Magan Medical Clinic, Dermatology
We provide quality dermatology care with compassion. Our specialty is medical dermatology, including:
If you have psoriasis or hair questions, Dr. Chiang possesses special expertise. He completed fellowships in both fields at University of California, San Francisco where he saw a wide spectrum of patients (including the most severe), performed clinical trials, and published research.
We take pleasure in serving our community including Covina, West Covina, San Dimas, Rancho Cucamonga, Baldwin Park, Azusa, Glendora, Upland, El Monte, Duarte, Monrovia, Arcadia, La Puente, and Diamond Bar.
Same day appointments often available. No referral is necessary if you have PPO insurance. We accept a wide range of insurance plans (unfortunately, we do not accept Medi-Cal as primary insurance, only as secondary insurance).
For appointments, please call (626) 331-6411. We look forward to serving you!
"What’s New in..."
A monthly column by Dr. Chiang
What's New in Alopecia areata
Alopecia areata is a relatively common disease affecting 2% of the population. It is characterized by bare patches lacking hair on the scalp. It appears quickly and many patients report it occurs “overnight.” The most effective treatment for patchy disease involving less than half the scalp is a series of steroid injections into the affected areas. This is usually repeated every 4 to 6 weeks until full regrowth is achieved.
However, there has been no good therapy for those who have more than half their scalp involved. In addition, anywhere the body has hair can also be affected, e.g. beard, mustache, armpits. It is just not practical to inject all of these areas at once. Oral steroids work temporarily but have side effects, esp. when used long-term. Also, once the oral steroids are stopped, the disease tends to return.
Thus, patients commonly ask me if there are any new medications available for extensive alopecia areata. The main answer I’m aware of are that there have been increasing case reports and limited studies that a class of medications called “JAK inhibitors” (named for the inflammatory enzyme the mediations block) seem to improve patients with extensive alopecia areata, esp tofacitinib. The medication is currently indicated for rheumatoid arthritis. One recent speaker Dr. Sidharthan reported that 7 of 12 patients in a single-arm clinical trial achieved more than 50% regrowth with tofacitinib after 6 months of treatment. Of those 12 patients, 7 had moderate to severe alopecia areata and 5 had complete scalp hair loss (alopecia totalis or alopecia universalis). However, the investigator had to push the dosage beyond what is currently being used for rheumatoid arthritis (5 mg twice daily) to twice the dosage (10 mg twice daily) for 6 of the 7 patients.
Side effects for tofacitinib include serious infections, cancer, stomach or intestinal perforation, and blood or liver issues. This is of course not to be taken lightly. In the clinical trial, there were no serious adverse events but there was a decreased platelet count (the cells that form clots) that resolved after discontinuing the medication, an increased white blood cell count (the cells that fight infection) that resolved after discontinuing the medication, liver inflammation that may have been due to patient-reported alcohol usage, self-limiting diarrhea, and blood in urine. While these weren’t considered serious, it is still a fairly high rate of side effects which is not surprising given that the investigator used twice the normal medication dosing.
Other limitations include that I am not aware of any double-blind placebo controlled trials, which is considered the gold standard in determining if a medication works. This is particularly important in alopecia areata where there is a high, fairly random, remission rate. That being said, 7 of 12 patients experiencing › 50% regrowth within months is suggestive of a true benefit. Also, I am not aware of any long term follow-up studies in reporting the average duration of the benefit, whether days, weeks, months, or years. Oral steroids have a fairly high remission rate, but also a high rate of relapse. As always with today’s medical system, cost is also a concern with tofacitinib retailing for about $3000/month for rheumatoid arthritis dosing and $6000/month for the dosages used in the above reported clinical trial. Thus, insurance companies may not cover it.
In summary, I’m not excited about tofacitinib, but it is an option to consider for patients with extensive alopecia areata who are willing to take on the risks and understand the effect may not be long-lasting.
If you have alopecia areata or have other skin questions, please make an appointment for dermatology consultation at (626) 331-6411 to discuss your options. You can also sign up for the National Alopecia Areata Foundation newsletter at https://naaf.org
Charles Chiang, MD, FAAD
- Karon A. JAK inhibitor improves alopecia, with caveats. Dermatology News 2016
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