Placebo-controlled oral pulse prednisolone therapy in alopecia areata

Epidemiology, Treatment Patterns, and Healthcare Resource Utilization Study of Patients With Alopecia Areata in Taiwan's National Health Insurance Research Database

OBJECTIVES

This study investigated the epidemiology, treatment patterns, and resource utilization in patients with alopecia areata (AA) in Taiwan using the National Health Insurance Research Database. AA severity was determined by treatment use and diagnostic codes in the year after enrollment (including corticosteroids, systemic immunosuppressants, topical immunotherapy, and phototherapy).

METHODS

The cross-sectional analysis was conducted to estimate the incidence and prevalence of AA from 2016 to 2020. For the longitudinal analysis, 2 cohorts were identified: mild/moderate and severe. The cohorts were matched based on age, gender, and comorbidities. Patients were enrolled upon their first claim with an AA diagnosis during the index period of 2017-2018.

RESULTS

The number of patients with AA increased from 3221 in 2016 to 3855 in 2020. The longitudinal analysis identified 1808 mild/moderate patients and 452 severe patients. Mild/moderate patients used higher levels of topical corticosteroids (82.41%) than severe patients (73.45%). Conversely, severe patients used more topical nonsteroids (41.81%) and systemic therapies (51.77%) than mild/moderate patients (0.44% and 16.15%, respectively). Oral glucocorticoids use was higher in severe patients (47.57%) relative to mild/moderate patients (14.88%), whereas the use of injectable forms was similar. The most used systemic immunosuppressants were methotrexate, cyclosporin, and azathioprine. Topical immunotherapy utilization decreased with subsequent treatment lines for severe patients. Treatment persistence at 6 months was low for all treatments. Severe patients had higher annual AA-related outpatient visits than the mild/moderate cohort.

CONCLUSIONS

These findings highlight the need for additional innovations and therapies to address the clinical and economic burden of AA.

Treatment Options for Alopecia Areata in Children and Adolescents

Alopecia areata (AA) lifetime incidence is around 2%, with many patients first experiencing symptoms during childhood. However, ritlecitinib is the only FDA-approved treatment for pediatric patients 12 years and older. This review outlines reported topical, injectable, and oral treatment options for pediatric patients with AA. Clinical studies were obtained via a PubMed search using the following search terms: alopecia areata, areata, universalis, or totalis and medication, therapy, treatment, drug, or management. Only studies with pediatric patients were included in this review. Commonly used therapies, including corticosteroids, methotrexate, and minoxidil, newer promising medications, such as Janus kinase inhibitors, and less frequently used topical and systemic treatments are included. A summary of the drug development pipeline and ongoing interventional clinical trials with pediatric patients is provided. Treatments demonstrate variable efficacy, and many patients require combination therapy for maximal response. More robust clinical data is needed for many of the medications reviewed in order to provide better care for these patients.

Modified platelet rich plasma therapy for alopecia totalis

Alopecia areata (AA) is an autoimmune disease characterized most commonly by patchy nonscarring hair loss which may progress to alopecia totalis which has poor prognosis. Platelet-rich plasma (PRP) therapy along with intralesional triamcinolone acetonide that is modified PRP proved to be beneficial in the case of alopecia totalis and helps in weaning patient off oral immunosuppression.

European expert consensus statement on the systemic treatment of alopecia areata

Alopecia areata is an autoimmune form of non-scarring hair loss. It is usually characterized by limited areas of hair loss. However, the disease may progress to complete scalp and body hair loss (alopecia totalis, alopecia universalis). In patients with alopecia areata hair loss significantly impacts the quality of life. Children and adolescents with alopecia areata often experience bullying, including physical aggression. The disease severity evaluation tools used in clinical practice are: the Severity of Alopecia Tool (SALT) score and the Alopecia Areata Scale (AAS). A SALT score equal to or greater than 20 constitutes a commonly accepted indication for systemic therapy in alopecia areata. When using the AAS, moderate to severe alopecia areata should be considered a medical indication for systemic treatment. Currently, the only two EMA-approved medications for alopecia areata are baricitinib (JAK 1/2 inhibitor) for adults and ritlecitinib (JAK 3/TEC inhibitor) for individuals aged 12 and older. Both are EMA-approved for patients with severe alopecia areata. Other systemic medications used off-label in alopecia areata include glucocorticosteroids, cyclosporine, methotrexate and azathioprine. Oral minoxidil is considered an adjuvant therapy with limited data confirming its possible efficacy. This consensus statement is to outline a systemic treatment algorithm for alopecia areata, indications for systemic treatment, available therapeutic options, their efficacy and safety, as well as the duration of the therapy.

Effectiveness of oral tofacitinib treatment on patients with moderate-to-severe alopecia areata in Iran

INTRODUCTION

Alopecia areata is an inflammatory hair loss and a common autoimmune disease. Conducting treatment studies on alopecia areata is difficult due to unpredictable periods and even spontaneous recovery from the disease. In this study, the effectiveness of tofacitinib in treating alopecia areata was investigated.

MATERIALS AND METHODS

The severity of the disease was evaluated using the Alopecia Severity Tool (SALT), and based on the medical history and patient's documents and photos, the score before and after the treatment was obtained. The patients were prescribed tofacitinib tablets at a dose of 5 mg twice a day for at least 6 months and were followed for a minimum of 18 months.

RESULTS

No side effect was observed in 97.9% of the patients. After 6 months, except for three patients who did not need any maintenance dose, others needed an average daily intake of 7 mg of tofacitinib. After 18 months, the hair loss decreased by 6.45 times compared to the beginning and by 0.5 times compared to the end of 6 months (p < 0.05). In addition, it was found that body hair loss decreased 4 times compared to the beginning and 0.6 times compared to the end of 6 months (p < 0.05). The reduction of nail involvement after 18 months and 6 months was 1.2 times and 0.6, respectively, (p < 0.05).

CONCLUSION

Treatment of alopecia areata with tofacitinib is recommended due to its effectiveness in reducing hair loss on the head, body, and nail involvement with few reversible side effects.

Alopecia areata: review of epidemiology, pathophysiology, current treatments and nanoparticulate delivery system

Alopecia areata (AA) is a kind of alopecia that affects hair follicles and nails. It typically comes with round patches and is a type of nonscarring hair loss. Various therapies are accessible for the management and treatment of AA, including topical, systemic and injectable modalities. It is a very complex type of autoimmune disease and is identified as round patches of hair loss and may occur at any age. This review paper highlights the epidemiology, clinical features, pathogenesis and new treatment options for AA, with a specific emphasis on nanoparticulate drug-delivery systems. By exploring these innovative treatment approaches, researchers aim to enhance the effectiveness and targeted delivery of therapeutic agents, ultimately improving outcomes for individuals living with AA.

Treatments for Moderate-to-Severe Alopecia Areata: A Systematic Narrative Review

Treatments for alopecia areata (AA) have traditionally been prescribed off-label, and there has been no universal agreement on how to best manage the condition. Baricitinib is the first oral selective Janus kinase (JAK) inhibitor approved for the treatment of adults with severe AA. As a better understanding of the evidence supporting the management of AA in clinical practice is needed, we conducted a systematic literature review and subsequent narrative review to describe available evidence pertaining to the efficacy and tolerability of treatments currently recommended for adults with moderate-to-severe forms of AA. From 2557 identified records, a total of 53 records were retained for data extraction: 9 reported data from 7 randomized controlled trials (RCTs) versus placebo, and 44 reported data from unique RCTs with no placebo arm, non-randomized trials, or observational studies. Across drug classes, data were reported heterogeneously, with little consistency of data collection or clinical endpoints used. The most robust evidence was for the JAK inhibitor class, in particular the JAK1/JAK2 inhibitor baricitinib. Five RCTs (three for baricitinib) demonstrated a consistent benefit of JAK inhibitor therapy over placebo across various clinical outcomes in adult patients with at least 50% scalp hair loss. Overall, hair regrowth varied widely for the other drug classes and was generally low for patients with moderate-to-severe AA. Relapses were commonly observed during treatment and upon discontinuation. Adverse effects were generally consistent with the known safety profile of each intervention. The heterogeneity observed prevented the conduct of a network meta-analysis or an indirect comparison of different treatments. We found that the current management of patients with moderate-to-severe AA often relies on the use of treatments that have not been well evaluated in clinical trials. The most robust evidence identified supported the use of baricitinib, and other oral JAK inhibitors, in patients with severe AA.

Treatments for alopecia areata: a network meta-analysis

BACKGROUND

Alopecia areata is an autoimmune disease leading to nonscarring hair loss on the scalp or body. There are different treatments including immunosuppressants, hair growth stimulants, and contact immunotherapy.

OBJECTIVES

To assess the benefits and harms of the treatments for alopecia areata (AA), alopecia totalis (AT), and alopecia universalis (AU) in children and adults.

SEARCH METHODS

The Cochrane Skin Specialised Register, CENTRAL, MEDLINE, Embase, ClinicalTrials.gov and WHO ICTRP were searched up to July 2022.

SELECTION CRITERIA

We included randomised controlled trials (RCTs) that evaluated classical immunosuppressants, biologics, small molecule inhibitors, contact immunotherapy, hair growth stimulants, and other therapies in paediatric and adult populations with AA.

DATA COLLECTION AND ANALYSIS

We used the standard procedures expected by Cochrane including assessment of risks of bias using RoB2 and the certainty of the evidence using GRADE. The primary outcomes were short-term hair regrowth ≥ 75% (between 12 and 26 weeks of follow-up), and incidence of serious adverse events. The secondary outcomes were long-term hair regrowth ≥ 75% (greater than 26 weeks of follow-up) and health-related quality of life. We could not perform a network meta-analysis as very few trials compared the same treatments. We presented direct comparisons and made a narrative description of the findings.

MAIN RESULTS

We included 63 studies that tested 47 different treatments in 4817 randomised participants. All trials used a parallel-group design except one that used a cross-over design. The mean sample size was 78 participants. All trials recruited outpatients from dermatology clinics. Participants were between 2 and 74 years old. The trials included patients with AA (n = 25), AT (n = 1), AU (n = 1), mixed cases (n = 31), and unclear types of alopecia (n = 4). Thirty-three out of 63 studies (52.3%) reported the proportion of participants achieving short-term hair regrowth ≥ 75% (between 12 and 26 weeks). Forty-seven studies (74.6%) reported serious adverse events and only one study (1.5%) reported health-related quality of life. Five studies (7.9%) reported the proportion of participants with long-term hair regrowth ≥ 75% (greater than 26 weeks). Amongst the variety of interventions found, we prioritised some groups of interventions for their relevance to clinical practice: systemic therapies (classical immunosuppressants, biologics, and small molecule inhibitors), and local therapies (intralesional corticosteroids, topical small molecule inhibitors, contact immunotherapy, hair growth stimulants and cryotherapy). Considering only the prioritised interventions, 14 studies from 12 comparisons reported short-term hair regrowth ≥ 75% and 22 studies from 10 comparisons reported serious adverse events (18 reported zero events and 4 reported at least one). One study (1 comparison) reported quality of life, and two studies (1 comparison) reported long-term hair regrowth ≥ 75%. For the main outcome of short-term hair regrowth ≥ 75%, the evidence is very uncertain about the effect of oral prednisolone or cyclosporine versus placebo (RR 4.68, 95% CI 0.57 to 38.27; 79 participants; 2 studies; very low-certainty evidence), intralesional betamethasone or triamcinolone versus placebo (RR 13.84, 95% CI 0.87 to 219.76; 231 participants; 1 study; very low-certainty evidence), oral ruxolitinib versus oral tofacitinib (RR 1.08, 95% CI 0.77 to 1.52; 80 participants; 1 study; very low-certainty evidence), diphencyprone or squaric acid dibutil ester versus placebo (RR 1.16, 95% CI 0.79 to 1.71; 99 participants; 1 study; very-low-certainty evidence), diphencyprone or squaric acid dibutyl ester versus topical minoxidil (RR 1.16, 95% CI 0.79 to 1.71; 99 participants; 1 study; very low-certainty evidence), diphencyprone plus topical minoxidil versus diphencyprone (RR 0.67, 95% CI 0.13 to 3.44; 30 participants; 1 study; very low-certainty evidence), topical minoxidil 1% and 2% versus placebo (RR 2.31, 95% CI 1.34 to 3.96; 202 participants; 2 studies; very low-certainty evidence) and cryotherapy versus fractional CO2 laser (RR 0.31, 95% CI 0.11 to 0.86; 80 participants; 1 study; very low-certainty evidence). The evidence suggests oral betamethasone may increase short-term hair regrowth ≥ 75% compared to prednisolone or azathioprine (RR 1.67, 95% CI 0.96 to 2.88; 80 participants; 2 studies; low-certainty evidence). There may be little to no difference between subcutaneous dupilumab and placebo in short-term hair regrowth ≥ 75% (RR 3.59, 95% CI 0.19 to 66.22; 60 participants; 1 study; low-certainty evidence) as well as between topical ruxolitinib and placebo (RR 5.00, 95% CI 0.25 to 100.89; 78 participants; 1 study; low-certainty evidence). However, baricitinib results in an increase in short-term hair regrowth ≥ 75% when compared to placebo (RR 7.54, 95% CI 3.90 to 14.58; 1200 participants; 2 studies; high-certainty evidence). For the incidence of serious adverse events, the evidence is very uncertain about the effect of topical ruxolitinib versus placebo (RR 0.33, 95% CI 0.01 to 7.94; 78 participants; 1 study; very low-certainty evidence). Baricitinib and apremilast may result in little to no difference in the incidence of serious adverse events versus placebo (RR 1.47, 95% CI 0.60 to 3.60; 1224 participants; 3 studies; low-certainty evidence). The same result is observed for subcutaneous dupilumab compared to placebo (RR 1.54, 95% CI 0.07 to 36.11; 60 participants; 1 study; low-certainty evidence). For health-related quality of life, the evidence is very uncertain about the effect of oral cyclosporine compared to placebo (MD 0.01, 95% CI -0.04 to 0.07; very low-certainty evidence). Baricitinib results in an increase in long-term hair regrowth ≥ 75% compared to placebo (RR 8.49, 95% CI 4.70 to 15.34; 1200 participants; 2 studies; high-certainty evidence). Regarding the risk of bias, the most relevant issues were the lack of details about randomisation and allocation concealment, the limited efforts to keep patients and assessors unaware of the assigned intervention, and losses to follow-up.

AUTHORS' CONCLUSIONS

We found that treatment with baricitinib results in an increase in short- and long-term hair regrowth compared to placebo. Although we found inconclusive results for the risk of serious adverse effects with baricitinib, the reported small incidence of serious adverse events in the baricitinib arm should be balanced with the expected benefits. We also found that the impact of other treatments on hair regrowth is very uncertain. Evidence for health-related quality of life is still scant.

The Efficacy and Adverse Effects of Corticosteroid Pulse Therapy in Alopecia Areata: A Review Article

INTRODUCTION

Alopecia areata (AA) is a common, non-scarring, autoimmune hair loss disorder, varying in severity from small round hairless patches to the total loss of scalp or body hair. As steroid pulse therapy outcomes for AA vary, this study aimed to review the related literature regarding the efficacy, relapse rates, side effects, and prognostic factors associated with the response to different pulse corticosteroid treatments.

METHODS

We performed a literature search on August 29, 2022, to provide an overview of the efficacy of pulse steroid therapy in patients with AA. The terms "pulse steroid therapy AND alopecia areata" and "pulse corticosteroid therapy AND alopecia areata" were searched on PubMed and Google Scholar.

RESULTS

A total of 24 articles were assessed. There was no difference in outcomes and side effects between intravenous and oral pulse corticosteroid therapy. The relapse rate and efficacy depended on the time of AA onset, age, and AA type: improved outcomes and decreased relapse were linked with recent onset (<6 months), a younger age (<10 years), and the multifocal type of AA. Patients with a past medical history of atopy, nail pitting, or thyroid disease and those with severe forms of AA like alopecia totalis and alopecia universalis had the least improvement.

CONCLUSIONS

All kinds of mentioned systemic pulse corticosteroids effectively induce hair regrowth in AA. Betamethasone pulse seems to be the most effective agent (followed by intramuscular triamcinolone), especially in severe cases, but more side effects may accompany it. Combining this agent with other medications can reduce the dosage and side effects. Pulses of prednisolone and methylprednisolone are less effective but safer, as they have low relapse rates and adverse effects. A combination of them with other drugs can increase their efficacy.

Guidelines for the Management of Patients with Alopecia Areata in Korea: Part II Systemic Treatment

BACKGROUND

Alopecia areata (AA) is a chronic disease with an unpredictable course and can have a severe psychological impact on an individual.

OBJECTIVE

To provide evidence and consensus-based statements regarding the treatment of patients with AA in Korea.

METHODS

We searched for relevant studies from inception to May 2021 regarding the systemic treatment of AA. Evidence-based recommendations were also prepared. The evidence for each statement was graded and classified according to the strength of the recommendations. Hair experts from the Korean Hair Research Society (KHRS) voted on the statement, and an agreement of 75% or greater was considered as having reached consensus.

RESULTS

Current evidence supports the efficacy of systemic corticosteroids, oral cyclosporine monotherapy or combination with systemic corticosteroids, and oral Janus kinase inhibitors in severe AA patients. Systemic steroids may be considered for pediatric patients with severe AA. A consensus was achieved in three out of nine (33.3%), and one out of three (33.3%) statements pertaining to systemic treatment in adult and pediatric AA, respectively.

CONCLUSION

The present study produced up-to-date, evidence-based treatment guidelines for AA associated with the consensus obtained by experts based on the Korean healthcare system.

Efficacy of Methotrexate Alone vs Methotrexate Plus Low-Dose Prednisone in Patients With Alopecia Areata Totalis or Universalis: A 2-Step Double-Blind Randomized Clinical Trial

Importance

Poor therapeutic results have been reported in patients with alopecia areata totalis (AT) or universalis (AU), the most severe and disabling types of alopecia areata (AA). Methotrexate, an inexpensive treatment, might be effective in AU and AT.

Objective

To evaluate the efficacy and tolerance of methotrexate alone or combined with low-dose prednisone in patients with chronic and recalcitrant AT and AU.

Design, Setting, and Participants

This academic, multicenter, double-blind, randomized clinical trial was conducted at 8 dermatology departments at university hospitals between March 2014 and December 2016 and included adult patients with AT or AU evolving for more than 6 months despite previous topical and systemic treatments. Data analysis was performed from October 2018 to June 2019.

Interventions

Patients were randomized to receive methotrexate (25 mg/wk) or placebo for 6 months. Patients with greater than 25% hair regrowth (HR) at month 6 continued their treatment until month 12. Patients with less than 25% HR were rerandomized: methotrexate plus prednisone (20 mg/d for 3 months and 15 mg/d for 3 months) or methotrexate plus placebo of prednisone.

Main Outcome and Measures

The primary end point assessed on photos by 4 international experts was complete or almost complete HR (Severity of Alopecia Tool [SALT] score <10) at month 12, while receiving methotrexate alone from the start of the study. Main secondary end points were the rate of major (greater than 50%) HR, quality of life, and treatment tolerance.

Results

A total of 89 patients (50 female, 39 male; mean [SD] age, 38.6 [14.3] years) with AT (n = 1) or AU (n = 88) were randomized: methotrexate (n = 45) or placebo (n = 44). At month 12, complete or almost complete HR (SALT score <10) was observed in 1 patient and no patient who received methotrexate alone or placebo, respectively, in 7 of 35 (20.0%; 95% CI, 8.4%-37.0%) patients who received methotrexate (for 6 or 12 months) plus prednisone, including 5 of 16 (31.2%; 95% CI, 11.0%-58.7%) who received methotrexate for 12 months and prednisone for 6 months. A greater improvement in quality of life was observed in patients who achieved a complete response compared with nonresponder patients. Two patients in the methotrexate group discontinued the study because of fatigue and nausea, which were observed in 7 (6.9%) and 14 (13.7%) patients receiving methotrexate, respectively. No severe treatment adverse effect was observed.

Conclusions and Relevance

In this randomized clinical trial, while methotrexate alone mainly allowed partial HR in patients with chronic AT or AU, its combination with low-dose prednisone allowed complete HR in up to 31% of patients. These results seem to be of the same order of magnitude as those recently reported with JAK inhibitors, with a much lower cost.

Trial Registration

ClinicalTrials.gov Identifier: NCT02037191.

Unmet Medical Needs in Chronic, Non-communicable Inflammatory Skin Diseases

An estimated 20-25% of the population is affected by chronic, non-communicable inflammatory skin diseases. Chronic skin inflammation has many causes. Among the most frequent chronic inflammatory skin diseases are atopic dermatitis, psoriasis, urticaria, lichen planus, and hidradenitis suppurativa, driven by a complex interplay of genetics and environmental factors. Autoimmunity is another important cause of chronic skin inflammation. The autoimmune response may be mainly T cell driven, such as in alopecia areata or vitiligo, or B cell driven in chronic spontaneous urticaria, pemphigus and pemphigoid diseases. Rare causes of chronic skin inflammation are autoinflammatory diseases, or rheumatic diseases, such as cutaneous lupus erythematosus or dermatomyositis. Whilst we have seen a significant improvement in diagnosis and treatment, several challenges remain. Especially for rarer causes of chronic skin inflammation, early diagnosis is often missed because of low awareness and lack of diagnostics. Systemic immunosuppression is the treatment of choice for almost all of these diseases. Adverse events due to immunosuppression, insufficient therapeutic responses and relapses remain a challenge. For atopic dermatitis and psoriasis, a broad spectrum of innovative treatments has been developed. However, treatment responses cannot be predicted so far. Hence, development of (bio)markers allowing selection of specific medications for individual patients is needed. Given the encouraging developments during the past years, we envision that many of these challenges in the diagnosis and treatment of chronic inflammatory skin diseases will be thoroughly addressed in the future.

Oral Tofacitinib and Systemic Corticosteroids, Alone or in Combination, in Patients With Moderate-to-Severe Alopecia Areata: A Retrospective Study

Introduction

Alopecia areata (AA) is an autoimmune hair loss mediated by CD8 + T cells. Treatment for moderate-to-severe AA is still challenging. Janus kinase inhibitors, such as tofacitinib, have been recently investigated as a promising treatment option for AA. Evidence on the combination use of oral tofacitinib and systemic corticosteroids (SCs) for AA is still lacking.

Objective

To compare the efficacy and safety of monotherapy of oral tofacitinib and SCs, as well as their combination in patients with moderate-to-severe AA.

Methods

Patients with moderate-to-severe AA, who have been treated with at least 3 months of monotherapy of tofacitinib or SCs, or in their combination, were included in this study. The efficacy and adverse events of these treatments were retrospectively analyzed.

Results

Sixty-one patients with moderate-to-severe AA were included in this study. There were 12 (66.7%) of 18 patients in the SCs group, 12 (60.0%) of 20 patients in the tofacitinib group, and 18 (78.3%) of 23 patients achieved SALT50, with no significant difference among the three groups. The ratio of patients who achieved SALT50 was significantly higher in patients with a short duration of current hair loss episode (≤2 years) than in those with a duration of current hair loss episode (&gt;2 years) in all the three groups. There were 66.7% patients in the SCs group, 35.0% patients in the tofacitinib group, and 56.5% patients in the combined group that showed adverse effects.

Conclusion

Tofacitinib was an effective treatment for patients with moderate-to-severe AA, and it was more tolerated than SCs. A combination of tofacitinib and SCs may have higher efficacy than SCs alone. Efficacy significantly decreased in patients with a current episode of disease for more than 2 years.

The effect of latanoprost 0.005% solution in the management of scalp alopecia areata, a randomized double-blind placebo-controlled trial

BACKGROUND

Alopecia areata (AA) is a recurrent chronic disease that affects hair follicles and results in hair loss. Make an increase in the number, thickness, and length of eyelashes is an important side effect of latanoprost eye drop.

OBJECTIVE

This study aimed to evaluate the effect of hypertrichosis property of latanoprost in the treatment of scalp AA.

METHODS

In this randomized double-blind placebo-controlled trial, thirty participants with scalp AA assigned to receive either topical latanoprost 0.005% solution or placebo for 12 weeks. In both arms, patients also received clobetasol 0.05% cream in isopropyl alcohol (1:1). The hair loss area pictured at baseline and the end of the fourth, eighth, and twelfth weeks. According to the images, the dermatologist assessed the hair loss area, hair density, and the severity of alopecia.

RESULTS

Latanoprost significantly increased hair density (37.2± 26.1 vs. 14.6 ± 18.6) and regrowth (58.3 ± 39.3 vs. 21.6 ± 24.1) based on the Severity of Alopecia Tool (SALT) system compared to the control group (P=0.03 and 0.02, respectively). However, there were no significant differences between the two groups in reduction in the hair loss area and SALT, and the incidence of side effects (P=0.718, 0.262, and ≥0.99, respectively).

CONCLUSION

Results showed the acceptable safety and efficacy of latanoprost 0.005% solution to increase hair density and regrowth. So, it could be safely used for the management of scalp AA. This article is protected by copyright. All rights reserved.

Alopecia areata - Current understanding and management

Alopecia areata (AA) is a chronic, immune-mediated disease characterized by acute or chronic non-scarring hair loss, with a heterogeneity in clinical manifestations ranging from patchy hair loss to complete scalp and body hair loss. An overview of the up-to-date pathophysiology and the underlying signaling pathways involved in AA together with diagnostic and therapeutic recommendations will be provided. Current treatments, including topical, systemic and injectable interventions show varying response and frequent relapses reflecting the unmet clinical need. Thus, the new emerging concepts and therapeutic approaches, including Janus kinase inhibitors are eagerly awaited. Traditional and emerging therapies of AA will be discussed, in order to provide physicians with guidance for AA management. Since the latter is so challenging and often tends to take a chronic course, it can have an enormous psychosocial burden on patients, compromising their quality of life and often causing depression and anxiety. Therefore, the psychosocial aspects of the disease need to be evaluated and addressed, in order to implement appropriate psychological support when needed.

A Retrospective Study on Alopecia Areata in Children: Clinical Characteristics and Treatment Choices

Background

Although children are affected frequently with alopecia areata (AA), data are limited on clinical characteristics and treatment choices.

Materials and Methods

We retrospectively reviewed the records of the pediatric dermatology department over a 12-year period to identify children with AA. Clinical data were collected.

Results

Three hundred and sixty-four children with AA were identified, aged 1-12 years, 214 males and 150 females. The mean age of onset was 6.6 years (±3.3). The disease presented with patches on the scalp in the majority (90.7%), whereas only 6 children had alopecia totalis or universalis. The most commonly prescribed treatment was topical steroids (69.1%), followed by the combination of topical steroids and minoxidil 2% (14.3%). Oral steroids were prescribed in only 16 children. Follow-up at 3 months was available for only 70 children and the majority (84.3%) had some hair regrowth. Hair regrowth was unrelated to the number of plaques (p = 0.257), disease location (p = 0.302), and atopy (p = 0.999). Hair regrowth only correlated with the type of treatment (p = 0.003) with potent topical and intralesional steroids giving the best results.

Conclusion

AA usually presents with a mild form in children, and potent topical steroids are the mainstay of treatment.

Potential of nanoparticulate based delivery systems for effective management of alopecia

In recent times, more than 50 % of the global population is facing hair-related issues (alopecia) which is seen mostly amongst the people in the age group of 30-40 years. The conventional topical dosage forms available in the market falls short in effectively managing alopecia. Despite various advancements in topical dosage forms, it is still disposed to limited clinical application and provides poor penetration of drug molecules into the skin. The exact etiology of alopecia is still unknown and various researchers link lifestyle, hereditary, and auto immune-based events with its existence. Nanoparticulate-based delivery are hence brought in use to enhance the permeability properties of the drug. In comparison to conventional methods nanotechnology-based drug delivery system tames drug molecules to a specific site with much better efficacy. This review is engrossed in the journey and role of nano technological-based drug delivery in the management of alopecia and its clinical application.

Oral Pulse Betamethasone, Methotrexate, and Combination Therapy to Treat Severe Alopecia Areata: A Randomized, Double-blind, Placebo-controlled, Clinical Trial

The purpose of this study is to compare oral betamethasone pulse therapy, methotrexate therapy and a combination of the two for patients with Alopecia Areata (AA) as an autoimmune disorder. In this study, 36 patients with severe AA were selected and classified into three groups of 12: 1- Oral betamethasone therapy (3 mg, once a week) with placebo; 2- Oral methotrexate (15 mg, once a week) with placebo; and 3- A combination of methotrexate (15 mg, once a week) and betamethasone (3 mg, once a week). The Severity Alopecia Tool (SALT) was used to measure improvements in the lesions through photographs, and the patients also rated their condition on the Visual Analogue Scale (VAS). Assessments were performed, and the results were compared at baseline and then at intervals of three months for nine months. The demographics and SALT score were similar in the three groups (P > 0.05). All the groups showed improvements in SALT, VAS and photographic scores three months after beginning the treatment (P < 0.001). Betamethasone therapy (P = 0.006) and combination therapy (P < 0.001) provided greater SALT improvement than methotrexate, and combination therapy led to a greater improvement in VAS and photographic findings compared to the two other groups (P < 0.05). Oral steroid, methotrexate and combination pulse therapy were effective treatments for AA, while oral steroid pulse therapy and combination therapy were superior to methotrexate.

Alopecia Areata: an Update on Etiopathogenesis, Diagnosis, and Management

Alopecia areata (AA) is a common chronic tissue-specific autoimmune disease, resulting in hair loss, that affects up to 2% of the general population. The exact pathobiology of AA has still remained elusive, while the common theory is the collapse of the immune privilege of the hair follicle caused by immunological mechanism. Multiple genetic and environment factors contribute to the pathogenesis of AA. There are several clinical treatments for AA, varying from one or multiple well-defined patches to more diffuse or total hair loss of the scalp (alopecia totalis) or hair loss of the entire body (alopecia universalis). The available treatments for AA, such as corticosteroids and other immunomodulators, minoxidil, and contact immunotherapy, are of limited efficacy with a high risk of adverse effects and high recurrence rates, especially for patients with severe AA. Recent insights into the pathogenesis of AA have led to the development of new treatment strategies, such as Janus kinase (JAK) inhibitors, biologics, and several small molecular agents. In addition, modern therapies for AA, including antihistamines, platelet-rich plasma (PRP) injection, and other novel therapies have been well explored. In this review, we discussed the recent advances in the pathogenesis, diagnosis, and treatment of AA.

Oral Methotrexate Monotherapy for Severe Alopecia Areata: A Single Center Retrospective Case Series

BACKGROUND

Although several therapeutic options have been suggested for alopecia areata (AA), none of them are consistently effective, thus making the management of severe or refractory cases challenging. Several studies have recently reported the usage of methotrexate (MTX) in AA; however, the pure effect of MTX monotherapy remains elusive.

OBJECTIVE

To evaluate efficacy and safety of oral methotrexate monotherapy for AA.

METHODS

We retrospectively reviewed the clinical course of AA patients including pediatric cases treated with MTX monotherapy. Their detailed clinical data including original severity of AA, final treatment outcome, the duration until the maximum response, and side effects, were assessed. Statistical analysis was performed to evaluate if the clinical factors including the duration of current alopecia, age, the presence of body hair loss, and sex were associated with treatment response.

RESULTS

All included patients had severe AA and failed standard therapies. Thirteen out of 15 cases demonstrated improvement during the monotherapy, and all responders demonstrated the maximum response within 1 year. Female patients had significantly better outcomes than male patients. Other factors did not significantly influence on the treatment outcome. None of the patients experienced side effects that were severe enough to terminate the treatment.

CONCLUSIONS

Our results support MTX monotherapy as a feasible option for severe AA patients who fail other standard therapies or for whom systemic corticosteroids are contraindicated.

Treatments for alopecia areata: A systematic review and network meta-analysis

Existing guidelines form no consensus for alopecia areata (AA) treatment due to the absence of a universal standard treatment and arbitrary selection of reference arms in randomized control trials (RCTs). The aim is to identify the best treatment and to rank treatments using systematic review and network meta-analysis. Data were extracted by the two investigators independently. Odds ratio (OR) of treatment success rate was pooled using the frequentist weighted least squares approach to random-model network meta-analysis. RCTs providing data of treatment success rate from PubMed, EMBASE, Web of Science, and manual search were included. About 54 RCTs consisting of 49 treatments and 3149 patients were included. Pentoxifylline plus topical corticosteroids had the highest treatment success rate compared with "no treatment," followed by pentoxifylline alone, topical calcipotriol plus narrowband ultraviolet radiation B phototherapy, topical calcipotriol, intralesional corticosteroids, systemic corticosteroids, minoxidil plus topical corticosteroids, topical bimatoprost, psoralen ultraviolet radiation A phototherapy, and tofacitinib. Even with the network meta-analysis, the best treatment because of independent loops and wide confidence intervals could not be identified. Treatment options above may be reasonable strategies, but further comparison is required.

Consensus on the treatment of alopecia areata - Brazilian Society of Dermatology

BACKGROUND

Alopecia areata is a highly frequent disease with an impact on quality of life and several treatment options with little clinical confirmatory evidence.

OBJECTIVE

To disseminate the recommendations of Brazilian dermatologists with expertise in the treatment of alopecia areata.

METHODS

Eight specialists with expertise in alopecia areata from different university centers were appointed by the Brazilian Society of Dermatology to reach a consensus on its treatment. Based on the adapted DELPHI methodology, the relevant elements were considered; then, an analysis of recent literature was carried out and the consensus was written down. Consensus on the management of alopecia areata was defined with the approval of at least 70% of the panel.

RESULTS/CONCLUSIONS

Intralesional injectable corticotherapy was considered the first option for localized disease in adults. In extensive cases with signs of activity, systemic corticosteroid therapy should be considered and can be used together with immunosuppressants (corticosteroid-sparing agents). The use of an immunosensitizer (diphencyprone) is an option for stable long-term cases. Evaluation of side effects is as important as the rate of hair regrowth.

Infection risk of dermatologic therapeutics during the COVID-19 pandemic: an evidence-based recalibration

Recommendations were made recently to limit or stop the use of oral and systemic immunotherapies for skin diseases due to potential risks to the patients during the current severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2) COVID-19 pandemic. Herein, we attempt to identify potentially safe immunotherapies that may be used in the treatment of cutaneous diseases during the current COVID-19 pandemic. We performed a literature review to approximate the risk of SARS-CoV-2 infection, including available data on the roles of relevant cytokines, cell subsets, and their mediators in eliciting an optimal immune response against respiratory viruses in murine gene deletion models and humans with congenital deficiencies were reviewed for viral infections risk and if possible coronaviruses specifically. Furthermore, reported risk of infections of biologic and non-biologic therapeutics for skin diseases from clinical trials and drug data registries were evaluated. Many of the immunotherapies used in dermatology have data to support their safe use during the COVID-19 pandemic including the biologics that target IgE, IL-4/13, TNF-α, IL-17, IL-12, and IL-23. Furthermore, we provide evidence to show that oral immunosuppressive medications such as methotrexate and cyclosporine do not significantly increase the risk to patients. Most biologic and conventional immunotherapies, based on doses and indications in dermatology, do not appear to increase risk of viral susceptibility and are most likely safe for use during the COVID-19 pandemic. The limitation of this study is availability of data on COVID-19.

Platelet-Rich Plasma and its Use for Cicatricial and Non-Cicatricial Alopecias: A Narrative Review

The concept and description of platelet-rich plasma (PRP) started in the field of hematology and is being extensively used in other fields of medicine. Interest in the application of PRP has been increasing in dermatology, such as in tissue regeneration, wound healing, scar revision, skin-rejuvenating effects, and alopecia. PRP is an autologous blood product containing high concentrations of platelets in a small volume of plasma. Different preparations of PRP may lead to different volumes of PRP, platelet concentration, and presence or absence of leukocytes. PRP is being used as a new therapy for some types of non-cicatricial alopecia such as androgenetic alopecia (AGA) and alopecia areata (AA) and, recently, new insights refer to the possibility of action in the field of cicatricial alopecia, like lichen planopillaris (LPP) and frontal fibrosing alopecia (FFA). This article aims to identify the major indications for the application of PRP in the field of hair disorders, including non-cicatricial and cicatricial alopecia.

Childhood Alopecia Areata: An Overview of Treatment and Recent Patents

BACKGROUND

Alopecia Areata (AA) is a systemic autoimmune condition that usually starts in childhood.

OBJECTIVE

This article aims to review genetics, therapy, prognosis, and recent patents for AA.

METHODS

We used clinical queries and keywords "alopecia areata" AND "childhood" as a search engine. Patents were searched using the key term "alopecia areata" in Patents.google.com and freepatentsonline. com.

RESULTS

Due to an immune-mediated damage to the hair follicles, hair is lost from the scalp and other areas of the body temporarily or even permanently. Children with AA are generally healthy. Evidence of genetic association and increased predisposition for AA was found by studying families with affected members. Pathophysiologically, T- lymphocytes attack hair follicles and cause inflammation and destruction of the hair follicles and hair loss. In mild cases, there would be well-demarcated round patchy scalp hair loss. The pathognomonic "exclamation mark hairs" may be seen at the lesion periphery. In more severe cases, the hair loss may affect the whole scalp and even the whole body. The clinical course is also variable, which may range from transient episodes of recurrent patchy hair loss to an indolent gradually deteriorating severe hair loss. The treatment of AA depends on factors including patients' age, the extent of the hair loss, duration of disease, psychological impact, availability and side effect profile of the treatments. For localized patchy alopecia, topical application of corticosteroids and/or intralesional corticosteroids are the treatment of choice. Other topical treatments include minoxidil, anthralin, coal tar and immunotherapy. In severe resistant cases, systemic immunosuppressants may be considered. Although herbal medicine, acupuncture, complementary and alternative medicine may be tried on children in some Asian communities, the evidence to support these practices is lacking. To date, only a few recent patents exist in topical treatments, including Il-31, laser and herbal medications. Clinical efficacy is pending for these treatment modalities.

CONCLUSION

None of the established therapeutic options are curative. However, newer treatment modalities, including excimer laser, interleukin-31 antibodies and biologics, are evolving so that there may be significant advances in treatment in the near future. AA can be psychosocially devastating. It is important to assess the quality of life, degree of anxiety, social phobia and mood of the patients and their families. Psychological support is imperative for those who are adversely affected psychosocially.

Italian Guidelines in diagnosis and treatment of alopecia areata

Alopecia areata (AA) is an organ-specific autoimmune disorder that targets anagen phase hair follicles. The course is unpredictable and current available treatments have variable efficacy. Nowadays, there is relatively little evidence on treatment of AA from well-designed clinical trials. Moreover, none of the treatments or devices commonly used to treat AA are specifically approved by the Food and Drug Administration. The Italian Study Group for Cutaneous Annexial Disease of the Italian Society of dermatology proposes these Italian guidelines for diagnosis and treatment of Alopecia Areata deeming useful for the daily management of the disease. This article summarizes evidence-based treatment associated with expert-based recommendations.

Sequential high- and low-dose systemic corticosteroid therapy for severe childhood alopecia areata

BACKGROUND

Given the limited number of therapeutic options, severe childhood alopecia areata (AA) poses a clinical challenge. The best and most rapid response rates can be achieved with high-dose systemic corticosteroids, however, relapse following treatment discontinuation is inevitable. Due to systemic side effects, long-term high-dose corticosteroid regimens are not feasible. Following initial pulse therapy, continuation of corticosteroid therapy at a dose below the Cushing threshold might be able to suppress disease activity without causing severe side effects.

PATIENTS AND METHODS

Thirteen children with severe AA were enrolled in our open observational study. Seven had alopecia totalis or universalis; the remaining six children had multifocal alopecia affecting more than 50 % of the scalp. The treatment regimen consisted of initial pulse therapy with prednisolone 2 mg/kg PO, which was subsequently tapered to a maintenance dose below the individual Cushing threshold within nine weeks. Children were followed-up for one to three years.

RESULTS

Sixty-two percent of individuals showed complete hair regrowth. The mean time to response was 6.6 weeks. Said response was sustained with maintenance therapy for the entire follow-up period. Noticeable side effects included weight gain (1-3 kg), which was observed in all children, and mild steroid acne in 23 % of cases.

CONCLUSIONS

Sequential high- and low-dose prednisolone therapy is an effective and safe therapeutic option for childhood AA.

Weekly Azathioprine Pulse versus Betamethasone Oral Mini-Pulse in the Treatment of Moderate-to-Severe Alopecia Areata

Background:

Corticosteroids are the most common agents used in the treatment of alopecia areata (AA), however, their long-term use is associated with severe side effects. Therefore, other immunosuppressive agents have been tried and azathioprine appears to be an effective and promising alternative.

Objective:

The main objective of this study was to compare the efficacy of 300 mg once weekly azathioprine pulse (WAP) and 5 mg betamethasone on 2 consecutive days every week in the management of AA.

Materials and Methods:

In this open-label, randomized comparative study, 50 patients of AA with >10% scalp area involvement were treated with either 300 mg WAP or 5 mg betamethasone on 2 consecutive days every week for 4 months or till complete scalp hair regrowth and followed up for next 5 months. Primary efficacy parameters were average percentage scalp hair regrowth and change in average Severity of Alopecia Tool (SALT) score at 4 months.

Results:

Twenty patients in WAP group and 21 patients in betamethasone group completed the study. The median percent scalp hair regrowth and the median change in SALT score was 44.52 and 9.5 in WAP group compared to 71.43 and 14 in betamethasone group at 4-month, respectively, which were statistically similar in two groups, however, side effects were significantly higher in betamethasone group. On further follow-up at 9 months, 10 (50%) patients in WAP group and 13 (62%) patients in betamethasone group achieved complete hair regrowth. Lack of control group was a limitation of our study.

Conclusion:

WAP and betamethasone therapy, both appear to be effective in the treatment of AA. However, betamethasone caused several side effects; therefore, WAP can be used as a better alternative to corticosteroids in AA.

Randomized controlled trial on a PRP-like cosmetic, biomimetic peptides based, for the treatment of alopecia areata

Background: Alopecia areata (AA) is a non-scarring auto-immune hair disorder. Recent researches explained the role of growth factors (GFs) in hair follicle cycling. The main reservoir of GFs are alpha-granules of platelets and novel procedures have been implemented aimed at collecting platelet-rich plasma (PRP). PRP has been safely implemented in many medical applications and has also been successfully used as alternative cell-based therapy for the treatment of hair growth disorders, among which also AA. Objectives: By means of a randomized double-blinded, placebo and active-controlled, parallel group study we have studied the efficacy of a cosmetic product (named TR-M-PRP plus) comprising biomimetic peptides specific for hair growth, mimicking PRP composition for the treatment of AA. Subjects were treated for three months and evaluated, at the end of the study and after one month of follow-up, as regards hair growth using SALT score. Results: TR-M-PRP plus-like topic produced a statistically significant (p < .001) clinical improvement in SALT score after 3 months of therapy, compared to baseline. Hair growth results further improved after 1 month of follow-up. Conclusions: This clinical investigation suggests that the biotechnological designed PRP-like cosmetic could represent a valid and safer alternative to autologous PRP for the treatment of AA.

Alteration of serum and tissue tumor necrosis factor alpha levels: A possible mechanism of action of oral pulse steroids in the treatment of alopecia areata

BACKGROUND

Alopecia areata (AA) is a multifactorial disease in which tumor necrosis factor alpha (TNF-α) plays an important role.

OBJECTIVE

To study the effect of oral pulse steroids on both serum and tissue levels of TNF-α in AA patients.

METHODS

Skin biopsies and serum samples were collected from 20 patients with patchy AA before and after treatment (oral prednisolone for two consecutive days every week for 3 months) for determination of the levels of TNF-α levels using ELISA technique.

RESULTS

Both serum and tissue levels of TNF-α in AA patients were significantly higher than in controls before (P < 0.001) as well as after treatment (P = 0.0169 and P = 0.3051), respectively. The duration of disease negatively correlated with tissue TNF-α before treatment (P < 0.0001). Serum and tissue levels of TNF-α dropped significantly after treatment (P < 0.0001). The percentage of reduction of both tissue and serum TNF-α levels correlated positively with the percentage of clinical improvement (r = 0.682, P = 0.0009; r = 0.567, P = 0.009, respectively).

CONCLUSION

TNF-α plays an important role in the evolution of AA lesions, and alteration in both serum and tissue levels of TNF-α could be considered one of the important mechanisms of action of systemic oral pulse steroids in the treatment of AA.

Alopecia Areata: a Comprehensive Review of Pathogenesis and Management

Alopecia areata is a common hair loss condition that is characterized by acute onset of non-scarring hair loss in usually sharply defined areas ranging from small patches to extensive or less frequently diffuse involvement. Depending on its acuity and extent, hair loss is an important cause of anxiety and disability. The current understanding is that the condition represents an organ-specific autoimmune disease of the hair follicle with a genetic background. Genome-wide association studies provide evidence for the involvement of both innate and acquired immunity in the pathogenesis, and mechanistic studies in mouse models of alopecia areata have specifically implicated an IFN-γ-driven immune response, including IFNγ, IFNγ-induced chemokines and cytotoxic CD8 T cells as the main drivers of disease pathogenesis. A meta-analysis of published trials on treatment of alopecia areata states that only few treatments have been well evaluated in randomized trials. Nevertheless, depending on patient age, affected surface area and disease duration, an empiric treatment algorithm can be designed with corticosteroids and topical immunotherapy remaining the mainstay of therapy. The obviously limited success of evidence-based therapies points to a more important complexity of hair loss. At the same time, the complexity of pathogenesis offers opportunities for the development of novel targeted therapies. New treatment opportunities based on the results of genome-wide association studies that implicate T cell and natural killer cell activation pathways are paving the way to new approaches in future clinical trials. Currently, there are ongoing studies with the CTLA4-Ig fusion protein abatacept, anti-IL15Rβ monoclonal antibodies and the Janus kinase inhibitors tofacitinib, ruxolitinib and baricitinib. Ultimately, the options available for adapting to the disease rather than treating it in an effort to cure may also be taken into consideration in selected cases of long-standing or recurrent small spot disease.

Alopecia areata treated with hydroxychloroquine: A retrospective study of nine pediatric cases

BACKGROUND/OBJECTIVES

Alopecia areata is a common hair loss condition that is often emotionally devastating for patients. There is a paucity of effective treatments available. Hydroxychloroquine has been reported as variably effective in inducing significant hair regrowth in adults with alopecia areata. The objective of this retrospective study was to assess the benefit and tolerability of hydroxychloroquine in pediatric alopecia areata.

METHODS

We conducted a retrospective review of nine children with a history of alopecia areata treated with hydroxychloroquine. Clinical data were obtained from patients treated at two tertiary care centers in the United States between July 1, 2013, and July 1, 2015.

RESULTS

Alopecia scores of five patients improved by 6 months of treatment. Four patients experienced no improvement from baseline evaluation. The most common side effect associated with treatment was gastrointestinal intolerance and headache.

CONCLUSION

This retrospective series suggests that hydroxychloroquine can be considered as a treatment option for alopecia areata in children.

A Comment on JAK Inhibitors for Treatment of Alopecia Areata

A meta-analysis of published trials on the treatment of alopecia areata (AA) came to the conclusion that most have been reported poorly and so small that any important clinical benefits are inconclusive, and considering the possibility of spontaneous remission, especially for those in the early stages of the disease, the options of not being treated or depending on individual preference, and of wearing a wig may be alternative ways of dealing with the condition. And yet, from clinical practice, we know that depending on patient age, surface area, disease duration, and comorbidities an empiric treatment algorithm can be designed that is successful in a significant proportion of patients. More recently, it has been suggested that Janus kinase (JAK) inhibitors may represent the drug of choice for AA, based on robust scientific background and preliminary clinical study results. The fact is that a sophisticated treatment of AA cannot be reduced to one drug, while in many patients, depending on disease duration and surface area, either intravenous methylprednisolone pulse therapy, intralesional triamcinolone acetonide or subcutaneous methotrexate will achieve remission rates in the range of the efficacy of the JAK inhibitors. Moreover, at this time point, affordability of the JAK inhibitors for long-term treatment, sustainability of treatment result, and long-term safety are major issues with regard to the treatment of AA with JAK inhibitors.

Alopecia Areata: An Update on Treatment Options for Children

Pediatric alopecia areata is a spectrum of autoimmune non-scarring alopecia in which some patients lose small patches of hair from their scalp but others lose more or all of the hair from the scalp and body, including eyebrows and eyelashes. Few studies have looked at therapies for this disorder in children, so much of the data are derived from adult literature and describe off-label use of medication. Generally, topical therapies consisting of topical steroids and topical irritating compounds/contact sensitizers are used. Systemic therapies that block the immune system, including Janus kinase (JAK) inhibitors, have also been used in this disease. This paper reviews the data on therapy for alopecia areata in pediatric patients.

Low-Dose Systemic Methotrexate Therapy for Recalcitrant Alopecia Areata

Background

Alopecia areata (AA) is an autoimmune skin disease difficult to manage and treat. The pathogenesis of AA features a T-cell-associated autoimmune process, and systemic immunosuppressive therapy is prescribed widely for AA.

Objective

To evaluate the efficacy and tolerance of systemic low-dose methotrexate (LD-MTX) therapy in treatment of recalcitrant AA multiplex.

Methods

In a retrospective, non-controlled study, we evaluated 29 patients with recalcitrant AA treated with LD-MTX and assessed the therapeutic response according to severity of disease, disease duration, cumulative dose of MTX, and drug safety.

Results

MTX was administered twice weekly, and the mean maximum weekly dose was 14.48 mg. The response was A5 (regrowth=100.0%) in 14 (48.3%) patients and A4 (regrowth of 75%~90%) in 12 (41.4%) patients. Three patients had poor response to LD-MTX treatment (A2: n=2 [6.9%], A1: n=1 [3.4%]). All three of the patients showing a poor response had disease durations exceeding 24 months. Relapse was observed in 31% of patients with more than 75% regrowth. Common side-effects were elevated liver enzyme levels and gastrointestinal discomfort.

Conclusion

LD-MTX appears to be an effective and well-tolerated treatment for recalcitrant AA multiplex.

Alopecia areata

Alopecia areata is an autoimmune disorder characterized by transient, non-scarring hair loss and preservation of the hair follicle. Hair loss can take many forms ranging from loss in well-defined patches to diffuse or total hair loss, which can affect all hair-bearing sites. Patchy alopecia areata affecting the scalp is the most common type. Alopecia areata affects nearly 2% of the general population at some point during their lifetime. Skin biopsies of affected skin show a lymphocytic infiltrate in and around the bulb or the lower part of the hair follicle in the anagen (hair growth) phase. A breakdown of immune privilege of the hair follicle is thought to be an important driver of alopecia areata. Genetic studies in patients and mouse models have shown that alopecia areata is a complex, polygenic disease. Several genetic susceptibility loci were identified to be associated with signalling pathways that are important to hair follicle cycling and development. Alopecia areata is usually diagnosed based on clinical manifestations, but dermoscopy and histopathology can be helpful. Alopecia areata is difficult to manage medically, but recent advances in understanding the molecular mechanisms have revealed new treatments and the possibility of remission in the near future.

Treating Alopecia Areata: Current Practices Versus New Directions

Alopecia areata (AA) is non-scarring hair loss resulting from an autoimmune disorder. Severity varies from patchy hair loss that often spontaneously resolves to severe and chronic cases that can progress to total loss of scalp and body hair. Many treatments are available; however, the efficacy of these treatments has not been confirmed, especially in severe cases, and relapse rates are high. First-line treatment often includes corticosteroids such as intralesional or topical steroids for mild cases and systemic steroids or topical immunotherapy with diphenylcyclopropenone or squaric acid dibutylester in severe cases. Minoxidil and bimatoprost may also be recommended, usually in combination with another treatment. Ongoing research and new insights into mechanisms have led to proposals of innovative therapies. New directions include biologics targeting immune response as well as lasers and autologous platelet-rich plasma therapy. Preliminary data are encouraging, and it is hoped this research will translate into new options for the treatment of AA in the near future.

Kombinierte Hoch-/Niedrig-Dosis-Therapie mit systemischen Glukokor-tikoiden bei schweren Verlaufsformen der Alopecia areata im Kindesalter

HINTERGRUND

Schwere Verlaufsformen der Alopecia areata (AA) im Kindesalter sind aufgrund limitierter Optionen therapeutisch herausfordernd. Systemische, hochdosierte Glukokortikoide weisen die schnellste Ansprechrate auf, nach dem Absetzen kommt es allerdings zu Rezidiven. Eine längerfristige Hochdosis-Anwendung ist aufgrund der zu erwartenden Nebenwirkungen nicht empfehlenswert. Eine dauerhafte Steroiderhaltungstherapie unterhalb der Cushing-Schwellen-Dosis nach Bolustherapie könnte die Krankheitsaktivität ohne Nebenwirkungen längerfristig unterdrücken.

PATIENTEN UND METHODIK

Im Rahmen einer offenen Anwendungsbeobachtung wurden 13 Kinder mit schweren Formen der AA in diese Studie eingeschlossen. Bei sieben Kindern lag eine AA totalis/universalis vor, bei sechs eine multifokale AA mit Befall von mehr als 50 % der Kopfhaut. Das Therapieregime sah eine initiale Prednisolon-Dosierung von 2 mg/kg Körpergeweicht (KG) vor und wurde innerhalb von neun Wochen auf eine Erhaltungsdosierung unter der individuellen Cushing-Schwelle reduziert. Der Nachbeobachtungszeitraum betrug ein bis drei Jahre.

ERGEBNISSE

Wir beobachteten in 62 % aller Fälle ein komplettes Nachwachsen der Haare. Die mittlere Dauer bis zum Ansprechen lag bei 6,6 Wochen und konnte mit der Erhaltungstherapie über den gesamten Beobachtungszeitraum aufrechterhalten werden. An Nebenwirkungen wurden ausschließlich eine Gewichtszunahme (1-3 kg) bei allen Behandelten sowie eine milde Steroidakne in 23 % der Fälle beobachtet.

SCHLUSSFOLGERUNGEN

Die kombinierte Hoch-/Niedrig-Dosis-Therapie mit systemischen Glukokortikoiden mittels Prednisolon zeigte eine hohe, dauerhafte Ansprechrate ohne signifikante Nebenwirkungen.