Expert Tips on Alopecia Management From AAD 2023

Scarring alopecia, stem cells, exosomes, and frontal fibrosing alopecia (FFA) were all hot topics of discussion during Ronda Farah’s, MD, FAAD, multiple alopecia sessions at the 2023 American Academy of Dermatology (AAD) Annual Meeting in New Orleans, Louisiana.

Farah, associate professor of dermatology at the University of Minnesota, cosmetic lead at the University of Minnesota Health clinics, and director of medical dermatology at the University of Minnesota Health Maple Grove Medical Center, discussed alopecia in-depth at her AAD sessions: “Cosmetic and Procedural Interventions for Scarring Alopecia,” “Stem Cells & Exosomes,” and “Cosmetics and FFA: Approach to Managing Facial Papules and Hyperpigmentation.”

Transcript

Ronda Farah, MD, FAAD: Hi, I'm Dr. Ronda Farah. I'm a dermatologist at the University of Minnesota, associate professor. I'm also the University of Minnesota Health cosmetic lead and I'm the director of the Maple Grove Medical Center. I'm also working with the American Academy of Dermatology on social media.

Dermatology Times®: What pearls did you share in your session, "Cosmetics and FAA: Approach to Managing Facial Papules and Hyperpigmentation?"

Farah: The cosmetics and frontal fibrosing alopecia talk is really focused for me on the forehead area. In the frontal fibrosing alopecia patient population, I try to keep the skin product away from the hair follicle as much as possible. I ask my patients not to apply that product directly on the hair follicle. Try to also keep sunscreens away unless they're non nanoparticle-based sunscreens, although we don't really know what the final verdict is going to be on sunscreens and I'm also leaning towards more physical-based sunscreens. And in addition to that, talking a little bit about the veins, the new article that came out in the JAAD and the utilization of this device on the forehead veins, which can become very prominent in frontal fibrosing alopecia and I think gently putting those out at the initial visit so that patients are aware those are typically there before they even start steroid injections. I am still utilizing some botulinumtoxin in frontal fibrosing alopecia. I do think that botulinumtoxin has been reported to cause depressions in the scalp so counseling patients on that, because knowing they can also have depressions from their scalp from frontal fibrosing alopecia is important. Also to limit that change in skin texture from the scalp at the front to lower down, I really work on removing seborrheic keratosis and sebaceous hyperplasia using topical tretinoin and oral isotretinoin, although that does have limited data to kind of help with that the facial papule appearance. Those are some of my big pearls for that talk.

Dermatology Times: What are the important takeaways from your session, "Cosmetic and Procedural Interventions for Scarring Alopecia?"

Farah: That session was great. We focused on scarring alopecia, we talked about using platelet rich plasma off-label which could be helpful, as there are case series and case reports. We talked a little bit about exosomes, which do not have strong medical evidence and will be marketed to you, including scalp serums. Lacking medical evidence, only one clinical study, I was able to identify to date that included a microneedle really muddying the waters, not FDA approved for injection, we are not using it. And then we also talked a little bit about photobiomodulation. That's off-label for darker skin types, but could be helpful in that population in our study.

Dermatology Times: What do you hope fellow physicians take away from your session, "Stem Cells & Exosomes?"

Farah: I'm passionate about exosomes because we performed a literature review. Two of the papers involved a human subject: one was just an abstract, the other one utilized a microneedle. That made it difficult in the second one to figure out if it was actually the microneedle or if it was the exosomes. All the other studies were pretty clinical. They were all in mice. They were promising, but they don't reach our level of evidence for evidence-based medicine. Exosomes are not FDA-approved to inject in the United States. There are reports of bacteremia, inflammation, blindness, neurologic issues, contamination with viruses, and concern for hepatitis C and HIV. People wonder if you can use exosomes topically, I wondered that too. From what I can make from my understanding, And again, I'm not a lawyer, but of these exposome products, they can be human. And if they're topical, they might get marketed to physicians and other clinicians as "Oh, well, it's topical, so you can use it." Well, maybe that is true. That seems like that might be true. Again, I'm not a lawyer, but those seem to not necessarily be regulated by the FDA. So, we're applying human product that's not necessarily regulated by the FDA. So, who's responsible for the product then? And from what I can understand, it appears to be the manufacturer. And so, if the manufacturer is not handling the human product correctly, or the manufacturer is outside the United States, that can make it difficult for a US patient. So, at this time, I do not recommend topical or injectable exosomes to my patients. I think it's a lot of items on the topical side that probably need some work, and my job is to discuss higher levels of medical evidence, although they do seem promising. We're working towards a study once we eventually have an investigational new drug application. So, I think exosomes could be exciting. But they're not something I would promote for hair growth. And you should also be aware as clinicians that the CDC has posted a "how-to" for patients on how to spot doctors or other types of clinicians who are telling you that they're doing a study on you with exosomes. So that is out there teaching the patient how to identify people who might be. And I'm not saying that this is happening. I just saw that the CDC had spent time developing that page. I'm not clear enough if that's happening. So, for me, it's about evidence-based medicine, and that's why I'm passionate about the exosomes topic.

[Transcript edited for clarity]