Top Treatment Interventions for Scarring Alopecias

Theodore Rosen, MD, professor of dermatology at Baylor College of Medicine in Houston, Texas, discussed multiple interventions for tackling hair loss last week at the Society for Dermatology Physician Assistants (SDPA) Annual Summer Meeting in Austin, Texas.¹

Rosen is also speaking today at the Maui Derm NP+PA Summer 2022 meeting.² He drilled down on 2022's biggest news in hair loss treatment in a session at this conference on new drugs and new therapies copresented this morning with George Martin, MD, program chairman of Maui Derm NP+PA Summer 2022, and a dermatologist at Dr George Martin Dermatology Associates in Kihei, Hawaii.

The FDA's June 13, 2022 approval of baricitinib (Olumiant; Eli Lilly and Company and Incyte) made this oral Janus kinase (JAK) inhibitor the first-in-disease systemic treatment specifcally okayed to treat adult patients with severe alopecia areata (AA).³

Baricitinib represents a major breakthrough that could deliver 80% scalp coverage for 1 out of 3 patients on a 4-mg daily dose or 1 out of 5 on a 2-mg dose at 36 weeks, Rosen noted.⁴ This much-anticipated approval addresses a long-standing, unmet need for a drug targeted to the complexities of this widespread condition, he added.

"We have had a variety of medications [FDA-approved for other indications] that worked as treatments for hair loss in certain areas, but there was no single drug that improved outcomes for the whole head," Rosen said in his session at Maui Derm NP+PA Summer 2022. "Baricitinib is a game-changer for severe AA--and it may be just of the first of several."

At the SDPA conference, Rosen covered a variety of scarring alopecias, including central centrifugal cicatricial alopecia (CCCA), and frontal fibrosing alopecia (FFA).

When it comes to CCCA, Rosen says this subtype of alopecia is more commonly found among Black patients.

“It used to be said that CCCA was caused by hair hygiene such as hot oils and hair straightening,” says Rosen. “Those thoughts have really taken a backseat now to the likelihood that most of these cases of CCCA are actually genetic.”

Rosen added that for FFA, the cause of this disease can more than likely be linked to genetics rather than hair hygiene and is predominantly reported in Caucasians.

“Let’s talk reality here. These are scarring alopecias. When the hair has been scarred over and the hair follicle doesn’t exist, then you are not likely to regrow a whole lot of hair. And you must tell patients that from the very beginning,” Rosen says.

Both of these scarring alopecias can be asymptomatic or highly symptomatic. If patients have symptoms, Rosen urged clinicians to make relieving those symptoms their first priority. The second priority is to stop the hair loss process from expanding, and the third is to potentially regrow their patient’s hair. However, Rosen warned to not promise the ability to regrow hair because you might not be able to do much. Realistically, most patients won’t grow more than 20%-30% of their hair back, according to Rosen.

For both CCCA and FFA, some therapies overlap including intralesional injections of corticosteroids every 6 to 8 weeks starting at 4 mg, topical steroids to relieve symptoms and potentially stop regression, and systemic steroids.

For FFA, says Rosen, both men and women have shown to do well on finasteride, but this medication has not helped most people with CCCA. He recommends 5 mg per day for both men and women. Hydroxychloroquine has also shown to be successful for FFA, but Rosen cautioned that systemic lupus can start with frontal hair loss, so the medication could be treating lupus and not the hair loss.

For CCCA, Rosen suggests using minoxidil (not the women’s version) for both men and women but says to avoid letting it drip down the face as it can cause hair growth in unwanted areas.

He also says medications like finasteride, minoxidil, and hydroxychloroquine can be started when symptoms have been almost eliminated by steroids.

Low-level light therapy (LLLT) can also be beneficial for hair loss, says Rosen. LLLT can be performed in both your office or at the patient’s home. When it comes to at-home treatments, he suggests Capillus is the best one, but the product is pricey. Rosen says to communicate with your patients that they will need to do the 6-minute treatment every day and the most expensive one is the best.

Rosen concluded that patients should see less hair shedding by 6 months, hair growth by 1 year, and cosmetic improvement by 2 years.

References

1. Rosen T. Ask the expert. Presented at: Society for Dermatology Physician Assistants Annual Summer Meeting. Held: June 16-19, 2022. Austin, Texas.

2. Rosen T, Martin G. New drugs and new drug therapies 2022. Presented at: Maui Derm NP + PA 2022. Held June 23-25, 2022, Colorado Springs, Colorado.

3. FDA approves first systemic treatment for alopecia areata. FDA. Published June 13, 2022. Accessed June 13, 2022. https://www.fda.gov/news-events/press-announcements/fda-approves-first-systemic-treatment-alopecia-areata