Alopecia, regardless of the cause, is a disfiguring disorder associated with significant impairments in health-related quality of life (HRQOL).1 The most common form of alopecia — androgenetic alopecia — affects more than 50 million men and 30 million women in the United States alone.2 In contrast, the autoimmune disorder alopecia areata (AA), which has historically had few treatment options, is relatively rare but still associated with a significant HRQOL burden among affected patients.3
We spoke with prominent alopecia researchers and experts to gain insights into the burden associated with hair loss as well as standard and new treatment options for alopecia.
Effects on Health and Well Being
Meenakshi Jolly, MD, MS, a professor of medicine and the director of the Rush Lupus Clinic at Rush University Medical Center in Chicago, told us that any unexpected hair loss, whether temporary or permanent, can negatively impact an individual’s mental and emotional well-being. First, she said, hair loss “heralds some underlying health issue [and] can incite worries, anxiety, stress, and contribute towards poor body image, social isolation, and depression.”
Dr Jolly commented that the psychological impacts of hair loss can also impair physical health. “Stress can cause flares of autoimmune disease [and] can adversely affect health behaviors including following medical care plans and visits with health professionals,” she explained.
According to Brett King, MD, an associate professor of dermatology at Yale School of Medicine, hair loss can be particularly devastating when it occurs at an early age. “It’s disfigurement,” Dr Brett said, adding that people may perceive patients with the disorder look ill even though they are physically well.
Dr Jolly stated that many patients with complaints of hair loss are typically first seen by their primary care provider. “If needed,” she said, “referrals may be made to an endocrinologist or a dermatologist or another specialist.”
The initial part of management, Dr Jolly explained, is to distinguish whether the hair loss is normal or if there is a pattern of hair loss. If the hair loss is not considered normal, a clinician will then undertake a search for sources/causes. “It may be simple things such as an unbalanced diet or wearing hair tightly pulled back,” she added.
In addition, Dr Jolly said that a careful review of a patient’s medications or existing medical disorders can help identify a cause of hair loss, while blood tests evaluating iron levels, thyroid function, or sex hormone levels can also help in identifying a driver for the alopecia. “Tests to evaluate for the presence of other conditions that may be associated with hair loss, such as autoimmune diseases or other inflammatory conditions, may also be helpful,” she said.
Dr Jolly cited several considerations that can be incorporated into a management plan for cases of reversible hair loss, such as telogen effluvium: stress management, proper hair care, balanced diet, correcting nutritional deficiencies or hormonal imbalances, addressing underlying autoimmune disease or inflammatory conditions, and removing medications, if possible.
Androgenetic alopecia may be managed by hair transplantation and/or oral finasteride and/or topical minoxidil.4
Unfortunately, limited options have historically been available for the autoimmune hair loss disorder AA. However, the US Food and Drug Administration recently approved the Janus kinase (JAK) inhibitor baricitinib for severe AA, potentially filling an unmet need for patients with the disorder.5
“We think JAK inhibitors work by interrupting the messaging between hair follicles and immune cells that leads to immune cells attacking hair follicles and ultimately hair loss,” Dr King explained, when asked about the clinical rationale for using JAK inhibitors in alopecia management. “When the messaging is interrupted, the immune cells leave hair follicles alone and the hair follicles can do what they are supposed to, that is, grow hair.”
Approval of baricitinib was based on the phase 3 BRAVE-AA1 (n=654) and Brave AA2 (n=546) trials, which included adult patients with severe AA lasting more than 6 months to less than 8 years. Results from these trials showed that treatment with baricitinib was associated with significantly greater hair regrowth than with placebo.6
Although promising, clinicians who manage patients with AA should be aware of some of the limitations associated with baricitinib, Dr Jolly suggested. “The medication is expensive and is associated with significant safety and side effect concerns,” she said. “Most adverse events noted in the studies were deemed as mild to moderate in severity, but independent adjudication for severity was not available.”
For the class of JAK inhibitors, Dr Jolly added, there is a black box warning about a potentially increased risk for adverse cardiovascular (CV) events such as stroke or heart attack among individuals with existent risks for CV events.7 In addition, there may be other risks associated with this drug class, including low white blood cell counts, cancer, blood clots, and serious infections.7
“Approval of this medication has improved the landscape for people with severe AA, but it should be used cautiously, given the potential side effects,” Dr Jolly added. “The medication should be prescribed only by physicians who are conversant with its use, such as rheumatologists, as it requires careful monitoring of potential side effects.”
In addition to pharmacologic approaches, Dr King noted that some patients with psychological distress related to their hair loss may also benefit from counseling and antidepressants, as these “may help people to cope” with their disorder.
Supporting Patients With Alopecia
Given the emotional and mental health effects of hair loss, there is a need for improved support services for patients with the disorder. Research suggests that interaction between family members and children with AA in a support group setting is a beneficial intervention that may lessen the burden associated with the disease.8
In addition, education of the public may help reduce the stigma associated with hair loss, according to Dr Jolly. “Bringing awareness to the suffering of patients with alopecia is important,” she commented. “We need to educate the public and health care providers to the effects of alopecia and help develop a multidisciplinary team of care for patients facing this issue and the resources available to them.”
1. Kim AB, Cheng BT, Hassan S. Association of mental health outcomes and lower patient satisfaction among adults with alopecia: a cross-sectional population-based study. JAAD Int. 2022;8:82-88.
2. Peyravian N, Deo S, Daunert S, Jimenez JJ. The inflammatory aspect of male and female pattern hair loss. J Inflamm Res. 2020;13:879-881. doi:10.2147/JIR.S275785.
3. Ito T, Kamei K, Yuasa A, et al. Health-related quality of life in patients with alopecia areata: results of a Japanese survey with norm-based comparisons. J Dermatol. 2022;49(6):584-593. doi:10.1111/1346-8138.16364
4. Mysore V, Parthasaradhi A, Kharkar RD, et al. Expert consensus on the management of androgenetic alopecia in India. Int J Trichology. 2019;11(3):101-106. doi:10.4103/ijt.ijt_24_19
5. US Food and Drug Administration (FDA). FDA approves first systemic treatment for alopecia areata. Published June 13, 2022. Accessed August 18, 2022. Available from: https://www.fda.gov/news-events/press-announcements/fda-approves-first-systemic-treatment-alopecia-areata
6. King B, Ohyama M, Kwon O, et al. Two phase 3 trials of baricitinib for alopecia areata. N Engl J Med. 2022;386(18):1687-1699. doi:10.1056/NEJMoa2110343
7. Kragstrup TW, Glintborg B, Svensson AL, et al. Waiting for JAK inhibitor safety data. RMD Open. 2022;8(1):e002236. doi:10.1136/rmdopen-2022-002236
8. Aschenbeck KA, McFarland SL, Hordinsky MK, Lindgren BR, Farah RS. Importance of group therapeutic support for family members of children with alopecia areata: a cross-sectional survey study. Pediatr Dermatol. 2017;34(4):427-432. doi:10.1111/pde.13176