Objective outcome measures: Collecting meaningful data on alopecia areata

Innovative strategies for the discovery of new drugs against alopecia areata: taking aim at the immune system

INTRODUCTION

The autoimmune hair loss condition alopecia areata (AA) exacts a substantial psychological and socioeconomic toll on patients. Biotechnology companies, dermatology clinics, and research institutions are dedicated to understanding AA pathogenesis and developing new therapeutic approaches. Despite recent efforts, many knowledge gaps persist, and multiple treatment development avenues remain unexplored.

AREAS COVERED

This review summarizes key AA disease mechanisms, current therapeutic methods, and emerging treatments, including Janus Kinase (JAK) inhibitors. The authors determine that innovative drug discovery strategies for AA are still needed due to continued unmet medical needs and the limited efficacy of current and emerging therapeutics. For prospective AA treatment developers, the authors identify the pre-clinical disease models available, their advantages, and limitations. Further, they outline treatment development opportunities that remain largely unmapped.

EXPERT OPINION

While recent advancements in AA therapeutics are promising, challenges remain, including the lack of consistent treatment efficacy, long-term use and safety issues, drug costs, and patient compliance. Future drug development research should focus on patient stratification utilizing robust biomarkers of AA disease activity and improved quantification of treatment response. Investigating superior modes of drug application and developing combination therapies may further improve outcomes. Spirited innovation will be needed to advance more effective treatments for AA.

Disease burden, clinical management and unmet treatment need of patients with moderate to severe alopecia areata; consensus statements, insights, and practices from CERTAAE (Central/Eastern EU, Russia, Türkiye AA experts) Delphi panel

Objectives

This study aims to update the understanding of Alopecia Areata (AA) in Poland, Czechia, Russia, and Türkiye, focusing on the disease burden, clinical management, and patient journey. It seeks to establish a consensus on optimal management strategies for AA in these regions.

Methods

A modified 2-round Delphi panel was conveyed with 23 Dermatologists (Russia; 4, Türkiye; 7, Poland; 6, and Czechia; 6). The Delphi questionnaire consisted of 61 statements and 43 questions designed to obtain an overall understanding of the perception and acceptance of available information regarding the care of patients with alopecia areata.

Results

The study revealed that moderate-to-severe AA significantly impacts patients' and their families' QoL, consistent with previous studies. AA was found to cause more substantial impairment when additional lesions appeared in visible areas besides the scalp. Work and productivity impairment were notably higher in adults with moderate-to-severe AA. Diagnostic consensus highlighted the importance of skin biopsies and trichoscopy, while the need for more practical severity scoring systems was emphasized. Current treatments, including topical therapies, corticosteroids, and systemic immune modifiers, were deemed insufficient, highlighting the unmet medical need.

Conclusion

The Delphi study underscores a significant disease burden and unmet medical needs in patients with moderate-to-severe AA. It highlights the necessity of access to novel treatments and further research to develop more effective therapies with a tolerable safety profile. The findings align with global research, emphasizing the psychosocial impact of AA and the need for standardized, effective treatment protocols.

Platelet-rich plasma efficacy in alopecia areata patients with normal and elevated levels of antibodies against thyroglobulin and thyroid peroxidase

AIM

To evaluate and compare the efficacy of platelet-rich plasma (PRP) therapy in alopecia areata (AA) patients with normal and with elevated levels of anti-thyroglobulin antibodies and/or anti-thyroid peroxidase antibodies.

Topical sodium valproate-loaded nanospanlastics versus conventional topical steroid therapy in alopecia areata: a randomized controlled study

BACKGROUND

A myriad of therapeutic modalities for alopecia areata are available; however, none is of high level of evidence, creating an immense need for the evaluation of other treatment modalities, of which topical sodium valproate is of potential role via proposed decrease in beta-catenin breakdown, despite its well-known side effect of hair fall as an oral therapy.

OBJECTIVE

Evaluating the efficacy and the safety of sodium valproate (SV)-loaded nanospanlastics, in comparison to topical corticosteroids, this is the currently available gold standard topical treatment for patchy AA.

METHODOLOGY

A total of 66 patients with patchy AA were randomly assigned to receive either topical mometasone furoate lotion or topical SV applied twice daily to all patches except a control patch, which was left untreated. Clinical, trichoscopic and biochemical assessments of beta-catenin tissue levels and Axin-2 gene expression were carried out at baseline and after 3 months.

RESULTS

Both therapeutic modalities were comparable. Potential efficacy was highlighted by significant improvement in the representative patch, the largest treated patch, to the control patch, the smallest untreated patch in both steroid and valproate groups (p = 0.027, 0.003 respectively). Both beta-catenin levels and Axin-2 gene expression were reduced after treatment, pointing to the inhibitory effect of dominating uncontrolled inflammatory milieu. Baseline beta-catenin was found to significantly negatively correlate with improvement in the representative patch in patients with baseline level above 0.42 ng/ml (p = - 0.042).

CONCLUSION

Both topical SV and steroids are of comparable modest efficacy. Thus, further evaluation of SV is due in combination with intralesional steroids and other anti-inflammatory treatment modalities, together with developing individualized approaches based on baseline beta-catenin level.

CLINICALTRIALS

GOV IDENTIFIER

NCT05017454, https://clinicaltrials.gov/ct2/show/NCT05017454 .

A comparative study of fractional CO2 laser with topical triamcinolone acetonide versus intralesional triamcinolone acetonide in the treatment of alopecia areata

Introduction

Alopecia areata (AA) is a non-scarring alopecia of chronic autoimmune etiology with heterogenous severity against the anagen hair follicle over the scalp, beard, or any part of the body and is associated with a significant psychological morbidity in the mental status of the patients leading the patients to seek treatment for cosmetic reasons. The management of AA is very unpredictable and is associated with various cosmetic adverse effects. This study aimed at comparing the efficacy and safety of a novel procedure of laser-assisted drug delivery system of steroids with the first-line procedure of intralesional steroids (ILS) for the treatment of patchy AA.

Aims and Objectives

To assess and compare the efficacy and safety of fractional CO2 laser in combination with topical triamcinolone acetonide aqueous solution and intralesional triamcinolone acetonide as a monotherapy and in the treatment of AA.

Materials and Methods

A total of 60 patchy AA patients were included in this study. Patients were randomized into two equal groups: Group A and Group B with 30 patients in each group using a computer-generated block randomization. Patients in Group A received fractional CO2 laser with topical triamcinolone acetonide aqueous solution and Group B received ILS. Both groups received treatment for five settings with each setting a gap of 3 weeks. The efficacy and safety of treatment modalities in both groups were assessed using global photograph assessment (GPA)-scale, lesional area density score percentage of improvement (LAD score improvement %), visual discomfort scale (VDS), visual analogue scale, and documentation of adverse effects in each setting.

Results

Efficacy of treatment modality-assessed using means score of GPA-scale and LAD score improvement % suggests quicker results to patients in Group B in initial settings but drastic improvement happens to patients in Group A in subsequent settings. At the end of 5th setting, GPA-scale and LAD score improvement % suggest maximum efficacy in patients in Group A and they are statistically significant (P-value < 0.001). The mean VDS in both groups suggests maximum discomfort in Group A, yet the patient satisfaction at the end of 5th setting was maximum with patients in Group A and they are statistically significant (P-value < 0.001). Cosmetic notable adverse effect of atrophy of skin was documented in 30% of patients in Group B.

Conclusion

This study showed that fractional CO2 laser with topical triamcinolone acetonide is a better treatment modality than the intralesional triamcinolone acetonide for the treatment of AA with respect to efficacy, safety, and adverse events.

Effectiveness and safety of baricitinib in patients with moderate-to-severe refractory alopecia areata in real world: An open-label, single-center study

PURPOSE

Baricitinib is a small-molecular drug that selectively inhibits the Janus Kinase (JAK) 1 and 2. However, it showed various efficiency and safety in treating moderate-to-severe alopecia areata (AA). This study was to describe the real-world effectiveness of baricitinib in treating moderate-to-severe refractory AA.

METHODS

Patients who were affected by moderate-to-severe AA and reported no shrinkage in the alopecia area after 6 months of conventional treatment were enrolled in the retrospective study. The patients were treated with baricitinib orally for at least 24 weeks. The severity of alopecia was evaluated at the end of 4, 12, and 24 weeks of treatment.

RESULTS

The 32 patients included 23 females and nine males, with a median duration of AA of 14.5 months. Among them, 28 patients received baricitinib 2 mg per day for 24 weeks while the other four patients increased the daily dose from 2 to 4 mg after the first 12 weeks due to the unobvious hair restoration. SALT value showed a significant decrease from baseline at week 12 and 24 (64.45 [44.68-100.00] vs. 26.80 [13.40-62.32], p < 0.0001 and 64.45 [44.68-100] vs. 9.40 [4.85-34.95], p < 0.0001). After 24 weeks of treatment, 50% of patients had an improvement of ≥2 points in IGA scores from the baseline, and IGA scores of 68.75% of patients were less than 2.

CONCLUSION

This 24-week research showed that baricitinib had favorable clinical efficacy and safety in treating moderate-to-severe AA, which is worthy of attention and expectation.

Treatments for alopecia areata: a network meta-analysis

BACKGROUND

Alopecia areata is an autoimmune disease leading to nonscarring hair loss on the scalp or body. There are different treatments including immunosuppressants, hair growth stimulants, and contact immunotherapy.

OBJECTIVES

To assess the benefits and harms of the treatments for alopecia areata (AA), alopecia totalis (AT), and alopecia universalis (AU) in children and adults.

SEARCH METHODS

The Cochrane Skin Specialised Register, CENTRAL, MEDLINE, Embase, ClinicalTrials.gov and WHO ICTRP were searched up to July 2022.

SELECTION CRITERIA

We included randomised controlled trials (RCTs) that evaluated classical immunosuppressants, biologics, small molecule inhibitors, contact immunotherapy, hair growth stimulants, and other therapies in paediatric and adult populations with AA.

DATA COLLECTION AND ANALYSIS

We used the standard procedures expected by Cochrane including assessment of risks of bias using RoB2 and the certainty of the evidence using GRADE. The primary outcomes were short-term hair regrowth ≥ 75% (between 12 and 26 weeks of follow-up), and incidence of serious adverse events. The secondary outcomes were long-term hair regrowth ≥ 75% (greater than 26 weeks of follow-up) and health-related quality of life. We could not perform a network meta-analysis as very few trials compared the same treatments. We presented direct comparisons and made a narrative description of the findings.

MAIN RESULTS

We included 63 studies that tested 47 different treatments in 4817 randomised participants. All trials used a parallel-group design except one that used a cross-over design. The mean sample size was 78 participants. All trials recruited outpatients from dermatology clinics. Participants were between 2 and 74 years old. The trials included patients with AA (n = 25), AT (n = 1), AU (n = 1), mixed cases (n = 31), and unclear types of alopecia (n = 4). Thirty-three out of 63 studies (52.3%) reported the proportion of participants achieving short-term hair regrowth ≥ 75% (between 12 and 26 weeks). Forty-seven studies (74.6%) reported serious adverse events and only one study (1.5%) reported health-related quality of life. Five studies (7.9%) reported the proportion of participants with long-term hair regrowth ≥ 75% (greater than 26 weeks). Amongst the variety of interventions found, we prioritised some groups of interventions for their relevance to clinical practice: systemic therapies (classical immunosuppressants, biologics, and small molecule inhibitors), and local therapies (intralesional corticosteroids, topical small molecule inhibitors, contact immunotherapy, hair growth stimulants and cryotherapy). Considering only the prioritised interventions, 14 studies from 12 comparisons reported short-term hair regrowth ≥ 75% and 22 studies from 10 comparisons reported serious adverse events (18 reported zero events and 4 reported at least one). One study (1 comparison) reported quality of life, and two studies (1 comparison) reported long-term hair regrowth ≥ 75%. For the main outcome of short-term hair regrowth ≥ 75%, the evidence is very uncertain about the effect of oral prednisolone or cyclosporine versus placebo (RR 4.68, 95% CI 0.57 to 38.27; 79 participants; 2 studies; very low-certainty evidence), intralesional betamethasone or triamcinolone versus placebo (RR 13.84, 95% CI 0.87 to 219.76; 231 participants; 1 study; very low-certainty evidence), oral ruxolitinib versus oral tofacitinib (RR 1.08, 95% CI 0.77 to 1.52; 80 participants; 1 study; very low-certainty evidence), diphencyprone or squaric acid dibutil ester versus placebo (RR 1.16, 95% CI 0.79 to 1.71; 99 participants; 1 study; very-low-certainty evidence), diphencyprone or squaric acid dibutyl ester versus topical minoxidil (RR 1.16, 95% CI 0.79 to 1.71; 99 participants; 1 study; very low-certainty evidence), diphencyprone plus topical minoxidil versus diphencyprone (RR 0.67, 95% CI 0.13 to 3.44; 30 participants; 1 study; very low-certainty evidence), topical minoxidil 1% and 2% versus placebo (RR 2.31, 95% CI 1.34 to 3.96; 202 participants; 2 studies; very low-certainty evidence) and cryotherapy versus fractional CO2 laser (RR 0.31, 95% CI 0.11 to 0.86; 80 participants; 1 study; very low-certainty evidence). The evidence suggests oral betamethasone may increase short-term hair regrowth ≥ 75% compared to prednisolone or azathioprine (RR 1.67, 95% CI 0.96 to 2.88; 80 participants; 2 studies; low-certainty evidence). There may be little to no difference between subcutaneous dupilumab and placebo in short-term hair regrowth ≥ 75% (RR 3.59, 95% CI 0.19 to 66.22; 60 participants; 1 study; low-certainty evidence) as well as between topical ruxolitinib and placebo (RR 5.00, 95% CI 0.25 to 100.89; 78 participants; 1 study; low-certainty evidence). However, baricitinib results in an increase in short-term hair regrowth ≥ 75% when compared to placebo (RR 7.54, 95% CI 3.90 to 14.58; 1200 participants; 2 studies; high-certainty evidence). For the incidence of serious adverse events, the evidence is very uncertain about the effect of topical ruxolitinib versus placebo (RR 0.33, 95% CI 0.01 to 7.94; 78 participants; 1 study; very low-certainty evidence). Baricitinib and apremilast may result in little to no difference in the incidence of serious adverse events versus placebo (RR 1.47, 95% CI 0.60 to 3.60; 1224 participants; 3 studies; low-certainty evidence). The same result is observed for subcutaneous dupilumab compared to placebo (RR 1.54, 95% CI 0.07 to 36.11; 60 participants; 1 study; low-certainty evidence). For health-related quality of life, the evidence is very uncertain about the effect of oral cyclosporine compared to placebo (MD 0.01, 95% CI -0.04 to 0.07; very low-certainty evidence). Baricitinib results in an increase in long-term hair regrowth ≥ 75% compared to placebo (RR 8.49, 95% CI 4.70 to 15.34; 1200 participants; 2 studies; high-certainty evidence). Regarding the risk of bias, the most relevant issues were the lack of details about randomisation and allocation concealment, the limited efforts to keep patients and assessors unaware of the assigned intervention, and losses to follow-up.

AUTHORS' CONCLUSIONS

We found that treatment with baricitinib results in an increase in short- and long-term hair regrowth compared to placebo. Although we found inconclusive results for the risk of serious adverse effects with baricitinib, the reported small incidence of serious adverse events in the baricitinib arm should be balanced with the expected benefits. We also found that the impact of other treatments on hair regrowth is very uncertain. Evidence for health-related quality of life is still scant.

Diagnosis and Management of Alopecia Areata: A Saudi Expert Consensus Statement (2023)

Alopecia areata (AA) is a complex autoimmune disease manifesting as a chronic inflammatory disease characterized by non-scarring patches of hair loss over the face, scalp, and body. Several treatments have been proposed for AA, but none are curative nor achieve a state of remission. The present consensus statement aims to present the evidence- and experience-based recommendations on the diagnosis and management of AA in Saudi Arabia. The Ministry of Health in Saudi Arabia has opted to initiate a meeting of a multidisciplinary group to discuss and concede on this topic. Eight dermatology experts and clinical pharmacists convened in eight consensus meetings. All content presented in this document was agreed upon by this working group, including diagnosis and severity assessment, prognostic indicators, and therapeutic options for AA. Special consideration was given to special patient populations including pediatric patients and patients with less frequent presentations of AA. Updates of the current recommendations will take place as new evidence evolves in the treatment of AA.

Two-dimensional planimetry for alopecia areata severity evaluation compared with severity of alopecia tool: A pilot study

BACKGROUND

Severity of Alopecia Tool (SALT) is widely used to assess the severity of alopecia areata (AA). However, physician-related subjectivity exists in SALT scoring (S1-5), especially with initial inspection in the clinical practice. This study investigated two-dimensional planimetric method to calculate actual surface area of AA, validating SALT scoring.

MATERIALS AND METHODS

SALT score was measured twice in each patient based on "initial" inspection in the clinic (SALT-I) and retrospective assessment of the "photograph" (SALT-P). Planimetric surface area was calculated by Image J program. Subgroup analysis was performed depending on the agreement between SALT-I and -P; score was described in the order of SALT-I and SALT-P.

RESULTS

A total of 93 subjects were enrolled. Planimetric surface area (cm2 ) of SALT-I was 2.5-74.9 (S1), 48.8-100.6 (S2), 83.6-205.4 (S3), and 282-367.9 (S4), while SALT-P was 2.5-59.2 (S1), 41.6-205.4 (S2), 48.8-183.2 (S3), and 282-367.9 (S4). In subgroup analysis, SALT-I and SALT-P agreed group showed planimetric surface area (cm2 ) as 2.5-59.2 (S1-1), 64.2-100.6 (S2-2), 168.3-183 (S3-3), and 282.6-367.9 (S4-4). Disagreed group showed the value as 54.7 (S1-2), 41.6-74.9 (S2-1), 83.6-205.4 (S2-3), and 48.8-88.6 (S3-2).

CONCLUSION

SALT-P was more clearly correlated with actual surface area than SALT-I. Planimetric surface area measurement could be used as a supplementary method especially in the S1 to S3, suggesting 60 cm2 , 100 cm2 , and 200 cm2 as objective cutoff values to differentiate S1, S2, and S3.

The relative efficacy of monotherapy with Janus kinase inhibitors, dupilumab and apremilast in adults with alopecia areata: Network meta-analyses of clinical trials

BACKGROUND

Janus kinase (JAK) inhibitors, biologics, and phosphodiesterase-4 (PDE-4) inhibitors are recent therapies for alopecia areata (AA)-albeit, knowledge gaps exist for these agents' relative efficacy.

OBJECTIVES

We determined the relative efficacy and safety of monotherapy with the aforementioned agents in adults with AA.

METHODS

The literature was systematically searched; we used data from randomized trials that investigated the agents' efficacy-as per Severity of Alopecia Tool (SALT) scores. Bayesian network meta-analyses were used to determine relative efficacy and safety. Effect modification was determined using a generalized linear model on aggregate data; evidence quality was evaluated.

RESULTS

Based on the surface under the cumulative ranking curve estimates obtained from multiple efficacy endpoints, regimens with the highest likelihood of achieving percent reduction in SALT scores, as well as a minimum 90%, 75% or 50% reduction in SALT scores are (in alphabetical order) baricitinib 4 mg once daily (QD), brepocitinib 60/30 mg QD, deuruxolitinib (CTP-543) 12 mg twice daily (BID), ritlecitinib 200/50 mg QD, ruxolitinib 20 mg BID and tofacitinib 5 mg BID. In contrast, dupilumab subcutaneous injections administered weekly and apremilast 30 mg BID were less likely to be effective. Discontinuation due to any adverse event was the least likely with oral JAK inhibitors, and more likely with dupilumab and apremilast.

CONCLUSIONS

Our results support the conduct of high-quality comparative trials to determine whether JAK inhibitors are more effective and safer than PDE4 inhibitors.

Markers of Venous Thromboembolism Risk in Patients with Alopecia Areata: Is There Anything to Worry about?

BACKGROUND

Numerous studies have indicated that alopecia areata is associated with a chronic systemic inflammation, which is considered as a risk factor for venous thromboembolism. The aim of the study was to evaluate the following markers of venous thromboembolism risk: soluble fibrin monomer complex (SFMC), thrombin-antithrombin complex (TATC), and prothrombin fragment 1 + 2 (F1 + 2) in patients with alopecia areata and compare them with healthy controls.

METHODS

In total, 51 patients with alopecia areata [35 women and 16 men; mean age: 38 (19-54) years] and 26 controls [18 women and 8 men; mean age: 37 (29-51) years] were enrolled in the study. The serum concentrations of thromboembolism markers were measured using an enzyme-linked immunosorbent assay (ELISA) kit.

RESULTS

An increased level of SFMC was detected in patients with alopecia areata compared with the controls [25.66 (20-34.86) versus 21.46 (15.38-29.48) µg/ml; p < 0.05)]. In addition, a higher level of F1 + 2 was observed in patients with alopecia areata in comparison with the control group [70150 (43720-86070) versus 38620 (31550-58840) pg/ml; p < 0.001]. No significant correlation was detected among SFMC or F1 + 2 and the Severity of Alopecia Tool (SALT) score, disease duration, or the number of the hair loss episodes.

CONCLUSION

Alopecia areata may be associated with an increased risk of venous thromboembolism. Regular screening and preventive management of venous thromboembolism may be beneficial in patients with alopecia areata, especially before and during systemic Janus kinase (JAK) inhibitors or glucocorticoid therapy.

Overview of alopecia areata for managed care and payer stakeholders in the United States

Alopecia areata (AA) is an autoimmune disease with a complex pathophysiology resulting in nonscarring hair loss in genetically susceptible individuals. We aim to provide health care decision makers an overview of the pathophysiology of AA, its causes and diagnosis, disease burden, costs, comorbidities, and information on current and emerging treatment options to help inform payer benefit design and prior authorization decisions. Literature searches for AA were conducted using PubMed between 2016 and 2022 inclusive, using search terms covering the causes and diagnosis of AA, pathophysiology, comorbidities, disease management, costs, and impact on quality of life (QoL). AA is a polygenic autoimmune disease that significantly impacts QoL. Patients with AA face economic burden and an increased prevalence of psychiatric disease, as well as numerous systemic comorbidities. AA is predominantly treated using corticosteroids, systemic immunosuppressants, and topical immunotherapy. Currently, there are limited data to reliably inform effective treatment decisions, particularly for patients with extensive disease. However, several novel therapies that specifically target the immunopathology of AA have emerged, including Janus kinase (JAK) 1/2 inhibitors such as baricitinib and deuruxolitinib, and the JAK3/tyrosine kinase expressed in hepatocellular carcinoma (TEC) family kinase inhibitor ritlecitinib. To support disease management, a disease severity classification tool, the Alopecia Areata Severity Scale, was recently developed that evaluates patients with AA holistically (extent of hair loss and other factors). AA is an autoimmune disease often associated with comorbidities and poor QoL, which poses a significant economic burden for payers and patients. Better treatments are needed for patients, and JAK inhibitors, among other approaches, may address this tremendous unmet medical need. DISCLOSURES: Dr King reports seats on advisory boards for and/or is a consultant and/or clinical trial investigator for AbbVie, Aclaris Therapeutics Inc, AltruBio Inc, Almirall, Arena Pharmaceuticals, Bioniz Therapeutics, Bristol Meyers Squibb, Concert Pharmaceuticals Inc, Dermavant Sciences Inc, Eli Lilly and Company, Equillium, Incyte Corp, Janssen Pharmaceuticals, LEO Pharma, Otsuka/Visterra Inc, Pfizer, Regeneron, Sanofi Genzyme, TWi Biotechnology Inc, and Viela Bio; and speakers bureaus for AbbVie, Incyte, LEO Pharma, Pfizer, Regeneron, and Sanofi Genzyme. Pezalla is a paid consultant to Pfizer for market access and payer strategy concerns; Fung, Tran, Bourret, Takiya, Peeples-Lamirande, and Napatalung are employees of Pfizer and hold stock in Pfizer. This article was funded by Pfizer.

An Assessment of Current Clinician-Reported and Patient-Reported Outcome Measures for Alopecia Areata: A Scoping Review

Although progress has been made in developing outcome measures for AA, the use of these measures remains unstandardized. A scoping review was conducted to identify the clinician-reported outcome measures (ClinROMs) and patient-reported outcome measures (PROMs) used in assessing and treating AA, the results of which revealed heterogeneity in AA outcome measures. Of 23 research studies ultimately included, only 2 ClinROMs were used by >15% of studies; likewise, of 110 clinical trials evaluated, numerous outcome instruments were used, but only one ClinROM was used by >5% of trials (Severity of Alopecia Tool). These results suggest the need for consensus and standardization in both research and trial settings.

Alopecia Areata Barbae in a Nutshell

Beard alopecia areata, or alopecia areata barbae, (BAA) is a subset of alopecia areata, a T-cell mediated inflammatory disease that disrupts the hair follicle cycle leading to early onset of catagen. The aim of this review is to help strengthen clinicians' skills in the evaluation, diagnosis, and management of BAA. We performed a literature review according to the modified PRISMA guidelines, using a combination of relevant key words in electronic databases. According to the data from the 25 articles on BAA reviewed here, BAA mostly affects middle-aged men (mean age 31 years) who typically experience patchy hair loss in the neck region, which spreads to the scalp within 12 months. Similar to AA, BAA is associated with autoimmune diseases such as H. pylori and thyroiditis; however, BAA has no clear genetic pattern of inheritance which is observed in alopecia areata. Common dermoscopic findings in BAA include vellus white hairs and exclamation mark hairs, which may help distinguish it from other pathologies affecting facial hair. In clinical trials, the ALBAS tool offers clinicians an objective metric to evaluate BAA severity. Until recently, topical steroids have been the mainstay therapy; however, topical and oral janus kinase inhibitors are achieving improved results, with up to 75% beard regrowth in an average of 12 months.

Development of a new classification and scoring system for scalp conditions: Scalp Photographic Index (SPI)

BACKGROUND AND OBJECTIVES

There has been no validated tool for objectively quantifying the overall condition and characteristics of the scalp. This study aimed to establish and validate a new classification and scoring system for evaluating scalp conditions.

METHODS

The Scalp Photographic Index (SPI) using a trichoscope grades 5 features of scalp conditions (Dryness, Oiliness, Erythema, Folliculitis, and Dandruff) on a score of 0 to 3. To evaluate the validity of SPI, SPI grading was performed by 3 experts on the scalps of 100 subjects along with a dermatologist's assessment of the scalps and a scalp-related symptom survey. For reliability assessment, 20 healthcare providers performed SPI grading for the 95 selected photographs of the scalp.

RESULTS

SPI grading and the dermatologist's scalp assessment showed good correlations for all five scalp features. Warmth showed a significant correlation with all features of SPI and the subjects' perception of a scalp pimple had a significant positive correlation with the folliculitis feature. SPI grading demonstrated good reliability with excellent internal consistency (Cronbach's α = 0.90) and strong inter- and intra-rater reliability (Kendall's W = 0.84, ICC(3,1) = 0.94).

CONCLUSIONS

SPI is an objective, reproducible, and validated numeric system for classifying and scoring scalp conditions.

Vitamin D supplementation for patients with alopecia areata: A protocol for systematic review and meta-analysis

BACKGROUND

Several studies have reported an association between low Vitamin D (VD) levels and Alopecia areata (AA), and suggested VD preparations as a potential therapy. VD has immunomodulatory function closely associated with a variety of skin diseases, but there is no conclusive evidence to support VD supplementation for patients with AA. Therefore, we will conduct a meta-analysis to collect and evaluate the efficacy and safety of VD supplementation in the treatment of AA.

METHODS

We will search the following databases according to the developed strategy: Cochrane Library, PubMed, Web of Science, EMBASE, Scopus, Google scholar for Randomized controlled trials related to VD supplementation for AA. The retrieval time is from the establishment of each database to July 2022. Two reviewers will independently complete the literature search and screening, risk of bias assessment and data extraction. Severity of Alopecia Tool, Alopecia Density and Extent, Lesional area and senstivity (score) will be the primary results. RevMan V.5.3 will be used for data analysis and synthesis. For dichotomous outcomes and the continuous outcomes, we will calculate risk ratio with 95% Confidence intervals and mean differences or standardized mean differences with 95% Confidence intervals respectively. The reporting bias will be investigated using funnel plots, and the asymmetry of the funnel plots will be explained using the Harbord modified test or the Egger's regression test.

RESULTS

The results of the study expect to provide a high-quality, evidence-based recommendation on VD supplementation in the treatment of AA for clinicians.

CONCLUSIONS

The study will provide scientific and useful evidence for better use of VD supplementation in treating AA.

Platelet-Rich Plasma in Alopecia Areata—A Steroid-Free Treatment Modality: A Systematic Review and Meta-Analysis of Randomized Clinical Trials

Background: Alopecia areata (AA) is a chronic autoimmune condition that can lead to a serious deterioration in patients’ quality of life. The first line of treatment in patchy AA is triamcinolone acetonide (TrA); however, the efficacy of the treatment varies greatly. Our aim was to investigate the therapeutic effects of platelet-rich plasma (PRP) in the treatment of AA. Method: We performed a systematic literature search in four databases. Randomized clinical trials (RCT) reporting on patients with AA treated with PRP were included, comparing PRP with TrA or a placebo. The primary outcome was the Severity of Alopecia Tool (SALT) score. Results: Our systematic search provided a total of 2747 articles. We identified four studies eligible for quantitative analysis. The pooled mean differences from the four studies did not exhibit a significant difference in the mean change in the SALT score when PRP and TrA groups were compared (MD =−2.04, CI: −4.72–0.65; I² = 80.4%, p = 0.14). Conclusions: PRP is a promising topical, steroid-free treatment modality in the therapy of AA. No significant difference was found between PRP and TrA treatment; however, further high-quality RCTs are needed to further assess the efficacy of PRP treatment and strengthen the quality of evidence.

Patients with alopecia areata are at risk of endothelial dysfunction: results of a case-control study

BACKGROUND

Alopecia areata is an autoimmune form of hair loss which may affect any hair-bearing area. It has been suggested that alopecia areata is associated with an increased risk of metabolic and cardiovascular comorbidities.

OBJECTIVES

The aim of the study was to evaluate the early predictors of cardiovascular diseases (endothelial function and arterial stiffness) in patients with alopecia areata without prior cardiovascular disease in comparison with healthy controls.

METHODS

Fifty-two patients with alopecia areata (38 women and 14 men, mean age: 41 [30 - 52]) and 34 healthy controls matched for age, gender and body mass index were enrolled in the study. Endothelial dysfunction expressed as reactive hyperemia index (RHI) and arterial stiffness identified by augmentation index (AI@75) were assessed with the use of the Endo-PAT 2000 device.

RESULTS

Endothelial dysfunction was observed in 22/52 (42%) patients with alopecia areata and in 4/34 (12%) healthy controls (p=0.002). Moreover, mean RHI was lower in patients with alopecia areata in comparison with control subjects (1.90 ± 0.31 vs 2.11 ± 0.45; p=0.03). No significant difference was present in AI@75 between patients with alopecia areata and the controls.

CONCLUSIONS

Patients with alopecia areata show abnormalities in the early predictors of cardiovascular diseases. Regular cardiovascular screening might be appropriate in every patient with alopecia areata.

Chemokine C-C Motif Ligand 7 (CCL7), a Biomarker of Atherosclerosis, Is Associated with the Severity of Alopecia Areata: A Preliminary Study

Alopecia areata is an autoimmune, inflammatory form of non-scarring hair loss that may affect any hair-bearing area. Recently, an increased risk of cardiovascular disorders has been described in patients with alopecia areata. The aim of the study was to evaluate the serum concentrations of proinflammatory proteins associated with atherosclerosis (chemokine C-C motif ligand 4; CCL4, chemokine C-C motif ligand 7, CCL7; and sortilin, SORT1), and cardiovascular risk (myeloperoxidase, MPO; interleukin 1 receptor-like 1, IL1RL1; and growth differentiation factor 15, GDF15) in patients with alopecia areata without symptoms or prior cardiovascular disease in comparison with healthy controls. Sixty otherwise healthy patients with alopecia areata and twenty control subjects matched for age, gender, and body mass index (BMI) were enrolled in the study. No significant differences in the serum levels of MPO, IL1RL1, CCL4, CCL7, SORT1, and GDF15 were detected between patients with alopecia areata and healthy controls. A positive correlation was found between the serum concentration of CCL7 and the severity of alopecia areata (r = 0.281, p = 0.03), while GDF15 correlated with age at the disease onset (r = 0.509, p < 0.0001). The results of the present study suggest that the severity of alopecia areata may be associated with an increased risk of atherosclerosis.

Alopecia areata and tofacitinib: a prospective multicenter study from a Saudi population

BACKGROUND

Alopecia areata (AA) is an autoimmune disorder characterized by nonscarring hair loss that can involve the scalp, face, and body. Severe AA subtypes have a poorer prognosis and can be challenging to treat. Tofacitinib, a recently introduced Janus kinase inhibitor, has shown positive results in treating AA. This multicenter study demonstrates the efficacy of tofacitinib and the patient response rate in a Saudi population. It also highlights patient characteristics that may serve as predictors of the therapeutic response to tofacitinib.

METHODS

A prospective cohort study design was utilized. Study participants were included from three medical centers in Riyadh, Saudi Arabia. The Severity of Alopecia Tool (SALT) score was used to assess the percentage of hair loss at baseline and the percentage of hair regrowth at 3 and 6 months.

RESULTS

The sample size was 68 with an average baseline SALT score of 76.8 ± 27.6%. Data at 6 months were available for 45 patients. Of these, 62.2% achieved a SALT score of >50%. Patients with a score of <50% had a significantly higher baseline SALT score compared to patients with >50% score. The past use of systemic steroids was associated with a diminished response to therapy (P = 0.015). The response to therapy was significantly higher in patients with AA compared to alopecia totalis and alopecia universalis.

CONCLUSIONS

Tofacitinib is an effective and well-tolerated treatment for severe AA and exhibits a good safety profile.

A Global eDelphi Exercise to Identify Core Domains and Domain Items for the Development of a Global Registry of Alopecia Areata Disease Severity and Treatment Safety (GRASS)

Importance

A recent expert consensus exercise emphasized the importance of developing a global network of patient registries for alopecia areata to redress the paucity of comparable, real-world data regarding the effectiveness and safety of existing and emerging therapies for alopecia areata.

Objective

To generate core domains and domain items for a global network of alopecia areata patient registries.

Evidence Review

Sixty-six participants, representing physicians, patient organizations, scientists, the pharmaceutical industry, and pharmacoeconomic experts, participated in a 3-round eDelphi process, culminating in a face-to-face meeting at the World Congress of Dermatology, Milan, Italy, June 14, 2019.

Findings

Ninety-two core data items, across 25 domains, achieved consensus agreement. Twenty further noncore items were retained to facilitate data harmonization in centers that wish to record them. Broad representation across multiple stakeholder groups was sought; however, the opinion of physicians was overrepresented.

Conclusions and Relevance

This study identifies the domains and domain items required to develop a global network of alopecia areata registries. These domains will facilitate a standardized approach that will enable the recording of a comprehensive, comparable data set required to oversee the introduction of new therapies and harness real-world evidence from existing therapies at a time when the alopecia areata treatment paradigm is being radically and positively disrupted. Reuse of similar, existing frameworks in atopic dermatitis, produced by the Treatment of Atopic Eczema (TREAT) Registry Taskforce, increases the potential to reuse existing resources, creates opportunities for comparison of data across dermatology subspecialty disease areas, and supports the concept of data harmonization.

Alopecia areata severity index (AASI): A reliable scoring system to assess the severity of alopecia areata on face and scalp-a pilot study

BACKGROUND

All scoring systems used in Alopecia Areata (AA) focus mainly on scalp and cannot assess the severity or treatment response when AA involves the beard hair, eyebrows, or eyelashes.

AIM

This study describes and assesses the reliability of a new scoring system "Alopecia Areata Severity Index" (AASI) for measuring the severity of AA of scalp, beard, and upper face.

METHODS

Scalp hair, beard hair, upper face (eyebrows and eyelashes) were individually assessed and the severity of AA was scored from 0 to 100 (0-50 in case of upper face). AASI score was then calculated as a sum of all these individual scores as AASI = AASI (scalp) + AASI (upper face) + AASI (beard)+. To test the inter-observer reliability of AASI score, 25 patients with varying severity of AA were scored by 4 trained dermatologists. Repeat scoring was performed after one week to test for intra-observer reliability.

RESULTS

Excellent inter-rater, as well as intra-observer reliability, was observed with Chronbach's alpha value of 0.999 (CI = 0.989-1.000). The intra-observer correlation coefficient with average measure was 0.999 (CI = 0.990-1.000) with statistically significant F test <0.005.

CONCLUSION

AASI score is a reliable scoring system to assess the severity of AA in patients with involvement of one or more areas of the body.

LIMITATIONS

Sample population belonged to single ethnic group.

Data assimilation of synthetic data as a novel strategy for predicting disease progression in alopecia areata

The goal of patient-specific treatment of diseases requires a connection between clinical observations with models that are able to accurately predict the disease progression. Even when realistic models are available, it is very difficult to parameterize them and often parameter estimates that are made using early time course data prove to be highly inaccurate. Inaccuracies can cause different predictions, especially when the progression depends sensitively on the parameters. In this study, we apply a Bayesian data assimilation method, where the data are incorporated sequentially, to a model of the autoimmune disease alopecia areata that is characterized by distinct spatial patterns of hair loss. Using synthetic data as simulated clinical observations, we show that our method is relatively robust with respect to variations in parameter estimates. Moreover, we compare convergence rates for parameters with different sensitivities, varying observational times and varying levels of noise. We find that this method works better for sparse observations, sensitive parameters and noisy observations. Taken together, we find that our data assimilation, in conjunction with our biologically inspired model, provides directions for individualized diagnosis and treatments.

Guidelines for clinical trials of frontal fibrosing alopecia: consensus recommendations from the International FFA Cooperative Group (IFFACG)

BACKGROUND

Frontal fibrosing alopecia (FFA) has become one of the most common causes of cicatricial alopecia worldwide. However, there is a lack of clear aetiology and robust clinical trial evidence for the efficacy and safety of agents currently used for treatment.

OBJECTIVES

To enable data to be collected worldwide on FFA using common criteria and assessment methods.

METHODS

A multicentre, international group of experts in hair loss was convened by email to create consensus recommendations for clinical trials. Consensus was defined at > 90% agreement on each recommended part of these guidelines.

RESULTS

Standardized diagnostic criteria, severity rating, staging, and investigator and patient assessment of scalp hair loss and other clinical features of FFA were created.

CONCLUSIONS

These guidelines should allow the collection of reliable aggregate data on FFA and advance efforts in both clinical and basic research to close knowledge gaps in this condition.

Current Treatment of Alopecia Areata

The number of alopecia areata (AA) clinical trials with Jak inhibitors of cytoplasmic tyrosine kinases, including Jak1, Jak2, Jak3, and tyrosine-protein kinase has increased significantly since the last Research Summit. This fact means that the conversation about current treatments for AA now also needs to include a discussion of traditionally used off-label therapies as well as evolving therapies as with Jak inhibitors.

Consensus on the treatment of alopecia areata - Brazilian Society of Dermatology

BACKGROUND

Alopecia areata is a highly frequent disease with an impact on quality of life and several treatment options with little clinical confirmatory evidence.

OBJECTIVE

To disseminate the recommendations of Brazilian dermatologists with expertise in the treatment of alopecia areata.

METHODS

Eight specialists with expertise in alopecia areata from different university centers were appointed by the Brazilian Society of Dermatology to reach a consensus on its treatment. Based on the adapted DELPHI methodology, the relevant elements were considered; then, an analysis of recent literature was carried out and the consensus was written down. Consensus on the management of alopecia areata was defined with the approval of at least 70% of the panel.

RESULTS/CONCLUSIONS

Intralesional injectable corticotherapy was considered the first option for localized disease in adults. In extensive cases with signs of activity, systemic corticosteroid therapy should be considered and can be used together with immunosuppressants (corticosteroid-sparing agents). The use of an immunosensitizer (diphencyprone) is an option for stable long-term cases. Evaluation of side effects is as important as the rate of hair regrowth.

The Alopecia Areata Investigator Global Assessment scale: a measure for evaluating clinically meaningful success in clinical trials

BACKGROUND

Content-valid and clinically meaningful instruments are required to evaluate outcomes of therapeutic interventions in alopecia areata (AA).

OBJECTIVES

To develop an Investigator's Global Assessment (IGA) to interpret treatment response in AA treatment studies.

METHODS

Qualitative interviews were conducted in the USA with expert dermatologists and with patients with AA who had experienced ≥ 50% scalp-hair loss. Thematic data analysis identified critical outcomes and evaluated the content validity of the new IGA.

RESULTS

Expert clinicians (n = 10) judged AA treatment success by the amount of scalp-hair growth (median 80% scalp hair). Adult (n = 25) and adolescent (n = 5) patients participated. Scalp-hair loss was the most bothersome AA sign/symptom for most patients. Perceived treatment success - short of 100% scalp hair - was the presence of ~ 70-90% scalp hair (median 80%). Using additional clinician and patient insights, the Alopecia Areata Investigator Global Assessment (AA-IGA™) was developed. This clinician-reported outcome assessment is an ordinal, static measure comprising five severity categories of scalp-hair loss. Nearly all clinicians and patients in this study agreed that, for patients with ≥ 50% scalp-hair loss, successful treatment would be hair regrowth resulting in ≤ 20% scalp-hair loss.

CONCLUSIONS

We recommend using the Severity of Alopecia Tool to assess the extent (0-100%) of scalp-hair loss. The AA-IGA is a robust ordinal measure providing distinct and clinically meaningful gradations of scalp-hair loss that reflects patients' and expert clinicians' perspectives and treatment expectations. What is already known about this topic? The Severity of Alopecia Tool is widely used to assess the extent of scalp-hair loss in patients with alopecia areata. Guidelines define treatment success as a 50% improvement in scalp hair, and clinical trials have used dynamic thresholds of 50% and 90%. However, there is no clinical consensus on these endpoints, and patient perspectives on treatment success are unknown. What does this study add? Through qualitative interviews with 10 expert dermatologists and 30 patients with alopecia areata who had experienced ≥ 50% scalp-hair loss, we developed the Alopecia Areata Investigator Global Assessment (AA-IGA™) to measure five clinically meaningful gradations of alopecia areata scalp-hair loss that reflects patients' and clinicians' perspectives and expectations of treatment success in alopecia areata treatment studies. What are the clinical implications of this work? The AA-IGA is a robust ordinal measure that can inform clinical evaluation of alopecia areata treatment outcomes. The AA-IGA can be used to determine clinically meaningful treatment success for alopecia areata, with success defined by patients and clinicians as reaching ≤ 20% scalp-hair loss. Linked Comment: Blome. Br J Dermatol 2020; 183:609.

The Alopecia Areata Consensus of Experts (ACE) study part II: Results of an international expert opinion on diagnosis and laboratory evaluation for alopecia areata

BACKGROUND

We previously reported the Alopecia Areata Consensus of Experts study, which presented results of an international expert opinion on treatments for alopecia areata.

OBJECTIVE

To report the results of the Alopecia Areata Consensus of Experts international expert opinion on diagnosis and laboratory evaluation for alopecia areata.

METHODS

Fifty hair experts from 5 continents were invited to participate in a 3-round Delphi process. Consensus threshold was set at greater than or equal to 66%.

RESULTS

Of 148 questions, expert consensus was achieved in 82 (55%). Round 1 consensus was achieved in 10 of 148 questions (7%). Round 2 achieved consensus in 47 of 77 questions (61%). The final face-to-face achieved consensus in 25 of 32 questions (78%). Consensus was greatest for laboratory evaluation (12 of 14 questions [86%]), followed by diagnosis (11 of 14 questions [79%]) of alopecia areata. Overall, etiopathogenesis achieved the least category consensus (31 of 68 questions [46%]).

LIMITATIONS

The study had low representation from Africa, South America, and Asia.

CONCLUSION

There is expert consensus on aspects of epidemiology, etiopathogenesis, clinical features, diagnosis, laboratory evaluation, and prognostic indicators of alopecia areata. The study also highlights areas where future clinical research could be directed to address unresolved hypotheses in alopecia areata patient care.

Excimer laser/light treatment of alopecia areata: A systematic review and meta-analyses

BACKGROUND

The excimer laser/light (EL) has been reported to be effective for alopecia areata (AA), but its treatment response has not been systematically reviewed.

OBJECTIVE

To determine the treatment response and safety of EL treatment of AA.

METHODS

A comprehensive search of the Medline, EMBASE, Cochrane library, and Web of Science (from inception to December 31, 2018) was conducted to identify prospective clinical studies assessing the treatment response of EL for AA. The primary outcome was cosmetically acceptable hair regrowth (hair regrowth ≥75%); random-effects meta-analyses using generic inverse variance weighting were performed to estimate treatment responses. The study was registered with PROSPERO (CRD42019121092).

RESULTS

Of 52 records initially identified, 13 full-text articles were finally assessed in terms of eligibility. A total of 9 prospective clinical studies (129 AA patients) including 5 controlled clinical trials were identified. Cosmetically acceptable hair regrowth was achieved in 50.2% (95% confidence interval 31.5%-68.9%; 8 studies). EL treatment significantly improved hair regrowth compared with untreated controls (relative risk 7.83; 95% confidence interval 2.11-29.11; 5 controlled clinical trials). No serious adverse effect was noted.

CONCLUSIONS

EL treatment appeared to produce a favorable therapeutic response in AA patients. The use of EL should be encouraged for AA patients with the advantages of the non-invasiveness and no systemic effect.

Efficacy of intradermal minoxidil 5% injections for treatment of patchy non-severe alopecia areata

BACKGROUND

Intradermal minoxidil is used as an off-label treatment for patchy non-severe alopecia areata (AA) either alone or in combination with steroids; however, studies estimating its efficacy are still lacking.

OBJECTIVES

To assess the efficacy of intradermal delivery of minoxidil 5% alone and in combination with intralesional triamcinolone acetonide for treatment of patchy non-severe AA.

PATIENTS AND METHODS

One hundred patches in twenty patients with patchy non-severe AA, five patches for each patient, were included in this prospective intra-patient comparative controlled clinical study. Four comparative patches per each patient were randomly assigned to receive 4 sessions, at a 4-week interval, of one of the following treatments: intralesional triamcinolone acetonide, intralesional minoxidil 5%, combination treatment, or micro-needling. The fifth patch was observed as the negative control. Treatment outcomes were assessed at baseline, and 1 month after treatment ends.

RESULTS

Minoxidil intradermal injection was nearly comparable to the micro-needling effect and its combination to steroids had no additive effect. Hair regrowth in response to minoxidil occurred earlier than the spontaneous recovery.

CONCLUSION

Monotherapy of intralesional minoxidil is of limited efficacy in treating non-severe patchy AA, but it speeds the recovery.

The Alopecia Areata Consensus of Experts (ACE) study: Results of an international expert opinion on treatments for alopecia areata

BACKGROUND

A systematic review failed to identify any systemic therapy used in alopecia areata (AA) where use is supported by robust evidence from high-quality randomized controlled trials.

OBJECTIVE

To produce an international consensus statement on the use and utility of various treatments for AA.

METHODS

Fifty hair experts from 5 continents were invited to participate in a 3-round Delphi process. Agreement of 66% or greater was considered consensus.

RESULTS

In the first round, consensus was achieved in 22 of 423 (5%) questions. After a face-to-face meeting in round 3, overall, consensus was achieved for only 130 (33%) treatment-specific questions. There was greater consensus for intralesional treatment of AA (19 [68%]) followed by topical treatment (25 [43%]). Consensus was achieved in 45 (36%) questions pertaining to systemic therapies in AA. The categories with the least consensus were phototherapy and nonprescription therapies.

LIMITATIONS

The study included a comprehensive list of systemic treatments for AA but not all treatments used.

CONCLUSION

Despite divergent opinions among experts, consensus was achieved on a number of pertinent questions. The concluding statement also highlights areas where expert consensus is lacking and where an international patient registry could enable further research.

Ruxolitinib cream for the treatment of patients with alopecia areata: A 2-part, double-blind, randomized, vehicle-controlled phase 2 study

BACKGROUND

There are currently no treatments for alopecia areata (AA) that are universally effective or approved by the US Food and Drug Administration. Oral ruxolitinib has shown efficacy in extensive AA. Ruxolitinib cream would potentially avoid systemic adverse effects.

OBJECTIVE

To assess the efficacy and safety of 1.5% ruxolitinib cream in patients with AA who had at least 25% hair loss by Severity of Alopecia Tool score.

METHODS

This was a 2-part study. Part A was an open-label, 24-week study of 1.5% ruxolitinib cream in patients with 25% to 99% hair loss followed by a 24-week extension period. Part B was a double-blind, vehicle-controlled, 24-week study of 1.5% ruxolitinib cream in patients with 25% to 100% hair loss, followed by a crossover to ruxolitinib cream in the vehicle group for 24 weeks and additional treatment time for the ruxolitinib cream group.

RESULTS

Although Part A results suggested potential efficacy of 1.5% ruxolitinib cream, there was no significant difference in hair regrowth based on 50% improvement in Severity of Alopecia Tool scores between patients receiving 1.5% ruxolitinib cream and vehicle in part B. There were no significant safety issues with 1.5% ruxolitinib cream.

LIMITATIONS

Single strength of ruxolitinib cream.

CONCLUSIONS

The 1.5% ruxolitinib cream did not have a significant effect in patients with AA.

Topographic Phenotypes of Alopecia Areata and Development of a Prognostic Prediction Model and Grading System: A Cluster Analysis

Importance

Diverse assessment tools and classification have been used for alopecia areata; however, their prognostic values are limited.

Objective

To identify the topographic phenotypes of alopecia areata using cluster analysis and to establish a prediction model and grading system for stratifying prognoses.

Design, Setting, and Participants

A retrospective cohort study of 321 patients with alopecia areata who visited a single tertiary referral center between October 2012 and February 2017 and underwent 4-view photographic assessment.

Exposures

Clinical photographs were reviewed to evaluate hair loss using the Severity of Alopecia Tool 2. Topographic phenotypes of alopecia areata were identified using hierarchical clustering with Ward's method. Differences in clinical characteristics and prognosis were compared across the clusters. The model was evaluated for its performance, accuracy, and interobserver reliability by comparison to conventional methods.

Main Outcomes and Measures

Topographic phenotypes of alopecia areata and their major (60%-89%) and complete regrowth probabilities (90%-100%) within 12 months.

Results

A total of 321 patients were clustered into 5 subgroups. Grade 1 (n = 200; major regrowth, 93.4%; complete regrowth, 65.2%) indicated limited hair loss, whereas grades 2A (n = 66; major regrowth, 87.8%; complete regrowth, 64.2%) and 2B (n = 20; major regrowth, 73.3%; complete regrowth, 45.5%) exhibited greater hair loss than grade 1. The temporal area was predominantly involved in grade 2B, but not in grade 2A, despite being comparable in total extent of hair loss. Grade 3 (n = 20; major regrowth, 45.5%; complete regrowth, 25.5%) included diffuse or extensive alopecia areata, and grade 4 (n = 15; major regrowth, 28.2%; complete regrowth, 16.7%) corresponded to alopecia (sub)totalis. No significant differences in prognosis (hazard ratio [HR] for major regrowth, 0.79; 95% CI, 0.56-1.12) were found between grades 2A and 1, whereas grades 2B (HR, 0.41; 95% CI, 0.21-0.81), 3 (HR, 0.24; 95% CI, 0.12-0.50), and 4 (HR, 0.16; 95% CI, 0.06-0.39) had significantly poorer response. Among multiple models, the cluster solution had the greatest prognostic performance and accuracy. The tree model of the cluster solution was converted into the Topography-based Alopecia Areata Severity Tool (TOAST), which revealed an excellent interobserver reliability among 4 dermatologists (median quadratic-weighted κ, 0.89).

Conclusions and Relevance

Temporal area involvement should be independently measured for better prognostic stratification. The TOAST is an effective tool for describing the topographical characteristics and prognosis of hair loss and may enable clinicians to establish better treatment plans.