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Amy McMichael, MDProfessor and ChairDepartment of DermatologyWake Forest Baptist HealthWinston-Salem, NC SC Derm 2019
DISCLOSURE/CONFLICTS OF INTEREST
Investigator
Allergan
Intendis
Procter & Gamble
Samumed
Casseopia
Concert
Alcaris
Incyte
Consultant
Johnson & Johnson
Procter & Gamble
Stiefel
Allergan
Bayer
Galderma
Incyte
Samumed
Aclaris
Anacor
Pfizer
Nutrafol
Bioniz
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Wake Forest Baptist Medical Center
Wake Forest School of Medicine
GOOD HAIR
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Distributed by Roadside Attractions
Special jury prize at 2009 Sundance Film Festival
▪The hair I had last year
▪The hair I had 25 years ago
▪The hair that the rest of my family has
▪ In my African American patients, it is hair that grows and shines as well as a measure of acceptance in society
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OUTLINE
▪ Discuss the most common forms of hair loss
▪ Highlight how dermoscopy can be helpful in hair loss
▪ Underscore treatment pearls
▪ Update treatment paradigms
▪ Give special time to hair loss in skin of color patients
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CLASSIFICATION OF AGA IN MALES:THE HAMILTON-NORWOOD SYSTEM
Hamilton JB. Ann NY Acad Dermatol. 1951;53:708-828.
Norwood OT. South Med J.1975;68:1359-1365. Reprinted with permission from South Med J.
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Ludwig E. British J Dermatol.1977;97:247. Reprinted with permission from British J Dermatol.
(A) Grade I (B) Grade II (C) Grade III
PATTERN HAIR LOSSTYPICAL EXAM FINDINGS
▪ Not usually difficult in men
▪ In women:
▪ Diffuse thinning at vertex, frontal scalp, +/- bitemporally
▪ Vellus hair present in areas of thinning, frontal hairline intact
▪ +/- positive pull test in active phase
▪ Can biopsy to distinguish from telogen effluvium
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occiput
frontal
Path photo courtesy of Len Sperling
▪ Dermoscopy shows fine hairs mixed with terminal hairs
▪ Increase in percentage of single-hair follicular units in the frontal area is also suggestive of early AGA
▪ Presence of > 6 short thin hairs in the frontal scalp may be diagnostic
Normal density AGA
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FEMALE PATTERN HAIR LOSS IN AFRICAN AMERICAN PT
hair shaft
variability
empty follicles
peripilar sign
Photo courtesy of Fernanda Torres
Severe
Moderate
MildMinoxidil 5%
Low level laserlight
Oral minoxidil Finasteride Dutasteride
Hair restoration surgery
Platelet rich plasma
Spironolactone
Flutamide
Hair piece/wig
Botanicals
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Severe
Moderate
Mild Minoxidil 5%
Low level laserlight
Finasteride/Dutasteride Oral minoxidil
Platelet rich plasma
Hair Restoration
Hair piece/wig
Botanicals
▪ Recent media and internet attention
▪ Study of 71 men reporting persistent sexual side effects, lasting > than 3 mo after stopping finasteride1
▪ Recruited from website for men experiencing sexual dysfunction
▪ Retrospective data on sexual dysfunction or depression
▪ Followed these men for 2 more publications
▪ 3rd study evaluated depression and found 75% of 61 patients reports depressive symptoms compared to controls with MPHL on college campus2
▪ Package insert:
▪ added persistent erectile dysfunction 2011 and libido/orgasm disorders 2012
1. Irwig MS, Kolakula S. J Sex Med. 2011
2. Irwig MS. J Clin Pyschiat. 2012
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▪ Singh MK and Avram M meta-analysis
▪ Prostate trials: more than 17,000 men in one trial looking at sexual dysfunction and >1,300 in other trials with no persistent sexual side effects or depression
▪ MPHL trials: more than 2,500 with no persistent sexual dysfunction
▪ Belknap SM et al: questioning adequacy of safety reporting
▪ Few side effects of any kind reported in woman
▪ Recommendations to patients:
▪ discuss outlier data on persistent sexual dysfunction with patients
▪ discuss safety seen in large trials
▪ discuss pre-existent sexual dysfunction and depression and treat only appropriate patients MK and Avram M. J of Clin Aesthet Dermatol, 2014
Monpour CM et al. J Natl Ca Inst. 2007
Belknap et al. JAMA Derm, 2015
Seal L, Eginli A, McMichael A JDD 2016
▪ 113 women with AGA in 24 week single-blinded trial▪ 5% minoxidil foam daily vs. 2% solution BID
▪ Greater, but not significant improvement in 5% foam group
▪ Significantly lower rates of local irritation for 5% foam vs. 2% solution (p=.046)
▪ Less interference in hair styling for 5% foam (p=.002)
▪ Minoxidil 5% foam approved by FDA as daily treatment for women – Feb 2014
SUCCESS =
application techniques +
not worse after stopping +
expectation of early shedding +
expectation of treatment time +
possible hypertrichosis
Blume-Peytavi U et al. JAAD. 2011;65:1126-34
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▪ 15 patients in a study (7 women, 8 men)
▪ Plucked hairs tested in sulfotransferase enzyme (STE) assay before and after minoxidil 6 mo twice daily treatment
▪ Data combined in meta-analysis of 50 previous patients
▪ STE predicted responders to treatment- 100% sensitivity, 71% specificity
▪ Commercial testing not available yet
-Goren A, Shapiro J, Roberts J, et al. Derm Therapy 2015, Vol 28, 13-16
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Oils
Butters
Lotions
Shampoo
Pre-poo
Conditioners
Food
Cooking products
▪ Data on effectiveness for hair and scalp disease sparse but rampant testimonials on social media
▪ Coconut oil1
▪ Reduced water retention and hair swelling
▪ Decreased protein loss incurred from wet combing
▪ Comedogenic
▪ Jojoba oil▪ Similar properties to sebum in lubricating hair shafts
▪ Can induce contact dermatitis
▪ Argan oil▪ Some data to suggest good lubrication for hair shafts
▪ Allergenicity
1. Rele AS, Mohile RB. J Cosmet Sci. 2003 Mar-Apr;54(2):175-92
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▪ Biotin highly commercialized in past decade with sales steadily increasing from July 2014 to June 2017
▪ Commercial availability in doses ranging from 30 mcg-10,000 mcg makes supra-physiologic dosing possible
▪ 2 assays which are commonly affected by high-dose biotin intake
▪ Competitive assay including free T3, free T4, thyroid stimulating hormone receptor antibody, estradiol, testosterone, cortisol, vitamin B12, and folate
▪ “Sandwich” immunometric assay and involves troponin, N-terminal prohormone of brain natriuretic peptide (NT-proBNP), TSH, HCG, SHBG, insulin, LH, and FSH
▪ Recommendation:
▪ Poor likelihood that biotin helps
▪ Stop biotin supplements in patients with hair loss
Piketty, Marie-Liesse, et al. Clinical Chemistry and Laboratory
Medicine (CCLM) 2017
CORTEXOLONE 17Α-PROPIONATE--
Clascoterone competes with DHT for binding to the AR in the scalp
▪ Clascoterone bound AR inhibits androgen responsive genes2
▪ Loss of specific gene expression that results in: ▪ Dermal papilla cell survival and
normal hair growth cycle
▪ Clascoterone is metabolized to cortexolone 21-propionate and cortexolone2
▪ Metabolites exhibit minimal activity
▪ Well-known safety profile
Androgen
Receptor
Clascoterone
DHT
1. Figure from: Ellis JA. Expert Rev Mol Med. 2002; https://www.ncbi.nlm.nih.gov/pubmed/14585162
2. Data on File. CB-03-01 Investigator’s Brochure. 2017. Cassiopea SpA.
Clascoterone
DHT can’t bind to AR with Clascoterone
present
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❖ Both active treatment groups had directionally larger changes from Baseline compared to Vehicle; although results
among the three treatment groups were not statistically significant (p=0.0971)
ClinicalTrials.gov Identifier: NCT02279823
▪ 78 completed the POC study treatment period
▪ Clascoterone (CB-03-01) & Minoxidil, the active treatment groups, showed larger TAHC changes from baseline vs. vehicle (p=0.0971)
▪ Minoxidil efficacy peaked at Month 4
▪ Skin reactions were mostly minimal/mild
▪ No significant systemic AEs were reported
▪ The Phase 2 Dose Ranging Study interim results demonstrate the potential as a novel treatment for AGA
Note: Clascoterone was referred to as CB-03-01 & cortexolone 17-α propionatePOC: Proof-of-Concept; TAHC: Target Area Hair Count; HGA: Hair Growth Assessment; AE: Adverse Events
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▪Biotin
▪Curcumin
▪Saw Palmetto
▪Vit A, C, D
▪Selenium
▪Resveratrol
▪Zinc
▪L-Methionine
▪L-Lysine
▪L-Cysteine
▪Organic kelp
▪Black pepper fruit
▪Red pepper extract
▪Keratin
▪ Oral minoxidil
▪ Plasma rich platelets (PRP)
▪ Bimatoprost
▪ Topical Wnt pathway activation
▪ Oral PGD2 receptor antagonist
Pietro Gentile et al. Stem Cells Trans Med 2015;4:1317-1323
29 yo man treated with PRP
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▪ Introduced by Rod Sinclair in Australia
▪ Doses at 0.25 mg daily (1/4 tab in Austr)
▪ Others have begun to use oral dosing in US at 0.625 mg (1/4 of 2.5mg tab)
▪ Concerns:
▪ Hypertrichosis
▪ Postural hypotension
▪ Fluid retention
▪ Urticaria/rash
▪ Telogen effluvium
Sinclair R. Int J Dermatol. 2018 Jan;57(1):104-109. doi: 10.1111/ijd.13838. Epub 2017
▪ 6-month, randomized in men with Norwood Hamilton stages II /V and women w/ Ludwig stage I/II.
▪ Two regimens of subdermal platelet-rich plasma injections (27 men and 9 women)
▪ 3 monthly sessions with 4th booster session 3 months later
▪ 2 sessions every 3 months for 2 sessions
▪ Patients in first treatment group - statistically significant increases in hair count.
▪ Shaft caliber improvement (+0.024 mm; P < .001).
▪ 20% mean increase in hair count and 44.1% increase in caliber
▪ Questionnaire results showed patients in first group were likely to be “very satisfied”
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▪ Many different regimens and costs▪ Mixed platelets with cellular matrix versus platelet injections alone
▪ Doses/amounts different in each trial +/- activators
▪ Regimen can be weekly for months or monthly with a tapering phase
▪ Costs range from $500-1200 per treatment
▪ What to tell patients▪ Long-term and costly treatment
▪ Need a series of treatments
▪ Case series show good outcomes
▪ May be helpful, small randomized controlled trials
▪ Trials:
▪ Gentile P et al. Stem Cells Trans Med 2015;4:1317-1323
▪ Alves R, Grimalt R. Derm Surg 2016;42:491-497
▪Mechanical centrifugation of scalp punch biopsy to isolate human hair follicle stem cells
▪Hair cells counted in each sample
▪11 patients treated with improvement in hair density
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▪ PGD 2 works via GPR 44 pathway
▪ Elevation of PGD2 levels in certain regions of the male scalp is associated with hair loss in those regions
▪ PGD2 inhibitors found to extend the anagen (growth) phase of the hair cycle, thereby promoting the growth of hair
▪ Has already been studied in Phase III study in seasonal allergic rhinitis and Phase II study in asthma
▪ Setipiprant is selective oral antagonist to the prostaglandin D2 (PGD2) receptor
▪ Trials for Setipiprant for AGA in men underway
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▪ Corticosteroids
▪ Topical
▪ Intralesional
▪ Systemic
▪ Topical Immunotherapy
▪ Minoxidil 5%
▪ Anthralin
▪ Excimer Laser
▪ Other immunosuppressive agents (ie MTX, JAK inhibitors)
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▪ Cytotoxic NKD2+ T cells are necessary and sufficient to induce alopecia in mice
▪ Interleukin 15 (required for the growth of natural killer cells) has been identified as a potential therapeutic target
▪ Janus kinase (JAK) inhibitors can affect signaling pathway of IL 151
▪ Inhibition of JAK-STAT signaling promotes hair growth by stimulating the activation and/or proliferation of HF stem cells2
1. Xing L et al. Nature Med 2014;20:1043-1049
2. Harel S, et al. Sci Adv. 2015 Oct; 1(9)
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▪ Crispin et al (Brett King) JCI Insight 2016
▪ 47% improved by at least 25% in SALT score
▪ Low side effects, ophiasis improved more than totalis/universalis, shorter duration of hair loss better
▪ Recommendations to patients:
▪ Prescribe these drugs with caution
▪ New clinical trials with topical JAK inhibitors are underway
▪ Expense and short remissions may outweigh benefits
▪ FDA fast tracking oral JAK inhibitor by Concert Pharma
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▪JAK 1/3 product in development
▪Multi-cytokine inhibitors (IL 2, 9, 15)
▪ Patchy alopecia areata
▪ Topical clobetasol foam BID for 5 day per week
▪ Can use clobestasol cream under occlusion 5 nights per week
▪ Minoxidil 5% solution or foam daily
▪ Intralesional steroids (5-7.5 mg/cc up to 3 cc) every 6-8 weeks
▪ Totalis/Universalis
▪ Topicals as above
▪ Prednisone taper, Methotrexate, Excimer laser, JAK inhibitors, Immunotherapy
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▪ Variant of lichenplanopilaris
▪ INCIDENCE APPEARS TO BE EXPLODING!
▪ Exam reveals progressive recession of fronto-temporal hair line with loss of follicular openings
▪ Atrophy of frontal scalp/forehead with vessel prominence
▪ Perifollicular erythema and hyperkeratosis in active areas
▪ Eyebrow loss
▪ Facial papules
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Case series from South Africa, lichen planus pigmentosus was associated with frontal fibrosing alopecia (FFA) 50% of the time and preceded FFA by years- BJD, 2013
Case report from India- Int J Dermatol 2014
2 Latina women in San Francisco with hyperpigmentation of the face prior to hair loss– JAAD 2014
Treatments reported include:
topical steroids, topical tacrolimus, Nd:YAG laser, hydroquinone, topical retinoids, sunscreen
None extremely successful
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TRACTION ALOPECIA
Not complete lossFringe sign
FRONTAL FIBROSING ALOPECIA
No fringe signPsuedo-fringeEyebrow lossLonely hair
▪ Therapeutic ladder:
▪ Intralesional corticosteroids every 4-8 weeks (5 mg/cc)
▪ Oral doxycycline
▪ Potent and ultrapotent topical steroids
▪ Hydroxychloroquine + quinacrine
▪ Methotrexate
▪ Mycophenylate mofitil
▪ P-PAR gamma agonist (pioglitazone, Actos®)*
▪ 5 alpha reductase inhibitor
▪ Oral corticosteroid for severe, progressive disease
▪ Cyclosporine
*Mirimani P, Karnik P. Arch Derm 2009 Dec;145(12)1363-6
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PPAR gamma important for healthy pilosebaceous units
and loss of this function may trigger pathogenesis of
LPP -Karnik P et al. J Invest Dermatol. 2009
May;129(5):1243-57
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Studies N # Remission Sx
Improvement
s
Cessation due
to side effects
Baibergenova A,
Walsh S. J Cutan
Med Surg, 2012
24 5 12 4
Spring et al.
JAAD, 201322 0 7 0
Mesinkovska
NA et al. JAAD,
2015
22 0 21 9
Recommendations to patients:
• 2nd or 3rd line drug
• Few remissions, limited likelihood of
improvement
• High likelihood of side effects
▪ 355 patients (343 women, 12 men)
▪ Eyebrow loss as initial presenting symptom was associated with milder disease
▪ Dutasteride or finasteride used in 111 (31%) patients with improvement in 52(47%) and stabilization in 59(53%)
▪ Recommendations to patients:
▪ Low side effect profile
▪ 50/50 chance of improvement/stabilization
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Oxybenzone/Avobenzone
Sunscreen/moisturizers
~1989
▪ First line treatment:▪ Topical tacrolimus ointment or pimecrolimus cream every other day
▪ Intralesional corticosteroids every 4-8 weeks for symptoms
▪ Mid-potency topical steroids increasing to ultrapotent for severe symptoms
▪ Hydroxychloroquine 200 mg twice daily
▪ Doxycycline
▪ 5-alpha reductase inhibitors (non-childbearing potential)
▪ Second line treatment▪ Methotrexate, mycophenylate mofitil
▪ P-PAR gamma agonist (pioglitazone, Actos®)
▪ Third line treatment:▪ Oral corticosteroid for severe, progressive disease
▪ Cyclosporine
▪ Nd:YAG laser
▪ Sunscreens????
Always combine treatments for best outcome!
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▪ 138 articles on “hair loss and African Americans” in Pub Med from 1968 – 2017 articles on dissecting cellulitis
▪ 77 articles on Central Centrifugal Cicatricial Alopecia
▪ 101 articles on Pseudofolliculitis barbae
▪ 225 Frontal fibrosing alopecia
▪ >40,000 articles on psoriasis
▪ > 20,000 articles on atopic dermatitis
TOP DIAGNOSES IN AFRICAN AMERICAN PATIENT VISITS TO DERMATOLOGISTSNATIONAL AMBULATORY MEDICAL CARE SURVEY 1993-2009
Diagnosis ICD-9 Code No. of Visits % of Visits
Acne 706.1 5,720,000 22.1%
Unspec. dermatitis 692.9 3,640,000 14.0%
Seb dermatitis 690.10 1,990,000 7.7%
Atopic derm 691.8 1,590,000 6.1%
Dyschromia 709.0 1,290,000 5.0%
Psoriasis 696.1 950,000 3.6%
Alopecia 704.00 920,000 3.6%
Keloid scar 701.4 830,000 3.2%
Viral warts 078.1 780,000 3.0%
Sebaceous cyst 706.2 780,000 3.0%
Davis SA, et al. J Drugs Dermatol 2012
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TOP DIAGNOSES IN AFRICAN AMERICAN PATIENT VISITS TO DERMATOLOGISTSNATIONAL AMBULATORY MEDICAL CARE SURVEY 1993-2009
Diagnosis ICD-9 Code No. of Visits % of Visits
Acne 706.1 5,720,000 22.1%
Unspec. dermatitis 692.9 3,640,000 14.0%
Seb dermatitis 690.10 1,990,000 7.7%
Atopic derm 691.8 1,590,000 6.1%
Dyschromia 709.0 1,290,000 5.0%
Psoriasis 696.1 950,000 3.6%
Alopecia 704.00 920,000 3.6%
Keloid scar 701.4 830,000 3.2%
Viral warts 078.1 780,000 3.0%
Sebaceous cyst 706.2 780,000 3.0%
Davis SA, et al. J Drugs Dermatol 2012
Hair Fragility
Inflammatory
Scalp Conditions
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▪ No prevalence data
▪ Study: 60 women studied: 30 Caucasian & 30 African American
▪ Broken hairs were significantly increased in African women (p = 0.0001)
▪ Study:103 African American women surveyed
▪ 50% of women between 21-60 years of age have modified their hairstyle to accommodate exercise
▪ Nearly 40% avoid exercise at times due to hair-related issues
▪ 55% reported breakage of hair shafts with normal styling
APPROACH TO HAIR BREAKAGE▪ Correct underlying abnormalities (Iron levels, thyroid, nutrition, etc)
▪ Give the hair a rest!▪ Consider stopping chemical relaxer, color, or heat for 6-12 months
▪ Place a hair weave that is not tight and will allow scalp care
▪ Loose braids
▪ Wig
▪ Natural hair but do not straighten with heat
▪ Serial trimming of hair (every 6-8 weeks)
▪ Use heat protectant products on the hair before styling
▪ Layering moisturizing regimen▪ Start with moisturizing shampoo and conditioner (should state for dry, damaged hair)
▪ Next apply a leave-in conditioner with coating agents to wet hair (dimethicone-coating agents)
▪ Add a leave-in conditioner (oils) to dry hair (after washing weekly and then as needed daily)
▪ Discuss the long wait for improvement
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▪ Used Trichometer measurements of hair max index (HMI)
▪ Tested Synsepalum dulcificum seed oil (Miracle seed oil)
▪ 8 month study
▪ Assessed breakage rates on hair shafts (unclear ethniticy)
▪ Subjects washed 3 times per week and applied test oil vs argan vs dimethiconevehicle
▪ Improvement significant for test oil by HMI and subject evaluation
Del Campo R, Zhang Y, Wakeford C, JCAD 2017
CENTRAL CENTRIFUGAL CICATRICIAL ALOPECIA
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CENTRAL CENTRIFUGAL SCARRING ALOPECIA EPIDEMIOLOGY
▪ Prevalence ranges from 2.7% in 604 South African women to 5.6% in 529 US women1,2
▪ Wide range of clinical severity
▪ Symptoms range from none to severe pruritus and pain
▪ Mostly women of African descent, ages 30-65
▪ Often accompanied by traction alopecia
▪ Pre-dated chemical relaxers
▪ Traction common theme1. Khumalo NP et al, BJD. 2007
2. Olsen EA et al, JAAD. 2011
3. Yolanda Lenzy, personal
communication, AAD 2016
▪ Frontal fibrosing alopecia
▪ Fibrotic kidney disease
▪ Scleroderma
▪ Possible pathogenesis of CCCA
Beamer et al 2016, Poster, presented at Wake Forest
Medical student research day
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▪ 487,104 black women older than 18 years of age were seen at Johns Hopkins Hospital during the 4-year study period.
▪ 447 women (0.09%) with a medical history of CCCA were identified, 62 of whom had uterine leiomyomas (ULs)
▪ Women with CCCA have nearly 5 times increased odds of having uterine leiomyomas compared with race-, age-, and sex-matched controls - Dina et al, JAMA Dermatol 2017
▪ 72 African American female subjects with ESRD on hemodialysis were surveyed for CCCA
▪ 49/72 subjects (68.1%) had CCCA based on clinical observation – unpublished, McMichael et al
▪ Dlova et al, Autosomal dominant inheritance of central centrifugal cicatricial alopecia in black South Africans. JAAD, 2014;70:679-682
▪ 14 index families with 31 immediate family members
▪ Pedigree analysis suggests autosomal dominance
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▪ 9 patients with vertex hair breakage
▪ 8/9 with biopsy results
▪ 5 showed typical CCCA changes
▪ 1 showed advanced end-stage scarring alopecia
▪ 2 showed premature desquamation of inner root sheath (suggestive of early CCCA)
▪ Callender V, Wright D, Davis E, Sperling L Arch Dermatol2012
Central Scalp Alopecia
Photographic Scale
in African American Women
Olsen EA, Callender V, Sperling L,
McMichael A, Anstrom KJ, Bergfeld W,
Durden F, Roberts J, Shapiro J
and Whiting DA— Derm Therapy Vol 21, 2008
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▪ Female pattern hair loss
▪ May exist comcomittantly with FPHL
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▪ Retrospective study of patients staged at beginning and end of treatment
▪ Treatment = IL Kenalog, topical steroids, +/- minoxidil
▪ N = 15
▪ After treatment:
▪ 5/15 (33.3%) had decreased severity scores (Improved)
▪ 8/15 (53.3%) had increased severity scores (Worsened)
▪ 2/15 (13.3%) had no change in severity scores
TREATMENT OF CCCA
Biopsy for extent of inflammation/alternate diagnosis Often complicated by seb derm and hair fragility Inflammatory Stage
▪ Decrease heat to vertex
▪ Decrease all traumatic hair styling methods
▪ Anti-dandruff shampoos weekly
▪ Decrease inflammation via topical and intralesional corticosteroids
▪ IL for 8 rounds with 7.5-10 mg/cc for max 3 cc/visit (q 6-8 weeks)
▪ Oral/topical antibiotics for pustular disease
▪ Push treatment until symptom free
Post-inflammatory treatment
▪ Monixidil solution for prolongation of anagen
▪ Surgical restoration
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NIGERIAN WOMANTREATMENT : IL KENALOG AND HAIR RESTORATION
Pretreatment Post-treatment
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▪ Decrease friction and traction behaviors to the area
▪ Anti-inflammatory treatments
▪ Mid-potency topical steroids 3-4 times per week
▪ Intralesional kenalog 5 mg/cc to the affected areas for 2-3 cycles
▪ Topical minoxidil 2 or 5% daily
▪ Surgical correction
▪ Follow improvement with photos
▪ Intralesional injections Kenalog 5 mg/cc X 3
▪ Topical minoxidil 5% daily maintenance
▪ Gentle hair care
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▪Hair that stays on your head is GOOD HAIR
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▪Hair that stays on your head is GOOD HAIR
▪Hair that grows in the normal genetically determined density without fragility and inflammatory attack is GOOD HAIR
▪Hair that stays on your head is GOOD HAIR
▪Hair that grows in the normal genetically determined density without fragility and inflammatory attack is GOOD HAIR
▪A pain-free and pruritus-free scalp grows GOOD HAIR
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▪Hair that stays on your head is GOOD HAIR
▪Hair that grows in the normal genetically determined density without fragility and inflammatory attack is GOOD HAIR
▪A pain-free and pruritus-free scalp grows GOOD HAIR
▪Hair care practices that allow you to live your life healthfully using whatever additions one desires leads to GOOD HAIR
THANK YOU FOR YOUR [email protected]
North American Hair Research Society www.nahrs.org
Cicatricial Alopecia Research Foundation www.carfintl.org
National Alopecia Areata Foundation www.naaf.org
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