Hair’s the Thing

There is finally a US Food and Drug Administration (FDA)-approved treatment for alopecia areata. Baricitinib (Olumiant; Eli Lilly and Company, Incyte) was approved for adults with severe alopecia areata in June 2022,¹ and several other Janus kinase (JAK) inhibitors are being studied for similar indications.

Alopecia areata is one type of alopecia that is receiving its share of headlines. Other forms, such as traction alopecia, central centrifugal cicatricial alopecia (CCCA), and frontal fibrosing alopecia (FFA), were hot topics at the Generational Dermatology Symposium 2023 in Rancho Mirage, CA.

“In 2023, hair loss is a reality for everyone,” said Wendy Roberts, MD, a dermatologist based in Rancho Mirage, CA, and the founder of the symposium, which just celebrated its 10th year.

“Be it hair loss related to age, COVID-19 infection, vaccination, booster, or medication, the need for education and hair rejuvenation has never been greater,” Dr. Roberts told Practical Dermatology®.

More than 80% of men and nearly half of women will experience significant hair loss during their lifetime. “For many, the thinning starts well before the fourth decade, and this statistic cries out for a generational approach,” said Dr. Roberts.

Her bottom line? “We should not wait for our patients to exhibit hair loss before we act,” she said.

Hair unit rejuvenation can prevent hair loss and fortify the follicular unit against stress and health-related effluviums.

Diagnosing and Treating CCCA

CCCA is the most common alopecia occurring in Black patients, according to Chesahna Kindred, MD, MBA. She is the founder of Kindred Hair & Skin Center in the Baltimore, MD metropolitan area.

CCCA likely has a genetic etiology that triggers inflammatory damage to the hair follicles, leading to scarring, Dr. Kindred said during a presentation at the Generational Dermatology Symposium.

The first step in diagnosing a patient with CCCA is a hair loss consultation. “This is a dedicated appointment where we obtain a thorough history, complete the scalp exam, order labs, and take photos,” Dr. Kindred said.

“I write down the notes for the patient on a template and hand it to the patient at the end of the session,” explained Dr. Kindred. The patient starts with an anti-seborrheic shampoo and hair supplements. “Rather unique to my practice, the patient also schedules a consultation with the in-house hair stylist,” she said.

The second appointment is the time for a biopsy. “All patients with suspected CCCA undergo a scalp biopsy that is sent to a dermatopathologist with a niche in alopecia,” said Dr. Kindred. “Dermoscopic photos of the biopsy site are taken as well, and if ready, lab results are reviewed and addressed during this visit.”

During the third appointment, Dr. Kindred reviews the results. “We discuss the biopsy results, review the dozen treatment options discussed during the initial consultation, and develop the treatment plan,” she said.

CCCA treatment may include corticosteroid injections, given monthly for 6 to 8 months, and an antibiotic, such as doxycycline or minocycline. Minoxidil is always used with other medications, according to information from the American Academy of Dermatology.²

FFA

FFA, a cicatricial alopecia that destroys the hair, causes permanent hair loss, according to Valerie D. Callender, MD, founder and medical director of Callender Dermatology in Glenn Dale, MD.

FFA is characterized by frontotemporal alopecia, and about 75% of patients with FFA also have eyebrow loss. Common early symptoms are itch or pain, and FFA also may be associated with prominent blood vessels in the temporal areas and noninflammatory facial papules, noted Dr. Callender.

FFA treatment includes intralesional corticosteroids or the 5-alpha-reductase inhibitors finasteride or dutasteride. Oral steroids are rarely used as treatment
of FFA.

Other therapies for FFA include high-potency topical corticosteroids and oral antibiotics such as doxycycline, tetracycline, or minocycline and off-label use of calcineurin inhibitors.

According to Dr. Callender, pioglitazone is occasionally used for FFA; however, clinicians also use this medication for another form of scarring alopecia, lichen planopilaris. Systemic retinoids are used mainly to treat the facial papules that are associated with FFA in a dose of 10 to
40mg/day, she said.

Traction Alopecia

The treatment of traction alopecia involves patient education on the cause of the hair loss, hairstyles that produce traction or pull on the hair, and discontinuing these traumatic hairstyles, noted Dr. Callender. “If the diagnosis and the change in hairstyling are made early, then traction alopecia is reversible.”

Medical management of traction alopecia includes topical corticosteroids, intralesional corticosteroids, and topical or oral minoxidil. “If medical treatment is unsuccessful, then platelet-rich plasma injections and hair transplantation offer an excellent option for patients,” she said.

Ending Race-Based Hair Discrimination

“Doctors, medical students, residents, or attendings may prejudge a patient or colleague based on their own bias toward hair styling,” said Brooke Jackson, MD, of Skin Wellness Dermatology Associates in Durham, NC.

Race-based hair discrimination still exists and has a negative effect on quality of life. “Every dermatologist of African descent has experienced some form of race-based hair discrimination during the course of one’s career,” she said. “To be told for decades that your natural hair is unattractive, to be forced by law to cover it, or to have unsolicited comments about one’s hair in the workplace has a long-lasting impact.”

Historically, natural hair is to be celebrated, and care for hair of Black women is an ongoing ritual and time for bonding with family and community, Dr. Jackson noted. “Forced assimilation to the European standard of beauty for survival, ie, financial security, was ultimately damaging to the health of one’s hair and self-esteem.”

How Prominent Is Race-Based Hair Discrimination?

Black women’s hair is 2.5 times more likely to be perceived as unprofessional, according to the 2023 CROWN Workplace Research Study, co-commissioned by Dove and LinkedIn.³ In addition, approximately 66% of Black women change their hair for a job interview. Black women also are 54% more likely to believe that they must wear their hair straight to a job interview to be successful.

To help end race-based hair discrimination, the CROWN Coalition, a national alliance founded by Dove, the National Urban League, Color of Change, and the Western Center on Law & Poverty, is supporting anti-hair discrimination legislation to address unfair grooming policies and has drawn attention to cultural and racial discrimination occurring in workplaces and public schools.

Everyone can do something to help end these practices, according to Dr. Jackson. “We are all biased in one way or another based on our experience,” she said. “Acknowledge that, and be aware of how it can affect your interactions with patients, coworkers, students, and staff.”

1. US Food and Drug Administration. FDA approves first systemic treatment for alopecia areata. Published June 13, 2022. Accessed April 12, 2023. www.fda.gov/news-events/press-announcements/fda-approves-first-systemic-treatment-alopecia-areata

2. American Academy of Dermatology Association. Hair loss types: central centrifugal cicatricial alopecia treatment. Last updated March 14, 2022. Accessed April 12, 2023. www.aad.org/public/diseases/hair-loss/types/ccca/treatment

3. Cision PR Newswire. Dove partners with LinkedIn in support of the CROWN act to help end race-based hair discrimination in the workplace. Published February 16, 2023. Accessed April 12, 2023. www.prnewswire.com/news-releases/dove-partners-with-linkedin-in-support-of-the-crown-act-to-help-end-race-based-hair-discrimination-in-the-workplace-301748816.html

4. Almohanna HM, Ahmed AA, Tsatalis JP, Tosti A. The role of vitamins and minerals in hair loss: a review. Dermatol Ther (Heidelb). 2019;9(1):51-70.