Episode Overview

Podcast: Derms on Drugs
Episode Title: What If Every Day Was a Bad Hair Day?
Date: December 12, 2025
Hosts: Dr. Matt Zirwas, Dr. Laura Ferris, Dr. Tim Patton
Guest: Dr. Maryanne Senna (Leahy Clinic, Hair Clinic Director)

This week, the gang deep-dives into the psychological impact of alopecia (especially alopecia areata), how patients perceive disease severity, measurement tools for quality of life, gender differences, and therapeutic decision-making. The episode blends evidence-based discussion with their trademark banter and practical pearls, ideal for dermatologists managing hair loss patients—or anyone keen on the mind-hair connection in medicine.

Key Discussion Points and Insights

1. Psychiatric Burden in Alopecia Areata ([01:27]–[16:16])

Main Study Reviewed

• Reference: "The Psychiatric Burden in Alopecia Areata: A Propensity Matched Cohort Study" (Dermatologic Therapies)
• Findings:
  • AA patients had significantly higher psychiatric comorbidity than controls:
    • 17.3% in AA vs. 3.9% in controls
    • Risk ratio/hazard ratio: 4.49 for psychiatric conditions
  • Depression risk was 5x higher, anxiety 4x, and elevated risk across insomnia, eating disorders, substance use, etc.
  • Women with AA had higher psychiatric comorbidity than men. However, men led in substance abuse.

Discussion Highlights

• Dr. Zirwas questions the association with psychotic disorders, seeing those more as fundamentally brain-based/genetic:

  • "I think of everything else in there as something where bad stuff's happening to you... but like psychotic is your brain's messed up... That one made me question the whole thing." ([04:24])

• Dr. Ferris and Dr. Senna explain even severe mental illnesses can be exacerbated by acute stressors.

• The bidirectional impact is discussed: Can pre-existing susceptibility to anxiety/depression make one more prone to developing AA or vice versa?

  • Dr. Senna: "I think it's a bit of a double-edged sword... Even if stress does cause an exacerbation or, or contribute... it's not the whole story." ([06:40])

• Real-world insight from clinical trial patients:

  • Severe life stressors (e.g., death of a spouse/child) often precede AA onset ([08:03]).
  • COVID-19 pandemic increased risks—especially for anxiety, insomnia, eating disorders, self-harm, and suicide ([10:09]).

• The unpredictability of AA is a psychological torment for many:

  • "It's the unpredictability of this disease... [that] really can mess with people because they don't know. And there's no test that we can do to promise them one way or the other..." – Dr. Senna ([11:43])

Measuring Counseling and Support

• Dr. Senna screens all AA patients for psychiatric issues, but only refers a handful for psychiatric care; most are already seeking help or receiving medication ([14:01]).
• Adolescents present the greatest challenge due to age-specific needs and lack of specialized therapists ([14:40]).
• Virtual therapy is increasingly accessible and covered by insurance ([15:21]).

Notable Quotes

• "This isn’t just you... This is part of your disease." – Dr. Ferris ([16:12])
• Dr. Senna describes a practical intake tool:
  • “How much is your hair loss bothering you?” on a happy→sad face Likert scale ([16:41])

2. Gender and Societal Context ([18:21]–[20:15])

• Strong gender asymmetry in social acceptance and adaptation to hair loss.
• For men, baldness can be trendy/acceptable (Michael Jordan, Vin Diesel), but for women, "there is zero cultural acceptance for women to have hair loss." – Dr. Senna ([18:21])
• Regrowth of eyelashes/eyebrows is especially valued by men; women can camouflage with makeup, men often can’t. ([19:46])

3. Patient Perceptions vs. Objective Measures ([20:18]–[32:50])

Major Study #2

• Reference: "Alopecia Areata: Impact on Patients' Quality of Life and Disease Perception" (Survey from Norway & Denmark – Vestergaard et al.)
• Surveyed 300+ patients:
  • 94% female
  • Over half rated their AA as severe (regardless of objective severity)
  • Many with objectively mild hair loss still self-rated as severe ([20:48])
• Younger patients had higher self-perceived severity and higher scores (SALT, DLQI, PUSH-D).

Correlations (or Lack Thereof)

• Poor correlation between objective scores (like SALT) and patients’ own experience of severity ([22:56])

• DLQI—a standard tool—doesn’t adequately capture what AA patients actually feel; some requirements (like needing DLQI>10 to qualify for systemic therapy in Denmark) may unfairly exclude candidates ([23:20])

• Discussion of "hair dysmorphic disorder" for those preoccupied with perceived hair loss despite having “more hair than I do” ([27:54])

• "I feel like it is unethical for me to treat those people... It's in a sense a form of body dysmorphic disorder." – Dr. Ferris ([28:17])

4. Scarring vs. Non-scarring Alopecia ([32:50]–[36:06])

Main Study #3

• Reference: "Quality of Life in Patients with Scarring and Non-scarring Alopecia: Exploratory Cross-sectional Study"
  • 510 patients, ~50/50 split, mean age 46
  • Non-scarring alopecia patients (mostly AA) reported worse quality of life and more anxiety/depression than those with scarring
  • On DLQI, scarring patients only outscored for symptoms (pain, burning)

Insights

• Dr. Senna sees high distress in both groups, especially among young patients with frontal fibrosing alopecia (FFA):
  • "My new young FFA patients are absolutely devastated." ([35:39])
• Younger age was a confounder—distress often higher in younger patients regardless of type.

5. Treatment Strategies and Pearls ([36:06]–[46:31])

JAK Inhibitor Choice

• Choice between baricitinib, ritlecitinib, and deuruxolitinib usually guided by side effect profile and insurance ([36:44])
  • For hypercholesterolemia, ritlecitinib may be safer
  • For baseline IBD or urticaria, avoid deuruxolitinib due to higher rates of GI/hypersensitivity side effects

Response Time and Switching

• Complete scalp hair loss: Try JAK inhibitors for up to one year before switching ([39:11])
• Partial loss: Six to nine months may suffice, evaluate for response
• If showing some improvement around 9 months, may extend; beyond a year without significant effect is “tricky” ([40:25])

Combination/Adjunctive Therapy

• Low-dose oral minoxidil is often added to JAK inhibitors ([41:21])

  • "Almost always," unless patient is medication-reluctant; starting dose 2.5 mg, can go higher in men ([42:03])

• Topical steroids under occlusion not routinely used; for practicality, most AA patients dislike the hassle ([42:44])

Off-Label/Adjuncts

• There is emerging data for apatasitinib (“a lot of hope,” especially with atopic patients) and for combining JAKs with dupilumab if there’s underlying AD ([43:57])

  • Response to dupilumab alone mostly in active, moderate/severe AD, not AA with just elevated IgE ([44:41])

• Mechanistic discussion of dupilumab’s paradoxical effect (may worsen or improve AA depending on TH1/TH2 skewing and T-reg homeostasis) ([45:26])

  • “If you have a heavy TH2 skewing with allergy…your Tregs come back up and your hair regrows.” – Dr. Senna

6. Memorable Moments & Quotes

"Hair Dysmorphic Disorder" ([29:02])

• Dr. Ferris and Dr. Senna jest about patients obsessed with perceived hair loss:
  • Zirwas: "I think you just coined a new disease. HDD – Hair Dysmorphic Disorder."
  • Senna: "The hair loss patient with no hair loss? Yeah, it certainly is."

Gender double standards ([18:21])

• Senna: "You can't think of a single bald woman like that. Right. There is zero cultural acceptance for women to have hair loss."

On patient self-assessment tools:

• "On our intake form for every hair loss patient: How much is your hair loss bothering you? With the happy face all the way to the sad face... just circling a number helps open the conversation." – Senna ([16:41])

On therapy access:

• "You can almost always find virtual therapists who take your insurance... Most of the therapists I've seen in the last five years, I've never met face-to-face. It's all virtual." – Zirwas ([15:21])

7. Trivia & Lighthearted Banter ([47:00]–[51:12])

• Competitive trivia round: Answers are words you can spell from the letters in "alopecia areata" (e.g. Croatia, pectoral, opera).
• The playful, self-deprecating humor is on display:
  • "I only needed 85 clues to get it. All right, go me." – Senna ([48:51])
  • "We’re all winners. That’s what’s so great about this. We all get a trophy." – Ferris ([51:09])

Timestamps for Major Segments

• [01:27] – Psychiatric burden study review
• [06:40] – Stress, triggers, and the chicken-egg effect in AA
• [10:09] – COVID impact on anxiety & related issues in AA
• [11:43] – The psychological torment of disease unpredictability
• [18:21] – Gender difference in social adaptation to hair loss
• [20:48] – Quality of life survey, objective vs. subjective severity
• [23:20] – Flaws of DLQI as an AA outcome tool
• [28:17] – Ethics around “hair dysmorphic disorder”
• [32:50] – Scarring vs. non-scarring alopecia, comparative distress
• [36:44] – JAK inhibitor selection in the real world
• [41:21] – Oral minoxidil combination therapy
• [43:57] – Data on newer JAKs, use of dupilumab
• [47:00]–[51:12] – Trivia and podcast wrap-up

Practical Takeaways

• Psychiatric screening should be routine in AA clinics; the risk is high and real.
• Perception of hair loss severity is only loosely correlated with measurable hair loss—listen to your patients.
• Women disproportionately bear the social cost of alopecia.
• DLQI is a poor barometer for AA; better tools and more individualized assessment are needed.
• Treatment approach: Match JAK agent to comorbidity/interface with insurance, combine with low-dose oral minoxidil, and be realistic about time frames for response.
• Be mindful of both overt and subtle distress—especially younger patients, adolescents, and those socially isolated by hair loss.

Notable Quotes (with Timestamps)

• "It's the unpredictability of this disease that... really can mess with people." – Dr. Senna ([11:43])
• "There is zero cultural acceptance for women to have hair loss." – Dr. Senna ([18:21])
• "Sometimes papers like this are helpful for me to say to patients who are struggling: You know, this isn't just you. This is part of your disease." – Dr. Ferris ([16:12])
• "I feel like it is unethical for me to treat those people... It's in a sense like a form of body dysmorphic disorder." – Dr. Ferris ([28:17])
• "If you have a heavy TH2 skewing with allergy... your Tregs come back up and your hair regrows." – Dr. Senna ([45:26])

For more episodes, check out Scholars in Medicine and subscribe to Derms on Drugs for your weekly dose of cutting-edge, high-energy dermatology discussion.