Telogen effluvium- Evaluation and Treatment- Anna WaékieI-Burnat

The speaker presented an extensive overview of Telogen Effluvium, a prevalent form of non-scarring hair loss that impacts around 11% of individuals with hair loss. Telogen Effluvium is characterized by a transition from the anagen to telogen hair growth phase and can be acute (lasting less than six months) or chronic (lasting over six months). Reversible factors like fever often trigger acute cases, while chronic cases are associated with persistent issues. The chronic condition primarily affects women and typically results in increased hair shedding rather than severe hair thinning, usually occurring two to three months after the causative factor. There are five mechanisms of Telogen Effluvium, the most common being the premature interruption of the anagen phase, often caused by factors like stress, fever, or surgery. Other mechanisms include excessive anagen phase prolongation (pregnancy), reduced anagen phase duration (hypothyroidism or iron deficiency), delayed teloptosis (e.g., in psoriasis), and premature teloptosis (after starting minoxidil or with use of keratolytic shampoos). Several factors can lead to Telogen Effluvium, including Physiologic (seasonal shedding is common in August and September), infections (every infection with fever,  COVID-19 or syphilis, HIV infection), endocrine imbalances (hyper/hypothyroidism), organ dysfunction (e.g., renal or hepatic failure), medications (oral retinoids, antithyroid drugs, anticonvulsants or oral contraceptives), stress (both psychological and surgery), inflammation of the scalp, crash diets, iron deficiency, and vitamin deficiencies. The speaker emphasized other connective tissue disorders like systemic lupus erythematosus, dermatomyositis and systemic sclerosis that can cause Telogen Effluvium. The speaker provides insights into the diagnostic process, which involves conducting tests like the pull test, trichoscopy, and trichogram to assess the percentage of hair in the telogen phase and distinguish Telogen Effluvium from other conditions. Identifying the underlying cause is critical, often necessitating a thorough patient history and laboratory tests, including complete blood count, thyroid function, iron profile, and vitamin D3 levels, which are vital for chronic cases.

The speaker discussed that acute Telogen Effluvium may not require treatment, but patient education is essential. In cases of chronic Telogen Effluvium, treatment can be initiated based on the diagnosis and underlying causes, with iron supplementation often recommended for low ferritin levels (below 30 μg/l). Various treatments like minoxidil, topical corticosteroids, platelet-rich plasma and multivitamin mesotherapy have been explored for Telogen Effluvium, but further research is needed to confirm their effectiveness. 

During the question-and-answer session, the speaker discussed the coexistence of chronic Telogen Effluvium and androgenetic alopecia. The role of biomimetic peptides in Telogen Effluvium treatment and the use of biotin supplements were also addressed.

Managing Alopecia Areata Through Trichoscopy- Lidia Rudnicka

The speaker begins by addressing a common concern among alopecia areata patients during their initial visits – whether their hair will regrow. She mentioned that while trichoscopy might seem like an answer, the available data suggests it's not a reliable predictor during the first visit. The speaker emphasized the importance of evaluating trichoscopy later in treatment, mainly when a patient has achieved complete hair regrowth. The speaker also discussed markers for disease activity or reactivation in alopecia areata, highlighting the significance of specific trichoscopy findings. The speaker explained that the presence of exclamation mark hairs, tapered hairs, black dots, and Pohl-Pinkus constrictions could indicate reactivation, which should prompt the consideration of increasing the treatment dose or adding additional therapies like corticosteroids. The speaker discussed scenarios where trichoscopy can help determine the effectiveness of treatment in patients who report no hair regrowth. Positive markers for treatment efficacy included rapidly regrowing hairs and pigtail hairs, while negative markers included exclamation mark hairs, tapered hairs, black dots, and broken hairs. She also mentioned the development of an alopecia areata predictive score based on findings from trichoscopy two months after treatment initiation, which can help predict the likelihood of hair regrowth without changing the treatment plan. 

The presentation shifted to tinea capitis, where trichoscopy played a vital role in diagnosis and treatment monitoring. The speaker demonstrated how trichoscopy findings could evolve during treatment and how a positive trichoscopy allowed for early intervention without waiting for mycological culture results. She also described specific trichoscopy features of tinea capitis, including coma hairs, corkscrew hairs, zigzag hairs, and morse code hairs. The speaker introduced UV-enhanced trichoscopy, a valuable tool for diagnosing conditions like Microsporum canis. This technique utilized UV light to enhance fluorescence and identify specific features.

In the non-cicatricial and cicatricial alopecia differentiation section, the speaker challenged the traditional view that non-cicatricial alopecia always presents yellow dots in trichoscopy. She explained that the presence of yellow dots might be influenced by sebum production and activity of the sebaceous gland, which varies with age. Thus, the absence of yellow dots should be considered in the context of the patient's age, and this doesn't necessarily negate the need for pharmacotherapy. However, the appearance of yellow dots can change over time in patients with long-lasting alopecia areata. Hair follicles in such cases may undergo atrophy, progressing to eventual follicular dropout. Opinions range from 10 to 30 years, but the consensus is that every patient should have the opportunity for pharmacotherapy, regardless of disease duration. When there is certainty or strong suspicion of alopecia areata despite the absence of yellow dots, the decision to initiate or continue pharmacotherapy should be made in consultation with the patient.

Late Onset Alopecia Areata- Antonella Tosti

The topic of discussion is "late onset alopecia areata," which refers to the onset of alopecia areata (hair loss) after age 50. It's highlighted that many elderly patients experience alopecia areata but initially developed the condition when they were young, experiencing relapses later in life. The talk focuses on understanding this unexpected phenomenon and its implications. Late-onset alopecia areata refers to the first occurrence of alopecia areata in individuals during later stages of life. Studies report varying percentages of late-onset cases, with some indicating that about 18% of patients experience this. Late-onset alopecia areata is more prevalent among females than males. The studies suggest that the condition usually presents as a mild form of the disease. One study assessed the extent of hair loss using a scoring system and found that most patients had a benign condition. The speaker discusses a study on alopecia areata in elderly individuals, particularly from Korea. The findings suggest that alopecia areata in the elderly share similar characteristics, typically presenting as mild and mainly affecting the scalp. Alopecia totalis and alopecia universalis are less common in this age group. Late-onset alopecia areata often lack a family history and typically don’t have a strong association with atopic dermatitis. It's frequently triggered by medications (e.g., weight loss drugs), COVID-19 infections, or vaccinations. Many patients with this condition have reported a specific trigger that led to its development. In late-onset alopecia areata, patients often identify triggers for their condition, even though these triggers may not always be confirmed. The patients generally have a better prognosis than those with early-onset alopecia areata. The response to treatment is usually positive, especially for those with patchy alopecia. When the condition starts after age 50, and it presents as alopecia totalis or universalis, the prognosis may not be as favourable. A recent study from Korea examined treatment responses in these patients. It found that patients with alopecia totalis had complete regrowth in only two out of 19 cases, while those with alopecia universalis showed partial remission in only three out of eight cases. This suggests that the prognosis is better for patchy cases than for severe forms of the condition. The study did not find significant differences between patients who developed the condition after 60 and those who developed it earlier. The disease often presents a unique characteristic known as the "sudden whitening of the hair," where patients experience rapid greying or whitening. This phenomenon is more common in these patients than other alopecia areata forms. The sudden whitening of hair can be observed as the hair turns white rapidly without complete hair loss. In some cases, the black hair may regrow while the white hair does not, resulting in a two-tone appearance. Trichoscopy, a method used for hair and scalp examination, may not be as useful in elderly patients with late-onset alopecia areata as in other age groups, as it may not display the typical features seen in younger patients.

In cases of late-onset alopecia areata, it's crucial to consider that patients may not exhibit the typical "yellow dots" seen in younger individuals with the condition. When diagnosing, it's essential to distinguish between scarring and non-scarring alopecia. To determine this, it's advisable to take a biopsy at the periphery of the patch and then proceed with a diagnosis. This approach simplifies the process and ensures an accurate classification. Late-onset alopecia areata is often associated with various medical conditions such as hypertension, diabetes, positive antinuclear antibodies, and thyroid diseases. One area that remains a subject of investigation is the potential association with cancer. It's unclear whether this association is a direct link or is influenced by the age of the patients. This question is significant when considering treatments like JAK inhibitors, as patients with late-onset alopecia areata may have a higher cancer risk. Most patients with this condition typically present with mild disease. Late-onset alopecia areata occurs in individuals who haven't had a history of the disease before. It's typically more common in females and might have a genetic predisposition. While the condition is generally not severe, there can be exceptions. In cases where you're uncertain about the diagnosis, especially whether it's scarring or non-scarring alopecia, a biopsy within the patch may be necessary to clarify the situation. Treatment with intralesional steroids, topical steroids, or topical immunotherapy is often suitable for mild cases. However, in severe cases, careful consideration is needed. Treatment with JAK inhibitors is an option for severe cases, but the discussion should be thorough with the patient due to the potential side effects. JAK inhibitors in this population need extra caution, and follow-up care should be more frequent. Diagnosing late-onset alopecia areata requires a clear clinical history and possible biopsy. While the condition is usually mild, severe cases may require more deliberation regarding treatment options, and the use of JAK inhibitors should be considered with caution due to the population's higher risk of side effects. Open communication with the patient is essential for understanding their expectations and preferences for treatment.

In the discussion, the use of various medications for alopecia areata treatment was mentioned, including tofacitinib, ruxolitinib, latanoprost, and bimatoprost. The speaker mentioned topical JAK inhibitors and prostaglandin agonists and even suggested combining the two for better results. Regarding treatment duration, it was suggested to stop treatment in non-responders after one year, although some patients might respond later. For responders, treatment is typically continued because discontinuation often leads to relapse. There was also a question about the longest patient duration on these medications. The discussion then touched on the presence of yellow dots as a diagnostic feature and how it might vary in different ethnicities. The speaker mentioned that individuals with dark scalps may exhibit pinpoint white dots rather than yellow dots, making diagnosis more challenging. Trichoscopy features might not be as evident in cases involving dark scalps.

JAK Inhibitors in Alopecia Areata- Bianca Maria Piraccini

The speaker discussed the significance of JAK inhibitors in understanding and treating alopecia areata. JAK inhibitors have shed light on the disease's pathophysiology, including the involvement of lymphocytes, inflammatory cytokines like Interleukin 15, cellular receptors, JAK molecules, and tyrosine kinase in the inflammatory process. Blocking this pathway can halt alopecia areata and promote hair regrowth, even restoring the hair follicle immune privilege. The speaker mentioned that there are eleven new molecules available for alopecia areata, with two of them, Baricitinib and Ritlecitinib, being FDA and EMA-approved as innovative therapies for alopecia areata. The remaining drugs are still in the approval process or are already approved for other conditions. The speaker emphasized the importance of using approved medications for alopecia areata. The speaker also discussed the results of phase three trials for three JAK inhibitors – Baricitinib, Ritlecitinib, and an upcoming third molecule – highlighting their effectiveness in achieving a cosmetically acceptable hair regrowth (SALT 20) over time. The side effects of these JAK inhibitors were relatively low compared to the placebo group, mainly involving infections like herpes virus disorders, rhinitis, and cephalia. The speaker explained that patients may show different response trajectories, with some experiencing early, gradual, or late responses, and recommended a minimum of one year of treatment before assessing the response. Trichoscopy, a tool for hair analysis, can reveal regrowth earlier than clinical observation. The speaker emphasized that factors like the severity of alopecia areata (significantly below 95% scalp involvement), and the duration of the current episode can affect the response to treatment. The speaker advised against waiting for spontaneous regrowth as the likelihood is low. It's essential to treat patients promptly and continue treatment to maintain stability and regrowth in the scalp, eyebrows, and eyelashes, as JAK inhibitors are effective in all these areas. The speaker also presented findings from a compassionate trial in Italy using Baricitinib to treat alopecia areata. The trial involved 23 medical centres and primarily targeted patients with over 50% hair loss. The study indicated promising results, with gradual hair regrowth and improved quality of life. Some patients experienced early responses in eyelashes and eyebrows. Similar outcomes were seen with Ritlecitinib in other trials. Side effects were mild. New drugs, like Deuruxolitinib, are on the horizon.

The presentation stressed the importance of continuous patient monitoring, personalized treatment based on age and severity, and the need to differentiate between effectiveness and adverse effects. It highlighted the chronic nature of alopecia areata, with patients requiring regular follow-up. Patient satisfaction and quality of life improvements were considered crucial indicators of success. Ineffective treatments should be changed promptly. Stress was not deemed the primary cause, and the condition often co-occurs with other autoimmune diseases, significantly affecting patients' lives. Spontaneous regrowth in severe cases was rare, emphasizing the importance of proactive management.

During the discussion, several questions were raised regarding the treatment of alopecia areata. The first question was about the choice of treatment for a child below the age of 12 with severe alopecia areata, depending on the presence or absence of atopic dermatitis. The suggested treatments included upadacitinib or tofacitinib for those with atopic dermatitis and tofacitinib for those without it. There were also questions regarding using JAK inhibitors in children under 12 and the appropriate dosage, with the suggested dose being 2.5 mg, depending on the child's weight. The discussion also emphasized the importance of considering the long-term nature of JAK inhibitor treatment. The conversation touched on shifting between different JAK inhibitors for non-responders, tapering the dosage for responders, and possible relapse. Additionally, lasers and dexamethasone were mentioned, with mixed opinions on their effectiveness in alopecia areata treatment. Finally, the importance of customization in treatment and giving the drug time to be effective was emphasized.

European Academy of Dermatology and Venereology (EADV), Berlin, 11-14 October 2023