Alopecia at the Oscars

Hair loss has been a huge talking point since the Will Smith incident in April. As a result, you may see more patients coming forward to seek treatment. We spoke to Dr Martin Wade for everything you need to know about alopecia areata

The Slap. Even if you’re not a fan of the Oscars, there’s a good chance you’ve seen footage of the incident that’s dominated the headlines.. Acclaimed actor – and later Oscar winner – Will Smith took to the stage and appeared to strike host Chris Rock across the face in response to a ‘joke’ he made about Will’s wife, Jada Pinkett-Smith.

Will Smith and wife Jada Pinkett-Smith

The ‘joke’ made light of Jada’s shaved head, referring to her as ‘GI Jane’ – afictional film character known for her baldness. Chris claims he didn’t know that Jada suffers from alopecia areata, which had caused hair loss in patches across her head. Choosing to embrace the condition, Jada shaved her hair off last year. Yet it seems that many, like Chris Rock, assumed Jada’s baldness was a style choice. While she has spoken openly about her hair loss previously, it hasn’t garnered much attention – until now.

GLOBAL IMPACT

Since the Oscars incident, people from across the world have been taking to social media to share their stories of alopecia, detailing how they manage it and the impact it’s had on their lives.

Dr Martin Wade is a consultant dermatologist who specialises in hair loss and scalp conditions. He says that his patients may welcome the increased publicity as it builds awareness of the struggles they face. “From a psychological point of view, it can be terribly damaging to a person,” Dr Wade says, explaining that it can significantly affect their daily lives. “They don’t want to leave the house or go to social events. Many pateints wear hats all the time, too”, he notes, highlighting that this can lead to increased stress and anxiety.

“I often get told by women, ‘It’s ok for a man to lose his hair, but it’s not normal for women’,” explains Dr Wade, emphasising that men also have a hard time coping with hair loss. He says this is especially the case for alopecia areata, which is not always on the scalp, and can affect facial hair too. Men also find it harder to camouflage the hair loss with make-up or semi-permanent tattooing on the face.

However, facial hair loss for both genders can have a practical impact too. “Eyelashes protect you from getting grit in your eyes, while nasal hair protects against dust and sneezing,” he explains.

So what is alopecia areata? And what should you do if your patients suffer from the condition? Dr Wade shares his advice…

WHAT IS ALOPECIA AREATA?

“A good starting point is to clarify that when people talk about alopecia, they tend to mean alopecia areata,” says Dr Wade. He explains that there are a number of different forms of alopecia. These include:

Androgenetic: commonly known as male pattern baldness, but can affect women too. Characterised by a receding hairline or general thinning all over the scalp.

Traction: caused by repeatedly pulling on your hair, often developed in those who wear hair tight in a ponytail or braids.

Scarring: also known as cicatricial alopecia, this refers to a collection of hair loss disorders that can cause permanent hair loss and also scar the scalp.

Telogen Effluvium: triggered by stress or trauma, such as childbirth, bereavement and serious illness, whereby large amounts of the scalp hair shift to the telogen (shedding) phase. This is a temporary condition with hair regrowth expected.

Alopecia areata, on the other hand, is when the body’s immune system attacks hair follicles, leading to patchy hair loss. This mainly occurs on the scalp, but can appear anywhere on the body. More advanced forms are called Totalis – whereby hair is lost across the entire scalp – and Universalis, which results in total hair loss over the whole body.

Men, women and children can all be affected by alopecia areata, and Dr Wade says research suggests that there’s a genetic basis to it. As a result, alopecia areata can be more common in some families than others.

Dr Wade also highlights that the condition can be unpredictable. He says, “Whatever scenario you can think of, I’ve seen it; we have had patients with one patch of alopecia areata that grows back, then 10 years later they get another patch; patients who always seem to have one patch on the go; patients who lose all their hair very rapidly over a month and then it all grows back; and patients who lose all their hair that doesn’t grow back. Even in these cases, the hair follicles are still there. It’s not a scarring process, it’s just that something has been shut down by the immune system.”

HOW CAN IT BE TREATED?

Correct diagnosis is key, emphasises Dr Wade. He advises practitioners to understand the different types and how they present, noting that even the same conditions don’t always look the same. “For alopecia areata, the most common presentation is patchy hair loss, but sometimes it can be diffuse and more subtle, making it harder to diagnose,” he says.

Prescription-strength topical steroid lotions on patchy hair loss is one of the first approaches for Dr Wade. “

Another very effective treatment for smaller patches is intralesional steroid injection with triamcinolone,” he explains, noting that these are conducted every two months, as and when required.

A more specialised treatment approach is topical immunotherapy. This involves applying diphenylcyclopropenone (DPCP) to the affected area to make a patient allergic to the chemical, before using a weaker concentration on a weekly basis to try and elicit a mild dermatitis on the scalp.

The next option is oral steroids, although these should only be used in the short term warns Dr Wade. He continues, “Sometimes I’ll use methotrexate, which is an immunosupressing medication that can work very well and can be used in the long term if needed.”

A new and evolving treatment is the use of JAK inhibitors. “If cost and availability aren’t an issue for patients with extensive alopecia areata, these can work quite well,” says Dr Wade.

JAK inhibitors are a type of drug that surpass the activity or response of one or more of Janus Kinase enzymes, which are known contributors to the autoimmune process. The drugs can therefore block the inflammatory pathways that occur in alopecia areata, reducing the inflammation that occurs around the hair follicles and allowing hair to grow again.

“The advantage of a JAK inhibitor over something like methotrexate is that, while it’s immunosupressing, it has a very narrow mechanism of action,” says Dr Wade, explaining that older drugs can be more widely immunosuppressive and have increased side effects as a result.

Dr Wade notes that there’s definitely public knowledge of JAK inhibitors, with parents even requesting them for their children’s treatment. Of course, in this scenario, he says practitioners need to ensure they are treating the patient appropriately and not simply satisfying the parent.

When it comes to minoxidil, Dr Wade believes it should be used as an adjuvant treatment to speed up recovery rather than a first-line treatment. “Alopecia areata is an autoimmune condition where the hair follicles are under attack, so we need to try and turn off the associated inflammatory process as the foremost primary treatment,” he explains, adding, “Minoxidil needs to be thought of as a hair fertiliser rather than sole treatment.”

And if you don’t have the appropriate knowledge and training to effectively diagnosis and treat alopecia areata, Dr Wade emphasises that referral to a consultant dermatologist is essential. “Clear diagnosis is imperative to successful treatment,” he concludes.

DR MARTIN WADE

Dr Martin Wade is a Consultant Dermatologist with a special interest in hair loss and scalp conditions based at his private clinic, The London Skin and Hair Clinic. He is a member of the British Association of Hair Restoration Surgery (BAHRS), the British Nail and Hair Society (BHNS) and the British Association of Dermatologists. Dr Wade’s NHS post is at Queens Hospital where he is the Educational Lead for Dermatology and Lead Clinician for the Skin Cancer MDT (multi-disciplinary team).