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Singh R, Kumar P, Kumar D, Aggarwal N, Chopra H, Kumar V. Alopecia areata: review of epidemiology, pathophysiology, current treatments and nanoparticulate delivery system. Ther Deliv 2024; 15:193-210. [PMID: 38449420 DOI: 10.4155/tde-2023-0071] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 03/08/2024] Open
Abstract
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.
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Affiliation(s)
- Robel Singh
- College of Pharmacy, PGIMS, Pt B D Sharma, University of Health Sciences-Rohtak, 124001, India
| | - Pawan Kumar
- Indian Pharmacopoeia Commision, Ministry of Health & Family Welfare, Govt. of India
| | - Davinder Kumar
- College of Pharmacy, PGIMS, Pt B D Sharma, University of Health Sciences-Rohtak, 124001, India
| | - Navidha Aggarwal
- MM College of Pharmacy, Maharishi Markandeshwar (Deemed to be University), Mullana, Ambala, 133207, India
| | - Hitesh Chopra
- Department of Biosciences, Saveetha School of Engineering, Saveetha Institute of Medical & Technical Sciences, Chennai, 602105, Tamil Nadu, India
| | - Virender Kumar
- College of Pharmacy, PGIMS, Pt B D Sharma, University of Health Sciences-Rohtak, 124001, India
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Mateos-Haro M, Novoa-Candia M, Sánchez Vanegas G, Correa-Pérez A, Gaetano Gil A, Fernández-García S, Ortega-Quijano D, Urueña Rodriguez MG, Saceda-Corralo D, Bennouna-Dalero T, Giraldo L, Tomlinson J, Vaño-Galván S, Zamora J. Treatments for alopecia areata: a network meta-analysis. Cochrane Database Syst Rev 2023; 10:CD013719. [PMID: 37870096 PMCID: PMC10591288 DOI: 10.1002/14651858.cd013719.pub2] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 10/24/2023]
Abstract
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.
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Affiliation(s)
- Miriam Mateos-Haro
- Clinical Biostatistics Unit, Hospital Universitario Ramón y Cajal (IRYCIS), Madrid, Spain
- Doctoral programme in Clinical Medicine and Public Health, Universidad de Granada, Granada, Spain
| | - Monica Novoa-Candia
- Paediatric Dermatology Department, Hospital San Jose-Fundación Universitaria de Ciencias de la Salud-FUCS, Bogotá, Colombia
| | | | - Andrea Correa-Pérez
- Clinical Biostatistics Unit, Hospital Universitario Ramón y Cajal (IRYCIS), Madrid, Spain
- Faculty of Medicine, Universidad Francisco de Vitoria, Madrid, Spain
| | - Andrea Gaetano Gil
- Clinical Biostatistics Unit, Hospital Universitario Ramón y Cajal (IRYCIS), Madrid, Spain
| | - Silvia Fernández-García
- WHO Collaborating Centre for Global Women's Health, Institute of Metabolism and Systems Research, University of Birmingham, Birmingham, UK
| | | | | | | | - Tayeb Bennouna-Dalero
- Preventive Medicine and Public Health Department, Hospital Universitario Ramón y Cajal, IRYCIS, Madrid, Spain
| | - Lucia Giraldo
- Paediatric Dermatology Department, Hospital San Jose-Fundación Universitaria de Ciencias de la Salud-FUCS, Bogotá, Colombia
| | | | - Sergio Vaño-Galván
- Department of Dermatology, Hospital Universitario Ramón y Cajal, Madrid, Spain
| | - Javier Zamora
- Institute of Metabolism and Systems Research, University of Birmingham, Birmingham, UK
- Clinical Biostatistics Unit, Hospital Universitario Ramón y Cajal (IRYCIS). CIBER Epidemiology and Public Health (CIBERESP), Madrid, Spain
- Cochrane Associate Centre of Madrid, Madrid, Spain
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Park H, Kim JE, Choi JW, Kim DY, Jang YH, Lee Y, Jeon J, Shin HT, Kim MS, Shin JW, Cho SB, Lew BL, Choi GS. Guidelines for the Management of Patients with Alopecia Areata in Korea: Part I Topical and Device-based Treatment. Ann Dermatol 2023; 35:190-204. [PMID: 37290953 DOI: 10.5021/ad.22.168] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/13/2022] [Revised: 12/17/2022] [Accepted: 01/24/2023] [Indexed: 06/10/2023] Open
Abstract
BACKGROUND Alopecia areata (AA) is a chronic disease with an unpredictable disease course and severe psychological impact. OBJECTIVE To provide evidence- and consensus-based insights regarding the treatment of patients with AA in Korea. METHODS We searched for relevant studies on the topical and device-based treatment of AA in the literature from inception until May 2021. 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 statements, and an agreement of 75% or greater was considered as consensus. RESULTS Currently, there remains a scarcity of topical treatments, which is supported by robust evidence from a number of high-quality randomized controlled trials. Current evidence supports the efficacy of topical corticosteroids, corticosteroid intralesional injection, and contact immunotherapy in AA patients. Topical corticosteroids and contact immunotherapy are recommended for pediatric AA. A consensus was achieved in 6 out of 14 (42.8%), and 1 out of 5 (20.0%) statements pertaining to topical and device-based treatments in AA, respectively. The expert consensus was from a single country, and the study may not cover all the treatments used. CONCLUSION The present study provides up-to-date, evidence-based treatment guidelines for AA based on the consensus reached among experts after considering regional healthcare circumstances, adding diversity to the previous guidelines.
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Affiliation(s)
- Hyunsun Park
- Department of Dermatology, SMG-SNU Boramae Medical Center, Seoul, Korea
| | - Jung Eun Kim
- Department of Dermatology, College of Medicine, The Catholic University of Korea, Seoul, Korea
| | - Jee Woong Choi
- Department of Dermatology, Ajou University School of Medicine, Suwon, Korea
| | - Do Young Kim
- Department of Dermatology, Yonsei University College of Medicine, Seoul, Korea
| | - Yong Hyun Jang
- Department of Dermatology, School of Medicine, Kyungpook National University, Daegu, Korea
| | - Young Lee
- Department of Dermatology, School of Medicine, Chungnam National University, Daejeon, Korea
| | - Jiehyun Jeon
- Department of Dermatology, Guro Hospital, Korea University College of Medicine, Seoul, Korea
| | - Hyun-Tae Shin
- Department of Dermatology, Inha University School of Medicine, Incheon, Korea
| | - Min Sung Kim
- Department of Dermatology, School of Medicine, Chosun University, Gwangju, Korea
| | - Jung Won Shin
- Department of Dermatology, Seoul National University Bundang Hospital, Bundang, Korea
| | - Sung Bin Cho
- Yonsei Seran Dermatology and Laser Clinic, Seoul, Korea
| | - Bark-Lynn Lew
- Department of Dermatology, Kyung Hee University School of Medicine, Seoul, Korea.
| | - Gwang Seong Choi
- Department of Dermatology, Inha University School of Medicine, Incheon, Korea
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Waśkiel‐Burnat A, Kołodziejak M, Sikora M, Stochmal A, Rakowska A, Olszewska M, Rudnicka L. Therapeutic management in paediatric alopecia areata: A systematic review. J Eur Acad Dermatol Venereol 2021; 35:1299-1308. [DOI: 10.1111/jdv.17187] [Citation(s) in RCA: 7] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/24/2020] [Accepted: 02/04/2021] [Indexed: 02/06/2023]
Affiliation(s)
- A. Waśkiel‐Burnat
- Department of Dermatology Medical University of Warsaw Warsaw Poland
| | - M. Kołodziejak
- Department of Dermatology Medical University of Warsaw Warsaw Poland
| | - M. Sikora
- Department of Dermatology Medical University of Warsaw Warsaw Poland
| | - A. Stochmal
- Department of Dermatology Medical University of Warsaw Warsaw Poland
| | - A. Rakowska
- Department of Dermatology Medical University of Warsaw Warsaw Poland
| | - M. Olszewska
- Department of Dermatology Medical University of Warsaw Warsaw Poland
| | - L. Rudnicka
- Department of Dermatology Medical University of Warsaw Warsaw Poland
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Abdallah MAER, Shareef R, Soltan MY. Efficacy of intradermal minoxidil 5% injections for treatment of patchy non-severe alopecia areata. J DERMATOL TREAT 2020; 33:1126-1129. [PMID: 32643454 DOI: 10.1080/09546634.2020.1793893] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/23/2022]
Abstract
BACKGROUND Intradermal minoxidil is used as an off-label treatment for patchy non-severe alopecia areata (AA) either alone or in combination with steroids; however, studies estimating its efficacy are still lacking. OBJECTIVES To assess the efficacy of intradermal delivery of minoxidil 5% alone and in combination with intralesional triamcinolone acetonide for treatment of patchy non-severe AA. PATIENTS AND METHODS One hundred patches in twenty patients with patchy non-severe AA, five patches for each patient, were included in this prospective intra-patient comparative controlled clinical study. Four comparative patches per each patient were randomly assigned to receive 4 sessions, at a 4-week interval, of one of the following treatments: intralesional triamcinolone acetonide, intralesional minoxidil 5%, combination treatment, or micro-needling. The fifth patch was observed as the negative control. Treatment outcomes were assessed at baseline, and 1 month after treatment ends. RESULTS Minoxidil intradermal injection was nearly comparable to the micro-needling effect and its combination to steroids had no additive effect. Hair regrowth in response to minoxidil occurred earlier than the spontaneous recovery. CONCLUSION Monotherapy of intralesional minoxidil is of limited efficacy in treating non-severe patchy AA, but it speeds the recovery.
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Affiliation(s)
| | - Rasha Shareef
- Faculty of Medicine, Department of Dermatology and Venereology, Ain Shams University, Cairo, Egypt
| | - Marwa Y Soltan
- Faculty of Medicine, Department of Dermatology and Venereology, Ain Shams University, Cairo, Egypt
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Suchonwanit P, Thammarucha S, Leerunyakul K. Minoxidil and its use in hair disorders: a review. Drug Des Devel Ther 2019; 13:2777-2786. [PMID: 31496654 PMCID: PMC6691938 DOI: 10.2147/dddt.s214907] [Citation(s) in RCA: 186] [Impact Index Per Article: 37.2] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/08/2019] [Accepted: 07/22/2019] [Indexed: 12/20/2022] Open
Abstract
Minoxidil was first introduced as an antihypertensive medication and the discovery of its common adverse event, hypertrichosis, led to the development of a topical formulation for promoting hair growth. To date, topical minoxidil is the mainstay treatment for androgenetic alopecia and is used as an off-label treatment for other hair loss conditions. Despite its widespread application, the exact mechanism of action of minoxidil is still not fully understood. In this article, we aim to review and update current information on the pharmacology, mechanism of action, clinical efficacy, and adverse events of topical minoxidil.
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Affiliation(s)
- Poonkiat Suchonwanit
- Division of Dermatology, Department of Medicine, Faculty of Medicine, Ramathibodi Hospital, Mahidol University, Bangkok, Thailand
| | - Sasima Thammarucha
- Division of Dermatology, Department of Medicine, Faculty of Medicine, Ramathibodi Hospital, Mahidol University, Bangkok, Thailand
| | - Kanchana Leerunyakul
- Division of Dermatology, Department of Medicine, Faculty of Medicine, Ramathibodi Hospital, Mahidol University, Bangkok, Thailand
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Freire P, Riera R, Martimbianco A, Petri V, Atallah A. Minoxidil for patchy alopecia areata: systematic review and meta‐analysis. J Eur Acad Dermatol Venereol 2019; 33:1792-1799. [DOI: 10.1111/jdv.15545] [Citation(s) in RCA: 16] [Impact Index Per Article: 3.2] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/23/2018] [Accepted: 01/18/2019] [Indexed: 11/28/2022]
Affiliation(s)
- P.C.B. Freire
- Department of Health Informatics Universidade Federal de São Paulo São Paulo Brazil
| | - R. Riera
- Discipline of Evidence‐Based Medicine Universidade Federal de São Paulo São Paulo Brazil
| | | | - V. Petri
- Department of Dermatology Universidade Federal de São Paulo São Paulo Brazil
| | - A.N. Atallah
- Evidence‐Based Medicine and Emergency Medicine Universidade Federal de São Paulo São Paulo Brazil
- Brazilian Cochrane Centre São Paulo Brazil
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Ranugha PSS, Betkerur J. Antihypertensives in dermatology Part I - Uses of antihypertensives in dermatology. Indian J Dermatol Venereol Leprol 2018; 84:6-15. [DOI: 10.4103/ijdvl.ijdvl_991_16] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/04/2022]
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McElwee KJ, Silva K, Boggess D, Bechtold L, King LE, Sundberg JP. Alopecia Areata in C3H/HeJ Mice Involves Leukocyte-mediated Root Sheath Disruption in Advance of Overt Hair Loss. Vet Pathol 2016; 40:643-50. [PMID: 14608017 DOI: 10.1354/vp.40-6-643] [Citation(s) in RCA: 27] [Impact Index Per Article: 3.4] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/19/2022]
Abstract
Alopecia areata (AA) can be induced in C3H/HeJ mice by grafting full-thickness AA-affected skin. An 8- to 12-week delay between surgery and overt hair loss onset provides an opportunity to examine disease pathogenesis. Normal haired C3H/HeJ mice were sham-grafted or grafted with AA-affected skin. Mice were euthanatized 2, 4, 6, 8, 10, and 12 weeks after surgery along with chronic AA-affected mice as a positive control. Until 6 weeks after grafting, inflammation was only evident around anagen-stage hair follicles in host skin adjacent to but not distant from the AA-affected graft. From 8 weeks on, AA-grafted but not sham-grafted mice exhibited a diffuse dermal inflammation at distant sites that progressively focused on anagen-stage hair follicles at 10 and 12 weeks. Perifollicular inflammation was primarily composed of CD4+ and CD8+ cells associated with follicular epithelium intercellular adhesion molecule -1 expression. Only CD8+ cells penetrated intrafollicularly by 12 weeks after surgery, although both CD4+ and CD8+ intrafollicular cells were observed in chronic AA-affected mice. Under electron microscopy, intrafollicular lymphocyte and macrophage infiltration associated with hair follicle dystrophy was prominent 10 weeks after surgery, primarily within the differentiating outer and inner root sheaths. This study shows that focal follicular inflammation develops some time in advance of overt hair loss and focuses on the differentiating root sheaths in C3H/HeJ mice. The severity of inflammation and the degree of hair follicle dystrophy induced by the infiltrate appear to reach a threshold level before overt hair loss occurs.
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Affiliation(s)
- K J McElwee
- The Jackson Laboratory, Bar Harbor, ME 64609, USA
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Abstract
BACKGROUND There is no cure for alopecia areata, nor is there any universally proven therapy that induces and sustains remission. Treatment choices are frequently based on disease duration, extent, and activity as well as the age of the patient. OBJECTIVE Our objective was to review all randomized controlled studies on the treatment of alopecia areata. METHODS We performed a search in the biomedical literature database PubMed, and used the terms 'alopecia areata treatment' and article type 'randomized controlled trials'. RESULTS Following this algorithm, we reviewed, analyzed, and reported on 29 trials that examined the efficacy of anthralin, antidepressants, biologics, calcineurin inhibitors, corticosteroids (topical and systemic), minoxidil, prostaglandin analogs, sensitizers, and a miscellaneous group of topical and oral drugs with less scientific evidence (aromatherapy, photodynamic therapy, azelaic acid, garlic gel, bexarotene, triiodothyronine, inosiplex, and total glucosides of paeony). CONCLUSION Using the American College of Physicians Guideline grading system, our assessment is that the majority of published randomized controlled studies of alopecia areata are only of moderate quality. A number of treatments were found to be effective, for example, topical and oral corticosteroids and the sensitizing agents diphenylcyclopropenone and dinitrochlorobenzene; however, most studies had major limitations that hinder the interpretation of these results.
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Abstract
Alopecia areata (AA) is a non-scarring autoimmune disease of the hair follicle that can present at any age. Pediatric cases are commonly seen in a dermatology clinic, and management can potentially be challenging, with a small proportion of cases experiencing a chronic relapsing course marked by distressing hair loss that can bring about significant psychosocial morbidity. We review the established treatments for pediatric alopecia areata, alongside second and third line therapies that have shown to be efficacious. We also offer a treatment algorithm as a guide to the treatment of pediatric AA.
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Affiliation(s)
- Etienne Wang
- National Skin Centre, 1 Mandalay Road, Singapore
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Rogers NE, Avram MR. Medical treatments for male and female pattern hair loss. J Am Acad Dermatol 2008; 59:547-66; quiz 567-8. [PMID: 18793935 DOI: 10.1016/j.jaad.2008.07.001] [Citation(s) in RCA: 151] [Impact Index Per Article: 9.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/13/2008] [Revised: 06/27/2008] [Accepted: 07/05/2008] [Indexed: 10/21/2022]
Abstract
UNLABELLED Male and female pattern hair loss affects a large percentage of the population, and patients frequently present for treatment of this to their dermatologist. Here we review the many treatments available for hair loss. We review the evidence for each, and outline the most effective treatment strategies for both men and women. LEARNING OBJECTIVE At the conclusion of this article, the reader should be able to describe the most effective treatments for hair loss, understand their mechanism(s) of action, and explain which treatments are the best in different settings.
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Abstract
BACKGROUND Alopecia areata is a disorder in which there is loss of hair causing patches of baldness but with no scarring of the affected area. It can affect the entire scalp (alopecia totalis) or cause loss of all body hair (alopecia universalis). It is a relatively common condition affecting 0.15% of the population. Although in many cases it can be a self-limiting condition, nevertheless hair loss can often have a severe social and emotional impact. OBJECTIVES To assess the effects of interventions used in the management of alopecia areata, alopecia totalis and alopecia universalis. SEARCH STRATEGY We searched the Cochrane Skin Group Specialised Register in February 2006, the Cochrane Central Register of Controlled Clinical Trials (The Cochrane Library Issue 1, 2006), MEDLINE (from 2003 to February 2006), EMBASE (from 2005 to February 2006), PsycINFO (from 1806 to February 2006), AMED (Allied and Complementary Medicine, from 1985 to February 2006), LILACS (Latin American and Caribbean Health Science Information database, from 1982 to February 2006), and reference lists of articles. We also searched online trials registries for ongoing trials. SELECTION CRITERIA Randomised controlled trials that evaluated the effectiveness of both topical and systemic interventions for alopecia areata, alopecia totalis, and alopecia universalis. DATA COLLECTION AND ANALYSIS Two authors assessed trial quality and extracted the data. We contacted trial authors for more information. We collected adverse effects information from the included trials. MAIN RESULTS Seventeen trials were included with a total of 540 participants. Each trial included from 6 to 85 participants and they assessed a range of interventions that included topical and oral corticosteroids, topical ciclosporin, photodynamic therapy and topical minoxidil. Overall, none of the interventions showed significant treatment benefit in terms of hair growth when compared with placebo. We did not find any studies where the participants self-assessed their hair growth or quality of life. AUTHORS' CONCLUSIONS Few treatments for alopecia areata have been well evaluated in randomised trials. We found no RCTs on the use of diphencyprone, dinitrochlorobenzene, intralesional corticosteroids or dithranol although they are commonly used for the treatment of alopecia areata. Similarly although topical steroids and minoxidil are widely prescribed and appear to be safe, there is no convincing evidence that they are beneficial in the long-term. Most trials have been reported poorly and are so small that any important clinical benefits are inconclusive. There is a desperate need for large well conducted studies that evaluate long-term effects of therapies on quality of life. Considering the possibility of spontaneous remission especially for those in the early stages of the disease, the options of not being treated therapeutically or, depending on individual preference wearing a wig may be alternative ways of dealing with this condition.
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Affiliation(s)
- F M Delamere
- Cochrane Skin Group, University of Nottingham, Centre of Evidence-Based Dermatology, Room A103, King's Meadow Campus, Lenton Lane, Nottingham, UK, NG7 2NR.
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Okada M, Tashiro-Yamaji J, Takahashi T, Nomi H, Yamamoto Y, Yamaguchi S, Ueda K, Kubota T, Yoshida R. Regulation of Hair Regrowth in Alopecic Site of IFN-γ−/−Mice by Macrophages Infiltrating into Allograft in IFN-γ+/+Mice. J Interferon Cytokine Res 2005; 25:564-74. [PMID: 16181057 DOI: 10.1089/jir.2005.25.564] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/12/2022] Open
Abstract
We previously demonstrated that around 6 weeks of age, most of the interferon-gamma (IFN-gamma)-/- C57BL/6 mice began to lose morphogenesis-derived hairs in their dorsal and occipital areas and that hair regrowth in the alopecic site was induced by intraperitoneal (i.p.) injection of IFN-gamma and allogeneic Meth A cells. Here, we explored the IFN-gamma mRNA expression in the cells infiltrating into allograft in IFN-gamma(+)/(+) mice by RT-PCR and adoptively transferred specific antigen-minus infiltrates into IFN-gamma-/- mice to assess the hair regrowth inducibility. IFN- gamma mRNA was expressed in the infiltrates on days 3-8 after allografting, with a peak on day 3 or 4, and CD4(+) and F4/80(+) cells were the major producers of IFN-gamma. All infiltrates on day 3 induced hair regrowth, whereas those on days 0-2 or 4-8 were ineffective or partially effective, respectively. The removal of F4/80(+) macrophages from all infiltrates failed to induce hair regrowth, whereas the removal of Ly-6C(+) macrophages rather accelerated the hair regrowth. These results showed that F4/80(+), Ly-6C(+), and CD4(+) and F4/80(+) cells were stimulatory, inhibitory, and IFN-gamma-producing cells, respectively, in the regulation of hair regrowth.
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Affiliation(s)
- Masashi Okada
- Department of Physiology, Osaka Medical College, Takatsuki, Japan
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18
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Arck PC, Handjiski B, Peters EMJ, Hagen E, Klapp BF, Paus R. Topical minoxidil counteracts stress-induced hair growth inhibition in mice. Exp Dermatol 2004; 12:580-90. [PMID: 14705798 DOI: 10.1034/j.1600-0625.2003.00028.x] [Citation(s) in RCA: 21] [Impact Index Per Article: 1.1] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/23/2022]
Abstract
Stress has long been suspected as a possible cause of hair loss in various species, even though convincing experimental evidence has not been available. Recently, we have shown in a murine model that sonic stress alters hair growth and cycling in vivo, and have postulated the existence of a 'brain-hair follicle axis' (BHA). In order to study whether a clinically available and widely used topically active hair growth stimulator mitigates stress-triggered hair growth inhibition in this stress model, we have applied a 5% minoxidil solution. Female CBA/J mice were depilated and randomized in to two groups: control (n = 20) and sonic stress (n = 20). These groups were further divided and either treated daily with 5% minoxidil solution or vehicle alone. The stress group was exposed to sonic stress for 24 h starting 14 days after anagen induction by depilation. All mice were sacrificed 16 days after the depilation and assessed by quantitative histomorphometry. Sonic stress significantly increased the number of hair follicles with apoptotic cells and inhibited intrafollicular keratinocyte proliferation. In addition, the number of clusters of perifollicular MHC class II+ cells and degranulated perifollicular mast cells was significantly enhanced in the stressed mice. In accordance with previous findings, all stressed mice showed an advanced hair cycle progression towards catagen. All of these stress-induced hair growth inhibitory changes along the BHA were down-regulated by topical minoxidil application. This encourages one to explore clinically whether topical minoxidil is a safe and effective pharmacologic tool for the management of stress-associated telogen effluvium in humans.
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Affiliation(s)
- Petra Clara Arck
- Department of Internal Medicine, Charité, Humboldt University, Berlin, Germany.
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19
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Abstract
Over the past decade, basic research has established alopecia areata as a T cell-mediated autoimmune disease and has clarified many of its genetic, cellular, and molecular aspects. Perifollicular and intrafollicular mononuclear cell infiltrates directed at anagen hair bulbs are characteristic and striking histologic features in early alopecia areata. The inflammatory infiltrate is composed predominantly of activated CD4+ and CD8+ T cells, together with macrophages and Langerhans cells. The initiation phase of alopecia areata is mediated by type 1 cytokines, including interleukin-2, interferon-gamma, and tumor necrosis factor-alpha. Like other diseases with a strong autoimmune component, alopecia areata has associated with it specific human leukocyte antigens, which determine susceptibility, severity, chronicity, and resistance. New topical immunomodulating drugs and biologic therapies that have been developed, or that are in development, for the treatment of other immune-mediated inflammatory skin diseases will likely be effective in alopecia areata as well. The present discussion addresses the treatment of alopecia areata within the framework of these new modalities.
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Affiliation(s)
- Vera H Price
- Department of Dermatology, University of California, San Francisco, California 94117, USA.
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20
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Freyschmidt-Paul P, Happle R, McElwee KJ, Hoffmann R. Alopecia areata: treatment of today and tomorrow. J Investig Dermatol Symp Proc 2003; 8:12-7. [PMID: 12894988 DOI: 10.1046/j.1523-1747.2003.12165.x] [Citation(s) in RCA: 23] [Impact Index Per Article: 1.1] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/20/2022]
Abstract
It is the aim of this article to review and appraise available data on treatments for alopecia areata (AA) according to the demands of evidence based medicine. Studies evaluating the efficacy of a treatment for AA should include appropriate controls, use cosmetically acceptable hair regrowth as a parameter for treatment success, include patients with AA totalis, universalis or extensive patchy AA, and exclude patients suffering from AA for less than 3 months. Moreover, the treatment must be safe over a prolonged period of time. Among the various therapeutic approaches presently available for AA, only treatment with contact sensitizers such as diphenylcyclopropenone or squaric acid dibutylester has been shown to be effective in studies that fulfill these criteria. Improved future treatments may be immunosuppressive or immunomodulatory targeting of the autoimmune pathogenesis of AA, or they may otherwise protect hair follicles from the injurious effects of inflammation. Such possible future therapeutic approaches include the incorporation of immunomodulatory agents into liposomes as an improved vehicle; inhibition of apoptosis mediated by the Fas-FasL system; inhibition of the lymphocyte homing receptor CD44v10; induction of tolerance.
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21
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22
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Abstract
Alopecia areata (AA) is a nonscarring hair loss condition. Among the many factors under investigation in the pathogenesis of AA, the main areas of concentration have been genetic constitution as well as nonspecific immune and organ-specific autoimmune reactions. Treatment with intralesional corticosteroid injections for localized patchy AA and topical immunotherapy for extensive AA have proven successful in the majority of patients, although all treatments are palliative and do not change the prognosis of the disease.
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Affiliation(s)
- S Madani
- Division of Dermatology, University of British Columbia
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23
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Abstract
Alopecia areata is a common form of non-scarring alopecia that appears equally in males and females of any age, although children and adolescents are more commonly affected. The disorder is usually characterized by limited alopecic patches on the scalp, but more severe forms may affect the entire scalp (alopecia totalis) or body (alopecia universalis). Characteristic nail changes may also accompany hair loss. Alopecia areata has been linked with certain human leukocyte antigen (HLA) class II alleles, indicating a probable autoimmune etiology. Current research implicates T lymphocytes in the pathogenetic mechanism of disease. Other autoimmune diseases are also linked with alopecia areata. The diagnosis of alopecia areata is usually made clinically, although a biopsy is diagnostic for this condition. Treatment is challenging and aims at the regrowth of hair in affected individuals. Intralesional corticosteroid injections are widely used in mild disease. Topical anthralin and minoxidil may also be clinically efficacious. Topical sensitizers, such as squaric acid dibutlyester and diphenyl-cyclopropenone, are sometimes employed. Various therapies for the disease may have efficacy in different patients, making a universal treatment algorithm difficult to implement. Patients should be handled on an individual basis, with the final outcome based on the cosmetic regrowth of hair. Maintenance therapy is also important in patients that do achieve acceptable regrowth, necessitating a highly motivated patient and good rapport with the treating physician.
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Affiliation(s)
- V H Price
- Department of Dermatology, University of California at San Francisco, USA
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25
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Abstract
Today there are new classes of hair growth promotors with proven efficacy. This article reviews the current state of the art agents for treatment of two of the most common forms of hair loss encountered in clinical practice, androgenetic alopecia and alopecia areata. Current therapeutic strategies are based on recent advances in the understanding of disordered hair growth. Practical treatment protocols are presented.
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Affiliation(s)
- J Shapiro
- University of British Columbia Hair Research and Treatment Centre, Division of Dermatology, Vancouver, Canada
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26
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Abstract
Some individuals question whether any treatment is effective in severe alopecia areata. Certainly many patients, especially those with mild disease, experience spontaneous hair regrowth; however, results of double-blind studies clearly indicate that some treatments do promote hair regrowth even in those with extensive disease. Some patients never show either spontaneous or treatment-related hair regrowth; others experience hair regrowth only while maintained on treatment, repeatedly losing hair within a few weeks of discontinuing treatment and regrowing it within several weeks after restarting treatment. Some patients who have been responsive to treatment may experience exacerbation of their disease such that even high-dose systemic steroids do not prevent the development of alopecia universalis. Some treatments appear to work on some patients some or all of the time, but no treatment appears to work on all patients all of the time. We would suggest a few practical points that we find useful: To maximize the potential for cosmetic hair growth in alopecia areata that is extensive or flaring, treat the entire scalp instead of "chasing" patches. Do not change any topical treatment sooner than 3 months after starting it; early regrowth may first be present at 3 months. Cosmetic regrowth may take a year or more to achieve. Maintenance treatment increases the likelihood of maintenance of cosmetic hair growth, but patches of hair loss may still come and go. Atopic patients who experience seasonal hair loss may benefit (ie, have less severe hair loss flares or respond more readily to topical therapy) by using an antihistamine or mast cell stabilizer prophylactically. Whether one looks at the therapeutic cup as half full or half empty, most patients urge us to continue to try to find safe, effective long-term treatments for this disease.
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Affiliation(s)
- V C Fiedler
- Department of Dermatology, University of Illinois at Chicago, USA
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27
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Abstract
Aproximately 1% of the population will have had alopecia areata by the age of 50 and the peak incidence occurs in children and young adults. All body hair may be affected including lashes and brows. Alopecia areata is a systemic disease with frequent involvement of nails or eyes. Alopecia areata has been associated with atopic dermatitis, autoimmune disease, vitiligo, and endocrine disease. The pathogenesis is unclear. There is no excellent therapy for alopecia areata although many interventions are tried. Immunotherapy with diphenylcyprone is currently being optimistically evaluated. The harmful psychological effects of alopecia areata in children must be anticipated and prevented.
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Affiliation(s)
- E E Sahn
- Department of Dermatology and Pediatrics, Medical University of South Carolina, Charleston 29425-2215, USA
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Zhang JG, Oliver RF. Immunohistological study of the development of the cellular infiltrate in the pelage follicles of the DEBR model for alopecia areata. Br J Dermatol 1994; 130:405-14. [PMID: 7910477 DOI: 10.1111/j.1365-2133.1994.tb03371.x] [Citation(s) in RCA: 41] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/27/2023]
Abstract
The Dundee experimental bald rat (DEBR) undergoes hair loss associated with perifollicular infiltrates of mononuclear cells (MNC), a pathological characteristic of human alopecia areata (AA). To investigate further the pathogenesis of the disease in this animal model, we have studied the development, composition and extent of the perifollicular MNC infiltration in young (6-week-old), prelesional (3-month-old), active lesional, and established lesional DEBR rats, using 6-week- and 6-month-old Wistar rats as normal controls. The proportions of hair follicles showing infiltration by MNC and their main subsets were determined using immunohistochemical staining of serial cryostat sections of flank skin biopsies. There was a good correlation between the degree of leucocyte (OX-1+) infiltration of anagen hair follicles and the development of hair loss. In 6-week-old DEBR skin, there were few perifollicular cells expressing MHC class II, with positively stained dendritic cells in the dermis above the sebaceous gland. There was a sparse perifollicular distribution of CD4+ cells (W3/25) and macrophages (ED-1+). No CD8+ cells (OX-8+) were seen associated with DEBR hair follicles, and only small numbers were present in Wistar rats. In prelesional DEBR rats there was an increased perifollicular presence of MHC class II+ cells, macrophages, and particularly of CD8+ cells, with little change in CD4+ cells. Active and established lesional rats, i.e. animals with overt loss of hair, showed a significant increase in the degree of MNC infiltration and the proportion of infiltrated follicles, the majority of which were in dystrophic anagen. In the perifollicular infiltrate the CD4+:CD8+ ratio was approximately 2:1. An intrafollicular infiltrate was prominent, and was composed of CD8+ cells and macrophages, with bulbar and suprabulbar keratinocytes expressing MHC class II antigens. CD4+ cells were not detected in follicular epithelium. ICAM-1 expression correlated with MNC infiltration. These results show marked similarities to lesional human AA. They also focus on a possible active role for CD8+ cells in the pathogenesis of hair loss in the DEBR rat.
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Affiliation(s)
- J G Zhang
- Department of Biological Sciences, University of Dundee, U.K
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