Dr. Maria Hordinsky presented an overview of key things adults need to know about alopecia areata, including the risks and benefits of current and evolving off-label treatment options. Dr. Hordinsky is Professor and Head of the Department of Dermatology at the University of Minnesota. She is recognized for her clinical expertise in alopecia areata and hair diseases.

1. TTreatment of Alopecia Areata:
Overview
Maria Hordinsky, MD
Professor and Chair
Department of Dermatology
University of Minnesota
Minneapolis, Minnesota
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2. Maria Hordinsky, MD
Disclosures:
– Grant/Research support from: Aclaris, National
Alopecia Areata Foundation, Pfizer, Lilly, Consultant
for: P&G, Concert, Cassiopea
– Section Editor on Hair Disease, UpToDate
– Editor with Dr. Amy McMichael, Hair and Scalp
Disorders, Medical, Surgical, and Cosmetic
Treatments, 2nd Edition, CRC Press
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3. Alopecia Areata
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4. AAlopecia Areata
•An autoimmune disease which can be associated
with hair loss anywhere on the body, along with
nail changes.
•A multifactorial condition
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5. EEPIDEMIOLOGY OF ALOPECIA AREATA
• Affects 1.7-2.1% of the population
• 50-80% of cases are sporadic
• Disease associations may vary around the world
and include vitiligo, thyroid disease, atopy (allergic
rhinitis, asthma, atopic dermatitis)
• Both males and females of all ages and races can
be affected
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6. CCurrent TTreatment:the Basics
Figure out what is most bothersome to the patient or family-
• Is it scalp hair loss?
• eyebrow loss?
• eyelash loss?
• nail issues?
• beard hair loss? All of the above?
• Is it that there is shedding every single day and
seeing all the hair loss is depressing and anxiety
provoking?
• Is it dealing with the recurrent hair loss despite
treatment?
• Other
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7. LLaboratory Tests
Selected based on the history and physical examination:
• Thyroid Function Studies
• Heme and Iron Profiles including serum ferritin and
hemoglobin
• If indicated,
• Non cycle dependent hormones such as DHEA-S and
total/free testosterone
• ANA or other autoantibodies
• “Nutrition Labs” including Vitamin D, Thiamine, Zinc,
total protein, other
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8. NNORMAL HAIR CYCLE
• Anagen –90% of follicles -lasts 2-7 years
• Catagen – 1-2% of follicles – lasts 2-3 weeks
• Telogen – Up to 10% of follicles – lasts 2-3 months
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9. Alopecia
Areata
Anagen
Attack
Anagen
Arrest !
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10. HHistopathology:
Normal Human Scalp: Horizontal Section
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12. Normal
Scalp:
Vertical
Section
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13. IIMMUNOLOGY
A hallmark of
alopecia areata:
•peribulbar
lymphocytes
around anagen
follicles
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14. TThe Clinic Visit in 2019 - the Treatment
Discussion
A number of treatments can induce hair growth in AA
but few have been tested in randomized controlled
trials and there are few published data on long-term
outcomes; most focus on hair regrowth.
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15. IIn the absence of an approved
treatment by the Federal Drug Administration,
choosing a treatment for AA takes into consideration several
factors including:
• age of the patient
• location of the loss
• disease extent
• disease activity
• presence of other medical problems
• scalp biopsy report on the hair cycle, inflammation
• Patient choice after a review of proposed treatment risks,
benefits and expectations.
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16. RRandomized Controlled Trials in Alopecia
Areata – fast forward the past 5 years
Hordinsky M, Donati A. Alopecia areata: an
evidence-based treatment update. Am J Clin
Dermatol. 15:231-245, 2014.
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17. RResults and Conclusions
• Using the American College of Physicians Guideline
grading system, the assessment was that the majority
of these studies were only of moderate quality.
• At the same time, a number of treatments were found
to be effective, for example, topical and oral
corticosteroids and the sensitizing agents
diphenylcyclopropenone and dinitrochlorobenzene.
• Most studies though had major limitations that
hindered the interpretation of study results.
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18. PPATCHY ALOPECIA AREATA:
TREATMENTS
• Topical or Intralesional Corticosteroids
3 to 10 mg/cc
• Minoxidil Solution- 2% or 5%
• Anthralin
• Combination Therapy
• Steroids in Shampoo Formulations
• Topical Immunotherapy
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19. •Usually reserved by many for rapid onset or rapidly
progressive, extensive AA
OOral Corticosteroids
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20. • Corticosteroids:
• Topical
• Intralesional
• Pulsed methlypredisolone
• Oral
• Topical minoxidil
• Topical immunotherapy
• DPCP
• SADBE
• Dithranol
• Phototherapy
• PDT
• PUVA
• NBUVB
• Laser therapy - Excimer laser/Fractional
Photothermolysis Laser
• Immunosuppresive agents
• Methotrexate
• Cyclosporine
• Prostaglandin analogues
• Biologics
TTreatments
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21. TThe Clinic Visit in 2019 -
the Treatment Discussion
The “buzz” about potential new treatments for
alopecia areata is out and patients want to
know “what’s new”?
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22. JJanus Kinase (JAK) Family
The janus kinase (JAK) family, including JAK1, JAK2, JAK3 and
tyrosine-protein kinase (TYK2), is a group of cytoplasmic
tyrosine kinases that mediate signal transduction via
interactions with Type 1 and Type 2 cytokine receptors
critical for leukocyte (white cell) activation, proliferation,
survival and function.
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23. EEmerging Directions
•Targeting intracellular
protein kinases, such as
the JAK family of tyrosine
kinases - and in
particular:
•Ruxolitinab:
JAK1/JAK2 inhibitor
•Tofacitinib:
JAK1/JAK3 inhibitor
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24. CCase 1
History
• 25-year-old female with a past medical history of
Hashimoto’s thyroiditis and a 10-year history of patchy
and extensive alopecia areata
• Previous treatments have included multiple courses and
trials of clobetaosl 0.05% shampoo, intralesional Kenalog
injections, topical steroids, Rogaine, and oral prednisone.
• Multiple family members have been diagnosed with
rheumatoid arthritis (RA) and her father has extensive AA
with RA
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25. Ongoing Clinical Trials in Adults
• Pfizer
• Concert
• Aclaris
• Lilly
• Bioniz Therapeutics, Inc.
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26. HHair Regrowth in a Patient With Long--sstanding
AAlopecia Totalis and Atopic Dermatitis Treated With
Dupilumab
• Lauren R. Penzi, MD; Mariko Yasuda, MD1; Athena Manatis-
Lornell, BA; et al Dina Hagigeorges, BS; Maryanne M. Senna, MD..
JAMA Dermatol. 2018;154(11):1358-1360.
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27. AAlopecia AAreata after Dupilumab for Atopic Dermatitis
Mitchell, Krystal et al. JAAD Case Reports, Volume 4, Issue 2, 143 - 144
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28. CCurrent Treatment of Alopecia Areata:
At the present time…
• Most physicians and health care providers generally prefer topical
therapy for AA.
• However, following the recently published studies in which
primarily the JAK inhibitors Tofacitinib or Ruxolitinib were shown
to reverse the alopecia areata process, there has been a surge of
enthusiasm for studying and using not only Tofacitinib and
Ruxolitinib but also other JAK inhibitors.
• Both topical and oral formulations are in clinical trials.
• Attention is also more focused on the psychological needs of
patients with alopecia areata.
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29. Activities Impacted by AA – 2017
(N=641)
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30. Integrated Behavioral Health in Alopecia
Areata Dermatology Care: Goals of Pilot Study
• To develop & implement an intervention to address AA patients’
psychosocial issues.
• How? Provision of integrated behavioral healthcare in dermatology.
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31. SSummary
With all the current clinical research activities, the
future is looking up for a disease that is common but
currently has no FDA approved therapy.
And in the mean time, still other therapies continue to
be tested such as the following
Simvastatin/Ezetimibe
Photobiomodulation
Platelet Rich Plasma
Antihistamines
Fecal Transplantation
Other Biologics
And yet more!
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