Hair loss is challenging for patients but can be particularly difficult when it is refractory to standard therapies. Patients may require off-label and/or alternative treatment options in order to experience improvements in their condition. At the Skin of Color Update, Crystal Aguh, MD, discussed alternative therapies for various types of hair loss.
Dr Aguh is an assistant professor of dermatology and the director of the Ethnic Skin Program at Johns Hopkins University School of Medicine in Columbia, MD. In an interview with The Dermatologist, she shared her approach to deciding when a patient needs an alternative therapy as well as important considerations when prescribing these therapies.
The Dermatologist: What is your approach to deciding when a patient needs to use an alternative therapy for hair loss?
Dr Aguh: When I treat hair loss, I first determine whether the patient has scarring or nonscarring alopecia. Nonscarring alopecia is usually a little easier in terms of the likelihood of getting the hair to grow back. Scarring alopecia, on the other hand, means the opening in the scalp where the hair would exit, called the follicular ostia, has been scarred over. Once complete scarring has occurred it is incredibly difficult to regenerate hair.
For this reason, with scarring alopecia, my treatment is aimed at making sure that the hair loss does not get any worse. Most of the conditions I discussed in my presentation that require some alternative therapies are scarring alopecias as those tend to be harder to treat in general.
The Dermatologist: Which alternative therapies have you found to be effect for hair loss?
Dr Aguh: One form of hair loss that is nonscarring but can be difficult to treat is androgenetic alopecia, or female-pattern hair loss. This is the one exception on the list, because this form of hair loss tends to be more challenging to treat in women compared with men.
An alternative therapy for this type of hair loss is oral minoxidil. This is a blood pressure therapy that when used at very low doses, lower than the dose typically used for blood pressure control, can effectively regrow hair. In addition, the oral option is a great workaround for patients who lack the enzyme in their scalp that activates topical forms of minoxidil. It is a nice alternative for patients who fail standard therapies.
In lichen planopilaris and frontal fibrosing alopecia (FFA), two forms of scarring alopecia, it is important to control the inflammation. There are two options I discuss for patients who do not respond to standard therapies. One is naltrexone, which is FDA-approved for alcohol and opioid abuse. In low doses, about 3 mg per day, naltrexone has anti-inflammatory effects. For patients with difficult-to-control inflammation, with itching and burning sensations that are classic signs of these conditions, naltrexone can be a useful agent.
The second option is a compounded cleanser formulation of tacrolimus. Tacrolimus (0.1%) is considered a standard therapy when used in an ointment form for these patients because it helps with inflammation. If compounded as a cleanser at a higher strength (ie, 0.3%), it can also be effective for controlling visible inflammation. Those are the two options I use for patients with FFA or lichen planopilaris who are not responding to standard therapies.
For central centrifugal cicatricial alopecia (CCCA), I have been using metformin, typically in a cream formulation. While oral metformin is a well-known first-line therapy for diabetes, topical forms have been shown to reduce scarring in murine models. I have prescribed topical metformin for my patients with CCCA who have not experienced any improvements with standard therapies. Some patients have not only seen stabilization of their disease but also have been fortunate enough to see some regrowth.
The Dermatologist: What are some pitfalls or clinical perils dermatologists should keep in mind when using these therapies in patients with skin of color?
Dr Aguh: For the last three therapies I recommended, none of them are commercially available and have to be compounded. For patients who have financial concerns, these may not be suitable alternatives for them because they are going to be more expensive than standard therapies that are available at local pharmacies.
In addition, oral minoxidil still requires some caution. While it is prescribed at lower doses than what is used to manage blood pressure for hair loss, patients can still experience low blood pressure. Generally, I avoid using oral minoxidil in really young patients because they tend to have lower blood pressure naturally. Also, oral minoxidil can cause hair growth on other areas, such as the face. It is really important to talk to patients about this side effect and just let them know that while it can be very effective at regrowing hair on their scalp, they may find themselves having to remove unwanted hair in other places.
The Dermatologist: What other research is needed to improve the treatment of these, particularly scarring, hair loss disorders?
Dr Aguh: One of the most important aspects we need is to determine the causes of alopecias, particularly lichen planopilaris and FFA, which are becoming increasingly more common. There are a lot more cases of these two forms of hair loss now compared with 30 to 40 years ago, and we are not quite sure why. Because it’s difficult to regrow hair, prevention is of utmost importance for these forms of hair loss.
The same can be said about CCCA. In the past, we thought it might be related to hairstyling practices, but as we continue to learn more about the condition, we are starting to see that this is not really true.
If we can identify people who are at risk and find out how to prevent these forms of hair loss, then I think we will be much more satisfied with the outcome in the long term.
The Dermatologist: What key takeaways would you like to leave with audience members?
Dr Aguh: I find that counseling about hairstyling practices has to be a critical component in discussing any form of hair loss, particularly for Black women. What commonly happens when women start experiencing hair loss is a tendency to want to camouflage it by doing things like adding extensions, weaves, or wigs. Sometimes, these things can create a second form of hair loss, like traction alopecia or acquired trichorrhexis nodosa. Both of those forms of hair loss can, over time, become even worse than the original reason why the patient came into the clinic.
I spend a lot of time talking to Black women about hairstyling practices, such as deep conditioning the hair every time they wash it, washing their hair once a week, incorporating the use of regular protein treatments to strengthen their hair, and avoiding any damaging hairstyles that are going to lead to breakage.
When I counsel patients, I do try to provide them with a list of products and resources. Many of them will find very helpful resources online. However, I stress to them that, even as we focus on the medical treatment of their hair loss, if they’re not focusing on the hairstyling piece at home, they may be disappointed with the outcome no matter what happens.
It’s not unusual for me to see a great improvement in a patient with CCCA only to find that they have developed traction alopecia that is so severe that they still feel like they cannot go without a wig. That is when it can be really disappointing because there is only so much that medical treatment can do to treat hair loss. Thus, it is really important that patients are adhering to healthy hair practices when they are not in their doctor’s office as well.
Treating hair loss is very difficult, and it can be equally frustrating for both the physician and patient. I would just ask physicians to keep an open mind and keep trying new therapies if they are finding that what they have tried so far is not working. It is really important to be persistent because eventually, a patient will respond to one treatment. It just takes time to figure out what is going to work best for that patient.
Aguh C. Hair & scalp disorders in SOC: alternative treatment options. Presented at: Skin of Color Update; September 13, 2020; virtual.