VIDEO: ‘Don’t discount what patients tell you’ when approaching alopecia areata treatment

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So, when we think about alopecia areata, there really is a lot for everybody to know, whether you are in primary care or pediatrics or you are a dermatologist who wants to practice contemporary medicine. … No. 1 is don’t discount what patients tell you. This is a disease that is, very frequently, awful to have. At the very least, it often causes people a lot of anxiety. Because you may only have one spot today, but if you develop another spot and it happens to be your eyebrow in a month … nobody can cover that up. And so don’t discount when patients tell you that they are distressed or sad or maybe even devastated. And so, let’s acknowledge their experience, and if we can’t provide them a solution or if we can’t answer their questions, then let’s refer them to a specialist, somebody who can answer their question, somebody who can better evaluate the entirety of their situation and offer appropriate treatment. So that’s No. 1. No. 2, let’s not leave behind the treatments … that we’ve always used. Intralesional triamcinolone — for sure the advent of oral [Janus kinase (JAK)] inhibitors doesn’t mean that we don’t use intralesional triamcinolone anymore, or topical corticosteroids. No, indeed, intralesional triamcinolone and topical corticosteroids are still going to be the standard of care for people who have very limited amount of hair loss. But when hair loss becomes more significant or when it becomes persistent or when it is refractory to treatment or when there is a little bit of scalp hair loss but there’s also involvement of eyebrows and/or eyelashes and/or facial hair, then let’s open our minds to this appropriate use of oral JAK inhibitors. And again, even for the dermatologists who don’t or don’t yet feel comfortable using these medicines, refer that patient to somebody who can have a full conversation about the role of oral JAK inhibitors and the possibility of their use in that particular patient. So, thinking about where we’ve come from and where we’re going, and to highlight that there is value in intralesional triamcinolone for the treatment of very mild alopecia areata, but that we need to reach for these newer therapies. Just yesterday I met a woman in her 50s who for the last 15 years has been getting monthly — literally every month — 50 to over 100 injections of intralesional triamcinolone into her scalp for the treatment of inarguably severe alopecia areata. And it’s had some benefit in that her scalp was covered with hair. Not so much so that she felt like she could not wear a wig. But nevertheless, she had a good amount of hair. Of course, the dermatologist who’s been treating her for all this time is very well meaning and is trying to do his best. But the effect of 15 years of chronic prednisone can be incredibly damaging. This woman has not had a bone density scan. And that’s sort of No. 1 on the list of things to do for her is to look there. Because very likely she has had some very negative impact or experienced some very negative impact of this chronic steroid use. And by the way, chronic steroid use that hasn’t netted her the benefit of being able to be without her wig. And so, it just highlights, again, sort of the interesting place we are in history where we’re coming from this relatively unsophisticated place, and we’re now in an era where this person should be treated with an oral JAK inhibitor. Like, we have a way to make her better with far less risk than 15 years of prednisone. Or coming from a time when we didn’t have anything for patients with more severe disease. There’s a role for the things that we've been doing, but absolutely there’s huge unmet need in alopecia areata for systemic therapies. And finally, we’ve landed in a time when we have reliably effective therapy with JAK inhibitors. And there are other medicines to come. And so really, it’s an unbelievably bright time for patients with this disease, and it’s a really exciting time to be in medicine, because we’re able to bring really interesting and innovative and highly effective therapies to patients with this disease that we didn’t have anything for in the past.