Prevalence and Management of Alopecia Areata in Black and Asian Patients

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In this interview, Dr Amy McMichael discusses the challenges Black and Asian patients with alopecia areata (AA) may face in diagnosis, treatment, and management, including limited access to dermatologists, disparities in health care interactions, and cultural factors influencing perceptions of the condition. 

The Dermatologist: Could you provide insights into the factors contributing to the increased prevalence of AA among Black and Asian patients? 

Dr McMichael: I do not think we can really say yet why the prevalence of AA is increased in African American patients and, in some studies, Latino patients and Asian patients.^1,2 I think we are now just learning that this is the case, and we have some very good data from the Nurses’ Health Study, both I and II, and also from the National Alopecia Areata Foundation (NAAF).^2,3 I think part of the reason why we are seeing the prevalence change is that more and more people of color are going to dermatologists, so they are being documented. I do not know that there is any change from the past because we do not have good records from the past to really tell us. I think the NAAF data are quite good because dermatologists had to make the assessment that the patient really did have AA. The recent Sy et al. article looking at patients with AA in an electronic medical database suggests that people of color are more likely to have the disease; however, what we do not have is documentation of how the diagnosis was made.⁴ I think we need more studies that have actual documentation of diagnosis. 

The Dermatologist: In your experience, what challenges do people of color with AA face in terms of diagnosis, treatment, and management? 

Dr McMichael: There are several things that I think are impactful about this diagnosis when we see it in patients of color. One of those is that many dermatologists do not practice in areas where these patients live. If you are going to see a dermatologist for your AA and you happen to be of African descent, finding a dermatologist who may be interested in hair loss or AA might be difficult in your area, which means you have to travel outside your area and that may necessitate taking time off from work, which means you also have to be able to afford to do so. And so that increases your risk of not really getting to the dermatologist and potentially not being able to follow up for treatments. Certainly, there are many people of color who have great insurance, they can drive, and they can take time off, but you must consider factors that might be keeping them from getting treatment and getting diagnosed properly. 

There are also some data to suggest that Asian patients have, at least for psoriasis visits, spent less time with the dermatologist compared to Caucasian patients. This is concerning because AA is one of those diagnoses where you need to be able to spend some time with the patient to discuss treatment options. If you are not allowing them the time to ask questions and really understand how the treatment is going to benefit them, then potentially they are also going to be at risk for not getting the right treatment. 

I think another issue would be cultural competency. If there is somebody whose first language is not English, are we allowing for there to be an interpreter? How much does the patient understand about their disease and about their treatment? If you do not have culturally competent staff in the office, it potentially minimizes the likelihood that the patient is going to get treatment. 

The Dermatologist: Are there any cultural or societal factors that might affect the experiences of people of color with AA and their perception of the condition? 

Dr McMichael: One of the things that we must think about is if there are potential cultural factors that might affect patients coming in to get diagnosed for AA in different groups of people of color or even how they might perceive treatment options. I do not think we can make blanket statements about any one group because we really have not studied that per se. At our center, we looked at our patients of color who were taking Janus kinase (JAK) inhibitors, but we did not compare them to anyone. We found that many patients did quite well with starting JAK inhibitors and had good outcomes, so we really do not know that there is any cultural barrier so to speak. I think, in general, patients get information from the internet. And I think the barrier there is that there are many forms of AA and patients of color, just like every other patient, may feel that they have one form of hair loss when they really have another, or they may be under the impression that complementary or integrative medicine treatments will work for AA when we do not have evidence of that. Patients of color are at risk for all the usual barriers of people not getting the right diagnosis or not understanding their diagnosis and therefore not understanding why they need the treatment that they need. 

The Dermatologist: What strategies do you think are essential for health care providers to adopt to provide culturally sensitive and effective care? 

Dr McMichael: We must think about how to provide culturally sensitive care for patients with AA no matter what racial group or ethnicity they self-identify as. Many patients of color, particularly women, have certain kinds of behaviors they do with their hair. They may wear locks, they may wear natural hair, they may use chemical relaxers, they may wear braids, and those sorts of things may or may not be something that every dermatologist is comfortable with. I think this is something that all dermatologists need to become comfortable with because many patients of color are coming to all kinds of dermatologists. There are not enough people of color in dermatology to take care of everybody who needs to be seen. If a Caucasian patient came to me and said, “I think I have a skin cancer,” my answer would not be, “You are of a different race than me and I do not understand White skin, so I am not going to take care of your skin cancer.” I enjoy seeing patients of all races and ethnicities, and I take care of all kinds of diseases. I think all dermatologists who practice general dermatology need to be able to understand different kinds of cultural hair care and how patients might, for instance, consider hair care to be a way to camouflage their disease, thinking about ways that would be helpful to wear their hair so it would allow them to treat their scalp if they need to put topical medications on their scalp. What kinds of topical medications would be compatible with their hairstyle? These things are not very difficult to learn, and they should be in the purview of every dermatologist to understand because you are not delivering appropriate health care if you do not. 

The Dermatologist: Are there any specific treatment approaches or therapeutic modalities that have shown efficacy or challenges in the management of AA among Black and Asian patients? 

Dr McMichael: For now, I do not think we have any specific treatments that we can say work best in any particular racial or ethnic group. Right now, our data are from the clinical trials that we have and, unfortunately, people of color often are not part of clinical trials. We cannot even slice the data to look at the patients of color in those trials because there are so few. So, at this point, we are going by real-world experience and the few people of color who were included in those trials. It appears that people of color do seem to respond to all the same treatments that Caucasian patients respond to, and I do not think there is any reason to think that they do not. For now, all the options that are open to patients should be offered to every patient. We may find later that specific JAK inhibitors work well in one group of patients, but it might not be related to race or ethnicity, it might be related to the extent of disease or how early the disease presented in that patient. I think we will find those sorts of groups, but for right now, we need to offer the whole kit and caboodle to all our patients and allow them to share in the decision-making about what kind of treatments we want to begin. 

References
1. Harries M, Macbeth AE, Holmes S, et al. The epidemiology of alopecia areata: a population-based cohort study in UK primary care. Br J Dermatol. 2022;186(2):257-265. doi:10.1111/bjd.20628 

2. Lee H, Jung SJ, Patel AB, Thompson JM, Qureshi A, Cho E. Racial characteristics of alopecia areata in the United States. J Am Acad Dermatol. 2020;83(4):1064-1070. doi:10.1016/j.jaad.2019.06.1300 

3. Thompson JM, Park MK, Qureshi AA, Cho E. Race and alopecia areata amongst women. J Investig Dermatol Symp Proc. 2018;19(1):S47-S50. doi:10.1016/j.jisp.2017.10.007 

4. Sy N, Mastacouris N, Strunk A, Garg A. Overall and racial and ethnic subgroup prevalences of alopecia areata, alopecia totalis, and alopecia universalis. JAMA Dermatol. 2023;159(4):419-423. doi:10.1001/jamadermatol.2023.0016