New research for hair regrowth untangled

Melissa Piliang, MD

‘Very quickly I found that as I was able to establish continuity with my patients I’d see them improve,’ Melissa Piliang, MD, said. ‘Sometimes their hair was growing back, and it was an emotional improvement.’

Hair loss is a traumatic experience for patients with conditions such as alopecia areata and lichen planopilaris, but recent research promises advances through such diverse treatment options as vitamin D, new light devices, biologic agents, a PPAR gamma receptor blocker, and hair follicle induction.

“There has been a lot of new innovation in the treatment of hair disorders, which has received increased research focus in the last few years,” said Melissa Piliang, MD, dermatologist and dermatopathologist at the Cleveland Clinic. Dr. Piliang discussed the state of hair research Friday during her Plenary presentation, “Hair Raising Ideas: What’s New in Hair Disorders.”

Dr. Piliang’s focus on hair research started in 2006, during her early years at Cleveland Clinic, when she worked with patients with alopecia.

“Very quickly I found that as I was able to establish continuity with my patients I’d see them improve,” she said. “Sometimes their hair was growing back, and it was an emotional improvement.

“People who have hair loss are understandably distraught about it and tend to be challenging patients. I found that I could help them with the emotional aspect, which I find very rewarding.”

An important finding in hair loss research is the role of vitamin D, which is vital for hair growth and hair cycling.

“When there are deficient vitamin D receptors, the phenotype is bald skin,” Dr. Piliang said. “When vitamin D is added, hair growth can be induced. Many people are deficient in vitamin D, so it is an important nutrient to include in the workup of patients with alopecia. In addition, vitamin D deficiency is associated with increased risk of autoimmune and other inflammatory diseases. In a review of alopecia patients seen in our hair clinic, we found that patients with lichen planopilaris were significantly more likely than control patients to be vitamin D deficient.”

Drug treatments

A JAK inhibitor and a PPAR gamma receptor blocker also show promise in hair regrowth.

Tofacitinib, a biologic developed for the treatment of rheumatoid arthritis, is being studied for use in treating alopecia areata. A recent report of full regrowth in a patient with psoriasis and alopecia universalis has brought this potential therapy to the forefront. Tofacitinib is a JAK inhibitor that is available as a tablet and also is being developed in a topical form.

“This is very exciting news for patients with alopecia areata and dermatologists who treat them,” Dr. Piliang said. “The patient experienced rapid regrowth of terminal, pigmented hairs. As new biologics became available, there was great hope that it would have efficacy in alopecia areata. Finally, we have one that is showing promise.

“We don’t know if it will have this effect on everybody, so there are many questions still to be answered. There are ongoing studies looking at the oral and topical forms of this medication and other similar JAK inhibitors. While preliminary reports are promising, more studies will need to be done.”

The PPAR gamma receptor blocker pioglitazone also is being studied after a patient who had lichen planopilaris had improvement in scalp inflammation after a course of pioglitazone.

“There is basic science evidence that PPAR gamma is involved in lipid metabolism in sebaceous glands of the scalp, which are in close proximity to the hair follicles,” Dr. Piliang said. “We previously thought the primary pathogenesis in lichen planopilaris was inflammation centered on the hair follicle, leading to the destruction of the hair follicle. But in this new paradigm, the inflammation is centered on the sebaceous gland, possibly as a response to oxidative stress or toxic lipids in the sebaceous glands.

“The hair follicle and sebaceous glands are very close to each other, so the hair follicle will be secondarily damaged. The theory is that the medication would shut off the buildup of toxic lipids, thus stopping the inflammatory process.”

Pioglitazone, which is approved by the FDA for the treatment of type 2 diabetes, increases insulin sensitivity in patients with insulin resistance. It does not affect blood sugar levels in patients who are not diabetic.”

Light devices

Light devices have gained in prominence in the last several years as a treatment for alopecia. These devices provide low-intensity light to the scalp and are commonly available without a prescription as hand-held units and caps. One research study has shown hair regrowth in patients using a hand-held device.

“Patients are able to administer the light in their home by using the device for a few minutes several times a week,” Dr. Piliang said. “I find these devices can fill a void for patients who are unable or unwilling to apply traditional topical treatments for androgenic alopecia.

“A recently published multicenter, placebo-controlled, double-blind study showed significant response to treatment versus control. While there are lingering questions about the mechanism of action, reproducibility, and persistence of response, it is a generally safe option.”

Growing new hair follicles

One intriguing method of hair regrowth is through growing new follicles by inducing hair follicle development from epidermis, but researchers have not had success despite years of effort. However, a new method is showing promise, which could benefit patients who have androgenetic alopecia or male pattern hair loss, and patients who have scarring alopecia.

“This is especially exciting for burn victims, people with scarring alopecia, and those with diffusely thin hair, which limits the amount hair available to transplant,” Dr. Piliang said. “Researchers from Columbia University and Durham University in the UK described a new technique that allowed them to induce hair follicle growth de novo from dermal papillae cells. The group developed a novel method whereby dermal papillae cells grow in a spheroid environment providing the 3D architecture needed for hair induction.”

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