Dr Matthew Harries is deputy lead of the NIHR Manchester Biomedical Research Centre's inflammatory hair diseases research programme and Consultant Dermatologist at Salford Royal, which is part of Northern Care Alliance NHS Foundation Trust.

In this blog post for Alopecia Awareness Month, Dr Harries shares his insight into research in this area and his hopes for alopecia patients in the future..

Although, disappointedly, sometimes trivialised as a cosmetic problem, alopecia is a term which covers a number of hair loss conditions. 

Hair loss can have a profound negative emotional impact. For someone with alopecia, the condition can affect self-confidence and reduce their quality of life.

People with alopecia are often perceived as being ill or suffering from cancer, and those affected can feel less attractive and struggle to with feelings relating to perceived loss of identity, femininity and masculinity. 

Therefore, it is no surprise that ongoing hair loss is linked with higher rates of depression, anxiety, and unemployment.

Manchester BRC’s inflammatory hair disease programme is working to improve outcomes for people with hair loss. A key strength of the programme is the close link between the hospital clinic and university laboratory, allowing clinical observation and patient feedback to inform research priorities that are important for our local population.

Alopecia areata (AA)

One of the most common types of hair loss is called alopecia areata (AA). AA is an autoimmune condition, whereby the immune system – which normally protects the body from viruses and bacteria – mistakenly attacks the hair follicles.

This causes patchy hair loss, which in some people can progress to complete loss of all scalp and body hair. We have recently published a series of studies, using primary care data from the Royal College of General Practitioners' (GPs) national patient registry, that estimates there are currently around 400,000 people in the UK who either have alopecia areata or have had it in the past. 

Health inequalities within AA

Importantly, but not previously recognised, AA is more common in some minority ethnic groups and in those living in lower socioeconomic areas. Unfortunately, these groups are less likely to be referred to hospital to see a dermatologist or access specialist treatment, identifying an important health inequality.

Our future work will explore pathways and barriers to hospital referral from different backgrounds, and identify ways to improve equitable access to specialist services.

We plan to set up a rapid access clinic to allow early assessment and treatment of suspected AA. This clinic will help us understand the early disease changes in AA and give an opportunity to study the effects of earlier treatment, with the aim of improving longer-term outcomes.

Currently available treatments     

The treatment landscape for AA is currently undergoing great change, with several new (but expensive) drugs being developed to treat the condition.

The Janus Kinase (JAK) Inhibitor class of drugs, which work by suppressing the immune response associated with AA, are showing great promise.

However, there are also various other drug targets being explored with several pharmaceutical companies registering clinical trials as part of their future research pipelines. These new therapies target various abnormal pathways identified as contributing to AA development, including agents that can block different pro-inflammatory signals, or others that help suppress immune cell responses.  

Although undoubtedly this is an exciting time for new AA therapies, we also need to be cautious and understand the longer-term safety and effectiveness of these drugs as they come to market, to allow patients, doctors, and the NHS to decide the best way these new treatments should be used.

To this end, the BRC Dermatology theme recently secured funding from the British Skin Foundation to set-up a national AA Registry (database), called “GRASS-UK” (Global Register of Alopecia areata Severity and treatment Safety-UK). This database will enable clinicians to assess longer-term safety and effectiveness of new drugs as they are introduced.

This registry adds to the growing portfolio and expertise at The University of  Manchester, which hosts other large national registries, including psoriasis (BADBIR) and rheumatology (BSRBR) registers.      

The laboratory

In our laboratory in Manchester, biological samples – obtained from consenting patients seen in clinic – are analysed to identify important processes and pathways that lead to the development of different inflammatory hair loss conditions. This includes not only AA but also scarring alopecias, where the hair follicle is destroyed and replaced with scar tissue – causing permanent hair loss.

Using hair follicles grown in the lab, we can induce certain changes within the samples to mimic aspects of the disease process in the hair follicle. Examples of this include immune privilege collapse (when the immune system attacks its own tissue), or epithelial-mesenchymal transition (when skin cells change appearance and behaviour, becoming more fibrous and scar-like).  

Using these models, we can efficiently screen and identify candidate treatment to stop or reverse these processes. The identified new drug targets can then be tested as a potential treatment of the disease through clinical trials, thereby completing the ‘research circle’ back to the clinic.

We are also working on new ways to assess people with hair loss, and approaches to predict disease relapse. Traditionally, most studies have involved taking scalp skin biopsies to study the follicle. However, this is uncomfortable and leaves a scar. We are now investigating less invasive approaches, such as using plucked hair samples instead of skin biopsies, or blood samples, that will start to allow us to predict progression and treatment responses more accurately –  but with fewer side effects.

Until they are affected by hair loss themselves, many people do not fully understand the psychosocial importance hair has. I have witnessed first-hand, working with patients living with alopecia, how it can negatively affect their quality of life, and this is why raising awareness of this sometimes underestimated condition is so important.

We thank all those who have taken part in our research, as without this engagement it would be impossible to understand these conditions or develop new treatments.

Importantly, I feel the future is bright for people with alopecia.

The growing interest from pharmaceutical companies has resulted in more investment into alopecia research, not only leading to a better understanding of the disease processes and identification of new treatment targets, but also helping to improve clinical assessment techniques and psychological support options. Alopecia UK has also played a key role in getting more alopecia research projects off the ground in the past few years. 

We anticipate that, over time, treatments for alopecia will increasingly be targeted to an individual using various clinical or biological markers to predict who will respond best to each therapy.

Improved understanding of the disease and new drug options are the first steps towards a truly personalised medicine approach to alopecia management.