New Hope for the Hopeless

The value of case reports in the literature has been minimized through the years, but so many of the things we use today have their origin in case reports.

I still remember the first case report describing improvement in alopecia areata with the use of an oral JAK inhibitor. The article was entitled “New Hope for the Hopeless” and it described the case of a 20-something man who had had alopecia universalis for several years and also happened to have rheumatoid arthritis. In the past (prior to about 5 to 10 years ago), we never even tried to treat alopecia universalis. It was considered untreatable and hopeless. However, the patient in this case report was started on an oral JAK inhibitor called tofacitinib for his rheumatoid arthritis, and all his hair grew back. It was like magic, but real. The JAK revolution was born.

Since that article was published in the early 2010s, we have had 3 JAK inhibitors approved to treat alopecia areata. We used to dread seeing the tearful hairless patient, but now we are empowered and invigorated to see these patients and tell them the good news: We can get their hair back! Visits for alopecia areata almost always involve crying—make sure you know where the tissue boxes are when you see “hair loss” as the chief complaint)—but now the patient’s eyes are filling with tears of hope instead of sadness.  

Among the valuable therapeutics that originated with care reports are options like propranolol for infantile hemangiomas, 5FU + calcipotriene for actinic keratoses, and low-dose oral minoxidil for hair loss. In our day-to-day practices, our anecdotal experiences shape our decision making and treatment regimens. All of us have “that one patient who had this strange side effect,” and therefore, we never prescribed that medicine again. We all have “that one patient who had that atypical presentation of scabies,” and therefore, we will never miss that diagnosis again. We have all tried “that one medication off-label that made miracles happen,” and therefore, we will consider that therapy every time we see that condition in the clinic.  

Practical Dermatology is placing a renewed emphasis on the case report because it is worthy of a warm embrace. Over the next couple of issues, you will get to read about generalized pustular psoriasis, scurvy (does anyone else like to say scurvy in a pirate voice? I sure do), and facial erythema secondary to tralokinumab.

This is how change happens: one case report at a time. I think Rachel Patten said it best in her power ballad “Fight Song” (a lyrical masterpiece, by the way) when she said “I might only have one match, but I can make an explosion.”  These solitary case reports are capable of changing practice, helping patients, and creating new hope for the hopeless.