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  • Writer's pictureEscuela de alopecia

2023-2025 Treatment - Alopecia areata, frontal fibrosing alopecia, lichen planopilaris, and decalvan

This blog post is dedicated solely to what is the treatment or what is my most updated idea of treatment, that is, 2023, 2024, and I would even say 2025, for some hair loss conditions that are not so common.

To start, we have:

  • Alopecia areata

  • Frontal fibrosing alopecia

  • Pilar and decalvans folliculitis

The level of the post will not be basic. There might be things that are not understood, but it's a text not so much for patients, but almost even more for healthcare professionals.

Everything or almost everything I'm going to tell you, is off-label use because there will never be clinical trials really for most of these conditions. Therefore, it will all be done a bit at the discretion of the treating physician, without other types of studies unfortunately.

Except for alopecia areata, which I'll talk about, currently, the management of alopecia areata in general has been quite simplified. Most conditions are mild conditions that result in some patches of hair loss. Even if we do nothing, doctors usually resolve these areas. Though it's true that in the future, patches may continue to appear in those patients.

We'll mainly talk about the severe conditions, which are the ones that most commonly come to the clinic, such as total alopecias, where the patient has nothing, or universal alopecias, where there's nothing on the body.

The current management, I think, is greatly simplified as follows:

In the case of more than a 30% involvement, I believe corticosteroid pulses are clearly the first choice of treatment. In the instance that the patient marvelously improves, we can start reducing the corticosteroid dosage and consider something topical or infiltrated to prevent the loss of corticosteroids from triggering a new outbreak.

And if the patient does not respond to this, there are clearly three different pathways. One option is to use the new drugs that have already been approved for alopecia areata, such as baricitinib approved last year or ruxolitinib approved in the summer of 2023. These drugs have an efficacy that is still somewhat debatable if they are better or worse than corticosteroids, but they do work quite well.

The problem with this is that they are very expensive and most patients, except for some specific ones with certain economic capacity or reimbursement insurance, will have to use them publicly, meaning that the National Health System has to justify their use and financing.

The other problem is the potential risks, such as the risk of thrombosis, especially in patients who smoke. Also, care must be taken with contraceptives in women due to the increased risk of thrombosis. And another potential problem is an increased long-term risk of cancer, although this is not currently proven.

If these drugs are not viable, the other option is to use topical difenciprona, that is, immunotherapy. And in the case of that not being viable, here we have to go back to older drugs, drugs from the past, which are the classic immunosuppressants.

Frontal fibrosing alopecia is clearly the primary cicatricial alopecia with the highest incidence and prevalence in the world currently. The current management hasn't changed much since it was described, more or less what we were doing approximately 6 or 7 years ago. And it's very straightforward; the treatment has two legs: explaining to the patient hormonal modulation management because we suspect this disease is autoimmune and has some hormonal importance. And that's why obviously contraceptives may make sense, of course, with adequate indication and things that reduce inflammation, which usually are corticosteroids or calcineurin inhibitors here.

And more or less every 3 months in case of inflammation, trichoscopy, injecting infiltrations, this tends to be sufficient for 80% of the patients, or better said, the patients stop. But there are some that don't improve and even continue to progress.

If they continue to progress, then we have to resort to medications that reduce inflammation or suppress the defenses. I believe here the first approach would be to use some antibiotics that are anti-inflammatory or also use hydroxychloroquine. In case they don’t respond, the next step would be to use classic immunosuppressants, for example, cyclosporine. And if not, the next step, and I think this will become a treatment because there are clinical trials underway and will even be approved, are the anti-TNF, that is, just like alopecia areata, by topical route.

In the case of decalvans folliculitis, there are also partial cases. But well, I can't talk here for 20 minutes or 50 minutes about all decalvans folliculitis. It's rare, rare, rare, but from time to time I see some. Decalvans folliculitis has two phases, an initial phase that is the most violent neutrophilic, and that needs to be stopped by all means because it eats, it eats, it eats all the scalp, it eats the follicles.

And in this case, besides periodic infiltrations of corticosteroids and oral antibiotics, this is usually more than enough to control the majority, if caught in time. In case it does not respond to this, I believe here, and fortunately the price is more reasonable, we can use biological drugs that act on the TNF pathway, such as adalimumab. Of course, off-label use. The good thing is that there are already biosimilar drugs that here at best we are already talking about a price of between 50 to 70 per month, which of course is money, but it is much less money than 700 per month, and they are biological drugs that are very safe.

Here we are very confident in terms of safety because we have decades of experience in psoriasis and other rheumatological conditions. Which leaves us more confident; they are very comfortable drugs. And currently, a decalvans folliculitis that does not respond and is in such a neutrophilic phase, I think anti-TNF can benefit quite a bit.

When it is in a more burned-out phase that looks like a flat canvas, here I think the management would be somewhat similar to the flat canvas, no more no less.

Except for alopecia areata, the rest, frontal fibrosing alopecia and decalvans folliculitis, the three that I've talked about, in all three, if stability is achieved for a few months and ideally more than a year, and the patient has enough donor area, it can be considered to reconstruct that with hair transplantation. But this cannot be done if the patient continues to have inflammation because otherwise it's a waste of time and money.

I hope I have been able to give you some guidance on what I believe will be the future of all this, current and in the coming years. I have told you a bit about my vision on this, very summarized obviously, each patient is unique, I don't know if a specific drug will work well for you. But those are my ideas somewhat at a textbook level.

I'll provide more information in the following video:

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