High Treatment Costs Burden Patients With Alopecia Areata Despite Limited Treatment Efficacy

Patients faced substantial expenses to manage their alopecia areata (AA) symptoms despite the limited efficacy of some therapies, according to a study published in Cutis.¹

AA is an autoimmune T-cell-mediated disease where hair follicles lose their immune privilege, resulting in hair loss in nonscarring patches, often on the scalp. Although there is no cure for AA, it is typically managed with prolonged medical treatments and cosmetic therapies, the cumulative costs of these treatments potentially burdening patients.^2,3

Prior research estimated the annual out-of-pocket AA treatment cost to range from $1354 to $2685, while the cost burden of individual therapies is poorly understood.¹ Therefore, the researchers conducted a literature review to identify the costs of AA therapies recommended by the American Academy of Dermatology (AAD).

The researchers searched PubMed for relevant articles through September 15, 2022, using the terms “alopecia” and “cost” in combination with AAD-recommended AA treatments. They also reviewed the reference lists of eligible studies to identify other potentially relevant studies.

Initially, 45 studies were identified. However, they excluded studies for various reasons, like not being primarily about AA or having no concrete cost data. Consequently, the researchers used 10 studies for their analysis. However, they did not compare costs across studies or perform a statistical analysis because of the differences in methods and outcome measures.

They identified 3 studies that analyzed total and out-of-pocket costs for AA treatment. One study found that 675 patients had median annual out-of-pocket spending of $1354 (interquartile range [IQR], $537-$3300), the most common expense categories being hair appointments (81.8%) and vitamins/supplements (67.7%).⁴ Another discovered that 57% of 216 patients reported being moderately to severely burdened by AA and willing to borrow money or use savings to cover out-of-pocket costs.⁵

The third study analyzed health care resource utilization and all-cause direct health care costs in privately insured patients with AA with or without alopecia totalis (AT) or alopecia universalis (AU) (n = 14,972) matched 1:3 with non-AA controls (n = 44,916).³ The mean total all-cause medical and pharmacy costs were higher in both AA groups compared with controls (AT/AU, $18,988 vs $11,030; non-AT/AU, $13,686 vs $9336; P < .001 for both). Similarly, the out-of-pocket costs were higher for patients with AA (AT/AU, $2685 vs $1457; non-AT/AU, $2223 vs $1341; P < .001 for both).

Two of these studies also investigated the cost of concealment.¹ Li et al found that patients' median yearly spending was highest on headwear or cosmetic items, like wigs, hats, and makeup ($450; IQR, $50-$1500).⁴ Similarly, Mesinkovska et al reported that 75% of 112 patients did not have insurance coverage for concealment costs.⁵ Consequently, they spent a mean of $2211 annually and 10.3 hours weekly on concealment.

Additionally, 3 studies investigated the cost of minoxidil for patients with AA.¹ Minoxidil is a popular over-the-counter AA treatment that can take up to 4 months to work, resulting in patients suffering a substantial cost burden before experiencing any benefits. Patients who did not experience hair regrowth after 4 months were advised to continue treatment for a year, causing them to spend hundreds of dollars for uncertain results.⁶

As for the association between gender and over-the-counter minoxidil cost, women paid for 2% regular-strength minoxidil solutions ($7.63/30 mL) close to what men paid for 5% extra-strength minoxidil solutions ($7.61/30 mL; P = .67).⁷ However, minoxidil 5% foams were priced significantly more when sold as a product directed at women ($11.27/30 mL) vs when directed at men ($8.05/30 mL; P < .001). In terms of oral vs topical minoxidil, a 3-month supply of oral minoxidil is cheaper than topical minoxidil ($48.30).⁸

Also, 2 studies analyzed the cost of diphencyprone (DPC) for patients with AA.¹ One study investigated the cost-efficiency of DPC in 29 patients with AA resistant to at least 2 conventional treatments.⁹ They found that most of the annual cost burden of DPC resulted from staff time and overhead than from DPC itself ($258 for the DPC; $978 in staff time and overhead for the department; $1233 directly charged to the patient).

Additionally, Lekhavat et al analyzed the economic impact of home use vs office use of DPC in 82 patients with extensive AA.¹⁰ They found that, at 48 weeks, the total cost to the health care provider was higher for the office use group (office, $683.52; home, $303.67; P < .001). Conversely, median out-of-pocket costs did not significantly vary between groups (office, $418.07; home, $189.69; P = .101).

As for Janus kinase (JAK) inhibitors, the estimated annual cost after FDA approval was $50,000.¹¹ A study reviewed the use of JAK inhibitors for AA treatment and found that their cost estimates before FDA approval aligned with the pricing of the now-approved JAK inhibitor baricitinib.¹² Therefore, the list price is $2739.99 for a 30-day supply of 2 mg baricitinib tablets or $5479.98 for 4 mg tablets; this equates to $32,879.88 for an annual supply of 2 mg tablets and $65,759.76 for 4 mg tablets; however, the out-of-pocket costs will vary.

Based on their findings, the researchers suggested steps providers can take to ease the burden of treatment costs for patients with AA.¹

“Increasing coverage of AA-associated expenses, such as minoxidil therapy or wigs, could decrease the cost burden on patients,” the authors concluded. “Providers also can inform patients about cost-saving tactics, such as purchasing minoxidil based on concentration and vehicle rather than marketing directed at men vs women.”

References

1. Patel PV, Coello A, Larrondo J, McMichael A. Evaluating the cost burden of alopecia areata treatment: a comprehensive review for dermatologists. Cutis. 2024;113(4):185-190. doi:10.12788/cutis.0994
2. Strazzulla LC, Wang EHC, Avila L, et al. Alopecia areata: an appraisal of new treatment approaches and overview of current therapies. J Am Acad Dermatol. 2018;78(1):15-24. doi:10.1016/j.jaad.2017.04.1142
3. Mostaghimi A, Gandhi K, Done N, et al. All-cause health care resource utilization and costs among adults with alopecia areata: a retrospective claims database study in the United States. J Manag Care Spec Pharm. 2022;28(4):426-434. doi:10.18553/jmcp.2022.28.4.426
4. Li SJ, Mostaghimi A, Tkachenko E, Huang KP. Association of out-of-pocket health care costs and financial burden for patients with alopecia areata. JAMA Dermatol. 2019;155(4):493-494. doi:10.1001/jamadermatol.2018.5218
5. Mesinkovska N, King B, Mirmirani P, Ko J, Cassella J. Burden of illness in alopecia areata: a cross-sectional online survey study. J Investig Dermatol Symp Proc. 2020;20(1):S62-S68. doi:10.1016/j.jisp.2020.05.007
6. Shrank AB. Minoxidil over the counter. BMJ. 1995;311(7004):526. doi:10.1136/bmj.311.7004.526
7. Wehner MR, Nead KT, Lipoff JB. Association between gender and drug cost for over-the-counter minoxidil. JAMA Dermatol. 2017;153(8):825-826. doi:10.1001/jamadermatol.2017.1394
8. Beach RA. Case series of oral minoxidil for androgenetic and traction alopecia: Tolerability & the five C's of oral therapy. Dermatol Ther. 2018;31(6):e12707. doi:10.1111/dth.12707
9. Bhat A, Sripathy K, Wahie S, et al. Efficacy and cost-efficiency of diphencyprone for alopecia areata. Br J Dermatol.2011;165:43-44.
10. Lekhavat C, Rattanaumpawan P, Juengsamranphong I. Economic impact of home-use versus office-use diphenylcyclopropenone in extensive alopecia areata.Skin Appendage Disord.2022;8:108-117.
11. GlobalData Healthcare. Can JAK inhibitors penetrate the alopecia areata market effectively? Pharmaceutical Technology. July 15, 2019. Accessed February 8, 2024. https://www.pharmaceutical-technology.com/analyst-comment/alopecia-areata-treatment-2019/
12. Dillon KL. A comprehensive literature review of JAK inhibitors in treatment of alopecia areata. Clin Cosmet Investig Dermatol. 2021;14:691-714. Published 2021 Jun 25. doi:10.2147/CCID.S309215