Shiva: My name is Shiva Mozaffarian and joining me today for a discussion about psoriasis and alopecia or hair loss is Victoria (Tori) Garcia-Albea who’s a certified pediatric nurse practitioner and certified dermatology nurse practitioner at the Lahey Clinic in the Department of Dermatology in Burlington, MA where she specializes in treating diseases of the skin, hair and nails in patients of all ages. Tori is also the Director of the Lahey Clinic Dermatology Nurse Practitioner Fellowship Program as well as the Assistant Director of the Lahey Dermatology Hair Loss Center for Excellence.

Welcome Tori and thank you so much for joining us on Psound Bytes™ today! I’m so looking forward to our discussion about hair loss and psoriasis. To start, could you please explain what alopecia is and what are some of the common causes that prompt hair loss?

Tori: Thank you so much for having me. The word alopecia means hair loss, and I explain to my patients that the term alopecia is sort of like the term dermatitis. It's really a symptom. It doesn't tell you why a patient is losing their hair. Sometimes we add another word to the diagnosis of alopecia to explain the type of hair loss or the etiology. For example, androgenetic alopecia, which is the genetic type of hair loss, female and male pattern hair thinning, or psoriatic alopecia, which would mean hair loss in the setting of psoriasis. There are many causes of alopecia and I like to separate alopecia into two categories, scarring alopecia and non-scarring alopecia. Scarring alopecia includes lichen planopilaris, frontal fibrosing alopecia, central centrifugal cicatricial alopecia, and sometimes traction alopecia. Non-scarring alopecia includes telogen effluvium, androgenetic alopecia, alopecia areata, trichotillomania, and psoriatic alopecia. Tinea capitis or ringworm which is a fungal infection of the scalp, can also cause hair loss.  You could also divide alopecia into inflammatory causes and non-inflammatory causes. Inflammatory types would be psoriatic alopecia, lichen planopilaris, frontal fibrosing alopecia, and alopecia areata.  Non inflammatory types include male and female pattern hair loss (that androgenetic alopecia type I mentioned before) and telogen effluvium. One of the most common types of non-inflammatory hair loss that I see is telogen effluvium. This is when patients experience an excessive amount of hair shedding. It's extremely distressing to patients because they fear that they're going to go bald. My patients tell me this all the time. What happens is instead of having the normal amount of hair in the telogen phase, which is the hair that falls out normally, we all lose about 100 hairs a day, which is normal. Instead of having that normal percentage of hair in that phase, which is normally 10%, for some reason there's an increase in how many hair follicles are in that phase, and it can be 20% or more, and therefore patients experience sometimes a doubling of how much hair is coming out. It's extremely distressing. It's very disturbing to see all this hair coming out when you brush, when you wash, et cetera. It is a temporary condition that is completely reversible without treatment. It is a non-scarring type of alopecia. It’s usually triggered by stress. It can be from illness like COVID. It can be from emotional stress. It can be from weight loss. Common stressful events like having a baby, being in a car accident, anything like that, that's stressful, can trigger a period of shedding, and it usually lasts 6 to 9 months and then it resolves. Sometimes patients have what we call chronic telogen effluvium, which is when for some reason they're in a prolonged state of telogen effluvium. This can be seen in patients who have chronic diseases such as psoriasis, arthritis, thyroid disease, and sometimes patients can have episodes of telogen effluvium back to back. And that leads to an excessive amount of thinning of the hair because they have basically prolonged shedding. Again, this condition is reversible and the hair will come back, but it takes a very long time and I have a lot of patients who come to me for help with this condition.

Shiva: And are there any symptoms associated with alopecia?

Tori: Some alopecias are asymptomatic. For example, people with androgenetic alopecia usually don't experience any itch, burning, or trichodenia, which is hair pain associated with the hair follicle. Some alopecias are symptomatic with itching, burning or that pain, that trichodesmium. Examples of symptomatic alopecias include lichen planopilaris, tinea capitis, psoriatic alopecia, which are usually itchy or burning. Some patients with alopecia areata experience some hair pain, which they describe as a unique feeling when the hair is about to fall out, which I usually consider a type of trichodenia. In this discussion, I will mostly be focusing on psoriatic alopecia.

Shiva: And where does alopecia typically occur?

Tori: Most people present with alopecia on their scalp because that's the area that people tend to be most bothered by. But certain types of alopecia can affect other body parts. For instance, alopecia areata can involve any hair bearing area, including the eyebrows, beard or body hair. Psoriatic alopecia primarily affects the scalp.

Shiva: So are there any diagnostic tests that can be done to determine the cause of alopecia?

Tori: Absolutely. Many times, the diagnosis of alopecia and the type of alopecia can be established through a thorough history, including the patient’s medical history and the family medical history, and a physical examination which includes a thorough examination of the scalp with trichoscopy, which is when we look at the scalp with a dermatoscope, which is like a magnifier with a light. We usually also include a full body examination and an examination of the nails. If the diagnosis is unclear from these measures, a scalp biopsy is usually the next step. We usually perform what's called a punch biopsy, which is a very small piece of skin that gets removed. The area is numbed before we do it, so the patient doesn't feel any pain.  Usually we put in 2 stitches after the procedure and the stitches would need to be removed 2 weeks later. In addition to the biopsy, if a fungal infection is suspected, we can do a skin scraping and examine it right under the microscope in the office looking for fungus. Or we can send a skin scraping to the lab to do a fungal culture. if we suspect a connective tissue disease, like lupus, there are blood tests that we can do as well.

Shiva: And how does hair loss relate to psoriasis? Is there a bidirectional relationship between psoriasis and alopecia areata? I recently read about a clinical trial exploring the role of IL-33, which has been shown to change the pathway of hair follicles in psoriasis. Is inflammation key to this relationship?

Tori: Yes, psoriatic alopecia usually occurs on the scalp, but again it can occur in other hair bearing areas. It is related to inflammation as you mentioned and IL-33 is a key pro-inflammatory cytokine that is involved in this process. There was a study from 2022 in which 80% of patients with psoriasis experienced alopecia at some time during their disease and of those patients, 75% experienced patchy psoriatic alopecia on their scalp. Other types of psoriatic alopecia include telogen effluvium, diffuse alopecia, and even scarring alopecia. In that study, the researchers found that the hair follicles of the patients with psoriasis had an increased proportion of catagen, or telogen hairs, which are the hairs that are falling out, atrophy of the sebaceous glands, hyperplasia of the skin cells or keratinocytes, and inflammation of certain cells called T cells. There are reports that patients with psoriatic alopecia have increased levels of IL-33 that pro-inflammatory component, which has been found to have a direct effect on keratinocytes, which is those skin cells. In the same study the researchers demonstrated that IL-33 increased gene production that are closely related to skin cell proliferation or thickening, which contributes to all the changes that we see in the hair follicles in patients who have psoriasis.

Shiva: And how significant is scalp psoriasis in the development of psoriatic alopecia?

Tori: Most patients with psoriatic alopecia also have scalp psoriasis and scalp psoriasis is present in patients with psoriasis about 45 to 56% of the time and it's commonly the first site that is affected. So a high number of patients with psoriasis will have scalp involvement and then a high number of them will have psoriatic alopecia. So I would say it's pretty common.  Aside from the basic biology of inflammation that can cause hair loss in our psoriasis patients, other factors are at play. Scalp psoriasis can be extremely itchy. When patients scratch, it increases the risk of psoriatic alopecia. Patients may be tempted to pick at the thick scale of scalp psoriasis, which can lead to hair loss and sometimes scarring. Stress, depression, decreased quality of life from psoriasis can lead to telogen effluvium, that condition that I described earlier, which involves excessive shedding. So all of these components contribute to that high likelihood of having psoriatic alopecia if patients have scalp psoriasis.

Shiva: So you mentioned itching, scratching and scarring on the scalp as a factor in psoriatic alopecia. Are there any medications used to treat psoriatic disease that could inhibit hair growth leading to hair loss?

Tori: In my experience, it's not common for our psoriasis treatments to cause hair loss or worsen it. One commonly used oral medication called methotrexate does have a known side effect of hair loss in some but not all patients. If one of my patients has psoriasis and has a complaint of hair loss, I might avoid using methotrexate for that person. However, the low risk of hair loss from methotrexate doesn't usually hinder me from using it in most cases, because this medicine is very effective. We have a lot of topical medicines that we use for scalp psoriasis that are directed to reduce itching and scratching. And so in my experience, most of the treatments that we use to improve the symptoms of scalp psoriasis are actually going to help reduce psoriatic alopecia.

Shiva: So you mentioned stress as a factor in hair loss and we know stress is also a trigger for psoriasis which exacerbates the disease. Could you expand a little bit on how stress impacts hair loss?

Tori: So as I stated earlier, psoriasis can be associated with increased stress levels. Patients are itchy. They actually often have higher rates of depression and worse scores on certain tests we do assessing patient’s quality of life and both of these are associated with telogen effluvium, that stress related type of hair loss. In addition, if psoriasis worsens when patients are under stress and if their psoriasis is located on the scalp, then that will increase the risk of psoriatic alopecia. So there are multiple reasons why stress negatively impacts psoriatic alopecia.

Shiva: So finding ways to reduce stress is probably a good idea overall.

Tori: Absolutely.

Shiva: Obviously losing your hair could cause a lot of emotional distress. Do you have any tips to help address the emotional impact of hair loss?

Tori: Yes, I think it can be difficult to fully understand how much hair loss bothers patients. Many times patients tell me they feel like they're not being taken seriously when they go seek help from medical providers. Sometimes they feel like their condition is cosmetic or that their provider thinks that it's a cosmetic concern and their providers are brushing them off. They don't really listen to what the patient might have to say. In my hair loss clinic I try to really listen to my patients. I believe them when they tell me their hair is coming out in handfuls and that they're fearful that they're going to go bald. I try to sit down when I take a hair history so that I can relate to patients on their level and really take the time to listen to them. I also focus on quickly establishing a diagnosis and giving patients treatment options. This gives them hope, and that's important. I usually go through all the treatment options by category, starting with the topicals, moving to oral medications, and then injections and biological medicines right when I meet the patient. This way, they know that if something doesn't work, we have other options lined up and I have other options for them. I'm not going to just try one thing and then give up. I think this also helps to establish trust, which is so important. By giving patients all the options, I get a sense of how bothersome the hair loss is to the patient. Sometimes I might see 10% hair loss, (so 10% of their total volume has gone), which may not sound like a lot but if the patient wants to do something that I think is kind of aggressive, then I know that the hair loss is so bothersome to them that they're desperate to fix it and they really want to try the most aggressive and effective treatment. I try to meet patients where they are and explain why I might recommend one treatment over another because I have to always consider safety and efficacy. So I never want to put somebody on something that I think is not safe.

Shiva: So we've spoken a lot so far about the causes of hair loss. Let’s now dig deeper into some of the treatments you just mentioned. If someone has severe scalp psoriasis and they experience hair loss, what treatment options do you consider?

Tori: For patients who have severe scalp psoriasis and psoriatic alopecia I would focus on systemic treatments. These are oral medications and injection medications. I can also prescribe topical medicines, but I wouldn't do topical treatment by itself because I don't think it's likely to get the patient to where they wanna be. I always try to aim for significant improvement, so at least a 5% improvement within three to six months of treatment. There’s a treatment that's called extract laser.  This is a noninvasive, narrow band UVB (Ultraviolet B) light treatment that can be very effective. It requires patients to receive 2 treatments a week in the dermatology office for at least 6 to 8 weeks, probably longer. So it can be difficult depending on patients, who if they live further away from the clinic or if their work is during the same hours that the clinic is open, they might not be candidates for this treatment. I like this treatment a lot because again, it's noninvasive, so it does not involve taking any medications and it really does not have any side effects. Intralesional steroid injections, the medication is called triamcinolone, is also a good option for scalp psoriasis. It's best for scalp psoriasis that does not involve more than 25% of the scalp, because it involves multiple injections every three months and it can be painful if we have to do more than 30 injections per time. It's very helpful for a small, stubborn areas of scalp psoriasis that are not going away with other treatments. There's a fairly new FDA approved medication called Deucravacitinib. It was approved for moderate-to-severe plaque psoriasis in 2022. It's a once daily oral medication. It is considered an immunosuppressant, so some patients may not be candidates for this medication. It has some side effects, but it works very well in the right patient. Some biologics, which are those injection medicines that you see ads for on TV, have specifically been studied for scalp psoriasis and those medications are what we usually reach for if patients have severe scalp psoriasis. They are self-injections so the patient gives the injection to themselves at a scheduled interval. Sometimes it's every two weeks, sometimes it's every month. Sometimes it's every 12 weeks. It depends on the specific medication. It sort of looks like an EpiPen. You don't have to draw anything out of a bottle like the old fashioned insulin. You don't even see the needle, and these are extremely effective for severe scalp psoriasis. So I like to keep in mind the entire patient, so not just their scalp, but I keep in mind whether they have psoriasis on their body or psoriatic arthritis in their joints and that also helps me pick my treatment.

Shiva: You mentioned topical treatment. Topical treatment is dependent on the delivery vehicle. What do you recommend for your patients who have scalp psoriasis and hair loss? You know, we see a lot of products promoted in different media that address hair loss. So how do you know what really works?

Tori: Excellent question. I get asked this question a lot and I think that it is very hard to know what products are really truly going to help and what are just gimmicks. So topical treatment on the scalp tends to be really messy and I think it's hard for us to ask our patients to adhere to regimens that involve daily application of messy products in the hair. So I do offer patients different formulations depending on their hair care routine and I try to match what will make their life less miserable. Ointments are way too messy so I would never use an ointment on the scalp. There are foams, sprays and solutions that tend to be more tolerable. There are some prescription shampoos that are pretty easy to use. So I usually go with something that the patient can use a few times a week without really disturbing their hair care routine. I also want to mention that in addition to treating patients for their psoriasis on their scalp to reduce inflammation, we can also use medicines that are specifically focusing on regrowing hair, and there's a wonderful medicine that's not new that you might have read about a while back that is oral minoxidil. This is an oral pill version of minoxidil, which is Rogaine, and this is extremely effective at stimulating hair growth. So just because the patient has psoriatic alopecia doesn't mean that we can only treat them by treating their psoriasis. We can use other remedies that we have. Now keep in mind there are so many products out there for hair loss and hair thickening and broadly speaking, I don't recommend any of them because I don't think they tend to be effective. People can try topical minoxidil. This comes as solution or foam. It's Rogaine. It's not glamorous. It's been around forever. It has 2% and 5%. I usually tell people to do the 5%. If people like to do more homeopathic treatments, rosemary oil, castor oil and peppermint oil have all been shown to be effective when they're applied topically to the scalp once a day. So patients can try either of those, but I usually don't recommend any vitamins. I don't recommend any thickening shampoos because they just don't work. There is one product that I recommend not using and it's kind of controversial and hard to get people to believe me, but biotin has actually recently been associated with increasing testosterone levels, which can cause hair thinning. And I know biotin is in like every hair growth product but I tell all of my patients not to take it and to stop taking it if they're on it.

Shiva: Yeah, and you see a lot of biotin products like vitamins for the hair, skin and the nails.

Tori: It's so frustrating because you're absolutely right, biotin is in all of those supplements. If it's in your multivitamin and it's a small amount, it's fine, but I don't want patients to be taking extra. Sometimes patients are taking hundreds of times the recommended daily value of what we really need, which is when we see it start to backfire. So the 5000 micrograms, 10,000 micrograms, that's way too much and it really can backfire.

Shiva: Certainly good to know. And another product I see a lot of is Keratin. Is Keratin OK to use?

Tori: Keratin is usually in shampoos and I think it's fine.  I don't think it causes any harm and I don't think it helps so if patients want to try it, that's fine. I get asked about vitamins like Nutrafol and Vegamour. First of all Nutrafol is very expensive, so I don't want patients to spend a lot of money on something that may or may not work. If they want to take it, it's fine. I don't think it's going to cause any problems, but it's not something that I actively tell people to go out and buy.

Shiva: It really sounds like the best thing to do with psoriatic alopecia is to control or prevent the inflammatory factors that ultimately are behind the cause of the hair loss. Am I understanding that correctly?

Tori:  Yes, as we've talked about throughout this discussion, the root cause of psoriatic alopecia is really the presence of the psoriatic plaques. And so you're absolutely right, we want to reduce inflammation in the skin.  Deciding on the correct treatment for each person is very individualized, and I take into consideration all of the areas where the psoriasis is active. I try to minimize the number of prescriptions I need to give people. So if they have psoriasis on their face and on their scalp, usually I try to come up with one topical medicine that can treat both areas. If patients have psoriatic arthritis, we do get more aggressive in our treatments because we want to prevent joint damage. If patients have other comorbidities because psoriatic disease can be associated with obesity, blood clots, liver disease, kidney disease, depression, we take all of those comorbidities into consideration. And of course, patient preference if they have severe scalp psoriasis and I think they would do best on a biologic but they have a needle phobia, we can come up with another plan that is effective and doesn't involve something that the patient really doesn't wanna do. We try to reduce inflammation systemically. Sometimes it's with a pill, sometimes it's with an injection and that will improve the hair loss over time as well.

Shiva: Once hair loss occurs, is it possible hair will grow back and if so, how long will this take?

Tori: The million dollar question. We've talked a lot about inflammation and psoriatic alopecia. We can also talk about treating hair loss as a separate entity, aside from psoriatic alopecia. In my experience psoriatic alopecia itself is usually not scarring and that means that there is the potential to regrow the hair with the right treatment. So as we've discussed, we reduce inflammation on the scalp, whether that's with topical medicines, with phototherapy, with injections or pills and then we can also treat the hair loss as we spoke a little bit about with oral minoxidil. We can also do topical minoxidil, but that can sometimes sting if patients have open areas of psoriasis. There are two other medications I haven't mentioned that are pills for hair loss. There's oral spironolactone and oral finasteride. Oral spironolactone and oral finasteride are both hormone medications. They reduce androgens, which are like testosterone, that generally is thought of as a treatment for androgenetic alopecia, which is again male and female pattern hair thinning. But we use them for a lot of other types of hair loss, including psoriatic alopecia and telogen effluvium. So these medications can be prescribed by your dermatology provider. We use them a lot and they're very effective. They not only reduce shedding, they can in many cases, regrow hair. I always try to explain to my patients that everything with the treatment of hair loss is slow. The results take at least six to nine months to see improvement. I take photographs at each visit that we can use for comparing so that we can track the improvement. It can be very reassuring to patients to see that hair growth in a picture because it can be difficult to notice when you're doing your hair every day. There is something called a hair transplant, which you have probably heard of. I wouldn't recommend it if patients have a lot of psoriatic disease on their scalp because that inflammation is going to make it less likely for the hair transplant to be successful. Once the inflammation is gone, a hair transplant can be considered. But it's very expensive and it's not covered by insurance. One other thing that I do offer my patients if they have hair loss, that's extensive enough that they would like to wear a wig or a hair piece, your provider can prescribe a scalp prosthesis which is another word for a hairpiece or a wig, and most insurance plans will cover some of the cost of the wig. Usually not all of it, but some of it. So if you are looking for a hairpiece, or if you already wear them, ask your dermatology provider to write you a prescription for a wig. I write scalp prosthesis on the prescription and then you submit the receipt from the wig with the prescription to your insurance and they can reimburse you for part of it.

Shiva: Such a good idea to take photos and track. I can imagine how people feel if they're losing their hair and have patches. They’re really just looking for that miracle cure. But you're right, you have to be patient.

Tori: Absolutely.

Shiva: And Tori, are there any new treatments in the pipeline to help with the issue of hair loss?

Tori: There always seem to be new medications coming down the pipeline for psoriatic disease, which is good for all of our patients. As we discussed, reducing the overall burden of inflammation in psoriatic disease will positively impact hair loss. So there are several new medications that are in studies or that might be coming to market pretty soon for psoriasis. Some of them are very similar to medications that are already on the market. So we have bimekizumab which is an anti-interleukin 17. We already have a couple of those. That's a biologic injection. We have another anti IL-23. We have a couple of those already on the market, so this new one is called, Picankibart. I'm sorry. I'm not really sure exactly how to say it. It's not out yet. We have a new class of medication for psoriasis. It's an oral medication that you take two times a day, which binds to inflammatory cells and destroys the inflammatory cells. This is called piclidenoson and hopefully that will be coming out soon because I think a lot of people like oral medications over injection ones. And then we have a handful of other biologics that are also in studies that hopefully will be coming to market. The other thing is we have something called biosimilars which are the injection medicines.

Shiva: This has been such an informative discussion about hair loss, how it affects people who have psoriasis, and what to do about it. Tori, do you have any final comments you'd like to share with our listeners?

Tori: Well, first of all, thank you so much for having me. This is my first time participating in a Psound Bytes™, so I'm very honored to be here. I hope it was informative and inspiring. And as I mentioned a little bit, there are a number of comorbidities associated with psoriasis such as heart disease, metabolic syndrome, depression, arthritis, kidney disease and we really need to pay attention to these comorbidities in our psoriasis patients and that also includes alopecia. I think it can be easy to overlook or dismiss hair loss in our patients with psoriatic disease because we're so focused on these other symptoms. We wanna make sure their joints aren't getting damaged. We wanna make sure they don't have high cholesterol or depression, but if you are a patient who is experiencing psoriatic alopecia or hair loss with your psoriatic disease, please ask us. Don't feel embarrassed, and if you don't get the attention from your provider, I think it's fair to look for another provider because we really need to be focusing on this because it affects the quality of life so much and I just try to remember that I never know how much hair loss might be bothering a patient until I ask them and have a discussion about it. I try to empower my patients and give them hope by showing them that I want to help them with their hair loss. I do understand that it can be so devastating, so I hope that empowers you as a patient.

Shiva: Such a great way to end this episode. Feeling empowered is so incredibly important.

Tori: Thank you so much for having me.

Shiva: Thank you Tori for being here today! It’s been such a pleasure having you here to talk about such an important issue for people with psoriatic disease. For our listeners, if you would like more information about scalp psoriasis and what you can do to treat it, contact our Patient Navigation Center to request the free “Scalp Psoriasis Quick Guide” by calling (800) 723-9166 or by emailing education@psoriasis.org.  And finally, thank you to our sponsors who provided support on behalf of this program activity through unrestricted educational grants: Bristol Myers Squibb, Janssen, Novartis and UCB.