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Update on advances in alopecia therapy

The lifetime risk of developing alopecia areata (AA) is 2.1% and, like other auto-immune diseases, AA has shown an increased incidence, which appears to be equal across ethnicities and gender, according to Dr. Carolyn Goh.

The assistant clinical professor in the Department of Medicine-Dermatology at UCLA’s David Geffen School of Medicine discussed the topic during a symposium at the recent annual meeting of the American Academy of Dermatology in Orlando, Fla.

As many as four patients per week that a dermatologist sees in the office or clinic are there because of alopecia areata, Dr. Goh said. Hair falls from the patient’s head because of an auto-immune, cell-mediated process, believed to due to the anagen hair follicle’s loss of immune privilege. Genetic polymorphisms have been identified in some populations.

“[Alopecia] can occur at any age,” the Los Angeles dermatologist noted, “but is less common under the age of three. The mean age of onset is in the thirties for both men and women.”

Considerable disease burden

The WHO 2010 estimates of the burden of the disease may not be accurate, she added, because some affected individuals may not present for care, and WHO did not consider factors such as emotional distress, interpersonal relationships and financial impacts in its assessment.

Several studies have linked AA with significant comorbidities, including atopy (atopic dermatitis, allergic rhinitis), thyroid disease (particularly in adults) and autoimmune disorders such as systemic lupus (particularly in younger patients), vitiligo and psoriasis.

“People [with AA] are at higher risk for depression and anxiety and may benefit from psychiatric referral,” Dr. Goh said. Several investigations have looked at AA comorbidities. One large case control study of more than 3,000 patients reported the risk of stroke was increased (HR: 1.161) within three years of AA diagnosis, independent of hyperlipidemia, hypertension or heart disease (Kang, et al: Sci Rep 2015)

“The hypothesis here was that there may be some treatment effect,” Dr. Goh said. “Maybe there is inflammation and oxidative stress associated with alopecia areata. We don’t know.”

A retrospective study produced different results. There was a lower risk for developing ischemic stroke (OR:0.39) and a trend to decreased risk of acute MI (OR:0.91) among 1,377 AA patients compared to 4131 matched controls (Huang, et al: J Am Acad Dermatol2016).

Other studies have also reported intriguing findings. Some analyses have associated AA with low levels of Vitamin D, which might affect disease severity. The Nurses’ Health Study, however, failed to uncover an association between vitamin D status and disease in an evaluation of 133 AA patients.

“There is a negative association with squamous cell carcinoma and basal cell carcinoma,” Dr. Goh revealed, “and a trend for melanoma in one particular study, but it was not significant.”

The traditional therapeutic ladder for AA is still valid, she added, but new treatments could add new steps. The Janus kinase (JAK) inhibitor ruxolitinib (20 mg b.i.d.) is one, but pricey at US$11,000 for a 30-day supply.

Biologics show good effect

One small trial of ruxolitinib (20 mg b.i.d.) in 12 patients with moderate to severe AA reported that three-quarters of the subjects enjoyed a greater than 50% hair regrowth three to six months after treatment, with relapses among all patients during the same period (Mackay-Wiggan: JCI Insight 2016).

Tofacitinib, a pan-JAK inhibitor, is less expensive at US$4,000 for a 30-day supply. The dose is started at 5 mg b.i.d. and may be increased up to 10 mg b.i.d.

Earlier this year a report of tofacitinib (5 to 10 mg, b.i.d.) combined with or without a corticosteroid (300 mg monthly for three months) in 65 AA patients resulted in a greater than 50% in their SALT (Severity of Alopecia Tool) scores (Liu: J Am Acad Dermatol 2017).

One other report in 12- to 17-year-old adolescents showed the therapy resulted in an 80% improvement in 10 of the 14 children, all but one given a 5 mg b.i.d. dose during a two- to 16-month period.

“Anecdotally, I have used this as well,” Dr. Goh disclosed. “I have had some really good success in some patients, and some lack of response in a few patients. A lot of patients don’t seem to see regrowth for a whole year.” She listed several other targeted therapies for AA patients, including ustekinumab, apremilast and abatacept “Simvastatin/ezetimibe is a nice option for patients who might not want to take immuno-suppressants, but might want to try something,” Dr. Goh said. “There are mixed data out there.”

There are a few studies about platelet-rich plasma (PRP), but many patients like it. People like the thought of themselves giving themselves the treatment.

“JAK inhibitors do seem to be promising,” she summarized regarding other options. “Other biologics may be helpful, but we have minimal data. Traditional therapies are still reliable, but they may take longer.”

Originally published in The Chronicle of Skin & Allergy (June 2017;23(4):page 8)

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