Day 3 Clinical Insights from the Inaugural RAPIDS Conference at the Hyatt Regency Grand Reserve in San Juan, Puerto Rico
Saturday, April 12, 2025
Pathophysiology and Impact of Alopecia Areata (Arash Mostaghimi, MD)
- Pathophysiology of Alopecia areata: Cytotoxic (CD8+ + CD4+) T lymphocytes attack hair follicles, INF-gamma induces catagen, and IL-15 activates and maintains T-cell inflammation.
- Evolved thinking in Alopecia is that the Th2 process may play a strong role since a common co-morbidity is Atopic dermatitis in 30-40% of patients.
- Multiple comorbidities: Atopic Dermatitis, Autoimmune disease, Cardiac conditions, Cancer, Anxiety, Depression, Sexual side effects, bullying
All I Want to Do Is Grow My Patient’s Hair ( Arash Mostaghini, MD)
- Beyond patchy disease…JAKs are the only good choice for treatment. Start baricitinib at 4mg, not 2mg. Stick with one of the JAKs and gain familiarity with it. The safety profile is good, but take a good medical history for malignancy risk and clotting risk.
- For patchy disease, most are self-limited, with 30-50% spontaneous resolution at 1 yr. Follow the patient’s lead on how/if they want to be treated. Intralesional steroids are the standard of care for patchy disease, need repeated (4-6) treatments, 4-6 weeks apart, and can be combined with other meds.
- Minoxidil data is limited, but it is inexpensive. Typical dosing is 2.5mg in men and 1.25mg in women. The major side effect is hirsutism and shedding with withdrawal.
Pediatric Management of Alopecia Areata (Lisa Swanson, MD)
- Three possible courses for Alopecia Areata in kids: It’s a one-time fluke, OR after regrowth, the hair is lost every few months or few years, and cycles, OR Alopecia progresses to losing ALL of the hair = totalis or universalis (only 2% of kids with alopecia areata).
- Treatment options in kids: Topical clobetasol + topical 5% minoxidil, Vitamin D3 and fexofenadine, Pulse Prednisone 5-10 MG/KG one weekend a month, low dose oral minoxidil, contact sensitizers like Squaric acid, and Oral JAK inhibitor-Ritlecitinib = 12 yrs and up.
- Baricitinib and Deuruxolitinib are only indicated for those aged 18 and up.
Immunology of Vitiligo (Lisa Swanson, MD)
- The pathogenesis of Vitiligo is autoimmune. CD8+ T cells mediate the destruction of the melanocytes. INF-gamma, IL-2, and IL-5 all signal through the JAK/STAT pathway.
- Vitiligo-associated conditions include Thyroid disease (Hashimoto’s and Graves ' disease), Morphea, Psoriasis, Atopic Dermatitis, Alopecia Areata, and Rheumatoid Arthritis.
- It can be triggered by psychological stress, oxidative stress, toxins, chemical exposure, UV radiation, Medications, Viral infections/vaccinations, or a genetic propensity.
How I Counsel a Patient with Vitiligo (Lisa Swanson, MD and Stephanie Simmerman, NP)
- Assess the PATIENT’S wishes for treatment. Treatment goals=halt progression, re-pigment skin, maintain repigmentation, and make your patient happy.
- Topical Ruxolitinib is the only FDA-approved topical treatment for ages 12 and up. It works best in sun-exposed areas. Takes time, so BE PATIENT! Combine it with Polypodium leucotomos.
- After repigmentation, there is a 30-40% chance of recurrence. Using tacrolimus 0.1% BID 2 days/week can reduce that to a 5-10% risk.
Panel: JAK Inhibitors (Peter Lio, MD)
- JAK inhibitors present an alternative to Oral corticosteroids, which are immunosuppressants. The JTF and AAD guidelines conditionally recommend AGAINST steroids because of a LOW certainty of evidence, and should only be used for the short term.
- JAK Targets: Abrocitinib and Upadacitinib block JAK1, Baricitinib and Ruxolitinib block JAK1&2, Delgocitinib blocks JAK1, JAK2, JAK3, and TYK2.
- Abrocitinib 200mg daily and Upadacitinib 30mg daily may be associated with better scores than Dupilumab (adult dose) in head-to-head trials.
Is There Still a Place for Traditional Immunosuppressants? (Jennifer Soung, MD)
- Methotrexate Clinical Pearls: can be combined with biologics to reduce immunogenicity, caffeine can reduce adverse symptoms, don't forget folic acid supplementation
- Cyclosporin Clinical Pearls: Limit use to SHORT periods for quick improvement; avoid using >2 years, which will increase the chance of kidney failure; NOT as safe as biologics
- Absolute contraindications for Methotrexate: pregnancy, Nursing, Alcoholism, Immunodeficiency, severe anemia/leukopenia/thrombocytopenia/bone marrow hypoplasia.
RAPID Fire Clinical Pearls in Immuno-Dermatology (Peter Lio, MD)
- A written EAP (Eczema Action Plan) has been proven better than verbal instructions given for patient and parent education on AD, understanding the treatment regimen, and adjusting medications based on severity and anatomic location.
- Patients want alternative treatments: Black tea compresses for facial dermatitis, Fish Oil for Psoriasis, and Garlic for Warts
- The Mind/Body connection is strong: HRT = Habit reversal therapy for eczema, mitigating needle phobia with: distraction, relaxation, behavioral therapy, vibration, hypnosis, or topical anesthetic.
