Ch 87: Alopecia Areata

Question 1

Characteristic hallmarks of AA

Answer 1

(+) black dots (cadaver hairs, point noir)

(+) exclamation point hairs

Question 2

Nail findings in AA

Answer 2

(+) nail pitting

(+) sandpaper-like appearance

Question 3

Conditions associated with AA

Answer 3

Cataracts, thyroid disease, vitiligo, atopic dermatitis, psoriasis, Cronkhite-Canada, Down syndrome

Question 4

Main drivers of disease pathogenesis (2)

Answer 4

1) Autoactive cytotoxic CD8 T cells, 2) interferon-gamma-driven immune response
* Cytotoxic subset: CD8+ NKG2D+ T cells

Question 5

Risk factors for AA

Answer 5

Family history
Major emotional stress
Antioxidant-oxidant imbalance

Question 6

Dermatoscopic findings in AA

Answer 6

(+) follicular ostia
(+) exclamation point hair
(+) black dots/cadaver hair
(+) yellow dots

Question 7

Phenomenon in which all pigmented hairs fall out and the patient is left with only white hair

Answer 7

Canities subita

Question 8

Diagnostics to order for AA

Answer 8

4mm punch (horizontal section)
Thyroid function tests
Iron/vitamin deficiencies

Question 9

Histopathologic findings in AA (general)

Answer 9

(+) generalized miniaturization
(+) marked increase in catagen and telogen hairs

*HP features are STAGE-DEPENDENT

Question 10

Histopathologic findings in AA (acute stage)

Answer 10

(+) “swarm of bees” - peribulbar immune infiltrate centered around the hair bulb (mostly CD4, CD8, NK cells +/- mast cells, plasma cells, eos)

Question 11

Differentials

Answer 11

Temporal triangular alopecia
Tinea capitis
Early scarring alopecia
Trichotillomania
Secondary syphilis (alopecia areolaris)
Androgenetic alopecia
Telogen effluvium
Anagen effluvium

Question 12

Prognosis: % of affected individuals having a solitary episode

Answer 12

25%

Spontaneous regrowth is common, diff body areas appear to regrow independently

Question 13

Prognosis: % of individuals with partial regrowth by 1 year

Answer 13

60% (but often followed by repeated episodes of hair loss)

Question 14

Prognosis: % of individuals with relapses within the 1st year

Answer 14

40%

Question 15

Poor Prognosis (4)

Answer 15

Involvement of occiput/hairline
Chronic relapsing course
Presence of nail changes
Childhood onset

Question 16

Prognosis:
% becoming AA totalis
% becoming AA universalis
RF for above

Answer 16

5% AA totalis
1% AA universalis
Younger age of onset, hair loss from trunk/extremities

Question 17

Treatment for <10yo

Answer 17

Topical corticosteroids (mometasone) +/- Minoxidil 5%

Question 18

Treatment for >10yo, <50% scalp involvement

Answer 18

ILSI (first-line)
Class I CS under occlusion
Class II +/- Minoxidil 5%
*If unresponsive, topical immunotherapy

Question 19

Treatment for >10yo, >50% scalp involvement

Answer 19

Topical immunotherapy (DPCP or SABDE)
JAK inhibitors
ILSI
Platelet-rich plasma injections
Scalp prosthesis

Question 20

Tx: ILSI (dosing, frequency, expected response)

Answer 20

2.5 to 10mg/mL Q4-6 weeks
15 to 40mg injected per session
Initial response in 4 to 8 weeks

*If no regrowth after 4 mos, consider other options.

Question 21

Tx: Systemic Corticosteroids (dosing, pulse, prognosis)

Answer 21

Pred 20 to 40mg OD, taper to 5mg in a few weeks
Pulse: Pred 100 to 300mg, or Methylpred IV 250mg

*Regrown hair frequently FALLS OUT again when treatment is discontinued. Does NOT alter long-term prognosis.

Question 22

Tx: Prostaglandin Analogs

Answer 22

Latanoprost, Bimatoprost - for AA of eyelashes, eyebrows, adjuvant tx

Question 23

Tx: Anthralin 0.2% to 0.1% cream/ointment (dosing, expected response)

Answer 23

First 2 wks: 20-30 mins OD
Next 2 wks: 45-60 mins OD, overnight if tolerated

New hair growth in 2-3 mos of treatment. Good choice for children. NOT suitable for eyebrows/beard.

Question 24

Tx: Anthralin 0.2% to 0.1% cream/ointment (MOA, SE)

Answer 24

Irritant, nonspecific immunomodulating effect (anti-Langerhans cell)

SE: irritation, scaling, folliculitis, regional LAD, brown discoloration of skin, staining of clothes

Question 25

Tx: Topical Immunotherapy (MOA)

- Diphenylcyclopropenone 2% solution

Answer 25

Creation of contact dermatitis (decrease in peribulbar CD4/CD8 lymphocyte ratio, shift in position of T-lymphocytes away from perifollicular area to interfollicular area and dermis)

Question 26

Tx: Topical Immunotherapy (MOA)

- Diphenylcyclopropenone 2% solution

Answer 26

2% solution to sensitize small scalp area 1wk prior to tx, then 0.0001% weekly. Do NOT wash scalp for 48 hours after tx, UV protection. Increase concentration per week until with mild erythema and mild itching.

Max dose: 2%
SE: severe contact eczema, discoloration (vitiligo/hyperpigmentation); Extreme caution in AD and dark skin types

Question 27

Tx: Photo(chemo)therapy (prog)

Answer 27

UVB or PUVA

*very high relapse rate

Question 28

Tx: Cyclosporine (dosing, SE)

Answer 28

4 to 6 mg/kg/day (+/- pred)

SE: elev LFTs, elev cholesterol, headaches, dysthesia, fatigue, diarrhea, gingival hyperplasia, flushing, myalgia

Question 29

Tx: Janus-Kinase inhibitors

Answer 29

Inhibit autoreactive CD8 T-cell infiltrate

Oral baricitinib, tofacitinib citrate (FDA-app for RA)
Oral ruxolitinib (FDA-app for myelofibrosis)