Tailoring Treatment for Alopecia Areata

Kristen Whitney, DO, FAAD, determines systemic treatment options for severe alopecia areata (AA) based on the patient’s medical history, past treatments tried, potential adverse events, in addition to the weighing risk vs benefit of the therapy, and the cost for the patient.

Kristen Whitney, DO, FAAD, dermatologist at Allegheny Health Network, examines patients with severe alopecia areata (AA) and explains her methods that help determine tailored treatments based on the individual needs of the patient. Whitney highlights how various treatment methods are important to the AA treatment landscape.

This transcript has been lightly edited for clarity.

The American Journal of Managed Care® (AJMC®): In cases of severe alopecia areata, when do you consider systemic treatments, and what factors influence your decision-making?

Whitney: I think you have to have an open conversation with the patient about how their hair loss affects them. Medically, severe AA is at least 50% of scalp hair loss that's been going on for at least 6 months, but that being said, some patients may have less involvement, and the hair loss is affecting the quality of life that they're not able to maintain a normal quality of life.

They could be struggling with anxiety and depression due to severe AA. What could be so bothersome to one patient might not be that bothersome to another. We get that baseline with them, go through treatments, and for more mild or moderate alopecia areata, we'll typically start with a topical steroid and/or steroid injections.

With those forms of alopecia areata, a lot of things are used off-label or are not FDA-approved. There are a few systemic medications we'll offer them, depending on the progress and if they're a good candidate for that.

Now, the FDA, we were really, really excited because about 2 years ago, they approved the JAK inhibitor baricitinib for alopecia areata, and it’s really changed the landscape for treatment for severe alopecia areata. More recently, ritlecitnib, another JAK inhibitor, has become available for adolescents and adults with AA.

For decades, we had few treatment options, so they're amazing medications, but as far as decision-making, of course, you always want to weigh the benefit vs risk. JAK inhibitors are considered safe medications in the right candidate, but they do have side effects to them.

Most of the common side effects that might be encountered with JAK inhibitors are not serious, but if you read the whole side effect profile, there are some serious potential side effects that are there such as major adverse cardiovascular events, serious infections, blood clots, heart attack, and stroke.

For the FDA to approve patients with alopecia areata for the JAK inhibitors, you have to have at least 50% scalp hair loss for at least 6 months. The JAK inhibitors are really expensive medications, typically about $2500 to $5000 a month to put patients on them.

Of course, patients are on these medications for a long period of time, chronically; that's a brief overview. So we kind of get a baseline as far as the patient's goals, their medical history, what other medications they might be on, and other medical comorbidities they might have. Their age plays a role in it, and then how the patient is doing with the medication as well.

One would consider systemic treatments, whether it's a JAK inhibitor or for whatever reason. If they don't qualify for a JAK inhibitor, or they're not the best candidate for it, then we have other systemic medications potentially that we could use off-label, things like methotrexate or cyclosporine. They have their own risk-benefit profile as well so it's a big conversation going through all these details and goals of treatment.