Severe and unresponsive HIV-associated alopecia areata successfully treated with thalidomide

Antiretroviral-Related Alopecia in HIV-Infected Patients

Objective: To review the literature evaluating antiretroviral-related alopecia and to provide guidance on the differential diagnosis and management of this condition.

DATA SOURCES

A literature search was performed using PubMed, MEDLINE, Embase, International Pharmaceutical Abstracts (IPA), Cumulative Index to Nursing and Allied Health (CINAHL), and the Cochrane database (through May 2014). Relevant conference abstracts and product monographs were reviewed. Search terms included antiretroviral, individual antiretroviral classes and names, highly active antiretroviral therapy, HIV, AIDS, alopecia, hair, hair loss and drug.

STUDY SELECTION AND DATA EXTRACTION

English-language studies and case reports were included. A total of 16 articles and 1 conference abstract were retrieved, with a total of 46 patients with hair loss.

DATA SYNTHESIS

The protease inhibitor class, in particular indinavir, was most commonly reported to cause hair loss, followed by the NRTI, lamivudine. The majority of cases presented with alopecia of the scalp alone, with a median time of onset of 2.5 months. Management involved discontinuing the drug in most cases, with at least partial reversal in half the cases.

CONCLUSIONS

In antiretroviral-induced alopecia, discontinuation of the suspected agent is the optimal management, and hair regrowth should occur within 1 to 3 months. Management may also include replacing the offending medication with an antiretroviral less likely to cause hair loss. It is essential to rule out other causes of alopecia with a complete patient history, including characterization of the hair loss and assessment of the patient's medical history, medication use, and family history of alopecia.

What causes alopecia areata?

The pathobiology of alopecia areata (AA), one of the most frequent autoimmune diseases and a major unsolved clinical problem, has intrigued dermatologists, hair biologists and immunologists for decades. Simultaneously, both affected patients and the physicians who take care of them are increasingly frustrated that there is still no fully satisfactory treatment. Much of this frustration results from the fact that the pathobiology of AA remains unclear, and no single AA pathogenesis concept can claim to be universally accepted. In fact, some investigators still harbour doubts whether this even is an autoimmune disease, and the relative importance of CD8(+) T cells, CD4(+) T cells and NKGD2(+) NK or NKT cells and the exact role of genetic factors in AA pathogenesis remain bones of contention. Also, is AA one disease, a spectrum of distinct disease entities or only a response pattern of normal hair follicles to immunologically mediated damage? During the past decade, substantial progress has been made in basic AA-related research, in the development of new models for translationally relevant AA research and in the identification of new therapeutic agents and targets for future AA management. This calls for a re-evaluation and public debate of currently prevalent AA pathobiology concepts. The present Controversies feature takes on this challenge, hoping to attract more skin biologists, immunologists and professional autoimmunity experts to this biologically fascinating and clinically important model disease.