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Can sunscreens cause frontal fibrosing alopecia? The jury’s out
NEW YORK – Is there an association between sunscreen use and frontal fibrosing alopecia? Perhaps, but causation is far from well established, according to Henry Lim, MD.
“Frontal fibrosing alopecia is becoming more common – definitely,” said Dr. Lim, speaking in an exclusive interview at the American Academy of Dermatology summer meeting. “Those of us who see patients would see, on average, probably a few patients a week with new-onset frontal fibrosing alopecia.”
Dr. Lim, program director of dermatology research and the photomedicine fellowship at Henry Ford Hospital, Detroit, said in a presentation at the meeting that, in the medical literature, just four surveys have been identified that examined the potential association of UV filters in sunscreen preparations with the risk for frontal fibrosing alopecia (FFA).
The first survey-based study questioned 205 women – 105 of whom had FFA – about sunscreen use, finding increased risk for FFA when sunscreen use was reported at least twice a week (Br J Dermatol. 2016 Oct;175:762-7). The second study, by contrast, looked at men only, examining 17 patients with FFA and 73 control participants. This study found increased frequency of FFA in patients who reported use of sunscreen or sunscreen-containing moisturizers (Br J Dermatol. 2011 Jul;177:260-1).
The final two survey-based studies each also found increased FFA frequency in patients using sunscreens, said Dr. Lim. The first of these was the largest among the FFA studies, surveying 308 patients, 19 of whom were men, with FFA and 347 control participants (Clin Exp Dermatol. 2019 Jun;44:404-10). The other study, involving women only, compared 130 patients with FFA and 130 control participants (Br J Dermatol. 2019 Apr;180:943-4).
Several factors need to be taken into consideration when evaluating the available data, said Dr. Lim. “With any type of retrospective study, there are some limitations, recall bias being one. No. 2, the studies were not designed to look at which sunscreens’ ingredient is causing the frontal fibrosing alopecia, so all we can say is that there is an association of sunscreen with frontal fibrosing alopecia without knowing which active ingredient is involved.”
Also, “there is no conclusion that we can draw in terms of causation,” he said. Data are insufficient for this kind of inference.
Titanium dioxide, a mineral filter used in some sunscreen preparations, has also been implicated in FFA. Elemental titanium has been detected in the hair shafts of some patients with alopecia, said Dr. Lim, noting a case report and another small study. In the smaller study, 20 patients were included. Of them, 16 were FFA-affected women, 4 were unaffected women, and 1 was an unaffected man. Here, however, titanium was found in the hair shaft of all participants save the one unaffected man (Br J Dermatol. 2019 Jul;181:216-7).
However, he warned, “the studies are still early. The numbers are still relatively small that have been examined.” Furthermore, the controls, meaning individuals who did not have FFA in the study, also had titanium element in their hair shaft. All of this means that it’s too early to draw firm conclusions about whether there’s a causal relationship between titanium-containing preparations and FFA.
In questioning after the session, an audience member pointed out that sunscreens are not the sole source of titanium among topical preparations; many cosmetics and hair products also use titanium.
Dr. Lim reported financial relationships with Eli Lilly, Estee Lauder, Ferndale Laboratories, Incyte Corporation, ISDIN, Pierre Fabre Dermatologie, and Unigen.
NEW YORK – Is there an association between sunscreen use and frontal fibrosing alopecia? Perhaps, but causation is far from well established, according to Henry Lim, MD.
“Frontal fibrosing alopecia is becoming more common – definitely,” said Dr. Lim, speaking in an exclusive interview at the American Academy of Dermatology summer meeting. “Those of us who see patients would see, on average, probably a few patients a week with new-onset frontal fibrosing alopecia.”
Dr. Lim, program director of dermatology research and the photomedicine fellowship at Henry Ford Hospital, Detroit, said in a presentation at the meeting that, in the medical literature, just four surveys have been identified that examined the potential association of UV filters in sunscreen preparations with the risk for frontal fibrosing alopecia (FFA).
The first survey-based study questioned 205 women – 105 of whom had FFA – about sunscreen use, finding increased risk for FFA when sunscreen use was reported at least twice a week (Br J Dermatol. 2016 Oct;175:762-7). The second study, by contrast, looked at men only, examining 17 patients with FFA and 73 control participants. This study found increased frequency of FFA in patients who reported use of sunscreen or sunscreen-containing moisturizers (Br J Dermatol. 2011 Jul;177:260-1).
The final two survey-based studies each also found increased FFA frequency in patients using sunscreens, said Dr. Lim. The first of these was the largest among the FFA studies, surveying 308 patients, 19 of whom were men, with FFA and 347 control participants (Clin Exp Dermatol. 2019 Jun;44:404-10). The other study, involving women only, compared 130 patients with FFA and 130 control participants (Br J Dermatol. 2019 Apr;180:943-4).
Several factors need to be taken into consideration when evaluating the available data, said Dr. Lim. “With any type of retrospective study, there are some limitations, recall bias being one. No. 2, the studies were not designed to look at which sunscreens’ ingredient is causing the frontal fibrosing alopecia, so all we can say is that there is an association of sunscreen with frontal fibrosing alopecia without knowing which active ingredient is involved.”
Also, “there is no conclusion that we can draw in terms of causation,” he said. Data are insufficient for this kind of inference.
Titanium dioxide, a mineral filter used in some sunscreen preparations, has also been implicated in FFA. Elemental titanium has been detected in the hair shafts of some patients with alopecia, said Dr. Lim, noting a case report and another small study. In the smaller study, 20 patients were included. Of them, 16 were FFA-affected women, 4 were unaffected women, and 1 was an unaffected man. Here, however, titanium was found in the hair shaft of all participants save the one unaffected man (Br J Dermatol. 2019 Jul;181:216-7).
However, he warned, “the studies are still early. The numbers are still relatively small that have been examined.” Furthermore, the controls, meaning individuals who did not have FFA in the study, also had titanium element in their hair shaft. All of this means that it’s too early to draw firm conclusions about whether there’s a causal relationship between titanium-containing preparations and FFA.
In questioning after the session, an audience member pointed out that sunscreens are not the sole source of titanium among topical preparations; many cosmetics and hair products also use titanium.
Dr. Lim reported financial relationships with Eli Lilly, Estee Lauder, Ferndale Laboratories, Incyte Corporation, ISDIN, Pierre Fabre Dermatologie, and Unigen.
NEW YORK – Is there an association between sunscreen use and frontal fibrosing alopecia? Perhaps, but causation is far from well established, according to Henry Lim, MD.
“Frontal fibrosing alopecia is becoming more common – definitely,” said Dr. Lim, speaking in an exclusive interview at the American Academy of Dermatology summer meeting. “Those of us who see patients would see, on average, probably a few patients a week with new-onset frontal fibrosing alopecia.”
Dr. Lim, program director of dermatology research and the photomedicine fellowship at Henry Ford Hospital, Detroit, said in a presentation at the meeting that, in the medical literature, just four surveys have been identified that examined the potential association of UV filters in sunscreen preparations with the risk for frontal fibrosing alopecia (FFA).
The first survey-based study questioned 205 women – 105 of whom had FFA – about sunscreen use, finding increased risk for FFA when sunscreen use was reported at least twice a week (Br J Dermatol. 2016 Oct;175:762-7). The second study, by contrast, looked at men only, examining 17 patients with FFA and 73 control participants. This study found increased frequency of FFA in patients who reported use of sunscreen or sunscreen-containing moisturizers (Br J Dermatol. 2011 Jul;177:260-1).
The final two survey-based studies each also found increased FFA frequency in patients using sunscreens, said Dr. Lim. The first of these was the largest among the FFA studies, surveying 308 patients, 19 of whom were men, with FFA and 347 control participants (Clin Exp Dermatol. 2019 Jun;44:404-10). The other study, involving women only, compared 130 patients with FFA and 130 control participants (Br J Dermatol. 2019 Apr;180:943-4).
Several factors need to be taken into consideration when evaluating the available data, said Dr. Lim. “With any type of retrospective study, there are some limitations, recall bias being one. No. 2, the studies were not designed to look at which sunscreens’ ingredient is causing the frontal fibrosing alopecia, so all we can say is that there is an association of sunscreen with frontal fibrosing alopecia without knowing which active ingredient is involved.”
Also, “there is no conclusion that we can draw in terms of causation,” he said. Data are insufficient for this kind of inference.
Titanium dioxide, a mineral filter used in some sunscreen preparations, has also been implicated in FFA. Elemental titanium has been detected in the hair shafts of some patients with alopecia, said Dr. Lim, noting a case report and another small study. In the smaller study, 20 patients were included. Of them, 16 were FFA-affected women, 4 were unaffected women, and 1 was an unaffected man. Here, however, titanium was found in the hair shaft of all participants save the one unaffected man (Br J Dermatol. 2019 Jul;181:216-7).
However, he warned, “the studies are still early. The numbers are still relatively small that have been examined.” Furthermore, the controls, meaning individuals who did not have FFA in the study, also had titanium element in their hair shaft. All of this means that it’s too early to draw firm conclusions about whether there’s a causal relationship between titanium-containing preparations and FFA.
In questioning after the session, an audience member pointed out that sunscreens are not the sole source of titanium among topical preparations; many cosmetics and hair products also use titanium.
Dr. Lim reported financial relationships with Eli Lilly, Estee Lauder, Ferndale Laboratories, Incyte Corporation, ISDIN, Pierre Fabre Dermatologie, and Unigen.
EXPERT ANALYSIS FROM SUMMER AAD 2019
Dermatitis associated with surgical implants merits conservative approach
NEW YORK – In patients who develop dermatitis after implantation of a device containing materials to which they have a contact allergy, explantation is not necessarily a cure for their symptoms.
“It can be difficult to predict who will or will not clear when the device is removed. In addition, in some cases device explantation could lead to other issues,” cautioned Ari M. Goldminz, MD, a dermatologist at Brigham and Women’s Hospital, Boston, MA. “Offering non-surgical options and a thorough investigation of other potential causes unrelated to the implant may provide a path to avoid explantation.” However, for other patients removal of the device might be the preferred option.
During his presentation at the American Academy of Dermatology summer meeting, he described illustrative cases. These patients developed dermatitis within weeks or months after receiving a surgical implant, and tested positive for a material that was in the implanted device.
In one of these cases, the suspected problem was a metal plate containing chromium that was placed during an orthopedic repair. Subsequent patch testing revealed a reaction to chromium and the implant was eventually removed.
However, there was no improvement in dermatitis following removal of the metal plate.
“The symptoms ultimately improved after starting on a low-chromium diet and avoiding other allergens identified on patch testing, such as those found in skin care products,” Dr. Goldminz explained. He does not discount the role that the implant may have played in the onset of dermatitis,, but improvement required avoidance strategies other than device explantation.
There are studies suggesting that patch testing prior to surgery can help certain patients and surgeons select implant materials, such as when patients have a clinical history of metal sensitivity (Arch Dermatol. 2012 Jun;148[6]:687-93). However, other studies have also found that positive patch test results do not necessarily predict outcomes following surgery (J Arthroplasty. 2016 Aug;31[8]1717-21).
Although it might make sense to consider pre-operative patch testing in patients with a clinical history of rashes from metallic objects, Dr. Goldminz indicated that some patients might still need to weigh the benefits of the implant against the risks of a hypersensitivity reaction when no devices free of the allergen are available.
“In certain cases, patients might decide the risk-to-benefit ratio favors the device depending on factors such as the indication for the surgery, alternative options available, and what device removal might involve,” Dr. Goldminz said. Additionally, when patients develop rashes thought to be related to materials present in an implanted device, there are also medical treatments that can be considered if device explantation is not preferred or if it is an impractical approach.
NEW YORK – In patients who develop dermatitis after implantation of a device containing materials to which they have a contact allergy, explantation is not necessarily a cure for their symptoms.
“It can be difficult to predict who will or will not clear when the device is removed. In addition, in some cases device explantation could lead to other issues,” cautioned Ari M. Goldminz, MD, a dermatologist at Brigham and Women’s Hospital, Boston, MA. “Offering non-surgical options and a thorough investigation of other potential causes unrelated to the implant may provide a path to avoid explantation.” However, for other patients removal of the device might be the preferred option.
During his presentation at the American Academy of Dermatology summer meeting, he described illustrative cases. These patients developed dermatitis within weeks or months after receiving a surgical implant, and tested positive for a material that was in the implanted device.
In one of these cases, the suspected problem was a metal plate containing chromium that was placed during an orthopedic repair. Subsequent patch testing revealed a reaction to chromium and the implant was eventually removed.
However, there was no improvement in dermatitis following removal of the metal plate.
“The symptoms ultimately improved after starting on a low-chromium diet and avoiding other allergens identified on patch testing, such as those found in skin care products,” Dr. Goldminz explained. He does not discount the role that the implant may have played in the onset of dermatitis,, but improvement required avoidance strategies other than device explantation.
There are studies suggesting that patch testing prior to surgery can help certain patients and surgeons select implant materials, such as when patients have a clinical history of metal sensitivity (Arch Dermatol. 2012 Jun;148[6]:687-93). However, other studies have also found that positive patch test results do not necessarily predict outcomes following surgery (J Arthroplasty. 2016 Aug;31[8]1717-21).
Although it might make sense to consider pre-operative patch testing in patients with a clinical history of rashes from metallic objects, Dr. Goldminz indicated that some patients might still need to weigh the benefits of the implant against the risks of a hypersensitivity reaction when no devices free of the allergen are available.
“In certain cases, patients might decide the risk-to-benefit ratio favors the device depending on factors such as the indication for the surgery, alternative options available, and what device removal might involve,” Dr. Goldminz said. Additionally, when patients develop rashes thought to be related to materials present in an implanted device, there are also medical treatments that can be considered if device explantation is not preferred or if it is an impractical approach.
NEW YORK – In patients who develop dermatitis after implantation of a device containing materials to which they have a contact allergy, explantation is not necessarily a cure for their symptoms.
“It can be difficult to predict who will or will not clear when the device is removed. In addition, in some cases device explantation could lead to other issues,” cautioned Ari M. Goldminz, MD, a dermatologist at Brigham and Women’s Hospital, Boston, MA. “Offering non-surgical options and a thorough investigation of other potential causes unrelated to the implant may provide a path to avoid explantation.” However, for other patients removal of the device might be the preferred option.
During his presentation at the American Academy of Dermatology summer meeting, he described illustrative cases. These patients developed dermatitis within weeks or months after receiving a surgical implant, and tested positive for a material that was in the implanted device.
In one of these cases, the suspected problem was a metal plate containing chromium that was placed during an orthopedic repair. Subsequent patch testing revealed a reaction to chromium and the implant was eventually removed.
However, there was no improvement in dermatitis following removal of the metal plate.
“The symptoms ultimately improved after starting on a low-chromium diet and avoiding other allergens identified on patch testing, such as those found in skin care products,” Dr. Goldminz explained. He does not discount the role that the implant may have played in the onset of dermatitis,, but improvement required avoidance strategies other than device explantation.
There are studies suggesting that patch testing prior to surgery can help certain patients and surgeons select implant materials, such as when patients have a clinical history of metal sensitivity (Arch Dermatol. 2012 Jun;148[6]:687-93). However, other studies have also found that positive patch test results do not necessarily predict outcomes following surgery (J Arthroplasty. 2016 Aug;31[8]1717-21).
Although it might make sense to consider pre-operative patch testing in patients with a clinical history of rashes from metallic objects, Dr. Goldminz indicated that some patients might still need to weigh the benefits of the implant against the risks of a hypersensitivity reaction when no devices free of the allergen are available.
“In certain cases, patients might decide the risk-to-benefit ratio favors the device depending on factors such as the indication for the surgery, alternative options available, and what device removal might involve,” Dr. Goldminz said. Additionally, when patients develop rashes thought to be related to materials present in an implanted device, there are also medical treatments that can be considered if device explantation is not preferred or if it is an impractical approach.
REPORTING FROM SUMMER AAD 2019