ORLANDO – Biotin is the most popular consumer supplement for alopecia and highly popular online, but should patients be taking it?
Patients may want something “natural” to treat their hair loss, but “natural is not always good,” Amy McMichael, MD, professor and chair of the department of dermatology at Wake Forest Baptist Health, Winston-Salem, N.C., said at the ODAC Dermatology, Aesthetic, & Surgical Conference.
Dosages of commercially available biotin supplements can vary significantly, with some doses as high as 10,000 mcg, making supraphysiological dosing possible. Dr. McMichael said that, not only is biotin unlikely to help with a patient’s alopecia, but a high intake of biotin can interfere with certain assays that use streptavidin-biotin capture techniques (Clin Chem Lab Med. 2017 May 1;55[6]:817-25). This could present a problem for a patient who experiences an MI or has a thyroid disorder where a high level of biotin could affect lab results, she noted.
FDA still concerned about biotin affecting troponin tests
Dr. McMichael advises patients that there is a
Questioning side effects of 5-alpha reductase inhibitors
Research in the early 2010s associated the 5-alpha reductase inhibitor finasteride with persistent sexual side effects and depression. But a later meta-analysis of the Prostate Cancer Prevention Trial and other trials did not find evidence of persistent sexual side effects or depression in men on finasteride, and the authors said that double-blind, placebo-controlled studies were needed (J Clin Aesthet Dermatol. 2014 Dec;7[12]:51-5).
However, two meta-analyses of 34 clinical trials published in 2015 found that none of the clinical trials evaluating finasteride treatment in patients with androgenic alopecia had accurate safety reporting (JAMA Dermatol. 2015 Jun;151[6]:600-6). Another study published by the same group in 2017 found that 0.8% of men aged 16-42 years to exposed to a 5-alpha reductase inhibitor developed persistent erectile dysfunction after a longer duration of exposure (median, 1,534 days). compared with a shorter duration of exposure (PeerJ. 2017 Mar 9;5:e3020).
The bottom line when considering use of 5-alpha reductase inhibitors in men is to discuss the outlier data on persistent sexual dysfunction in the studies, ask patients whether they have a history of sexual dysfunction and depression, and then only treat appropriate patients with no such history, Dr. McMichael said.
Use of 5-alpha reductase inhibitors also appears to be related to an increased risk of type 2 diabetes in men with benign prostatic hyperplasia, according to more recent data. In a study of patients in the U.K. Clinical Practice Research Datalink and Taiwanese National Health Insurance Research Database who received dutasteride, finasteride, or the alpha blocker tamsulosin, there was a slightly increased risk of type 2 diabetes among those who took the two 5-alpha reductase inhibitors, compared with those on tamsulosin (BMJ. 2019;365:l1204). In light of these results, Dr. McMichael advised clinicians to be aware of these risks and to consider screening patients for type 2 diabetes and ask them about their family history, but the results shouldn’t affect patients at risk for type 2 diabetes or metabolic disorder.
JAK inhibitors for alopecia areata
Within the past few years, promising results for Janus kinase (JAK) inhibitors like tofacitinib and ruxolitinib for alopecia areata have been reported, but they are currently not a first-line therapy, Dr. McMichael said. Consider methotrexate first in older adolescents and adults with more than 50% hair loss, followed by a JAK inhibitor if there is no improvement or methotrexate is not tolerated well.
Clinicians can consider enrolling their patients in a clinical trial to give them access to JAK inhibitors as a treatment option, she noted, and if a trial is not available, it may be worth appealing to an insurance company using an article titled “Alopecia areata is a medical disease” coauthored by Dr. McMichael and others (Am Acad Dermatol. 2018 Apr;78[4]:832-4). After two denials by insurance, the manufacturer’s patient assistance program (Xelsource) may be helpful in obtaining tofacitinib (Xeljanz) through a letter and references. There are adolescent data on JAK inhibitors for alopecia, but “absolutely no data” in very young children, so prior to adolescence, she would not recommend this treatment. In a study of 13 adolescents with alopecia areata, totalis, or universalis, those treated with tofacitinib for a mean of 6.5 months, 9 had significant hair regrowth with treatment and adverse events were mild (J Am Acad Dermatol. 2017 Jan;76[1]:29-32).
Dr. McMichael reports being an investigator for Allergan, Intendis, Proctor & Gamble, Samumed, Cassiopia, Concert, Aclaris, and Incyte; and is a consultant for Johnson & Johnson, Proctor & Gamble, Allergan, Bayer, Galderma, Incyte, Samumed, Aclaris, Anacor, Pfizer, Nutrafol, Bioniz, and Almirall.