Current Trends in Hair Loss Management in the UK

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Commonly referred to dermatology secondary care, conditions such as alopecia areata (AA), female pattern hair loss (FPHL), and frontal fibrosing alopecia (FFA) are often associated with anxiety, depression, and, in severe cases, suicidal thoughts.¹ Despite the emotional toll, treatment options remain limited, with most therapies lacking robust evidence from high-quality studies.² The recent introduction of Janus kinase (JAK) inhibitors represents a potential paradigm shift in treatment approaches, yet the clinical landscape remains uncertain. 

The advent of JAK inhibitors, such as baricitinib and ritlecitinib, has brought new hope for patients suffering from AA. These agents target inflammatory cytokines involved in the pathogenesis of AA, particularly those signaling through the JAK/STAT pathway.³ However, existing management guidelines do not incorporate these new therapies, leaving a gap in knowledge regarding their practical application in dermatology clinics.

Study Aims and Methods

To better understand current prescribing practices for hair loss among UK dermatologists, a survey was conducted targeting members of the British Hair and Nail Society (BHNS). The survey sought to assess the treatment approaches used for mild to moderate AA, severe AA (including alopecia totalis and alopecia universalis), FPHL, and FFA. Participants were asked about their clinical practices, treatment preferences, and how the COVID-19 pandemic affected service delivery.⁴

Data were collected through an online questionnaire distributed between July and December 2022, with a response rate of 40%. Analysis of the data utilized descriptive statistics to highlight trends in treatment practices.

Results

The survey revealed that 38% of respondents experienced disruptions in providing care due to the pandemic, primarily due to increased demands in general dermatology. The majority (69%) practiced in dedicated hair clinics, reflecting a commitment to specialized care. Notably, researchers found there was a consistent median number of new patients seen for AA and FFA pre- and post-COVID, while referrals for FPHL increased.

For mild to moderate AA, the study stated that topical corticosteroids emerged as the most commonly prescribed first-line treatment, followed by intralesional corticosteroids and oral corticosteroids. Notably, 82% of dermatologists reported intralesional corticosteroids as the most effective option. For severe AA, researchers found oral corticosteroids were the preferred first-line treatment, though concerns about side effects limited their use. JAK inhibitors were also utilized, predominantly in private practice.

Topical minoxidil was overwhelmingly favored as the first-line treatment for FPHL, the study found, used by 84% of respondents. Interestingly, oral minoxidil was identified by 42% of participants as the most effective treatment, reflecting a growing recognition of its benefits despite limited availability in NHS settings.

The study found a diverse range of approaches were used for FFA management, with topical corticosteroids and intralesional corticosteroids being the most commonly employed first-line treatments. However, researchers statedthe efficacy of these treatments remains uncertain, echoing the broader issue of insufficient evidence in the literature.

Discussion 

The survey highlights a moderate consensus on the management of mild to moderate AA, with topical and intralesional corticosteroids being preferred. However, the lack of strong evidence for various treatments leads to variability in practice. Notably, the unavailability of JAK inhibitors on the NHS may limit clinician experience and willingness to incorporate these therapies.

The diverse treatment strategies for FFA reflect the uncertainty surrounding effective therapies in this area. Many clinicians reported using multiple concurrent treatments, likely due to the inadequate evidence base for any single agent.

Conclusion

This study provided insights into the real-world prescribing practices of UK dermatologists for common hair loss conditions. With the recent introduction of JAK inhibitors, a shift in treatment paradigms may be imminent, provided these therapies gain NHS approval. The results of this survey not only aim to support clinicians in their decision-making but also inform policymakers about the positioning of new, high-cost therapeutic agents in the treatment landscape for hair loss.

As dermatologists navigate the complexities of hair loss management, the study stated ongoing research and data collection will be essential to refine treatment protocols, ensure equitable care, and enhance patient outcomes in this emotionally charged arena.

References

1. Macbeth AE, Holmes S, Harries M, et al. The associated burden of mental health conditions in alopecia areata: a population-based study in UK primary care. Br J Dermatol. 2022;187(1):73-81. doi:10.1111/bjd.21055
2. Messenger AG, McKillop J, Farrant P, et al. British association of dermatologists' guidelines for the management of alopecia areata 2012. Br J Dermatol. 2012;166(5):916-926. doi:10.1111/j.1365-2133.2012.10955.x
3. Kwon O, Senna MM, Sinclair R, et al. Efficacy and safety of baricitinib in patients with severe alopecia areata over 52 weeks of continuous therapy in two phase III trials (BRAVE-AA1 and BRAVE-AA2). Am J Clin Dermatol. 2023;24(3):443-451. doi:10.1007/s40257-023-00764-w
4. Frewen J, Alsaadi D, Asfour L, et al. Prescribing patterns amongst UK dermatologists for the treatment of alopecia areata, female pattern hair loss, and frontal fibrosing alopecia. JEADV Clin Pract. 2024; 1–10. doi: 10.1002/jvc2.495