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The BHNS hair has organised a monthly Journal Club with reviews and analysis on a range of publications.

April 2021 - Hair and Nail Papers

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British Hair and Nail Society Journal Club April 2021


Research letter:

Hair stylists as screeners for scarring hair loss within the African American community: a cross sectional study

S A Veerabagu, M J Lauth, A Obayomi, M Correa, A T Murina. Volume 184, Number 4, P769-770

What: A cross-sectional study whereby hair stylists in 92 salons across New Orleans with a predominantly African American clientele were educated on early signs of central centrifugal cicatricial alopecia (CCCA). Training also covered management strategies for CCCA and when review by a dermatologist was advised.

Why: CCCA is often diagnosed in the late stages of the disease process at the point of blatant alopecia. This study aimed to investigate whether there is a hidden resource for the early diagnosis of CCCA in hair stylists.

Methods: Participants were asked to complete a pre-test survey in which stylists were asked how confident they felt identifying the stage at which medical review was necessary for hair loss.

They were also shown photographs of various cases of CCCA ranging in severity and asked what their recommendations would be for clients presenting like this (from options including OTC shampoos, vitamin supplementation or dermatology referral). A two-minute educational video covering the association between CCCA and specific styling practices and the importance of early medical input was shown to the participants. Finally, participants completed a post-test survey similar to the pre-test quiz.

Exclusion: 113 salons across New Orleans were approached to participate in this study. 21 salons declined participation. No other exclusions were made.

Demographic: 91.7% of study participants were female. 83.3% identified as African American. Of their clientele, the hair stylists described their customers as predominantly African American (83.3%) or multiple ethnicities (10%).


The predominant outcome measured was the proportion of stylists who would ‘refer to a doctor’. From the pre-test survey, the rates of referral for mild, moderate and severe CCCA were as follows; 32.25%, 41.90% and 60.89%. Following the intervention (educational video), rates of referral for mild, moderate and severe CCCA increased to 53.85%, 67.07% and 71.65% respectively.

A decrease in the number of stylists who would continue current styling practices in mild CCCA was also seen (51.5%). 89.2% participants felt confident to identify when an individual with hair loss required medical review and 95.8% stylists expressed a desire to learn more about this subject.

Author conclusions: The instructional video successfully educated stylists about the need for early identification of hair loss and prompt referral for medical review.  Stylists were also less likely to recommend that a client continues their current hair styling practices if signs of CCCA were present, thereby potentially limiting the disease process.

Limitations: Cross-sectional nature and short term. Authors also recognised the risk of response bias from participants and that the study had a narrow geographical range.

Thoughts: This study proposes a very promising intervention for the progression of CCCA because not only do the hair stylists represent a valuable means of screening individuals for hair loss but they also serve as part of the management by advising a change in styling practices. Perhaps an observational study seeing the techniques learnt here put to practice would be an interesting next step for this area of research.



Concise reports:

Laser therapy is a safe and effective treatment for unwanted hair in adults undergoing male to female sex reassignment

V Vilenchik, K Thomas, L Baker, E Hitchens, D Keith, Volume 46, Number 3, P541-543

What: An observational study examining the use of laser hair removal (LHR) for individuals transitioning from male to female.

Why: The safety and efficacy of LHR has been previously well established in female and male patient groups, however, there is limited data available for use in transgender individuals. This study aimed to provide preliminary information on this topic as well as focus on the importance of the feminization process for the psychological wellbeing of many transgender women.

Methods: The study ran from one regional laser centre within a large teaching hospital based in the UK. All transgender woman who attended the clinic from 2015 to 2020 seeking LHR for unwanted hair were included. This was irrespective of the site of the hair. Data from a total of 48 individuals were included within the study.

Data on the treatment itself and its outcome were collected prospectively. Outcomes included clinician-observed percentage reduction in hair growth (by the end of follow-up) and patient-reported satisfaction rating. Adverse effects were also documented. R software was employed for statistical analysis.

Exclusion: Participants were required to be over 16 years of age.

Demographic: Mean age 38.81 years

Results: 89.4% of patients required treatment for face and neck hair and 10.6% of individuals received LHR for unwanted hair in the groin/genital region. This was usually as a pre-op measure ahead of gender-affirming surgery. Number of LHR sessions ranged from 2-15, with a mean of 7.31. Treatment in 95.6% of individuals was with long-pulsed alexandrite laser. Long-pulsed Nd:YAG laser was used in the remainder.

A statistically significant reduction in hair growth following LHR was observed. The mean ‘clinician-observed percentage reduction in hair-growth’ was 66.3%. Furthermore, 76.6% of patients reported their outcome as ‘much better’ or ‘very much better’ than expected. No adverse events were documented. This included scarring.

Author conclusions: The information obtained from this study in conjuncture with previous literature on the association between gender-affirming treatments and improved mental health outcomes help demonstrate that LHR is not simply cosmetic but medically necessary as part of the gender reassignment process. The removal of facial hair should be prioritised over other body sites as part of the feminisation process for transgender women.

Limitations: Although thought to limit post-operative intravaginal and urethral hair growth, conclusions cannot be drawn about the benefits of LHR in the groin/genital region ahead of gender-affirmation surgery as the sample size was too small in this study. Further data is required for the Nd:YAG laser given that only a few patients received this treatment.

Thoughts: It is becoming increasingly important to ensure adequate representation of all patient groups, including transgender individuals, within research. This study produced some very valuable initial data about the use of LHR in patients who are in the process of transitioning/have transitioned.



Novel mutation of TRPSI in a patient with tricho-rhino-phalangeal syndrome

 S Li, Z Chen, Y Yang, Volume 46, Number 3, P557-559

What: A report of a new TRPS1 mutation presenting in a young woman with hair abnormalities later diagnosed with tricho-rhino-phalangeal syndrome (TRPS) type III.

Why: This case demonstrates the first occasion where this particular pathogenic missense mutation site in the TRPS1 gene has been identified in TRPS.

Case: TRPS is an autosomal dominant condition characterised by cranio-facial, skeletal and hair abnormalities. Hair abnormalities include thin, slow growing scalp hair and laterally sparse eyebrows. It is caused by mutations arising in the TRPS1 gene that leads to disruption of zinc-finger transcription and subsequent interference of chondrocyte and periosteum development amongst other consequences. There are three distinct subtypes.

A 21-year-old woman of Chinese descent presented with sparse, slow-growing scalp hair. She was noted to be of short stature, and had crowded teeth and small hands and feet. There was no family history of similar features.

Genetic testing of the patient’s blood compared to her parents’ samples identified a mutation not previously identified in the TRPS1 gene (c.2786T>G). This genetic abnormality and her symptoms were consistent with a diagnosis of TRPS type III. The mutation was de novo as it was not shared by either of her parents.

Author conclusions: This study reports a newly identified de novo TRPS1 mutation in a classic case of TRPS type III.

Limitations: This study does not examine whether this newly reported mutation differs in presentation from previously reported mutations. 

Thoughts: This paper highlights that although the Human Genome Mutation Database and ExAC database represent amazing resources, there are still endless variations in our DNA yet to be discovered. More frequent genetic testing in patients with unusual symptom combinations could be a valuable means of identifying these mutations.

Clinicopathological cases:

Nail-plate dystrophy of the fifth toenail: thinking outside the box

E Dika, M Lambertini, C Misciali, P A Fanti, F Contedini, V Pinto, M Pignatti, F Cipriani, B Corti, B M Piraccini. Volume 46, Number 3, P584-587

What: The case of a middle-age woman presenting with a history of an ongoing, painful nail-plate abnormality effecting her fifth toe, later diagnosed as an onychocytic matricoma (OCM), a benign tumour of the nail matrix. 

Why: OCM is very rare with only a few examples documented in the literature (<10). This case report recommends consideration of a diagnosis of OCM for any acquired localised monodactylous longitudinal pachyonychia.

Case: A 59-year-old woman presented with a painful, dystrophic fifth toenail. Splinter haemorrhages, yellow discolouration with an isolated blueish blotch, increased transverse curvature and longitudinal thickening of the nail-plate were seen on onychoscopy. These features had been present for 2 years and she had previously received two separate diagnoses of frictional melanonychia with nail-plate abnormalities.

A diagnosis of onychocytic matricoma (OCM) was made following longitudinal biopsy.  Key histological findings included basaloid cells and prekeratogenous zone cells with mild clear cytoplasm, rounded nuclei and a superimposed eosinophilic layer of keratogenic cells in the epithelium of the matrix and nail-bed and epidermoid spheres in the dermis consistent with proliferating epithelial buds.

Treatment consisted of surgical excision of the lesion.

Author conclusions: OCM is extremely rare and diagnosis is challenging. The following features should spark consideration of a diagnosis of OCM; nail colour changes (yellowish discolouration or areas of pigmentation), rough or thickened nail surface and increased transverse curvature of the nail. Splinter haemorrhages can be present/representative of trauma.

OCM are thought to be more common in women and occur in fingernails more commonly than toenails.

Investigation of choice for OCM is longitudinal biopsy including nail matrix.

Differential diagnoses can include onychocytic carcinoma and onychopapilloma.

Limitations: Given the rareness of this condition, day to day relevance is limited.

Thoughts: As this case demonstrates, it is important to be open-minded with your differential diagnoses when a patient represent with ongoing symptoms. This woman was previously diagnosed with frictional melanonychia on multiple occasions before the definitive diagnosis was made. It is easy to be close minded when patients have already been given a diagnosis, therefore clinicians should be mindful and actively work to avoid this. 


Memorable patients:

Female pattern hair loss with acromegaly

Y Mizukami, K Sugawara, D Tsuruta. Volume 46, Number 3, P607-609

What: A case report of a woman exhibiting female pattern hair loss (FPHL) as result of a growth hormone (GH) secreting pituitary adenoma 

Why: This case demonstrates the importance of measuring GH levels along with oestrogen and testosterone in the work up for FPHL as a pituitary adenoma can be a rare cause of hair loss.

Case: A 28-year-old woman presented with hair thinning on the crown of her head. Follicular miniaturisation was seen on trichoscopy. Other symptoms included hypertrichosis elsewhere on her body, an enlarged nose and protrusion of her chin. She also suffered with Type 2 diabetes.

Elevated serum GH and insulin-like growth factor (IGF-1) raised suspicion of a diagnosis of acromegaly therefore further investigation was organised. Dehydroepiandrosterone sulfate (DHEA-S) levels were also raised, but there was no imbalance in female hormones nor evidence of thyroid and adrenal dysfunction.  MRI head demonstrated a pituitary adenoma which was subsequently resected.

Following treatment, the woman’s hair loss began to steadily improve without the need for additional topical or systemic medication.

Author conclusions: Typically, raised serum GH and IGF-1 are associated with proliferation of hair follicle cells and hair growth. The authors suggest here however that prolonged exposure to these high levels may cause GH or IGF-1 receptor desensitisation and subsequent hair loss.

Limitations: Conclusions should not be drawn from this study as it is a case report and provides only low-quality evidence.

Thoughts: Although the authors offer some proposals for the mechanism of hair loss in this case, further research is required in order to understand the pathomechanism of FPHL and its relation to GH and IGF-1 levels.



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