Topical Conversations

This video is sponsored by Sun Pharma. Its content is editorially independent of the sponsor. .In this episode of Topical Conversations, Natasha Mesinkovska, MD, joins Tracee Blackburn, PA-C, to discuss personalized care in dermatology and how pharmacogenetic testing can help inform treatment selection for patients with alopecia areata (AA). Rethinking personalized care For Mesinkovska, personalized care begins with a shift in perspective: rather than asking what the treatment is for a particular disease, clinicians can consider what the appropriate treatment is for the individual patient. Blackburn agrees, emphasizing the importance of looking beyond the diagnosis on the chart and considering each patient holistically. This individualized approach is particularly relevant as dermatologic treatment options become increasingly targeted and clinicians have more tools available to help guide treatment decisions. Pharmacogenetic testing before deuruxolitinib Mesinkovska and Blackburn explore pharmacogenetic testing through the lens of deuruxolitinib treatment for AA. Before initiating deuruxolitinib, patients undergo CYP2C9 genotype testing to determine how they metabolize the medication. Mesinkovska explains that CYP2C9 is an enzyme involved in metabolizing deuruxolitinib. Genetic variation can affect CYP2C9 activity, meaning patients may metabolize the medication differently. Testing before treatment allows clinicians to identify patients whose CYP2C9 genotype may affect their exposure to the drug. Blackburn frames the test for patients as an additional step in making sure the selected therapy is appropriate for them, with Mesinkovska adding that, unlike routine laboratory monitoring, CYP2C9 genotype testing is performed at baseline and does not need to be repeated. Understanding the results Mesinkovska encourages clinicians not to be intimidated by the genetic component of the test. She breaks its use down into 3 basic questions: What does the test tell us? How is it ordered and reported? And how do we interpret the report? Results categorize patients according to their CYP2C9 metabolizer status. Dr Mesinkovska discusses normal, intermediate, and poor metabolizers and how the result can inform whether treatment with deuruxolitinib is appropriate. Importantly, she stresses what the test does not do: It does not predict whether a patient will experience hair regrowth. Rather, it identifies differences in drug metabolism that may place certain patients at risk for increased exposure to the medication. Incorporating testing into clinical workflows Although adding another pretreatment test may initially seem like an additional logistical hurdle, both clinicians describe pharmacogenetic testing as readily incorporated into their existing workflows. Blackburn notes that familiarity with the appropriate laboratory test and ordering process can make the additional step relatively straightforward. She also sets expectations with patients that results may take approximately 2 weeks, helping prevent concern when other baseline laboratory results return sooner. For Mesinkovska, the turnaround time has not represented a significant treatment delay. The testing period often overlaps with other steps already required before treatment initiation, including prior authorization and other baseline evaluations. She also emphasizes that pharmacogenetic testing is only one component of treatment selection. Clinicians must still review a patient's medications, medical history, and potential contraindications before initiating therapy. Looking toward more individualized dermatologic care Mesinkovska and Blackburn close by reflecting on the broader movement toward more precise, individualized dermatologic care. As diagnostic and therapeutic options continue to advance, pharmacogenetic testing represents another tool clinicians can use to better understand whether a particular treatment is appropriate for an individual patient.

This video is sponsored by Sun Pharma. Its content is editorially independent of the sponsor.In this episode of Topical Conversations, Meena Singh, MD, and Terry Faleye, PA-C, discuss why speed of disease control has become an increasingly important consideration in the management of alopecia areata (AA). As treatment options continue to expand, they explore how earlier signs of response can influence patient confidence, improve treatment persistence, and reshape conversations about what patients can expect during therapy. Using deuruxolitinib as an example, they highlight how evolving efficacy data have changed both provider expectations and the patient experience.The importance of speed in a disease with significant psychosocial impactThe treatment landscape for moderate to severe AA has changed substantially with the availability of multiple FDA-approved Janus kinase (JAK) inhibitors. While efficacy remains the primary goal, Dr Singh and Faleye emphasize that when patients begin to see improvement can be nearly as important as how much improvement they ultimately achieve.For many patients, AA develops suddenly and is accompanied by considerable emotional distress. Faleye notes that many individuals present with little understanding of the disease itself, making education about its chronic nature and treatment course an essential part of the initial visit.The ability to demonstrate visible improvement early in treatment can provide reassurance during what is often an emotionally challenging period. Both speakers describe how even small signs of regrowth can reinforce that treatment is working, helping patients remain engaged and optimistic rather than becoming discouraged after months without visible progress.How earlier responses are changing treatment conversationsHistorically, clinicians often counseled patients that meaningful regrowth might not occur for many months, if at all. Dr Singh notes that this has changed with newer therapies.She discusses how clinical studies of deuruxolitinib demonstrated statistically significant, clinically meaningful hair regrowth as early as 8 weeks, despite the primary efficacy endpoint occurring later in treatment. In her own practice, she has observed patients with extensive scalp involvement experience dramatic improvement within the first few months of therapy, fundamentally changing how she frames expectations at treatment initiation.Faleye similarly points to the secondary efficacy assessments at weeks 8, 12, 16, and 20 as particularly meaningful from a clinical perspective. Seeing evidence of earlier response provides reassurance to both patients and clinicians that therapy is moving in the right direction.She also shares the experience of a patient who had an inadequate response to a different JAK inhibitor but later achieved substantial regrowth after initiating deuruxolitinib, reinforcing her confidence in discussing treatment expectations with appropriate patients.Clinical success and patient-defined success are not always the sameOne of the recurring themes throughout the discussion is that clinicians and patients often define treatment success differently.Dr Singh notes that patients may become excited by the appearance of fine vellus hairs, even though these early changes would not yet represent meaningful terminal hair regrowth from a clinical trial perspective. Nevertheless, these visible signs frequently provide patients with reassurance that treatment is working.Faleye agrees, emphasizing that these seemingly modest improvements often have an outsized effect on treatment adherence. While clinicians recognize that additional regrowth is needed to achieve optimal outcomes, patients may view these early changes as important milestones that motivate them to continue therapy.Recognizing early indicators of responseThe speakers encourage clinicians to look beyond scalp hair counts alone when assessing early treatment response.Dr Singh notes that eyebrow, eyelash, and beard regrowth, even when limited, can represent meaningful early signs that therapy is having an effect. Likewise, a noticeable reduction in hair shedding may precede visible regrowth and can be an encouraging indicator to discuss during follow-up visits.Faleye adds that improvements that may seem minor clinically can carry tremendous significance for individual patients. She recalls an older patient whose primary concern was beard patchiness; seeing early beard regrowth substantially improved the patient's outlook despite relatively modest overall changes.Recognizing and reinforcing these individualized treatment successes can strengthen the therapeutic relationship and support continued adherence while more substantial regrowth develops.Early treatment may help change the long-term trajectoryThe discussion also highlights the importance of identifying and treating AA promptly whenever appropriate.Faleye observes that patients with longstanding disease may be less likely to pursue treatment because of previous disappointments or because they remain unaware that newer therapeutic options are available. At the same time, these individuals can present greater treatment challenges than patients who begin therapy earlier in the disease course.Both speakers emphasize the importance of educating patients about advances in AA management and encouraging timely intervention when indicated.A changing patient experiencePerhaps one of the most meaningful changes, according to Dr Singh, is the transformation she sees in patients between their initial consultation and early follow-up visits. Patients who begin experiencing regrowth within the first few months often return with noticeably greater optimism and confidence, changing the tone of subsequent visits.For both clinicians, the availability of therapies capable of producing earlier, meaningful responses has altered not only treatment strategies but also the overall patient experience. They conclude that recognizing early improvements, setting realistic expectations, and initiating effective therapy promptly can all contribute to better long-term engagement and outcomes for patients with AA.

In this episode of Topical Conversations, Dr E. James Song and Dr Michael Cameron explore the profound burden of alopecia areata (AA) and how JAK inhibitors, particularly baricitinib, have revolutionized treatment. They discuss pivotal trial data and share real-world experiences, highlighting the transformative impact of this therapy on patients' lives. Prevalence of alopecia areata The prevalence of alopecia areata is not well-defined, with epidemiologic data varying widely. Dr Cameron suspects that AA is more common than currently realized; patients with a genetic predisposition to AA can experience hair loss triggered by stress or viral infections, indicating that the condition might be underreported and underdiagnosed. Emotional toll on patients The emotional burden of AA is immense. Both Dr Cameron and Dr Song emphasize that the condition can be emotionally debilitating for patients, noting that dismissive comments patients often hear can minimize the perceived impact of the disease and worsen the emotional burden of AA. Limited options before JAK inhibitors Historically, treatment options for AA were limited and often ineffective. Dr Cameron recounted that earlier methods involved injecting the scalp with Kenalog or using off-label methotrexate and chronic steroids, which were broadly immunosuppressive and had limited efficacy. These treatments were not suitable for long-term use and often provided inadequate results. Revolutionizing treatment The approval of baricitinib in 2022 marked a significant advancement in the treatment of AA. Prior to this, there were no effective treatments for the condition. Dr Song shared that his clinical experience with baricitinib has been remarkable, often exceeding expectations from clinical trial data. Most of his patients have seen meaningful improvements, even if they did not meet the strict responder criteria used in trials. Clinical and real-world effectiveness Both Dr Song and Dr Cameron noted that binary endpoints in clinical trials can be misleading. A patient who improves significantly might still be classified as a nonresponder according to trial definitions. Dr Cameron emphasized that his real-world experience with baricitinib has been excellent, particularly for regrowing eyebrows and eyelashes, which are crucial for many patients' senses of identity. Safety profile and misconceptions around JAK inhibitors Dr Cameron also addresses the misconceptions surrounding JAK inhibitors, particularly in the United States. He points out that dermatologists in Canada and Japan use these treatments more frequently and report positive outcomes. The safety data for baricitinib does not indicate significant risks, and the medication is generally well-tolerated. Initiating conversations and treatment Dr Cameron emphasized the importance of early discussions about baricitinib, even if patients do not meet the clinical trial criteria of 50% scalp baldness. He highlights the functional and cultural significance of beards, eyebrows, and eyelashes for many patients and recommends starting treatment based on individual needs. The approach to treating AA is evolving. Emerging guidelines suggest that factors such as eyebrow and eyelash loss, inadequate response to topicals, severe anxiety or depression, and rapidly progressing hair loss should be considered when determining the severity of AA and initiating treatment. The advent of baricitinib has significantly transformed the treatment landscape for alopecia areata, offering new hope and improved outcomes for patients. Insights from Dr Song and Dr Cameron underscore the importance of early intervention, understanding the emotional impact of AA, and advocating for patient access to effective treatments. As research and guidelines continue to evolve, dermatologists are better equipped to provide compassionate and effective care for individuals affected by this challenging condition.

In this episode of Topical Conversations, Charlie Dunn, MD, shares a valuable pearl for the management of frontal fibrosing alopecia (FFA). FFA is a clinical variant of lichen planopilaris (LPP) characterized by slow, progressive perifollicular inflammation resulting in eventual complete hair loss, primarily at the frontotemporal hairline. While historically observed mainly in postmenopausal women, there are increasing reports of men and children being affected. The etiology remains unclear, although hormonal influences, autoimmunity, genetics, immune dysregulation, and environmental factors like sunscreen exposure are speculated to play a role. Navigating limited treatment strategies Due to a limited understanding of its pathogenesis, there is a lack of standardized, evidence-based therapies, making FFA challenging to treat. Commonly utilized treatments include high-potency corticosteroids, intralesional corticosteroid injections, topical and oral minoxidil, 5-alpha reductase inhibitors such as dutasteride and finasteride, hydroxychloroquine, and tetracycline antibiotics like doxycycline. For refractory cases, therapeutic options become even scarcer. Growing evidence on the role of the JAK pathway in FFA Recent translational research suggests the Janus kinase (JAK) pathway may play a crucial role in lichenoid inflammatory dermatoses, including FFA and LPP. One study demonstrated that levels of JAK1 and JAK3 were elevated in lesional skin of patients with LPP, and there is growing evidence supporting the use of JAK inhibitors, both orally and topically, as promising treatments for FFA and LPP. Several case series have demonstrated significant reductions in disease activity within 1 to 4 months of treatment with oral baricitinib, oral tofacitinib, topical tofacitinib, and topical ruxolitinib in varying doses. Treatment pearl: JAK inhibitors for improved outcomes A notable treatment pearl gleaned from the discussion is the potential efficacy of JAK inhibitors for FFA. The frontal hairline area tends to have thinner skin, making it more amenable to topical treatments. Additionally, patient compliance may be higher with topical therapies, as they typically do not require lab monitoring. Therefore, when faced with a challenging case of FFA, considering topical or oral JAK inhibitors may offer a promising treatment strategy for eligible patients.