In this feature video, Dr Amy McMichael shares what will be presented during her session, “What You Need To Know NOW About Hair Loss in Skin of Color,” held at the 2023 Fall Clinical Dermatology Conference.

Amy McMichael, MD, is a professor in the department of dermatology at Wake Forest Baptist Health in Winston-Salem, NC.

Transcript:

What are the latest updates in treating AA in patients with skin of color?

Dr Amy McMichael: In patients with skin of color who have alopecia areata, I don't think that there is any real difference in the approach to treatment. I've been asked what do we do differently in this patient population with alopecia areata? I tahink the real difference comes into account when you think about diagnosis. I think that patients who are skin of color often are missed in terms of their diagnosis of alopecia areata.

I think one of the reasons is that in children who have patchy hair loss and they're African-American, one of the first things that comes to mind is tinea capitis. And indeed, this is a common thing that happens in children of African-American descent. However, I think you have to use your powers of clinical evaluation, use your trichoscopy, look at if there are exclamation point hairs versus pigtail hairs, which would be more likely associated with tinea capitis. Look at the pull test. Those are going to be things that are going to help you figure out, "Okay, what's going on here?" Just look at the eyebrows, eyelashes, nails, all of those things are going to help you make that diagnosis earlier.

And we know from lots of data now from the two pivotal trials for JAK inhibitors and from previous research by Dr. Brett King, that the earlier you get to treatment, the better you do. We don't want to prolong the treatment, so I think the diagnosis is really the breaking point. I think even in adults with alopecia areata, people have mistaken it for telogen effluvium. If it's more diffused, they've mistaken it for female pattern hair loss. They've mistaken it for central centrifugal cicatricial alopecia, or CCCA, which is much more common in African-American women than any other component of the population. So, I think we have to be very diligent about our diagnostic skills when we're looking at alopecia areata in patients with skin of color. And particularly in adults, if there is a question, biopsy, and make sure that you're not missing even discoid lesions of lupus in that patient population, which is also very common.

How can physicians determine if JAK inhibitors are the best treatment option for patients with AA?

Dr Amy McMichael: One of the big things I think that we're going to have to do as we move forward in the treatment of alopecia areata is really figure out, "Okay, which patient is going to be right for JAK inhibitors?" I think that our trials are giving us hints about how to choose patients for that particular treatment. What we know is that at least in one of our now FDA approved treatments, we can treat children 12 and above. I think that those patients are certainly going to be on our roster. We haven't gone really into the elderly populations with the clinical trials, and I think that most people who are early in their treatment of patients are going to stick with adults less than 65.

There is some concern with JAK inhibitors about solid tumors and even potentially hematologic tumors or cardiac events. Those issues were brought about because of the old data looking at patients with rheumatoid arthritis on JAK inhibitors. They're typically a lot older. They're typically a lot sicker. They've been on immunosuppressant agents including large doses of prednisone and large doses of other immunosuppressants for many years, so they're in a different risk profile. However, that's the data that we have long term. So, we have to be careful about our older patients, making sure that they don't have history of vascular disease, blood clots, history of cancer, that sort of thing. I think those patients, for right now, this is not the best treatment option for them.

Patients who have very small amounts of hair loss where a topical and/or injection might do better, certainly I probably wouldn't pull out a JAK inhibitor, but when you start getting into patients when they've lost their eyebrows, their eyelashes, maybe their nasal hairs, and they can't stop getting upper respiratory tract infections because their nasal hairs are missing, then you have to start looking into the nuances of treatment of patients that might not have significant loss on their scalp, but may have loss of the facial hair and/or nose hairs.

So, I think you have to really look at the person, decide what their risks are, how they would like to treat, because this certainly is something that is easy to take as a pill, but you have to have some monitoring with laboratory tests. Is that something that they're willing to do on a regular basis? I think that ultimately they have to be open to using these adjunctive treatments when we need to because obviously, not everybody is going to have a hundred percent regrowth. So, I think we're picking our patients widely now, but trying to be safe and trying to make sure that we follow guidelines as far as we know what they are from our current trials.

What additional tips and insights would you like to share with your colleagues regarding your session for Fall Clinical on JAK Inhibitors in Alopecia Areata?

Dr Amy McMichael: Well, I'm really excited about talking about alopecia areata at Fall Clinical. We're going to have some really cool cases, and I would love for everyone to come and hear about our cases and maybe fill in how they've managed cases and let us know what you think. We're going to talk about the pathophysiology of alopecia areata because I think that some of the things that we're learning now are new to a lot of people, and it sort of makes sense now that we have all this data from the JAKs. We're going to talk about the ways that you can maximize your patient's frame of mind, really getting in there and talking about the psychosocial aspects of alopecia areata and making it easy for people to address that in a short dermatology visit. I think that's the key. Right? We don't have 50 minutes to talk to patients about their overall mental health, but there are some tricks and tips that I'm going to give to talk about how to assess your patient's mental health and how to really make sure that you're treating the whole patient rather than just the disease itself.