Psoriasis Challenges and Alopecia Areata Advances

Speaker 1 (00:05): 

Welcome to the Practical Dermatology Podcast. This month, we have a conversation with Dr. Brittany Craiglow, a psoriasis update from Dr. Mona Shahriari, and the latest news from around dermatology. Now, here's Dr. Mona Shahriari. 

Dr. Mona Shahriari (00:18): 

So I think we've all heard the saying "location, location, location" when it comes to real estate, but what if I told you that this is just as relevant when we're talking about plaque psoriasis? When we think about plaque psoriasis, it's not just about how much skin is involved, but where does it show up? Many of our patients have disease in what we call high-impact sites, like the scalp, nails, palms, soles, or even the genital area. And even though psoriasis in these locations may account for only 1% or 2% of the total body surface area, the burden can be enormous, because when it affects how you wash your hair, use your hands, walk, or even feel intimate, that small percentage can feel like 100% of your body, and that's why I always encourage clinicians to do a complete head-to-toe skin exam for every new psoriasis patient, including a careful exam of the scalp and the nails, because if we don't look, we miss disease, and when we miss disease, we underestimate severity and potentially undertreat our patients. 

(01:17): 

So I'm going to start with the scalp. Over half the patients with plaque psoriasis have scalp involvement, and importantly, it's more common and often more severe in patients with skin of color, particularly in Asian and Black patients. And scalp psoriasis can be frequently misdiagnosed, underdiagnosed, and undertreated, especially when it comes to systemic therapy. And part of the challenge in treating scalp disease is that topical treatments can be difficult to use consistently and effectively on the scalp. I'm a woman with long hair, so it's definitely challenging to use any topical on my scalp. But that challenge can be magnified in patients with tightly coiled or Afro-textured hair, where haircare and styling practices can impact the ability to use certain topicals, and the formulation or regimen of some agents can make that adherence piece unrealistic or even harmful. For example, frequent hair washing of Afro-textured hair can actually lead to scalp dryness and breakage. 

(02:12): 

That's why I have a very low threshold to consider systemics when the scalp is involved. And also, recognizing scalp psoriasis matters for another reason, because patients with scalp involvement have a three- to four-fold higher risk of developing psoriatic arthritis. So when we diagnose psoriasis on the scalp, we're not just treating the skin; we may be identifying patients that are at higher risk for joint disease early in their disease course when intervention can truly be disease-modifying, and we can select a therapy that not only treats the skin but protects their joints. 

(02:41): 

Now, moving on to the nails, more than half the patients with plaque psoriasis can have nail involvement, and it exists on a spectrum. For some patients, it's a cosmetic annoyance. For others, it can be disfiguring, painful, and even functionally limiting, affecting everything from typing to opening jars, you name it. And nail psoriasis is also an independent risk factor for psoriatic arthritis, which is why a nail exam in my clinic is not optional, it's essential. 

(03:08): 

Now, let's talk about palmoplantar psoriasis. This does impact one in five patients, so it's a little less prevalent than the last two, but this is where the disease becomes impossible to hide. You show your hands to the world, no matter what. And this is not going to just be problematic from a functional standpoint, like buttoning your shirt, holding a phone, or walking without pain, but the psychosocial burden can be just as profound. You go to shake someone's hand,they pull away. You go to grab an apple at the grocery store, someone sees you, now they think you contaminated the entire produce section. So that burden that these patients experience beyond the skin cannot be overstated. And on top of that, treating palmoplantar psoriasis with topicals can be very challenging, because, let's face it, we not only have thick skin in those areas, but we're washing our hands a lot, we have socks going on and off; all of this can impact the ability of a drug to be effective in topical form. 

(03:59): 

Lastly, I'm going to touch upon genital psoriasis, which is an area that represents only about 1% or 2% of the body surface area, but to some patients, it feels so much more than that. And there's also significant stigma around rashes in the groin when you think about sexually transmitted diseases especially, and so this can deeply affect intimacy, relationships, even self-esteem. For some women, it can even impact their desire to become pregnant out of fear of passing this onto their child. And unless we ask, many patients will never volunteer these symptoms. 

(04:30): 

And the conversation can be uncomfortable for both myself and the patient, so what I usually do is I ask my patients, "Psoriasis can sometimes show up in the private areas. I do have treatments for that. Has this ever happened foryou? Would it be OK if I examine that area?" And by asking permission and framing it in this non-judgmental way, it can make the conversation a little bit more palatable for myself and the patient. And sometimes a patient prefers a dermatologist who's of the same gender to review those areas; that's OK. I have no problem referring to a colleague in those scenarios. 

(05:04): 

But the good news is the future is bright. As a specialty, we're finally recognizing that psoriasis in high-impact sites does deserve targeted, aggressive treatment. And pharmaceutical development has also taken notice, with dedicated trials now looking at the safety and efficacy of our most effective systemics, especially in patients with high-impact site involvement, and newer therapies are actually building this into trial design from the very start. So psoriasis in high-impact sites is no longer an afterthought; it's the strategy. And because when disease lives in places that affect how someone works, walks, touches, or connects with another human being, that's not mild disease; that's life-altering disease, and we recognize it early, we treat it intentionally, we don't just have the potential to clear the skin, we have the potential to change someone's life. 

Speaker 1 (05:49): 

Next, Dr. Lisa Swanson is joined by Dr. Brittany Craiglow to talk about new developments in alopecia areata treatments. 

Dr. Lisa Swanson (05:55): 

Hello everybody, and welcome to another Practical Dermatology Podcast. You guys are in for a real treat today. We have, as our guest, Dr. Britt Craiglow, infamous Swiftie, mystical, magical, like Benson Boone says. Britt, hello and welcome. 

Dr. Brittany Craiglow (06:18): 

Hi. Thank you for having me. I don't know about infamous, but I'll take it, I guess I'll take it. 

Dr. Lisa Swanson (06:28): 

We are so lucky to have you. I feel so excited to talk with you. I feel so optimistic, excited, about where we're at with alopecia areata and where we're going with alopecia areata. I know alopecia areata is a topic that's near and dear to your heart. Tell me how you're feeling right now, in the end of 2025, beginning 2026, the state of alopecia areata. 

Dr. Brittany Craiglow (06:57): 

Yeah, I totally agree. It's wild, I now find myself saying with patients, "This is a treatable disease, period. This is a treatable disease." That is not something that we were saying even a few years ago. And I think, unfortunately, that's still something that most patients aren't hearing, so it's great that we're doing this to get the word out. But we have entered a new era, to harken back to the Swiftie callout there, but yeah, we have options now and it's really incredible. We have patients that we never thought we would be able to help, and now we can, and it's really fun and it's just getting better. I think it's really exciting to see where the next few years will bring us, too. 

Dr. Lisa Swanson (07:53): 

I know, I know, right? And of course, we're going to talk about the JAK inhibitors, because that's one of the biggest reasons why alopecia areata is now a fun condition to treat. But I wanted to quickly talk about dupilumab, because we know that sometimes we see new-onset alopecia areata in patients that we treat for eczema with dupi, and we know that there are some patients with alopecia areata who benefit from dupi. I have been using baseline serum IgE as a barometer of if I think that treatment will be successful. What are your thoughts? Is that what you do? I want to do what you do. 

Dr. Brittany Craiglow (08:31): 

Yeah. The dupilumab story is really an interesting one, and I think it's still being written. But as you mentioned, when dupi first came out, we had these reports of people treated for atopic dermatitis who developed alopecia areata or maybe had worsening of alopecia areata, which I'm not sure if it's more that the diseases co-occur frequently, but nevertheless, we saw that. And then, there were patients who had both diseases who were being treated for eczema who regrew their hair. 

(09:04): 

So basically, if you take all-comers with alopecia areata, dupilumab isn't a great choice; most people are not going to respond. However, if you choose the right patients, and these patients tend to be patients with AD themselves, other history of atopy, like asthma, seasonal allergies, a strong family history of atopic dermatitis or elevated IgE, as you just mentioned, they really may be good candidates. I'm starting to find that I think especially children, especially the very young children, sometimes we see these kids who, 12 months, 18 months old, lose all of their hair, often they have comorbid AD and often they respond to dupilumab. So there's this phenotype, I think, that we're looking for when we think about choosing the drug, and of course, dupilumab, we love the safety, we can get it approved for atopic dermatitis. So it really is a great choice in those patients especially who are younger and maybe have another disease that would benefit from it anyways. 

Dr. Lisa Swanson (10:08): 

Yeah, yeah. And do you feel like, if you're trying to treat alopecia areata, maybe in addition to atopic dermatitis, and you're using dupi, do you feel like the AD doses are good enough? Or I know there was one study with Dr. Guttman-Yassky where she used actually higher doses. What are your thoughts on that? 

Dr. Brittany Craiglow (10:27): 

Yeah. So in that study, they did weekly dosing. I actually find that most patients actually respond pretty well to the AD dosing. Now, there may be patients who I'm missing where I'm not bumping it up, and every so often, I do. But I think if you choose the right patient... You have to give it some time, like everything with hair. Hair is very slow, and I think that's an important thing for us to know, but also patients and families, and the thinking is that dupilumab, if it's going to work, we may need to give it even a little bit longer than a JAK inhibitor. But I think in general, in my experience, the traditional dosing is often effective. 

Dr. Lisa Swanson (11:08): 

And then, I alluded to the JAK inhibitors, they have revolutionized the treatment of alopecia areata. They have made seeing alopecia areata patients so much more fun and so much more hopeful. I still remember the first article I ever read about JAKs for alopecia areata, and it was called “New Hope for the Hopeless,” and I think that really sums it up. We've got three FDA-approved to treat alopecia areata, we've got two that are approved 18-and-up, deuruxolitiniband baricitinib, and then we have ritlecitinib approved 12-and-up. Hopefully, we start seeing these age indications getting lower over time. What are your thoughts about our three treatment options available? Are you just excited about all of them? Are there things you've noticed that are nuances to any of them? 

Dr. Brittany Craiglow (11:57): 

Yeah. It's incredible that we have choices now, I think, and hopefully, next year, baricitinib will be approved down to 12, and in the next year or two, we'll probably also see upadacitinib approved for alopecia areas. So all of a sudden, we may be talking about even more options. 

(12:16): 

I think what's really interesting that we're finding, and we just published this not too long ago, I think when we were first doing this, mostly with off-label tofacitinib and we didn't have other choices, it was tofacitinib or bust. And then, I think I had a feeling, well, if you don't respond to that, then you're probably not going to respond to another JAK inhibitor. But as it turns out, that's actually not the case. And so, we have seen basically every iteration of failing the first drug and growing on the second. So I think what's super exciting now with choices is that ... Obviously, hopefully, we hit it out of the park with the first drug, but we know, looking at the trials, only about 40%-ish of patients will respond. That number we can push up, I think, in real life by doing things like adding oral minoxidil, et cetera. But if you have a patient who doesn't do well with one, then you can try another one, which is great. 

(13:16): 

I think, importantly, we need to give it enough time. Every so often, I'll see a patient who had no hair growth at three months and so they were switched. Three months is really too early. I think most of us who do a lot of hair would say that really nine months at least is probably a fair trial, and we don't necessarily expect complete regrowth at that time. And often I say, now that we do have some choices, depending on the patient, I like to see something byaround six months. It doesn't have to be a lot, maybe it's just vellus growth, especially patients who have longer duration of hair loss and more severe disease, they often take longer, not always, so we have to give it time. But we can always move on, which is super exciting. It's not really like one is necessarily the best. We're all different, the way we metabolize these drugs is different, the way whatever's driving it in each person is probably a little bit different, so failure of one does not necessarily predict failure of another. 

Dr. Lisa Swanson (14:21): 

Definitely, definitely. And I know in clinic, I have the spiels that I use when I'm talking about typically safety, when I'm going over my isotretinoin counseling, when I'm going over my biologic counseling, and certainly when I'm going over my JAK inhibitor counseling, would you want to share your safety spiel about JAK inhibitors? Do you have something you say every time, or do you switch it up on the fly? 

 Dr. Brittany Craiglow (14:46): 

Yeah, it's a great question. I think it's an important one, because if you don't do this a lot and you're faced with a patient who might benefit, it's like, "Well, what do I say? It's complicated." I think we have to tailor the conversation a little bit to the patient in front of us. But for me, I try to be very thorough in the conversation, and this takes time, and that's hard in a busy clinic, but we really owe it to our patients to give them all the information. And so, I go through the box warning, I use all of the words. I say, "This medicine carries an increased risk of infection, blood clots, major cardiovascular events, cancer." And then, usually, when I say that, I pause and I say, "I know that sounds like a lot, it sounds like this is like straight-up poisonous and why would anybody give that to anybody?" 

(15:41): 

And then, I say, "We have to take a little bit of a step back and understand the context for that warning, and that it came from a clinical trial of people who are very different from you or your child, and this was the ORAL Surveillance study, patients over 50, at least one cardiovascular risk factor, who had RA, who were also taking methotrexate, many of whom were also on concomitant prednisone." And I think it's important to say, "I'm not saying this to dismiss the risk, because there is some risk." We certainly don't want anybody leaving our office thinking this is a vitamin. But in general, in patients in dermatology, the risks are very, very low. They're not zero, but the risks are low. 

(16:27): 

And often, the conversation that I have is... We always talk about we're weighing risk and benefit, but I think what we're really weighing in dermatology is largely risk of the treatment versus the risk or the consequence of not treating, and that for most patients with alopecia areata is huge. What does it mean to be 13 years old, have no hair, you're not going to school, you quit your sports, you're maybe having suicidal thoughts? That is a huge risk. And then, the other thing we're learning is that with treatment, the sooner, the better. We want our patients to have the best chance of responding, and so the best chance they have is now, is starting as soon as possible. And so, there are patients floating around out there who will literally lose their chance at ever having hair because they're not being treated soon enough, so I think weighing that risk with risk of not treating. 

(17:21): 

And then, the other thing that I often find myself saying is that I treat largely pediatric patients and I use a lot of these drugs off-label, and I say, "Several of these medicines are approved down to age two for juvenile arthritis, and if this were arthritis, I don't think we would be having a big conversation about it, we would just be doing it." And I think alopecia areata can be as debilitating, if not more so, than arthritis, it's just different. And with arthritis, we don't say things like, "Well, you're only uncomfortable some of the time. Well, you're still able to go to school, so we're not going to treat you." That's ridiculous, right? 

Dr. Lisa Swanson (17:57): 

Yeah, yeah. 

Dr. Brittany Craiglow (17:58): 

But we still have this old-school approach to AA, where it's, quote, "cosmetic," which it absolutely is not. But I think we really need to remind ourselves, this is a disease. In medicine, we treat diseases. We are not gatekeepers ofmedications. Our jobs are really just to inform people so that they can make a decision that feels good to them. 

Dr. Lisa Swanson (18:20): 

Yeah, yeah. No, I love that. I sometimes joke when I'm talking to people, practitioners that are a little bit JAK-afraid, that they should start with an alopecia areata patient, because I think you could read the entirety of the box warning verbatim in an ominous tone to a patient and family dealing with alopecia areata, and they would say, "OK, let's do this." 

Dr. Brittany Craiglow (18:43): 

100%, yeah. This is dramatically life-altering in a way that not a lot of things are, and what we're offering with these medications is a chance for normalcy. Most of these patients have had their world completely turned upside down. I had a mom recently say to me, "It feels like we've had a death in the family." And I think if you heard that and you didn't know the disease, you might think, "Wow, they need to get some help, this is pretty extreme." But I think you say that to anybody who's lived it, and it resonates. They're like, "Yeah, that is what it feels like." It's profound. 

Dr. Lisa Swanson (19:23): 

Yeah, yeah. Well, we're practicing in such exciting times that we now have tools in our toolbox, more to come, younger indications, can't wait for all of that. In our closing minute or two, let's play two truths and a lie. So Britt, go ahead and tell me three things about yourself, two of which are true, one is a lie, and I'm going to try to guess. 

Dr. Brittany Craiglow (19:46): 

OK. All right, here we go. So I played competitive water polo in college, I saw the Eras Tour four times, and in high school, I won a year's supply of Special K. 

Dr. Lisa Swanson (20:09): 

These are awesome. OK. So I know that the Eras Tour thing is true, because you and I have talked about our love for Taylor. 

Dr. Brittany Craiglow (20:17): 

Yeah. I needed to give you a gimme. 

Dr. Lisa Swanson (20:19): 

Yes, that one's a gimme. So water polo, how did you get into water polo? 

 Dr. Brittany Craiglow (20:25): 

Yeah, it's a fairly uncommon sport. But I had a friend whose sister played and they were looking for people for the team, and so I joined as a freshman and I loved it, and so it just snowballed from there. 

Dr. Lisa Swanson (20:47): 

Gotcha. And how did you win all that Special K? 

Dr. Brittany Craiglow (20:51): 

Yeah, it was actually just from the cereal box. I opened the cereal box, and there was a ticket in there that was like, "You won." And so, I envisioned a truck coming to my house and dumping hundreds of boxes, but it was actually just a case of 24 boxes. 

Dr. Lisa Swanson (21:19): 

Oh, what they thought you would consume in a year? 

Dr. Brittany Craiglow (21:22): 

Yes. 

Dr. Lisa Swanson (21:23): 

So I think the lie is the Special K. 

Dr. Brittany Craiglow (21:28): 

Oh, I got you, Dr. Swanson. 

Dr. Lisa Swanson (21:31): 

It was water polo? 

Dr. Brittany Craiglow (21:32): 

That actually happened. I did not play water polo, no. I was a field hockey player, not water polo, though. Yeah, so the Special K thing really and truly was real. I thought that we would be working our way out of all of these boxes, and it really was just came by UPS and it wasn't as much as it might have been. 

Dr. Lisa Swanson (21:59): 

I love it, I love it. I think shout-out to all water polar players though, I think that's the toughest sport out there. 

Dr. Brittany Craiglow (22:04): 

It is an incredible sport. I have some patients who play. The level of athleticism required for that is pretty unbelievable. 

Dr. Lisa Swanson (22:14): 

Yeah. You're basically playing soccer while treading water, and you can't stand on a regular surface the entire time. 

Dr. Brittany Craiglow (22:22): 

No, it's like impossible, yeah. 

Dr. Lisa Swanson (22:25): 

Well, thank you so much, Britt Craiglow, thank you for joining us. I hope all the listeners got a lot out of this. Thanks for tuning in. 

Dr. Brittany Craiglow (22:33): 

Thank you. 

Speaker 1 (22:34): 

And now for the news. We begin with one of our most read clinical findings of the year in a study showing Mohs micrographic surgery lowering local recurrence in high-stage cutaneous squamous cell carcinoma. The retrospective analysis of more than 200 patients with primary high-stage cutaneous squamous cell carcinoma showed most surgery was linked with fewer local recurrences than wide local excision. Disease-specific and overall survival were similar between procedures, but authors said the data reinforced Mohs as a potential first-line option for high-stage tumors. The researchers emphasized the value of margin-controlled surgery for improving local tumor control. 

(23:10): 

Cardiodermatology was another topic that captured major attention this year. A multi-specialty-focused presentation earlier this year at the Masterclasses in Dermatology conference highlighted the significant cardiovascular risks tied to chronic inflammatory skin diseases, including psoriasis, atopic dermatitis and hidradenitis suppurativa. Given by Dr. Brittany Weber, director of the Cardio-Rheumatology Clinic and an assistant professor of medicine at Harvard Medical School, she talked at length about the need for collaborative multi-disciplinary care, careful monitoring of treatment-related cardiovascular risks, and broader use of advanced imaging tools to detect early disease. Dr. Weber's talk also echoed the call for clearer guidelines to help dermatologists assess and manage cardiometabolic risk right in the clinic. 

(23:56): 

In regulatory news, dupilumab gained FDA approval this year for chronic spontaneous urticaria in adults and adolescents who remain uncontrolled on antihistamines. The approval was supported by the LIBERTY-CUPID Phase 3 program, where dupilumab significantly reduced itch and urticaria activity. Safety findings aligned with its established profile across other Type 2 inflammatory conditions. The approval marks the first new targeted therapy for CSU in more than a decade.