Assessing severity in skin of color patients

Assessing severity in skin of color patients

There is considerable heterogeneity in the clinical presentation of alopecia areata (AA), with notable differences in clinical measures across patient ethnicities.^1-4 These differences can complicate diagnosis and disease severity assessment. Knowledge of accurate clinical presentation and suitable severity assessment are essential to providing quality care in a timely manner and minimizing the substantial impacts of AA on quality of life.

Skin of color patients in AA: Lack of representation and its impact on clinical practice

AA is more prevalent among skin of color (SOC) populations relative to White patients (prevalence ratio compared with White patients: Asian, 2.47; Black, 1.35; Hispanic/Latino, 1.26).^5,6 Despite this, SOC patients are still underrepresented in research and literature. This may result in medical professionals being less aware of how the condition presents in different hair textures and skin tones,⁷ impacting diagnosis accuracy, timing, and evaluation of disease severity in SOC patients.^6,7

Clinician assumptions based on the prevalence of other hair loss disorders in certain demographics may also contribute to misdiagnosis; for instance, SOC patients may be misdiagnosed with central centrifugal cicatricial alopecia (CCCA) because this condition has an increased prevalence among patients of African descent.⁷

Improving the inclusivity of diagnosis and severity assessment procedures

Several clinical assessment tools can be used to evaluate disease severity in AA. The Severity of Alopecia Tool (SALT) and its updated counterpart SALT II are standardized to quantify overall scalp hair loss by dividing the scalp region into four areas (right profile, left profile, vertex, and posterior) and assessing the percentage of hair loss in each region to calculate the total sum.^3,8 SALT II includes additional parameters, such as hair density and hair loss pattern, and assesses smaller increments of scalp coverage.⁸

Overall scalp hair loss activity in patients with pigmented hair can be evaluated with the use of Alopecia Areata Progression Index (AAPI) through detailed trichoscopy.^9,10

Hair loss in other body regions can be assessed with Brigham Eyebrow Tool for Alopecia Areata (BETA), Brigham Eyelash Tool for Alopecia Areata (BELA), and ALopecia BArbae Severity (ALBAS).⁹

However, sole reliance on SALT and other severity assessment tools for initial clinical observation may result in inaccurate evaluation, especially in SOC populations.⁷ The importance of thorough patient history (including possible culture-specific hair practices)trichoscopy and biopsy, have been highlighted as important for improving both diagnosis and the accuracy of severity assessment^1,7.

Furthermore, distinguishing AA from other hair loss disorders that are particularly prevalent in certain SOC populations (such as CCCA in people of African descent) is crucial to addressing potential bias and subsequent misdiagnosis.¹¹ In addition to dermoscopy, non-invasive procedures like the wash test and pull test can help achieve this.⁴

Results from a recently published large, real-world study (N=267) show that the clinical characteristics of AA vary across different patient ethnicities; for example, clinician-reported eyelash hair loss was found to be more prevalent in non-Hispanic Black patients compared with non-Hispanic White, non-Hispanic Asian, and Hispanic patients.² Furthermore, specific trichoscopic features in SOC patients have been identified and can inform the clinical assessment of AA in these patient populations. These data highlight the importance of characterizing AA in diverse SOC patient populations to improve the inclusivity and, therefore, quality of clinical assessment.

Moving forward

There is a clear need to improve diagnostic and severity assessment procedures to be more inclusive of SOC populations. Better representation of these populations in research and further studies into the specific characteristics of AA clinical presentation in SOC patients are warranted.

Although there is no single solution to this multi-factorial issue, raising awareness among clinicians about the unique presentation of AA in SOC patients, as well as encouraging a combined approach of clinical assessment methods to overcome potential bias and inaccuracies, will lead to improved clinical practice and patient outcomes.