Complementary and alternative medicine for alopecia areata: A systematic review.

BACKGROUND: Despite high use of complementary and alternative medicine (CAM) for alopecia areata (AA), efficacy and safety remain unclear. OBJECTIVE: To identify all CAM therapies studied for treatment of AA. Outcomes of interest included disease course and psychologic well-being. METHODS: PubMed and Embase were searched to identify English articles containing original data investigating CAM in individuals with AA from 1950-2018. Quality was assessed with Oxford Centre for Evidence Based Medicine criteria. RESULTS: Of 1015 initial citations, 16 articles met inclusion criteria: 5 randomized controlled trials, 5 prospective controlled cohorts, 4 prospective noncontrolled cohorts, 1 retrospective cohort, and 1 case series. CAM therapies with best evidence and efficacy for hair growth in AA include essential oil aromatherapy, topical garlic, and oral glucosides of peony with compound glycyrrhizin. Hypnosis and mindfulness psychotherapy represent low-quality evidence for improvement of psychologic and quality of life outcomes. Adverse events were rare and mild for all therapies evaluated. LIMITATIONS: Inconsistent or poorly reported study methodology and nonstandardized outcomes limit the conclusions that can be made from these studies. CONCLUSIONS: This work serves to inform physician treatment of patients with AA seeking CAM while encouraging further investigation into these therapies to address some of the therapeutic challenges of AA.

Development of the alopecia areata scale for clinical use: Results of an academic-industry collaborative effort.

BACKGROUND: The current classification for alopecia areata (AA) does not provide a consistent assessment of disease severity. OBJECTIVE: To develop an AA severity scale based on expert experience. METHODS: A modified Delphi process was utilized. An advisory group of 22 AA clinical experts from the United States was formed to develop this AA scale. Representatives from the pharmaceutical industry provided feedback during its development. RESULTS: Survey responses were used to draft severity criteria, aspiring to develop a simple scale that may be easily applied in clinical practice. A consensus vote was held to determine the final AA severity statement, with all AA experts agreeing to adopt the proposed scale. LIMITATIONS: The scale is a static assessment intended to be used in clinical practice and not clinical trials. CONCLUSION: The final AA disease severity scale, anchored in the extent of hair loss, captures key features commonly used by AA experts in clinical practice. This scale will better aid clinicians in appropriately assessing severity in patients with this common disease.

Brigham Eyebrow Tool for Alopecia: A Reliable Assessment of Eyebrow Alopecia Areata.

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.

Cardiovascular risk in patients with alopecia areata (AA): A propensity-matched retrospective analysis.

BACKGROUND: The cardiovascular risk of patients with alopecia areata (AA) is not well characterized, with limited studies evaluating the risk of acute myocardial infarction (AMI) and ischemic stroke. OBJECTIVE: We sought to determine the risk for patients with AA to develop subsequent stroke and AMI. METHODS: We conducted propensity-matched retrospective analysis between January 1, 2000, and January 1, 2010, from Brigham and Women's Hospital and Massachusetts General Hospital in Boston, MA. A comprehensive research patient data repository search was done for International Classification of Diseases, Ninth Revision code 704.01 and cases were verified using a natural language processing program. Propensity score matching was used to identify controls for AA cases based on age, race, gender, smoking status, and history of hypertension, diabetes, and hyperlipidemia. RESULTS: We identified 1377 cases of AA matched with 4131 controls. Patients with AA had decreased odds for developing stroke (odds ratio 0.39, 95% CI 0.18-0.87) and a trend toward decreased risk of AMI (odds ratio 0.91, 95% CI 0.59-1.39). LIMITATIONS: This was a retrospective study using a clinical database. CONCLUSION: Patients with AA had decreased risk for stroke and AMI, although not statistically significant. Further studies are needed to confirm these findings in other AA cohorts and to elucidate a potential mechanism.

Treatment Patterns for Alopecia Areata in the US.

Importance: Alopecia areata (AA) is characterized by hair loss ranging from patches of hair loss to more extensive forms, including alopecia totalis (AT) and alopecia universalis (AU). There is a lack of consensus for treatment. Understanding current practice patterns could help the identification of treatment needs and development of standards of care. Objective: To review treatment patterns for adults with AA in the US between 2015 and 2020. Design, Setting, and Participants: This retrospective cohort study used medicine and pharmacy claims for commercially insured individuals from the IBM MarketScan Research Database to assess adults (≥18 years) newly treated for AA between October 15, 2015, and February 28, 2020. Alopecia areata was identified based on having at least 1 diagnosis of International Statistical Classification of Diseases and Related Health Problems, Tenth Revision code L63.x. Patients were required to have at least 365 days of continuous health plan enrollment before and after the cohort entry date. Patients were required to be free of AA diagnosis codes 365 days before the cohort entry date. Statistical analyses were conducted between 2019 and 2023. Main Outcomes and Measures: Main outcomes were treatment patterns for all patients with AA and subgroups of (1) patients with AT or AU and (2) those cared for by a dermatologist on the cohort entry date. Longitudinal therapy course during the first year after the diagnosis was also examined. Results: The study cohort consisted of 45 483 individuals (mean [SD] age, 43.8 [14.2] years; 29 903 [65.7%] female). During the year of follow-up, 30 217 patients (66.4%) received at least 1 AA treatment. The most common treatments were intralesional (19 014 [41.8%]), topical (18 604 [40.9%]), intramuscular (17 328 [38.1%]), and oral (9378 [20.6%]) corticosteroids. Compared with patients without AT or AU, patients with AT or AU a lower frequency of intralesional steroid (359 [11.1%] vs 18 655 [44.1%], P < .001) and higher frequency of topical corticosteroid (817 [25.4%] vs 17 787 [42.1%], P < .001) use. Almost half of patients (21 489 [47.2%]) received no treatment on the day of diagnosis. By 12 months, 32 659 (71.8%) were not receiving any treatment, making no treatment the largest study group. Conclusions and Relevance: In this large cohort study of commercially insured individuals, corticosteroids were the most commonly used treatment for adults with AA between 2015 and 2020. At 365 days after diagnosis, more than two-thirds of patients were no longer receiving any AA treatment. Further studies are needed to understand the reasons for the absence of treatment.

Factors influencing alopecia areata treatment decisions: A qualitative assessment.

Background: Alopecia areata (AA) is a disease of hair loss in which patients may benefit from comprehensive understanding of AA's disease process and therapeutic options during treatment decision-making. Objective: Determine factors influencing patients' AA treatment decision-making. Methods: Qualitative interviews were conducted using semi-structured interview guides. Interviews were coded using inductive thematic analysis. Results: Twenty-one participants with AA were interviewed. Coding interrater reliability was κ = 0.87-0.91, indicating strong-almost perfect agreement. Participants faced multiple barriers, including lack of access to health care (n = 10, 47.6%) and lack of transparency about their condition and treatment options (n = 9, 42.9%). Information about AA was sought from primarily the internet (n = 15, 71.4%) and physician recommendation (n = 15, 71.4%). When choosing AA treatments, patients often considered treatment efficacy (n = 21, 100%), safety (n = 21, 100%), and convenience of use (n = 20, 95.2%). Limitations: Referral and regional biases may be present and limit generalizability. Conclusions: Patients with AA face various challenges including medical uncertainty and lack of information. Patients need trustworthy and accessible sources of information regarding their treatment that also take into consideration their preferences and values.

Physician values in alopecia areata treatment decision-making: A qualitative assessment.

Background: Alopecia areata (AA) is a disease of hair loss with multiple treatment options. Physicians play an important role in guiding patients during the decision-making process. Objective: Assess physicians' values and attitudes when helping patients choose an AA treatment. Methods: Semi-structured qualitative interviews were conducted with dermatologists of varying practice type and location. Each interview was coded independently twice using inductive thematic analysis. Interrater reliability and code frequencies were determined. Results: Fourteen participants were interviewed. Interrater reliability was κ = 0.85 to 0.97. Dermatologists wanted patients to consider various treatment factors (ie, efficacy, safety, convenience of use, accessibility) and also assessed patients' AA clinical severity and personality traits. Participants often encountered various barriers to effective communication with patients, which may be mitigated by shared decision-making. Shared decision-making tools were perceived to potentially improve patient care and communication, although physicians expressed concern about lack of individualization, limitations of time, and the appropriateness of information. Conclusion: AA treatment decision-making is a complex process that often utilizes the expertise of a dermatologist, during which shared decision-making tools may be of value to both patients and physicians.

Cannabis Use among Patients with Alopecia Areata: A Cross-Sectional Survey Study.

Importance: Little is known about cannabis use among patients with alopecia areata (AA). These patients often experience significant psychosocial burden and may seek alternative therapies beyond that of traditional medical treatments, such as cannabis. Objective: To characterize cannabis use among patients with AA. Design: This was a cross-sectional study conducted from March 9, 2021, to March 22, 2021, using a web-based survey distributed to adult patients with AA using the National AA Foundation's email listserv and social media platforms. Results: 1,087 participants completed the survey (completion rate: 88.1%). Most participants were female (n = 870, 83.3%) and Caucasian (n = 771, 73.8%), with a mean age of 47.6 ± 15.5 years. 65.9% (n = 689) of participants with AA had a history of cannabis use and among those, 51.8% (n = 357) were current cannabis users. The most common reason for cannabis use among current users was for AA-related symptoms (n = 199, 55.7%), with the greatest perceived improvement in symptoms of stress (n = 261, 73.1%) and anxiety, sadness, and depression (n = 234, 65.6%). 80.4% (n = 287) indicated that cannabis had no impact on their hair loss. Conclusion: Cannabis use is common among patients with AA and is often used to alleviate the psychosocial symptoms related to AA, despite the lack of perceived improvement in hair regrowth.

Shared Decision-Making, Therapeutic Choice, and Decisional Regret in Patients With Alopecia Areata.

Importance: Alopecia areata (AA) is an autoimmune disorder of hair loss with a complex and evolving treatment landscape, making it an ideal setting for shared decision-making (SDM) between patients and physicians. Given the varying efficacy, experience, and risks of treatments for AA, we sought to evaluate patient preferences for SDM and the association of SDM with decisional regret. Objective: To evaluate patient preferences for SDM and the association of SDM with decisional regret. Design, Setting, and Participants: A cross-sectional online survey using the validated SDMQ9 scale for shared decision-making and Decisional Regret Scale (DRS) was distributed using the National Alopecia Areata Foundation (NAAF) with the aim of assessing (1) patient preferences in SDM when making treatment decisions, (2) how patients perceived the last decision to have been made, (3) which components of SDM were incorporated into the last decision, and (4) decisional regret related to their last treatment decision. The survey was distributed from July 12, 2021, to August 2, 2021, and data analysis occurred from October 2021 to March 2022. Main Outcomes and Measures: Primary outcomes included (1) patient preferences in incorporation of SDM, (2) how patients made their most recent treatment decision, (3) which components of SDM were incorporated into their most recent treatment decision measured with the validated SDMQ9, and (4) an assessment of decisional regret in relation to SDM components and the most recent treatment modality used by the patient as measured by the validated DRS. Results: Of 1387 individuals who initiated the survey, 1074 completed it and were included in the analysis (77.4% completion rate). Overall, 917 respondents were women (85.4%). There were 5 American Indian or Alaska Native respondents (0.5%), 33 were Asian (3.1%), 112 Black or African American (10.4%), 836 White (77.8%), and 36 were multiracial (3.4%) or other (36 [3.4%]). The mean age (SD) was 49.3 (15.4) years. Most respondents preferred making the final treatment decision themselves after considering their physician's opinion (503 [46.8%]). Of those who preferred to make treatment decisions using SDM, most made the last AA treatment decision with their physician (596 [55%]; 95% CI, 53%-58%; P < .001). The components of SDM implemented by the patients' dermatologists most identified were the physician "explained the advantages and disadvantages of treatment options" (472 [44%]), and the physician "asked me which treatment option I prefer" (494 [45.9%]). Incorporation of SDM by physicians was generally associated with decreased decisional regret (all ORs with 95% CIs greater than 1.1; P < .01). The treatments associated with the lowest decisional regret were Janus kinase (JAK) inhibitors, followed by biologics, and deciding not to treat; whereas, the highest decisional regret was reported with anthralin and minoxidil. Conclusions and Relevance: The findings of this cross-sectional survey study suggest that patients with AA prefer to make treatment decisions with their dermatologist using SDM. When SDM is used, patients report less decisional regret, indicating that SDM may help improve the patient-reported quality of treatment decisions. Newer, more efficacious therapies such as JAK inhibitors may be related to lower decisional regret. Future studies should seek to devise solutions to implement SDM as the AA treatment landscape continues to evolve.

Evaluation of Stigma Toward Individuals With Alopecia.

Importance: Perceived stigma among patients with alopecia is associated with impaired quality of life; however, the magnitude of laypersons' stigma toward individuals with alopecia is unknown. Objective: To determine the prevalence and magnitude of laypersons' stigma toward individuals with varying degrees of alopecia and whether stigma increases with increased severity of alopecia. Design, Setting, and Participants: This was a cross-sectional study using an internet survey administered to a convenience sample of adult respondents in the US participating on the Amazon Mechanical Turk platform. Portrait images of 6 individuals without hair loss were created using artificial intelligence and stock images. Each portrait was edited to create 2 additional versions, 1 with scalp hair loss and 1 with complete hair loss, for a total of 18 images. On January 9 to 10, 2020, the survey presented each internet respondent with 1 randomly selected portrait to be used in answering a series of stigma-related questions from 3 domains: stereotypes, social distance, and disease-related myths; the third domain was presented only to respondents who believed that the individual pictured had a medical condition. Main Outcomes and Measures: The main outcome was the prevalence and magnitude of stigma of laypersons toward individuals with alopecia and the percentage of laypersons who believed the individual pictured had a medical condition as recorded in survey responses. Results: The survey was completed by 2015 respondents (99.9% completion rate) with a mean age of 37 (range, 18-78) years; 1014 (50.3%) were men; 1596 (79.2%) were White; and 1397 (69.3%) had a college or postcollege education. Endorsement of every stigma item increased as alopecia severity increased (2.4%-27.6%). Absolute change on the stereotype (0.5-0.6) and social distance scales (0.2-0.5) also increased, indicating more stigma. The percentage of respondents believing the individual pictured had a medical condition increased as alopecia severity increased (33.6%-75.7%; P < .001). Among the subgroup of respondents who were asked to rate their agreement with disease-related myths, the absolute change on the myth scale decreased as alopecia severity increased, indicating decreased stigma (-0.7 to -1.2). Conclusions and Relevance: This cross-sectional survey study found that stigmatizing attitudes of laypersons toward patients with alopecia exist across a multitude of social and professional scenarios. Stigma prevalence and magnitude vary by alopecia severity and possibly by whether alopecia is believed to be a medical condition.

Creating and Managing a Phototherapy Center.

Phototherapy is a safe and effective treatment for many benign and malignant inflammatory cutaneous diseases. Treatment courses require consistent visits over the course of weeks to months, and one barrier for patients in accessing this treatment is the lack of a geographically convenient phototherapy center. To expand access, new phototherapy centers can be created, and this can be done in a series of steps. These include considering the physical space, anticipating the finances, laying the operational groundwork, and establishing a consent and education process.

Optimizing Narrowband UVB Phototherapy Regimens for Psoriasis.

Psoriasis is a chronic, autoimmune condition characterized by abnormal epidermal hyperproliferation affecting about 3.2% of adults in the United States. Narrowband UVB (NBUVB) is a commonly used phototherapy option for patients with psoriasis and is an effective first-line therapy for generalized plaque psoriasis. This article covers fundamental considerations for physicians using NBUVB and highlights changes in the newest guideline recommendations for phototherapy treatment. Protocols for treatment initiation, maintenance, dose increases, and maintenance are compared and discussed. Readers will achieve a greater understanding of the fundamentals of NBUVB phototherapy and promising advances in the field, including home phototherapy and combination treatment.

The Impact of Alopecia Areata on Sexual Quality of Life.

BACKGROUND: Alopecia areata (AA) is an autoimmune disease characterized by patches of hair loss that can cause decreased quality of life. This study evaluates the sexual quality of life for patients with AA. METHODS: We surveyed patients in the National Alopecia Areata Foundation patient registry using an online version of the validated Sexual Quality of Life for Females (SQOL-F) and Sexual Quality of Life for Males (SQOL-M) questionnaires. MAIN OUTCOME MEASURES: Patient sexual quality of life was measured using the SQOL-F and SQOL-M instruments. RESULTS: Eighty-one participants with AA (64 females and 17 males) completed the surveys. The mean age was 39.7 ± 13.8 years for women and 37.4 ± 9.9 years for men. Women had a decreased sexual quality of life with mean SQOL-F score of 51.3 ± 22.9. Men had a decreased sexual quality of life with mean SQOL-M score of 62.7 ± 33.9 (higher scores indicate greater sexual quality of life). No statistical difference was found between these two cohorts (P = 0.12). In discussing negative aspects of their sexuality, women strongly identified with emotional statements such as "I feel embarrassed" (n = 48, 75.0%) while men strongly identified with emotional statements such as "I feel anxious" (n = 7, 46.7%). Both cohorts strongly identified with "I feel like I have lost something" (n = 48, 76.2% and n = 7, 43.8%, respectively). CONCLUSIONS: This study demonstrates that AA has a negative impact on the patient's sexual quality of life.

Development and pilot-testing of the Alopecia Areata Assessment Tool (ALTO).

BACKGROUND: Alopecia areata (AA) is an autoimmune disease characterized by non-scarring hair loss. The lack of a definitive biomarker or formal diagnostic criteria for AA limits our ability to define the epidemiology of the disease. In this study, we developed and tested the Alopecia Areata Assessment Tool (ALTO) in an academic medical center to validate the ability of this questionnaire in identifying AA cases. METHODS: The ALTO is a novel, self-administered questionnaire consisting of 8 closed-ended questions derived by the Delphi method. This prospective pilot study was administered during a 1-year period in outpatient dermatology clinics. Eligible patients (18 years or older with chief concern of hair loss) were recruited consecutively. No patients declined to participate. The patient's hair loss diagnosis was determined by a board-certified dermatologist. Nine scoring algorithms were created and used to evaluate the accuracy of the ALTO in identifying AA. RESULTS: 239 patients (59 AA cases and 180 non-AA cases) completed the ALTO and were included for analysis. Algorithm 5 demonstrated the highest sensitivity (89.8%) while algorithm 3 demonstrated the highest specificity (97.8%). Select questions were also effective in clarifying disease phenotype. CONCLUSION: In this study. we have successfully demonstrated that ALTO is a simple tool capable of discriminating AA from other types of hair loss. The ALTO may be useful to identify individuals with AA within large populations.

Second lymphomas and other malignant neoplasms in patients with mycosis fungoides and Sezary syndrome: evidence from population-based and clinical cohorts.

OBJECTIVE: To assess risks for developing second malignancies in patients with mycosis fungoides or Sézary syndrome. DESIGN: Retrospective study of 2 cohorts. SETTING: Nine population-based US cancer registries that constitute the Surveillance, Epidemiology, and End Results Program (SEER-9), and Stanford University referral center cohort of patients with cutaneous lymphoma. Patients with mycosis fungoides or Sézary syndrome from the SEER-9 registry diagnosed and followed up from 1984 through 2001 and from the Stanford University cohort diagnosed and followed up from 1973 through 2001. MAIN OUTCOME MEASURES: Relative risk was estimated using the standardized incidence ratio (SIR). The expected cancer incidence for both cohorts was calculated using age-, sex-, race-, and calendar year-specific SEER-9 incidence rates for the general population. Nonmelanoma skin cancers were excluded because these cancers are not routinely reported by the SEER database. RESULTS: In the SEER-9 cohort (n = 1798), there were 197 second instances of cancer (SIR = 1.32; 95% confidence interval [CI], 1.15-1.52) at all sites. Significantly elevated risk (P<.01) was observed for Hodgkin disease (6 cases; SIR = 17.14; 95% CI, 6.25-37.26) and non-Hodgkin lymphoma (27 cases; SIR = 5.08; 95% CI, 3.34-7.38). Elevated risk (P<.05) was also observed for melanoma (10 cases; SIR = 2.60; 95% CI, 1.25-4.79), and urinary cancer (21 cases; SIR = 1.74; 95% CI, 1.08-2.66). In the Stanford University cohort (n = 429), there were 37 second instances of cancer (SIR = 1.04; 95% CI, 0.76-1.44). Elevated risk (P<.01) was observed for Hodgkin disease (3 cases; SIR = 27.27; 95% CI, 5.35-77.54). Elevated risk (P<.05) was also observed for biliary cancer (2 cases; SIR = 11.76; 95% CI, 1.51-42.02). CONCLUSION: Updated SEER (population based) and Stanford (clinic based) data confirm the generalizability of earlier findings of increased risk of lymphoma in patients with mycosis fungoides or Sézary syndrome.