What If Every Day Was a Bad Hair Day?

Welcome to season two of Derms on Drugs of Video Podcast brought to you by scholars in medicine, the best educational platform and dermatology and provided no cost medical providers. Derms on Drugs is we're cutting edge derm meets the Derms comedy. Matt Zyres from Dr. Dermatology and each week I'm joining my residency buddies Dr. Laura Ferris from the University of North Carolina and Dr. Tim Patton from the University of Pittsburgh and we use our 60 years of combined. I've combined during experience to discuss debate and dissect the hottest topics and dermatology it is everything you need to know to be on the cutting edge of Derm and you have some fun listening new episodes drop every Friday on scholarship medicine, Apple podcast, Spotify and other major podcast platforms and the video component. I want to remind people has a key figures tables from the articles that we talk about. All right, let's go ahead and get into it. I am so excited this week we have got Dr. Mary and Senna from actually she's at the Leahy clinic. It runs a hair clinic and we are really going to get into an interesting topic today so so we're going to be getting initially into the idea of the psychological effects of alopecia and alopecia are you know and other types of alopecia and it's some really interesting data kind of a lot of it cut me cut me kind of off guard. But let's go ahead and get into it. Dr. Ferris let's get started with you. What do you got? All right, I'm going to start with a paper in dermatologic therapies called the psychiatric burden and alopecia areata a propensity matched cohort study. This is Lou Zach and I'm sure I'm saying that wrong at all, publish just you know recently. Okay, so when I say propensity matched cohort study you say try not to know where this is going. Okay, so the authors wanted to quantify how much more likely newly diagnosed alopecia alopecia areata patients are to develop anxiety depression and Somnia, you know all the usual players compared to those who do not have a so they looked at 10 years worth of data in trinetics and they were matched with controls who had been in for coded for a general examination. And so this was a large cohort so there were 57,389 pairs they were paired one to one. And so to be an AA cohort you had to have at least one recorded diagnosis of alopecia areata between January 1, 2015 and April 25 and at least six months of continuous EHR activity prior to that. And then the adult the controls were matched on things like age sex, etc. So how did they come up with the diagnoses using ICD 10 coding and so if they had a baseline diagnosis they were excluded and you know and they were looking at things like depression, self harm, bipolar disorders, schizophrenia. And they used a couple of fancy statistical methods that we'll talk about. Okay, so what is the main take home point or do we're we're AA patients more likely to have a psychiatric diagnosis. Yes, and the 17.3% versus 3.9% and the non AA crowd. So if you look at this, yeah, it's it's a big difference. So if you look at this in terms of risk ratio, let's say risk ratio of 4.49 if you look at it by hazard ratio, it's actually the same 4.49. So, you know, basically what was high depression risk over five times higher and the AA group anxiety risk four times higher and some are substance use and some near eating disorder. So basically everything came up higher in women, the psychiatric comorbidity was higher 18% versus 13.6% men and this was particularly true for depression, anxiety and eating disorders men, however, did lead in substance abuse. So let me assume my first question when I was looking at this, the one that made me question the whole thing was the these psychotic disorders. I think of everything else in there as something where like bad stuff's happening to you, you get anxious depressed and so I'm eating disorder, whatever. But like psychotic is your brain's messed up like you've you've got, you know, that's genetic. It's whatever. So that one made me question the whole thing a little bit. So one that if you look at the percent risk it's low right so it's 0.4 in the AA group versus 0.1 in the non AA group versus things like, you know, anxiety, which is like 10% and 3%. So one, this isn't like a, even though the risk ratio, the ratio is high that absolute numbers relatively low. So what I would say is that I think how do you get diagnosed with the psychotic disorder? It's usually of an episode and you know, we do know that people can have, you know, stressors contribute to that right. So you can have underlying disorder, but you might be well controlled. But when you have an acute stressor and things like alopecia, erotic can be that. That was kind of my interpretation that it throws people over the edge right. So personality disorder should be not, I mean, it should be part of your personality right it should not be related to things like AA. But you know, in my view, like when do you present and get a diagnosis of these things that's when it's exacerbated enough that you have to hit the medical system. That's your center in your experience. Right. We also talk some about the psyche, the, the immunologic effects of stress and psych disorders and whatever. And we're all comfortable with the idea that like psychological stress can cause telogen of fluveum. But do you think there's any two wayness here that like people or it's the susceptibility to anxiety and depression makes you more likely to get alopecia or yada or is it, you know, do you think this is pretty consistent with your experience though that people like get AA and it makes them anxious and depressed. So I think it's a bit of a double edge sword sword right because at the one hand, you don't want people who get AA to be think, you know, crud, this is something I did. This is my fault because we know that even if stress does cause an exacerbation or or contribute somehow to onset of disease. It's not the whole story. We know that there's more of that right. But I think probably the most telling examples that I see of telogen of fluveum like triggers leading to exacerbations of disease is in my patients who sometimes are on Jack inhibitors have completely regrown. They'll have, you know, got a bit loss of a loved one or something major that happens right not the day to day stress that we all experience but something really bad that happens and they'll go through a flare now they won't lose all their hair, but they'll develop patches and we it's come to the point where we actually screen them. And the vast majority of people will have had some trigger it's either weight loss, the common ones are weight loss adjustment in their thyroid medication, significant stress or those are probably the top three or stopping a hormone medication, stopping HRT, stopping a birth control hormonal leading IUD or birth control pill. And it's like I would say 90% of my exacerbations have a telogen of fluveum trigger. I have a question about this for you to so we did, you know, some of the early Jack inhibitor AA studies and so, you know, when you have patients in a clinical trial, you really get to know them a little better than you do when you just have a patient is in your clinic for 15 or 30 minutes. That's just you fairs. I don't talk to the clinical trial patients either. You don't, but I do. And so one of the things that really struck me was the number of people who had a severely traumatic event prior to developing AA like oh, I was fine. And then it was like horrible things like the death of a child or the death of a spouse and something that was very unexpected and then they developed AA. So I agree with you. I think that there is this, you know, important psychiatric component to it. I mean, it's not everyone. It's not everyone. It's not everyone. There are definitely a subset of patients, right. Just like a taught a to be can contribute to a there are subset of patients who I think are a bit more subject to this. What I what I think is neuro inflammatory process that contribute to their AA pathogenesis. Now I agree. And so yes, I think it's interesting. So, you know, it is like the chicken and the egg question, right. So are you also capturing things. But you know, they did try to control for that by not having looking for people who did not have any of these diagnoses prior to their diagnosis of AA. So, you know, the interesting little statistical thing that I thought was interesting. Because I'm always like what's the, you know, what's the risk ratio. What's the hazard ratio. But basically risk ratio is access burden over also more people with AA will end up with these diagnoses hazard ratio also controls for like the time to event. So, you know, and so what they the hazard ratio being elevated suggested there's more of it. But it's also. more likely to occur sooner. So, and that was the elevated hazard ratio sort of takes that into account as well. So I thought that that was interesting. The other interesting things that they did was, you know, it's like, okay, well, this whole the study ran over COVID. And so they actually compared like pre and post COVID. And so the risk did go up higher after COVID for particularly anxiety and insomnia eating disorders, self harm and suicide. So is that just COVID effect? It may be, but I thought that was interesting that they just comment there too. Like one thing that I was kind of thinking about is, you know, we got our first FDA approval for a bear sitnip and July 2022. And I think they looked at the data from like March 2020 to January 2025. So yeah, yeah. And and so like you would think maybe, oh, they're anxiety might go down. Of course, we don't know severity of these cases. We don't know, you know, anything like that. But you'd almost like, well, now at least there's an option. But maybe it's sort of, you know, patients are aware of their newly diagnosed. It's hard to know. But I did think that was interesting too. Yeah, that's the treatment landscape, like change dramatically. And that's also, yeah. Brussels that I hadn't thought about before that since this is basically an unselected population of alopecia, eryata patients, the vast majority of them are going to be fairly mild. And so these psychiatric stuff is for people who, you know, four times more likely to be anxious or depressed, probably the majority of them were mild alopecia, eryata, not, you know, salt 70. It's the unpredictability of this disease that absolutely and understandably, right, really can mess with people because they don't know. And there's no test that we can do to promise them one way or the other if they're just going to have, you know, a couple patches that will spontaneously regrow and never be an issue again or patchy persistence disease or lose everything. They don't know why I came about. They don't know, you know, what caused it. And, you know, sometimes those, those types of alopecia eryata can be even harder to camouflage or deal with in some cases. So do you have a number you give people? So say somebody comes in with one pat, you know, we need one spot or a couple, they're like, ah, injection done. But they're like, well, what are the chances all my hair's going to fall out? What do you, the number I give people is probably one in, probably 90% chance you're going to be fine. I'm making that up completely. Is there any data? Is there a number you give people? I mean, the range really varies depending on what study you look at. But it's somewhere around 10% to as high as 30%, which I think is a high estimation. I think it's probably somewhere in the 10 to 15% range. You're right. You're right. Sometimes you just make stuff up and you're actually right. That's right. You take enough shots eventually, you make one. That's right. Mary United question. You said you screen pretty much all your AA patients, right? With those psychiatric questions, do you have a like system in place where hey, look, the rate of psychiatric disease is so high, I really want you to see somebody or do you discuss it and then they say, I'm going to be okay. I know that I'm in good hands in your care. Like how many patients do you actually sort of say, hey, go go see a psychiatric professional about this because I mean, it's no surprise that there were higher rates of psychiatric disease, but it's like, what are what what am I going to do with these patients? I mean, I'm probably like terrible at saying here's what you should do and you should talk to somebody about this. You just kind of make a note of it and then I don't know the next step. Yeah, I think it's an excellent question. Interestingly enough, patients are pretty insightful and those who I am like this person need help are usually already seeing someone or have already started medication. Now, you know, we're in this sort of environment where PCPs are prescribing it to depressants and anxiolidics and things like that. So a lot of patients at the time they come to me anyway, right, have already had access to some of these people. We do also have a social worker here at Leahy who we work with. So when we do group sessions, she comes and gives a presentation, gives out her information in case people want to contact her and oftentimes, you know, I probably refer me at maybe a handful of patients to her in the four years that Benares. It's not really common. I think the the question comes up most commonly and again, understandably with the adolescent population, right, the kids who all of a sudden lost their hair are like floundering, don't know where to go and those are sometimes the hardest patients to find the right care for because it's a particular age group and you want someone to who understands alopecia. So I usually connect them first with like, Daph and some patients of pork groups and things like that. But that's one that that I often have tie have a hard time finding access for, right, someone I direct go to. And just the other thing I would say is of interest as as somebody who has seen many therapists over the years, you now can almost always find virtual therapists who take your insurance. So if somebody has insurance, even if it's terrible insurance, there will be therapists by the most of the therapists I've seen in the last five years, I've never met face to face. Then all of the visits virtually and it's been covered by insurance. Now, my my workplace has a high deductible plan. So I'm still paying basically, you know, the full price, but at least it's going towards my deductible now. Yeah, that's a great point. I have referred a couple recently to to those online things. I don't know how they've worked out seeing them back soon to I could probably find out, but yeah, they are another great option. Well, I would sometimes like papers like this are helpful for me to say to patients who are struggling like, you know, this isn't just you, like this isn't you, like this is part of your disease. And I think sometimes patients need to hear that. Like you're not, you know, how could we expect you to deal with this? You're not just somebody who's not coping well. This is part of your disease. And you know, if you had high blood pressure as part of your disease, I'd send you to somebody. So why would I not send you to somebody? Sometimes that's helpful. I think that and I just a quick thing to like you don't have to do like a head seven in some depression scale and this and that like on our intake form and the front page for every hair loss patient, how much is your hair loss bothering you? Like your score, you know, with the happy face all the way to the sad face, right? And they circle it. And so you know if you're walking into a room that's like a nine hour or 10, or if it's a room, that's a two, right? And that's really helpful because it helps you kind of gauge where you're going. And sometimes patients will be reluctant. They feel embarrassed admitting how much their hair loss is bothering them. But by writing it down and just circling a number, you kind of have an opportunity to just open the conversation if you choose to. And so Ferris says you first I love that. And I hope that on your Lycord scale, the unhappy face is somebody is a happy face that's got no hair and the happy face is one that's got like hair drawn on. But we need to update it. Yeah, that's good. Yeah. But Ferris, you know, as you know, I'd like to take everything to an extreme. So what I will do and admit what I do reasonably frequently is say to people, you know, anybody who had any normal person who has what you have would be really psychologically, like just depressed and anxious. If you don't need to see a therapist, there is something wrong with you. That's the that's, you know, I don't say I don't bring that out often, but I have brought that out. Whenever I have a real trouble, it's an extreme way to handle that situation. Yeah. I bet they they had one disease and now they have to. Right. Strong work, Matt. I have to say to like for women to this is tricky, right? Because like if you think about it, I'm really dating myself here, but like back in the day, like Michael Jordan bald hot, right? Like Vin Diesel bald and handsome, right? Tyson Beckford. Good looking. Bruce Willis, right? Old school Bruce Willis handsome, right? Heartthrob. You can't think of a single bald woman like that, right? There is zero cultural acceptance for women to have hair loss. And the other kicker is not always, but often women are wearing their hair longer. So even when they start regrowing on a Jack inhibitor, they're not taking off that wig for years because they don't look like themselves, right? If the hair is growing a centimeter a month, it's taken years by the time they feel like they can go out and have their identity back. So I, while it can affect everybody, we have to treat everyone the same thing about everyone the same. For women, I do think they're sort of this disproportionate effect when it comes to these egosocial homo-bitties. Some of my men with totalis or universalis on Jack's, who are happiest, got their eyebrows on eyelashes back, but not their scalp hair. And they're like, this is, I was, I was, I was, I was, like, I didn't want to have to start getting a haircut in my shampoo again. But I look really weird with no eyebrows or eyelashes. Yeah. It's been, yeah, it's been interesting. Yeah. It's been interesting. Because that is kind of the opposite direction because eyebrows and eyelashes, it is socially acceptable for women to, you know, use an eyebrow pencil and use false eyelashes. Men are not going to do that. And so eyebrows and eyelashes, I think are more impactful for men Not just because they cared less about their scalp, but because also because they don't have a way to cover it up Whereas women do have a way to cover up eyebrow and eyelash Totally agree. Yeah. Yeah. All right, Pat and what do you got? All right, my deep dive is from July 20, 25 edition of the acta Dermado veneerio logica alopecia areata impact on patients quality of life and disease perception a survey based study by vestor guard at all is written by like a bunch of likings Senior author was morque a name that up until I read this paper was exclusively Associated with an alien played by Robin Williams and as a title states. What's that and Mindy? Mindy Yeah, Nanyu Nanyu. All right as a title states It was a survey conducted in Norway and Denmark. Why leave Sweden out? It's right between the two subjects were recruited from social media sites Surveyed on an objective measure of disease the salt score as well as two questionnaires that measured how their disease impacted their life the deal QI and the push D scores and patients were also asked to subjectively rank their AA as mild modern and severe over Over 300 respondents 94% of their respondents were female which you know that that may skew the results of we've already discussed because it may have a larger effect in females over half of the respondents perceived their AA to be severe the younger patients at higher percentages of severe disease perception compared to patients older than 60 Younger patients tended to have worse deal QI and pushed the and salt scores. So that all seems to track Overall objective severity scores 15% mild 29% moderate and 56% severe and that's just them answering the question mild moderate severe It doesn't have anything to tie to any of the other scores When you left out patients with alopecia universalis and totalis the percentages were 25 mild 38 moderate and 37% severe Figure two was pretty interesting when focusing in on the patients who perceived their disease as severe so For like DLQI you could have a DLQI of five or less and still proceed your disease to be severe You could have scored less than 20 on the push D score lower scores being better still perceived your disease to be severe and the salt score was kind of crazy You could have a salt score of less than 24 like you could have a salt of five and still perceive your disease to be severe So that's a paper how how strong of a coming I assume there was some level of correlation between salt scores and perceive perceived disease severity Did they report that of like how is you know, is it a correlation coefficient? So as I think of a correlation coefficient of zero is no correlation correlation correlation of one is perfectly correlated Did they say like they did those calculations for DLQI And also for the push D and the correlation was pretty poor like DLQI QI it was terrible and it was the correlation of DLQI versus salt and there was a very poor correlation But was so DLQI was closely associated with perceived disease severity? I'm sure it was stronger than salt It depended right so like if you had my if your perception of disease was mild um Then the likelihood that you had a salt score or I'm sorry DLQI of greater than 10 was like zero like none of those patients did Like if you had mild disease 100% of the patients had like a DLQI of five or less or something That's like the top bar But as you got down so so in other words, I think everyone agrees This is mild. I'm fine But what people don't agree on is I have really really severe disease and you would objectively look at them and say you have a salt of five But some patients will still say well, I still have severe disease And same with the you know, they would do the DLQI and the push D questionnaire And actually have pretty good scores, but they would still be calling their disease severe So I think with the the argument that the paper was making and I think successfully DLQI pushed assault may not be the best way to evaluate severity disease in AA patients But what is also probably true when I think this is where it gets kind of tricky is that Patients with mild AA objectively mild AA maybe overestimating how bother AA is which like that feels like really mean to say like That they're the ones with the disease. So how could I say? You have one little spot like this isn't that bad In the discussion the authors mentioned that a DLQI score of greater than 10 is required by the Danish AA guidelines to initiate systemic treatment And right, I mean, I wouldn't say that that makes any sense right that you're you're probably not treating patients who Like may actually have severe disease because the DLQI is just not capturing severity It seems that DLQI is just a poor measure of AA severity But it also this data raises some important questions especially those severe patients how to providers draw the line on offering more aggressive therapy Um, is it solely based on how severe patients perceive their disease to be disease to be if a patient with objectively mild disease rates their diseases severe Are they a reasonable candidate for the loop lit Fulo this paper was funded by Pfizer and some of the authors were employees of Pfizer Um, so you know, I think it deserves a little bit of scrutiny, but You know what? Pfizer has that thing that they leave back of the office that says You know, it's got the normal like less than 20 mile 20 to 50 moderate 50 to 95 severe 95 grader rare severe But you can upgrade by one If they have Signific Matt you better not be making fun of it. I'm not I No, but here's the thing though you don't know Like they didn't ask do they have eyebrow eyebrow eyelash involvement to your point They didn't ask where is this patch is it right here in the front of your head or is it someplace you can camouflage it Are they responding to treatments or not and yeah, I think 5% I mean, I mean that's what someone that you're gonna put on a jacket But listen if suddenly you had 30% of your hair on your head gone That's actually a lot of hair gone You know, and if you're not a browser so maybe you know, maybe you try some initial treatments But if they're not responding That could be a reason if they are not you know in the clinical trials We use the salt of 50 or more so basically 50% or more scale per loss But and so a lot of the payers are saying well, that's what you need to show in order to get this person to treat But if they're not responding to treatments and they're going from 30 to 40 in no eyebrows and not wanting to go to work You know, I think we you know, the point is we have to we really do have to think about that Um, and the other thing is the dlqi is horrible for a a I mean it's asking like how how it she's so painful or stinging has your scalp in How much does your hair loss you know affect what clothes you pick out right there are much better measures And and we saw it in the in the clinical trials right for the jack inhibitors people would have full regreels of hair You would seat on their face and be like yes They had their life back and the dlqi would not budge Yep, so it's just not a good measure Um, of this at also these these really didn't surprise me Pat and I think what are some physician Objective measure and the reason is like think about not AA but like think about the patients who come in to see you for hair loss And you're like I cannot see Anything that would look like here like you have a full thick head of hair more here than I do Yeah, yeah, I would have a surgery to do a lot not infrequently You're no tim patten you're a mad sire Yeah, or yeah, I mean So I you know, I feel like it is unethical for me to Ain't treat those people right to be like here's what y'all all do this and I can you know And if I don't like do a cash for us, but what What do you mean an ethical to treat them it's With something aggressive so let's say that I had a fancy hair clinic and I could offer them PRP for $2000 Out of pocket To do I don't think it is I think there's some you know, it's in a sense like a form a body dysmorphic disorder I mean I that people come in and they are like in tears over hair that I've never had that thick in my entire life And like you know they want to see what medications they can get and they want to get a panel blood work And they want to go see somebody for PRP. I'm like I can't get good conscious say that's a good idea Huh, that's a fair she I think you just coined a new disease HDD Hair dysmorphic disorder Okay, but it's a thing right Mary-Anne would you agree? You're gonna hear lost patient with no hair loss. Yeah, yeah, it certainly is and you know you just gotta be Real with people I have to say and I like I said I'm like 98 99% of my patients are hair loss Those patients are few and far between yes, they really are Most people have real hair a lot. I mean even if it's like mild female pattern or mild, you know, male There's hair loss there that you can do something about Um, but thankfully those patients are few and far between yeah, no I agree they're few and far between but you know, it's also think about Biola like we have so many biologics for psoriasis. We all have the patient who has 1% BSA and they're like I just would like to be on one of those yeah sky-rizzy like I think sky-rizzy is a great drug But I'm not gonna give it to somebody with 1% BSA who's tried nothing It's just not the right thing to do and I do think we need to have some input I'm bringing it back out of here again, my the zirous measure of if a drug should be covered is we you can either go on the drug or we will write you a check for half of the cost of the drug for a year. Right? So for that 1% BSA person, you can either have skyreasy or we'll give you a check for 20 grand. And if they say I would rather have the skyreasy than they get it. Really? So what if they say I'll take the money because I'm going to go in and be like, okay. It's a hypothetical situation. All right. Yeah. Padney, anything else weird or interesting come out of yours? I mean, probably, but that that's all I that's what jumped out at me. There was there was like you'll got a ton of different numbers. I'm like, I could talk about this for 20 minutes, but that's what jumped out at me is the severe disease that objectively have mild in that's a tricky situation for us as practitioners, I think. The other thing I wanted to talk about from it a little bit was it did say that the younger somebody was the more severe they perceive their disease or the or the or the worse it affected like so is it I feel like younger people did it affects them more than older people, which would make some sense, I guess, but did it my they also had higher salt score like they had higher salt scores. So the fact that they perceive their that kind of map they scored higher on DLQI. Now that could be a perception thing too, but okay. I mean, Dr. Sennoy, do you think like the longer someone's been living with something like I've always been amazing. That's another reason why in some of the you know, face through clinical trust, he's he's Jack and he's not much moved because at baseline you asked him the GLQI and they're like, yeah, I'm coping all right. Like I've been dealing with this forever and like let's see how this goes. This would be great. And so it's low to start you don't get movement on it, right? And it kind of stays put. And so I think the longer people have dealt with it even really severe alopecia area, the more adjusted they get to it somehow. Whereas it you know, so it has something to do I think with duration of disease too, that if you and also like listen, you know, if you're in a teenager, you're in your 20s, you're in your 30s, you know, you're trying to meet a life partner. You're trying to go out and have fun. You're trying, you know, you're just coming into your own, right? And you're dealing with this. It's a lot different than if you are say more settled. Now that's not to say that everyone who's older is settled. That's because sometimes glued off with it. But in general, you know, like people sort of are at bare minimum, right? More comfortable in their own skin, right? Then you are when you're younger. You have some life experience in your body. I think that all contributes. All right. Let's let's jump on to mine here. So this was quality of life in patients with scarring and non-scarring alopecia and exploratory cross-sectional study, 510 patients, but roughly 50/50 between scarring and non-scarring 75% female 25% male 46 years old on average, hair lusteration, the mean was six years. 42% of the patients had alopecia ariata, 21% had FFA, 16% had LPP, about 10% had angrigenic, some tealogen afluvia, a little folliculitis to calvins thrown in. And the interesting takeaway, quality of life was worse with non-scarring alopecia, primarily AA, compared to scarring alopecia. And more anxiety and depression with the non-scarring, but as you would have expected on DLQI, which we all agree is not the best measure for hair loss. The people with scarring alopecia, the one thing that they had a higher score on was symptoms, but everything else, so meaning pain, burning blood, everything else to people with non-scarring had higher scores. Maryann, you said this earlier, it's the unpredictability, I think, that makes this make sense, because you would assume that somebody who's got hair loss and their head hurts, and you're saying, "Oh, and it's never going to grow back." They should have more anxiety and depression than somebody who doesn't hurt, and you're like, "Hey, we're going to do it back." But is this your experience? Not at all. I mean, I definitely think the AA patients, especially the ones that are actively progressing, or kind of persistent, severe, they definitely carry a lot of anxiety and worry and all of that, but my scarring alopecia patients really do too, because they don't know what's going to end. No one's studying their disease that well, and there's no FDA-approved treatments, and they kind of feel like left hanging out in the wind, but the one thing, and I might be wrong, because it was just like, yes, I looked at the papers, but I thought the AA group here was younger too. And that was just, I thought about it. I was going to say that, but 10 years or something. And that was one thing that jumped out to me, that might have played a role as well, again. Yeah, so you don't feel like there's a huge difference. Everybody hates it. You're scarring and the non-scarring. It's not like the. Yeah. My new young FFA patients are absolutely devastated. If I compare a brand new girl, a woman in her 30s with mild FFA and a new diagnosis, to the same age kind of demographic coming in with a patch of AA, the FFA wins every time when it comes to you, turn and worry and all of that. Okay, so I kind of want to open up a little bit more now to some general AA questions I've got. So, one of the interesting questions, when you're seeing somebody with AA that's bad enough to warrant a jack, do you have any rhyme or reason for why you would pick one over the other? Right? Or is it basically which one's easier for insurance to get on? We don't have comparative trials. There are data close enough that I'm not comfortable saying one's better than the other. Do you have any rhyme or reason for picking one of the three over the others? So, the first thing is, you might think a little bit about side-effect profile if someone has crazy familial hypercholestralemia, maybe you're thinking more towards ritlisitinib over barisitinib or duroxylitinib because it tends to not elevate. Lipids as much because it doesn't target jack too as much. If someone has baseline and inflammatory bowel disease, hyper sensitivity, urticaria, any GI sort of distress at baseline, I'm probably going to shy away from let Fulow simply because you get 10% of the patients and clinical trials having diarrhea, and then you have about 4% to 5% having hyper sensitivity reactions or urticaria and stuff like that. So, those are some initial thoughts I have. Other than that, I think barisitinib is really great. They've done a very good job at showing their safety profile, not just across AA patients and they're large clinical trials. But also, we have data from the rheumatoid arthritis population. We have all this data globally. So, there's a lot of safety. So, for patients who tend to be more tentative or worried, well usually start there, I also like that you have a 2 and a 4 that you can kind of tightrate, up, tightrate down if people don't want to be on the full dose long term. Sometimes though more recently, I've had patients who say I've had a partial response or haven't done well with barisitinib or lip Fulow. I think there is something about the BID dosing with duroxylitinib and tophysinib that some patients just need the dose pushed a little bit more. And I think being able to do that with zelgians or with lexelvy can be helpful in some cases. All right. Next is how long? So, we've talked about a few articles over the last year. And basically my takeaway has been, you give somebody six months if they're not showing really good regrowth and progressively getting better, six months is probably a reasonable cutoff for like let's switch to a different drug. Is that the you have a, like how do you decide when to switch in somebody who's not a home run? So, it really depends highly on baseline severity. If someone has complete scalp hair loss at baseline, I'm given them a year. I'm giving them at least nine months. Before you switch. A hundred percent. You switch to dooner and it's not the new med. It's longer time on a jack usually. Okay. So, hopefully under review at the jack, we have a multi-site study that we did hundreds of patients looking at jacky switching. And all of them had to be on the original jacky for at least six months or more. And we break it down by how long they were on the original jacky, but you got to give people time to be able to respond, especially if they're severe, if they're less severe, if they're more like a 50 salt, then you have my six months I'm like hoping to see something. I still might give them up to nine months, but usually by then I'm hoping to see a little bit more. - Okay. - So anybody would say, we're gonna give you a year, do you ever, like looking at some of the data seems like maybe out to a year you can start to see, you know, some regrowth, but I feel hard pressed to ever say, this is worth continuing greater than a year. - Yeah, greater than a year is tricky. Unless they really start showing some movement at like month nine or something once a year. Otherwise it's tricky. It's not likely it's gonna do much. - Do you ever think of maybe goosing the effect a little bit with corticosteroids? Like you six months, just some pulse dexamethasone or a little bit of prednisone? - Yeah, I'll often, you know, give people who are like, kind of moving, but need a little push. Always with monocetyl, obviously loaders, Romanocetyl. And then sometimes with like, you know, weekend pulses of dexamethasone or pred. - So do you, so that's interesting. The monocetyl, I've seen, you know, Brett King has published a couple of things about this. And I've always been like, yeah, I don't know. Like doesn't make sense to me, but I don't know. Like do you do that in most of your AA patients when you started Jack? You put a lot more on the list. - Unless they're sort of reluctant to take an oral medication to begin with, that I'm not gonna try to push them on too. But yeah, almost always. And, you know, back in the day when people had, you know, severe AA and happened to be a monocetyl for their hypertension, they regrouped hair just on AA. I just don't monocetyl rather. So, you know, it's not everybody, but I did have a patient of my own who had severe AA. She was allergic to steroids. It couldn't do steroids. I said, this is a Hail Mary, but I'll give you monocetyl. She fully regrouped all over her hair, which I was like, what is that? - That was an end of one. But, I just wanted to add a fit to adding monocetyl. - When you're doing it with a Jack, what's your dough? Do you start at 2.5? Do you go to what do you do? - 2.5 is the average starting dose in guys. I'll push it. And women, you know, you can go up to five. I usually hover around 2.5, 'cause when the hair hopefully starts coming in, then the facial hair becomes an issue for the women. - Okay, do you ever do? There's been a couple of reports now of clubatosol under a skit under a swim cap to get it to jumpstart it. And then, which, you know, is safer than do it. You would assume safer than doing like, you know, I am K or Dex pulses, which I always thought, well, yeah, but then once the hair grows a little, then the clubatosol is not gonna get to the scalp. But if they're starting on a Jack, maybe it can jumpstart them, you know. - Yeah, I don't routinely do that. I wouldn't fault anyone who tried it, but like, I just feel like that makes the patient so miserable. Usually if they're thinking about starting a Jack, their life is like, oh, like the last thing they wanna do is be slaubing and clubatosol on their head and going to bed with a swim cap. I mean, talk about really feeling like, I've really hit a low point here, you know what I mean? So I try to think of the practical implications of what I'm telling people to do as well. - Fair, fair, patent fair. She got any other burning AA questions? - There was a paper, I think it was in one of our six packs where it looked at basically patients who had been on multiple Jacks, like tried multiple Jacks. Just it was not many patients, seven patients. But I think the last Jack before they got the hair growth was a patissette nib. More than it was any of the other Jacks, can do you have any feel of a patissette nib? And do you think that, you know, I kinda looked at that and said, well, maybe you've had a siten nibs the most effective thing. Like people went on a patissette nib after failing two or three and bang, all of a sudden they had the hair growth. - Yeah, so what you're. - The patissette nib, right, is like depleting or just has completed phase three trials. Think a lot of people have a lot of hope in that. I mean, you know, I wonder sometimes how many of these patients have, you know, might be having ATP too and so the Jack one really helps with that as well. The dosing on a patissette nib could also be a little bit better depending on which dose they're treating with, right? And then, you know, the other thing that I'm starting to toy with a little bit that can help some patients again, if there's some background ATP is like also combining with dipilium app with a Jack. - Do you think that works? I mean, obviously there's some early reports on that and then it's like, oh, we have Jack inhibitors, but do you still do that? - Or do you? - Yeah, I'm okay. Now, in my experience, like Emma Gutman's group, she's like if the IGE, you know, baseline's over 200 or higher, or they have a history of ATP or family history of ATP, they regrow that. Unfortunately, it's not been my experience. The times that I use it, the patients that I think it works best in and it's amazing are people who have active, moderate to severe atopic dermatitis. In my experience, and they regrow like crazy. And you don't combine it with a Jack inhibitor. You just do that and then we let them go. Okay. - Yeah, that's so fascinating to me because I think of AA as like a TH1. And so Dupas should make it worse, right? - You, if you have a heavy TH2 skewing with allergy in all this and animal models, they've shown you have a huge depletion in your T-regs, which we know is the case in AA. Your T-regs also start acting like TH2 cells and drive the inflammation. So I think what happens is if you're really severe and you bring down that TH2, your T-regs come back up and you have more homestasis and your hair regrows. Whereas if you are, you're like kind of teetering, you're like maybe you're a little genetically predisposed to getting AA, you haven't gotten it yet. Your, you know, your atopic dermatitis is mild, your T-regs are more or less normal and then someone gives you Dupi and you get rid of that TH2 and now you're like TH1. - Wow. - You develop AA on Dupalia Mab. So I think it's all where the patients at when they start. - Thank you, that's the first time anybody has explained that in a way that I buy. - There was a commentary we did years ago in JAD on it. It's like Dupalia Mab, like friend of, or something, what are these? - Okay. All right. - Sherri Vardees, who I know is one of our loyal listeners. He actually sent me a photo within the last two weeks of a young atopic girl, Alopeche Ariata. Brother was on Dupi, she started Dupi and has like a full head of hair. It was impressive. - It's amazing when it works. - Yep. - All right, Pat and let's do some trivia. So Dr. Sennah, the rule is, you got to let Pat finish reading the question and then you use shout out the answer as quick as you can. - I'm gonna stink at this, I can tell you right now. - No, this is the lame category. We've had a few hair people on. So I kind of exhausted my hair, cool trivia. I just went really lame. So these are words, the answers are words that are spelled using the letters in Alopeche Ariata. - Oh my gosh, okay. - All of the letters are these letters? - No, no. The words are made of letters. No, it's not all the letters. - Okay. - Like if the answer was par, that would be the answer. - Got it, got it. - Was that, was that one of them? - That would be too easy. - Okay. - Here we go. It's the only country that falls into this category. - Peru, no. - No, there's no you. - Shoot. - It's a little silly. - We'll be in clues in a little bit so we don't like running away. - The only country is outside. - I'm gonna stick it. - Yeah. - Poland, there's actually two, but if you go by this trick, you can only use like L once. There's only one. It starts with the C. - Now I can't even think of any countries to start with the letter C. Cuba, Canada, Cuba, - Gronkling. - Second letter is R. - Croatia. - That's it. - That's it. - Croatia, Croatia. - There we go. - There we go. - I'm gonna move to get it. All right, go me. - That's pretty good. - That's good. - That was good. After two letters, that's very important. - That is good. - If this was real a fortune, you'd just win the jackpot. - Okay. - So what do I win guys? - All right. - So these are undying admiration. - That's right. - Just work more than any money amount. - This adjective could be used to describe the group of muscles that are strengthened by pushups and bench presses. - Pecs. - Pectoral. - Pectoral. - Pectoral, yeah. Very good. - Wow. - All right, third and final. This is terrible. The number one hit song, Mac the Knife, was adapted from the opening song of a German musical whose name when translated into English means the three penny blank. - The three penny, what? - Are we trying to figure out what word goes in blank? - Yes. - The three penny blank. - The three penny. - Alpaca. - Uh. [LAUGHTER] That was like, that was like, for many, love, red. [MUSIC] If it's a musical, if it's a musical, if it's something on stage and people are singing, you could call it a microphone, a musical, like people are in stage and singing. It's a musical. Like Carmen would be a more famous example. Opera. Oh. Oh. All right. That was good. Good. That was so hard. That was so lazy. There's so many A's. There's like, what's going on? Yeah, it's tough. All right. Well, that was good. We got one. Matt got the fewest clues. I needed the most clues. So that's how we would, I would structure the winning on this one. Yeah. So like points for clue, Matt would win. Yeah. Because you're a clue. But we don't do that. We don't play that way. No, we're all winners. We're all winners. That's what's so great about this. Be all get a trophy. Exactly. That's right. Thank you. But, Dr. Senneth, thank you for coming on. This was so much fun. And I now feel much better about dealing with A A patients who really appreciate you. And I really appreciate all of our linear listeners for tuning in. I hope you laughed once or twice. Hope you learned to think or two. But mostly I'm hoping that you're planning to join us again next week. And until then, I'm Matt Zyrus. I'm Tim Patton and I'm Laura Ferris and we are Derms on drugs.