Evaluating the Cost Burden of Alopecia Areata Treatment: A Comprehensive Review for Dermatologists
Alopecia areata (AA) is managed with prolonged medical treatments and cosmetic therapies, whose cost can be burdensome. We sought to identify the costs of AA treatment and consolidate the available data for the practicing dermatologist by performing a PubMed search of articles indexed for MEDLINE. Ten studies including approximately 16,000 patients with AA across a range of Oxford Centre for Evidence-Based Medicine Levels of Evidence were included. Studies showed that despite the limited efficacy of many AA therapies, patients incurred substantial expenses to manage their AA.
Practice Points
- Hair loss treatments and concealment techniques cost the average patient thousands of dollars. Much of this cost burden comes from items not covered by insurance.
- Providers should be wary of gender- or marketing-related surcharges for minoxidil solutions, and oral minoxidil may be a cost-effective option.
- Self-administering diphencyprone at home is more cost- and time-effective than in-office diphencyprone administration and does not decrease efficacy.
Alopecia areata (AA) affects 4.5 million individuals in the United States, with 66% younger than 30 years.1,2 Inflammation causes hair loss in well-circumscribed, nonscarring patches on the body with a predilection for the scalp.3-6 The disease can devastate a patient’s self-esteem, in turn reducing quality of life.1,7 Alopecia areata is an autoimmune T-cell–mediated disease in which hair follicles lose their immune privilege.8-10 Several specific mechanisms in the cytokine interactions between T cells and the hair follicle have been discovered, revealing the Janus kinase–signal transducer and activator of transcription (JAK-STAT) pathway as pivotal in the pathogenesis of the disease and leading to the use of JAK inhibitors for treatment.11
There is no cure for AA, and the condition is managed with prolonged medical treatments and cosmetic therapies.2 Although some patients may be able to manage the annual cost, the cumulative cost of AA treatment can be burdensome.12 This cumulative cost may increase if newer, potentially expensive treatments become the standard of care. Patients with AA report dipping into their savings (41.3%) and cutting back on food or clothing expenses (33.9%) to account for the cost of alopecia treatment. Although prior estimates of the annual out-of-pocket cost of AA treatments range from $1354 to $2685, the cost burden of individual therapies is poorly understood.12-14
Patients who must juggle expensive medical bills with basic living expenses may be lost to follow-up or fall into treatment nonadherence.15 Other patients’ out-of-pocket costs may be manageable, but the costs to the health care system may compromise care in other ways. We conducted a literature review of the recommended therapies for AA based on American Academy of Dermatology (AAD) guidelines to identify the costs of alopecia treatment and consolidate the available data for the practicing dermatologist.
Methods
We conducted a PubMed search of articles indexed for MEDLINE through September 15, 2022, using the terms alopecia and cost plus one of the treatments (n=21) identified by the AAD2 for the treatment of AA (Figure). The reference lists of included articles were reviewed to identify other potentially relevant studies. Forty-five articles were identified.
Given the dearth of cost research in alopecia and the paucity of large prospective studies, we excluded articles that were not available in their full-text form or were not in English (n=3), articles whose primary study topic was not AA or an expert-approved alopecia treatment (n=15), and articles with no concrete cost data (n=17), which yielded 10 relevant articles that we studied using qualitative analysis.
Due to substantial differences in study methods and outcome measures, we did not compare the costs of alopecia among studies and did not perform statistical analysis. The quality of each study was investigated and assigned a level of evidence per the 2009 criteria from the Centre for Evidence-Based Medicine.16
