Steroid Treatments for Hair LossSelection of a therapy for a patient with alopecia areata AA is frequently based on the age of the patient, disease extent, perhaps disease duration, patient expectations, cost of therapy in terms of time commitment, and financial resources, as well as the results of screening laboratory studies that rule out the presence of other co-morbidities such as corticosteroids treatment for alopecia, low iron stores, thyroid abnormalities, low vitamin D, or other autoimmune diseases. Although there is currently clenbuterol achat en pharmacie cure for AA and no universally proven therapy that induces and sustains remission, many therapies are available which can be of benefit to both affected children and adults. Before selecting a treatment for patients with extensive long-standing AA, a scalp biopsy may provide corticosteroids treatment for alopecia information about the degree of inflammation and follicle differentiation. Recent clinical and translational research observations with the systemic Janus kinase Corticosteroids treatment for alopecia inhibitors and interleukin-2 IL-2 have excited the clinical and AA patient communities and have led to clinical trials, as well as to the off-label use of these more expensive and targeted systemic corticosteroids treatment for alopecia. Author links open overlay panel Maria K. Under an Elsevier user license.
Alopecia areata: a new treatment plan
Many therapeutic modalities have been used to treat alopecia areata, with variable efficacy and safety profiles. Unfortunately, none of these agents is curative or preventive. Also, many of these therapeutic agents have not been subjected to randomized, controlled trials, and, except for topical immunotherapy, there are few published studies on long-term outcomes. In this paper, the therapeutic agents are organized according to their efficacy and safety profiles into first-line, second-line, and third-line options.
Alopecia areata is a common, nonscarring, autoimmune disease that can affect any hair- bearing area. Alopecia areata is a lymphocyte cell-mediated inflammatory type of hair loss, but its pathogenesis is not fully understood. The disease can present as a single, well demarcated patch of hair loss, multiple patches, or extensive hair loss in a form of total loss of scalp hair alopecia totalis or loss of entire scalp and body hair alopecia universalis.
A number of treatments can induce hair regrowth in alopecia areata but do not change the course of the disease. This review discusses the therapeutic options and management strategies for alopecia areata.
Several studies have shown the efficacy of intralesional corticosteroid injections. The most widely used agent is triamcinolone acetonide. Different concentrations of triamcinolone acetonide are used, in the range of 2. A maximum volume of 3 mL on the scalp in one visit is recommended.
Corticosteroid is injected into the deep dermis level or just beneath the dermis in the upper subcutis. The injections can be repeated at 4—6 weekly intervals.
The use of mesotherapy multi-injectors with 5—7 needles is an alternative approach to decrease injection pain and to make the procedure more homogenous. To alleviate injection pain, topical anesthetic may be applied 30—60 minutes before the treatment. Many forms of topical corticosteroids have been prescribed for alopecia areata, including creams, gels, ointments, lotions, and foams.
Sixty-one percent of patients using 0. Folliculitis is a common side effect to topical corticosteroids. Telangiectasia and atrophy may develop rarely.
In a placebo-controlled, double-blind study, hair regrowth was observed in The adverse effects of topical minoxidil include contact dermatitis and facial hypertrichosis. A few controlled trials have assessed the efficacy of topical anthralin in the treatment of alopecia areata. Severe irritation and staining of skin and clothes are some of the possible adverse events with anthralin.
Topical sensitizers that have been used in the treatment of alopecia areata include diphenylcyclopropenone, squaric acid dibutylester SADBE , and dinitrochlorobenzene. Dinitrochlorobenzene is no longer used because it was shown to be mutagenic in the Ames test.
SADBE is expensive and not stable in acetone. After two weeks, 0. The diphenylcyclopropenone concentration is increased gradually every week until mild dermatitis is observed.
The scalp should be protected from the sun during this time. Once hair regrowth is obtained on the treated half of the scalp, both sides are treated. Both sides of the scalp can be treated from the start also. Diphenylcyclopropenone is applied on a weekly basis by a trained nurse. If there is no response after 6 months of treatment, diphenylcyclopropenone can be discontinued. SADBE is applied once or twice per week. Eyelash hypertrichosis is a common adverse effect to the use of these antiglaucoma eye drops.
Complete regrowth of the eyelashes was noted in In a comparative study of topical tretinoin 0. Larger, double-blind, placebo-controlled trials are needed. In a nonblinded randomized study, 9. Sulfasalazine is a combination of sulfapyridine and 5-aminosalicylic acid linked by a diazo bond. Sulfasalazine has both immunomodulatory and immunosuppressive actions that include suppression of T cell proliferation and reducing the synthesis of cytokines, including interleukin IL 6, 1, and 12, tumor necrosis factor alpha, and antibody production.
Several case reports and case series showed good hair regrowth with sulfasalazine in the treatment of alopecia areata. A moderate response was seen in Initially, patients should have a complete blood count, liver function tests, creatinine, and glucosephosphate dehydrogenase level measurement. Complete blood counts and liver function tests should be performed at 2—4-week intervals during the first three months of therapy.
The reported relapse rates are In a treatment of 42 alopecia areata patches with the nm excimer laser, hair regrowth was observed in No regrowth of hair was noted on the control patches.
Laser therapy was administered twice a week for a maximum of 24 sessions. Apart from erythema at the treated sites, there were no significant adverse effects. Relapses of alopecia areata were observed in two patients with patchy alopecia areata of the scalp who had shown complete regrowth earlier.
Also, the use of excimer laser in children with alopecia areata has been reported to have a good success rate. Good hair regrowth was achieved with fractional Er: Glass laser in a single case report. Systemic corticosteroids are one of the commonly prescribed therapies in patients with extensive alopecia areata. Various forms of corticosteroids have been used in different regimens. In a study of patients treated with pulse corticosteroid therapy, a good response was achieved in The weekly dosages of methotrexate were 15—25 mg.
The onset of hair regrowth was seen after a median delay of three months. In a retrospective trial of methotrexate in 14 children with alopecia areata, approximately one third of patients experienced a clinically relevant therapeutic response.
Adverse effects to methotrexate include persistent nausea, transient elevation of hepatic enzymes, and leucopenia. Azathioprine, a thiopurine analog immunosuppressive drug, has been used to treat a vast array of autoimmune diseases. Azathioprine also decreases the number of Langerhans cells and other antigen-presenting cells in the skin. Although tumor necrosis factor alpha is implicated in the pathogenesis of alopecia areata, there are several reported cases that have shown either development of alopecia areata or complete failure to respond to different tumor necrosis factor alpha inhibitors, including adalimumab, 71 , 74 infliximab, 75 , 76 and etanercept.
Alopecia areata is considered to be an example of a psychosomatic disorder, leading to dramatic and devastating emotions which can negatively impact patient self-esteem, body image, and self-confidence. One important step that should not be overlooked during the course of management of alopecia areata is offering psychological support to foster increased self-esteem and adaptation to this disease.
Helping patients with alopecia areata cope with depression and an unpredictable disease like alopecia areata can be achieved by several ways, including education of the patient about the nature of disease, psychotherapy, hypnotherapy, 83 antidepressants, 84 , 85 and support groups. Hypnotherapy may significantly improve depression, anxiety, and quality of life, but not hair regrowth.
Other therapeutic agents have been tried, with some degree of success. These modalities include aromatherapy, 87 a combination of topical garlic gel and betamethasone valerate cream, 88 topical azelic acid, 89 oral zinc supplementation, 90 — 92 topical onion juice, 93 a simvastatin-ezetimibe combination, 94 , 95 inosiplex, 96 — 98 and intralesional injections of candida antigen. There are other modalities of therapy that have not shown good efficacy. These agents include imiquimod, , topical calcineurin inhibitors, — botulinum toxin type A, topical tri-iodothyronine ointment, photodynamic therapy, — and topical 5-fluorounacil.
Treatment options should be selected according to patient age and extent of disease. If there is no good improvement after 6 months, short-contact anthralin is considered as second-line therapy. Excimer laser can be used, particularly in patchy alopecia areata.
Intralesional injections of triamcinolone acetonide are used to treat persistent alopecic patches. For patients who respond poorly to diphenylcyclopropenone and those who cannot use it, second-line therapies can be used.
Several reviews of alopecia areata therapy suggest topical minoxidil and topical corticosteroids — but, as discussed earlier, the yield of these topical agents in the treatment of extensive alopecia areata is limited.
Therefore, we suggest that patients with extensive resistant disease can use sulfasalazine with or without systemic corticosteroids. Systemic steroids are used as bridge therapy until the sulfasalazine takes effect. Treatment with sulfasalazine is generally well tolerated and characterized by a lower incidence of serious side effects in comparison with other systemic therapies like corticosteroids and methotrexate. The other second-line therapy is PUVA-turban.
It is a well tolerated therapy with minimal local phototoxic side effects and without the systemic side effects of PUVA. These options are selected based on a balance between the efficacy and safety of these therapeutic agents. If these therapies fail or are not tolerated, third-line therapeutic options can be discussed with patients in terms of the expected outcome of therapy and possible side effects.
These agents include methotrexate with or without a systemic corticosteroid, azathioprine, cyclosporine, and pulse therapy of corticosteroids. While using these drugs, close monitoring of patients is important to avoid possible side effects. A summary of an alopecia areata treatment plan is shown as an algorithmic approach in Figure 1. National Center for Biotechnology Information , U. Clin Cosmet Investig Dermatol.
Published online Jul This is an Open Access article which permits unrestricted noncommercial use, provided the original work is properly cited. This article has been cited by other articles in PMC. Abstract Many therapeutic modalities have been used to treat alopecia areata, with variable efficacy and safety profiles. Introduction Alopecia areata is a common, nonscarring, autoimmune disease that can affect any hair- bearing area.
First-line therapies Intralesional corticosteroids Several studies have shown the efficacy of intralesional corticosteroid injections. Topical corticosteroids Many forms of topical corticosteroids have been prescribed for alopecia areata, including creams, gels, ointments, lotions, and foams.