In our first full day of lectures, Amy McMichael, MD, kicked off this update on alopecia areata with an examination of alopecia areata (AA) epidemiology. The disease is most prevalent in non-White females, including Asian, Black, and Hispanic women, and this trend carries through from the pediatric to adult population. Prevalence increases in patients with other atopic conditions, but AA also is associated with diabetes, thyroid disorders, hypertension, obesity, and depression. On dermoscopy, this condition is characterized by exclamation point hairs, which should be differentiated from pigtail hairs in tinea capitus, and yellow dots within the follicular ostium.  

She shifted gears to review treatments for alopecia areata, some decades old and some new to the marketplace in 2023. For refractory alopecia areata, contact immunotherapy such as topical squaric acid dibutyl ester has been used despite risk of cutaneous side effects, which can range from mild to severe. Like all treatments for alopecia areata, maintenance is required to reduce incidence of relapse. Dr McMichael showed 2 trials that used oral minoxidil. While on its own this hypertensive drug rarely led to significant hair growth in patients with AA, it may boost efficacy of other systemic agents, as one patient only responded to tofacitinib after its addition into the treatment regimen after a year of solo therapy. Another combination treatment that has been studied is methotrexate with low-dose prednisone, which allowed for complete regrowth in 7 of 35 patients with either alopecia totalis or universalis, despite many of the responders obtaining <25% hair regrowth with 6 months of methotrexate alone.  

There are some new prominent players in the treatment of alopecia areata, which is now understood to be a complex inflammatory condition. While topical ruxolitinib was not demonstrated to be effective, oral JAK inhibitors are nothing short of a monumental breakthrough for AA with the approval of barcitinib for adults, ritlecitinib for ages 12+, and deuruxolitinib currently in a long-term extension study. Dr McMichael recommended uptitrating to 4 mg in patients who do not respond to the 2-mg dose of baricitinib. Some emerging treatments to be on the lookout for include bempikibart (an IL-7 receptor inhibitor), ustekinumab, other JAK inhibitors, and dupilumab. Platelet-rich plasma and microneedling may also be powerful adjunct therapies.