Webinar: AA in skin of color populations
Transcript: Alopecia areata in skin of color patients
Supported by Pfizer
Antonella Tosti, MD; Arash Mostaghimi, MD, MPA, MPH; Kristen Lo Sicco, MD, FAAD; Loren Krueger, MD
All transcripts are created from interview footage and directly reflect the content of the interview at the time. The content is that of the speaker and is not adjusted by Medthority.
- Let's get started. So first, my disclosures. I work broadly across the alopecia realm, particularly in clinical trials. So I've worked with many companies. Again, this content is not related to any of that work. So a question you guys were asking in your pre test, what is the association between race and alopecia areata? And the answer is that it's quite complicated, let me get into some of the specifics of it. So the first study that really looked at this came out of Amme Clarks group, where they use a very large dataset out of Northwell and looked at the relative incidents of disease separated through different racial groups. So you can see here, out of 1200 cases they split their groups into both race and ethnicity, white, Black, Asian, Hispanic, and Latino ethnicity, and then other multiracial. And what you can see on the far right column is you can see the standardized incidence rates per a hundred thousand patient year. So while overall the average was 21.1, whites had an incidence of 18.6, Blacks, 24.1, Asians, much higher, 56.2, and Hispanics and other multiracial about the same as Blacks. So the question became, you know, why is this? Is this a question of who presents for treatment? Is it a question of true incidents? Is it a question of some genetic inclination? But the answer gets a little bit more interesting once you start looking at hair color. So here's a study, and this is a little bit small on the left side, but this is using a database called the UK Biobank. And the UK Biobank is fantastic because not only does it have collections of data on race and ethnicity, but it also has data on hair color. And this is hair color, your natural hair color. So even if you're older and your hair has changed or you've dyed your hair, it's not about that, it's about what your baseline hair color was. So as you can see here, they have, again, a similar predilection towards Asian and Blacks. It's important though, these Blacks are not African American, these are of African origin as this is a UK dataset. So you can see that while in the control group, about 90% of the people were white and the case group only of the people with alopecia areata, only 87 or so of those were white. And it was three times more, 7.3 versus 2.3 in the control group percentages of Asians reflected in alopecia areata cases and a mild elevation, 2.5 versus 2.2 of Black patients. But the real interesting part is when you look at the bottom, you can see that the number of patients in the case group, the proportion of people in the dark brown and black hair were substantial, with black being twice as represented there and blondes and redheads having a decreased representation in the case group. So what we did was we took this data, and we adjusted the racial predilection based on hair color. And what we identified was that when you keep the race, but adjust for the color of the hair, so only compare, for example, among people that had dark hair, you'd find that using white patients as a reference pretty much all of the results washed out. Where maybe Asians may have an inclination towards a higher prevalence, but it crosses one, it's not statistically significant. Black and Caribbean patients may actually be somewhat protected and again, somewhat similar results from multiracial and other. So the bottom line is really what we're seeing is that alopecia areata appears to have a predilection towards people with dark hair. Patients of skin of color have darker hair. And that's why we're having more of those patients reported in our data sets. So it's not a direct association, but the association is through hair type. When you look at the black hair incidents, it's about the same through all different cultures. Alright, so that's the epidemiology. But what does this mean for presentation? How does this disease look in these patients? So globally, the presentation is the same. The majority of alopecia areata occurs on the scalp, followed by the eyebrows and eyelashes, followed by the beard. And then some patients will go on to have universal disease all over their body. That story, that sort of mental image you have of alopecia areata is maintained. There's a couple things in patients with type three, and four hair that make their clinical presentation a little bit different. The first is that curly hair can really hide a lot of stuff. So if you think about the density of hair, we know that African American patients have lower hair density on average than Caucasian and Asian patients who may have two or even three times the number of hair follicles. That said, the curliness, the high coil of the type three and four hair, really type four hair makes it so that each hair takes up a much larger volume. You can lose hair, you can lose little areas of hair, and unless you really go digging through the hair, you won't be able to identify it. So I often find that these patients present to me a little bit later or present to me because their stylist or a barber, or something along those lines notice their hair loss, particularly if they have a longer hairstyle. It's less likely to be spontaneously visible as it is in some of our other patients. And then the second thing is that the range of mimickers is much higher. Often in patients of color, we use distribution of hair loss as a marker for what might be causing their hair. We use this for Caucasians as well, of course to differentiate androgenetic alopecia and things along those lines. But the range of the differential is different. Let me walk you through what I mean. So just to make sure that we're all on the same page with regards to nomenclature, when I'm saying type three and four hair, what I'm really meaning is the tightly coiled hair that one sees more traditionally in patients of African descent, type three hair has coils, but more loose coils. Type one and two are straight, or just slightly wavy hair. Among patients of color, Asian patients will have more of the type one to two hair, whereas African American patients are more in the type four, occasionally in the type three as well. So as I said, some presentations of this population are totally clear. You can see this is the standard round circular patch of alopecia areata that we see in these patients, easy to identify, presents suddenly and is pretty clear. What is challenging is when we get to either areas where there's partial fallout, diffused loss or partial regrowth. Let me give you a set of two cases. This is two African American women who presented with scalp hair loss at the vertex. And they weren't sure how long it had been going on, it seemed to be a little bit progressive over time. And if you show these pictures looking at the crown of a woman with this type of hair loss, you're not seeing the smooth patches that I showed you in the previous picture. And you're looking and you're like, wow, this might be CCCA, a scarring progressive alopecia that has a very different profile than alopecia areata, a very different treatment and very different prognosis. And this case in the published case reports and the international general trichology, both of these patients were biopsied and both of them were identified to have alopecia areata. So you can see that this presentation can be quite confusing because it mimics a known disorder common to African-American women. Similarly here on the right we have alopecia areata. We have smooth patches in the temple with a little bit of regrowth on the left. We have a patient that has traction alopecia. Whenever we look at hair, particularly at the vertex or particularly in the frontal temporal region of patients who may have hairstyles or braids, or other extensions that put pressure on those areas, we're prone to think about traction alopecia, again, traction alopecia being something that is not very easily treated. So you don't want to put the patient on the left on a chronic medication that may not help, or you also don't want to have the patient on the right being denied therapy because we misdiagnose it as traction. This challenge also presented in clinical trials. This is a set of two patients from one of Dr. McMichael posters about patients who were sent into the Baricitinib phase three study for alopecia areata. So on the top you see a patient that has CCCA, and traction alopecia, so a mix of two common conditions. And on the bottom you have a patient with alopecia areata who has more smooth patches. I take care of hair patients all the time, is what I do all the time. And I looked at these two cases, it can be really hard to tell the difference. You can really be fooled for one or the other. So what are we to do in this scenario? The key things that we are to do are to consider doing full examinations, and take full histories of all of these patients is important to look at the time course and the nature of presentation, where it starts, how it progresses, how it moves over time. The second thing that's really important is that while alopecia areata is a diagnosis that is a clinical diagnosis, I often find myself being more inclined towards biopsying in patients with skin of color, not in patients that have the classic presentation that I showed you at the beginning, but in patients for whom I'm not sure, or if I think they may have a mixed picture, it's important to get a sense of what their diagnosis is and how much of it may or may not be reversible before you start. And finally, I think you have to really approach these patients with a sense of curiosity, of camaraderie, of compassion, really connect to them. And you can't just be an alopecia areata doctor when you're working with skin of color patients. You have to think about how hair fits into their lives, into their lifestyles, and how regardless of their type of hair loss, how you can make them look and feel the way that they want. And some of my other colleagues are going to talk to you more about those strategies, and how to be more precise in these diagnoses moving forward. This wraps up my section, next I'm gonna turn it over to Dr. Lo Sicco.
- Thank you so much Dr. Mostaghimi. That was a wonderful presentation. Thanks to EGP Health for hosting this, and especially to Dr. Antonella Tosti for helping to bring all of us together today. My name is Kristen Lo Sicco, and I'm an associate professor of dermatology at NYU Langone Health. And today I'm going to talk about precision in practice tools for assessing alopecia area of severity and diverse populations. These are my disclosures, most of which are really hair related. And hopefully by the end of our lecture today, we'll review tools and methodologies for assessing alopecia areata severity in skin of color patients specifically, talk about current limitations in the severity assessments that we have, specifically the SALT score. And then correlate dermatoscopic, and dermatopathologic findings whenever possible. So to review again what Dr. Mostaghimi had spoken about in the recent JAMA article, looking at a database, that this database study showed that alopecia areata disproportionately affects skin of color patients. And like Dr. Mostaghimi said from some of the UK studies, this correlated with the hair color, right. So in this study specifically in JAMA dermatology, it showed that the Asian population had the highest prevalence followed by black population, closely followed by the Hispanic, Latino or Latina population specifically. And we know that patients of these races, and ethnicities are more likely to have darkly pigmented hair. In another study also, it did show that in the Black population, they might also be more likely to present with more severe types of alopecia areata including alopecia totalis and universalis. So let's review a couple of more things in terms of the epidemiology of alopecia areata in Black patients so that we can take this together as well. And I'll be repeating specifically, and intentionally things that Dr. Mostaghimi said, so that we can help to really bring this into our core memories. There's at least one study showing that there's a significant female predominance of alopecia areata in Black patients, specifically the ratio is actually 2.7 to one in that study. It also showed that there was an increased prevalence in younger patients around the age of 27, and over 75% of those patients were actually diagnosed with alopecia areata before 40 years old. So much younger in presentation. And similar to Caucasian patients or non-skin of color patients, many of these patients also had at least one atopic condition. And that was allergic rhinitis, atopic dermatitis or asthma or less commonly all three. And we call that of course the atopic triad. And then again, to repeat about AA characterization, while the majority, over 68% of patients in that study had patch type alopecia areata, there were signs that patients were more likely to present when they did with alopecia totalis and universalis and having Black patients compared to the Caucasian population specifically. And in this study, looking at Black patients, a smaller proportion, but still over 20% of people had eyebrow, eyelash or facial hair involvement. And then a smaller proportion around 15 or 16% also had nail involvement as well. And at least in Caucasian studies, nail involvement can portend poorer prognosis for the treatment of alopecia areata. So let's review the validated scoring system that we have right now to assess severity in alopecia areata. And this is an important tool that we use in clinical trials when bringing new medications to the forefront to treat this disease process. So the SALT score stands for severity of alopecia tool. It is a validated tool that's used to measure the total percentage of scalp hair loss. And you can see that the scalp is really divided into four quadrants, the right and left profiles, the top of the scalp and the back of the scalp. And it's important to consider, while this is very important, it was developed by Dr. Elise Olson et all years ago. It was validated in a lighter skin cohort. And like Dr. Mostaghimi said, curly hair can be very camouflaging, which can be very good to help to camouflage, but might be a drawback when we're trying to assess the level of scalp that is not covered because curlier hair can be more camouflaging to areas of the scalp that might have hair lost underneath. Another thing to consider too is because the SALT score is validated in a lighter population is that when you have a darker scalp against darker hair, that might also be more camouflaging and harder for the greater to assess loss in that area. So these are the potential drawbacks for this, the tools that we have available to us right now. So there are different scales that have been brought forth, and this is one of my favorites called the Alopecia Areata Severity Scale. I think it's so important, I actually have... This was published in JAAD, Dr. Brett King was the first author on this study. And many of us on this presentation today took part in publishing this article. And this really is one that we should take a picture of and put it as a smart phrase in our clinical notes. Why? Because we can help to assess the severity of somebody with alopecia areata that goes beyond the scalp involvement. I think the biggest issue to access of care is that insurance companies are still looking at percentage of scalp loss, but we know that alopecia areata is well beyond the percentage of scalp hair that is lost. There can be brow and lash involvement, facial hair involvement, loss of psychosocial functioning, inadequate response to treatment or recalcitrant disease. And then of course multifocal disease, denoting rapidly progressive alopecia areata. And so this score can help to upgrade. I'll use for an example, let's look in the middle here. Somebody with moderate scalp hair loss, which is defined as 21 to 49%. So they're not yet at severity for just the scalp hair loss, but if they answer yes, so any of those following questions that I reviewed, you can upgrade them. So if a patient came into you with 40% scalp hair loss, but had a negative impact on their psychosocial functioning, you can upgrade them from moderate to severe. Document that in your note. And then the hope is that they might have a better access to care because the JAK inhibitors that we currently have are currently FDA approved for severe alopecia areata. So first let's end... Dr. Tosti was actually largely responsible for describing the alopecia areata trichoscopic features that we have in our patients. The majority of studies that we have though have focused on patients with lighter skin types. We're gonna go over this first, and then we're gonna go over some novelties that Dr. McMichael and her group helped to uncover for skin of color patients. So exclamation point hairs that are present, and these can be seen in lighter or darker skin patients. An exclamation point hairs are hairs that look like an exclamation point, that means that they're tapered more proximal to the scalp and thicker the further we get away from the scalp and the thicker hair is actually the normal diameter. And the taper that's more proximal to the scalp is actually the thinner caliber hair. And that's a result of the inflammatory infiltrate, causing an abrupt cessation of the hair shaft formation. And that's why that kind of stricture is caused and that is the clinical pathologic correlation does correlate with disease activity as does yellow dots, black dots as well as broken hair, so we have data on this. Yellow dots are not specific to alopecia areata, they can be found in androgenetic alopecia as well as other types of alopecia. But when you do find them, they're thought to represent distended follicular osteo and like I said, also correlate with disease activity. Black dots and broken hairs are very similar in that the hair shaft has become vulnerable when there's inflammation surrounding it. So a black dot is an aerial shot of the top of the hair shaft, and the hair shaft has become so vulnerable and weak, it breaks off as it's trying to exit the scalp. And that's why it looks like a black dot. And a broken hair is just that, although the hair made it out of the scalp, it was too weak and broke off for it to be a longer hair. So that becomes a broken hair. Then we have signs of regrowth and that's the shorter vellus hairs. And these are defined as pigtail hairs that are coiled hairs as they're regrowing and lighter tapered hairs as well. So now let's review the alopecia dermatoscopy in skin of color patients. So we can see that these same buzzwords can be used, but they look a little bit differently. And you can see the exclamation point hair can be a little bit more subtle to find. And this hair you can see in this shot is thicker compared to the hair in the previous window. Yellow dots can look almost yellowish whitish in patients with skin of color. Black dots and broken hairs are more easily identified however. Just bring your attention to the pigtail hair here, and that's the coiled hair. The hair in this shot is much more coiled in a patient with tighter curl pattern hair, or curlier hair compared to the pigtail hair in the lighter skin patient, right? So we can see the coiled hair in the previous figure here. And again, lighter tapered hairs and pigtail hairs are thought to be a marker of regrowth. And then it was Dr. McMichael's group that helped to distinguish some novel features in skin of color patients with alopecia areata. And that is a perifollicular or peripilar hyper and hypopigmentation. We don't have large studies looking at clinical pathologic correlation for these entities. And importantly, we don't have a lot of studies really looking at whether or not this represents disease activity or severity. So really this represents a gap in our knowledge, and a need for more studies for this area specifically. If we look at the third column here too, it's important to remember what a normal darkly pigmented scalp looks like. Remember the honeycomb pattern, a honeycomb pattern scalp is actually a normal pigment pattern. So we can actually see pinpoint white dots that can be normal if they're small, regular distributed, that can be a normal finding. If you can see larger white dots that are larger, irregularly shaped and sometimes coalescing, that could be a sign of potentially another type of alopecia called scarring alopecia. And then another thing that was mentioned in Dr. McMichael's and another paper was diffuse erythema and perifollicular scale. And I thought this was really interesting because we don't typically see a lot of epidermal change with alopecia areata because the inflammatory infiltrate is deeper. So the question is, is this, you know... At least what was proposed, was the violaceous skin surrounding the follicles and the white gray scaling at the follicular openings were thought to represent vasodilatation from superficial capillaries in the inflammatory process, and then abnormal keratinization or declamation of the follicular infundibulum. So are these again, are they part of the disease activity as well as severity? So we need to do some more studies hopefully, so we can help to elucidate more of the connections here. So hopefully in conclusion, we can note that alopecia areata disproportionately affects patients with skin of color, alopecia areata in Black patients has a female and younger predominance and there is an increased risk of alopecia totalis and universalis noted in several studies. The current severity tools that we have do have current limitations, and the alopecia areata severity scale and others that take into context beyond just scalp involvement can help us to really capture the whole disease process beyond just scalp involvement. It's important to use our dermatoscopes as trichoscopes as we look at patient scalp with skin of color, and not anyone who walks into our clinic to help to clinch a diagnosis. And it's important for recognizing the skin of color specific trichoscopic features for diagnostic accuracy as well. Thanks so much for your attention, and I'm happy to introduce, she needs no introduction really, but Dr. Antonella Tosti is a legend in the hair space and we're very grateful that she's put this together for us today.
- Thank you very much Kristen. And we are going to discuss a little bit real life in these patients. I'm going to repeat some information, and these are my disclosures and I'm going to repeat some of the information that you have already heard because I think this is the most important take home message that you have to get. So alopecia areata is common in skin of color populations, especially in women and young patients. And prognosis may be bad in these patients, and often it's associated with atopic dermatitis in this population. And, you know, these patients may have disparities in the healthcare. This is a very common problem in patients of color because they have less commonly insurance, or they have insurance that don't cover properly the dermatological consultation. So accessibility to dermatological care can be more difficult as well as accessibility to effective drugs. And you have to keep in mind that patients of color often have more than one disease because there are some disease like traction alopecia or central centrifugal alopecia that are very, very common in this population. So it's quite common as Dr. Mostaghimi show you that a patient may have both. And so it may be difficult in this case to assess the severity and to perform a SALT score because it's complicated by the coexistence of two diseases. And I'm going to show you some example of that, okay. So traction alopecia, most women of color have some degree of traction alopecia. Why? Because of the way they style their hair, okay. And it's very typical for traction alopecia effect to the marginal scalp as you see here and have like this fringe sign, okay. So what happened? That you may have a patient with alopecia areata, and also has the traction alopecia. So it's not a differential diagnosis here, it is the coexistent and you have to determinate how much of the scalp is affected by one condition and what's the percentage of the scalp affected by the other condition. And you know, even more difficult may be the problem with CCCA, as Dr. Mostaghimi show you, CCCA may be very difficult to distinguish from alopecia areata. And again, this is a very common disease in patients of color. And during the clinical trials, I just seen several patients with both conditions that were very difficult to assess. So keep in mind this is not one or the other, maybe both, okay? And so how you differentiate, of course trichoscopy is very helpful. I developed trichoscopy and this is my tool in every patient. So I think Dr. Lo Sicco show you how this is important. Use your dermatoscope on every patient. And you can see here that the pinpoint white dots that correspond to the hair follicle openings in people of color, they are regularly distributed. And you can see the signs of disease activity like broken hair, or black dots inside these pinpoint white dots. And then if you look at the other disorder like traction alopecia, or central cicatricial alopecia, trichoscopy is completely different, okay. Why? Because the pinpoint white dots are irregularly distributed. You can see how irregular they're here, and they have white patches in the middle, okay. And then in traction alopecia you have very typically these casts surrounding the proximal shaft that indicate the pulling of the hair. And in CCA you instead have these white gray halos that are a very typical finding. So trichoscopy is not only useful to assess the disease stage and the severity of alopecia areata, but is also useful to evaluate the whole scalp. And so to determinate, which part of the scalp are affected by alopecia areata and which part may be affected by other disorders. Now I have some real history, okay. So this is a patient of mine, she's 36, and she comes with this, you know, with patchy alopecia, including this area affecting the marginal scalp, okay. And you have the history. So she has alopecia areata since childhood, but she had alopecia totalis when she was 11, okay? And then she recover of the alopecia totalis. And since then she never had complete loss, but she has a chronic disease, since the age of 20, so it's already 16 years, she's experiencing patches that come and go. And so she's never free of disease, okay? And this is very... Usually very, very distressing for the patient. And so she complains that she cannot really camouflage alopecia, and this is important, in patient of color, camouflaging alopecia areata is often more difficult, okay. Because if they have... It's difficult, these patients had very long hair that, you know, are able to cover the patches, okay. And this patient will be afraid or her life to develop alopecia totalis again because she had this experience. And so she wants to know why she has this chronic disease happening, you know, recurring. And she wants to know if a special diet can help her. And as show you, she has this marginal alopecia with even a fringe sign. So the question is, is she just alopecia areata, or alopecia areata traction alopecia? And this presentation makes more difficult to assess the severity using the SALT score. Her trichoscopy, so she has trichoscopy of alopecia areata, you know, where the pinpoint white dots are regularly distributed and she has black dots and broken hair, okay. It is less common in people of color to see the typical exclamation mark hair. And this is another patient. This is a male and this patient is 22. And you know, he has since the age of 21, she develop multiple patches that progressively increase in number to involve most of the scalp, and he had been using a clobetasol solution, topical minoxidil, triamcinolone acetamide, very typical treatment, including a pulse prednisolone, okay. Now is on oral cyclosporine, okay. And here you see the clinical images. So the patient of course cannot camouflage the problem, and is very concern about, you know, going out meeting people, okay. And I'm going to show the trichoscopy. And here you see very well the very regularly distributed white dots in the area of her loss. But this, you know, here, the clinical imaging, the clinical presentation is very typical. You don't have any doubt on the diagnosis and on the severity in this case. And so how would you classify severity based on the SALT score? Of course this severe disease, do you think it's a candidate for JAK inhibitors? I think definitely he is. And which drug would you recommend and why? You know, he has this family history of increased cholesterol, okay, so maybe it's better to choose a drug that has not this side effect, okay. So a selective JAK inhibitor is a good choice for this patient. And he had a complete regrowth after treatment with ritlecitinib. You know, this was even early responder, so he responded very well in six months. And this reality change his life. Keep in mind that for young patients, you know, the disease is even more difficult to manage. So I'm going now to introduce the next speaker, which is Dr. Krueger, okay, from the Emory University. Thank you.
- Thank you so much. That was so wonderful, wonderful perspective. I'm so happy to be here. Thank you to the amazing speakers who have done such a fabulous job of talking about this important topic. I work out of Atlanta and I see here in scalp disorders, and there has been so much beautiful information shared by experts in the field. I just wanna take a moment to shift gears and kind of augment what we've been discussing. A rich discussion on sensitive but incredibly important topic, which is cultural sensitivity in treating alopecia areata in skin of color patients. I have no relevant disclosures. So we cannot talk about cultural sensitivity without addressing the quality of life impact here, right. So we know cultural sensitivity infuses empathy and understanding for unique experiences. So we have to address the quality of life impact. So this is a study of 100 Black women who have alopecia. This is alopecia broadly, not just alopecia areata. And what they found when looking at the Hairdex quality of life scores is that emotions, symptoms and self-confidence were the most impactful for Black women dealing with alopecia on their quality of life. So we know that hair loss takes a toll on all, but particularly in the realm of emotion, symptoms and self-confidence in our skin of color patients. Interestingly, 55 participants in that study perceived spending money on ineffective treatments. So imagine that feeling of spending so much money, and resources and not having efficacy in your treatment. Also, less than half of the patients in that study reported resolution of their symptoms, and they reported that they were unhappy, or less than half were happy with their treatment. Interestingly, in this study, they did find, and I think this was touched on earlier, that biopsy actually had a positive impact on quality of life. So it seems that biopsy in this unique patient population may help to build some trust. I think this is such a rich topic, quality of life and alopecia, especially thinking about alopecia areata, just think about expanding this beyond Black women. There are other races, ethnicities we could touch on, thinking about religion and how all that plays a role, so more to learn and more to come here. And I just wanna frame this conversation by saying communication is key, and our approach is everything, especially when we know that it's so impactful for our patients, right. So this is one study that was published in JAMA Dermatology in 2021 and there's a lot of text on this slide, but hopefully it's helpful for you to grab a snapshot. There's a beautiful table in that publication as well. But our approach and communication starts with how we take the history and examine our patients. So for our history gathering, it's suggested that we maintain that in a seated position. We lead the conversation with, you know, symptomatology, how long it's been going on, as well as quality of life before we ask about things like hairstyling, which we know hairstyling has a role in some forms of alopecia, likely not as much in alopecia areata, but is still such an important part of the conversation we're having with patients. Additionally, it's recommended that there's another visitor in the room, engage them in the conversation as well. Also ask humble questions about hairstyling, leading with those things that cross cultures. So do you color your hair? Do you straighten your hair? So that's not specific necessarily to one cultural group. And leading with those seems less threatening. When examining patients, you want to assess their comfort in removing hair adornments to fully assess the scalp, right? So you wanna make sure you're looking at the scalp fully. And I think this definitely comes into play with disorders such as, you know, differentiating frontal fibrosing alopecia from traction alopecia to Ophiasis pattern alopecia areata that we've talked a lot about today. We don't wanna stop at just viewing the frontal scalp, like I mentioned. Take a second to view the scalp holistically to see if there are any other clues. Based on that study, it is totally fine to use gloves or not use gloves, whatever is your preference. So another thing that's really important is our communication and asking about how we're styling our hair. So there are a couple different styles here that you may see commonly, whether you're using heat to flat iron the hair, chemical relaxants, whether your hair is in a natural style, something like twists, braids, locks, those will have an impact in how we counsel our patients. So from the patient perspective, and even sometimes, you know, in terms of hair loss disorders, alopecia and hairstyling are intertwined. Again, perhaps less so for alopecia areata, but we have to be comfortable with addressing hairstyling. So we know that 64% of patients will wear a style to help conceal their hair loss. 44% of patients report wearing a wig, and 45% of patients will report wearing a hat or bandana. Why we should know about this as providers is one, we can uniquely use these styles or these tools to support our patients through their hair loss, and through their unique treatments. However, we also must be aware that in these particular patients, hairstyling can cause or exacerbate other forms of alopecia, right. Traction alopecia, acquired trichorrhexis nodosa are major considerations here. So for a hair care 101, so this is what I'm recommending to maintain hair health for my curly textured hair patients who are dealing with some form of alopecia, including alopecia areata. You wanna wash the hair every seven to 14 days with a moisturizing shampoo, always follow that, the shampoo with a conditioner, ideally you're using a leave-in conditioner after washing and we're reapplying that conditioner every two to three days to the hair shaft, not necessarily to the scalp. Avoiding high tension styling is important, especially for patients with chemically relaxed hair, and you want to apply a heat protectant to hair before using any heat treatment. And then I know all of us from the holistic perspective, and the patients are really interested in what can we do that's natural to help our hair. The truth is there are some things that are out there, right. And I just wanna introduce the idea of hair oils because you will have your skin of color patients coming in requesting to use hair oils. So I'm not a huge fan of hair oil, but they do have some role. So they mainly can provide cosmetic shine. So if you want to give some shine or gloss to the hair, they do seal the hair cuticle, and they will protect against frizz and create a barrier against some environmental factors. There are two types of oils that you can use on the scalp. One is an essential oil and the other is a carrier oil. So usually when a patient comes in, they're gonna suggest, well, I'm using peppermint oil, tea tree oil or rosemary, which we know has some evidence comparable to minoxidil 2%. And these are examples of the essential oils. So they have medicinal or healing properties, however, they often come in concentrated forms. So if you're applying that directly to the scalp, you will very likely develop an irritant or allergic reaction. It's quite common also it does a great job of concealing, flaking or seborrheic dermatitis, but that will return very rapidly again. So an important consideration if you're gonna use something like rosemary oil for its limited growth benefits, or tea tree oil for its help with seborrheic dermatitis is these essential oils need to be diluted in a carrier oil. So something that has a sealing or penetrating property, examples are jojoba oil, castor oil, you hear quite a bit. Coconut oil or olive oil are acceptable as well. Lastly, I just wanna take a moment to say build your resources as a provider and the way that, that was, you know, most successful for me, there was a patient that came in who loved their hairstylist and had a healthy hairstyle in place. I would often ask them, who's your stylist? You know, who do you go to? What kind of styles do you like to wear? And I would write that down and develop my repertoire, or treasure chest of resources that I could provide to other patients. Empower your patients with other tools for camouflage that can very easily be hair fibers in skin of color patients. It can also be wearing unique styles like plating, or twisting, a wig as long as it's not glued on or causing damage, or other conditions such as acquired trichorrhexis nodosa or traction and, you know, collaborate and learn from those around us. We have to learn and interact more with our stylists to provide the best care for our patients. Here are some wonderful resources. So these are some textbooks that you may consider recommending to patients, or picking up to learn more. So "Getting to the Root" by Dr. Lenzy, "90 Days to Beautiful Hair" by Dr. Aguh. And then if you're looking for some patient facing resources to provide, consider checking out, Skin of Color Society's website. There is a lot of helpful information about hair care, as well as hair disorders as well. So thank you very much.
- Thank you very much for the fantastic presentation. So I ask all the speakers to come back, and then now we have some question and answer. So I can read the questions. How do you approach diagnostic uncertainty when trichoscopy findings are ambiguous or atypical in skin of color patients? I think Dr. Mostaghimi is the right person to answer this question. - How I approach diagnostic uncertainty when I... So I have to be honest, I'm not as good as trichoscopy as some of my colleagues on this call, not nearly as good. So I will look and I will learn what I can, but I do believe that right now, particularly because you are putting somebody on potentially a long-term therapy, a long-term therapy, that even if you know the diagnosis of alopecia areata may not work for everybody, that's when you have a conversation and really go more towards more invasive evaluations, which are biopsies. And as was mentioned during the course of detox, patients are not always averse to biopsy. And in fact, that may increase the therapeutic alliance as was mentioned earlier. So, you know, if you can't figure it out from clinical examination history and trichoscopy, you need a little more tissue.
- Very good. So other question, are there validated patients reported outcome measures that capture the lived experience of alopecia areata in skin of color? I think, Kristen, you can answer this question.
- Sure. The question was how does studies capture the lived experience of patients with skin of color in alopecia areata? - It's validated. So the question is that there are any validated measures?
- And I think Loren can also help us to answer this question, but to my knowledge, I don't think we have validated scoring systems in patients of skin of color. I think unfortunately much of what we do in medicine is focused on non-kin of color, which represents a gap. And this is the whole reason why we're, you know, we're doing this symposium and while many of us are focused on helping to close this gap in skin of color. Loren, do you agree?
- 100% agree. I think there are a number of different measures that we use to look at quality of life across many dermatologic diseases and some of those can be applied in alopecia. There's the Hairdecx that was mentioned in that study as well. However, I think there needs to be a much deeper dive into how this may disproportionately, or differentially affect certain populations, right. So we can make sure we're being... And providing holistic care. So, great point.
- So next one is a trichoscopy question. So what is your experience with peripilar hyperpigmentation or honeycomb pattern in alopecia areata, and how do you distinguish these from scaring alopecia? So, or chronic lupus? So they're normal in the black scalp to see peripilar hyperpigmentation and honeycomb pattern, these are normal features of the black scalp. So you see that in alopecia areata, you see that in normal scalp. So how do you distinguish from chronic lupus, discoid lupus? What is typical of discoid lupus, they lose pigment. So this is the only situation where the honeycomb pattern disappear. So discoid lupus is very easy to recognize by trichoscopy and scarring alopecia, you know, you have an increased number of these very disorganized pinpoint white dots. And then depending on the type of alopecia, you see other findings. You know, trichoscopy of the black scalp is more difficult. I publish a paper a few years ago, and my new book has a chapter on that and I also publish a chapter for the "Skin of Color Society" book. So you may find information about that. So what gaps exist in alopecia areata research for skin or color population and how can clinical trial be made more inclusive? Okay, let's have Dr. Mostaghimi answer this question again.
- Sure. So you know, so much of the experience of hair loss is attached to culture, and societal expectations and norms and really about self-expression that a lot of the experience of patients, not just skin of color patients, but patients of all different groups, races, religions, really has not been individually explored, not only for alopecia areata, but for other types of hair loss. And that's something that we need to put an increasing emphasis on. If you look at trials, trials for alopecia areata actually have pretty good representation of African American patients. The most important thing that we're lacking right now is consistent reporting standard, especially around not just race, but around hair type. So changing the standards of how we choose to show who is in our trials include an evaluation of hair type, may get to the core of how diverse the trials are. Are the patients really matching the patients that we're seeing in real life? And if not, how can we increase the representation of those patients and trials?
- So thank you very much to everybody. I think we reached our goal, and I hope you learn from this webinar.
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