Brittany Gareth Craiglow, MD, FAAD, kicked off the session “Alopecia Areata Power Hour,” at the 2023 AAD Annual Meeting, by recognizing the psychosocial impact of alopecia areata (AA) and clinical factors that influence disease severity. 

“[The] scalp is the most commonly affected area, but it can affect any hair-bearing area, eyebrows, eyelashes, etc., and it can also affect nails,” said Dr Craiglow. “Genetics are important. Instead of focusing on how did [the patient] get it, it’s important to focus on how to treat it.”  

“How worried should [dermatologists] be about the patient?” she asked. Characteristics associated with worse prognosis include:

• Early onset
• Extensive hair loss
• Ophiasis pattern
• Nail involvement
• Family history of AA
• Personal history of atopy

Dr Craiglow sarcastically mentioned, “It’s just hair, right?” She drove her point about the importance of hair home with the help of some pictures wherein the villains are portrayed without hair and sometimes without even eyebrows and eyelashes, “Study after study has shown that AA has a negative impact on the health-related quality of life and, importantly, has a similar impact to atopic dermatitis and psoriasis.” 

To assess AA severity, the Severity of Alopecia Tool (SALT) score is traditionally used, “Now that we have approved therapy, insurance companies request [the] SALT score.”

“One of the most important things [dermatologists] can do for patients is to acknowledge that AA is difficult for them and find out how they’re feeling. Do not minimize their problem and ask them to rate how much this bothers them,” she said. “Tell them that it is normal for hair loss to be very upsetting.”

Some of the AA treatments are topical, intralesional, systemic corticosteroids, topical irritants, topical immunotherapy, minoxidil, and systemic immunomodulatory therapy. 

As for the therapeutic approach, some of the factors to consider are age, extent of disease, duration of disease, psychosocial impact, and patient/family level of desire/motivation to treat.

Regarding minoxidil, Dr Craiglow said, “Minoxidil adjuvant therapy may enhance response to systemic Janus kinase (JAK) inhibitors.” She recommended the following doses (daily or divided twice a day):

• Women: 1.25 mg–5 mg
• Men: 2.5 mg–10 mg
• Children:
  • <20 kg: 0.625 mg daily
  • 20 kg–40 kg: 1.25 mg daily
  • >40 kg: 2.5 mg daily

Furthermore, Dr Craiglow discussed successful randomized controlled trials of JAK Inhibitors for AA, including ritlecitinib, deuruxolitinib, and baricitinib.

After showing different studies, she explained that some of the factors influencing response are dose, baseline severity, duration of current episode, and adjuvant oral minoxidil.

Finally, Dr Craiglow reviewed some of the previous cases wherein different treatment approaches were used and worked wonders, “Think about dupilumab in patients with concomitant atopy and/or elevated IgE.” In one case, a 19-year-old man with very severe AA started Olumiant 4 mg daily and restarted minoxidil 10 mg daily. After 3.5 months, there was significant hair growth. 

Dr Craiglow summarized the session with some take-home insights that AA is a serious disease affecting patients’ quality of life, regrowth takes time, and combination therapy is often best. “Treating hair loss is incredibly rewarding,” she concluded.

Reference
Craiglow BG. Alopecia areata power hour. Presented at: AAD Annual Meeting; March 17–21, 2023; New Orleans, LA.