Continuing medical education
Alopecia areata: An appraisal of new treatment approaches and overview of current therapies

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Many therapies are available for the treatment of alopecia areata, including topical, systemic, and injectable modalities. However, these treatment methods produce variable clinical outcomes and there are no currently available treatments that induce and sustain remission. When making management decisions, clinicians must first stratify patients into pediatric versus adult populations. Disease severity should then be determined (limited vs extensive) before deciding the final course of therapy. The second article in this continuing medical education series describes the evidence supporting new treatment methods, among them Janus kinase inhibitors. We evaluate the evidence concerning the efficacy, side effects, and durability of these medications. An overview of conventional therapy is also provided with new insights gleaned from recent studies. Finally, future promising therapeutic options that have not yet been fully evaluated will also be presented.

Section snippets

Approach to treatment

Key points

  1. Alopecia areata is unpredictable, and therefore no treatment may be appropriate for a subgroup of patients as spontaneous remission rates range from 8% to 68%, depending on disease severity

  2. Extent of hair loss and age of the patient are the most important factors to consider when determining management approaches

  3. Patients should be educated about hairpieces and camouflage techniques

Few treatment methods have been evaluated by randomized control trials to determine the most efficacious modalities

Intralesional corticosteroids

Key points

  1. Intralesional corticosteroids are considered a first-line treatment method for limited disease, and can be used as adjunctive therapy in extensive disease

  2. Patients should be monitored for side effects, including skin atrophy, which may warrant dose modification or treatment discontinuation

Intralesional corticosteroids, most commonly triamcinolone acetonide (TAC), are the criterion standard for treating patchy AA of limited extent and for cosmetically sensitive areas, such as the eyebrows. Tan

Topical corticosteroids

Key points

  1. Topical corticosteroids may be used alone or in conjunction with other treatments, including intralesional corticosteroids

  2. Pediatric patients may prefer treatment with topical corticosteroids compared to injections

Topically applied corticosteroids likely provide some benefit in AA, especially in patients with limited disease, although the results may be inferior to intralesional therapy. Evidence from split scalp studies has confirmed that regrowth results from local and not systemic effects of

Minoxidil

Key point

  1. 5% minoxidil foam or solution may be used as adjuvant therapy in alopecia areata

As a monotherapy for AA, minoxidil may be insufficient to promote complete hair regrowth. Nonetheless, many studies have suggested that it does stimulate hair growth in patients with AA, though less commonly in severe forms of the disease. For example, a long-term study of 30 patients evaluated the efficacy of 3% minoxidil twice daily compared to placebo for 12 weeks followed by 52 weeks of minoxidil treatment. At

Oral corticosteroids

Key point

  1. Short courses (6 weeks) of oral corticosteroids are often sufficient to stimulate hair regrowth; however, the side effect profile precludes long-term use and the likelihood of relapse is significant

Systemic corticosteroids are widely used in autoimmune diseases and have demonstrated a significant benefit in most clinical variants of AA, with reduced efficacy in ophiasis and alopecia universalis (AU) types.21 In a study of 32 patients who completed at least a 6-week course of prednisone at a

Methotrexate

Key point

  1. Methotrexate may be effective for patients who fail standard therapy

Successful treatment of AA with methotrexate has been reported in both adult and pediatric populations. Chartaux and Joly24 described 33 patients with either AT or AU (mean disease duration, 7.7 years) who failed standard therapy and found that methotrexate (15-25 mg) alone or in combination with oral corticosteroids (prednisone 10-20 mg/day) resulted in complete hair regrowth in 63% of those on combined treatment and 57% of

Topical immunotherapy

Key points

  1. Diphenylcyclopropenone has a success rate of approximately 60% to 70%, and is an option for the treatment of patients with extensive disease (>50% scalp involvement)

  2. Patients who do not respond to diphenylcyclopropenone may be treated with squaric acid dibutylester

Topical immunotherapy, including squaric acid dibutylester (SADBE) and diphenylcyclopropenone (DPCP), causes an allergic contact dermatitis and through an incompletely understood mechanism may cause antigenic competition, changing the

Novel therapeutic method using Janus kinase inhibitors

Key points

  1. Oral Janus kinase inhibitors, including tofacitinib, ruxolitinib, and baricitinib, have been shown to be efficacious in alopecia areata

  2. The durability of response to these medications is variable, and most patients experience recurrence of hair loss after discontinuation

  3. Topical Janus kinase inhibitors may also be effective but have not been fully evaluated

JAK inhibitors have already demonstrated efficacy in multiple inflammatory diseases, such as psoriasis, rheumatoid arthritis, and vitiligo,

Future directions

Key point

  1. Existing medications are being evaluated for their utility in AA

Statins may have antiinflammatory properties,57 and recently 40 mg/10 mg daily simvastatin/ezetimibe for 24 weeks was investigated in patients with AA (40-70% scalp involvement). Of the 19 patients who completed the study, 14 were considered responders, suggesting that this treatment method should be explored in future studies.58 Apremilast, an oral phosphodiesterase-4 inhibitor, has been shown to prevent AA development in human

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    Funding sources: None.

    Dr Shapiro is a consultant for Aclaris Therapeutics, Applied Biology, Incyte, Replicel Life Sciences, and Samumed. Dr Christiano is a consultant for Aclaris Therapeutics and a principal investigator for Pfizer. The other authors have no conflicts of interest to declare.

    Ms Strazzulla and Dr Wang contributed equally to this article.

    Date of release: January 2018

    Expiration date: January 2021

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