Dr King on Alopecia Areata and its Treatment

Brett King, MD, PhD, is an associate professor of dermatology at Yale School of Medicine. He specializes in skin diseases resistant to first-line therapies with special interests in atopic dermatitis, vitiligo, and more. He met with The Dermatologist to discuss alopecia areata and its treatment following his presentation on the topic at the Interdisciplinary Autoimmune Summit IAS 2021.

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Transcript

For those in rheumatology and gastro, who may not be familiar, can you provide some basic background on alopecia areata?

Dr King:  First of all, it's important to understand alopecia simply means hair loss. There are many forms of hair loss. Androgenetic alopecia, which is synonymous with male-pattern baldness or male-pattern alopecia, or female-pattern hair loss or female-pattern alopecia, is the most common form of alopecia or hair loss across all ages.

Alopecia areata is the second most common form of hair loss or the second most common form of alopecia across all ages. Now, if we think about, say, the age group under 20, alopecia areata is likely the most common cause of hair loss in that age group, which is an important consideration depending on the age of patients that you commonly see. 

The presentation of alopecia areata is usually such that the diagnosis is unequivocal, and that is the sudden onset of well-described typically circular patches of hair loss, usually involving the scalp, but any hair-bearing site can be involved. Eyebrows, eyelashes, facial hair in men, or body hair in everybody. 

Because some presentations of alopecia areata have clinical overlap with other forms of hair loss, a biopsy is uncommonly, but sometimes needed to make the diagnosis.

What associations exist between AA and other autoimmune IMI diseases such as atrophy or lupus?

Dr King: AA commonly co-occurs with other autoimmune and inflammatory diseases. Most common is the association with autoimmune thyroid disease and atopic dermatitis. Each of them is more than twice as common in patients with alopecia areata as in the general population, but the association extends with other autoimmune and inflammatory diseases, too.

What are the current treatment options for AA and particularly what might be on the horizon?

Dr King: When thinking about a treatment algorithm for alopecia areata, we consider age, we consider extent or severity of scalp hair loss, or hair loss involving special sites such as the eyebrows or eyelashes. Then we also consider the impact on the patient.

Very generally speaking, intralesional triamcinolone, so injections of triamcinolone or corticosteroid into the skin, in particular into patches of hair loss, is the mainstay of treatment for relatively mild disease, which I think of as scalp hair loss involving less than 20 percent of the scalp hair-bearing area.

I should say, topical corticosteroids are often used as well for, again, mild disease. Sometimes topical immunotherapy is used which involves giving people allergic contact dermatitis, think poison oak or poison ivy, and then having them take that chemical and rubbing it on spots in hair loss to try to regrow hair. Again, you would only consider this for somebody with very limited scalp hair loss.

For more severe scalp hair loss, so now let's think of the category of people with greater than 20 percent scalp hair loss, we're going to think about systemic therapy. Historically, we've used prednisone a lot for the treatment of these patients, azathioprine, mycophenolate, methotrexate, cyclosporin, but with fairly mixed results. I would say overall fairly unimpressive results. 

However, in an era when those were the therapeutic options, then that is what we used. For me, what's on the horizon, and what is so exciting in alopecia areata right now is that recent advancements in our understanding of the immunopathogenesis of the disease have led to the much more targeted treatment of the disease with JAK inhibitors or Janus kinase inhibitors. We have numerous reports and case series showing efficacy of off-label use of JAK inhibitors for the treatment of the disease, but super exciting is that more recently we've had clinical trial results, in particular, phase 2 clinical trial results of different JAK inhibitors showing efficacy. Again, this is the real excitement in this field right now.

Regarding your recent study in "Journal of Patient-Reported Outcomes,"1 how significant is the emotional and psychological impact of AA?

Dr King: In this study, which is a particularly interesting and novel study in alopecia areata, patients with more than 50 percent scalp hair loss were interviewed and asked open-ended questions to explore their life experiences with alopecia areata. Patients repeatedly described a profoundly negative impact of the disease.

AA is particularly awful, not for physical symptoms which are usually absent or mild, but because alopecia areata destroys one's visible identity. Turning people into ghosts of themselves. Truly, it's science fiction. People don't recognize themselves, and they become unrecognizable to others when you erase all of the hair on one's head.

Again, think about this. Erase your scalp hair, your eyebrows, your eyelashes, facial hair in men, and you erase a hugely important and defining part of who you are. It's usually totally devastating. All this makes sense, because think about evolution.

Over the past million or so years, humans or we have evolved to lose almost all the hair on our bodies, except for that on our heads, which makes you think it's important for identity, for social communication, and for protecting vital structures, such as our heads or our eyes. 

Reference:

1. Aldhouse NVJ, Kitchen H, Knight S, et al. "'You lose your hair, what's the big deal?' I was so embarrassed, I was so self-conscious, I was so depressed:" a qualitative interview study to understand the psychosocial burden of alopecia areata. J Patient Rep Outcomes. Published online September, 11 2020;4(1):76. doi:10.1186/s41687-020-00240-7