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Treatment of Alopecia Areata: Overview

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.

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Treatment of Alopecia Areata: Overview

  1. 1. TTreatment of Alopecia Areata: Overview Maria Hordinsky, MD Professor and Chair Department of Dermatology University of Minnesota Minneapolis, Minnesota NOT FOR DISTRIBUTION OR REPRODUCTION
  2. 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 NOT FOR DISTRIBUTION OR REPRODUCTION
  3. 3. Alopecia Areata NOT FOR DISTRIBUTION OR REPRODUCTION
  4. 4. AAlopecia Areata •An autoimmune disease which can be associated with hair loss anywhere on the body, along with nail changes. •A multifactorial condition NOT FOR DISTRIBUTION OR REPRODUCTION
  5. 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 NOT FOR DISTRIBUTION OR REPRODUCTION
  6. 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 NOT FOR DISTRIBUTION OR REPRODUCTION
  7. 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 NOT FOR DISTRIBUTION OR REPRODUCTION
  8. 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 NOT FOR DISTRIBUTION OR REPRODUCTION
  9. 9. Alopecia Areata Anagen Attack Anagen Arrest ! NOT FOR DISTRIBUTION OR REPRODUCTION
  10. 10. HHistopathology: Normal Human Scalp: Horizontal Section NOT FOR DISTRIBUTION OR REPRODUCTION
  11. 11. NOT FOR DISTRIBUTION OR REPRODUCTION
  12. 12. Normal Scalp: Vertical Section NOT FOR DISTRIBUTION OR REPRODUCTION
  13. 13. IIMMUNOLOGY A hallmark of alopecia areata: •peribulbar lymphocytes around anagen follicles NOT FOR DISTRIBUTION OR REPRODUCTION
  14. 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. NOT FOR DISTRIBUTION OR REPRODUCTION
  15. 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. NOT FOR DISTRIBUTION OR REPRODUCTION
  16. 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. NOT FOR DISTRIBUTION OR REPRODUCTION
  17. 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. NOT FOR DISTRIBUTION OR REPRODUCTION
  18. 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 NOT FOR DISTRIBUTION OR REPRODUCTION
  19. 19. •Usually reserved by many for rapid onset or rapidly progressive, extensive AA OOral Corticosteroids NOT FOR DISTRIBUTION OR REPRODUCTION
  20. 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 NOT FOR DISTRIBUTION OR REPRODUCTION
  21. 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”? NOT FOR DISTRIBUTION OR REPRODUCTION
  22. 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. NOT FOR DISTRIBUTION OR REPRODUCTION
  23. 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 NOT FOR DISTRIBUTION OR REPRODUCTION
  24. 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 NOT FOR DISTRIBUTION OR REPRODUCTION
  25. 25. Ongoing Clinical Trials in Adults • Pfizer • Concert • Aclaris • Lilly • Bioniz Therapeutics, Inc. NOT FOR DISTRIBUTION OR REPRODUCTION
  26. 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. NOT FOR DISTRIBUTION OR REPRODUCTION
  27. 27. AAlopecia AAreata after Dupilumab for Atopic Dermatitis Mitchell, Krystal et al. JAAD Case Reports, Volume 4, Issue 2, 143 - 144 NOT FOR DISTRIBUTION OR REPRODUCTION
  28. 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. NOT FOR DISTRIBUTION OR REPRODUCTION
  29. 29. Activities Impacted by AA – 2017 (N=641) NOT FOR DISTRIBUTION OR REPRODUCTION
  30. 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. NOT FOR DISTRIBUTION OR REPRODUCTION
  31. 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! NOT FOR DISTRIBUTION OR REPRODUCTION
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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.

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