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Announcer:
You’re listening to DermConsult on ReachMD, and this episode is sponsored by Lilly. Here’s your host, Dr. Charles Turck.

Dr. Turck:
Welcome to DermConsult on ReachMD. I’m Dr. Charles Turck, and joining me to share how we can implement various assessment tools for alopecia areata into practice is Dr. Arash Mostaghimi. Not only is he an Assistant Professor at Harvard Medical School, but he’s also the Director of the Dermatology Inpatient Service and Co-Director of the Complex Medical Dermatology Fellowship program at Brigham and Women’s Hospital in Boston. Dr. Mostaghimi, welcome to the program.

Dr. Mostaghimi:
Thanks so much for having me.

Dr. Turck:
Dr. Mostaghimi, let’s start by taking a look at some assessment tools for alopecia areata. What can you tell us about the Severity of Alopecia Tool?

Dr. Mostaghimi:
So the Severity of Alopecia Tool, or the SALT tool, is the primary tool we use in dermatology clinics to assess the severity of alopecia areata. So, this is something that until recently was more in the clinical realm, but now that we have one FDA-approved medication already and hopefully a couple more on the way, we’re going to find that some insurers are going to require us to document this in our charts in order to justify access to medication for some of our patients. So, the SALT tool sounds fancy, but really all it is, is a percentage of hair loss on the scalp that you can use with a basic calculator or just with a back of the envelope calculations to classify patients into mild, moderate, or severe alopecia.

Dr. Turck:
And how can we use the Dermatology Life Quality Index tool to assess the impact this condition has on our patients?

Dr. Mostaghimi:
The Dermatology Life Quality tool, or DLQI, is a standard measure that we use, and its greatest role in dermatology is to compare between different disease states in dermatology. I actually don’t think it works very well for alopecia areata. While in alopecia areata it’s super important to obtain an insight into what the impact of the disease is on a given patient, the DLQI has lots of parts of it that are focused on physical symptoms or limitations, for example at work, based on those symptoms. So, the lack of itching or bleeding scan and the limitations on your ability to conduct tasks in alopecia areata make it so that the DLQI doesn’t, in my opinion, appropriately capture the experience of this disease, which is largely psychosocial in this aspect. There is one part of the DLQI which does focus on psychosocial disease, but that part is watered down by the other aspects. So, although it’s something you may see recorded in some clinical trials for alopecia areata, it wouldn’t be my go-to for assessing what really matters for these patients.

Dr. Turck:
Now if we look at one more tool, Dr. Mostaghimi, can you tell us how we can evaluate treatment outcomes using the Alopecia Areata Investigator Global Assessment tool?

Dr. Mostaghimi:
So the Global Investigator tool is basically a way of translating the SALT score, that first one we talked about which is a percentage, into a more global measure of hair loss. It’s a back of the envelope calculation for roughly putting people in different categories. So, you may find that for some insurer, they ask you to use this assessment tool instead of the SALT score. Ultimately I think in the clinical setting, we’re not going to be critically calculating every percentage of hair loss. That’s more reserved for a clinical trial setting, and you may find that just documentation of the general improvement or general category of the patient using a more global index may be faster and more sufficient for all the needs we have in clinical care.

Dr. Turck:
For those just tuning in, you’re listening to DermConsult on ReachMD. I’m Dr. Charles Turck, and I’m speaking with Dr. Arash Mostaghimi about available assessment tools for alopecia areata. So, with those key assessment tools in mind, Dr. Mostaghimi, what do we need to know about adopting them into practice?

Dr. Mostaghimi:
So I think at present, there’s a gap in alopecia areata assessment in that while qualitatively those of us who take care of these patients with alopecia areata or any type of hair loss, we know what those patients report to us. We know the experiences they’ve had in life. We know that they’re often tearful. They often are foregoing social interactions. They’re often paying a lot of money for wigs and cosmetics. They sometimes are limited in what they do at work, are sensitive to give presentations at work, go to school, or make new friends; all these different ways in which hair has an impact on how we socialize and display ourselves to others.

The hard part is that we haven’t quite perfected any of the right tools to capture this accurately and consistently, both in a clinical trial setting, but specifically what we’re talking about in a clinical setting. So that’s a research gap that our group in conjunction with collaborators across the United States and Europe are trying to assess right now. The quantitative part – the idea of looking at what percentage of hair loss somebody has – that I think is also not the most fantastic measure. At present, severe hair loss as defined in the clinical trials is 50 percent or more hair loss. And to this I ask people, “Okay, show me the 49 percent of your hair that you’re willing to lose and still not have it qualify as severe hair loss.” We’ve done research, and other studies have demonstrated that areas of hair loss really matter in determining severity. If you have hair loss in the front of your scalp versus the back of your scalp, that’s a different experience. These areas of hair loss and their importance matters as a function of your race and a function of your gender. Men and women have different preferences for where they want to have hair. In general, people who have lost hair in the front of the scalp feel that it’s a more significant impact on them than hair in the back. The SALT score, while they give you a percentage, they fail to capture the nuances of where the hair is, where it isn’t, or if your hair hits the level of thickness, length, and other cosmesis that allows you to go out and enjoy yourself without having to worry about the way that your hair looks. So while we have these tools, and we’re going to be asked to use them in order to qualify our patients for new FDA-approved JAK inhibitors for this disease, I think there’s a lot of learning that we still have to do, and we haven’t quite figured out the exact approach we should take.

Dr. Turck:
So once we adopt the tools that we have at our disposal into practice, is there any way that we can use the results and our patients’ perspectives to inform our treatment approach?

Dr. Mostaghimi:
Absolutely. They’re not without use. One thing that I find valuable is, often patients have a hard time remembering where they are in their hair loss journey. So, for example, when you see somebody and they have, let’s say, 60, 70, and 80 percent hair loss at the beginning, they may not feel better even after gaining back 20 to 30 percent of their hair because they still have to wear a wig, don’t feel comfortable going out, or can’t go in a pool without feeling self-conscious. So, one advantage of the SALT score is that you can demonstrate to people that, “Hey, the percentage of hair that you’re growing on your scalp is improving over time.” And it may feel slow because they’re living it day by day. They don’t see it in the same way that we do when we see them every couple months, so even though it may not be grown to the point where they’re fully satisfied, they are making progress. Their percentage of hair growth is increasing, and you can get a sense of the trajectory and also if it’s leveling off or not, which may be an indication to either add new therapies or switch therapies around. So, there is some use to it in the clinical setting beyond just what you do with insurance, but the primary use is going to be for signaling to insurance the severity of disease.

Dr. Turck:
To wrap things up, Dr. Mostaghimi, do you have any final thoughts to leave with our listeners today?

Dr. Mostaghimi:
So we’ve reviewed today different measurement tools to assess both the quantitative and qualitative experiences of patients with alopecia areata. And while I’m excited that we have those tools and that we’ve made great strides with regards to now the first FDA-approved drug for this disease, and hopefully additional FDA-approved drugs that will be coming over the next year and a half, there’s a large gap that remains. And that’s our ability to translate clearly the experiences of our patients into quantifiable measures that will improve their access to the medication. Unlike psoriasis and atopic dermatitis where we’ve done a wonderful job as a field explaining these diseases to insurance companies and making sure that our patients have great access to top-line biologic therapy, many insurers and individuals still see alopecia areata as a cosmetic disease. Now those of us that care for patients, as I mentioned before, understand its impact on their quality of life and their day-to-day function, and we need to continue to advocate to create tools that truly capture that and allow insurers to understand the benefits of this for their patients. So, while we’ve made great strides, our work is not yet done. I’m excited to see what comes next.

Dr. Turck:
Well as we consider those parting insights, I want to thank Dr. Arash Mostaghimi for helping us better understand how we can assess the severity and impact of alopecia areata. Dr. Mostaghimi, it was great having you on the program.

Dr. Mostaghimi:
Thanks so much.

Announcer:
This episode of DermConsult was sponsored by Lilly. To access other episodes in this series, visit ReachMD dot com slash Derm Consult, where you can Be Part of the Knowledge. Thanks for listening!