Alopecia Areata Clinical Case Review

Britt Craiglow, MD, an Associate Professor Adjunct of Dermatology at Yale Medical School, discusses the results of the case and the personal impact treating cases like this has on both patients and clinicians:

"So, let's take a look at his results. This is after 3 months of treatment with baricitinib 4 mg daily plus oral minoxidil. You can see he had a really pretty incredible response very quickly. You know what’s really interesting is that regrowth is kind of all over the map. I’ve done this in lots and lots of patients and I still can’t really look at someone and say, “Oh, I predict this is how you’re going to respond." So, some people grow in really uniformly, other people come in patchy. Other people at 3 months really don’t have much to show, but then over 4, 5 or 6 months, they start to creep up. So, he obviously has had a very robust response by 3 months. And then you can see at 14 months he has complete regrowth of scalp hair. And so we’re not seeing his face. But his eyebrows and eyelashes did respond, but only partially. So, we’re still working on those. This is something that in patients, if patches remain or if there’s persistent eyebrow loss, sometimes we will do intralesional triamcinolone down the line to see if we can get the patient to where they want to be. But as you can imagine, this is really, really life altering for this patient. And I have to say, as a dermatologist, it’s so much fun to see. We often say that if you could see this patient’s face, you would really even feel more the excitement in the room. And honestly, it’s just getting the patient back to normal.

So, sometimes people will say, “Oh, this is a cosmetic disease.” And when we say cosmetic, we’re really talking about enhancing appearance. And in alopecia areata we're not trying to enhance appearance. We’re not trying to get people to look like a celebrity. They just want to look normal. They just want to be themselves. They just want to, you know, get away from all the unwanted attention that you get when you don't have hair, especially when you don’t have eyebrows or eyelashes. To be able to just go to the grocery store and not have stares and not have comments and things like that.

And so this patient really kind of feels like himself again, which is really, really rewarding. So, that was a bit of a whirlwind through this patient's story. But I think really importantly, when we see patients with alopecia areata, asking them how they’re doing. You know, our job is to treat them medically, but also the whole person. And I think it’s really important to acknowledge that this disease is a big deal. It’s really normal for hair loss to be hard. Oftentimes I'll say, you know, on a scale from zero to 10, how much is it affecting you? You know, zero, it’s no big deal. Ten, it’s ruining your life. And I often will say, a lot of my patients are a 10. We want to give people permission to say how it really is affecting them. Because I think a lot of people, they don't feel comfortable saying it. They’ve been dismissed in the past or they’ve gotten — in this case of oftentimes children or teenagers — they've gotten a lot of positive reinforcement for sort of being tough or brave. And again, just because someone’s coping doesn’t mean that they like what’s happening, right? And so I think again, just giving them space to say how it’s affecting them is really, really useful. And that connection with your patient kind of makes the response even more exciting, right? Because not only do they look different, but they feel different. They feel better. And so, really for patients with severe alopecia areata, JAK inhibitors really are, I would say, the standard of care for these patients. And really exciting, we now have two FDA-approved treatments for severe AA. So, in this patient, if I were to see him now, I would have ritlecitinib as an on-label option, and that would've been my choice just given ease of access primarily. But we do have these two choices, which is really exciting and just makes things a lot easier for us in terms of getting medication to our patients.

So, I think in dermatology oftentimes there’s this feeling like, treating hair loss is hard and the visits take longer. And while that may be true in some cases, I think having on-label options really changes that, it changes the discussion to be able to say, “Hey, this medicine was studied in people like you. This medicine is approved for patients like you,” that makes it easier. But then in the end, that may be a little bit of extra time really comes back to you because it is super rewarding to see these patients and to feel like their life is kind of theirs again because of a decision that you made with them. So, I hope this was helpful for you, and maybe the next time you have a patient come in with severe AA, you’ll feel a little bit more comfortable reaching for one of these new options. Thanks so much."