Alopecia Treatments: Hope For The Hopeless

You may be wondering, “what are the best treatments for alopecia areata? Can hair grow back after alopecia areata? Are JAK inhibitors safe?” In this episode of the Skincredible Podcast, Dr. Lisa Swanson takes a comprehensive look at the latest alopecia areata treatments, from traditional therapies to cutting-edge medications that are truly changing lives in a world where treatments used to be very limited.

This episode will help you stay up-to-date on treatments available as of May of 2026 for Alopecia Areata and it will also help you discover why early intervention has shown to lead to better results. Dr. Swanson reviews the most effective treatment options for both children and adults, including observation, topical therapies like Minoxidil and Clobetasol, intralesional steroids, vitamin D, Allegra, Dupixent, pulse Prednisone, low dose oral Minoxidil, contact sensitizers such as Dinitrochlorobenzene (DNCB), Squaric Acid, Diphencyprone (DPCP), and JAK inhibitors.

The episode also explores in detail the exciting new era of JAK inhibitors for alopecia areata, including Olumiant (baricitinib), Litfulo (ritlecitinib), Leqselvi (deuruxolitinib), and the upcoming approval of Rinvoq (upadacitinib). Dr. Swanson explains how these medications work, who may be a candidate, who may not be, required blood work and monitoring, common side effects, safety considerations, insurance challenges, and what patients can realistically expect when it comes to hair regrowth in general.

You'll also hear Dr. Swanson’s valuable insights on popular hair loss remedies frequently discussed online, including rosemary oil, garlic, essential oils, capsaicin, PRP (platelet-rich plasma), red light therapy, laser therapy, cryotherapy, and PUVA treatment.

Whether you're living with alopecia areata, caring for a child with hair loss, or a healthcare professional looking to stay current on the latest advances, this episode provides practical guidance, expert insights, and hope for patients navigating autoimmune hair loss.

Keywords

Dermatology, Hair Loss, Alopecia, Alopecia Areata, Alopecia Totalis, Alopecia Universalis, Diffuse Alopecia, Loose Anagen Alopecia, Traction Alopecia, Hair, Skin, Skin Expert, Dermatologist, JAK Inhibitors, Olumiant, Litfulo, Leqselvi, Rinvoq, Minoxidil, Hair Regrowth, Autoimmune Disease, Alopecia Totalis, Alopecia Universalis, Dupixent, Vitamin D, Allegra, Contact Sensitizers, Dinitrochlorobenzene (DNCB), Squaric Acid, Diphencyprone (DPCP), 

Links, Attachments

NAAF: https://www.naaf.org

Find a Pediatric Dermatologist near you: https://pedsderm.net/for-patients-families/find-a-pediatric-dermatologist/

Find an Adult Dermatologist near you: https://find-a-derm.aad.org/ 

Chapters

00:00 Welcome, A Side Note About Breast MRIs 

04:25 Alopecia Areata Treatments

04:52 Observation, Especially in Pediatric Patients

05:39 Topical Steroids at Bedtime and Topical Minoxidil in Morning

09:00 Kids Do Better On Treatments

10:07 Follow Up and Expectations From Treatment

11:30 Intralesional Steroids

13:40 AAD or Society for Pediatric Dermatology Lookup

14:50 Vitamin D and Allegra Over The Counter

17:00 Dupixent

20:00 Pulse Prednisone

21:05 Oral Minoxidil

23:15 Safety Label on Minoxidil

24:30 Contact Sensitizers

27:00 JAK Inhibitors & Alopecia Discovery

30:00 Quality of Life Improvement with Treatment

31:20 Olumiant

33:05 Litfulo 

36:15 Leqselvi

37:00 Labs Checked With JAK Inhibitors

39:00 Safety Warnings

40:40 The 4 Cs

44:00 Coming Soon: Rinvoq

46:50 The Importance of JAK Inhibitors & Early Intervention

51:30 Natural Remidies and Social Media Trends

53:30 Excimer Laser & PUVA

55:00 Red Light

56:00 Conclusion

The information shared on this podcast is for educational purposes only and is not a substitute for personalized medical advice. Always consult your  physician regarding your health.

Transcript

SPEAKER_01 0:00

Hello, everybody, and welcome to another fun-filled episode of the Skin Credible Podcast. I am one of your hosts, Dr. Lisa Swanson, and I'm here with Anna. Hello. Hello. And I want to apologize to any of our visual watchers because I came, I probably have lines all over my face. I came here from a breast MRI. Oh, yes. Important. Screening. Good. No, right? I heard I have to do it every year in addition to mammogram. I heard Amanda Pete, the actress, say on a podcast that she had to do it every year because she had dense and busy breaths. And uh that applies to me as well. And it is a very interesting experience because I've had MRIs before. They don't bother me. Like the ka chink, ka chink, ka chink, whatever. Sure. Uh and lying still, usually not a problem. They give you headphones, you know. In a movie or something sometimes. No, in a movie. Oh, sad. Okay. But usually they'll off they'll be like, who do you want to listen to? You know, like, what do you want to listen to? But for the breast MRI, you have to lie down flat on your stomach. Face down. Yeah. And like your face is in this thing, and there's this bar right here on your sternum. Oh my goodness. And they tell you, don't eat a lot before you come. Because there's this pressure like the whole time.

SPEAKER_02 1:27

Yeah.

SPEAKER_01 1:27

That's probably the worst part of it, is just like the pressure. Yeah. And then I am dramatographic, meaning for the audience, dramatographism is where when your skin is rubbed, scratched, irritated, it kind of hives up. So for my face to be in this thing, face down, like a face plant for like 20 to 30 minutes. Oh. It's horrifying when I get up.

SPEAKER_02 1:52

You look great.

SPEAKER_01 1:53

I can't even tell. Thank you. It's had a little bit of time to settle down, but I warned the tech. I was like, this is gonna happen. And when this is not dangerous. Wow. And when it was done, she said, You don't look as bad as you said you would.

SPEAKER_02 2:09

That's a good kind of surprise. We like those surprises.

SPEAKER_01 2:12

And I'm like, okay, well, thank you. At least it's not as bad. That's important. Just like build it up to be this bad thing. And then people are pleasantly surprised. Yeah. Um, but I, of course, listened to Taylor Swift. Of course you did. Yeah, you get the specific album or like Spotify. She asked. She said, Do you want her most recent album? Or I was like, no, just a mix. I celebrate her entire catalog. Of course you do. Of course I do. And so it was a mix. And so for those of you that are maybe gonna undergo an MRI of any kind, I recommend the music because not only is it distracting and helps, you know, just kind of relax you depending on what you're listening to, but it also helps you know how long you've been in there. Because of the lengths of the songs. Because of the lengths of the songs. So the whole time I'm counting, I'm like, okay, this is song number one. Okay, song number two. And the whole thing was over like right about the end of song six. I think I heard a little bit of song seven. And so it helps you keep track. But doesn't Taezer Swift have like 13-minute songs? She does, but that one was not a part of the playlist. Yeah. Yeah. If they have oh, of course. Yeah. All too well. It's my favorite. It's my favorite song. And it's 10 minutes. So if that was part of it, you'd only probably have to listen to that twice. And then you'd be and you'd be done. Well done. Yeah. Yeah. So for those of you out there that have dense and busy breasts, if you have not yet had your first breast MRI, it's okay. It's not too bad. But definitely don't eat a lot before you go because of that pressure. Like sometimes it just like hurts. And other times it kind of makes you a little bit nauseous. You know, don't leave the MRI center and head to your podcast recording. You know, give yourself some time for everything to calm down a little bit. Yeah. Yeah. Yeah. Good thing there's good lights in here, too. I know, I know. And I think it it gave me some time in the car to just kind of let things settle. Sure. But I digress because we are talking about a very important topic today. Very important. We educated the audience on LP chariata as a whole. And now we're to the fun part, the treatment part. Because it's such a good thing. We just used to have virtually nothing. And now we have stuff. We have really good stuff. That's great. Yeah. We love to hear that. Yeah. And we have choices for people. And I think that's always really good. So I wanted to kind of cover everything we got. And we're ready. Yes. Yeah, let's do it. So, first option, observation. Especially for the pediatric patient. There are a lot of pediatric patients who develop a patch or two or three of alopiciata, give it a few months, and it just spontaneously regrows. So if it's a child with allopiciata, you just notice the spot, it is reasonable to just see if it returns on its own because that's very likely. Okay. Um, now, the more severe, the less likely the chances of spontaneous improvement. Okay. So if if you have several patches, if you've had it for a while, then your chances of just like all of a sudden one day being all better probably lower. But you could choose to just give it a beat and just see what happens. Option number two, topical medicines. I use a lot of these in my pediatric patients because they don't hurt. Yeah. And they actually work pretty darn well in the pediatric space. Interesting, more so than adults. Yes. And I think a lot of dermatologists who see primarily adults, they might not even entertain topicals. And I see why. They're not as effective in the adult space. What I do is I prescribe a topical steroid to use at bedtime, usually clobazole, which is one of our stronger topical steroids. And then I have the family supply over-the-counter rogain in the morning. The two-pronged effect is important because when you have alopecia ariata, your hair follicles are under attack by your immune system. It's a mistake of the immune system. It's this autoimmune process. We don't know for sure what sets it off, but there's a swarm of bees of inflammation around your hair follicles. What the topical steroid does is it calms down that inflammation.

SPEAKER_02 6:26

Okay.

SPEAKER_01 6:26

And then the topical rogain says, okay, follicles, let's regrow. You know, ready set, grow. Let's do it. And so the combination is really crucial, in my opinion, to get the absolute best results. Because you're working as an anti-inflammatory, you also want those follicles to be at their utmost and their best.

SPEAKER_02 6:45

Yeah. And that's just on the affected areas, then just the spots of the clebatazole is cheap, generic.

SPEAKER_01 6:51

It's available in numerous formulations. I like the foam version the best. And while it is generic, sometimes it is viewed by insurance as fancy. And so sometimes there's cost and coverage issues with the foam. The other alternative is the solution, which is like a thin liquid, which is fine, but can make the surrounding hair look a little bit greasy.

SPEAKER_02 7:12

The solution really made me itchy, like my neck and my like other places that I didn't put it on, even though I waited for it to dry and stuff before going to bed.

SPEAKER_01 7:21

This is not an uncommon scenario. And we actually learned this lesson lesson from Rogaine. So Rogaine is available over the counter. What people want, you want to buy the men's strength foam. There's a women's strength, but it's useless and costs more. Talk about gender inequality. Yes. Um, I think they call it like the pink tax. I've heard of that. Ridiculous. But you want the men's strength, which is a 5% monoxidal, and you want it in the foam version. So it's like a and this is for two reasons. Number one, the foam is far less irritating, and there's an ingredient in the solution that can actually even cause an allergic contact dermatitis. The foam doesn't do that. Yeah. Number two, the foam won't make your hair look greasy and stuff like that.

SPEAKER_02 8:09

Yeah, the solution is exceptionally greasy. Yes. It's gross.

SPEAKER_01 8:13

The foam is a little bit more expensive, but it's worth it. We do the rogain in the morning, the steroid at night. Why do we do that? So we always like rogain in the morning because let's say you use it at night and you put it on the spots and you're very careful.

SPEAKER_02 8:28

Yeah.

SPEAKER_01 8:29

Well, then your head gets on your pillow. And then your face gets on the pillow. And then all of a sudden you have hair where you don't want hair. No, thank you. Right, right. The only side effect I see with rogain foam, especially in the kids, is too much hair. It really works in kids.

SPEAKER_02 8:48

Really works in kids. Why do you think that is? This kid's skin more sensitive or receptive.

SPEAKER_01 8:54

It's interesting because almost no matter the disease state and the medicine being looked at, kids always do better. And people wonder if it's because they've had overall less treatment through the years.

SPEAKER_02 9:07

Yeah.

SPEAKER_01 9:08

Maybe. Or just like you develop kind of a tolerance to things perhaps over time. And then also your immune system is much more malleable when you're young. And so, regardless of if we're looking at a cream or a pill or a shot, and regardless of if we're looking at eczema, psoriasis, allopiciata, the kids always do better.

SPEAKER_02 9:25

So just like our brains are more stuck in their ways as we get older, also our immune system.

SPEAKER_00 9:29

So is so is our immune system. Yeah. It's like, I've been doing it this way for this many years. I know what I'm doing.

SPEAKER_01 9:36

I know what I'm doing. Don't tell me how to live. And whereas a kid's immune system is like, okay, you want me to adjust? Like, I'm happy to adjust. Yeah. Yeah. The Rogaine foam, of course, is over the counter. No prescription needed. Okay. Clobetasol is prescription, so you want to get a prescription from your dermatologist for that. I find the combination works really, really well. I'll follow up two to three months after starting it. Okay. And at that appointment, I want to see stubble. Furry. Yes. Yes.

SPEAKER_02 10:02

It's not like it's going to grow that fast. Three months is enough time for a little bit.

SPEAKER_01 10:05

And sometimes the first hair that comes back is almost like a peach fuzz. You know, almost like a vellus hair, which are the hairs that cover our bodies except for our palms and soles and aren't usually that visibly noticeable. I want to see signs of that at the two to three month follow-up visit.

SPEAKER_00 10:20

Okay.

SPEAKER_01 10:21

And if we're seeing that, then we're optimistic. We're like, okay, let's just continue. If we're not seeing anything, then I usually have a discussion with the parents, like, okay, do you want to do something else or you want to give it more time? I think very important to think about realistic expectations with these treatments. It does take time because like your immune system is attacking these follicles. There's literally, if you look at it under the microscope, this they call it swarm of bees of lymphocytes that are swarming your hair follicle. With the medicine, regardless of which option, we're telling the immune system to knock it off. And it has to kind of take time to calm down. And then those hair follicles have to reactivate, re-enter the antigen phase, which is the growing phase, and then start growing hair. So that takes time.

SPEAKER_03 11:06

Sure.

SPEAKER_01 11:06

I think everybody would love a treatment for alopecia of any kind that worked overnight. I mean of course. Oh my gosh. But it's important to give this time to kind of do what it's going to do. Now, intralational steroids is not something I do a lot because I see primarily kids. Intralational steroids is where instead of you're using a topical steroid, you use a little teeny shot and you actually inject it straight into the patch on the scalp. Okay. Um, it can be very effective. It is a very commonly chosen treatment option for adults with alopecia ariata, especially if they have one or two or three or four spots. If you have 50% of your scalp that's alopeciic, I don't think that's a great option for you.

SPEAKER_02 11:48

Sounds like pain.

SPEAKER_01 11:49

Pain. They are very painful. The one advantage to them is that you don't have to do anything at home. For some folks, that is a big advantage. They know that they probably won't be great with the topicals and stuff. So they like the idea of coming in once a month and doing these SHOTs, and then, you know, they can kind of ride the rest of the time. With the interlesional steroids, we do it about every month. Okay. You come in for your follow-up visits. Regardless of which treatment option I choose and my patients choose, I'm taking pictures at each appointment to monitor progress. And that's really important because sometimes those early signs of improvement, if you are a parent seeing your child every day, you're not going to necessarily see those. So I find the pictures really, really helpful in terms of like, are we responding? Are we starting to see some response?

SPEAKER_02 12:34

Are you still similarly expecting about three months and setting people up for that kind of time frame? Yes.

SPEAKER_01 12:39

Yeah. I think if you're doing intrational steroids, you want to give it at least three appointments to kind of see how are we working. You also want to make sure that you're seeing somebody that's taking good care of you. Yeah. Because intrational steroids can cause atrophy, meaning your skin thins and it can even cause atrophy of the lower levels of the skin. So you get kind of this sunken depression.

SPEAKER_00 13:02

Yeah.

SPEAKER_01 13:02

When that is noticed and the treatment is stopped, your skin can repair itself and everything can be just fine. But if it is not noticed because the person caring for you, maybe this isn't their area of expertise, and they keep doing the shots, then it can become permanent and can cause issues. So make sure you're seeing somebody trustworthy. The American Academy of Dermatology on their website has a place where you can click to find a board-certified dermatologist in your neck of the woods. We can link that. Yes, that'd be great. And you type in your zip code and it gives you a list and you can call those offices and say, hey, I'm dealing with alopecia, or hey, I'm dealing with eczema, or hey, I'm dealing with I need a skin check. And the offices can help guide you into which person would be the best suited for you. Uh, because a lot of dermatologists might specialize in some little niches and stuff. But seeing a board certified dermatologist is so incredibly important. And if the patient is a pediatric patient, the Society for Pediatric Dermatology offers the same thing. So you can go in there and you can click find a find a PEEDS derm and you can type in the zip code and you can connect with somebody. Shorter list. Yes. Yes.

SPEAKER_00 14:17

Especially if you're an Idaho.

SPEAKER_01 14:19

If you if you type in an Idaho zip code, yep, just one name pops up. At least for now, maybe somebody out there who's a pediatric dermatologist is interested in making a change in their life and wanting to come out to the beautiful gem state and enjoy our potato. So shameless plug. Shameless plug. Please, someone come help me. Please, please, please. Um, vitamin D and Allegra. So both of these have limited evidence as to their efficacy. But they're both so harmless that I think it's fine if people want to try them. Yeah. Either as a solo treatment or like they want to do the topicals, but they want to do something more. Maybe they do the vitamin D and Allegra also. This is like a prescription strength vitamin D, or just over the counter? Just over the counter. The recommended dose for kids is 400 international units. For adults, it's 600 international units daily. Um, vitamin D, you know, you can buy Amazon, anywhere at the grocery store. There have been two small studies showing benefit with vitamin D. The whole reason vitamin D became um suspected as a potential treatment was we started to notice that a lot of alopecia areata patients flared in the winter. Oh. So people were like, well, maybe it's because there's less sun, sure, and maybe it means their vitamin D is dipping. And so that was the whole theory as to why this was looked at. Interesting. I'm not completely convinced of its efficacy for alopecia areata, but I also view it as no harm to try. Yeah. And then Allegra, similar situation. Um, Allegra is an allergy pill. Yeah. Um, there are some patients whose allopici areiata flares in the springtime.

SPEAKER_00 16:02

Okay.

SPEAKER_01 16:02

And uh, and so for those patients, there might be an allergy component, maybe a daily Allegra could help. There might be a connection between what we call type two inflammatory diseases and alopecia areata. Type two inflammatory diseases include eczema, asthma, allergies, eosinophilic esophagitis. And there are some people who believe that alopecia areata is actually in this family, too. Interesting. There are a lot of patients who have both eczema and alopecia areata, or asthma and alopecia areata. And so that's where the idea of a lager comes in. That's also where the idea of dupixant comes in. Interesting. Now, dupixant is very interesting because listeners will remember dupixen from our eczema episodes and our lovely patients who had been on dupixin. It's approved to treat eczema, asthma, eosinophilic esophagitis, amongst a whole host of other things. Dupixin and alopiciariata is very interesting because since dupixen came out nine and a half years ago, we have had reports of patients who go on dupixin for their eczema or their asthma and they get new onset alopiciariata. Whoa. Weird. We have also had reports of people who have alopecia areata who go on dupixin and their hair regrows. So opposite effects kind of interesting. So it seems like for some people, it's a rare side effect of dupixin, but for some people it can actually kind of turn on alopecia areiata. For other people, it can treat it, which is why I put the two question marks.

SPEAKER_02 17:39

And we don't know which person is which until we try. Actually, we might.

SPEAKER_01 17:44

Oh, yes. Tell us more. So this wonderful dermatologist, Dr. Gutman Yasky, she's in New York at Mount Sinai. Nice. She did a study looking at dupixant for alopecia areiata. Okay. And what she found, she found two big take-home things. Number one, for dupixant to work for alopecia areata, often it requires higher doses than what we usually do for eczema. So the studies she did were in adults, and an adult with eczema on dupe gets 300 milligrams every two weeks. Okay. She found that she got optimal results with 300 milligrams once a week. So a shot every week. So seems like we might need higher doses. Okay. Number two, and most important, as I'm talking with patients in clinic, if your baseline blood level of something called serum IgE is greater than 200, then dupixant has a shot, pun intended, of working. But a really good shot of working.

SPEAKER_02 18:45

And is that something you would normally test or only if you were willing to consider the dupixant?

SPEAKER_01 18:49

Only if you were willing to consider the dupixin. Okay. If your baseline IgE is greater than 200, the dupixin has a really good chance of improving your alopiciariata. If it's less than 200, it has virtually no chance of improving allopiciata.

SPEAKER_02 19:03

That's great to know.

SPEAKER_01 19:04

Yeah. Yeah. And so sometimes if I have a patient who's kind of ready for a more major treatment for their alopiciariata. And so we're thinking maybe about the oral jack inhibitors, but we're not sure. Maybe they're young. We'll talk about the approved ages of the jack inhibitors, which are older.

SPEAKER_03 19:22

Yeah.

SPEAKER_01 19:23

Dupixants approved on the age of six months old for eczema. It's a medicine we trust. It's a medicine that's quite safe. And so sometimes I'll do the labs required for the jack inhibitor plus a serum IgE level to tell me and the patient's parents like, are they a good dupixant candidate or not? That's good, but then just shooting in the door. Exactly, exactly. Literally shooting with your shooting your shot, right? Pulse prednisone. So we know that if we had a patient with allopiciota and we started them on prednisone every day, prednisone is an anti-inflammatory, we know their hair would regrow and we would be the hero doctor. But then you can't take prednisone forever.

SPEAKER_02 19:59

Yeah.

SPEAKER_01 20:00

And so the day would come where you need to stop it.

SPEAKER_02 20:02

Okay.

SPEAKER_01 20:02

And then we know the allopiciata would come back and it would come back worse. Oh no. Yep. It's what we call rebound. So to get around that, we do something called pulse dosing of the prednisone. Meaning we have patients take a big dose just one weekend a month. Okay. Half on Saturday, half on Sunday. Most of the kids I treat, this is something that I think is used most commonly in the pediatric space as opposed to the adult space. Okay. But most of the time, the kids that I treat with pulse prednisone, they do fine. They sail right on through it. And then a small percentage of kids feel super hyper and a small percentage of kids almost feel like they have the flu. Oh yeah. Interesting. I'd heard the hyper part, but not the flu part. But most of my pediatric patients, it's like they didn't do anything at all.

SPEAKER_00 20:45

Okay.

SPEAKER_01 20:45

And it's kind of nice just one week in a month to kind of be thinking about it. Definitely. Now I will commonly combine that with low dose oral monoxidyl. And when you think about it, pulse prednisone and low dose oral monoxidal in combination are kind of like the clebatazole and the rogain, right? Yeah. We have the steroid that's telling the immune system to knock it off. Yeah. And then we have the rogain or the low dose oral monoxidal telling the hair to, okay, let's grow. Let's do this thing. So it's basically like oral rogain. It is. So back in the day when monoxidal was created as a pill, it was created as a pill for high blood pressure. And they observed that people taking monoxidal were growing hair like gorillas. Now, nobody wants to be a gorilla. No, thanks. And so we weren't really using the pill monoxidil for decades. Okay. But it was the origin of the formulation of topical rogaine foam because it's topical monoxidil.

SPEAKER_02 21:39

Yeah.

SPEAKER_01 21:40

Now, about five or six years ago, somebody very smart said, we don't want people to be like gorillas. But what if we used really, really low dose oral monoxidil? Could we get hair to grow without turning them into a gorilla? Yeah, that's great. And yes, we can. And so most of the time, patients for a high blood Pressure are taking 20 milligrams a day or higher of monoxidal. For LP chariata and other forms of hair loss, we prescribe the 2.5 milligram pill.

unknown 22:08

Okay.

SPEAKER_01 22:08

And we have people take, depending on their age and weight, anywhere from a quarter pill Monday, Wednesday, Friday. Baby dose. Baby dose to a quarter pill a day, to a half a pill a day, to one pill a day. We're using small doses. Um and so we don't get any effect on the blood pressure. It's not going to lower your blood pressure. Because it's like a tenth of the actual dose you would start with. Exactly. And even less if you're doing a quarter of it, right? Not every day, yeah. And so very, very safe, very well tolerated. When female patients take low dose oral monoxidil, about a quarter of them will notice increased hair growth where they don't want it, like on their face. But only 3% of female patients stop the medicine because of it. So most of the time it's a minor nuisance. Worth it. It's not a good thing. Yeah, that they can handle. Okay. And then the label on monoxidil. So I prescribe monoxidil for my mom. And she told me that the label for it is the scariest thing that she has ever read.

SPEAKER_02 23:07

Your mom would read that.

SPEAKER_01 23:08

She reads them all.

SPEAKER_02 23:09

She reads them all. She's one. She's a reader. She's a reader.

SPEAKER_01 23:11

It talks about like it can have some bad side effects that can uh affect the ability of your heart to like pump properly. Oh my goodness.

SPEAKER_00 23:18

This is so, so, so, so, so, so rare.

SPEAKER_01 23:21

Even in standard blood pressure doses.

SPEAKER_00 23:24

Yeah.

SPEAKER_01 23:24

And so the general dermatology community is not stressing so much over the low dose oral monoxidal on its safety. But I do tell patients, if you notice leg swelling, stop the medicine and call me because that could potentially be a sign that something's up. It's also so cheap. Low dose oral monoxidal is so cheap. Prednisone, so cheap. And so if a patient is coming to see me and their alopichariata is pretty bad, or we've we've given it a good solid try with the topicals and we're just not making headway. This can be a nice kind of path to more aggressive treatments. Okay. Because you don't have to get blood work done with pulse prednisone and low dose oral monoxidyl. The medicines are super cheap. Anybody can get them at any pharmacy. And so sometimes that's a bit of a stepping stone for people that maybe one day they're going to end up on a jack inhibitor, but they're just not ready yet. I think that can be a good, a good option for them. And then once the hair has regrown, then we continue the low dose oral monoxidyl. We start tapering off the pulse prednisone.

SPEAKER_02 24:27

Okay.

SPEAKER_01 24:28

Because you could theoretically take low-dose oral monoxidil for decades. And a lot of dermatologists are on low dose oral monoxidol. Contact sensitizers. These are things that we used to use quite a bit that we're not really using so much anymore. But I wanted to mention it just in case somebody out there is seeing their dermatologist and it gets brought up. There are several of them. There's scoric acid, DPCP, DNCB. Those are three different. So scoric acid, D P C P, DNCB. A B C D E F G S. I know, right? All the initials. All the initials. We actually apply it to their upper inner arm and we tell them, okay, we're going to put it on. It's painless when we put it on. Yeah. You're going to get a rash in one to two weeks. Okay. In the area. In that area where we applied it. We're basically making them allergic to it by applying it to their skin. And then they are to call me and tell me how bad the rash was on a scale of one to ten. And then we can prescribe the appropriate strength of that contact sensitizer.

SPEAKER_00 25:24

Okay.

SPEAKER_01 25:25

What it's trying to do is it's it it works by creating a rash because you're allergic to it. We need the rash, but we don't want it to be too bad. We tell patients two to three days of a little bit pink, a little bit itchy, a little bit scaly. Okay. That's our goal. And the immune system is so attracted to the contact sensitizer, it leaves the hair alone. Oh, we're distracted.

SPEAKER_02 25:48

We're going to go play with this rash.

SPEAKER_01 25:49

Exactly. Exactly. Exactly. So it's like, hey, immune system, come look over here. And so the immune system goes, looks over there, leaves the hair alone, the hair regrows.

SPEAKER_02 25:57

But then the immune system goes back to being naughty or no? No.

SPEAKER_01 26:01

Kind of breaks it out of that cycle. Nice. Um now, alopecia areiata. Regardless of what treatment you choose, there is a chance that it recurs down the road. So sometimes you're not permanently training the immune system to leave it alone, but it can be a very effective treatment treatment. And it's something that I used a lot earlier in my career because my mentor and hero, Dr. Ron Hansen, he was a big fan of scoric acid. We used it for basically every alopecia areyata patient. It can work, but it is a real pain in the butt of a treatment because the rash is part of it. You need the rash for it to work.

SPEAKER_00 26:35

Yeah.

SPEAKER_01 26:35

And the rash can be more than you bargain for. And even if you're super careful in getting the medicine just on the spots on your head, you can't help but, oh, this itches. Maybe you scratch in your sleep and then you touch other places.

SPEAKER_02 26:47

Plus, if you're saying there's some overlap with eczema kiddos, I mean that probably wouldn't be an option for them because they're already so miserable.

SPEAKER_01 26:53

Yeah. So I would say that it's a rare choice that I make in clinic today, but it is something that there are a lot of practitioners out there who are still utilizing it. So I wanted listeners to be aware. Okay. Jack inhibitors. This is where it gets so, so cool and so, so fun. So jack inhibitors work to decrease inflammation in the skin and elsewhere. You'll see jack inhibitors on commercials for various conditions like arthritis and Crohn's disease and stuff. But we use them in dermatology because they're very effective at decreasing inflammation in the skin.

SPEAKER_00 27:26

Okay.

SPEAKER_01 27:27

And they are particularly great with alopecia areiata. I remember the very first article I ever read about jack inhibitors for alopecia areiata. And the title of it was New Hope for the Hopeless. I love that. Because literally, patients that had severe alopecia areata or alopecia totalis universalis, there was a time that was not that long ago that we would simply say, I'm sorry, there's nothing we can do.

SPEAKER_00 27:58

So sad.

SPEAKER_01 27:59

And with this first publication, two dermatologists at Yale reported the case of a 20-something-year-old guy that had had alopecia universalis for 10 to 15 years.

SPEAKER_02 28:12

Whoa. And it's harder at that point, right?

SPEAKER_01 28:14

Yes, much harder. And he also was diagnosed with rheumatoid arthritis. So he was put on a jack inhibitor called Zell Jans to treat his RA. Wow. And all of his hair regrew.

SPEAKER_02 28:28

All of it? All of it. That's so crazy. And it wasn't even intentional. It was like to treat something else.

SPEAKER_01 28:34

That's cool. And so I remember reading this article being like, what? I think the entire dermatology community was like, what? No way, yeah. Because alopecia universalis, that's the worst of the worst. There's not like you've lost your scalp hair, your eyebrows, your eyelashes, your body here. Yeah. And we know that duration of disease matters. And this gentleman had had it for 10 to 15 years. And so to see the hair come back, it was like, oh my gosh. That's incredible. Yes. What a shock for him, too. A pleasant one. I know. Such a such a cool thing. And really started this jack revolution for alope shariata. Cool. And so for the first several years, there was a group of us, myself included, that was using Zell Jans off label to treat Lopezariata. You'll notice Zell Jans is not here on this list because it is not FDA approved to treat allopiciata. But back then we didn't have, we didn't have an FDA-approved option. And this was a way that we could offer our patients a way to get their hair back. And so I was eager to do so and treated a bunch of patients with Zell Jans early on in the Jack Revolution. And I think that's really what has made me into the dermatologist I am today. Like I saw the wonderfulness of patients who were truly hopeless. Yeah. And then they go on this pill, all their hair regrows, their quality of life improves, their outlook on life improves. They feel like themselves again. That's huge. When I'm speaking now to dermatology practitioners across the country, I am telling them get comfortable with these jack inhibitors, learn how to talk about them with your patients and their families. Because treating patients with alopecia areata with these jack inhibitors is going to change the practitioner's life. Like my life is forever changed by the patients that I've treated. And I think because I started with alopicia areiata and I saw all the wonder that it could do, I've just never looked back. I just think this family medicines offers so much potential for wellness for our patients and their families that we have never seen before. Again, there was a time not long ago where a lot of these patients we would be like, I'm sorry there's nothing we can do to help. And it's those patients that were included in all the trials for Illuminant, Lip Fulo, and Lexalvi. All of these patients that we would be like, I'm sorry there's nothing. That's really cool. And now they're going on these medicines and they're growing their hair. It's really a wonderful thing. To touch on each of them, so Illumient was the first one approved. Okay. Illuminant is currently approved, age 18 and up, but we're eagerly anticipating approval down to 12. The studies have been completed. They were announced last year. So we're hoping for label expansion. Illumient comes as either two milligrams a day or four milligrams a day. And a word of advice to practitioners out there listening, start with four milligrams a day. And it's oral. It's a pill. All of these are pills. Okay. In fact, that brings up a good point. Listeners may have remembered that we have a couple topical jack inhibitors. Yeah. We have obsolura for eczema and vitiligo, and we have enzepco for chronic hand eczema. In my experience, and I think this has also been proven in several studies, the topical jack inhibitors, they just aren't able to penetrate to the level deep enough to impact that swarm of bees when it comes to LP chariata. So I don't believe that topical jack inhibitors are effective in LP chariata. And I think that's pretty well proven, but I know sometimes I hear people still trying. When you're prescribing aluminum, just do the four milligrams. Like if you're treating a teenager or an adult, just do four milligrams. Okay. I am grateful for the two milligram version because I use that off-label to treat the kiddos that I see. And the audience is going to meet and hear from one of those patients, little Stephanie. Yep. And she is on the Illuminate two milligrams a day. So I'm grateful that that comes in that lower dose because that's what I use off-label for the kiddos. Yeah. Illuminant, very well tolerated, really a very safe jack inhibitor, approved in Europe to also treat eczema, but was not approved for eczema here in the States. Lit Foolo is also one pill a day. It just comes in one dose, 50 milligrams, one pill a day. It has a couple things that are a little bit different about it compared to the other jack inhibitors. Sometimes in about 5-6% of patients, we'll see urticaria. Erticaria means hives. And we don't see that with the other JECs.

SPEAKER_02 33:10

And the higher dose is not apples to apples.

SPEAKER_01 33:13

Correct. Correct. Yes. There's not been a head-to-head, literally, a head-to-head study for allopiciata. So all we have to go on with these three that are currently approved and more on the way is just kind of our gestalt after treating patients, you know? And failure of one oral jack inhibitor does not mean the others will fail too. Okay. These are actually all slightly different from each other in terms of their mechanism of action. So failure of one does not mean the others would fail. Yes. So yeah, options are still open. To that point, it's important to understand that these medicines take time. We are going to give it at least six months. And most of the time, we're also starting our patients on low dose oral monoxidal along with the jack inhibitor. In a perfect world, we'd like to give it a year.

SPEAKER_00 34:02

Wow.

SPEAKER_01 34:03

Because there are patients, the primary endpoints in the studies were at six months with secondary endpoints at a year. And there were patients in the studies of all three of these medicines that had no hair regrowth at six months and by a year had a full head of hair. Wow. Yes. So worth the wait. Yes. So six months is like that's the soonest that I would contemplate making a change for my patient. When you start one of these, automatically you're like, I'm doing this for six months, regardless of what happens. Yeah. But I think most people would make the argument that you don't really know for a year with some of these. And the other thing that's special about lip fullo is that you don't have to check a lipid panel. You don't have to check cholesterol with lip foolo with other jack inhibitors you do. Okay. And we'll talk in a moment about blood testing. Lit fullo is approved down to age 12.

SPEAKER_02 34:51

Nice.

SPEAKER_01 34:51

So it's our one jack inhibitor right now, approved down to 12 to help treat the teenagers.

SPEAKER_02 34:57

And a lot of insurances, I'm assuming, would want you to try all the above stuff, probably.

SPEAKER_01 35:02

I mean, I think the biggest thing we encounter with insurance with alpiciariata is frustratingly, insurance companies who deny it because they say alopiciariata is cosmetic. Oh, so annoying. Okay. So it's not so much about the tried and failed. It's about them not wanting to treat the condition. Not wanting to treat the condition at all. And there are even some insurance companies that won't even cover the cost of visits if alopecia is the only thing that's talked about. I know. We sh we push back hard on this because alopiciariata is an autoimmune condition. This is not a cosmetic disease. Life altering. Life altering. And so we push back hard. Yeah. Now the manufacturers of each of these three medicines, they have policies and procedures in place where if your insurance company says it's cosmetic since they're not covering it for that reason, they have programs through which you can get the medicine for free or for like $25 a month. So that's not the end of the world if an insurance company tells us that we have a workaround. Uh Lexelvi is the newest of the three to get approved. It's approved down to 18. It is one pill twice a day. So that's a little bit different with the Lexelvi. Although head-to-head studies have not been done, the Lexelvi data is quite good. Okay. Being approved 18 and up, I haven't prescribed a ton of Lexelvi, but very excited to see the age indication get lower so that I can get more experience with it. The twice-a-day dosing is a little bit of a suboptimal thing, but still so nice to have the three choices. With Lexelvi, the one thing that's a little bit special with it, you do need to have one blood test done before you start that looks at an enzyme that metabolizes the medicine. There are some people who just like genetically are low in this enzyme, and it doesn't hurt you to be low in the enzyme unless you go on a medicine like Lexinework or something. Yeah. So they just want to make sure that your body can process the medicine okay. Speaking about that, these medicines do require blood work.

unknown 37:01

Okay.

SPEAKER_01 37:01

All oral jack inhibitors require blood work. Yeah. We check blood work before we start the medicine. And then every clinician probably does things a little bit differently in terms of how frequently they're rechecking the blood work. I can tell the audience what I do, but again, there's different, there's no hard and fast rules for this. And if your practitioner does it a little bit differently, that's okay. That's what they feel comfortable with.

SPEAKER_00 37:24

Okay.

SPEAKER_01 37:24

So I do the baseline labs and then recheck it three months and then recheck six months after that, and then uh every six to twelve months, depending on the age and health of the patient. What are we checking with the labs? At baseline, we're checking a CBC, which is a blood count, a metabolic panel, which includes liver and kidney, a lipid panel, which includes cholesterol. We're also screening for infections people might not know they have. So we're screening for tuberculosis, hepatitis B, and hepatitis C. And then with the repeat labs, we're just rechecking the CBC, the CMP, the metabolic panel, and the lipid panel. Are they like immunosuppressive in nature? So what I tell patients whenever they're starting a JAC inhibitor, whether it be for alope shariata or for eczema, I tell them that these medicines are wonderful, wonderful. But they have a little bit of safety baggage that I can sum up in three points.

SPEAKER_00 38:16

Okay.

SPEAKER_01 38:17

Number one, we do have to do labs for these medicines. Number two, they increase the risk of certain viruses, like the cold sore virus and shingles. And I ask if they've had a history of cold sores or if they want to be vaccinated for the shingles. The shingles vaccine is indicated age 50 and up or 19 and up if you're on an immunosuppressing medication. And an oral jack inhibitor counts.

SPEAKER_00 38:39

Okay.

SPEAKER_01 38:39

I, for one, can't wait to get the shingles shot. There's data that it prevents dementia. What? Yes. Yes. We all need the shingles vaccine. I know. And so I've had shingles. It hurts. It hurts real bad. Yeah. I had it inside my mouth. And even kids get shingles. Yeah. But I'm 47, so in three years I can get it. I would sign up for it today if the age indication changed. And then number three, there is a safety warning on all members of the Jack Inhibitor family. Okay. That safety warning is based on a different Jack Inhibitor called Zelljans, being studied for a different condition, rheumatoid arthritis. Okay. In a different patient population. Everybody was older than 50 with at least one cardiovascular risk factor. Oh. They were all on methotrexate. Oh. 57% of them were on prednisone. Geez, that's a lot. Uh-huh. And because of safety concerns from that study, the FDA thought it prudent to put a safety warning on all JAC inhibitors. Even though none of these kids are probably on methotrexate, they're not on. And also different disease states, patients are actually predisposed to different conditions. Okay. Rheumatoid arthritis patients do have an increased risk of a lot of these things, just inherently because of their disease and the inflammation that's occurring as a result of that. And in these studies we have to date looking at safety for our JAC inhibitors that we use in allopichariat and eczema, we are not seeing those same safety signals. That's good. So the safety warning is something that's important to tell patients about. It's important to come to terms with yourself if you are a practitioner, like understand it, understand what you might want to look at when you're considering it for your patients. The kind of four categories of patient that I think, oh, maybe this is a more detailed safety discussion. We call them the four C's. So the first is SIGs cigarette. Okay. Yeah. So if you are a current or former smoker, your risk is greater for a lot of these things by virtue of being a smoker. Yeah. The second is clots. So has the patient had a history of blood clots already?

SPEAKER_02 40:54

Family also or just personal history?

SPEAKER_01 40:56

Personal history. And if there is family history, I do inquire about that. Like, oh, your mom had a blood clot. Tell me the story about that. Like, was she was it after she drove cross country and there's a logical explanation for that? Or was she young and healthy and 30 years old and all of a sudden had blood clot? Sure. In which case did they check her for hereditary clotting disorders? Yeah. And if so, did you get checked? So I will ask about family history just to see if there's any sort of genetic family thing that's going on. Factor fiblitin? Yes. Yeah. Somebody with factor fiblidin and jack inhibitors is not the best choice for the case. And then number three, cancer. Have you ever had cancer? What type was it? When was it? How long ago? How was it treated? Do you still see your oncologist today? All of those sorts of things. And sometimes if if there's some sort of history, I'll I'll reach out to the oncologist and be like, how would you, what would you think about us starting this medicine? And then number four, conception. If are if there's a woman of childbearing potential, is she thinking about getting pregnant? What are her family planning goals? Yeah. Because we know that you shouldn't be on a jack inhibitor if you're pregnant. Okay. Um, I should also take a moment to review what's actually in the boxed warning. Yeah. I don't perseverate a lot on it in clinic, and I typically only talk about it if people ask, like, oh, what is the warning? You know. And I say, Oh, it's all all the best stuff. Blood clots, mace events, which is like heart attacks and strokes, okay, cancer, immunodeficiency, and death.

SPEAKER_02 42:36

Oh.

unknown 42:37

Yeah.

SPEAKER_02 42:38

Oh. Scary.

SPEAKER_01 42:39

All the big five scary things. Oh my goodness.

SPEAKER_02 42:42

Is it like a typical black box warning? Yeah. Okay.

SPEAKER_01 42:45

And you know where a black box got its name? So we're actually now referring it to as just box warning. The whole reason they were called black box is because literally when you open up the package insert, there's a black box around the warning.

SPEAKER_02 42:58

Oh. Like on the ink. Well, yeah, black box just sounds so scary. I know, I know.

SPEAKER_01 43:03

You're like, am I going to get it in this like locked black box, you know? Again, we are not seeing these same safety signals in our alopeciariata and eczema patients who are on our jacks that are used for alopeciariata and for eczema. And this is all very reassuring. I think it's very important to still ask your patients about their past medical history, their medication uh list. Some of these jack inhibitors will have medication interactions. So you want to make sure that you're providing your med list to your treating practitioner so that they can double check in their interaction checker that everything is cool. So practice responsible medicine. Of course, of course. I also wanted to tell you. So right now, we have the three oral jack inhibitors approved. We're about to get a fourth, and it's a medicine that our listeners have heard of before because it's Rinvoke. Nice. Yes. So Rinvoke is one of our two oral jacks approved for eczema.

SPEAKER_00 43:58

Yeah.

SPEAKER_01 43:58

And we are about to see. Approval for alpha chariot. Exciting. And they studied down to age 12. So we're really hopeful that once it gets approved, it'll be immediately down to age 12. That's awesome. This will be a huge, huge thing for us. I've treated a few patients with Rinvoke. One of them also had Crohn's disease. Rinvoke is approved to treat Crohn's disease. Two of them had atopic dermatitis, had eczema. Rinvoke is approved to treat eczema. So I've been able to dabble, and Rinvoke is highly effective at treating algae chariot. Yeah.

SPEAKER_02 44:29

Very encouraging.

SPEAKER_01 44:30

And it also is just one pill a day. Nice. In the studies, they looked at 15 milligrams and 30 milligrams a day. It looks like the 30 is a bit better. Okay. Um, and so it'll be interesting to see how exactly the FDA approves it. Yeah. For eczema, we have to start with 15 and then go up to 30 if we're not getting better.

SPEAKER_00 44:48

Okay.

SPEAKER_01 44:49

And so it'll be interesting to see if the FDA wants to approve allopetiriad in the same way. Yeah. Or if they approve both doses and it's up to us to choose, kind of like Illuminant. Sure. So we'll see how that cookie crumbles. Very exciting stuff. And oftentimes when you're when the person caring for you talks about Jack inhibitors, they will typically also recommend low dose oral monoxidal in conjunction. We really think that gives it a major boost. Okay. It's such an exciting time in dermatology to be able to offer these things to our patients and their families. I gave a talk at a conference two or three years ago with a colleague of mine, Dr. Mona Sheriari. Folks who uh listen might also listen to Dr. Sheriari's podcast, which is called The Medical Sisterhood. And I was a guest on there not too long ago. We had a great episode, great time together. Mona's amazing. But we were doing this talk on jack inhibitors, and I had this brainstorm one one night when I was watching television, you know, probably The Bachelor or something with Larry. And I was like, this is what we should call our talk. Did it ever did I ever tell you?

SPEAKER_03 45:53

No.

SPEAKER_01 45:54

Baby Got Jack.

SPEAKER_00 45:56

Baby got Jack. Right? It was a huge hit.

SPEAKER_01 46:00

Everybody loved it. For those listeners that aren't immediately understanding where this reference comes from, maybe you're young or something. There was a song called Baby Got Back.

SPEAKER_03 46:10

Yeah.

SPEAKER_01 46:10

Yes. And it's an awesome song. It even made an appearance on uh Friends. Really? Ross and Rachel were singing it to their baby, Emma. Because it was like the one thing that would really make Emma giggle. It's a wonderful time to be in dermatology, being able to offer these treatments to our patients. And it's a it's a really great time to have LPG areata because we have these treatments.

SPEAKER_02 46:35

Yeah.

SPEAKER_01 46:35

One last closing comment that I want to make. I think that we are saving these jack inhibitors. We're keeping them in our back pocket and we are using them as a last resort. We need to stop doing that. And I think even I subconsciously did it by placing them last. Sure. Now maybe that's because I knew I wanted to spend a lot of time on them, and maybe that's because I view them as very special. Yeah. But we are keeping them for like, oh, if it gets really bad, or if they lose all their hair, or if everything else fails. Newer data is showing us that we need to be intervening earlier. So there was data from Illuminant in the teenagers where they actually broke down the success rates according to how long they had had the condition.

SPEAKER_02 47:28

Oh wow.

SPEAKER_01 47:29

And the patients who had had it less than two years did twice as good as the patients who had had it longer than two years. Sooner intervention is better. Sooner intervention is better. Number two, there was a study on Litful where they included patients with at least 25% alopecia on their scalp. Okay. Most of the pivotal trials you have to have 50%. Okay. Gotcha. So Litfulo did a study where you just had to have 25% or above. Okay. And what they saw was the absolute best efficacy for the patients with 25 to 50% alopecia. And the the the graphic of it is amazingly visual. It's like those patients did the absolute best, and then the 50 to 75 did second best, and then the 75 to 85 did third best, and then so on and so forth.

SPEAKER_02 48:19

So it goes back to early intervention again.

SPEAKER_01 48:21

Early intervention. Third thing that proves this point in the alumniant studies, patients were put on Illuminant versus placebo. Okay. They were on the treatment placebo group for six months, and then they all got real thing out to a year. Okay. For patients that had success, which we die we define as um less than 20% alopecia on the scalp. Okay. Because less than 20% alopecia on the scalp means that you can typically hide and so you're able to kind of live and function normally. And so they took the patients who achieve success and then they re-randomized them to either stay on medicine or be taken off medicine. Which I like because the data from it I think is very telling and very informative. But I also hate it for those patients. Like they're in this trial, they get their hair back, and then they get randomized to placebo and they lose their hair. Because when you look at what happens when people stop the medicine, about 80% of them lose their hair again. Okay. But 20% of them don't. So what's special about that 20% that they are able to stop the jack inhibitor and maintain their hair? We view these jack inhibitors for alopecia areata as kind of a forever thing.

SPEAKER_02 49:39

Yeah.

SPEAKER_01 49:39

At least until we have something better than them. So what's special about that 20% that they can be off of it and do okay? Number one, they had patchy alopecia, not totalis, not universalis. Okay. Number two, they had disease duration less than four years. So we need to be talking about these earlier. I think it's very reasonable for families to not be completely 100% on board the first time they hear about a jack inhibitor. It's a big step to take. But they know about it. They know about it. We need to be planting the seed earlier and putting it out there so that patients and their families can just kind of marinate in it for a little while. Sure. And they know when they get to that point, you know, they're ready for it. They can do their research, ask their questions. Exactly. Exactly. So I think patients out there who are listening, be an advocate for yourself. Yeah. And ask your dermatology clinician about them. Yeah. And, you know, do they think you'd be a good candidate? Sure. And then for the dermatology clinicians out there, be talking to your patients about these. Because even if at that first visit they're not ready, or maybe their alopecia areata isn't that bad yet, sure. It plants the seeds. So if things worsen, or if they just get to a point of frustration and desperation, they know they're there.

SPEAKER_02 51:07

Yeah.

SPEAKER_01 51:08

That first article will always stick with me. Yeah. These medications truly provide new hope for the hopeless.

SPEAKER_02 51:16

That is exciting. I did see a few things online that I wanted to run by you. Yes. That seem to be unconventional or like maybe naturopathic. Garlic, rosemary, capsaicin, essential oils, cryotherapy. Yeah. Low-level lasers like the eczema laser, PRP, platelet-rich plasma, red light, and puva turbines. Oh man. Any of that actually work? So read them to me one by one. Well, garlic, rosemary, capsaicin, or essential oils.

SPEAKER_01 51:46

So garlic, rosemary, essential oils, basically what those are potentially going to do, they're kind of going to act like contact sensitizers.

SPEAKER_02 51:54

Okay.

SPEAKER_01 51:54

They're going to irritate your scalp. Gotcha. They're going to distract the immune system to potentially come check it out. Yeah. Do I think that'll really be a solidly effective treatment? No. The one in the middle of that list. Capsaicin. I would just say no. So capsaicin is chili pepper cream. And we use it for patients who are itchy or patients who are having like neuralgia or neuropathy where their nerves are confused. Okay. And the chili pepper in the capsaicin distracts the nerves and it can improve itch, pain, etc. Okay. I see no reason why it would be helpful for allopician.

SPEAKER_02 52:29

Okay.

SPEAKER_01 52:29

Yeah.

SPEAKER_02 52:30

And then cryotherapy?

SPEAKER_01 52:31

Cryotherapy. Yeah. I mean, I think that's just like give the immune system something to handle over here because you're like causing epidermal destruction. Yeah. And so the immune system is going to want to help heal that. Yeah. Except you might scar or like you might blister. Yeah. Yeah. I don't I don't love that idea. Although I will say, so this stems more from the keloid world. So cheloids are thick scars. Yeah. And we will often use intralesional steroids to treat keloids. Sometimes you get better benefit if you spray a little with cryo and then inject the steroid because the cryotherapy expands your cells. So then the steroid is able to get into them more. That was a trick my mentor in hero, Dr. Ron Hansen, taught me. So maybe some people are like freezing a little before they do the intralesional steroids. However, I don't think you need to do that for alopiciariata for penetration of the steroid because you're not dealing with that thick, big key load. Yeah.

SPEAKER_02 53:25

Gotcha. And then I guess I'll put eczema laser and puva in the same category, maybe.

SPEAKER_01 53:31

So eczema laser, I actually tried that. Okay. Um, back in the day when we were both in Colorado. Yeah. Um, I just like kind of self-initiated. I had like five patients with alopeciariata. This was before the Jack Revolution. Yeah. And we use eczema laser pretty effectively to treat vitiligo. And vitiligo and alopeciariata have a lot in common. They're both autoimmune conditions. And with alopeciariata, the immune system is attacking the hair. With vitiligo, the immune system is attacking the melanocytes, which make your pigment. And jack inhibitors work well for both. Okay. So the two conditions have a lot in common. For that reason, I tried eczema laser for alopiciariata patients. Was not impressed. It didn't help any of my five. Now I realize that's a small, you know, number of patients, but I kind of stopped trying at that point in time. And then PUVA. Nobody should be doing PUVA anymore. No. PUVA was something that we used in the old days. So what PUVA is, is you take something called sorrelin and you either take it by mouth or you do a sorolin bath where you soak your skin in it. So some people would do it like they'd, if they had like psoriasis on their palms and soles, they'd soak their hands and feet. Not good for skin cancer. Not good for skin cancer. PUVA caused huge rates of skin cancer. Now, back in the day, again, we've come a long way. Yeah. We used the tools that were at our disposal. And, you know, looking back on that now with the other options available, like we wouldn't have done PUVA ever if we if we were living today. In my opinion, nobody should be doing PUVA today.

SPEAKER_02 55:02

Okay.

SPEAKER_01 55:03

Fair enough. And then red light.

unknown 55:05

Red light.

SPEAKER_01 55:06

Gosh, I think I think red light is on the internet to help everything.

SPEAKER_02 55:10

Everything. Make you younger, more beautiful, collagen production.

SPEAKER_01 55:14

But I feel like the amount of actual science showing benefit with Ryth, red light, very, very poor. I also see no reason why red light would help with alpiciariata. Red light is more like helping the deeper levels of your skin in a in a kind of a collagen and elastin and kind of youthful sort of way.

SPEAKER_02 55:30

Okay.

SPEAKER_01 55:30

So while I don't think red light would be dangerous, I don't see how it could help.

SPEAKER_02 55:34

Okay.

SPEAKER_01 55:35

Yeah.

SPEAKER_02 55:35

And then platelet-rich plasma.

SPEAKER_01 55:37

Oh, yes. PRP is very interesting. So PRP is where you go to a hair center or a dermatologist's office. Yeah. You have your blood drawn and they spin it down to platelet-rich plasma.

SPEAKER_02 55:51

Yeah.

SPEAKER_01 55:51

And so it's your own blood cells, but just a certain part of them. And then they take that and they inject it into your scalp.

SPEAKER_00 55:58

Yeah.

SPEAKER_01 55:58

This is used primarily for androgenetic alopecia, which is the common cause of male pattern baldness and female pattern hair thinning. It's very, very common. And PRP is used predominantly for that. They think it kind of rejuvenates the aging hair follicle. There have been mixed results in the studies. There have been a lot of different uh strategies in terms of timing of those treatments. So, like you might read one article where they did it once a month for six months, and then you read another article where they did it once every three months for a year. There's no kind of standardized approach. And I think the jury is still out. There are definitely believers in it in the dermatology community. And then there are people who are like, I'm not sure. Sure. It also is viewed as cosmetic. Uh insurance does not cover PRP. It's expensive. It's expensive. It's not like earth-shatteringly expensive, but you typically do have to have several treatments and stuff. So I I wouldn't do PRP for alopecia areata. Sure. But I am open to it uh if I'm talking to a patient about androgenetic alopecia and they're willing to invest the time and money and all that kind of stuff. Um, but I don't think the science is there for alopecia ariata.

SPEAKER_02 57:13

That's fair. Yeah. Thank you. Anything else on the internet? No, those are the main things that I saw.

SPEAKER_00 57:17

Basically on social media, you know, people get wild out there.

SPEAKER_02 57:21

I know.

SPEAKER_00 57:21

I know. It's almost too much to tackle. Yeah.

SPEAKER_01 57:24

But those were some good highlights to help our listeners.

SPEAKER_02 57:26

Yeah. Yeah. Some common ones.

SPEAKER_01 57:28

Well, thank you guys so much for tuning in. I hope you learned a lot. I hope you grew your knowledge bank, right? Because we're talking about growing hair. Grew your knowledge bank when it comes to the treatments for alopecia areata. And if you're a patient or a parent of a patient, I hope you feel much more knowledgeable and equipped to have some good, solid discussions with your treating provider. And if you are a clinician, I hope you feel empowered and emboldened to go out there and really treat alopecia areata because you're really going to change some lives by doing so, including your own. Thank you guys so much for listening.

SPEAKER_02 58:01

Make sure to like and follow, subscribe, share with your friends. Thanks, guys.