Hair & Nails

BERLIN — Oral ivermectin proved superior to conventional therapy with malathion lotion for the treatment of difficult to eradicate head lice infestations in a large multinational randomized trial.

The number needed to treat—that is, the number of patients who needed to be treated with two doses of oral ivermectin 1 week apart instead of two applications of topical malathion in order for one additional patient to become louse-free—was 9.8, Dr. Olivier Chosidow reported at the annual congress of the European Academy of Dermatology and Venereology.

“Our randomized trial suggests strongly that ivermectin could be valuable, at least in patients who've previously failed standard therapy because their head lice aren't sensitive enough to local insecticides,” said Dr. Chosidow of the University of Paris.

He reported on 812 patients with head lice infestation in 376 randomized households. All participants were at least 2 years old and weighed at least 15 kg. At enrollment, all had live head lice detected by combing which had not been eradicated by topical insecticide therapy 2–6 weeks earlier. The households were randomized to double-blind/double-placebo supervised treatment with two single doses of oral ivermectin (Stromectol, Mectizan) at 400 mcg/kg or 0.5% malathion lotion, both administered on days 1 and 8.

The primary study end point was the absence of head lice upon inspection by combing on day 15. The success rate was 95% in the ivermectin group, compared with 85% in the malathion group. The secondary end points were the absence of head lice on days 2, 8, 22, and 29. The ivermectin group fared significantly better at each time point.

Generally mild treatment-related adverse events were noted in 7.5% of the ivermectin group and 10.9% who received malathion. There were no serious adverse events. It is well-established that ivermectin does not cross the human blood/brain barrier, according to Dr. Chosidow. Families appreciated the convenience of oral therapy.

Oral ivermectin is not approved by the Food and Drug Administration for the treatment of pediculosis. However, the Centers for Disease Control and Prevention guidelines recommend it for the treatment of scabies as an alternative to first-line topical 5% permethrin.

Dr. Erwin Tschachler, EADV secretary-general elect, singled out Dr. Chosidow's study as one of the infectious disease highlights of the congress.

“This is the first time an oral therapy for this parasitic infestation has been successful,” commented Dr. Tschacler, head of the research division for biology and pathobiology of the skin at the University of Vienna Medical School.

Although head lice are associated with low socioeconomic status, no socioeconomic stratum is immune to infestation, and outbreaks are a growing problem in many European countries, he added.

Dr. Chosidow received a research grant from Johnson & Johnson, which sponsored the ivermectin study.

'Ivermectin could be valuable, at least in patients who've previously failed standard therapy.'

Source Dr. Chosidow

BERLIN — Oral ivermectin proved superior to conventional therapy with malathion lotion for the treatment of difficult to eradicate head lice infestations in a large multinational randomized trial.

The number needed to treat—that is, the number of patients who needed to be treated with two doses of oral ivermectin 1 week apart instead of two applications of topical malathion in order for one additional patient to become louse-free—was 9.8, Dr. Olivier Chosidow reported at the annual congress of the European Academy of Dermatology and Venereology.

“Our randomized trial suggests strongly that ivermectin could be valuable, at least in patients who've previously failed standard therapy because their head lice aren't sensitive enough to local insecticides,” said Dr. Chosidow of the University of Paris.

He reported on 812 patients with head lice infestation in 376 randomized households. All participants were at least 2 years old and weighed at least 15 kg. At enrollment, all had live head lice detected by combing which had not been eradicated by topical insecticide therapy 2–6 weeks earlier. The households were randomized to double-blind/double-placebo supervised treatment with two single doses of oral ivermectin (Stromectol, Mectizan) at 400 mcg/kg or 0.5% malathion lotion, both administered on days 1 and 8.

The primary study end point was the absence of head lice upon inspection by combing on day 15. The success rate was 95% in the ivermectin group, compared with 85% in the malathion group. The secondary end points were the absence of head lice on days 2, 8, 22, and 29. The ivermectin group fared significantly better at each time point.

Generally mild treatment-related adverse events were noted in 7.5% of the ivermectin group and 10.9% who received malathion. There were no serious adverse events. It is well-established that ivermectin does not cross the human blood/brain barrier, according to Dr. Chosidow. Families appreciated the convenience of oral therapy.

Oral ivermectin is not approved by the Food and Drug Administration for the treatment of pediculosis. However, the Centers for Disease Control and Prevention guidelines recommend it for the treatment of scabies as an alternative to first-line topical 5% permethrin.

Dr. Erwin Tschachler, EADV secretary-general elect, singled out Dr. Chosidow's study as one of the infectious disease highlights of the congress.

“This is the first time an oral therapy for this parasitic infestation has been successful,” commented Dr. Tschacler, head of the research division for biology and pathobiology of the skin at the University of Vienna Medical School.

Although head lice are associated with low socioeconomic status, no socioeconomic stratum is immune to infestation, and outbreaks are a growing problem in many European countries, he added.

Dr. Chosidow received a research grant from Johnson & Johnson, which sponsored the ivermectin study.

'Ivermectin could be valuable, at least in patients who've previously failed standard therapy.'

Source Dr. Chosidow

BERLIN — Oral ivermectin proved superior to conventional therapy with malathion lotion for the treatment of difficult to eradicate head lice infestations in a large multinational randomized trial.

The number needed to treat—that is, the number of patients who needed to be treated with two doses of oral ivermectin 1 week apart instead of two applications of topical malathion in order for one additional patient to become louse-free—was 9.8, Dr. Olivier Chosidow reported at the annual congress of the European Academy of Dermatology and Venereology.

“Our randomized trial suggests strongly that ivermectin could be valuable, at least in patients who've previously failed standard therapy because their head lice aren't sensitive enough to local insecticides,” said Dr. Chosidow of the University of Paris.

He reported on 812 patients with head lice infestation in 376 randomized households. All participants were at least 2 years old and weighed at least 15 kg. At enrollment, all had live head lice detected by combing which had not been eradicated by topical insecticide therapy 2–6 weeks earlier. The households were randomized to double-blind/double-placebo supervised treatment with two single doses of oral ivermectin (Stromectol, Mectizan) at 400 mcg/kg or 0.5% malathion lotion, both administered on days 1 and 8.

The primary study end point was the absence of head lice upon inspection by combing on day 15. The success rate was 95% in the ivermectin group, compared with 85% in the malathion group. The secondary end points were the absence of head lice on days 2, 8, 22, and 29. The ivermectin group fared significantly better at each time point.

Generally mild treatment-related adverse events were noted in 7.5% of the ivermectin group and 10.9% who received malathion. There were no serious adverse events. It is well-established that ivermectin does not cross the human blood/brain barrier, according to Dr. Chosidow. Families appreciated the convenience of oral therapy.

Oral ivermectin is not approved by the Food and Drug Administration for the treatment of pediculosis. However, the Centers for Disease Control and Prevention guidelines recommend it for the treatment of scabies as an alternative to first-line topical 5% permethrin.

Dr. Erwin Tschachler, EADV secretary-general elect, singled out Dr. Chosidow's study as one of the infectious disease highlights of the congress.

“This is the first time an oral therapy for this parasitic infestation has been successful,” commented Dr. Tschacler, head of the research division for biology and pathobiology of the skin at the University of Vienna Medical School.

Although head lice are associated with low socioeconomic status, no socioeconomic stratum is immune to infestation, and outbreaks are a growing problem in many European countries, he added.

Dr. Chosidow received a research grant from Johnson & Johnson, which sponsored the ivermectin study.

'Ivermectin could be valuable, at least in patients who've previously failed standard therapy.'

Source Dr. Chosidow

BUDAPEST, HUNGARY — The oral probiotic Lactobacillus paracasei achieved substantial, clinically meaningful reductions in dandruff in a double-blind, placebo-controlled randomized trial.

Consumption of the probiotic also resulted in several secondary benefits, including reduced scalp erythema, itching, and greasiness, along with a steady decline over time in scalp Malassezia yeast counts, Dr. Audrey Gueniche reported at the annual congress of the European Society for Dermatological Research.

She and her coworkers at L'Oréal in Clichy, France, had previously shown that the probiotic speeds recovery of skin barrier function following controlled damage induced by tape stripping. They also demonstrated that L. paracasei helps regulate skin immune function.

Since those defects play an important role in dandruff conditions, the investigators decided to explore L. paracasei as a potential treatment for this common flaky scalp condition.

Thirty white men with moderate to severe dandruff were randomized to 57 days of daily consumption of L. paracasei in powder form or to placebo. Participants had to agree not to consume yogurt or other food products produced by the bacterial fermentation of milk during the trial and not to alter their customary face and scalp hygiene routine.

Biweekly clinical assessments documented declining levels of free and adherent dandruff, the coprimary study endpoints. The divergence between probiotic and placebo became significant after 4–5 weeks. After 57 days, the probiotic group had a 70% reduction from baseline in their standardized free dandruff score and a 72% decrease in adherent dandruff, compared with reductions of 23% and 34%, respectively, in the placebo group.

Investigator ratings of scalp erythema showed a 58% reduction in the probiotic group after 57 days and a 31% decrease with placebo. The reductions in dandruff and erythema scores were still maintained 1 week after the end of probiotic supplementation, according to Dr. Gueniche.

Global efficacy ratings made by blinded investigators on day 57 showed that 64% of patients in the probiotic arm were scored as having "good improvement" or "total healing," compared with 27% of controls, she reported.

Patients in the probiotic group rated their dandruff as reduced by 57% at the study's end, compared with a self-assessed 16% decrease in the placebo group. The L. paracasei group rated its scalp pruritus as 47% improved, versus a 13% reduction for controls. The probiotic users also rated their scalp erythema as 72% improved, compared with a 43% reduction reported in the placebo group.

Total Malassezia yeast counts showed a significant decrease over time in the probiotic group. In terms of M. restricta and M. globosa—the two species that have been identified as the major players in dandruff conditions—scalp counts increased sharply in the placebo group from day 15 on but remained steady over time in the probiotic treatment arm, Dr. Gueniche said.

Source Elsevier Global Medical News

BUDAPEST, HUNGARY — The oral probiotic Lactobacillus paracasei achieved substantial, clinically meaningful reductions in dandruff in a double-blind, placebo-controlled randomized trial.

Consumption of the probiotic also resulted in several secondary benefits, including reduced scalp erythema, itching, and greasiness, along with a steady decline over time in scalp Malassezia yeast counts, Dr. Audrey Gueniche reported at the annual congress of the European Society for Dermatological Research.

She and her coworkers at L'Oréal in Clichy, France, had previously shown that the probiotic speeds recovery of skin barrier function following controlled damage induced by tape stripping. They also demonstrated that L. paracasei helps regulate skin immune function.

Since those defects play an important role in dandruff conditions, the investigators decided to explore L. paracasei as a potential treatment for this common flaky scalp condition.

Thirty white men with moderate to severe dandruff were randomized to 57 days of daily consumption of L. paracasei in powder form or to placebo. Participants had to agree not to consume yogurt or other food products produced by the bacterial fermentation of milk during the trial and not to alter their customary face and scalp hygiene routine.

Biweekly clinical assessments documented declining levels of free and adherent dandruff, the coprimary study endpoints. The divergence between probiotic and placebo became significant after 4–5 weeks. After 57 days, the probiotic group had a 70% reduction from baseline in their standardized free dandruff score and a 72% decrease in adherent dandruff, compared with reductions of 23% and 34%, respectively, in the placebo group.

Investigator ratings of scalp erythema showed a 58% reduction in the probiotic group after 57 days and a 31% decrease with placebo. The reductions in dandruff and erythema scores were still maintained 1 week after the end of probiotic supplementation, according to Dr. Gueniche.

Global efficacy ratings made by blinded investigators on day 57 showed that 64% of patients in the probiotic arm were scored as having "good improvement" or "total healing," compared with 27% of controls, she reported.

Patients in the probiotic group rated their dandruff as reduced by 57% at the study's end, compared with a self-assessed 16% decrease in the placebo group. The L. paracasei group rated its scalp pruritus as 47% improved, versus a 13% reduction for controls. The probiotic users also rated their scalp erythema as 72% improved, compared with a 43% reduction reported in the placebo group.

Total Malassezia yeast counts showed a significant decrease over time in the probiotic group. In terms of M. restricta and M. globosa—the two species that have been identified as the major players in dandruff conditions—scalp counts increased sharply in the placebo group from day 15 on but remained steady over time in the probiotic treatment arm, Dr. Gueniche said.

Source Elsevier Global Medical News

BUDAPEST, HUNGARY — The oral probiotic Lactobacillus paracasei achieved substantial, clinically meaningful reductions in dandruff in a double-blind, placebo-controlled randomized trial.

Consumption of the probiotic also resulted in several secondary benefits, including reduced scalp erythema, itching, and greasiness, along with a steady decline over time in scalp Malassezia yeast counts, Dr. Audrey Gueniche reported at the annual congress of the European Society for Dermatological Research.

She and her coworkers at L'Oréal in Clichy, France, had previously shown that the probiotic speeds recovery of skin barrier function following controlled damage induced by tape stripping. They also demonstrated that L. paracasei helps regulate skin immune function.

Since those defects play an important role in dandruff conditions, the investigators decided to explore L. paracasei as a potential treatment for this common flaky scalp condition.

Thirty white men with moderate to severe dandruff were randomized to 57 days of daily consumption of L. paracasei in powder form or to placebo. Participants had to agree not to consume yogurt or other food products produced by the bacterial fermentation of milk during the trial and not to alter their customary face and scalp hygiene routine.

Biweekly clinical assessments documented declining levels of free and adherent dandruff, the coprimary study endpoints. The divergence between probiotic and placebo became significant after 4–5 weeks. After 57 days, the probiotic group had a 70% reduction from baseline in their standardized free dandruff score and a 72% decrease in adherent dandruff, compared with reductions of 23% and 34%, respectively, in the placebo group.

Investigator ratings of scalp erythema showed a 58% reduction in the probiotic group after 57 days and a 31% decrease with placebo. The reductions in dandruff and erythema scores were still maintained 1 week after the end of probiotic supplementation, according to Dr. Gueniche.

Global efficacy ratings made by blinded investigators on day 57 showed that 64% of patients in the probiotic arm were scored as having "good improvement" or "total healing," compared with 27% of controls, she reported.

Patients in the probiotic group rated their dandruff as reduced by 57% at the study's end, compared with a self-assessed 16% decrease in the placebo group. The L. paracasei group rated its scalp pruritus as 47% improved, versus a 13% reduction for controls. The probiotic users also rated their scalp erythema as 72% improved, compared with a 43% reduction reported in the placebo group.

Total Malassezia yeast counts showed a significant decrease over time in the probiotic group. In terms of M. restricta and M. globosa—the two species that have been identified as the major players in dandruff conditions—scalp counts increased sharply in the placebo group from day 15 on but remained steady over time in the probiotic treatment arm, Dr. Gueniche said.

Source Elsevier Global Medical News

New genetic research is yielding some important clues into the puzzling condition of alopecia areata, Dr. Maria Hordinsky reported at the women's and pediatric dermatology seminar sponsored by Skin Disease Education Foundation (SDEF).

By doing whole-genome analysis on thousands of samples gathered over the last 9 years, investigators have found four genes associated with the disease. Surprisingly, none of the genes is implicated in psoriasis, which has long been considered a risk factor for alopecia areata. Conversely, none of the genes associated with psoriasis appears to be implicated in alopecia areata. Investigators announced the findings this year at the annual meeting of the Society for Investigative Dermatology in Montreal.

These findings have important consequences for treatment and research, according to Dr. Hordinsky, chair of the dermatology department at the University of Minnesota, Minneapolis.

"We've all been scratching our heads for the past couple of years wondering why on Earth the new biologics that work so well in psoriasis are not working in this disease," she said. "So now with this data, maybe one possibility is that the diseases are just completely different in the way they're molecularly structured. The thinking has changed in the past couple of months. If you were to start a clinical trial today in alopecia areata, based on the new information, you probably wouldn't pick some of the biologics that were picked a few years ago."

For now, though, Dr. Hordinsky emphasized that there is no "best" treatment for alopecia areata. Patients with patchy alopecia areata sometimes respond to topical or intralesional corticosteroids, minoxidil solution, anthralin, steroid-containing shampoos, excimer laser therapy, or combination treatment.

For extensive alopecia areata, Dr. Hordinsky suggested prednisone, topical minoxidil, PUVA, immunotherapy, pulse methylprednisolone, narrow-band UVB, or combination therapy. Other possible treatments include cyclosporine, tacrolimus, dapsone, sulfasalazine, hydroxychloroquine, retinoids, and biologics.

She recommended focusing on the patient's nail to diagnose alopecia areata. Between 10% and 66% of patients with alopecia areata have nail abnormalities, and these abnormalities may precede, follow, or occur concurrently with hair loss, she noted. Nail pitting is the most common abnormality, but there may also be longitudinal ridging, koilonychia, brittle nails, onycholysis, onychomadesis, and periungual erythema.

Dr. Hordinsky's presentation concentrated on alopecia areata in children, but she said that there are few differences in the pathophysiology of pediatric versus adult disease. "It's a disease that affects all ages, all races, and is seen equally in males and females."

The difference in children involves the psychosocial aspects of the disease, and physicians need to be sensitive to these issues. "It's not like body dysmorphic disorder, where people get fixated on something that's not quite right, worrying that their nose is imperfect or something," she pointed out. "This disease can result in very rapid, and sometimes dramatic, alteration in physical appearance. So there's a psychological adaptation that has to take place. Patients have to figure out: How do you live with this disease? How do you make yourself more normal looking so you fit better into your age group, into your peer groups, into school?"

Physicians can refer patients and their families to the National Alopecia Areata Foundation (www.naaf.org

She encouraged all physicians to register patients—and their families—with the national Alopecia Areata Registry (www.alopeciaareataregistry.org

Dr. Hordinsky did not disclose relevant conflicts of interest in her presentation. SDEF and this news organization are owned by Elsevier.

A child with alopecia areata universalis is shown prior to any treatment.

Source Photos courtesy Dr. R. Berrada

The child had significant hair growth after undergoing 50 sessions of PUVA therapy.

Source Photos courtesy Dr. R. Berrada

New genetic research is yielding some important clues into the puzzling condition of alopecia areata, Dr. Maria Hordinsky reported at the women's and pediatric dermatology seminar sponsored by Skin Disease Education Foundation (SDEF).

By doing whole-genome analysis on thousands of samples gathered over the last 9 years, investigators have found four genes associated with the disease. Surprisingly, none of the genes is implicated in psoriasis, which has long been considered a risk factor for alopecia areata. Conversely, none of the genes associated with psoriasis appears to be implicated in alopecia areata. Investigators announced the findings this year at the annual meeting of the Society for Investigative Dermatology in Montreal.

These findings have important consequences for treatment and research, according to Dr. Hordinsky, chair of the dermatology department at the University of Minnesota, Minneapolis.

"We've all been scratching our heads for the past couple of years wondering why on Earth the new biologics that work so well in psoriasis are not working in this disease," she said. "So now with this data, maybe one possibility is that the diseases are just completely different in the way they're molecularly structured. The thinking has changed in the past couple of months. If you were to start a clinical trial today in alopecia areata, based on the new information, you probably wouldn't pick some of the biologics that were picked a few years ago."

For now, though, Dr. Hordinsky emphasized that there is no "best" treatment for alopecia areata. Patients with patchy alopecia areata sometimes respond to topical or intralesional corticosteroids, minoxidil solution, anthralin, steroid-containing shampoos, excimer laser therapy, or combination treatment.

For extensive alopecia areata, Dr. Hordinsky suggested prednisone, topical minoxidil, PUVA, immunotherapy, pulse methylprednisolone, narrow-band UVB, or combination therapy. Other possible treatments include cyclosporine, tacrolimus, dapsone, sulfasalazine, hydroxychloroquine, retinoids, and biologics.

She recommended focusing on the patient's nail to diagnose alopecia areata. Between 10% and 66% of patients with alopecia areata have nail abnormalities, and these abnormalities may precede, follow, or occur concurrently with hair loss, she noted. Nail pitting is the most common abnormality, but there may also be longitudinal ridging, koilonychia, brittle nails, onycholysis, onychomadesis, and periungual erythema.

Dr. Hordinsky's presentation concentrated on alopecia areata in children, but she said that there are few differences in the pathophysiology of pediatric versus adult disease. "It's a disease that affects all ages, all races, and is seen equally in males and females."

The difference in children involves the psychosocial aspects of the disease, and physicians need to be sensitive to these issues. "It's not like body dysmorphic disorder, where people get fixated on something that's not quite right, worrying that their nose is imperfect or something," she pointed out. "This disease can result in very rapid, and sometimes dramatic, alteration in physical appearance. So there's a psychological adaptation that has to take place. Patients have to figure out: How do you live with this disease? How do you make yourself more normal looking so you fit better into your age group, into your peer groups, into school?"

Physicians can refer patients and their families to the National Alopecia Areata Foundation (www.naaf.org

She encouraged all physicians to register patients—and their families—with the national Alopecia Areata Registry (www.alopeciaareataregistry.org

Dr. Hordinsky did not disclose relevant conflicts of interest in her presentation. SDEF and this news organization are owned by Elsevier.

A child with alopecia areata universalis is shown prior to any treatment.

Source Photos courtesy Dr. R. Berrada

The child had significant hair growth after undergoing 50 sessions of PUVA therapy.

Source Photos courtesy Dr. R. Berrada

New genetic research is yielding some important clues into the puzzling condition of alopecia areata, Dr. Maria Hordinsky reported at the women's and pediatric dermatology seminar sponsored by Skin Disease Education Foundation (SDEF).

By doing whole-genome analysis on thousands of samples gathered over the last 9 years, investigators have found four genes associated with the disease. Surprisingly, none of the genes is implicated in psoriasis, which has long been considered a risk factor for alopecia areata. Conversely, none of the genes associated with psoriasis appears to be implicated in alopecia areata. Investigators announced the findings this year at the annual meeting of the Society for Investigative Dermatology in Montreal.

These findings have important consequences for treatment and research, according to Dr. Hordinsky, chair of the dermatology department at the University of Minnesota, Minneapolis.

"We've all been scratching our heads for the past couple of years wondering why on Earth the new biologics that work so well in psoriasis are not working in this disease," she said. "So now with this data, maybe one possibility is that the diseases are just completely different in the way they're molecularly structured. The thinking has changed in the past couple of months. If you were to start a clinical trial today in alopecia areata, based on the new information, you probably wouldn't pick some of the biologics that were picked a few years ago."

For now, though, Dr. Hordinsky emphasized that there is no "best" treatment for alopecia areata. Patients with patchy alopecia areata sometimes respond to topical or intralesional corticosteroids, minoxidil solution, anthralin, steroid-containing shampoos, excimer laser therapy, or combination treatment.

For extensive alopecia areata, Dr. Hordinsky suggested prednisone, topical minoxidil, PUVA, immunotherapy, pulse methylprednisolone, narrow-band UVB, or combination therapy. Other possible treatments include cyclosporine, tacrolimus, dapsone, sulfasalazine, hydroxychloroquine, retinoids, and biologics.

She recommended focusing on the patient's nail to diagnose alopecia areata. Between 10% and 66% of patients with alopecia areata have nail abnormalities, and these abnormalities may precede, follow, or occur concurrently with hair loss, she noted. Nail pitting is the most common abnormality, but there may also be longitudinal ridging, koilonychia, brittle nails, onycholysis, onychomadesis, and periungual erythema.

Dr. Hordinsky's presentation concentrated on alopecia areata in children, but she said that there are few differences in the pathophysiology of pediatric versus adult disease. "It's a disease that affects all ages, all races, and is seen equally in males and females."

The difference in children involves the psychosocial aspects of the disease, and physicians need to be sensitive to these issues. "It's not like body dysmorphic disorder, where people get fixated on something that's not quite right, worrying that their nose is imperfect or something," she pointed out. "This disease can result in very rapid, and sometimes dramatic, alteration in physical appearance. So there's a psychological adaptation that has to take place. Patients have to figure out: How do you live with this disease? How do you make yourself more normal looking so you fit better into your age group, into your peer groups, into school?"

Physicians can refer patients and their families to the National Alopecia Areata Foundation (www.naaf.org

She encouraged all physicians to register patients—and their families—with the national Alopecia Areata Registry (www.alopeciaareataregistry.org

Dr. Hordinsky did not disclose relevant conflicts of interest in her presentation. SDEF and this news organization are owned by Elsevier.

A child with alopecia areata universalis is shown prior to any treatment.

Source Photos courtesy Dr. R. Berrada

The child had significant hair growth after undergoing 50 sessions of PUVA therapy.

Source Photos courtesy Dr. R. Berrada

The glutamate modulator N-acetylcysteine significantly reduces trichotillomania symptoms, according to a study of 50 patients.

In what the investigators described as the first clinical trial assessing a glutamatergic agent for this disorder, N-acetylcysteine was judged effective by both patients and physicians, to a degree comparable with other medications plus cognitive-behavioral therapy.

“N-acetylcysteine is an amino acid, is available in health-food stores, is cheaper than most insurance copayments, and seems to be well tolerated. [It] could be an effective treatment option for people with trichotillomania,” said Dr. Jon E. Grant and his associates at the University of Minnesota, Minneapolis (Arch. Gen. Psychiatry 2009;66:756–63).

Moreover, the study results indicate that “pharmacologic manipulation of the glutamate system (in the nucleus accumbens) may target core symptoms of compulsive behaviors,” they added.

Trichotillomania is the recurrent pulling out of hair—head hair, eyebrows, eyelashes, pubic hair, or other body hair—to obtain relief of tension, which leads to noticeable hair loss. There is no Food and Drug Administration-approved treatment for trichotillomania at present, but glutamatergic dysfunction has been implicated in the pathogenesis of disorders that have a compulsive component, and glutamate modulators like N-acetylcysteine have been used to treat cocaine urges and gambling behavior.

Dr. Grant and his colleagues assessed the agent in 45 women and 5 men (mean age, 34 years) who reported spending a mean of 65 minutes every day pulling out hair, usually from multiple sites. Most of these patients had never sought mental health treatment for hair pulling.

Thirty of the study subjects (60%) reported having at least one clinically important comorbid disorder, such as major depressive disorder; an anxiety disorder; another impulse-control disorder, such as skin picking or nail biting; or an eating disorder. Four patients were receiving psychotherapy, and 28 were taking a psychotropic medication or a stimulant.

Subjects were randomly assigned to receive 12 weeks of N-acetylcysteine or a matching placebo. A significant treatment effect was evident at 9 weeks and persisted for the duration of the study.

At the conclusion of treatment, those who had taken N-acetylcysteine showed significant improvement on both the severity subscale and the “resistance and control” subscale of the Massachusetts General Hospital Hairpulling Scale, as well as on the Psychiatric Institute Trichotillomania Scale.

A total of 56% of those in the active-treatment group said they were “much” or “very much” improved on the Clinical Global Impression (CGI) scale, compared with 16% of the placebo group.

Patients who received N-acetylcysteine did not show a greater improvement in psychosocial functioning than those who received placebo. However, this sample may have been too small to detect a meaningful difference between the two groups, given that at baseline, most of the subjects had only mild psychosocial dysfunction and reported a quality of life in the “average” range, Dr. Grant and his associates said.

Dr. Grant has received research grants from Forest Pharmaceuticals, GlaxoSmithKline, and Somaxon Pharmaceuticals and has served as a consultant to Pfizer Pharmaceuticals and Somaxon. In addition, Dr. Grant, who also is a lawyer, has consulted for law offices as an expert regarding impulse control disorders.

This patient extracted most of the hair from a wide area of the scalp.

Source ©Elsevier 2004, Habif: Clinical Dermatology, 4th ed.

The glutamate modulator N-acetylcysteine significantly reduces trichotillomania symptoms, according to a study of 50 patients.

In what the investigators described as the first clinical trial assessing a glutamatergic agent for this disorder, N-acetylcysteine was judged effective by both patients and physicians, to a degree comparable with other medications plus cognitive-behavioral therapy.

“N-acetylcysteine is an amino acid, is available in health-food stores, is cheaper than most insurance copayments, and seems to be well tolerated. [It] could be an effective treatment option for people with trichotillomania,” said Dr. Jon E. Grant and his associates at the University of Minnesota, Minneapolis (Arch. Gen. Psychiatry 2009;66:756–63).

Moreover, the study results indicate that “pharmacologic manipulation of the glutamate system (in the nucleus accumbens) may target core symptoms of compulsive behaviors,” they added.

Trichotillomania is the recurrent pulling out of hair—head hair, eyebrows, eyelashes, pubic hair, or other body hair—to obtain relief of tension, which leads to noticeable hair loss. There is no Food and Drug Administration-approved treatment for trichotillomania at present, but glutamatergic dysfunction has been implicated in the pathogenesis of disorders that have a compulsive component, and glutamate modulators like N-acetylcysteine have been used to treat cocaine urges and gambling behavior.

Dr. Grant and his colleagues assessed the agent in 45 women and 5 men (mean age, 34 years) who reported spending a mean of 65 minutes every day pulling out hair, usually from multiple sites. Most of these patients had never sought mental health treatment for hair pulling.

Thirty of the study subjects (60%) reported having at least one clinically important comorbid disorder, such as major depressive disorder; an anxiety disorder; another impulse-control disorder, such as skin picking or nail biting; or an eating disorder. Four patients were receiving psychotherapy, and 28 were taking a psychotropic medication or a stimulant.

Subjects were randomly assigned to receive 12 weeks of N-acetylcysteine or a matching placebo. A significant treatment effect was evident at 9 weeks and persisted for the duration of the study.

At the conclusion of treatment, those who had taken N-acetylcysteine showed significant improvement on both the severity subscale and the “resistance and control” subscale of the Massachusetts General Hospital Hairpulling Scale, as well as on the Psychiatric Institute Trichotillomania Scale.

A total of 56% of those in the active-treatment group said they were “much” or “very much” improved on the Clinical Global Impression (CGI) scale, compared with 16% of the placebo group.

Patients who received N-acetylcysteine did not show a greater improvement in psychosocial functioning than those who received placebo. However, this sample may have been too small to detect a meaningful difference between the two groups, given that at baseline, most of the subjects had only mild psychosocial dysfunction and reported a quality of life in the “average” range, Dr. Grant and his associates said.

Dr. Grant has received research grants from Forest Pharmaceuticals, GlaxoSmithKline, and Somaxon Pharmaceuticals and has served as a consultant to Pfizer Pharmaceuticals and Somaxon. In addition, Dr. Grant, who also is a lawyer, has consulted for law offices as an expert regarding impulse control disorders.

This patient extracted most of the hair from a wide area of the scalp.

Source ©Elsevier 2004, Habif: Clinical Dermatology, 4th ed.

The glutamate modulator N-acetylcysteine significantly reduces trichotillomania symptoms, according to a study of 50 patients.

In what the investigators described as the first clinical trial assessing a glutamatergic agent for this disorder, N-acetylcysteine was judged effective by both patients and physicians, to a degree comparable with other medications plus cognitive-behavioral therapy.

“N-acetylcysteine is an amino acid, is available in health-food stores, is cheaper than most insurance copayments, and seems to be well tolerated. [It] could be an effective treatment option for people with trichotillomania,” said Dr. Jon E. Grant and his associates at the University of Minnesota, Minneapolis (Arch. Gen. Psychiatry 2009;66:756–63).

Moreover, the study results indicate that “pharmacologic manipulation of the glutamate system (in the nucleus accumbens) may target core symptoms of compulsive behaviors,” they added.

Trichotillomania is the recurrent pulling out of hair—head hair, eyebrows, eyelashes, pubic hair, or other body hair—to obtain relief of tension, which leads to noticeable hair loss. There is no Food and Drug Administration-approved treatment for trichotillomania at present, but glutamatergic dysfunction has been implicated in the pathogenesis of disorders that have a compulsive component, and glutamate modulators like N-acetylcysteine have been used to treat cocaine urges and gambling behavior.

Dr. Grant and his colleagues assessed the agent in 45 women and 5 men (mean age, 34 years) who reported spending a mean of 65 minutes every day pulling out hair, usually from multiple sites. Most of these patients had never sought mental health treatment for hair pulling.

Thirty of the study subjects (60%) reported having at least one clinically important comorbid disorder, such as major depressive disorder; an anxiety disorder; another impulse-control disorder, such as skin picking or nail biting; or an eating disorder. Four patients were receiving psychotherapy, and 28 were taking a psychotropic medication or a stimulant.

Subjects were randomly assigned to receive 12 weeks of N-acetylcysteine or a matching placebo. A significant treatment effect was evident at 9 weeks and persisted for the duration of the study.

At the conclusion of treatment, those who had taken N-acetylcysteine showed significant improvement on both the severity subscale and the “resistance and control” subscale of the Massachusetts General Hospital Hairpulling Scale, as well as on the Psychiatric Institute Trichotillomania Scale.

A total of 56% of those in the active-treatment group said they were “much” or “very much” improved on the Clinical Global Impression (CGI) scale, compared with 16% of the placebo group.

Patients who received N-acetylcysteine did not show a greater improvement in psychosocial functioning than those who received placebo. However, this sample may have been too small to detect a meaningful difference between the two groups, given that at baseline, most of the subjects had only mild psychosocial dysfunction and reported a quality of life in the “average” range, Dr. Grant and his associates said.

Dr. Grant has received research grants from Forest Pharmaceuticals, GlaxoSmithKline, and Somaxon Pharmaceuticals and has served as a consultant to Pfizer Pharmaceuticals and Somaxon. In addition, Dr. Grant, who also is a lawyer, has consulted for law offices as an expert regarding impulse control disorders.

This patient extracted most of the hair from a wide area of the scalp.

Source ©Elsevier 2004, Habif: Clinical Dermatology, 4th ed.

Ingrid E. Roseborough, MD and Amy J. McMichael, MD

The unique properties of hair in those patients of African descent allow a limitless range of hair-care options. For the clinician, a general understanding of hair-care practices is an important aid in the diagnosis and treatment of hair shaft and scalp disorders. This review highlights common hair-care practices in women, men, and children of color. Cleansing, moisturizing, and styling techniques are discussed, as well as potential complications associated with their use.

*For a PDF of the full article, click on the link to the left of this introduction.

Ingrid E. Roseborough, MD and Amy J. McMichael, MD

The unique properties of hair in those patients of African descent allow a limitless range of hair-care options. For the clinician, a general understanding of hair-care practices is an important aid in the diagnosis and treatment of hair shaft and scalp disorders. This review highlights common hair-care practices in women, men, and children of color. Cleansing, moisturizing, and styling techniques are discussed, as well as potential complications associated with their use.

*For a PDF of the full article, click on the link to the left of this introduction.

Ingrid E. Roseborough, MD and Amy J. McMichael, MD

The unique properties of hair in those patients of African descent allow a limitless range of hair-care options. For the clinician, a general understanding of hair-care practices is an important aid in the diagnosis and treatment of hair shaft and scalp disorders. This review highlights common hair-care practices in women, men, and children of color. Cleansing, moisturizing, and styling techniques are discussed, as well as potential complications associated with their use.

*For a PDF of the full article, click on the link to the left of this introduction.