New genetic research is yielding some important clues into the puzzling condition of alopecia areata, Dr. Maria Hordinsky reported at the women's and pediatric dermatology seminar sponsored by Skin Disease Education Foundation (SDEF).
By doing whole-genome analysis on thousands of samples gathered over the last 9 years, investigators have found four genes associated with the disease. Surprisingly, none of the genes is implicated in psoriasis, which has long been considered a risk factor for alopecia areata. Conversely, none of the genes associated with psoriasis appears to be implicated in alopecia areata. Investigators announced the findings this year at the annual meeting of the Society for Investigative Dermatology in Montreal.
These findings have important consequences for treatment and research, according to Dr. Hordinsky, chair of the dermatology department at the University of Minnesota, Minneapolis.
"We've all been scratching our heads for the past couple of years wondering why on Earth the new biologics that work so well in psoriasis are not working in this disease," she said. "So now with this data, maybe one possibility is that the diseases are just completely different in the way they're molecularly structured. The thinking has changed in the past couple of months. If you were to start a clinical trial today in alopecia areata, based on the new information, you probably wouldn't pick some of the biologics that were picked a few years ago."
For now, though, Dr. Hordinsky emphasized that there is no "best" treatment for alopecia areata. Patients with patchy alopecia areata sometimes respond to topical or intralesional corticosteroids, minoxidil solution, anthralin, steroid-containing shampoos, excimer laser therapy, or combination treatment.
For extensive alopecia areata, Dr. Hordinsky suggested prednisone, topical minoxidil, PUVA, immunotherapy, pulse methylprednisolone, narrow-band UVB, or combination therapy. Other possible treatments include cyclosporine, tacrolimus, dapsone, sulfasalazine, hydroxychloroquine, retinoids, and biologics.
She recommended focusing on the patient's nail to diagnose alopecia areata. Between 10% and 66% of patients with alopecia areata have nail abnormalities, and these abnormalities may precede, follow, or occur concurrently with hair loss, she noted. Nail pitting is the most common abnormality, but there may also be longitudinal ridging, koilonychia, brittle nails, onycholysis, onychomadesis, and periungual erythema.
Dr. Hordinsky's presentation concentrated on alopecia areata in children, but she said that there are few differences in the pathophysiology of pediatric versus adult disease. "It's a disease that affects all ages, all races, and is seen equally in males and females."
The difference in children involves the psychosocial aspects of the disease, and physicians need to be sensitive to these issues. "It's not like body dysmorphic disorder, where people get fixated on something that's not quite right, worrying that their nose is imperfect or something," she pointed out. "This disease can result in very rapid, and sometimes dramatic, alteration in physical appearance. So there's a psychological adaptation that has to take place. Patients have to figure out: How do you live with this disease? How do you make yourself more normal looking so you fit better into your age group, into your peer groups, into school?"
Physicians can refer patients and their families to the National Alopecia Areata Foundation (www.naaf.org
She encouraged all physicians to register patients—and their families—with the national Alopecia Areata Registry (www.alopeciaareataregistry.org
Dr. Hordinsky did not disclose relevant conflicts of interest in her presentation. SDEF and this news organization are owned by Elsevier.
A child with alopecia areata universalis is shown prior to any treatment.
Source Photos courtesy Dr. R. Berrada
The child had significant hair growth after undergoing 50 sessions of PUVA therapy.
Source Photos courtesy Dr. R. Berrada