Alopecia Areata Clinical Case Review

Brett King, MD, associate professor of dermatology at the Yale School of Medicine, discusses the treatment options for the case:

"So thinking about treatment options for this patient, we have to think about what the treatment paradigm looks like across the disease severity spectrum. And so we have to consider an algorithm such as this. And again, we all might have our own algorithm. This is the one that I've developed over time, thinking about mild, moderate, and severe alopecia areata. And so thinking about treatment options, we have to put our patient in one of these boxes. Does he have mild, moderate, or severe disease? Well, here I present the Alopecia Areata Scale.

This was a scale developed recently by a group of alopecia experts, and it's an useful tool that we can bring to our patients in clinic. And the idea here is that we're going to anchor our initial assessment of severity in terms of amount of scalp hair loss, mild diseases less than or equal to 20% scalp hair loss. Moderate disease is 21 to 49% scalp per loss, and then severe disease is 50 to 100% scalp hair loss. But because there are many aspects of alopecia areata, it's not just scalp hair loss, we have these other factors to consider down below, such as noticeable involvement of eyebrows or eyelashes, refractoriness to treatment, diffuse, positive hair pull test, suggesting that somebody might have 10% today, but they're going to rapidly evolve to 50% or maybe complete scalp hair loss.

And then of course, we have to consider the psychosocial impact of disease. So the idea is that we're gonna make our initial assessment based on amount of scalp care loss, but then we can modify the disease severity. We can take a patient who's mild disease by amount of scalp hair loss and make the moderate if one of these other factors are present, or we can take somebody who has moderate disease by amount of scalp hair loss, and make them severe with the presence of one of these other factors. So let's apply this scale to our patient. So here is another representative patient such as ours. He has less than or equal to 20% scalp hair loss. This is certainly the patient at hand, but our patient who we're talking about today has had an inadequate response to treatment over the last six months.

And so we might say that he has moderate disease. By the Alopecia Areata Scale, we can say he has moderate disease. So going back to our scale or rather going back to our treatment algorithm across mild, moderate, and severe disease, we have these options for mild or moderate disease. So why is oral minoxidil in this treatment algorithm? I have a feeling that this will be new to many of the viewers. Back in 1987, there was a clinical trial of oral minoxidil, five milligrams BID, in or patients across the entire severity spectrum of disease. And we see that in patients with less than 75% scalp hair loss, 38% had a quote cosmetic response to oral minoxidil treatment. And so we really should be thinking about this drug which we've been thinking about a lot in the last couple of years for the treatment of androgenetic alopecia. We should also be thinking about it in the treatment of alopecia areata. And so that's why oral minoxidil is in my treatment algorithm."