whether the inflammation is a primary or secondary event in disease pathogenesis, and whether the inflammatory reaction reflects an autoimmune process. In this paper, we show that the cholesterol biosynthetic pathway is impaired in the skin and hair follicles of PCA patients. Treatment of hair follicle cells with BM15766, a cholesterol biosynthesis inhibitor, or 7-dehydrocholesterol (7-DHC), a sterol precursor, stimulates the expression of pro-inflammatory chemokine genes. Painting of mouse skin with 7-DHC or BM15766 inhibits hair growth, causes follicular plugging and induces the infiltration of inflammatory cells into the interfollicular dermis. Our results demonstrate that cholesterologenic changes within hair follicle cells trigger an innate immune response that is associated with the induction of toll-like receptor (TLR) and interferon (IFN) gene expression, and the recruitment of macrophages that surround the hair follicles and initiate their destruction. These findings reveal a previously unsuspected role for cholesterol precursors in PCA pathogenesis and identify a novel link between sterols and inflammation that may prove transformative in the diagnosis and treatment of these disorders.
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http://journals.plos.org/plosone/article?id=10.1371/journal.pone.0038449PLOS
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC3369908PMC
December 2012