Alopecia areata (AA) is an autoimmune disease that presents as nonscarring hair loss. In the United States, it is estimated that AA affects 0.1–0.2% of the population, with a lifetime risk of 2.1% (Alkhalifah et al., 2010Alkhalifah A. Alsantali A. Wang E. McElwee K.J. Shapiro J. Alopecia areata update: part I. Clinical picture, histopathology, and pathogenesis.J Am Acad Dermatol. 2010; 62 ([quiz 189]): 177-188Abstract Full Text Full Text PDF PubMed Scopus (325) Google Scholar). Willingness to pay (WTP) is a monetary, preference-based measure designed to gauge patients’ WTP out of pocket (in US$) for a cure or control of their condition. To our knowledge, this is the first study measuring WTP in patients with AA. Patients indicated they were willing to pay a median of $500–1,000 or approximately 13–22% of their monthly income for a permanent cure for AA; 33% of patients (n = 13) were willing to pay $5,000 for a permanent cure and 15% (n = 6) were willing to pay $5,000 to control the disease. Patients with higher AA Symptom Impact Scale (AASIS) scores were more willing to pay > $1,000 (mean AASIS score 47.8 vs. 26.0, P = 0.012) and > $5,000 (mean AASIS score 53.2 vs. 25.8, P = 0.003) for a cure. Similarly, patients with higher AASIS scores were more willing to pay > $1,000 (mean AASIS score 53.7 vs. 30.4, P = 0.012) and > $5,000 (mean AASIS score 66.3 vs. 30.9, P = 0.003) to control disease (Table 2). Furthermore, patients with higher Severity of Alopecia Tool scores (≥ 25%) had significantly higher AASIS scores than those with lower Severity of Alopecia Tool scores (<25%) (mean AASIS 59.1 vs. 20.1, P < 0.0001). The average Severity of Alopecia Tool score for all 40 patients was 28.3%.Table 1Demographics of Patients with AAPatient CharacteristicsValue1Values are n (%) except where indicated. Not all categories round to 100%.Age, y (range)40.5 (18–68)Disease duration, y <18 (20) 1–512 (30) >519 (48)Male12 (30)Hispanic7 (18)Race Black3 (8) Asian14 (35) White15 (38) Multiple and/or other8 (20)Education completed High school4 (10) 2-year college8 (20) 4-year college15 (38) Graduate school8 (20) Professional school5 (13)Annual income, $ <10,0009 (23) 10,000–49,9994 (10) 50,000–100,00014 (35) >100,00013 (33)Abbreviation: AA, alopecia areata.1 Values are n (%) except where indicated. Not all categories round to 100%. Open table in a new tab Table 2WTP for Cure or Treatment of AAQuestionnaire ItemAASIS ScorenValues, Mean (SD)P-Value1Statistical test used is the Wilcoxon test.WTP for cure <$1,0002326.0 (21.5)0.012WTP for cure >$1,0001647.8 (30.0)WTP for cure <$5,0002625.8 (20.8)0.003WTP for cure >$5,0001353.2 (30.0)WTP for control <$1,0003030.4 (26.6)0.012WTP for control >$1,0001053.7 (25.8)WTP for control <$5,0003430.9 (25.6)0.003WTP for control >$5,000666.3 (22.4)Abbreviations: AA, alopecia areata; AASIS, Alopecia Areata Symptom Impact Scale; WTP, willingness to pay.1 Statistical test used is the Wilcoxon test. Open table in a new tab Abbreviation: AA, alopecia areata. Abbreviations: AA, alopecia areata; AASIS, Alopecia Areata Symptom Impact Scale; WTP, willingness to pay. Our results indicate that 33% of patients with AA were willing to pay ≥ $5,000 for a permanent cure, comparable with the WTP of patients with vitiligo (32.9%) (Radtke et al., 2009Radtke M.A. Schäfer I. Gajur A. Langenbruch A. Augustin M. Willingness-to-pay and quality of life in patients with vitiligo.Br J Dermatol. 2009; 161: 134-139Crossref PubMed Scopus (91) Google Scholar). For a permanent cure, our patients were willing to pay a median of $500–1,000, compared with patients with atopic dermatitis who were willing to pay a median of €1,000 (∼ US $1,132) and patients with rosacea who were willing to pay €500 (∼ US $566) (Beikert et al., 2014Beikert F.C. Langenbruch A.K. Radtke M.A. Kornek T. Purwins S. Augustin M. Willingness to pay and quality of life in patients with atopic dermatitis.Arch Dermatol Res. 2014; 306: 279-286Crossref PubMed Scopus (66) Google Scholar). The median WTP as a percentage of monthly income was 10–20%, which is comparable with the percentage found with patients with atopic dermatitis and psoriasis and slightly more than that found with patients with rosacea (Beikert et al., 2014Beikert F.C. Langenbruch A.K. Radtke M.A. Kornek T. Purwins S. Augustin M. Willingness to pay and quality of life in patients with atopic dermatitis.Arch Dermatol Res. 2014; 306: 279-286Crossref PubMed Scopus (66) Google Scholar). Severity of the disease was associated with QOL, a finding also noted in psoriasis. QOL was associated with WTP for both control and cure of the disease. Our patients reported a WTP at levels similar to patients with vitiligo, atopic dermatitis, and psoriasis, demonstrating the need for ongoing research toward a potential cure for AA. One limitation of our study was the small sample size; thus, further large-scale studies are warranted to validate our findings. A total of 40 patients with AA were recruited from the dermatology clinic at the University of California, Los Angeles (Table 1). Patients completed the AASIS and a WTP questionnaire and were assessed by a dermatologist to calculate the Severity of Alopecia Tool score (Mendoza et al., 2013Mendoza T.R. Osei J.S. Shi Q. Duvic M. Development of the alopecia areata symptom impact scale.J Investig Dermatol Symp Proc. 2013; 16: S51-S52Abstract Full Text Full Text PDF PubMed Scopus (21) Google Scholar, Olsen et al., 2004Olsen E.A. Hordinsky M.K. Price V.H. Roberts J.L. Shapiro J. Canfield D. et al.Alopecia areata investigational assessment guidelines--part II. National Alopecia Areata Foundation.J Am Acad Dermatol. 2004; 51: 440-447Abstract Full Text Full Text PDF PubMed Google Scholar). Our WTP questionnaire was a nonvalidated questionnaire that was based on those developed from previous WTP studies (Beikert et al., 2014Beikert F.C. Langenbruch A.K. Radtke M.A. Kornek T. Purwins S. Augustin M. Willingness to pay and quality of life in patients with atopic dermatitis.Arch Dermatol Res. 2014; 306: 279-286Crossref PubMed Scopus (66) Google Scholar, Radtke et al., 2009Radtke M.A. Schäfer I. Gajur A. Langenbruch A. Augustin M. Willingness-to-pay and quality of life in patients with vitiligo.Br J Dermatol. 2009; 161: 134-139Crossref PubMed Scopus (91) Google Scholar). All patients provided written consent to participate, and study materials were approved by the University of California, Los Angeles Institutional Review Board. Statistical analyses were performed using the Fisher’s exact test (for categorical data) or Wilcoxon test (for continuous data) as appropriate using Statistical Package for the Social Sciences V23 (IBM, Armonk, NY). Jean-Phillip Okhovat: http://orcid.org/0000-0002-4371-587X Tristan Grogan: http://orcid.org/0000-0001-9471-2938 Lewei Duan: http://orcid.org/0000-0003-0324-5655 Carolyn Goh: http://orcid.org/0000-0003-3923-5125 The authors state no conflict of interest. This article is published as part of a supplement sponsored by the National Alopecia Areata Foundation . Funding for the Summit and publication of this supplement was provided by the National Alopecia Areata Foundation. This Summit was supported (in part) by the National Institute of Arthritis and Musculoskeletal and Skin Diseases under Award Number R13AR074890 . The opinions or views expressed in this professional supplement are those of the authors and do not necessarily reflect the official views, opinions, or recommendations of the National Institutes of Health or the National Alopecia Areata Foundation. We would like to thank Melvin Chiu for assistance and support with helping to develop the willingness to pay questionnaire. This article summarizes the work from a previous publication (Okhovat et al, 2017Okhovat J.P. Grogan T. Duan L. Goh C. Willingness to pay and quality of life in alopecia areata.J Am Acad Dermatol. 2017; 77: 1183-1184Abstract Full Text Full Text PDF Scopus (7) Google Scholar) and has been reproduced with permission from the Journal of the American Academy of Dermatology. Statistical analyses for this research were supported by the National Institutes of Health, National Center for Advancing Translational Science, University of California, Los Angeles, Clinical and Translational Science Institute (grant number UL1TR000124). City, State, and County where work was done were Los, Angeles, California, USA. Conceptualization: JPO, TG, LD, CG; Data Curation: JPO, TG, LD, CG; Investigation: JPO, TG, LD, CG; Methodology: JPO, TG, LD, CG; Validation: JPO, TG, LD, CG; Writing - Original Draft Preparation: JPO, CG; Writing - Review and Editing: JPO, TG, LD, CG
Alopecia areata (AA) has been recently shown to also include T-helper cell type 2/IL-23 activation, in addition to T-helper cell type 1/IFN-skewing. The success of Jak inhibition together with IL-4Rα antagonism and limited response to IL-17A and PDE4 (protein) inhibition in AA are increasing our understanding of the complex immune interplay in AA. Trials testing targeted therapeutics are needed to further elucidate the pathogenic contribution of various cytokines.
Although alopecia areata (AA) has been traditionally classified as a strictly T helper type 1-mediated process, the T helper type 2 (Th2) pathway may contribute to an AA-like phenotype in some individuals. Herein, we describe three clinical cases that support the potential role of Th2 activity through the upregulation of IL-4 and IL-13 in an AA-like phenotype.
Human genetic studies of diseases that are multifactorial and prevalent have generated a wealth of knowledge about the genetic architecture of chronic diseases. Generalizable attributes are shaping the development of models to explain how the human genome influences our health and can be leveraged to improve it. Importantly, both rare and common genetic variants contribute to disease risk and provide complementary information. Although initial genetic studies of alopecia areata have yielded insight with high clinical impact, there remains a number of important unanswered questions pertaining to disease biology and patient care that could be addressed by further genetic investigations.
There are no tools to evaluate eyebrow involvement in patients with alopecia areata. We developed and assessed the reliability of the Brigham Eyebrow Tool for Alopecia (BETA) as a quantitative evaluation of eyebrow alopecia areata. BETA uses facial landmarks of eyebrow anatomy and is calculated using surface area and density. A total of 50 eyebrow images with varying levels of hair loss were distributed to six board-certified dermatologists at three academic medical centers with standardized instructions and examples. Interrater and intrarater reliability were calculated using intraclass correlation coefficients (ICCs). BETA demonstrated high interrater (ICC = 0.88, confidence interval = 0.83-0.92 right eyebrow scores and ICC = 0.90, confidence interval = 0.85-0.94 left eyebrow scores) and intrarater (ICC = 0.90, confidence interval = 0.85-0.93 right eyebrow scores and ICC = 0.91, confidence interval = 0.87-0.94 left eyebrow scores) reliability. When measured in the same patient with varying degrees of hair loss over time, BETA demonstrated sensitivity to change. BETA is a simple and reliable objective assessment of eyebrow alopecia areata. BETA is easy-to-use and quick to calculate, making it feasible for a variety of clinical and research settings. Although developed for alopecia areata, we hope that BETA will be investigated in other etiologies of eyebrow alopecia to serve as a universal tool for monitoring disease progression, improvement, and response to treatment.
Alopecia areata (AA) is a common autoimmune skin disease resulting in the loss of hair on the scalp and elsewhere on the body that affects over 146 million people worldwide at some point in their lives. Founded in 1981, the National AA Foundation (NAAF) is a nonprofit organization that supports research to find a cure or acceptable treatment for AA, supports those with the disease, and educates the public about AA. NAAF conducts research summits every two years to review progress and create new directions in its funded and promoted research. This report from the seventh AA Research Summit, Forging the Future, held December 4-5, 2018 in New York City provides highlights of the research presented and future research priorities identified during targeted discussion sessions.
As each time before, the 2018 National Alopecia Areata Foundation Summit Meeting once again provided an excellent opportunity to reconsider important frontiers in current alopecia areata (AA) research. In the following, I comment on selected major open questions in the rapidly evolving field of AA pathobiology (Dainichi and Kabashima, 2017; Gilhar et al., 2016; McElwee et al., 2013; Paus et al., 2018; Pratt et al., 2017), with emphasis on a much-needed, pathobiology-based reclassification of AA, biomarkers, and the potential role of atopy in AA.
Alopecia areata is a common autoimmune condition that disproportionately affects children and can significantly hinder quality of life. Few safe and effective therapies are available for the treatment of severely affected pediatric patients. JAK inhibitors have been recently established as an effective and well-tolerated therapy in adults, but there are limited data regarding the use of JAK inhibitors to treat alopecia areata in children. Here, we review the available literature regarding the use of JAK inhibitors in children in dermatology and across other medical disciplines.
Meaningful patient input to understand disease experience and patient expectations for improvement with treatment is essential for the selection and development of outcome measures for alopecia areata (AA) clinical trials. This study explored the physical signs and symptoms of AA through 30 semistructured interviews with adult (n = 25) and adolescent (n = 5) patients experienced with severe or very severe AA. Scalp hair loss was overwhelmingly the most important sign and symptom of AA. Nearly all patients (90%) considered scalp hair loss in their top three most bothersome physical signs and symptoms of AA, with 77% (n = 23) naming scalp hair loss as the most bothersome symptom. Other identified signs and symptoms in the top three most bothersome included eyebrow, eyelash, nose, body, and facial hair loss, as well as eye irritation and nail damage and/or appearance. Eyebrow (16%, n = 4), eyelash (4%, n = 1), nasal (4%, n = 1), and body (4%, n = 1) hair loss were identified by seven adult patients as the most bothersome signs and symptoms of AA. Conceptual saturation confirmed that a comprehensive understanding of this patient population's physical AA-related signs and symptoms was obtained. These findings indicate that the primary objective for new AA treatments for this patient population should be meaningful improvement in scalp hair growth to address the most troubling unmet need.
Alopecia areata affects not only scalp hair but also other sites of body hair, including eyebrows. Our objective was to investigate the importance of eyebrows in the treatment goals of patients with alopecia areata. Through an online questionnaire, subjects were asked to assess satisfaction with the visually depicted level of response to treatment, using edited photographs depicting a range of eyebrows and scalp hair growth. The questionnaire was completed by 1,741 adults. Absent or partial growth of eyebrows and scalp hair elicited <25% satisfaction. Images depicting either complete eyebrows or complete scalp hair achieved satisfaction in >50% of participants. More participants were satisfied with complete eyebrows and no scalp hair (69%) than complete eyebrows and partial scalp hair (51%). Only when both eyebrows and scalp hair were completely regrown did extreme satisfaction levels reach 90.4%. Limitations include the online nature of the survey, lack of control group, and self-reported severity of alopecia areata in participants. These results suggest that eyebrows may be as important as scalp hair for patients assessing theoretical responses to treatment for alopecia areata. Future clinical studies should consider growth of eyebrows as an outcome measure on par with scalp hair growth.
Previous QOL and disease burden studies have not captured all relevant aspects of living with alopecia areata (AA). To better understand the burden and everyday experience of living with moderate-to-severe AA, a cross-sectional, online, quantitative-qualitative survey was developed to assess symptoms, relationships, productivity, treatments, and financial burden. Adult patients were recruited from the National Alopecia Areata Foundation database. Data were analyzed descriptively. A total of 216 patients completed the survey. Most were female (83%), aged ≥45 years (59%), and white (78%). Nearly 2 of 3 respondents (62%) made different major life decisions (regarding relationships, education, or career) owing to AA. Most respondents (85%) stated coping with AA as a daily challenge, citing mental health issues, concealing hair loss, and others' reactions; 47% reported anxiety and/or depression. Many patients (75%) persistently concealed hair loss (mean time spent, 10.3 h/wk). Treatment discontinuation was common owing to lack of efficacy, side effects, and cost. Associated expenditures included buying wigs or hairpieces and psychotherapy (mean ∼$2,000/y each). Survey respondents comprised a self-selected sample, which may not reflect the entire population. The impact of AA extends beyond cosmetic concerns and carries a considerable psychosocial burden. Efficacious, less burdensome AA treatments are needed to regrow hair and alleviate psychosocial sequelae.
Platelet-rich plasma (PRP) is an autologous preparation of plasma with concentrated platelets containing various growth factors and cytokines that enhance the body's inherent capacity to repair and regenerate hair follicles. A few studies and case reports support the use of PRP for the treatment of alopecia areata (AA). Further large-scale studies are needed to evaluate the efficacy of PRP as monotherapy or in association with other therapeutic modalities for AA. Although PRP is relatively safe and potentially effective, there is no standardized protocol or recommendations for the number of PRP sessions required to treat and maintain hair growth.
The International Dermatology Outcome Measures is a nonprofit organization dedicated to developing evidence-based, patient-centered outcome measures for dermatologic conditions. At the 2018 Alopecia Areata Research Summit, Dr Gottlieb, President of the International Dermatology Outcome Measures, presented an overview of their work in psoriasis, hidradenitis suppurativa, acne, and eczema and discussed the potential areas of mutual interest with the National Alopecia Areata Foundation. Herein, we present a summary of the topics discussed.
Legacy Healthcare has developed and patented a topical botanical with a unique mechanism of action, an extensive clinical data package, and excellent safety from the 2.2 million units already sold, all of which has enabled it to enter late-stage clinical development for alopecia areata (AA), chemotherapy-induced alopecia, and soon female androgenetic alopecia. As this drug candidate is very safe, the European Medicines Agency agreed to Legacy Healthcare's request to initiate late-stage clinical trial first in children, the neediest population suffering from AA. The initial trend from the phase II/III trial conducted to assess the efficacy and safety of the drug candidate in pediatric AA (RAAINBOW trial) looks promising, although no conclusions can be made. This drug candidate seems to offer several potential safety and economic advantages over other investigational synthetic and biologic compounds currently being investigated in populations with AA overall and especially for children.
Diversity in medicine is an important topic, especially in specialties where very little diversity exists among providers. The conversation of diversity in medicine usually involves gender and ethnic diversity with a focus on direct patient care. Very little work has been done on the clinical research side of medicine and even less has been done in the dermatology clinical research space. As clinical trial research in skin diseases moves forward with new medications and treatments, one important consideration will be to reach those patients who have the diseases of interest. As the US population becomes more diverse, it will be imperative to have a plan for clinical research that includes this diverse population. The US Census Bureau population projections are that there will be a majority–minority shift in the next 50 years. Among the population under age 18 years, whites will decrease from 53% in 2012 to 23% in 2060. Hispanics will increase from 24% to 38%, and those people of two or more races will increase in the population as well (Frey, 2012Frey W.H. Census projects new “majority minority” tipping points.https://www.brookings.edu/opinions/census-projects-new-majority-minority-tipping-points/Google Scholar). The reality of diversity in this country is indisputable, and the known benefits of diversity in the medical workforce are as follows: improvement in patient care, increased access to care for patients with low incomes, racial and ethnic diversity, non–English-speaking patients, individuals with Medicaid, and lastly, race-concordant visits show higher patients satisfaction than race-discordant visits (Cooper and Powe, 2004Cooper L.A. Powe N.R. Disparities in patient experiences, healthcare processes, and outcomes: the role of patient–provider racial, ethnic, and language concordance. The Commonwealth Fund, New York, NY2004Google Scholar). Dermatology has fallen significantly behind in the US population with only 3% of dermatologists having African American ancestry compared with 12% of the current African American population and 4.2% of dermatologists having Hispanic descent compared with 16.3% of the current Hispanic population (Pandya et al., 2016Pandya A.G. Alexis A.F. Berger T.G. Wintroub B.U. Increasing racial and ethnic diversity in dermatology: A call to action.J Am Acad Dermatol. 2016; 74: 584-587Abstract Full Text Full Text PDF PubMed Scopus (56) Google Scholar). Therefore, it is no surprise that the demographic shift in the US population is not reflected in dermatology clinical researchers. The impact of this lack of diversity can result in an inability to generalize results and studies that may fail to detect the relevant findings in specific groups. The National Institutes of Health enforces federal law requiring the inclusion of women and minorities in all clinical research as appropriate for scientific goals (National Institutes of Health, 2019National Institutes of HealthGuidelines for the review of inclusion on the basis of sex/gender, race, ethnicity, and age in clinical research.https://grants.nih.gov/grants/peer/guidelines_general/Review_Human_subjects_Inclusion.pdfGoogle Scholar). The Food and Drug Administration currently requires that all investigational new drug and new drug application studies should include demographic information before approval, and it is clear that African Americans, Hispanic individuals, and women are generally underrepresented in clinical and randomized controlled trials as well as within specific subspecialties. Charrow et al., 2017Charrow A. Xia F.D. Joyce C. Mostaghimi A. Diversity in dermatology clinical trials: a systematic review.JAMA Dermatol. 2017; 153: 193-198Crossref PubMed Scopus (33) Google Scholar assessed the representation of racial and/or ethnic minorities and women in dermatology randomized clinical trials (RCTs) between the years 2010 and 2015 (. A total of 626 RCTs were evaluated across eczema, seborrheic dermatitis, psoriasis, acne, lichen planus, vitiligo, and alopecia areata. Moreover, 52 of 626 international studies (11.3%) and 58 of 97 studies (59.8%) conducted exclusively within the US reported on the racial or ethnic demographics of study participants. Race was not always reported, but when it was reported in the US RCTs, 74.4% of study participants were white. These authors did note that eight RCTs in alopecia areata were included in their evaluation, but no underrepresented minorities (URM) were included in these trials. In fact, the likelihood that URM patients will participate in dermatology trials is not reported commonly in the dermatology literature. Only one reference reported the likelihood of African American participation in clinical dermatology trials with a study that examined parents in pediatric dermatology clinic (Shaw et al., 2009Shaw M.G. Morrell D.S. Corbie-Smith G.M. Goldsmith L.A. Perceptions of pediatric clinical research among African American and Caucasian parents.J Natl Med Assoc. 2009; 101: 900-907Crossref PubMed Scopus (21) Google Scholar). These authors showed that disparities existed between white and African American parents with white parents being slightly more trusting and more knowledgeable about research than African American parents. African American parents were more inclined to think that their children would be used as guinea pigs. This begs the question of what dermatology clinical research investigators should do to increase diversity in all clinical trials, but specifically those involving alopecia areata. These specific recommendations were noted in an editorial by Charrow et al., 2017Charrow A. Xia F.D. Joyce C. Mostaghimi A. Diversity in dermatology clinical trials: a systematic review.JAMA Dermatol. 2017; 153: 193-198Crossref PubMed Scopus (33) Google Scholar (Desai et al., 2017Desai S.R. Hernandez C. McMichael A.J. Spectrum of diversity in dermatology: the need to broaden clinical trial participants in our increasingly multiethnic and multicultural society.JAMA Dermatol. 2017; 153: 132-134Crossref Scopus (2) Google Scholar). It will be important to utilize the standardized race and/or ethnicity language for study inclusion to facilitate tracking specific research data. There should be a clearly defined minimum set of demographic data collected including specific diversity data in all the studies. There should be an identification and prioritization of dermatologic knowledge and research gaps for underrepresented groups. Finally, when planning racially, culturally, and gender-inclusive studies, it is best to always include the methods to disseminate results back to the stakeholders in question. In terms of recruitment of URM patients for clinical trials, there are several practices that have been shown to increase success. Site commitment and effort important in the actual process can move the needle toward more recruitment of URM participants. To increase the further success, incentives for patients and staff workers can be offered. It has been shown that more the community connections in place, higher is the success. There is a role for sponsors as well, with more successful URM recruitment when sponsors reinforce diversity recruitment. Although it may seem simple, staff that can speak the same language as the diverse populations in the area of the research site can help as well. Finally, having a culturally competent staff is an important factor. Although a complete review of how to increase cultural competence in the dermatology workplace is beyond the scope of this review, the RISK method has been described as an easy way to explain what is needed where the mnemonic stands for: resources, individual identity, skills, and knowledge (McKesey et al., 2017McKesey J. Berger T.G. Lim H.W. McMichael A.J. Torres A. Pandya A.G. Cultural competence for the 21st century dermatologist practicing in the United States.J Am Acad Dermatol. 2017; 77: 1159-1169Abstract Full Text Full Text PDF PubMed Scopus (14) Google Scholar). These four factors can define and direct the clinical trialist’s actions that can impact recruitment and retention of URM participants in research trials. Clarifying what will be needed to bring diversity of clinical trials for alopecia areata includes training researchers on the diverse backgrounds of patients with alopecia areata. Including diverse students and researchers on grants and research projects, including implicit bias training, and diversifying clinical research staff can all support the diversity in alopecia areata clinical trials. Working with the National Alopecia Areata Foundation to publish clinical trial recruitment information on social media and encouraging industry partners to make diversity in studies a priority are final recommendations for increasing diversity in alopecia areata clinical trials. Amy J. McMichael: http://orcid.org/0000-0002-5342-2181 AJM has received research, speaking, and/or consulting support from a variety of companies, including Aclaris, Allergan, Bioniz, Cassiopea, Concert Pharmaceuticals, Covance, eResearch Technology Inc, Galderma, Incyte, Informa Healthcare, Johnson & Johnson, Keranetics, Merck & C Inc, Pfizer, Proctor & Gamble, Samumed, and UpToDate. There are no conflicts pertinent to this manuscript. This article is published as part of a supplement sponsored by the National Alopecia Areata Foundation . Funding for the Summit and publication of this supplement was provided by the National Alopecia Areata Foundation. This Summit was supported (in part) by the National Institute of Arthritis and Musculoskeletal and Skin Diseases under Award Number R13AR074890 . The opinions or views expressed in this professional supplement are those of the author and do not necessarily reflect the official views, opinions or recommendations of the National Institutes of Health or the National Alopecia Areata Foundation.
Alopecia areata (AA) is an autoimmune hair loss condition that is difficult to treat and frequently disruptive to the psychosocial well-being of patients. Platelet-rich plasma (PRP) is an innovative therapy that provides concentrated GFs that impart anti-inflammatory effects. Optical coherence tomography (OCT) is a noninvasive imaging modality with the potential for providing quantitative monitoring of AA response to PRP. Our objective is to share our experience using OCT to monitor the therapeutic progress of patients with AA treated with PRP. Two patients with patchy AA and one with alopecia universalis were treated with PRP three times at 6-week intervals as part of a larger clinical trial. Patients were followed from baseline to week 24 with OCT imaging. OCT demonstrates an increase in hair density associated with improvement in inflammation at week 24. Conversely, the patient with alopecia universalis did not experience any significant change in follicular activity. This case series exemplifies the potential of PRP in inflammatory regulation as well as hair regrowth in patchy AA, whereas there is no notable advantage in alopecia universalis. Our findings add evidence on the possible value of OCT in quantitatively assessing hair growth progress throughout a treatment course.
Alopecia areata (AA), which is defined as an autoimmune hair loss disease, has a serious impact on the quality of life for patients with AA worldwide. In this study, to our knowledge, a previously unreported method of AA induction in C3H mice has been established and validated. Using this method, we showed that dermal injection of 1-3 million of a mixture of skin cells freshly isolated from AA-affected skin induces AA in more than 80% of healthy mice. Contrary to the previous protocol, the induction of AA by this approach does not need any surgical AA skin grafting, cell manipulation, or high number of activated T cells. We also showed that dermal injection of adherent myeloid cells (mainly CD11b+) in healthy mice is as potent as a mixture of none adherent CD3+ T cells and CD19+ B cells in the induction of AA. Interestingly, most of the mice (7 out of 8) that received non-adherent cells developed AA universalis, whereas most of the mice (5 out of 7) that received adherent cells developed patchy AA. Finally, we found a high number of stage-specific embryonic antigen-expressing cells whose expression in monocytes in an inflammatory disease causes the release of inflammatory cytokines, TNF-α and IL-1β, from these cells in AA-affected skin.
The C3H/HeJ model has long dominated basic alopecia areata (AA) in vivo research and has been used as proof-of-principle that Jak inhibitors are suitable agents for AA management in vivo. However, its histologic features are not typical of human AA, and it is questionable whether it is sufficiently clinically predictive for evaluating the therapeutic effects of candidate AA agents. Instead, the humanized mouse model of AA has been used to functionally demonstrate the role of key immune cells in AA pathogenesis and to discover human-specific pharmacologic targets in AA management. Therefore, we advocate the use of both models in future preclinical AA research.
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.
