VIDEO: Treating alopecia areata holistically in clinical practice

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So, it’s interesting to think about the spectrum of alopecia areata, and in dermatology and in medicine in general, we like to think of things in terms of mild, moderate and severe. In alopecia areata, I think the field has transformed so quickly that there wasn’t a whole lot of historical precedent for, or even needing to think about, the spectrum of disease. But a few years ago, in work that was done with Eli Lilly, a scale was developed called the AA-IGA, or Investigative Global Assessment, that conceived of the spectrum of disease in terms of, I think, mild, moderate and severe. And those categories are based on the amount of scalp hair loss. So essentially, 1% to 20% scalp hair loss being mild, 21% to 49% scalp hair loss being moderate, and then greater than 50% scalp hair loss being severe. Now, I think those are useful. That construct has been used in clinical trials. I think in clinical practice, it’s important to think of the disease a little bit more holistically, right? Because we have to think about eyebrows, we have to think about eyelashes, we have to think about whether or not somebody is refractory to treatment. So, considering these other aspects of disease, we actually sought to create another scale, another severity scale, just in the last couple of years that takes account of more of the entirety of the disease and that scale was published. It’s called the Alopecia Areata Scale. And I think what’s useful about that and why that is pertinent to the question of how do we treat limited or mild alopecia areata vs. how do we treat severe alopecia areata is that mild may be just a little bit of scalp hair loss, but if all we’re thinking about is scalp hair loss — but if there is eyebrows involvement, if there are eyelashes involvement — then I think we need to allow for that person with “mild” alopecia areata by the extent of scalp hair loss to have a more severe disease rating. And so, another way of thinking of the question is we treat people who have one or a few spots of hair loss with intralesional triamcinolone, which is the mainstay of treatment and has been the mainstay of treatment forever. We often use topical corticosteroids for these people as well. We sometimes use topical immunotherapy, but for people who have moderate to severe disease — so now a lot more scalp hair loss, and I think even really more than 20% scalp hair loss merits consideration of systemic therapy — it’s very hard, right? Once we have 20% scalp hair loss, we’re talking about somebody getting 30, 40, 50, 60 injections in order to treat that amount of scalp hair loss. And so really more than 20% scalp hair loss, we need to be thinking about systemic therapy. But I think even sometimes with less than 20% scalp hair loss but involvement of eyebrows, involvement of eyelashes, people who aren’t responding to the steroid injections, they need to be thought of as having more severe disease. And again, we reach for systemic therapy in those patients.