How to Diagnose and Manage Alopecia Areata

During an afternoon session at the 2022 Fall Clinical Dermatology Conference in Las Vegas, Nevada, Brett King, MD, PhD, Associate Professor of Dermatology at Yale School of Medicine, Valerie D. Callender , MD, founder and medical director of the Callender Dermatology & Cosmetic Center, and Maria K. Hordinsky, MD, professor and chair of the Department of Dermatology at the University of Minnesota, presented their strategies for diagnosing patients with alopecia areata (AA) and how to integrate new therapies into clinical practice.

AA is an autoimmune disease characterized by rapid hair loss on the scalp, eyebrows, eyelashes and, in some severe cases, bodily damage. AAs can have an unpredictable prognosis, with relapses, remissions, and persistent hair loss. Generally, AA is more prevalent in children, but it affects both sexes and all ethnicities equally.

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Clinical presentations of AA include:

  • Patchy hair loss
  • Total alopecia
  • Universal alopecia
  • Model of ophiasis
  • Inverse-Ophiasis (or sisaipho) model
  • Diffuse pattern
  • Beard alopecia
  • Alopecia areata of the nails

To accurately diagnose AA, dermatologists must perform a medical history review, physical exam, dermoscopy, hair pull test, and biopsy. Another tool to use is the Alopecia Areta Investigator Global Assessment (AA-IGA), which examines disease severity based on the amount of hair loss from the scalp.

According to the speakers, several factors should be considered when choosing a treatment option for children and adults with AA, such as:

  • Patient’s age
  • Location of hair loss
  • Extent of disease
  • disease severity
  • Presence of other medical conditions
  • Scalp biopsy report on hair cycle and inflammation
  • Choice of patient/parent after careful consideration of the proposed treatment and its risks, benefits and expectations
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For patchy AA, suggested treatments are topical or intralesional corticosteroids, minoxidil solution, anthralin, steroids in shampoo formulations, and topical immunotherapy. Treatment options for extensive AA include topical corticosteroids, topical minoxidil, topical immunotherapy, dithranol, oral vitamin D, phototherapy, laser therapy, and biologics.

Janus Kinase (JAK) inhibitors also show positive results for the effective management of AA. Oral ruxolitnib has been shown to induce hair regrowth in patients with moderate to severe AA. Tofacitinib is another JAK inhibitor that has been studied in relation to the treatment of AA in adolescents and adults.

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Concluding their presentation, King, Callender, and Hordinsky pointed out that there are various clinical presentations of AA ranging from patchy areas of hair loss to complete scalp involvement and hair loss. Current treatments include topical, intralesional, and systemic interventions. However, these treatments demonstrate varying degrees of success.

Reference

King B, Callender V, Hordinsky M. The “how to” to diagnose and manage alopecia areata. Fall 2022 Clinical Dermatology Conference. October 21, 2022. Las Vegas, Nevada.

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