Pulse corticosteroid therapy for alopecia areata: study of 139 patients

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.

Trichoscopy pattern in alopecia areata: A systematic review and meta-analysis

BACKGROUND

The incidence of alopecia areata (AA) has increased over the last few decades. Trichoscopy is a noninvasive procedure performed in dermatology clinics and is a helpful tool in determining the correct diagnosis of hair loss presentations.

OBJECTIVE

Through mapping the researches that have been done to represent the spectrum of trichoscopic findings in AA and to identify the most characteristic patterns.

METHODS

Thirty-nine studies were eligible for the quantitative analysis. Meta-analysis and subgroup analysis were performed.

RESULTS

Thirty-nine studies (29 cross-sectional, five retrospective, two descriptive, one case series, one observational, and one cohort) with a total of 3204 patients were included. About 66.7% of the studies were from Asia, 25.6% from Europe, and 7.7% from Africa. The most characteristic trichoscopic findings of AA were as follows; yellow dots, black dots, broken hairs, short vellus hairs, and tapering hairs.

CONCLUSION

There is no single pathognomonic diagnostic trichoscopic finding in AA rather than a constellation of characteristic findings. The five most characteristic trichoscopic findings in AA are: yellow dots, black dots, broken hairs, short vellus hairs, and tapering hairs. Yellow dots and short vellus hairs considered the most sensitive clues for AA, while black dots and tapering hairs are the most specific ones. Furthermore, trichoscopy is a useful tool that allows monitoring of response during the treatment of AA. Treatment responded cases will show an increase in short vellus hairs, but loss of tapering hairs, broken hairs, and black dots, while yellow dots are the least responsive to the treatment.

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.

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.

Altered T cell subpopulations and serum anti-TYRP2 and tyrosinase antibodies in the acute and chronic phase of alopecia areata in the C3H/HeJ mouse model

BACKGROUND

C3H/HeJ mouse models progress gradually in hair loss from acute to chronic phase and reflect the symptoms of patients with alopecia areata (AA). However, the underlying pathological characteristics alteration associated with disease progression and autoantigens remain unclear.

OBJECTIVE

We aimed at elucidating the pathological differences between acute and chronic-AA in the C3H/HeJ mouse model.

METHODS

We analyzed populations of PBMCs, skin-draining lymph node (SDLN) cells, and cutaneous cells of AA mice using flow cytometry. The cytokine and chemokine expressions in the serum and skin were determined using multiplex assay and qPCR. The antibody serum levels were determined using ELISA and the antigen-specific T cells were detected using the MHC class I tetramer.

RESULTS

The CD8⁺NKG2D⁺ T and CD8⁺ T_EM cell percentage in the chronic-AA SDLNs or among the unaffected and acute-AA mice PBMCs increased. The Th1 and CD4⁺ T_EM cell percentage in the SDLNs and among PBMCs increased in the unaffected and AA mice. The percentage of CD8⁺ T_EM/T_RM cells and MHC class I expression increased in the lesions of acute-AA or the non-lesions and lesions of chronic-AA. The Th1 cells, dendritic cell-related cytokines, CD11c⁺ cells and MHC class II expression increased in the skin of AA mice. The antibody levels and TYRP2 and tyrosinase-specific CD8⁺ T cell percentages were upregulated in AA mice.

CONCLUSION

These results suggest that the CD8⁺ and CD4⁺ T cell subpopulations, cytokine and chemokine expressions differ between the disease phases. Moreover, TYRP2 and tyrosinase are potential autoreactive targets in the AA mouse model.

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.

Alopecia areata: a review on diagnosis, immunological etiopathogenesis and treatment options

Patients suffering from alopecia areata (AA) can lose hair in focal regions, the complete scalp, including eyelashes and eyebrows, or even the entire body. The exact pathology is not yet known, but the most described theory is a collapse of the immune privilege system, which can be found in some specific regions of the body. Different treatment options, local and systemic, are available, but none of them have been proven to be effective in the long term as well for every treatment there should be considered for the possible side effects. In many cases, treated or non-treated, relapse often occurs. The prognosis is uncertain and is negatively influenced by the subtypes alopecia totalis and alopecia universalis and characteristics such as associated nail lesions, hair loss for more than 10 years and a positive familial history. The unpredictable course of the disease also makes it a mental struggle and AA patients are more often associated with depression and anxiety compared to the healthy population. Research into immunology and genetics, more particularly in the field of dendritic cells (DC), is recommended for AA as there is evidence of the possible role of DC in the treatment of other autoimmune diseases such as multiple Sclerosis and cancer. Promising therapies for the future treatment of AA are JAK-STAT inhibitors and PRP.

Development of a scoring system to predict outcomes of i.v. corticosteroid pulse therapy in rapidly progressive alopecia areata adopting digital image analysis of hair recovery

Alopecia areata (AA) is a common autoimmune disease manifesting varying degrees of hair loss. Rapidly progressive AA (RP-AA) is a severe subtype of AA and often resistant to skin-directed treatments. i.v. corticosteroid pulse therapy has been applied for RP-AA; however, the treatment outcome can only become evaluable several months after the intervention, discomposing the patients. In this study, we attempted to develop a scoring system to predict treatment outcomes based on statistical correlations between newly identified predictors and the recovery rates calculated by digital image analysis. Thirty RP-AA patients (15 men and 15 women) who underwent pulse therapy and demonstrated total hair loss during the clinical course were included. The percentages of hair regrowth (%HR) at 6 months after the treatment were quantitatively calculated by image analysis software. The correlation between %HR and clinicopathological and immunological variables were statistically assessed. The analysis identified four confirmatory contributors including female sex (P = 0.015), absence of previous AA history (P = 0.02), lower peripheral blood eosinophil count (P = 0.02) and mild to moderate cell infiltration around the hair bulb (P = 0.034), together with a potential contributor, namely absence of atopic dermatitis in their medical history (P = 0.08). The scoring system was developed by double counting confirmatory variables and single counting a potential variable. Importantly, the scores obtained by this system demonstrated significant correlation with %HR (r = 0.61, P < 0.001). The usefulness of this scoring system was further validated by assessing additional 20 cases of RP-AA. When combined with a recently published algorithm for early detection of self-healing subset, the current scoring system may help strategize the therapeutic approach for RP-AA.

Hair regrowth following fecal microbiota transplantation in an elderly patient with alopecia areata: A case report and review of the literature

BACKGROUND

Alopecia areata is a hair loss disease associated with genetics, autoimmunity, and other factors. There is an intriguing link between alopecia areata and gut dysbiosis. Fecal microbiota transplantation (FMT) has been recommended to treat Clostridium difficile (previously known as Clostridioides difficile) infection, and has also shown potentials in the treatment of inflammatory bowel disease, irritable bowel syndrome, and non-alcohol fatty liver disease.

CASE SUMMARY

An 86-year-old man, with a history of sigmoid colon carcinoma, suffered from recurrent abdominal pain and distension, and diarrhea for six months, with inappetence. At admission, he was also diagnosed with depression. Upon physical examination, the patient presented with a 1.5 cm × 2.0 cm alopecia areata on his right occiput. Due to the negative results of laboratory testing, capsule endoscopy, and colonoscopy, the patient was diagnosed with noninfectious diarrhea, depressive disorder, and patchy alopecia areata. Considering that noninfectious diarrhea in the elderly patient was mainly caused by gut dysbiosis, he was given six rounds of FMT. His diarrhea improved remarkably one month after FMT, with improved appetite and disappearance of abdominal pain, distension, and depressive symptoms. Surprisingly, he reported new hair growth on the affected region of his scalp, with some of his white hair gradually turning to black, without taking any other therapies for alopecia areata before and after FMT.

CONCLUSION

FMT might act as a potential therapy for patients who suffer from alopecia areata. Large and well-designed studies are required to confirm the role of FMT in alopecia areata.

Combined intravenous pulse and topical corticosteroid therapy for severe alopecia areata in children: Comparison of two regimens

There is no universally accepted treatment for severe pediatric alopecia areata (AA). This prospective study comprised 73 patients (aged 1-18 years) with severe AA (>30% of scalp surface area): 37 received 1-day intravenous dexamethasone pulses (1-DP) and 36 received 3-day pulses (3-DP), monthly, for 6-12 months. Also, all patients applied topical clobetasol propionate under plastic wrap occlusion. Patients achieving >50% regrowth were considered good responders (GR). All patients reached short term, while 65/73 were available for the long-term follow-up (mean 33.3 ± 15.3 vs. 27.7 ± 14.3 months, 1-DP and 3-DP, respectively). Relapses during therapy were more frequent in 1-DP group. 3-DP patients were more frequently GR in comparison with 1-DP. 3-DP patients with disease duration <6 months had better outcomes. Patients without Hashimoto thyroiditis (HT) had 9.8-fold higher chance of being GR in comparison with HT patients. The best results were achieved in AA plurifocalis (AAP). No patient had severe short-term side-effects. At the long-term follow-up, 67% of 3-DP patients had stable results. Only 14.2% AAP patients experienced relapses. Patients had no long-term side-effects. 3-DP were more efficacious than 1-DP. Short disease duration and no HT were good prognostic factors. 3-DP protocol is well-tolerated, with beneficial effects and long-lasting results in severe pediatric AA.

Predictive factors of response to pulse methylprednisolone therapy in patients with alopecia areata: A follow-up study of 105 Japanese patients

Pulse corticosteroid therapy is effective for alopecia areata (AA) in the early stage. The risk and efficacy of this therapy for patients with several backgrounds, however, remains controversial. To explore the predictive factors of the response and risk factors of this therapy, data from 105 AA patients treated with methylprednisolone (500 mg) i.v. for 3 days consecutively in our facility were retrospectively analyzed. Among good responders, longer time from the onset to therapy was correlated with longer time required for hair regrowth (P = 0.037, n = 27). Multivariate models demonstrated that "severity", "relapse" and longer "duration from the latest onset" were significantly and independently associated with poorer outcome (P < 0.01). "History of atopic dermatitis (AD)" was also associated with poorer outcome, but this correlation could be explained by the effect that duration from the latest onset of AA was longer among participants with AD. We propose that earlier initiation of pulse corticosteroid therapy is preferable for better outcome of AA, particularly among patients with AD. Clinicians should be mindful of the occurrence of mild adverse effects in the elderly patients.

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.

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.

Chronological clinicopathological characterization of rapidly progressive alopecia areata resistant to multiple i.v. corticosteroid pulse therapies: An implication for improving the efficacy

Intravenous corticosteroid pulse therapy (pulse therapy) has been reported to be effective for rapidly progressive alopecia areata (RP-AA). Mostly, a single 3-day administration of corticosteroid (methylprednisolone 500 mg/day) has been performed in Japan; however, to what extent additional administrations improve the outcome has not been fully elucidated. To assess the advantage of repeating the pulse therapy to RP-AA cases refractory to the initial intervention, retrospective clinicopathological analysis was performed. Detailed chronological analysis was conducted in eight cases (one man and seven women; average age, 38.3 ± 10.4 years) demonstrating total scalp hair loss 3 months after the first pulse therapy and treated with additional rounds of the pulse therapy. All cases manifested total hair loss, scalp edema, itch or pain on the scalp after the initial intervention. Histopathological analyses of affected lesions prior to additional pulse therapies revealed persisting dense perifollicular lymphocytic inflammation in all cases. Interestingly, such inflammatory change tended to be severer when compared with previously reported pulse therapy good responders. Extra pulse therapy resulted in partial regrowth of terminal hairs in three out of eight cases, but all of them experienced relapse in the long run. The literature review also suggested limited efficacy of repeating pulse therapy to severe AA cases. These findings suggested that the efficacy of currently conducted repetitive pulse therapy is limited in RP-AA cases with extensive perifollicular inflammation and resistant to the initial pulse therapy. Modulation of the dose and the interval of intervention, in combination with alternative approaches, may be required to achieve a successful outcome.

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

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.

Multiple courses of pulse corticosteroid therapy for alopecia areata

Various systemic corticosteroid therapies are used for alopecia areata (AA). Pulse therapy using methylprednisolone is a treatment approach for AA. The efficacy of multiple courses of pulse therapy for various severities of AA was evaluated. AA patients with less than 50% hair loss, less than or equal to 6 months after AA onset, needed 1.9 courses of pulse therapy for vellus hair to develop. On the other hand, AA patients with more than 50% hair loss, less than 6 months after AA onset, needed more courses of pulse therapy for vellus hair to develop. Regardless of the disease duration, AA patients with less than 50% hair loss showed a good response rate (100%) after both a short period and a long period after therapy. After receiving multiple courses of pulse therapy, the AA patients with more than 50% hair loss also showed improvement with limited adverse reactions.

Efficacy and Safety of Methotrexate Combined with Low- to Moderate-Dose Corticosteroids for Severe Alopecia Areata

BACKGROUND

In severe alopecia areata (AA), spontaneous recovery is unlikely, and treatment is not standardized.

OBJECTIVE

To evaluate the efficacy and safety of methotrexate (MTX) used alone or combined with low- to moderate-dose oral corticosteroids (OC) for treating severe AA (totalis, universalis and severe multifocal).

METHODS

Retrospective monocentric study of all consecutive patients receiving this treatment between 2006 and 2012. Efficacy was defined as achieving a total regrowth of terminal hair.

RESULTS

26 patients were included (17 with AA universalis or totalis and 9 with severe multifocal AA). Total regrowth was noted in 15/26 patients. After 3 months of treatment, hair regrowth >80% was associated with further complete regrowth, and hair regrowth <30% was associated with later treatment failure (p = 0.0014). When treatment was tapered, 11/15 patients with initial complete efficacy experienced AA relapse.

CONCLUSION

MTX combined with low- to moderate-dose OC may be an efficient and well-tolerated treatment for severe AA. However, long-term maintenance treatment is usually required.

Comparison of High-Dose Corticosteroid Pulse Therapy and Combination Therapy Using Oral Cyclosporine with Low-Dose Corticosteroid in Severe Alopecia Areata

BACKGROUND

Severe alopecia areata (AA) is resistant to conventional treatment. Although systemic oral corticosteroids are an effective treatment for patients with severe AA, those drugs have many adverse effects. Corticosteroid pulse therapy has been introduced to increase therapeutic effects and reduce adverse effects. However, the treatment modality in severe AA is still controversial.

OBJECTIVE

To evaluate the effectiveness of corticosteroid pulse therapy in patients with severe AA compared with treatment with oral cyclosporine with corticosteroid.

METHODS

A total of 82 patients with severe AA were treated with corticosteroid pulse therapy, and 60 patients were treated with oral cyclosporine with corticosteroid. Both groups were retrospectively evaluated for therapeutic efficacy according to AA type and disease duration.

RESULTS

In 82 patients treated with corticosteroid pulse therapy, 53 (64.6%) were good responders (>50% hair regrowth). Patients with the plurifocal (PF) type of AA and those with a short disease duration (≤3 months) showed better responses. In 60 patients treated with oral cyclosporine with corticosteroid, 30 (50.0%) patients showed a good response. The AA type or disease duration, however, did not significantly affect the response to treatment.

CONCLUSION

Corticosteroid pulse therapy may be a better treatment option than combination therapy in severe AA patients with the PF type.

High Relapse Rates Despite Early Intervention with Intravenous Methylprednisolone Pulse Therapy for Severe Childhood Alopecia Areata

BACKGROUND

Previous data suggest that early application of intravenous methylprednisolone pulse therapy (IV-MPPT) may improve the disease course of alopecia areata. The objective of this study was to investigate the outcome of IV-MPPT in severe childhood alopecia areata, predominantly with short disease duration.

METHODS

Eighteen children (10 girls, 8 boys) younger than 17 years old (median age 7.7 yrs, range 2.1-16.5 yrs) treated with IV-MPPT for severe childhood alopecia areata in a referral center for pediatric dermatology over 3 years (median disease duration 4 mos, range 1-12 mos) were retrospectively evaluated. Five patients had alopecia areata totalis or universalis and 13 had alopecia multilocularis. The median scalp area affected by alopecia was 60% (range 30%-100%). All patients underwent two or three cycles of IV-MPPT at monthly intervals (maximum 500 mg/day on three consecutive days).

RESULTS

Within 7 months after the last IV-MPPT session, 10 of 18 children had good response (≥75% of hair regrowth), with eight showing improvement within the first 4 months. Of the remaining eight patients, one had moderate response (50%-74% regrowth), three had poor response (1%-49% regrowth), and four (all with alopecia areata universalis or totalis) had no response. Seven of the initial 10 good responders experienced relapses, with marked hair loss after the last IV-MPPT session. The estimated median time to relapse was 8 months (95% confidence interval 7, 9 mos).

CONCLUSION

IV-MPPT, even early in the course of disease, did not affect long-term outcome of alopecia areata in our group of severely affected patients.

Detailed clinicopathological characterization of progressive alopecia areata patients treated with i.v. corticosteroid pulse therapy toward optimization of inclusion criteria

The management of progressive alopecia areata (AA) is often challenging. Recently, i.v. corticosteroid pulse therapy has been reported to be effective for acute and severe AA, however, inclusion criteria have not been sufficiently precise, leaving a chance that its efficacy could be further improved by optimizing therapeutic indications. In our attempts to delineate the factors that correlate with favorable outcomes, we minutely evaluated the clinicopathological findings and the prognoses of single-round steroid pulse-treated progressive AA cases with full sets of image and pathology records during the course. Almost complete hair regrowth has been achieved and maintained up to 2 years in five out of seven AA patients with varying degrees of clinical severity. Interestingly, the worst clinical presentation observed during the course correlated with the size of the area where hairs with dystrophic roots were pulled rather than the extent of visible hair loss on the first visit. Dermoscopy detected disease spread but contributed little in assessing prognoses. Dense perifollicular cell infiltration was detected in all cases treated within 4 weeks of onset and those treated later but with excellent response. Importantly, the cases with poor or incomplete hair regrowth were treated 6-8 weeks of onset and showed moderate inflammatory change with high telogen conversion rate. These findings mandate global dermoscopy and hair pull test for judging the treatment indication and suggest that early administration of high-dose corticosteroid, ideally within 4 weeks of onset, enable efficient suppression of active inflammation and maximize the effectiveness of the remedy.

Alopecia areata: an evidence-based treatment update

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.

Early intervention with high-dose steroid pulse therapy prolongs disease-free interval of severe alopecia areata: a retrospective study

Background

Spontaneous recovery of severe alopecia areata is rare and the condition is difficult to treat.

Objective

The aim of this study is to investigate and compare the effects and safety of steroid pulse therapy between oral and intravenous administrations between 1999 and 2010 at the Department of Dermatology, National Cheng Kung University Hospital.

Methods

Data were retrospectively retrieved. A satisfactory response was defined as more than 75% hair regrowth in the balding area.

Results

A total of 85 patients with more than 50% hair loss were identified and treated, with an overall satisfactory response rate of 51.8%. The mean follow-up time was 37.6 months, with a relapse rate of 22.7%. Patients with alopecia areata (hereafter, AA) of recent onset within one year showed higher response rates (p<0.001) and lower relapse rates compared to patients with AA persisting for more than 1 year. Further, even in patients with alopecia totalis, alopecia universalis or ophiasis type, early treatment resulted in a satisfactory response rate of 47% among the treated patients. In general, oral therapy was as effective and well-tolerated as intravenous therapy.

Conclusion

The response rate is determined by disease severity and time of intervention, not by the administration form of steroid pulse therapy. Oral steroid pulse therapy can be considered as the first-line treatment for patients with severe AA of recent onset within one year.

Videocapillaroscopic alterations in alopecia areata

Alopecia areata (AA) is a common hair disorder observed in dermatological practice; however, the exact mechanisms that lead to the hair loss are still unknown. Disturbances in the blood supply of hair follicles may be one of the elements in the complex pathogenesis of AA. Nailfold videocapillaroscopy is a noninvasive technique that allows analysis of skin microcirculation in vivo. The aim of the study was the videocapillaroscopic assessment of skin microcirculation in AA patients. The study included 44 patients with patchy alopecia areata, 27 with alopecia universalis or totalis, and 40 healthy volunteers. Nailfold videocapillaroscopy was performed in all participants according to a standard protocol. Obtained images were assessed qualitatively and quantitatively. Two types of videocapillaroscopic images were distinguished in the study. Abnormal videocapillaroscopic images were found in 42% of patients. Tortuous and branching capillaries (P = 0.013, P = 0.001), decreased density of capillaries (P = 0.009), enlargement of the efferent limb (P < 0.017), or top part of the loop (P = 0.009) were observed significantly more often than in the control group. Only some patients with AA presented with microvascular abnormalities characterised by altered videocapillaroscopic images. More studies, including larger group of patients with AA, are required to determine the role of observed videocapillaroscopic alterations in AA.

Treatment options for alopecia: an update, looking to the future

INTRODUCTION

Hair loss is a very common complaint. The diagnosis is based on clinical, dermoscopic and pathological examination. The treatment is usually continuous and requires strong compliance.

AREAS COVERED

This article aims to i) summarize current treatment options for the most common forms of hair loss; ii) update the literature on treatment options to emerge over the 3 years since the release of the first edition of this article in 2009; and iii) outline future strategies for treating alopecia.

EXPERT OPINION

There is good evidence-based information for the treatment of androgenetic alopecia. There are very few good-quality randomized studies, and no information about long-term results for most of the available treatments for alopecia areata and cicatricial alopecias. Significant research success has been achieved over the past few years through i) discovering the genetic profile of alopecia areata; ii) working on follicular neogenesis in androgenetic alopecia; and iii) discovering the PPAR-γ pathway in scarring alopecia.

Alopecia areata: a new treatment plan

Many therapeutic modalities have been used to treat alopecia areata, with variable efficacy and safety profiles. Unfortunately, none of these agents is curative or preventive. Also, many of these therapeutic agents have not been subjected to randomized, controlled trials, and, except for topical immunotherapy, there are few published studies on long-term outcomes. The treatment plan is designed according to the patient's age and extent of disease. In this paper, the therapeutic agents are organized according to their efficacy and safety profiles into first-line, second-line, and third-line options.

Prognostic factors in methylprednisolone pulse therapy for alopecia areata

Many treatments induce remission in patients with alopecia areata. Systemic steroids, for example, are effective in the treatment of severe alopecia areata but have many side-effects. To avoid these side-effects, high-dose bolus infusions of methylprednisolone have been used to treat severe alopecia areata. The purpose of this study was to evaluate the prognostic factors associated with pulse therapy and to establish proper indications for methylprednisolone pulse therapy. Seventy patients with severe alopecia areata were treated i.v. with methylprednisolone on 3 consecutive days. All of the patients had rapid and extensive hair loss with the bald area exceeding 50% of the scalp. Seventy percent of the patients showed terminal hair growth and 41.4% showed complete responses with acceptable cosmetic outcomes. The prognostic factors that influenced successful outcome were the disease duration before treatment and the type of alopecia areata. Based on these two factors, a good response was obtained for all types of alopecia areata with a duration of 3months or less before treatment and for the plurifocal type of alopecia areata with a duration of 4-6months. Methylprednisolone pulse therapy is indicated for those alopecia areata patients who fall within our good response group.

Coudability hairs: a revisited sign of alopecia areata assessed by trichoscopy

BACKGROUND

We have previously reported several trichoscopic (dermatoscopic) characteristics, such as black dots, 'exclamation-mark' hairs, broken hairs, yellow dots and clustered short vellus hairs as being useful clinical indicators for alopecia areata (AA). 'Coudability hairs', which are normal-looking hairs tapered at the proximal end, have been previously reported as another sign of AA.

AIMS

To use trichoscopy to evaluate coudability hairs as a clinical indicator for the disease activity of AA and a substitute-marker for the hair-pull test.

METHODS

Trichoscopic examinations of hair loss and perilesional areas on the scalps of 100 East Asian patients with AA were performed using a dermatoscope. Using Spearman's rank-order correlation coefficient by rank test, we examined the correlations of scores between coudability and AA disease activity, severity or duration and other trichoscopic features, and then evaluated the coudability score as a surrogate-marker for the hair-pull test.

RESULTS

Coudability scores correlated positively with AA disease activity, hair-pull tests, short duration, black dots and exclamation-mark hairs, and correlated negatively with short vellus hairs.

CONCLUSIONS

Coudability hairs, more closely perceived by trichoscopy, are useful-markers for disease activity in AA and provide a surrogate-marker for the hair-pull test.

An update on alopecia areata

PURPOSE OF REVIEW

Alopecia areata is one of the most frequent organ-restricted autoimmune diseases, yet its pathogenesis is still unclear. In addition, although alopecia areata often results in significant psychological distress, effective treatment is lacking.

RECENT FINDINGS

New potential susceptibility loci have been implicated, but the strongest evidence points to certain class II human leukocyte antigen alleles. There is new evidence for the collapse of hair follicle immune privilege as a key step in the pathogenesis of alopecia areata. There is also new basic science evidence for stress as a contributing factor in the development of alopecia areata. Few treatments for alopecia areata have been well evaluated in randomized trials.

SUMMARY

Although multiple potential susceptibility loci have been implicated, the genetics of alopecia areata is still unclear. The role of any potential environmental contributors is also unclear. Quality evidence for efficacy of currently used treatments for alopecia areata is lacking.

Adolescent hair loss

PURPOSE OF REVIEW

Hair loss, or alopecia, may occur as a primary skin disorder or because of an underlying health problem. It may be upsetting to patients, particularly adolescents who are experiencing physical, emotional, and psychological transitions. Understanding the impact of alopecia is important for care providers who see adolescents.

RECENT FINDINGS

The most common forms of alopecia in adolescence are telogen effluvium, androgenetic alopecia, and alopecia areata. Telogen effluvium may present suddenly or insidiously secondary to a variety of triggers. Androgenetic alopecia may begin in adolescence, and topical minoxidil is effective at retarding further hair loss. It may be a sign of underlying androgen excess, particularly polycystic ovary syndrome in women. Alopecia areata is less common, but may be distressing, especially if hair loss is extensive. Because treatments for alopecia are not curative, helping affected patients cope by offering support and nonpharmacologic techniques to help appear more like their peers should be part of care.

SUMMARY

Physicians need to be skilled in evaluating the most common forms of alopecia presenting in adolescence and should be aware of potential treatments, including the value of psychosocial support.