Global Prevalence of Polycystic ovary syndrome Estimated at 11.5%

Meta-analysis using Rotterdam Criteria Estimates PCOS Prevalence at 11.5%

Polycystic ovary syndrome (PCOS) is the most common endocrine disorder of women of reproductive age. PCOS is not one condition but rather an array of different presention. Patients may have clinical or laboratory signs of hyperandrogenism and irregular periods. Further evidence of the condition comes from an ultrasound showing cysts or an elevated AMH level.

Authors from Iran recently performed a meta-analysis of all published studied related to PCOS to better understand the true prevalence. They found a total of 35 studies with 12,365,646 patients. The mean age ranged from 10-45 years. Global prevalence of PCOS was 9.2% (95% CI: 6.8-12.5%) based on meta-analysis. Results showed that the global prevalence of PCOS was 5.5% (95% CI: 3.9-7.7%) based on NIH criteria, 11.5 (95% CI: 6.6-19.4) based on Rotterdam criteria, and 7.1% (95% CI: 2.3-20.2%) based on AES criteria.

COMMENT

PCOS is common! About 1 in 10 women have PCOS. The Rotterdam Criteria, which are the most widely used criteria for diagnosing PCOS, remind us that the confidence interval is large and and the true prevalence may even be up to 19%. Regardless of what the exact prevalence truly is, the main point must not be missed: PCOS is common. It must always be on our list of possibilities when women present with irregular periods, acne, hirsutism, androgenetic alopecia. PCOS must always be at least a passing thought when patients present with other medical issues like high cholesterol, low HDL, obesity, diabetes, acanthosis nigricans, depression and infertility. PCOS is underdiagnosed.

REFERENCE

Salari N et al. Global prevalence of polycystic ovary syndrome in women worldwide: a comprehensive systematic review and meta-analysis. Arch Gynecol Obstet. 2024 Jun 26. doi: 10.1007/s00404-024-07607-x. Online ahead of print.

Scalp Alopecia due to a Clinically Unapparent or Minimally Apparent Neoplasm (SACUMAN): Long Name for An Important Concept

Scalp alopecia due to a clinically unapparent or minimally apparent neoplasm (SACUMAN) is a rare condition. It refers to a type of alopecia neoplastica wherey neoplastic cells invade the are in and around hair follicles and cause hair loss. However, they do so in a manner which is quite subtle and leave the underlying skin looking fairly normal.

I was very interested to read a report recently by Tomasini et al. outlining a cause of basal cell carcinoma mimicking androgenetic alopecia.

Tomasini CF et al. 2024

Authors reported the case of a 74-year-old woman who presented with concerns about a 5-year history of progressive hair loss. The patient had a past medical history of breast cancer. What was so interesting about this case is that the patient was initially diagnosed with androgenetic alopecia and treated with minoxidil. She did not improve with minoxidil. The patient ultimately had a scalp biopsy which showed morpheaform basal cell carcinoma (BCC)

Scalp photos (left) and trichoscopic photos (right) from a 74 year old patient with basal cell carcinoma mimicking androgenetic alopecia. This is a form of alopecia neoplastica. Tomasini CF et al. Giant Morpheaform Basal Cell Carcinoma Mimicking Scarring Alopecia: Exception Prone to Neglect. Dermatopathology (Basel) . 2024 Jun 5;11(2):154-160. doi: 10.3390/dermatopathology11020016.

COMMENT

This was an interesting case of quite a subtle clinical presentation of alopecia neoplastica. It is a nice reminder that we always need to consider a biopsy when something does not seem quite right or a patient does not respond to therapy or when a patient’s past medical history broadens the possible differential diagnosis. The possibility of alopecia neoplastica must be considered in all patients with a prior history of cancer. What was interesting in this case is that the patient ended up having alopecia neoplastica - just not from prior breast cancer.

The authors remind us that secondary alopecia neoplastica due to morpheaform BCC on the scalp is an exceedingly rare condition. However, it possesses subtle clinical features that may mimic both scarring and non-scarring alopecia. Early recognition will limit the ability of this tumor to cause extensive local destruction.

REFERENCE

Tomasini CF et al. Giant Morpheaform Basal Cell Carcinoma Mimicking Scarring Alopecia: Exception Prone to Neglect. Dermatopathology (Basel) . 2024 Jun 5;11(2):154-160. doi: 10.3390/dermatopathology11020016.

Dissecting Cellulitis in a 13 Year old Male

Authors from Australia Report the Youngest Male Patient to Date with DSC.

I was interested to read a report from Australia of a 13 year old male with dissecting cellulitis. Dissecting cellulitis is a neutrophilic scarring alopecia typically affecting males 18-30. The patient’s age makes this case unique and quite unexpected.

The patient was initially treated with doxycycline, clindamycin and topical steroids without much benefit. He was then switched to a treatment plan involving isotretinoin 10 mg daily (0.20 mg/kg), sublingual minoxidil 0.45 mg twice daily, oral prednisolone 25 mg daily for 2 weeks (then1 2.5 mg daily for 4 weeks) and antiseptic shampoo.

After 4 weeks of treatment, the patient’s inflammatory scalp lesions were documented to have flattened. There were no new nodules or pustules that had appeared and there was significant hair regrowth in some of the scalp patches. At week 10, there was further improvement and the authors report that the patient’s prednisone was reduced to 10 mg daily.

Here are photos from the patient’s initial presentation:

Initial presentation of DSC in a 13 year old male. The patient had patches of hair loss, pustules and nodules that were characteristic of dissecting cellulitis. Note how it looks so similar to alopecia areata - except it’s more red, more boggy/swollen, and sinus tracts can be seen. SOURCE: Meryl Thomas 1 2, Valerie Yii 1, Rodney Sinclair 1 3. Dissecting cellulitis of the scalp in a paediatric male. Australas J Dermatol. 2024 Jun 24. doi: 10.1111/ajd.14342.

Here are photos from week 10 following treatment with isotretinoin 10 mg daily (0.20 mg/kg), sublingual minoxidil 0.45 mg twice daily, oral prednisolone 25 mg daily for 2 weeks:

Appearance of the scalp after 10 weeks of treatment. The patient had patches of hair loss, pustules and nodules that were characteristic of dissecting cellulitis. SOURCE: Meryl Thomas 1 2, Valerie Yii 1, Rodney Sinclair 1 3. Dissecting cellulitis of the scalp in a paediatric male. Australas J Dermatol. 2024 Jun 24. doi: 10.1111/ajd.14342

COMMENT

The authors remind us that this is one of the youngest DSC patients reported in the literature. The youngest patient ever was a 10 year old girl (Ramesh V 1990). The male in this study here, however, is the youngest male. Prior to that, the youngest male with DSC was a 15 year old male reported by Arneja JS et al in the Can J Plast Surg.

We don’t really know if the sublingual minoxidil did anything here but it sure is tempting to believe that it did. Oral isotretinoin and prednisone were probably key players.

First line treatments for DSC include isotretinoin and antibiotics. Topical antibiotics, oral antibiotics, oral steroids all have a role. My first-line, second-line and third-line treatments are shown below.

REFERENCES

Meryl Thomas, Valerie Yii, Rodney Sinclair. Dissecting cellulitis of the scalp in a paediatric male. Australas J Dermatol. 2024 Jun 24. doi: 10.1111/ajd.14342. Online ahead of print.

Ramesh V. Dissecting cellulitis of the scalp in 2 girls. Dermatologica. 1990;180(1):48–50.

Arneja JS, Vashi CN, Gursel E, Lelli JL. Management of fulminant dissecting cellulitis of the scalp in the pediatric population: case report and literature review. Can J Plast Surg. 2007;15(4):211–4.

Chemical Scalp Burns After Hair Coloring: Is this Story Becoming More Common?

The Classic Story Of Hair Highlighting Burns

I was interested to read a report in the Journal of Clinical Medicine about a scarring alopecia that followed hair highlighting by a 17-year-old female. This story appears all too commonly - and I do wonder if reports are actually increasing worldwide. This is something I’m seeing often!

The authors describe a 17 year old who attended a hairdressing salon in order to lighten the hair. Within a very short time of applying the preparation to her hair, the woman felt a strong burning sensation on her scalp. The preparation was then washed off and further activities were discontinued. Initially, the patient experienced erythema, swelling, and painful inflammatory infiltration. Pain, swelling and erosions and hair continued over the next few days and eventually the patient developed purulent discharge.

The patient was treated with antibiotics, antifungals and had local wound care but eventually developed a large area of scarring alopecia. She had a tissue expander placed but it needed to be removed sooner after the procedure due to purulent discharge.

Figure 1. Appearance of the lesion during treatment-ulceration after chemical burn in the parietaloccipital part of the scalp. A necrotic eschar is visible in the central part, the surrounding skin is healing. SOURCE: Welc N et al. Chemical Scalp Burn after Hair Coloring-Case Report with Literature Review. J Clin Med. 2024 Jun 17;13(12):3542. doi: 10.3390/jcm13123542.

Figure 2. The appearance of the lesion during treatment-ulcer after chemical burn in the parietooccipital part of the scalp (1–3) during the healing process, complicated by the enlargement of erosions and leakage of purulent contents (2). After complete healing, an area of scarring is visible at the site of the original ulcer (4). SOURCE: Welc N et al. Chemical Scalp Burn after Hair Coloring-Case Report with Literature Review. J Clin Med. 2024 Jun 17;13(12):3542. doi: 10.3390/jcm13123542.

Comments

These sorts of chemical dye related burns are not that uncommon. The story is classic - within seconds to minutes of the hair reagents being applied to the scalp the patient has pain, burning. Soon thereafter, the patient develops swelling, redness, worsening pain and shedding. A patch of scarring alopecia often ensures. The cause is thought to be a chemical burn from agents such as hydrogen peroxide or other oxidizing agents.

I don’t think we fully understand this phenomenon yet! Why does this happen to some and not others? Is it always an error of the hairdressing team? Or are there idiosyncratic factors? I don’t think we fully know all the factors.

This phenomenon does appear to be increasing. I’m hearing more and more and more stories just like this.

More research is needed to understand the chemical scalp burn that follows hair highlighting in some patients.

REFERENCE

Welc N et al. Chemical Scalp Burn after Hair Coloring-Case Report with Literature Review. J Clin Med. 2024 Jun 17;13(12):3542. doi: 10.3390/jcm13123542.

Discoid Lupus: Response to Hydroxychloroquine (Plaquenil)

Regrowth of Scalp Discoid lupus (DLE) with Hydroxychloroquine

Discoid lupus erythematosus (DLE) is an inflammatory condition of the skin that can potentially cause scarring. When DLE affects the scalp, it may cause scarring alopecia. A variety of treatments are available, although topical steroids, steroids injections, calcineurin inhibitors, and hydroxychloroquine (HCQ) are first-line treatments in my practice.

Liang K R et al, 2024

I enjoyed reading a case report of a very nice response of a patient with DLE to treatment with HCQ. The study was conducted by Liang et al. in the journal Cureus. The patient presented was a 46-year-old female with isolated scalp DLE. A biopsy confirmed the diagnosis. The patient first underwent several therapy trials without help, including intralesional corticosteroids, topical tacrolimus and topical corticosteroids.

Here is a photo of the scalp before successful therapy:

Initial appearance of discoid lupus in a 46 year old patient. Source: Liang K R, Lee C, Hilts A, et al. (June 28, 2024) Resolution of Discoid Lupus Alopecia With Systemic Hydroxychloroquine and Topical Pimecrolimus Combination Therapy. Cureus 16(6): e63419. doi:10.7759/cureus.63419

Hydroxychloroquine and Pimecrolimus Stopped Disease and Regrew Hair

Treatment with hydroxychloroquine and topical pimecrolimus ultimately led to a halting of inflammation and some degree of regrowth. Improvement was noted within 8 weeks, and significant hair regrowth was noted at 12 months.

Here are “before and after” photos the authors present:

Source: Liang K R, Lee C, Hilts A, et al. (June 28, 2024) Resolution of Discoid Lupus Alopecia With Systemic Hydroxychloroquine and Topical Pimecrolimus Combination Therapy. Cureus 16(6): e63419. doi:10.7759/cureus.63419

After 1 year of treatment the authors report complete resolution

The authors report complete resolution after 1 year. Source: Liang K R, Lee C, Hilts A, et al. (June 28, 2024) Resolution of Discoid Lupus Alopecia With Systemic Hydroxychloroquine and Topical Pimecrolimus Combination Therapy. Cureus 16(6): e63419. doi:10.7759/cureus.63419

COMMENT

I liked this paper. My treatment ladder for DLE puts hdyroxychoroquine (Plaquenil) front and center as a key first-line agent along with topical steroids, steroid injections, and topical tacrolimus or pimecrolimus. This case report by Liang et al. highlights the benefits of evidence-based decision-making when selecting treatments.

The only concern I have with this paper is that 200 mg twice daily of hydroxychloroquine is rarely a good dose for women. I don’t know the patient’s weight, so I can’t comment on the dose and whether it’s appropriate. However, the dose is 5 mg/kg body weight or 6/6 mg /kg ideal body weight (lean body weight)—whichever is lower. For many women, a dose of 400 mg is just too high.

Options like methotrexate or acitretin are second line agents in my practice - the side effects are much greater than HCQ. The authors of this study remind us that methotrexate and retinoids are similarly effective to HCQ. With fewer side effects with HCQ, it just makes sense to keep this as a first line agent.

REFERENCE

Liang K R, Lee C, Hilts A, et al. (June 28, 2024) Resolution of Discoid Lupus Alopecia With Systemic Hydroxychloroquine and Topical Pimecrolimus Combination Therapy. Cureus 16(6): e63419. doi:10.7759/cureus.63419

Topical tofacitinib for FFA : Yes, it's on the list!

Topical tofacitinib for LPP and FFA

Oral and topical JAK inhibitors continue to be studied in scarring alopecia. A small number of studies point to potential benefits of oral and topical JAK inhibitors in the treatment of lichen planopilaris and frontal fibrosing alopecia. Topical JAK inhibitors have an obvious interest given that they have less systemic absorption than oral JAK inhibitors. This is important given that oral JAK inhibitors come with their share of side effects including infections, blood test abnormalities, and other issues. To date, there have only been a limited number of patients who have been reported to use topical JAK inhibitors to treat their scarring alopecia. These were 2 cases of women with FFA who showed improvement with the use of tofacitinib 2% cream.

Li-Chi Chen et al. 2024

A new study from Boston retrospectively examined how well patients did with topical tofacitinib treatments. There were 37 female and 4 male patients in this study. Most were white (90.2%). Most had FFA (75.6%), or LPP/FFA overlap (17.1%). 7.3 % had classic LPP without typical FFA. The average age at diagnosis was 57.8 years and the mean disease duration was 4.6 years.

Topical tofacitinib 2% cream was used as the sole therapy in one-quarter of patients (24.4%) and as an adjunctive treatment in three-quarters of patients (75.6%). The average duration of treatment duration was 9.0 months. 60 % used the topical tofacitinib 2-3 times daily, and 40 % used it 1-2 times daily.

All in all patients using topical tofacitinib demonstrated a significant reduction in LPPAI scores after receiving topical tofacitinib. LPPAI scores fell from 3.03 before treatment to 1.40 after treatment. This represented a 48% decrease in LPPAI score at 6 months

What was more important in this study was the data on hairline outcomes. Topical tofacitinib seemed to help stop the progression of hairline recession. Of 38 patients with FFA or FFA/LPP overlap, 31.6% had improvement and 60.5% had stabilization of the frontotemporal hairline. About 8% of patients using topical tofacitinib really didn’t see much benefit. Side effects were mild and included irritation in 2 patients and acne in 1 patient. 1 patient ultimately discontinued the treatment due the scalp irritation.

COMMENT

I really liked this study. It shows clear evidence that topical tofacitinib does something positive for patients with FFA and LPP. Almost 60% of patients in this study were using topical tofacitinib twice per day - so this is a pretty committed group. Topical tofacitinib is not cheap - so this sort of dedication sure comes with a cost.

I like this study because it gives me practical and useful information to share with patients. At least in this study 41.6% of patients had improvement and 60.5% had stabilization of the frontotemporal hairline. I’m always a bit skeptical of data on stabilization as it can take 2 years to really confidently prove there is stabilization, but certainly, the data on improvement and the overall trend is really encouraging.

I’ve been using topical tofacitinib in several of my FFA patients with reasonable benefit in some patients but not all. One problem of using topical tofacitinib is that there is no standard formula. I have creams and gels in my toolbox and they sure seem to work differently in different patients. This is the main problem with all topical compounded products. My topical tofacitinib is different than the topical tofacitinib used in this particular study - so is this study relevant to my own patients? Probably there is some relevance!

In conclusion, this is the first good size study of topical tofacitinib in FFA/LPP.

REFERENCES

Li-Chi Chen, Chino Ogbutor, Kristen J Kelley and Maryanne M Senna. Topical tofacitinib for patients with lichen planopilaris and/or frontal fibrosing alopecia. J Am Acad Dermatol. 2024 Jun;90(6):1260-1262. doi: 10.1016/j.jaad.2024.01.060. Epub 2024 Feb 2.

Yang C.C., Khanna T., Sallee B., Christiano A.M., Bordone L.A.: Tofacitinib for the treatment of lichen planopilaris: a case series. Dermatol Ther 2018; 31:

Moussa A., Bhoyrul B., Asfour L., Kazmi A., Eisman S., Sinclair R.D.: Treatment of lichen planopilaris with baricitinib: a retrospective study. J Am Acad Dermatol 2022; 87: pp. 663-666.

Plante J., Eason C., Snyder A., Elston D.: Tofacitinib in the treatment of lichen planopilaris: a retrospective review. J Am Acad Dermatol 2020; 83: pp. 1487-1489.

Baricitinib for Pediatric Patients with Severe AA

New Study Supports Effectiveness of Baricitinib in Pediatric Patients

JAK inhibitors are increasingly used for the treatment of severe AA. In 2023, the JAK inhibitor ritlecitinib became the first drug approved by FDA for treating alopecia areata in individuals in the 12 - 18 age group. Of course, the drug is approved for adults as well. But what’s unique about ritlecitinib is its approval in the 12-18 age group.

I can only imagine that we’ll be seeing more and more and more approvals for alopecia areata drugs in the pediatric population. Advanced alopecia areata affects a significant number of children. Children and adolescents respond just as well to these drugs as adults - and have fewer side effects.

Baricitinib for Alopecia Areata in Pediatric Patients.

It should be no surprise then that a handful of studies have already emerged examining the benefits of baricitinib in the treatment of alopecia areata in children and adolescents.

A new study from China reported outcomes of 10 pediatric patients with severe AA receiving baricitinib. Patients ranged in age from 1 year and 10 months to 13 years so there were some pretty young patients in this study. In fact, 75% were under 6.5 years. There were 5 male patients and 5 female patients.

The median baseline SALT score was 87.50 indicating fairly advanced AA to start with. The median age of onset of AA was 3 years and the median duration of the current episode of AA was 3 months. Most patients had been on other treatments before starting baricitinib, including topical steroids (8 patients), steroid injections ( 8 patients), oral steroids (4 patients), methotrexate (2 patients and tofacitinib (1 patient).

In this study, pediatric patients received 2 mg per day except for 1 patient who failed 2 mg and received 4 mg. Unfortunately, the exact protocol of this study was not clear to me. It appears the authors reduced the dose to half in patients who achieved a SALT score of 20 or less at 12 weeks.

All in all the median duration of treatment was 15 months. At week 36, 80 % of patient had a SALT score 20 or less.

Side effects were mild and just one patient experienced temporary mild neutropenia.

What was interesting in this study is what happens when the drug is stopped. Patients in this study were followed to see what happens after the drug is stopped. 4 of 9 patients still had complete remission with a follow-up of 22.5 months. 5 patients relapsed after stopping the drug, with an average time to relapse of 14.2 months.

COMMENT

This is another study for the books for JAK inhibitors in young children. I suspect this will be an increasing trend in our field. I’m not particularly focused on the great success of JAK inhibitors in this particular study because it included some patients with less severe forms of AA and the average (median) duration of alopecia was just 3 months. Clearly we expect better success in less severe forms and those with shorter duration of AA. Nevertheless, this study is a nice reminder that JAK inhibitors tend to be well tolerated in children, but lifelong treatment is probably going to be the norm for most patients with severe forms of AA. Long-term side effects of continuous JAK inhibitor therapy are completely unknown at the present time.

REFERENCES

Zhao M et al. Baricitinib therapy for paediatric patients with severe alopecia areata. J Eur Acad Dermatol Venereol. 2024 May 22.

Zhan J et al. Real-data on the use of baricitinib in adolescents with severe alopecia areata. J Eur Acad Dermatol Venereol. 2023 Apr 17. doi: 1

Moussa A et al.Treatment of moderate-to-severe alopecia areata in adolescents withbaricitinib: a retrospective review of 29 patients. J Am Acad Dermatol.2023;88(5):1194–6.3.

Asfour L et al.Treatment of moderate-to-severe alopecia areata with baricitinib in preadolescent children. Br J Dermatol. 2023;189(2):248–50

Generic Tofacitinib for Treating Severe Alopecia Areata: Where does it fit in?

Generic Tofacitinib for Alopecia Areata

The JAK inhibitors ritlecitinib and baricitinib are approved by many health regulatory bodies across the world for the treatment of advanced alopecia. Baricitinib was FDA approved on June 13, 2022 and ritlecitinib was FDA approved on June 23 2023.

Even though it’s not formally stamped with the seal of approval, tofacitinib has been used ‘off-label’ for treating alopecia areata since 2015. The world has a lot of experience treating alopecia areata with tofacitinib. While the clinical trial data is not as rigorous for tofacitinib as for baricitinib or ritlecitinib, we sure have a good amount of experience with tofacitinib. Quite a few reasonably good studies to back up its effectiveness.

Generic tofacitinib is now available and offers a cost savings over brand name tofacitinib (Xeljanz). The drug is just a small fraction of the cost of oral ritlecitinib or oral baricitinib.

I was very interested to read a recent study investigating the benefits of generic tofacitinib for treating alopecia areata.

Jian  J et al. 2024

Authors conducted a retrospective study evaluating the efectiveness and tolerability of generic tofacitinib in patients with AA. The study included patients with AA who received at least 6 months of treatment with generic tofacitinib. Efficacy was determined by the Severity of Alopecia Tool (SALT).

A total of 20 patients (median age 24  years) with a median baseline SALT score of 87.5 (IQR 72.5–95) treated with generic tofacitinib were enrolled. 2 patients had totalis and 10 patients had universalis.

These 20 patients had a mean follow-up duration of 11.7 months. 50% or so received 10 mg and 25 % received 15 mg. At the end of follow-up, 95% of patients noted a noticeable change in scalp appearance (increased scalp coverage with hair. The authors found that an absolute SALT score<20% was achieved by 15 of 20 patients (75%) at week 24. Only one patient discontinued taking tofacitinib because of lack of efficacy.

COMMENT

I liked this study. Granted, it’s a small study and it’s not an elegant randomized controlled study. But the follow-up interval was reasonably good (at least for typical studies in our field) and the conclusion was pretty clear: A large proportion of patients with alopecia areata using generic tofacitinib had improvement in their hair and side effects were low. Most patients stuck to standard dosing (5 mg BID) but some patients did use 15 mg doses.

I’ve been using JAK inhibitors for almost a decade now - starting, of course, with tofacitinib. From tofacitinib, I have added ruxolitinib, baricitinib, ritlecitinib and upadacitinib to my JAK inhibitor toolbox.

In the last year or two, we’ve switched some of our patients from brand name tofacitinib (i.e. our Xeljanz patients) to generic tofacitinib. At first, I did this with trepidation. What if it does not work as well? What if we lose the good regrowth the patient had on tofacitinib brand name (Xeljanz)? Surprisingly, patients have been doing great and there has been no real evidence of deterioration or flare when using generic tofacitinib.

The main benefit of the switch has been the cost savings. Here in Canada, brand name tofacitinib Xeljanz is about $ 1,706 CAD per month and generic is about $453 CAD. This compares to about $ 4,000 for baricitinib.

Let’s face it. There are some tough discussions to make in this new JAK inhibitor era. For those who only use FDA-approved or Health Canada-approved drugs (or EMA-approved drugs), you’re not going to be up for a discussion or the tough realities that exist for patients.

Being a physician is not about connecting people with drugs. It’s not a matching game of “disease A” gets approved “drug B”. Rather, being a physician is about understanding each patient and their unique circumstances and connecting them with a treatment plan which meets their specific goals and objectives and is in line with their risk tolerance. Being a physician is about understanding very well what I call the SAFE principle. The ideal treatment is very SAFE, very AFFORDABLE, very FEASIBLE to use AND very EFFECTIVE.

The ideal treatment for the patient in front of me today is the one that aligns best with the patient’s views of the importance of each of these categories.

When it comes to comparing JAK inhibitors, there is a lot we still don’t know. We’d like to feel that new JAKs are safer for specifically treating alopecia areata than old JAKs but there is no good data really to support that. Maybe there will be someday or maybe the old JAKs will prove safer. Who knows. We know the new JAKS are astronomically more expensive so that category has no debate. The feasibility is about the same - all JAKs are pretty easy to use. As far as effectiveness. we’ve not seen a huge signal that any given JAK is dramatically better than another. Sure, there might be slight differences but nothing is dramatic quite yet. All of our current JAK inhibitors help some patients and do absolutely nothing for others.

The SAFE principle is a guiding principle and will always be a guiding principle for me. Different patients place different emphasis on different components of the SAFE principle. For some, the cost of a medication is everything - it’s the key deciding factor. If drug A causes cancer in 1 in 10,000 people and drug B has no risk of cancer at all but drug A is $ 100 per month and drug B is $2000 per month, there are many people that will choose drug A over drug B. There are also many people who will reject drug A and choose drug B any day over drug A.

We must never forget the SAFE principle.

FDA approval does not mean complete safety. It means reasonable safety. FDA approval does not mean affordable. The FDA has nothing to do with that. FDA approval does not mean a drug is feasible to use. FDA approval does not mean effective. FDA approval often equates to some inkling of effectiveness but many rather ineffective drugs still can - and have - received approval.

This study reminds us that in 2024 generic tofacitinib is still there in the alopecia areata treatment toolbox. I prescribe ritlecitinib, baricitinib, upadacitinib and tofacitinib. Why is that? Because I don’t believe in templates and don’t work the mindset that disease A gets drug A. I treat individual patients with treatments that align with their values. Once I understand a patient’s risk tolerance, insurance coverage (or lack thereof) and treatment expectations, I can plan out which JAK inhibitor makes sense (if it make sense to start a JAK inhiibitor at all).

REFERENCE

Jian  J et al. Effectiveness and safety of generic tofacitinib in alopecia areata: is the generic a cost-effective option? A retrospective study. Arch Dermatol Res. 2024 May 11;316(5):154. doi: 10.1007/s00403-024-02879-4.

Vaccination before Starting Biologics: Are We Going a Good Job?

New study Suggests We Don’t Vaccinated Enough - Especially our Younger Patients

There is a great deal of information that must be conveyed to patients before starting JAK inhibitors. One of these is a review of infections and ways to reduce the risk of infection through vaccination.

Immunization against zoster, influenza and pneumococcus are generally recommended before starting JAK inhibitors. For example, zoster is recommended at age 19 or above now by the CDC (and 50 years of age and over in the general population). Influenza is recommended yearly. Pneumococcous is now recommended at 19 and over in immunocompromised patients (rather than 65 years in the general population).

Review of other vaccinations such as meningococcus, Haemophilus influenzae type b, Neisseria meningitidis, hepatitis B, diphtheria and tetanus, HPV can also be reviewed.

Hren and Khattri, 2024

A new study reminds us all that we are not getting our patients vaccinated before starging biologics and JAK inhibitors as often as we should be!

Authors from New York reviewed patients  ≥ 19-years-old prescribed a biologic or JAK inhibitor for a range of immune diseases. (including atopic dermatitis, psoriasis, psoriatic arthritis, and alopecia areata) between 10/2003 and 10/2023 at a large tertiary institution.

Overall, vaccination rates among patients on biologics and JAK inhibitors were low, with rates being significantly lower in patients 19-64 years-old, compared to those ≥ 65 years-old for most disease states (p < 0.01).

Among patients with atopic dermatitis, psoriasis, and alopecia areata, on average, 9.39% were vaccinated for influenza, 6.76% for herpes zoster, 16.56% for pneumococcal pneumonia, and 63.98% for COVID-19. Only 3.16% of patients were adequately vaccinated for HepB after an abnormal HepB SA test.

Specific rates for alopecia areata are shown in the chart below:

Comment

This study is a nice reminder that our patients are not being vaccinated as often as they should. There is clearly a very large amount of room for improvement! It’s not always known that patients 19 and over can receive the zoster vaccine and the pneumococcal vaccination series. Drug companies often inquire about the tuberculosis status of patients before starting the drug - but perhaps more emphasis can be given to thoroughly reviewing the vaccination status of patients. There is a lot of talk about before starting JAK inhibitors.

Overall, more training of physicians is needed to ensure that patient safety on JAK inhibitors is maximized.

REFERENCE

Hren MG and Khattri S. Low rates of vaccination among atopic dermatitis, alopecia areata, psoriasis, and psoriatic arthritis patients on biologics. Arch Dermatol Res. 2024 May 25;316(6):285.

Infectious Diseases with JAK Inhibitors for Alopecia Areata

 1 in 3 Patients Using JAK Inhibitors Will Have Some Sort of Infection

Authors from Italy set out to retrospectively review infectious disease events in patients receiving JAK inhibitors over the period from July 2021 to October 2023. There were 91 patients in their study, including 85 treated with baricitinib and 6 with upadacitinib. There were no patients treated with ritlecitinib in this particular study as ritlecitinib had not been approved in Europe until Sept 2023.

The authors observed 34 infectious events in 28 patients (30.8%). Five patients had multiple infectious events (5.5%).

Patients in this study were followed for a minimum of 7.1 weeks up to a maximum of 88.7 weeks, with a mean of 32  weeks. The onset of infectious events ranged from a minimum of 1 week to a maximum of 52 weeks, with a mean of 11.4 weeks.

Of the 34 total infectious events, 17 were viral (50.0%), 14 were bacterial (41.2%) and 3 were fungal (8.8%). The most frequent infections were upper respiratory tract infections (URTI) (8.8%), herpes simplex virus (HSV) infections (6.6%) candidiasis (3.3%), folliculitis (2.2%), conjunctivitis (2.2%) and gingival infections (2.2%). Seventeen patients (60.7%) suspended treatment with the JAK inhibitor until the infection was clinically resolved. The interruption time ranged from a minimum of 2 days for minor events such as herpes labialis to a maximum of 90 days in case of

pneumonia. The mean interruption time was 13.4 days. There was only one patient where the JAK inhibitor needed to be stopped permanently. This was a 26-year-old woman with concomitant atopic dermatitis who presented multiple cutaneous abscesses resistant to both topical and systemic antibiotics

Comments

This was a helpful study that showed that 30% of the patients developed at least one infectious event. 5 % have multiple. Prescribers of JAK inhibitors need to be aware and prepared for 1 in 3 patients contacting them about infectious diseases. This is similar to the clinical trials where about 30 % of patients developed infections. This does not mean that the Jak inhibitor caused the infection. What’s so interesting about the randomized controlled trials is that they showed that both patients using JAK inhibitors and patients using placebo had a great number of infectious.

For example in the BRAVE AA 1 trial, infections occurred in 31.4% of patients treated with 4-mg baricitinib, 25.1% with 2-mg baricitinib - and 28.0% with placebo!   The fact that there is a similar rate of infections in treatment and placebo groups suggest that the JAK inhibitor might not always be to blame!

URTIs were among the most common infection in this study and were seen in 8.8% of patients. This is similar to baricitinib clinical trials reporting this side effect in 7.6% of patients receiving 4-mg group. The high rate of HSV infection in this study -  6.6% - was higher than the 1.3 % seen in baricitinib 4 mg groups. Interestingly there were no cases of zoster in this study. That’s something that was seen in 1 % of 4 mg baricitinib users and 0.5% of placebo in the original BRAVE AA trials.

Stopping treatment in patients with serious infection is the way to go. In this study 60% of patients needed top stop. With a mean of 13.4 days, this study reminds us that it’s not always a 1 or 2-day stoppage. Patients need to be prepared to stop until they are better.

Vaccinations could be helpful to reduce the risk of some infections. These include vaccinations against zoster, pneumococcus and influenza among others. Studies have shown that patients using JAK inhibitors are generally not adequately vaccinated before starting treatment.

REFERENCE

Giacomo Caldarola et al. Infectious events in patients with alopecia areata treated with JAK inhibitors: low burden and minimal impact on persistence in treatment. Expert Opin Drug Saf. 2024 May 8:1-5.

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

Minoxidil and Occular Hypertension: Is there a link ?

Are there any concerns about minoxidil use in patients with glaucoma?

There is no good evidence to date that topical minoxidil has a major effect on ocular pressures. However, there are dozens and dozens of reports in the medical literature about eye-related side effects with minoxidil. The question then becomes - is minoxidil truly responsible for a particular side effect and if so - how common is this side effect?

This is the case for minoxidil and glaucoma. Over the years, there have been grumblings that minoxidil somehow affects eye pressures in some people. Despite the grumblings, there is really no good evidence to support direct link.

Glaucoma is fairly common. About 1 in 50 people over the age of 40 have glaucoma. Hair loss is pretty common too. A large proportion of adults over the age of 40 have some sort of hair loss. So that means there is going to be lots of people with glaucoma who have hair loss and lots of people with hair loss who have glaucoma. It also means there are going to be lots of people with hair loss who start treatments who develop glaucoma.

Erichev VP et al. 2024

A new report by Erichev and colleagues describes a 31-year-old male patient who presented with complaints of diplopia and increased intraocular pressure (IOP) up to 30 mm Hg (normal is less than 21 mm Hg). The patient had been using minoxidil topically for androgenic alopecia for 8 years. The patient responded well to discontinuation of minoxidil and topical therapy with prostaglandin analogues. After 4 months, an attempt was made to replace topical hypotensive therapy with carbonic anhydrase inhibitors, but the previous hypotensive regimen had to be resumed due to an increase in IOP. During 10 months of observation, no signs of progression were detected.

Comment

This study is interesting - but like so many manuscripts and reports on the subject - does not prove the minoxidil caused the increased eye pressures. If minoxidil caused increased pressures, would we expect the pressures to rise sooner than 8 years? If minoxidil caused increased pressures, would simply stopping the drug (without using other drugs) be sufficient for treatment?

This is an interesting paper that keeps us thinking.

All patients with glaucoma need periodic follow up for their glaucoma and periodic testing for eye pressures. Further study and more rigorous documentation of eye pressure changes following minoxidil initiation will allow us all to determine if truly minoxidil affects eye pressure.

REFERENCE

Erichev VP et al. Vestn Oftalmol. 2024;140(2. Vyp. 2):90-93. doi: 10.17116/oftalma202414002290.[Minoxidil-induced ophthalmic hypertension (case report)]

Hair Repigmentation from the Drug Acitretin in an 80 Year old Man

50 mg Acitretin Caused Hair Repigmentation after 20 months of Treatment

I read with great interest a nice report by Dr Eunice Chow and Dr Thomas Salopek from the University of Alberta regarding an 80-year-old man who had remarkable hair repigmentation after using the vitamin A derivative acitretin.

The man was diagnosed with a skin condition known as pityriasis rubra pilaris (PRP) and was started on acitretin 40 mg daily and then increased to 50 mg once daily. His medical history included hypertension and diabetes. His medication list also included aspirin, betamethasone valerate 0.1% cream, hydrocortisone valerate 0.2% cream, indapamide, lisinopril, and metformin. After 18 months of treatment with acitretin and topical steroids, he resolved all cutaneous and nail changes completely. What was so interesting about this report was that by the 20th month, he started noticing that his previously white hair started to darken ! A photo from this nice report is shown below:

Hair repigmentation in a patient using acitretin. FROM: Chow  EY and Salopek TG. Acitretin-Induced Repigmentation of Gray Hair: A Case Report. Cureus. 2024 Apr 14;16(4):e58261. doi: 10.7759/cureus.58261. eCollection 2024 Apr.

Other Reports of Acitretin-Induced Repigmentation

The authors point out that this is not the first report of acitretin causing repigmentation. There are, in fact, a few other reports in the medical literature (see reference below). However, most other reports describe patients who not only experienced hair repigmentation but also experienced curling of the hair. What was unique about this report is that the patient experienced repigmentation but not hair curling.

Hair repigmentation has also been reported with etretinate therapy (another retinoid) and I’ve put this reference in the reference list too

Why would acitretin darken hair?

The authors point out that the exact mechanism by which acitretin darkens hair is not known. The authors propose that several mechanisms could be important. One such mechanism is the ability of acitretin to lower IL-6 levels. IL-6 normally functions to inhibit melanogenesis so lowering IL-6 could favor pigmentation. Another possible mechanism is through acitretin’s ability to increase retinoic acid and, in turn, upregulate the C KIT receptor (which would sensitive melanocyte stem cells to the KIT ligand).

Summary and Conclusion

This was a nice report that reminds us all to keep acitretin on our list of drugs that cause hair repigmentation.

The authors remind us in their report that several classes of drugs can induce hair repigmentation. These include:

a) monoclonal antibodies (adalimumab, dupilumab, checkpoint inhibitors, secukinumab, Ustekinumab

b) tyrosine kinase inhibitors (imatinib, sorafenib, erlotinib, dasatinib_

c) immunosuppressants (thalidomide, cyclosporine and prednisone)

d) others (retinoids, interferons, latanoprost, tamoxifen, levodopa, L-thyroxine, others)

REFERENCE

Chow  EY and Salopek TG. Acitretin-Induced Repigmentation of Gray Hair: A Case Report. Cureus. 2024 Apr 14;16(4):e58261. doi: 10.7759/cureus.58261. eCollection 2024 Apr.

Seckin D, Yildiz A. Repigmentation and curling of hair after acitretin therapy. . Australas J Dermatol. 2009;50:214–216.

Ward PD, Miller HL, Shipman AR. A case of repigmentation and curling of hair on acitretin therapy. . Clin Exp Dermatol. 2014;39:91–92.

Nagase K, Inoue T, Narisawa Y. Manifest hair repigmentation associated with etretinate therapy. J Dermatol. 2017;44:0–5.

Hair Loss with Tepezza

TEPEZZA (teprotumumab-trbw) Causes Hair Loss

TEPEZZA (teprotumumab-trbw) is an insulin-like growth factor-1 receptor inhibitor indicated for the treatment of thyroid eye disease. Clinical studies have shown that about 13 % of patients using this drug have hair loss compared to 8% of controls.

I was interested to read a report by Wang et al of side effects of TEPEZZA (teprotumumab-trbw) found in the FDA Adverse Events Reporting System database. Alopecia was ranked the sixth most common side effect and had a reporting odds ratio of 7.84 (with a confidence interval of 6.75–9.1).

This study reminds us of the hair loss associated with TEPEZZA (teprotumumab-trbw). Patients receiving this drug for thyroid eye disease must be aware of this side effect.

REFERENCE

Wang X-L et al. An observational study on the safety of teprotumumab based on FAERS database. Endocrine. 2024 May 17. doi: 10.1007/s12020-024-03852-x. Online ahead of print.

Another Study Highlights Alopecia Areata Risk Following COVID19

COVID 19 Increases the Risk of Alopecia Areata

A study examining claims data from Japan and Korea showed that patients with COVID-19 infection were at increased risk for developing alopecia areata. Specifically, SARS-CoV-2 infection was associated with a 66 % increased risk of incident AA (aHR, 1.66; 95% CI, 1.38-1.99).

Interestingly, having severe COVID-19 infection increased the risk of alopecia areata, but having two or more doses of the COVID-19 vaccine before infection decreased the risk of developing AA.

REFERENCE

Kyung S et al. Risks of alopecia areata in long COVID: Binational population-based cohort studies from South Korea and Japan. J Med Virol. 2024 May;96(5):e29668.

Bicalutamide 50 mg Superior to Spironolactone 100 mg in FPHL

Bicalutamide 50 mg more effective than Spironolactone 100 mg

I was very interested to read a study from India which set out to compare the effectiveness of spironolactone and bicalutamide in the treatment of female-pattern hair loss (FPHL). The study was a retrospective study of 120 female patients 18-50 years of age who used these drugs. Group A comprised patients who were taking 100 mg of spironolactone once daily, along with 2% minoxidil and Group B comprised patients who were taking 50 mg of bicalutamide once daily along with topical minoxidil 2%. Patients were analysed at approximately 24 weeks from the start of the treatment.

24 week results showed a mean reduction in hair loss severity score on the Sinclair scale of 19.51% in spironolactone group compared to 28.20% in bicalutamide group. This was felt to be statistically significant. On global photographic assessment, researchers found a greater improvement in the bicalutamide group compared to the spironolactone group, although this was not significant (p = 0.139).

Conclusions and Comments

With a study design like this, it’s really hard to say if bicalutamide truly beats our spironolactone. One things this is not - is a randomized controlled trial. The study uses Sinclair scales as opposed to quantitative measurements which makes it challenging to really offer definitive conclusions. However, it sure does seem that spironolactone and bicalutamide area in a similar league of effectiveness - and both appear to be good options for FPHL.

More studies are needed.

REFERENCES

Abhijeet Kumar Jha et al. Efficacy and safety of spironolactone versus bicalutamide in female pattern hair loss: A retrospective comparative study. Australas J Dermatol. 2024 May 19.doi: 10.1111/ajd.14306. Online ahead of print.

Thinking of Using Oral Minoxidil Above 5 mg? Maybe think again!

Higher Doses of Oral Minoxidil Increase Heart Rate

I read with interest another nice study by our Brazilian colleagues. The authors set out to understand the effects of higher doses of oral minoxidil (ie above 5 mg) on blood pressure and heart rate in males.

The authors studied 11 males. These males had been using 5 mg oral minoxidil for 24 weeks as part of the authors’ prior research. At 24 weeks, the dose was increased to 7.5 mg. The authors wanted to see what would happen to various hemodynamic parameters like blood pressure and heart rate in males using higher doses.

The mean age of patients in this study was 37.9. 73% were white, 18 % were brown and 9% were black. Heart rate increased from 72.6 before treatment to 75.7 at week 24 (with the 5 mg dose) to 81.3 at week 30 (with the 7.5 mg dose). The change in heart rate from before treatment to week 30 was found to be statistically signficant. Mean arterial pressure, systolic blood pressure and diastolic blood pressure were not altered by either than 5 mg or 7.5 mg doses.

Comment

I think this is really helpful. We know that oral minoxidil increases heart rate. In fact this was one of the major problems with using oral minoxidil in the 1970s and 1980s for blood pressure control. The increase in heart rate that was seen often required a beta blocker to reduce the heart rate.

It appears that for many males, oral minoxidil has a safe threshold of around 5 mg. Now, it would be a big mistake to think that all males have this magic cut off o 5 mg That’s just simply not the way human beings work. Some males are going to experience a rise in heart rate at lower doses and some not until even higher doses. But on average this study reminds us that doses over 5 mg are particularly more likely to raise the heart ratre.

I think it’s great to see that higher doses of oral minoxidil did not affect blood pressure. However, I don’t personally think it’ a good idea to have 8 more beats of the heart per minute if it’s not necessary. That’s 4 million more beat per year! Yikes.

As a disclaimer, I’m not a cardiologist. However, I am a medical doctor. I do have a heart, and I am very interested in understanding how to keep it healthy. Through the years, I’ve come to understand that lower heart rate correlates with longevity in many animal models, including humans. I am concerned about any drug that increases heart rate. The world famous Framingham Heart Study taught us that an increased heart rate increases the likelihood that a person will develop heart failure and cardiovascular disease. Higher heart rate was also associated with higher all‐cause and cardiovascular mortality.

In short, I’m concerned about any dose that increases heart rate!

Keeping oral minoxidil at doses 5 mg or less makes good sense. Sure, we’ll get better results above 5 mg but that’s not how we practice medicine. Many hair loss conditions are best treated with higher does than standard. it’s the side effects that limit the dosing.

The authors of this study state that “doses above 5 mg should not be considered the standard for hair loss treatment and should only be used in exceptional circumstances.” This sounds really wise although I can’t see myself supporting 7.5 mg all that often.

Congratulations to the authors for another nice study.

REFERENCES

Baltazar Dias Sanabria et al. Oral minoxidil 7.5 mg for hair loss increases heart rate with no change in blood pressure in 24 h Holter and 24 h ambulatory blood pressure monitoring.An Bras Dermatol. 2024 May 20:S0365-0596(24)00097-7.

Ho Je et al. Long‐term Cardiovascular Risks Associated With an Elevated Heart Rate: The Framingham Heart Study. J Am Heart Assoc. 2014 Jun; 3(3): e000668.

New Study Highlights Risks for Hydroxychloroquine Retinopathy

Hydroxychloroquine Retinopathy and my ABCDEFG Memory Tool

If you’ve followed my discussions and topics for a while now, you’ll probably have come to see that hydroxychloroquine retinopathy is something I talk about fairly often. Please consider reviewing the following links if interested.

Jorge AM et al. 2023

A new study set out to identify risk factors for hydroxychloroquine retinopathy. The researchers evaluated 4,677 long-term hydroxychloroquine users. This included 83 % females and 13 % males. The mean age at the start of hydroxychloroquine treatment was 52 years. There were 125 patients that developed hydroxychloroquine retinopathy within 15 years (102 parafoveal, 23 pericentral).

The following were the risk factors for developing hydroxychloroquine retinopathy:

a) Older age at time of hydroxychloroquine initiation

The adjusted hazard ratios (HRs) were 2.48 (95% CI, 1.28-4.78) for those aged 45 to 54 years, 3.82 (95% CI, 2.05-7.14) for those aged 55 to 64 years, and 5.68 (95% CI, 2.99-10.79) for those aged 65 years or older compared with those younger than 45 years.

b) Females

The risk of retinopathy was higher among females than males (HR, 3.83 [95% CI, 1.86-7.89])

c) Chronic Kidney Disease

The risk of retinopathy was higher among patients with chronic kidney disease stage 3 or greater (HR, 1.95 [95% CI, 1.25-3.04]) compared to lower stages

d) Tamoxifen Use

The risk of retinopathy was higher and among individuals with tamoxifen use (HR, 3.43 [95% CI, 1.08-10.89]).

e) Race

The likelihood of pericentral retinopathy was higher among Asian patients (HR, 15.02 [95% CI, 4.82-46.87]) and Black patients (HR, 5.51 [95% CI, 1.22-24.97]) compared with non-Hispanic White patients.

Conclusions and Comments

This was an interesting study and adds to our growing body of literature highlighting the risk factors for hydroxychloroquine retinopathy. Many of the risks shown in this study are not new but this study captures the magnitude of the risk in ways that not all prior studies could. I use the ABCDEFG memory tool in my practice to capture the risk factors associated with hydroxychlorquine retinopathy:

A = Age

B = Black and Asian patients

C = Cancer drugs (mainly tamoxifen)

D = Duration and Dose of the drug

E = Eye diseases (ie prior macular disease makes screening more difficult)

F = Females

G = Glomerular filtration (ie chronic kidney disease).

REFERENCES

Jorge AM et al. Risk Factors for Hydroxychloroquine Retinopathy and Its Subtypes. JAMA Netw Open. 2024 May 1;7(5):e2410677.

Down Syndrome: Six Fold Increased Risk of Alopecia Areata

Altered Immune System Function Leads to Increased Risk of Alopecia Areata in Down Syndrome

It’s well known that patients with Trisomy 21 (Down syndrome) are at increased risk for a variety of immune mediated and autoimmune mediated medical conditions.

Dermatological Conditions that may be more common in Down Syndrome include:

1. Dry Skin and Ichthyosis

2. Keratosis pilaris

3. Pityriasis rubra pilaris

4. Elastosis perforans serpiginosa

5. Seborrheic Dermatitis

6. Palmoplantar keratoderma

7. Psoriasis

8. Cafe au lait macules

9. Lumbosacacral dermal melanosis

10. Syringomas

11. Geographic tongue

12. Angular cheilitis

13. Vitiligo

14. Alopecia areata

15. Fungal infections

16. Folliculitis

17. Lichen nitidus

18. Hidradenitis

19. Blood disorders

Alopecia Areata In Patients with Trisomy 21

I read with interest a recent study that examined the prevalence of different immune related diagnoses in a cohort of 1299 patients with Down syndrome compared to a 2605 patient control cohort at the Mount Sinai Health System in New York, NY. The evaluation spanned about 18 years of data.

Individuals with trisomy 21 had a six fold higher odds of alopecia areata compared to controls (OR 6.06, p = 0.01).

Other conditions that were increased in alopecia areata included sepsis (OR 4.79, p < 0.001, purpura and other hemorrhagic conditions (OR 2.31, p < 0.001), rosacea (OR 3.11, p < 0.001). In this particular study, there was a lower odds of a diagnosis of herpesviral infection (OR 0.42, p = 0.01), and viral warts (OR 0.51, p = 0.04).

Patients with Down Syndrome have an increased risk to develop alopecia areata.

Comment and Summary

It’s well known that the immune system functions slightly differently in patients with Trisomy 21 compared to controls. Past studies have highlighted several skin issues that are more common in patients with Trisomy 21. Alopecia areata is more common in patients with Trisomy 21 and past studies have put the number at around 10 % (compared to 2 % in the general population). This study by Gansa et al agrees with the general trend of prior data. Alopecia areata in patients with Down Syndrome tends to give more hair loss than seen in patients without Down syndrome.

REFERENCE

Gansa W et al. Dysregulation of the Immune System in a Natural History Study of 1299 Individuals with Down Syndrome. J Clin Immunol. 2024 May 22;44(6):130. doi: 10.1007/s10875-024-01725-6.

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Anabolic Steroids may cause hair loss in about 25% of Users

Side Effects of Anabolic Steroids: Hair Loss Among the Topic Side Effects

I work with many athletes and bodybuilders who experience hair loss from anabolic steroids. Patients often want to know the answer to a simple question “How likely is a particular side effect - like hair loss?” It can often be quite challenging to give precise estimate on the risk of a given side effect. I’ve spoken about this subject before:

When a study comes out that gives me assistance in formulating these sorts of estimates, I generally take to the study. One such study was the recent study by Josué Cruz Dos Santos et al published in the European Journal of Investigation in Health, Psychology and Education.

Josué Cruz Dos Santos et al 2024

Consider now the recent study by Josué Cruz Dos Santos and colleagues. The authors estimated the risk of side effects in Brazilian male athletes using anabolic steroids. In the study, the substances most used by the athletes were Sustanon 250 or Durateston, Nandrolone Decanoate (Deca or Deca-Durabolin), and Testosterone. The most reported acute side effects were acne at 33.8%, irritability at 32.1%, hair loss at 23.7%, and nervousness at 23.7%. The most-reported chronic side effects were arterial hypertension at 36.0%m liver disease at 28.0%, and cancer at 8.0%.

Comment:

Anabolic steroids have the potential to cause a range of side effects. About 25 % of patients will experience hair loss. Like everything in life, the occurrence of various side effects does not mean a patient will stop their anabolic steroids. The risk of continuing will need to be balanced by the benefits of continuing. When it comes to hair loss, some users of anabolic steroids will consider treatment for the hair loss with topical or oral 5 alpha-reductase inhibitors or a range of other evidence-based treatments. Others will consider a hair transplant. Others will lower their dose of the anabolic steroids. Others will stop their anabolic steroids.

As I say to patients, there is no one single right or wrong answer!

REFERENCE

Josué Cruz Dos Santos et al. The Use of Anabolic Steroids by Bodybuilders in the State of Sergipe, Brazil. Eur J Investig Health Psychol Educ. 2024 May 16;14(5):1451-1469.

Diphencyprone for Alopecia Areata During Pregnancy: Not Recommended ... but Maybe Not so Harmful.

Case Report Outlines Use of Diphencyprone (DPCP) in Pregnancy

I was interested to read a recent report outlining the use of DPCP in pregnancy. Now, generally speaking DPCP is contraindicated in pregnancy simply because we don’t have enough data. So far there are a limited number of women in the world who have been documented to have used DPCP during their pregnancies. Interestingly, outcomes have been very good so far for mothers and babies.

A new report formally documents the use of DPCP during pregnancy. The patient stopped DPCP in her first pregnancy and developed completed hair loss after delivery (SALT 100). In order to reduce the chances of severe hair loss in and following subsequency pregnancies, the patient stated her wish to continue DPCP during her subsequent pregnancies. The patient used DPCP 2% monthly treatment during her second and third pregnancies. This was, however, against the clinician’s recommendation.

Treatment started 4 months into the second pregnancy and continued throughout the entire duration of the third pregnancy. DPCP treatments resulted in significantly less hair loss compared to the first pregnancy. What was so interesting about this report was that there were no documented complications during her pregnancies and vaginal deliveries. Furthermore, no teratogenic effects or anomalies noted in any of her children to date.

Comment

I don’t think we’re ready quite yet to make DPCP use in pregnancy a routine thing, but this case report is valuable in that it documents yet one more good outcome of babies born to mothers who use DPCP during pregnancy. Back in 2012, I reviewed a study showing that DPCP does not tend to get absorbed into the bloodstream. It is unlikely that DPCP reaches that baby. However, these are rather speculative, and more studies are needed.

REFERENCE

Desai DD et al. Use of diphenylcyclopropenone for alopecia areata treatment during pregnancy. JAAD Case Rep. 2024 Apr 19:48:88-89.