Welcome to ReachMD.
This medical industry feature, titled “Expert Perspectives on Alopecia Areata: A Look at Common Misconceptions” is sponsored by Pfizer Medical Affairs.
This video is for U.S. residents only and is intended to be viewed as it was originally produced by Pfizer. The information provided is for educational purposes only and is not intended to replace discussions with a healthcare provider.
Pfizer does not have an FDA approved treatment for Alopecia Areata.
Drs. King and Piliang are consultants for Pfizer.
Hello, everyone, and welcome. I'm Dr. Brett King, and it is a sincere pleasure to be here today with Dr. Melissa Piliang to discuss Alopecia Areata: misperceptions and facts.
Thank you. Hello, I'm Dr. Melissa Piliang, I'm an assistant professor of dermatology and pathology at Cleveland Clinic where I run an alopecia clinic.
I have a strong interest in alopecia areata, both in my clinical practice and in my research areas and it is my pleasure to join you today.
So, let's dive into the common misperceptions about alopecia areata. what are the things that patients hear? What are the things that, that many of us as providers perpetuate?
There are many misperceptions about alopecia areata. One is that diet can cause or exacerbate alopecia areata or that changing your diet or adding vitamin, vitamin D supplementation will cause the hair to regrow. Because vitamin D deficiency is commonly seen in patients with alopecia areata.
Do you believe that diet is a factor that affects alopecia areata?
I really don't believe it. And I, don't believe that we have evidence in support of it. As you point out, vitamin D deficiency is associated or has been associated in, you know, small series of patients with alopecia areata.
And indeed, vitamin D deficiency has been associated with several autoimmune diseases in general. But it's really important to recognize an association with, and separate associations from cause and effect. Vitamin D deficiency is not uncommon in general. And so, to find it in association with a disease does not necessarily mean that if, well, in fact, it doesn't mean at all that if we replete or give back vitamin D that the problem is going to go away.
Unfortunately, biology is much more complicated than that. And so, really, in the absence of, you know, high quality data or mechanistic data regarding vitamin D or just diet in general, I really think it's imperative that we, try to disabuse this notion amongst, disabuse ourselves of this notion both providers and patients. I’m always really clear with patients, you know, eat, right, be healthy, exercise, you know, do yoga to relax, you know, do those things. But you don't do them for your hair, you do them for your overall health.
Yes, same with me. And, you know, for patients, when conventional treatments have failed to work, they feel very desperate and will try anything. And often they have, you know, helpful friends and family members who make suggestions about things.
So patients try many alternatives, including diets and supplements. And none of these have been demonstrated to work for alopecia areata. And they can be quite expensive and even dangerous. Restrictive diets can be especially dangerous and lead to nutritional deficiencies, especially in young children. So, like you, I recommend a healthy, well-balanced, nutritious diet and for just patients to eat well.
Yeah,it's so true, and I'm sure that you've encountered this in your patients. But, you know, the person, I mean, going gluten free is really sort of unbelievably common among any patient trying to make their disease better, going milk free, you know, paleo, all of these things I've seen amongst many, many, many patients, maybe even the majority of patients, yet, you know, they're still in my clinic, they’re still in your clinic and they have no hair. or, you know, or they'll adopt one of these dietary changes and then they'll grow, literally 100 hairs and say, See, I think it's working.
Let's move on to our next misperception of disease. In, your experience, is AA more prevalent in women than men?
It is not, in my experience. So, because alopecia areata is believed to be a cosmetic condition affecting appearance, people assume it is more common in women than in men and that women feel more of an impact. But, so far, there are only inconsistent data that alopecia areata is more common in women.
There's no significant differences in age of onset, duration or type of alopecia based on sex. And there is significant psychosocial burden associated with the disease. It impacts men, women, and children. And, for example, more than 50% of people with alopecia areata have poor health-related quality of life.
And in my practice, I have lots of men who have severe alopecia areata, and it is just as distressing for them as it is for my women patients and maybe in some cases even more so.
Yeah, I think, people will say, at least in men, it's acceptable to have a shaved head. But, the problem there is that, it’s relatively uncommon if your alopecia areata is that bad that you don't have eyebrows involvement, that you don't have beard involvement in men.
And so, it might be a little bit different if, indeed, severe alopecia areata were simply scalp involvement. But, severe alopecia areata is frequently eyebrows, eyelashes, facial hair. And so, I agree with you completely; men are no less affected than women. And just speaking to the proportion of patients, I feel I'm pretty sure I see just as many men with severe disease as I do women. there’s certainly not a gross distortion in one way or the other.
No, I completely agree. And, you know, the beard area and even the shaving of the head, if patients have dark hair that you can still see the hair regrowing and you can still see the patches and the beard area can be exceptionally distressing for men.
Many men want to wear a beard for cultural or religious reasons, and if you have alopecia areata in big patches, it's really, really impactful and very upsetting.
Yup, I agree. What else have we not covered?
So, I don't know that this is a myth per se, but patients are frequently told if they wait, there's a good chance that the hair will regrow. While this may be true for a subset of patients with limited hair loss, it's not, just not true for those with severe hair loss.
So, alopecia areata, as you know, can present with multiple patches. They can relapse and remit over time. Sometimes one patch is lost and then it regrows and another one comes, or sometimes the hair starts to regrow and then the regrowth is lost.
So, in that cycle of growing and losing and growing and losing, adds to the stress and anxiety of patients. But less than 10% of patients who progressed to alopecia totalis or universalis will experience full recovery. So really thinking that you can wait it out and it will regrow and is own, on its own is really unlikely for patients who have more severe disease.
Thinking about this topic we can kind of move even beyond, what kind of scant epidemiology there is on this to, I think, really concrete data now because we have clinical trial data in large numbers of patients, hundreds and hundreds of patients showing that therapies that seem to be showing promise, well, there's a placebo-controlled period that is, you know, 24 weeks or 36 weeks long. And, when you look at the proportion of patients who start with severe scalp hair loss and achieve, you know, near-complete scalp hair regrowth or very low amount of scalp hair regrowth, we're down in the 2, 3, 4% range.
And so, really, we don't even have to rely on, you know, our instinct or what we believe to be true. But there's really high-quality data now to say that the chances of spontaneous remission for patients with severe disease is extremely low.
And so, we really shouldn't be telling patients when they say, Well, if I do nothing, you know, what are my chances of spontaneously regrowing? We can say with great confidence, Oh, your chances are really in the, you know, 2, 3, 4%, um, range, um, which I think is, which I think is helpful.
I mean, for me, you know, kind of a theme of I think everything that we're talking about and trying to advance here is let's have discussions with patients based in data, based in what we know to be true.
Let's move out of the era of what we believe to be true or what somebody else said was true. Because now we have just a lot of great data about pathophysiology and also emerging kind of epidemiology in a sense.
Can I ask you how does AA, or the way AA manifests, it's really quite variable from patient to patient and for sure it can be unpredictable as you pointed out. How do you discuss the natural disease course of AA with your patients based on the data?
Yeah, so, this is a really frustrating part of alopecia areata. The prognosis varies widely, and when a new patient comes in with a patch of alopecia areata, I really cannot, or you cannot, we cannot predict their course. Some patients will regrow and never have another patch. That's a small minority, but it happens. Some people will regrow and be fine and have another patch somewhere else a few years later and then regrow and have another patch a few years later. But many patients will have a patch all the time, or bigger patches or progress onto losing more than 50% of their hair.
I explain it to patients as: alopecia areata is a disease with a mind of its own. It can come and go seemingly without cause or reason. That, that part of the disease is particularly frustrating on patients and can cause significant anxiety because if they regrow their hair, they're waiting for it to happen again, for, you know, to see one strand out and they think it's all starting or, you know, some in the shower and they're just always worried. They're very anxious when they see any kind of hair loss. And the other piece of this is, that when patients regrow hair, because we know it can spontaneously regrow, sometimes that can be hard to determine if it's the disease or the treatment. And this, this bit can lead patients to attribute success to dietary or lifestyle changes and add to the myth that there are effective, that these are effective treatments.
I had one patient who was wearing a copper lining in his baseball cap and also doing treatments from me, but the copper lining was supposed to be anti-inflammatory, and all his hair came back that they attributed to the copper, not to the topical steroids and the injections and all the other things we were doing. So, um, you know, I think it's really an interesting, um, situation to follow.
No, I agree that the words that I share with patients, and I think I first heard this from Dr. Shapiro, and he said, the only thing that is predictable about alopecia areata is that it is unpredictable. It's so concise and so true. It's just unpredictable and, more than anything, patients want to control it. We can't make hair grow back in four weeks. And so, it really adds to, you know, what is so distressing about this and, therefore, leads us to try to do everything that we can to control it. Hence, you know, vitamin D supplementation, hence, diet. Hence, you know, the copper in the cap kind of thing. You know, we just want to do everything we can to, our patients, want to do everything they can to control it and completely understandably. So, thank you so much, Dr. Piliang for being here today. It's, it really is an honor to share this space with you. You are one of the experts in the field. And so, it's immensely helpful for me and for listeners to hear from you and to hear about your experiences with treating patients with this disease.
Thank you so much, it was my pleasure to be here with you. Thank you.
This program was sponsored by Pfizer Medical Affairs. If you missed any part of this discussion, visit Reachmd.com/IndustryFeature. This is ReachMD. Be part of the knowledge.
- Aldhouse NVJ, Kitchen H, Knight S, et al. "'You lose your hair, what's the big deal?' I was so embarrassed, I was so self-conscious, I was so depressed:" a qualitative interview study to understand the psychosocial burden of alopecia areata. J Patient Rep Outcomes. 2020;4(1):76. Published 2020 Sep 11. doi:10.1186/s41687-020-00240-7
- Hussain ST, Mostaghimi A, Barr PJ, Brown JR, Joyce C, Huang KP. Utilization of Mental Health Resources and Complementary and Alternative Therapies for Alopecia Areata: A U.S. Survey. Int J Trichology. 2017;9(4):160-164. doi:10.4103/ijt.ijt_53_17
- King B, Ko J, Forman S, et al. Efficacy and safety of the oral Janus kinase inhibitor baricitinib in the treatment of adults with alopecia areata: Phase 2 results from a randomized controlled study. J Am Acad Dermatol. 2021;85(4):847-853. doi:10.1016/j.jaad.2021.05.050
- King BA, Mesinkovska NA, Craiglow B, et al. Development of the alopecia areata scale for clinical use: Results of an academic-industry collaborative effort. J Am Acad Dermatol. 2022;86(2):359-364. doi:10.1016/j.jaad.2021.08.043
- Mesinkovska N, King B, Mirmirani P, Ko J, Cassella J. Burden of Illness in Alopecia Areata: A Cross-Sectional Online Survey Study. J Investig Dermatol Symp Proc. 2020;20(1):S62-S68. doi:10.1016/j.jisp.2020.05.007
- Peeva E, Guttman-Yassky E, Banerjee A, et al. Maintenance, withdrawal, and re-treatment with ritlecitinib and brepocitinib in patients with alopecia areata in a single-blind extension of a phase 2a randomized clinical trial. J Am Acad Dermatol. 2022;87(2):390-393. doi:10.1016/j.jaad.2021.12.008
- Pham CT, Romero K, Almohanna HM, Griggs J, Ahmed A, Tosti A. The Role of Diet as an Adjuvant Treatment in Scarring and Nonscarring Alopecia. Skin Appendage Disord. 2020;6(2):88-96. doi:10.1159/000504786
- Pratt CH, King LE Jr, Messenger AG, Christiano AM, Sundberg JP. Alopecia areata. Nat Rev Dis Primers. 2017;3:17011. Published 2017 Mar 16. doi:10.1038/nrdp.2017.11
- Thompson JM, Mirza MA, Park MK, Qureshi AA, Cho E. The Role of Micronutrients in Alopecia Areata: A Review. Am J Clin Dermatol. 2017;18(5):663-679. doi:10.1007/s40257-017-0285-x
- Tosti A, Bellavista S, Iorizzo M. Alopecia areata: a long term follow-up study of 191 patients. J Am Acad Dermatol. 2006;55(3):438-441. doi:10.1016/j.jaad.2006.05.008
- Trüeb RM, Dias MFRG. Alopecia Areata: a Comprehensive Review of Pathogenesis and Management. Clin Rev Allergy Immunol. 2018;54(1):68-87. doi:10.1007/s12016-017-8620-9