COMMENTARY

Alopecia Areata: The Clinical that there is usually an increased prev-

alence of other autoimmune conditions
in AA families (Blaumeiser et al., 2006;
Situation Goh et al., 2006).
Maria K. Hordinsky1 This description typified the clinic
visit until recently. The visit now must
In the absence of an approved treatment by the US Food and Drug Adminis- include a discussion of JAK inhibitors,
tration, choosing one of the many off-label treatments available for a child, teen, which are increasingly being used off
or adult with alopecia areata (AA) can be challenging. The physician or midlevel label based on several recently pub-
provider treating a patient with AA needs to take into consideration the age of lished studies and meeting pre-
the patient, location of hair loss, disease extent and activity, and any ongoing sentations (Craiglow et al., 2016, 2017;
medical or psychological issues. Many patients and their families have now also Jabbari et al., 2016; Liu et al., 2017;
heard the “buzz” about evolving research, particularly with JAK inhibitors, for Mackay-Wiggan et al., 2016). Patients
the treatment of AA. This means that today’s clinic visit with the AA patient and some physicians and midlevel
should include not only a discussion about traditionally used off-label treatments providers are eager to try new
but also evolving therapies and clinical research opportunities. approaches and off-label therapies with
the support of industry patient assis-
Journal of Investigative Dermatology Symposium Proceedings (2018) 19, S9eS11. doi:10.1016/
tance programs or, in some cases,
j.jisp.2017.10.015
insurance coverage. However, there are
still some patients, particularly those
with long-standing recalcitrant exten-
sive AA who have tried and failed
Introduction disease and that they will have periods previous treatments, who prefer not to
The clinic visit for a patient with of regrowth, stability, or loss. Patients treat and who come to clinic to “catch
alopecia areata (AA) starts with a good also need to understand that even if an up” on the latest emerging treatments
medical history and review of medica- episode is successfully treated, AA can and clinical research studies. Patients
tion and supplement use and associated recur and that at the present time, we and parents of affected children and
medical conditions, including atopic do not have biomarkers to predict when young adults view the emerging treat-
conditions or an immunodeficiency AA may flare (Alkhalifah et al., 2010). ments and opportunities for clinical
(Karimkhani et al., 2017). Information There are several treatment options trial participation with interest and
should also be obtained about use of not approved by the U.S. Food and hope.
any cosmetic camouflage techniques, Drug administration to pick from and
scalp or eyebrow prostheses, and scalp/ recommend to the patient with AA. The Summary of commonly used
hair care habits. treatment selection is usually based on treatments for AA
Current and past treatments and their patient age, location of the hair loss, Treatment of stable patchy AA may
efficacy should be noted. A review of disease extent and activity, and other include the use of topical or intrale-
patient and family goals, visit expecta- medical or psychological issues the sional corticosteroids, 2% or 5%
tions, and discussion of how the disease patient may have (Hordinsky and topical minoxidil when there is fine
is affecting the patient in the social and Donati, 2014). Many physicians and vellus or indeterminate hair growth
home environments will round out the midlevel providers will screen for present, anthralin, topical immuno-
first part of the visit. The focus of the common diseases reported to be more therapy, or combinations such as a
clinical examination should be on frequently present in patients with hair topical steroid with topical minoxidil. A
assessing skin health and documenting loss, including AA. The screening can steroid-containing shampoo may be
the extent of hair loss and disease include checking for the presence of effective in the management of patchy
activity. Activity can be ascertained by thyroid disease, low iron stores, ane- persistent AA and diffuse AA charac-
the presence or absence of positive hair mia, hormone abnormalities if indi- terized by scalp hair thinning. Topical
pull test results. Disease involvement of cated, and possibly nutritional steroids may also be applied to new
finger and toenails should also be deficiencies. Information about the ge- areas with a surrounding margin to
noted. Once disease extent and activity netics of AA may be provided, recog- prevent disease spread and promote
have been ascertained, the conversa- nizing that AA is a multifactorial new hair growth. Local injection of
tion can turn to a discussion of what we condition. Patients may also want to intralesional triamcinolone acetonide
know about AA. Patients need to know there is an increased risk of AA ranging in concentrations from 3 to
understand that AA is an autoimmune for relatives of individuals with AA and 10 mg/ml has been a preferred treat-
ment for scalp and eyebrow AA in the
1
Department of Dermatology, University of Minnesota Medical School, Minneapolis, Minnesota, USA United States since the late 1950s and
Correspondence: Maria Hordinsky, 420 Delaware Street SE, MMD 98 Minneapolis, Minnesota 55455, is considered by many to be the stan-
USA. E-mail: hordi001@umn.edu dard of care, particularly for affected
ª 2017 The Author. Published by Elsevier, Inc. on behalf of the Society for Investigative Dermatology. adults. Adverse effects tend to be local,

www.jidsponline.org S9
 COMMENTARY
with the potential for adrenal gland
suppression. Topical immunotherapy
with diphenylcyclopropenone (DPCP),
squaric acid dibutylester, or dinitro-
chlorobenzene has also long been
another accepted therapy for AA. In
particular, DPCP is recommended
throughout the world. Although topical
immunotherapy is not specifically
banned by the Food and Drug Admin-
istration in the United States, other
aspects of increasing regulatory over-
sight are making the use of immuno-
therapy with chemicals such as DPCP
or squaric acid dibutylester difficult in
some large health care systems. Photo-
therapy, including excimer laser treat-
ment to small areas of hair loss, has also
been successful in some studies
(Hordinsky, 2013; Hordinsky and
Donati, 2014).
Many treatments are also available
for patients with alopecia totalis or
alopecia universalis. These include
those already discussed, as well as
oral immunosuppressive agents such
as prednisone, methotrexate, cyclo-
sporine, or, in patients with more
extensive disease, intravenous methyl
prednisolone sodium succinate or
immunoglobulin. Patients with active
shedding may be prescribed oral pred-
nisone to turn off disease activity and
then be given more commonly used
hair growth-promoting treatments.
With all these available choices,
selection of the right treatment for each
patient can be challenging. To guide
the practitioner, a review of random-
ized controlled trials in AA was pub-
lished in 2014 (Hordinsky and Donati,
2014). Twenty-nine trials were identi-
fied. Using the American College of
Physicians Guideline grading system,
the authors concluded that most of
these studies were of only moderate
quality and that most had major
limitations that hindered the interpre-
tation of study results. At the same
time, a number of treatments were
found to be effective, particularly
topical and oral corticosteroids and the
sensitizing agents DPCP and dinitro-
chlorobenzene. Most of these studies
involved adult patients. At the present
time, there are limited treatment studies
of pediatric AA, but of the studies
available for review, the use of potent
topical steroids such as clobetasol
S10 Journal of Investigative Dermatology Symposium Proceedings (2018), Volume 19
propionate cream 0.05% has been
found to be more effective than a lower
potency topical steroid such as 1%
hydrocortisone (Lenane et al., 2014).
There are no good studies on the use of
oral corticosteroids in children with
AA, but there is evidence for the use of
pulsed high-dose systemic corticoste-
roids, particularly in the setting of acute
crises of hair loss. There are also studies
supporting the use of immunotherapy
in children, particularly in those with
chronic and extensive AA.
Part of the therapeutic plan for the
AA patient may also include cosmetic
camouflage with wigs or scalp pros-
theses, and these should be proac-
tively discussed. Patients can also be
referred to Locks of Love, a nonprofit
organization that provides hair pros-
theses for children younger than
18 years.
Summary
Physicians and midlevel providers still
generally prefer topical therapy for AA.
However, with the recently published
studies in which the systemic JAK
inhibitors (e.g., tofacitinib or
ruxolitinib) have been shown to reverse
the AA process, there has been a surge
of enthusiasm for using more aggressive
systemic therapies. These include not
only JAK inhibitors, but also low-
dose IL-2 and simvastatin/ezetimibe
(Castela et al., 2014; Lattouf et al.,
2015). Until clinical research studies
are completed, there will be ongoing
debate regarding the risks and benefits,
cost, and sustainability of using JAK
inhibitors or other new approaches for
the treatment of AA. This is particularly
true in the case of children with AA. For
patients with AA, there is also always
the option of choosing “no treatment”
or a holistic approach to this disease.
Affected adults and children should
be assessed for their psychosocial well-
being and for issues of self-confidence,
self-image, and acceptance by peers,
particularly in the pediatric population.
Parental anxiety, frustration, guilt, and
expectations must also be proactively
managed (Alfani et al., 2012; Huang
et al., 2013).
More research needs to be done for
both adult and pediatric AA (both on
new treatments and established adult
treatments in the pediatric population),
with detailed outcome measurements
and follow-up data. In the meantime,
local chapters of the National Alopecia
Areata Foundation and other AA sup-
port groups will continue to be impor-
tant resources for patients and health
care providers on current research
activities, insight into this condition,
and emotional support.
CONFLICT OF INTEREST
The author has received grants from Incyte and
Pfizer.
ACKNOWLEDGMENTS
Funding for the Summit and the publication of this
article was provided by the National Alopecia
Areata Foundation. Funding for this Summit was
also made possible (in part) by a grant
(1 R13AR071266) from the National Institute of
Arthritis and Musculoskeletal and Skin Diseases
(NIAMS). The views expressed in written confer-
ence materials or publications and by speakers
and moderators do not necessarily reflect the
official policies of the Department of Health and
Human Services; nor does mention of trade
names, commercial practices, or organizations
imply endorsement by the U.S. Government.
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COMMENTARY
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