Continuing medical education
Alopecia areata update: Part II. Treatment

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Various therapeutic agents have been described for the treatment of alopecia areata (AA), but none are curative or preventive. The aim of AA treatment is to suppress the activity of the disease. The high rate of spontaneous remission and the paucity of randomized, double-blind, placebo-controlled studies make the evidence-based assessment of these therapies difficult. The second part of this two-part series on AA discusses treatment options in detail and suggests treatment plans according to specific disease presentation. It also reviews recently reported experimental treatment options and potential directions for future disease management.

Learning objectives

After completing this learning activity, participants should be able to compare the efficacy and safety of various treatment options, formulate a treatment plan tailored to individual patients, and recognize recently described treatments and potential therapeutic approaches.

Section snippets

Intralesional corticosteroids

Key points

  1. Intralesional corticosteroids are the treatment of choice for adults

  2. The authors' preference is triamcinolone acetonide 5mg/mL to the scalp and 2.5mg/mL to the face every 4 to 6 weeks

  3. Treatment should be stopped if there is no improvement after 6 months

Although intralesional corticosteroids (ILCSs) have been used in the treatment of AA for about 50 years, there are no published randomized controlled trials.1, 3 Hair regrowth has been reported in 71% of patients with subtotal AA treated by

Topical corticosteroids

Key points

  1. Topical midpotent corticosteroids are the treatment of choice in children

  2. The authors combine topical corticosteroids with minoxidil 5%

Different forms of topical corticosteroids have been used to treat AA, with varying degrees of efficacy. In a randomized, double-blinded, placebo-controlled trial using desoximetasone cream 0.25%, the complete regrowth rates in the active and control groups were 57.6% and 39.2%, respectively.7 These results were not statistically significant when compared with

Topical immunotherapy

Key points

  1. Diphenylcyclopropenone (DPCP) is the treatment of choice for adults with more than 50% scalp involvement

  2. Sensitization with DPCP 2% is followed by weekly application of the lowest concentration that can cause mild irritation

  3. Squaric acid dibutylester is an alternative in patients who do not develop allergic reaction to DPCP

  4. Treatment should be stopped if there is no improvement after 6 months

  5. The success rate is 50% to 60%, with a relapse rate up to 62% at a median period of 2 and a half years

Systemic corticosteroids

Key points

  1. Daily, weekly, and monthly pulse corticosteroids have been used with varying success

  2. The use of systemic corticosteroids is limited by their side effect profile and a higher rate of relapse

Several forms of systemic corticosteroids have been described in the literature with better success rates in multifocal AA and less favorable results with ophiasis and universalis AA.61 In a placebo-controlled trial of oral prednisolone 200 mg once weekly for 3 months, it was shown that a moderate regrowth of

Cyclosporine

Key points

  1. Cyclosporine has been used alone or in conjunction with corticosteroids with a success rate up to 76.6%

  2. Cyclosporine use is limited by its side effects and high relapse rate

Cyclosporine is an immunosuppressant agent that inhibits helper T-cell activation and suppresses interferon gamma (IFN-γ) production. Success rates with oral cyclosporine range from 25% in some trials81 to 76.7% in others if combined with methylprednisolone.82 Notably, however, AA has been reported in several organ transplant

Management plan

At the patient's first visit, a careful medical history and a good physical examination should be carried out, including an examination of all hair-bearing areas and nails. Full information about his or her disease, including the relapsing nature of AA, prognosis, and risk/benefit ratio of treatment options, should be provided. It is important that the physician spends enough time with the patient to answer his or her questions and to address the psychosocial effects of AA, because this affects

Vitamin D

1, 25-dihydroxycholecalciferol [1, 25(OH)2D3] is the biologic active form of the vitamin D3.125 Vitamin D has a multitude of biologic effects interacting with the innate and adaptive immune system, mainly leading to its downregulation.126 It regulates the differentiation of B cells, T cells, dendritic cells, and the expression of Toll-like receptors.126 There is growing evidence that vitamin D may help in several autoimmune diseases like multiple sclerosis and type I diabetes mellitus,127 lupus,

Summary

There has been little progress in the treatment of AA in the past decade, and ILCSs are still the preferred method of treatment for most patients. Newer topical and systemic agents (eg, biologics) have been tried, but the outcomes have been unattractive. We are still in need of developing treatment options for refractory cases and for specific hair-bearing sites (ie, eyelashes) where treatment choices are almost nonexistent. Because of higher psychiatric morbidity in patients with AA,

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    Funding sources: None.

    Conflicts of interest: Dr Shapiro is a consultant for Johnson and Johnson Inc. Drs Shapiro and McElwee are cofounders of TrichoScience Innovations Inc. The other authors, editors, and peer reviewers have no relevant financial relationships.

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