The Psychiatric Burden of Pediatric Alopecia Areata: A Q&A With Brittany Craiglow, MD

Alopecia areata (AA), an autoimmune disease that causes patchy or complete hair loss, is still frequently classified by payers as a "cosmetic" condition, despite mounting evidence of its psychiatric toll. A 1991 study of patients with AA found a 39% lifetime prevalence of both major depressive disorder and generalized anxiety disorder, well above general population rates.¹ That burden looks different in children and adolescents than it does in adults, and it factors directly into how clinicians weigh the risks and benefits of starting systemic treatment at a young age.

Brittany G. Craiglow, MD, FAAD, a board-certified, fellowship-trained pediatric dermatologist and associate professor adjunct of dermatology at Yale School of Medicine who also practices at Middlebury Dermatology in Connecticut, discussed the psychiatric and psychosocial burden of pediatric AA, what makes treating children and adolescents different from treating adults, and how she weighs benefit and risk when considering Janus kinase (JAK) inhibitor therapy in younger patients, in the first installment of a 3-part interview with The American Journal of Managed Care^® (AJMC^®).

This transcript has been lightly edited for clarity.

The American Journal of Managed Care^® (AJMC^®): One study found that patients with alopecia areata have a 39% lifetime prevalence of major depressive disorder and generalized anxiety disorder.¹ What does that figure mean for how clinicians and payers should be thinking about AA as a disease category?

Craiglow: AA is often considered to be just hair, but we know from the patient experience that it's really so much more than that. We see increased rates of anxiety and depression. We see kids who get bullied in school or withdraw from activities, and that, by the way, is sort of normal; I don't think it's some failure of the person to be able to adjust or accept it. It's really, really hard to look in a mirror and see somebody looking back at you who doesn't look like you. It's often kind of a loss of identity. So I think it's not just hair; it has these profound impacts on a patient's life in so many different areas. And it's also a systemic disease. There's a basis in science: it's autoimmune. So we really have to look at the whole person when we're thinking about treating it.

AJMC: How often do you see the psychiatric and psychosocial burden of AA go unrecognized or untreated in pediatric patients, and what are the downstream consequences when it does?

Craiglow: Often, at first glance, patients say they're doing okay, or that it doesn't really bother them, and that's a coping mechanism. Especially in kids, it's tricky, because they get a lot of positive reinforcement for coping, which is an important life skill, but I think oftentimes that means kids think they're not brave, or not tough, or not strong, if they're not able to say how they really feel. So a lot of kids put on a brave face and say they're fine because it's hard for them to admit how they really feel, and they're worried they'll be judged for it. Because we hear people say, "It's just hair. At least you're not sick. It could be so much worse." When you're hearing that from somebody else, it's really, really difficult to say, "This is really awful. I'm having a really hard time."

So as physicians, it often takes a little more time to get on the patient's side and let them know we understand where they're coming from. Simple things, like "This is really hard, isn't it?," to let them know we get it, are really important. I have many patients who have successfully regrown hair and, looking back, say, "I'm realizing I never really processed this." I really do think it's a traumatic experience, and if you're being told, “You're brave, you’re tough, you're strong,” when on the inside you're feeling terrible. That's a complicated psychology and we see these prolonged effects of it.

AJMC: What makes treating AA in children and adolescents meaningfully different from treating adults, clinically, psychologically, and from a family-dynamics standpoint?

Craiglow: Treating AA in anyone is super important. It has this remarkable ability to change not only the way patients look but also the way they interact with the world and the way the world interacts with them. I think it's important to understand that we're just restoring normal; we're not looking to enhance their appearance. They just want to look normal, like themselves. In adolescence, the way you look and your peer relationships are really important, especially in this day and age of social media. We see kids who have all their hair who feel very self-conscious or feel like they need to do this thing or that thing to fit in, and when you look very different, that adds this extra layer of complexity. Socially, it can be really, really hard.

AJMC: How do you weigh the benefit-risk calculus differently for a 14-year-old versus a 40-year-old when considering JAK inhibitor initiation?

Craiglow: I often say that as a largely pediatric dermatologist, I'm very lucky, in that most of my patients are really healthy. They don't have many comorbidities; if they do, it's often something like atopic dermatitis, which will typically improve with a JAK inhibitor anyway. They don't have a laundry list of medications. So we obviously have to talk about risk with JAK inhibitors, and on an individual basis, that risk is very low in patients with inflammatory skin disease, probably lower than the average adult patient with rheumatoid arthritis, for example. In kids, it's often a little easier because they're healthy; they're not coming to the table with other risk factors like smoking. One thing that's a little tricky with parents is that they want their kid to get back to normal, but they worry about risk, especially long term. So it's important to talk about the data we have.

And I often talk about the risk of not treating. We always say we're comparing risk and benefit, but really we're comparing risk of treating vs not treating. If you don't treat a patient who has stopped playing sports or who's moved to online school, then what's that ripple effect going to look like down the road? We also know that the earlier you treat, the better the chance of hair regrowth. So getting these kids on treatment very early is really important; some of them may actually be able to go off therapy eventually, but we want all of our patients to have the best chance possible at meaningful regrowth.

References

1. Colón EA, Popkin MK, Callies AL, Dessert NJ, Hordinsky MK. Lifetime prevalence of psychiatric disorders in patients with alopecia areata. Compr Psychiatry. 1991;32(3):245-251. doi:10.1016/0010-440X(91)90045-E