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Pelzer C, Iorizzo M. Alopecia Areata of the Nails: Diagnosis and Management. J Clin Med 2024; 13:3292. [PMID: 38893003 PMCID: PMC11172645 DOI: 10.3390/jcm13113292] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/01/2024] [Revised: 05/24/2024] [Accepted: 05/28/2024] [Indexed: 06/21/2024] Open
Abstract
Background: Alopecia areata (AA) is a common form of non-scarring alopecia characterized by acute hair loss. Nail involvement, though not always present, can occur in AA patients. Nail changes are more frequent in severe forms of AA and in children. Methods: Literature related to nail changes in AA was comprehensively reviewed after a search on the PubMed database without time restrictions in order to identify common clinical presentations and associated factors to aid clinicians with the correct evaluation and management of these dystrophies. Results: Nail changes in AA include pitting, trachyonychia, leukonychia, red lunula, and miscellaneous alterations such as longitudinal ridging and brittle nails. Nail changes are usually asymptomatic but, nevertheless, sometimes cosmetically disfiguring and can be associated with a reduced quality of life and impaired daily activities. Conclusions: Nail changes in AA may precede or follow hair loss and can occur as an isolated finding. Diagnosis may require a biopsy for definitive identification. Spontaneous improvement is possible, particularly in children, and treatment is not always necessary. Further research is, however, needed to establish a consensus on treatment approaches according to age and severity.
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Affiliation(s)
- Christin Pelzer
- Department of Dermatology, Venereology and Allergology, Kantonsspital St. Gallen, 9000 St. Gallen, Switzerland;
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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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A phase 2a randomized vehicle-controlled multi-center study of the safety and efficacy of delgocitinib in subjects with moderate-to-severe alopecia areata. Arch Dermatol Res 2023; 315:181-189. [PMID: 35230488 DOI: 10.1007/s00403-022-02336-0] [Citation(s) in RCA: 8] [Impact Index Per Article: 8.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/26/2021] [Revised: 01/18/2022] [Accepted: 02/10/2022] [Indexed: 12/13/2022]
Abstract
Alopecia areata/AA is an autoimmune cause of nonscarring hair loss. The pathogenesis of AA involves many immune axes, including Th1/Th2 pathways. Delgocitinib is a pan-Janus kinase/JAK inhibitor that broadly blocks pro-inflammatory cytokines and has been effective in other inflammatory skin conditions. Recent human studies/reports have shown that use of some systemic JAK inhibitors led to hair regrowth, suggesting this medication class as a potential therapy for AA. However, topical treatment is desirable due to potential systemic side effects. To assess the efficacy and safety of topical delgocitinib in AA, we conducted a double-blind, randomized, vehicle-controlled clinical trial in 31 moderate-to-severe AA patients that were randomized 2:1 to receive delgocitinib ointment 30 mg/g (n = 20) or ointment vehicle (n = 11) for 12 weeks. The primary endpoint was change in severity of Alopecia Tool/SALT score from baseline to week 12. The secondary endpoint included safety profile by reported adverse events. Twenty-three subjects completed the trial, with eight discontinuing mostly due to voluntary withdrawal. Ten patients receiving delgocitinib ointment and three patients receiving vehicle showed SALT score improvements after 12 weeks, but the mean percent SALT improvement at week 12 compared to baseline between the two arms was not significant (p = 0.92). Our study suggests that delgocitinib ointment is not effective in moderate-to-severe AA, likely due to its inability to penetrate sufficiently deeply into the dermis of the scalp, but larger studies are necessary to assess whether a different formulation of topical JAK inhibitors may be suitable to treat mild or more localized forms of AA.
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Dube V, Bhushan R. Tofacitinib for the Treatment of Twenty-Nail Dystrophy: A Single Case Report. Indian J Dermatol 2022; 67:725-727. [PMID: 36998870 PMCID: PMC10043728 DOI: 10.4103/ijd.ijd_492_22] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 04/01/2023] Open
Abstract
Twenty nail dystrophy refers to the condition of trachyonychia affecting all the twenty nails. The term trachyonychia is used to describe thin brittle nails with excessive longitudinal ridging. Treatment of twenty nail dystrophy is difficult due to poor bioavailability of drugs in nails. Tofacitinib is novel JAK-STAT inhibitor that has been used successfully for the treatment of nail dystrophy with alopecia areata suggests the possibility of the drug being used for twenty nail dystrophy.
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Affiliation(s)
- Vineet Dube
- From the Consultant Dermatologist, Chandrapur, Maharashtra, India
| | - Ravi Bhushan
- Senior Resident, Department of Dermatology, Venereology and Leprology, Government Medical College and Hospital, Chandrapur, Maharashtra, India
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Sahay G. Resistant alopecia areata treated with tofacitinib. Int J Trichology 2022; 14:181-182. [DOI: 10.4103/ijt.ijt_63_22] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/08/2022] [Revised: 09/03/2022] [Accepted: 09/19/2022] [Indexed: 11/06/2022] Open
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Dillon KAL. A Comprehensive Literature Review of JAK Inhibitors in Treatment of Alopecia Areata. Clin Cosmet Investig Dermatol 2021; 14:691-714. [PMID: 34211288 PMCID: PMC8242127 DOI: 10.2147/ccid.s309215] [Citation(s) in RCA: 33] [Impact Index Per Article: 11.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/06/2021] [Accepted: 05/28/2021] [Indexed: 12/13/2022]
Abstract
Alopecia areata (AA) is a chronic, immune-mediated form of nonscarring alopecia that is multifactorial and results in localized patches. It is often described as a self-limiting condition that results in the spontaneous regrowth of hair in most cases. However, this regrowth may take several months or years to occur in some patients, leading to the development of psychoemotional trauma in those that are affected. Although several therapies for AA have been developed and tested, there is no specific treatment that has been approved, leading to the availability of many off-label conventional treatment options, with very limited responses. More recently, with the advancement of pre-clinical and genetic studies, a greater understanding of the pathomechanisms involved in the development of AA has been uncovered. This has resulted in the introduction of targeted therapies that use small molecules to block specific pathways involved in AA pathophysiology. As such, the use of janus kinase (JAK) inhibitors for treatment of AA has emerged. JAK inhibitors block the T-cell mediated inflammatory response thought to be the driving factor behind AA pathogenesis, by inhibiting the janus kinase (JAK) signal transducer and activator of transcription (STAT) signaling pathway, leading to a reversal of hair loss in AA patients. Thus, in an effort to demonstrate the efficacy of JAK inhibitors in the treatment of AA, several studies have been published within recent years. However, the question remains, “Are JAK inhibitors effective and safe in the management of Alopecia Areata?”. This review aims to provide a comprehensive report on the role, efficacy, and outcomes of using JAK inhibitors in the treatment of AA. To competently answer the research question highlighted, the most recent, quality articles published over a 10–15-year period were sourced using PubMed, NCBI, Research gate, Medline, Cochrane Central Register of Controlled Trials, EMBASE and Google scholar. The literature search was primarily focused on randomized controlled trials (RCTs); however, in the absence of such, only the most recently published case reports, case series, clinical trials and open-label studies published to date were included.
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Affiliation(s)
- Kerry-Ann L Dillon
- Department of Microbiology, Immunology and Pharmacology, St. George's University School of Medicine, True Blue, Grenada.,Department of Dermatology, School of Health, Sport & Professional Practice, Faculty of Life Sciences and Education, University of South Wales, Pontypridd, South Wales, UK
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Novoa-Candia M, Sánchez Vanegas G, Arevalo-Rodriguez I, Vaño-Galván S, Urueña Rodriguez MG, Giraldo L, Saceda-Corralo D, Tobias A, Tomlinson J, Ortega-Quijano D, Zamora J. Treatments for alopecia areata: a network meta-analysis. Hippokratia 2020. [DOI: 10.1002/14651858.cd013719] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/09/2022]
Affiliation(s)
- Monica Novoa-Candia
- Paediatric Dermatology Department; Hospital San Jose-Fundación Universitaria de Ciencias de la Salud-FUCS; Bogotá Colombia
| | | | - Ingrid Arevalo-Rodriguez
- Clinical Biostatistics Unit; Hospital Universitario Ramón y Cajal (IRYCIS). CIBER Epidemiology and Public Health (CIBERESP); Madrid Spain
- Centro Asociado Cochrane de Ecuador; Centro de Investigación de Salud Pública y Epidemiología Clínica (CISPEC). Facultad de Ciencias de la Salud Eugenio Espejo, Universidad UTE; Quito Ecuador
| | | | | | - Lucia Giraldo
- Paediatric Dermatology Department; Hospital San Jose-Fundación Universitaria de Ciencias de la Salud-FUCS; Bogotá Colombia
| | | | - Aurelio Tobias
- Tommy’s National Centre for Miscarriage Research, Institute of Metabolism and Systems Research; University of Birmingham; Birmingham UK
| | | | | | - Javier Zamora
- Clinical Biostatistics Unit; Hospital Universitario Ramón y Cajal (IRYCIS). CIBER Epidemiology and Public Health (CIBERESP); Madrid Spain
- Women’s Health Research Unit, Centre for Primary Care and Public Health; Queen Mary University of London; London UK
- Cochrane Associate Centre of Madrid; Madrid Spain
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Yesudian PD, de Berker DAR. Inflammatory nail conditions. Part 2: nail changes in lichen planus and alopecia areata. Clin Exp Dermatol 2020; 46:16-20. [PMID: 32799372 DOI: 10.1111/ced.14352] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/27/2020] [Accepted: 05/29/2020] [Indexed: 02/03/2023]
Abstract
Nail changes are frequently seen in patients with cutaneous lichen planus and alopecia areata. This manuscript provides an updated overview on the clinical features, management and prognosis of both conditions. Searches of electronic databases PubMed and EMBASE were conducted and eligible articles were accessed. Practical management principles relevant to these two conditions are also included.
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Affiliation(s)
- P D Yesudian
- Department of Dermatology, Wrexham Maelor Hospital, Wrexham, UK
| | - D A R de Berker
- Department of Dermatology, Bristol Royal Infirmary, Bristol, UK
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Ferreira SB, Ferreira RB, Scheinberg MA. Topical tofacitinib in treatment of alopecia areata. EINSTEIN-SAO PAULO 2020; 18:eAI5452. [PMID: 32785452 PMCID: PMC7416648 DOI: 10.31744/einstein_journal/2020ai5452] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/17/2019] [Accepted: 01/09/2020] [Indexed: 11/22/2022] Open
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Ismail FF, Sinclair R. JAK inhibition in the treatment of alopecia areata – a promising new dawn? Expert Rev Clin Pharmacol 2019; 13:43-51. [DOI: 10.1080/17512433.2020.1702878] [Citation(s) in RCA: 11] [Impact Index Per Article: 2.2] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/09/2023]
Affiliation(s)
| | - Rodney Sinclair
- Sinclair Dermatology, Melbourne, Australia
- Department of Medicine, University of Melbourne, Melbourne, Australia
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Bhandary DJ, Girisha BS, Mahadevappa BN. Clinico-Dermoscopic Pattern of Beard Alopecia Areata: A Cross-Sectional Study. Indian Dermatol Online J 2019; 10:644-649. [PMID: 31807442 PMCID: PMC6859745 DOI: 10.4103/idoj.idoj_508_18] [Citation(s) in RCA: 10] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/03/2023] Open
Abstract
Background: Alopecia areata (AA) is an autoimmune condition affecting hair-bearing regions of the body. Few studies worldwide have focused exclusively on beard alopecia areata (BAA). Aims: To describe the clinical associations, comorbidities, and dermoscopy of BAA. Materials and Methods: Forty-six patients with BAA were recruited for this hospital-based cross-sectional study. Patients with disease onset of less than 1 month, patches showing extension, and appearance of new patches within the past 1 month were grouped under active disease. Dermoscopy was performed using handheld polarized dermoscope. Chi-square test was applied to know the various associations. P value <0.05 was considered statistically significant. STATA 11.2 was used for analysis of data. Results: The mean age was 31.07 ± 8.72 years. The majority (50%) belonged to 20–29 age group. Twenty-two (48%) patients had active disease. Fourteen (30.43%) patients had extra-beard manifestation of AA. Statistically significant association was noted between active disease and extra-beard manifestation (P = 0.034). Diabetes mellitus and hypertension were noted in one and three patients, respectively. Alcohol abuse was noted in six patients and smoking in five patients. Dermoscopic findings such as black dots, short vellus hair, tapering hair, nonfollicular white dots, regrowing hair, yellow dots, and black dots were similar to findings noted in AA. Uncommon findings such as peripilar sign, i-hair, perifollicular hemorrhage, and tulip hair were observed in BAA. Limitations: Small sample size, lack of follow-up. Conclusion: Trichoscopy of BAA may reveal newer nonfollicular findings, in addition to the follicular findings already described in literature for AA.
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Montilla AM, Gómez-García F, Gómez-Arias PJ, Gay-Mimbrera J, Hernández-Parada J, Isla-Tejera B, Ruano J. Scoping Review on the Use of Drugs Targeting JAK/STAT Pathway in Atopic Dermatitis, Vitiligo, and Alopecia Areata. Dermatol Ther (Heidelb) 2019; 9:655-683. [PMID: 31606872 PMCID: PMC6828894 DOI: 10.1007/s13555-019-00329-y] [Citation(s) in RCA: 47] [Impact Index Per Article: 9.4] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/25/2019] [Indexed: 12/14/2022] Open
Abstract
INTRODUCTION The JAK/STAT signaling pathway is involved in the immune-mediated inflammatory skin diseases atopic dermatitis (AD), vitiligo, and alopecia areata (AA), and represents a potential target when developing treatments. So far, no drugs targeting this pathway have been approved for the treatment of dermatological diseases. We reviewed the use of drugs blocking the JAK/STAT pathway in the aforementioned diseases. METHODS An a priori protocol was published. We used Joanna Briggs Institute Reviewer's Manual methodology to conduct the review and PRISMA Extension for Scoping Review (PRISMA-ScR) to report results. MEDLINE, EMBASE, CINAHL, Scopus, and Web of Science databases were searched in a three-step approach on April 2019 by two researchers. RESULTS Ninety-six mainly multicenter observational studies were included (66, 10, and 20 studies on AA, vitiligo, and AD, respectively). Tofacitinib and ruxolitinib were mainly used for the three diseases, and also upadacitinib, abrocitinib, baricitinib, cerdulatinib, delgocitinib, gusacitinib for AD, and baricitinib, PF-06700841, and PF-06651600 for AA. All patients with AD improved, whereas patients with vitiligo and patients with AA showed varied responses, including unresponsive cases. The safety profiles were similar for all drugs and diseases, mainly comprising mild or no adverse events. CONCLUSIONS Evidence on the efficacy and safety of drugs targeting the JAK/STAT pathway for the treatment of patients with AD, vitiligo, or AA is increasing but is still of low quality.
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Affiliation(s)
- Ana M Montilla
- Immune-mediated Inflammatory Skin Diseases Group, IMIBIC/Reina Sofía University Hospital/University of Córdoba, 14004, Córdoba, Spain
- School of Medicine, University of Córdoba, 14004, Córdoba, Spain
| | - Francisco Gómez-García
- Immune-mediated Inflammatory Skin Diseases Group, IMIBIC/Reina Sofía University Hospital/University of Córdoba, 14004, Córdoba, Spain
- Department of Dermatology, Reina Sofía University Hospital, 14004, Córdoba, Spain
| | - Pedro J Gómez-Arias
- Immune-mediated Inflammatory Skin Diseases Group, IMIBIC/Reina Sofía University Hospital/University of Córdoba, 14004, Córdoba, Spain
- Department of Dermatology, Reina Sofía University Hospital, 14004, Córdoba, Spain
| | - Jesús Gay-Mimbrera
- Immune-mediated Inflammatory Skin Diseases Group, IMIBIC/Reina Sofía University Hospital/University of Córdoba, 14004, Córdoba, Spain
| | | | - Beatriz Isla-Tejera
- Immune-mediated Inflammatory Skin Diseases Group, IMIBIC/Reina Sofía University Hospital/University of Córdoba, 14004, Córdoba, Spain
- Department of Pharmacy, Reina Sofía University Hospital, 14004, Córdoba, Spain
| | - Juan Ruano
- Immune-mediated Inflammatory Skin Diseases Group, IMIBIC/Reina Sofía University Hospital/University of Córdoba, 14004, Córdoba, Spain.
- Department of Dermatology, Reina Sofía University Hospital, 14004, Córdoba, Spain.
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Berbert Ferreira R, Ferreira SB, Scheinberg MA. An excellent response to tofacitinib in a Brazilian adolescent patient with alopecia areata: A case report and a review of the literature. Clin Case Rep 2019; 7:2539-2542. [PMID: 31893096 PMCID: PMC6935663 DOI: 10.1002/ccr3.2484] [Citation(s) in RCA: 8] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/02/2019] [Revised: 08/04/2019] [Accepted: 08/06/2019] [Indexed: 01/06/2023] Open
Abstract
Alopecia areata is a common autoimmune disease, with a negative impact in health-related quality of life, especially when affecting children and adolescents. Current medical therapies, mainly for severe disease, are not effective. There are no FDA (Food and Drug Administration)- or ANVISA (Agência Nacional de Vigilância Sanitária)-approved therapy for children with alopecia areata. JAK inhibitors are emerging as a promising therapy.
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Tegtmeyer K, Zhao J, Maloney NJ, Atassi G, Beestrum M, Lio PA. Off-label studies on tofacitinib in dermatology: a review. J DERMATOL TREAT 2019; 32:399-409. [PMID: 31581859 DOI: 10.1080/09546634.2019.1673877] [Citation(s) in RCA: 16] [Impact Index Per Article: 3.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/25/2022]
Abstract
PURPOSE Tofacitinib citrate is an oral Janus kinase 1/3 inhibitor approved for rheumatoid arthritis, ulcerative colitis, and active psoriatic arthritis. Tofacitinib is being increasingly used off-label for dermatological conditions, with varying efficacy across recent studies. A review of these studies will be a helpful resource for dermatologists considering the use of tofacitinib for conditions refractory to first-line therapies. MATERIALS AND METHODS MEDLINE, Embase, CINAHL Plus, Cochrane Library, Scopus, Web of Science, Clinicaltrials.gov, and the WHO International Clinical Trials Registry Platform were all searched for articles and trials mentioning the term 'tofacitinib', then manually reviewed to identify published data on off-label uses of tofacitinib. The article was structured according to the quality of the evidence available. RESULTS Tofacitinib appears to show strong efficacy for numerous dermatologic conditions. Randomized controlled trial data is available for atopic dermatitis, alopecia areata, and plaque psoriasis. Case report and case series data is available for numerous other dermatologic conditions. CONCLUSION While tofacitinib has a wide array of immunoregulatory properties, making it a possible candidate for treating many dermatologic conditions refractory to other treatments, further testing is needed to better characterize its efficacy and utility moving forward, as well as its safety and adverse effect profile.
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Affiliation(s)
- Kyle Tegtmeyer
- Department of Dermatology, Northwestern University Feinberg School of Medicine, Chicago, IL, USA
| | - Jeffrey Zhao
- Department of Dermatology, Northwestern University Feinberg School of Medicine, Chicago, IL, USA
| | - Nolan J Maloney
- Division of Dermatology, Department of Medicine, David Geffen School of Medicine at UCLA, Los Angeles, CA, USA
| | - Giancarlo Atassi
- Department of Dermatology, Northwestern University Feinberg School of Medicine, Chicago, IL, USA
| | - Molly Beestrum
- Department of Dermatology, Northwestern University Feinberg School of Medicine, Chicago, IL, USA
| | - Peter A Lio
- Department of Dermatology & Pediatrics, Northwestern University Feinberg School of Medicine, Chicago, IL, USA.,Medical Dermatology Associates of Chicago, Chicago, IL, USA
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15
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de Oliveira AB, Alpalhão M, Filipe P, Maia-Silva J. The role of Janus kinase inhibitors in the treatment of alopecia areata: A systematic review. Dermatol Ther 2019; 32:e13053. [PMID: 31381252 DOI: 10.1111/dth.13053] [Citation(s) in RCA: 15] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/03/2019] [Revised: 07/29/2019] [Accepted: 07/31/2019] [Indexed: 12/18/2022]
Abstract
Alopecia areata (AA) is a non-scarring alopecia, which often carries a major impact on patients' quality of life. Currently there is no single approved treatment that effectively induces permanent remission. Recently, the JAK-STAT signaling pathway has emerged as a possible therapeutic target leading to increased interest in the use of Janus kinase (JAK) inhibitors (JAKis) in the treatment of this pathology. This review of the literature summarizes information on patients with AA who underwent treatment with JAKis and discusses the current evidence on the efficacy and safety of its use. A literature search was conducted in different databases to identify clinical trials and case reports published in January 2019. Several clinical studies have shown very promising results in the treatment of AA with oral formulas of JAKis. These agents, however, need chronic administration to maintain response. Topical formulations did not show satisfactory responses. The safety profile of these agents appears to be favorable. Current evidence is promising regarding the efficacy and safety of oral JAKis. However, the data obtained are of low quality, originating predominantly from reports of clinical cases. Further studies are needed to confirm these data and to optimize its long-term efficacy and safety.
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Affiliation(s)
| | - Miguel Alpalhão
- Dermatology and Venereology Department, Hospital de Santa Maria, Centro Hospitalar Lisboa Norte, Lisbon, Portugal.,Dermatology Investigation Unit, Instituto de Medicina Molecular, University of Lisbon, Lisbon, Portugal
| | - Paulo Filipe
- Dermatology and Venereology Department, Hospital de Santa Maria, Centro Hospitalar Lisboa Norte, Lisbon, Portugal.,Dermatology Investigation Unit, Instituto de Medicina Molecular, University of Lisbon, Lisbon, Portugal.,Universitary Clinic of Dermatology, Faculty of Medicine, University of Lisbon, Lisbon, Portugal
| | - João Maia-Silva
- Dermatology and Venereology Department, Hospital de Santa Maria, Centro Hospitalar Lisboa Norte, Lisbon, Portugal.,Dermatology Investigation Unit, Instituto de Medicina Molecular, University of Lisbon, Lisbon, Portugal.,Universitary Clinic of Dermatology, Faculty of Medicine, University of Lisbon, Lisbon, Portugal
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16
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Phan K, Sebaratnam DF. JAK inhibitors for alopecia areata: a systematic review and meta-analysis. J Eur Acad Dermatol Venereol 2019; 33:850-856. [PMID: 30762909 DOI: 10.1111/jdv.15489] [Citation(s) in RCA: 114] [Impact Index Per Article: 22.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/03/2018] [Accepted: 01/18/2019] [Indexed: 12/14/2022]
Abstract
There have been a number of case reports and small clinical trials reporting promising outcomes of Janus Kinase (JAK) inhibitors tofacitinib, ruxolitinib and baricitinib for alopecia areata (AA). The majority of the literature to date is based on small volume data, with a lack of definitive evidence or guidelines. To determine the expected response of AA to JAK inhibitor therapy and factors which influence response and recurrence rates. A systematic review and meta-analysis was performed according to PRISMA guidelines. From 30 studies and 289 cases, there were 72.4% responders, good responders 45.7% and partial responders 21.4%. Mean time to initial hair growth was 2.2 ± 6.7 months, and time to complete hair regrowth was 6.7 ± 2.2 months. All 37 recurrences occurred when treatment was ceased after 2.7 months. Oral route was significantly associated with response to treatment compared to topical therapy. No difference was found between paediatric and adult cases in proportion of responses. There is promising low-quality evidence regarding the effectiveness of JAK inhibitors in AA. Future large-sized randomized studies are required to confirm findings.
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Affiliation(s)
- K Phan
- Department of Dermatology, Liverpool Hospital, Sydney, NSW, Australia.,Faculty of Medicine, University of New South Wales, Sydney, NSW, Australia
| | - D F Sebaratnam
- Department of Dermatology, Liverpool Hospital, Sydney, NSW, Australia.,Faculty of Medicine, University of New South Wales, Sydney, NSW, Australia.,Departments of Dermatology, Sydney Children's Hospitals' Network, Sydney, NSW, Australia
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17
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Abstract
Various advancements in the diagnosis and management of nail diseases have transpired in recent years. To provide the best care for patients with nail complaints, it is essential that physicians be updated on new diagnostic and treatment modalities. The purpose of this article is to discuss new and oncoming diagnostic and management options for nail disorders, including nail psoriasis, retronychia, brittle nails, onychotillomania, trauma, trachyonychia, and pyogenic granulomas.
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18
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Crowley EL, Fine SC, Katipunan KK, Gooderham MJ. The Use of Janus Kinase Inhibitors in Alopecia Areata: A Review of the Literature. J Cutan Med Surg 2019; 23:289-297. [DOI: 10.1177/1203475418824079] [Citation(s) in RCA: 11] [Impact Index Per Article: 2.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/15/2022]
Abstract
Alopecia areata (AA) is a chronic, immune-mediated disorder that targets hair follicle epithelium, thereby restricting hair growth in localized patches. Although several therapies for AA have been tested, responses with traditional therapies have been limited. In recent years, numerous reports have been published of patients with AA responding to Janus kinase (JAK) inhibitors. This literature review aims to describe AA pathophysiology, explore how and why JAK inhibitors can be used for AA treatment, and review published case reports, case series, and open-label studies published to date. Pathogenesis of AA includes interactions between genetic, environmental, and immune factors and is mediated by the cytokines interferon-γ and interleukin (IL)-15. JAK inhibition resulting in hair regrowth in some cases supports that AA is associated with the Janus kinase-signal transducer and activator of transcription (JAK-STAT) signaling pathway. The emergence of JAK inhibitors for AA therapy is changing the way health care providers think about and treat AA. A mixture of animal model studies and human case studies have reported the use of baricitinib (JAK 1/2), ruxolitinib (JAK 1/2), and tofacitinib (JAK 1/3) for the management of AA. JAK inhibition has shown potential as an effective AA therapy when used in case studies, case series, and open-label trials. Formal clinical trials are ongoing and will yield more definitive conclusions about the safety and efficacy of JAK inhibitors.
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Affiliation(s)
- Erika L. Crowley
- SKiN Centre for Dermatology, Peterborough, ON, Canada
- Trent University, Peterborough, ON, Canada
| | - Shamone C. Fine
- SKiN Centre for Dermatology, Peterborough, ON, Canada
- Trent University, Peterborough, ON, Canada
| | - Kathleen Kwan Katipunan
- SKiN Centre for Dermatology, Peterborough, ON, Canada
- Probity Medical Research, Waterloo, ON, Canada
| | - Melinda J. Gooderham
- SKiN Centre for Dermatology, Peterborough, ON, Canada
- Probity Medical Research, Waterloo, ON, Canada
- Queen’s University, Kingston, ON, Canada
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19
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Triyangkulsri K, Suchonwanit P. Role of janus kinase inhibitors in the treatment of alopecia areata. DRUG DESIGN DEVELOPMENT AND THERAPY 2018; 12:2323-2335. [PMID: 30100707 PMCID: PMC6067625 DOI: 10.2147/dddt.s172638] [Citation(s) in RCA: 40] [Impact Index Per Article: 6.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Indexed: 12/14/2022]
Abstract
Alopecia areata (AA) is a common hair loss disorder worldwide with characteristic exclamation mark hairs. Although AA is self-limited, it can last for several months or even years in some patients. Currently, there is no US Food and Drug Administration-approved treatment for AA. Many off-label treatments are available but with limited efficacy. Through a better understanding of molecular biology, many targeted therapies have emerged as new alternatives for various autoimmune diseases. Various janus kinase (JAK) and signal transducer and activator of transcription (STAT) proteins form signaling pathways, which transmit extracellular cytokine signals to the nucleus and induce DNA transcriptions. By inhibiting JAK, T-cell-mediated inflammatory responses are suppressed. Increasing evidence suggests that JAK inhibitors (JAKis) are effective in the treatment of many autoimmune diseases, including AA. Among these, several studies on tofacitinib, ruxolitinib, and baricitinib in AA had been published, demonstrating promising outcomes of these agents. Unlike oral formulations, efficacy of topical forms of tofacitinib and ruxolitinib reported in these studies is still unsatisfactory and requires improvement. This review aims to summarize evidence of the efficacy and safety of JAKis in the treatment of AA.
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Affiliation(s)
- Korn Triyangkulsri
- Division of Dermatology, Department of Medicine, Faculty of Medicine, Ramathibodi Hospital, Mahidol University, Bangkok, Thailand,
| | - Poonkiat Suchonwanit
- Division of Dermatology, Department of Medicine, Faculty of Medicine, Ramathibodi Hospital, Mahidol University, Bangkok, Thailand,
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20
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Wang EHC, Sallee BN, Tejeda CI, Christiano AM. JAK Inhibitors for Treatment of Alopecia Areata. J Invest Dermatol 2018; 138:1911-1916. [PMID: 30057345 DOI: 10.1016/j.jid.2018.05.027] [Citation(s) in RCA: 47] [Impact Index Per Article: 7.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/27/2018] [Revised: 05/22/2018] [Accepted: 05/27/2018] [Indexed: 01/25/2023]
Abstract
The advancement of genetic and preclinical studies has uncovered the mechanisms involved in the pathogenesis of alopecia areata (AA). The development of targeted therapies using small molecules blocking specific pathways for the treatment of AA is underway. By repurposing Food and Drug Administration-approved small molecule JAK inhibitors as treatments for AA, it has been demonstrated that JAK inhibitors can effectively reverse hair loss in patients with moderate to severe AA. In this review, we summarize and discuss the current preclinical and clinical studies on JAK inhibitors, as well as the prospects of using JAK inhibitors for the treatment of AA.
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Affiliation(s)
- Eddy H C Wang
- Department of Dermatology, Columbia University, New York, New York, USA
| | - Brigitte N Sallee
- Department of Dermatology, Columbia University, New York, New York, USA
| | - Christina I Tejeda
- Columbia College of Physicians and Surgeons, Columbia University, New York, New York, USA
| | - Angela M Christiano
- Department of Dermatology, Columbia University, New York, New York, USA; Genetics and Development, Columbia University, New York, New York, USA.
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21
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Lee JS, Huh CH, Kwon O, Yoon HS, Cho S, Park HS. Nail involvement in patients with moderate-to-severe alopecia areata treated with oral tofacitinib. J DERMATOL TREAT 2018; 29:819-822. [DOI: 10.1080/09546634.2018.1466024] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/27/2022]
Affiliation(s)
- Ji Su Lee
- Department of Dermatology, SMG-SNU Boramae Medical Center, Seoul, Korea
| | - Chang-Hun Huh
- Department of Dermatology, Seoul National University Bundang Hospital, Gyeonggi, Korea
| | - Ohsang Kwon
- Department of Dermatology, Seoul National University Hospital, Seoul, Korea
| | - Hyun-Sun Yoon
- Department of Dermatology, SMG-SNU Boramae Medical Center, Seoul, Korea
| | - Soyun Cho
- Department of Dermatology, SMG-SNU Boramae Medical Center, Seoul, Korea
| | - Hyun-sun Park
- Department of Dermatology, SMG-SNU Boramae Medical Center, Seoul, Korea
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22
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Chelidze K, Lipner SR. Nail changes in alopecia areata: an update and review. Int J Dermatol 2018; 57:776-783. [DOI: 10.1111/ijd.13866] [Citation(s) in RCA: 30] [Impact Index Per Article: 5.0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/14/2017] [Revised: 11/11/2017] [Accepted: 11/12/2017] [Indexed: 11/27/2022]
Affiliation(s)
- Khatiya Chelidze
- Department of Dermatology; Weill Cornell Medicine; New York NY USA
| | - Shari R. Lipner
- Department of Dermatology; Weill Cornell Medicine; New York NY USA
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23
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Wang ECE, Dai Z, Christiano AM. Novel therapies for alopecia areata: The era of rational drug development. J Allergy Clin Immunol 2017; 141:499-504. [PMID: 29155099 DOI: 10.1016/j.jaci.2017.10.028] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/18/2017] [Revised: 09/29/2017] [Accepted: 10/11/2017] [Indexed: 12/19/2022]
Abstract
Treatments for alopecia areata (AA) have evolved over the decades from broad and nonspecific therapies to those that are now more targeted and rationally selected. This was achieved by means of close cooperation and communication between clinicians and basic scientists, which resulted in the elucidation and understanding of the unique pathophysiology of AA. In this review we discuss this evolution and how novel therapies for AA have changed over the decades, what we have in our current arsenal of drugs for this potentially devastating disease, and what the future holds.
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Affiliation(s)
- Etienne C E Wang
- Department of Dermatology, Columbia University, New York, NY; National Skin Center, Singapore
| | - Zhenpeng Dai
- Department of Dermatology, Columbia University, New York, NY
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24
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Abstract
Alopecia areata (AA), a prevalent inflammatory cause of hair loss, lacks FDA-approved therapeutics for extensive cases, which are associated with very poor rates of spontaneous hair regrowth and major psychological distress. Current treatments for severe cases include broad immune-suppressants, which are associated with significant adverse effects, precluding long-term use, with rapid hair loss following treatment termination. As a result of the extent of the disease in severe cases, topical contact sensitizers and intralesional treatments are of limited use. The pathogenesis of AA is not yet fully understood, but recent investigations of the immune activation in AA skin reveal Th1/IFN-γ, as well as Th2, PDE4, IL-23, and IL-9 upregulations. Tissue analyses of both animal models and human lesions following broad-acting and cytokine-specific therapeutics (such as JAK inhibitors and ustekinumab, respectively) provide another opportunity for important insights into the pathogenesis of AA. As reviewed in this paper, numerous novel therapeutics are undergoing clinical trials for AA, emphasizing the potential transformation of the clinical practice of AA, which is currently lacking. Dermatologists are already familiar with the revolution in disease management of psoriasis, stemming from better understanding of immune dysregulations, and atopic dermatitis will soon follow a similar path. In light of these recent developments, the therapeutic arena of AA treatments is finally getting more exciting. AA will join the lengthening list of dermatologic diseases with mechanism-targeted drugs, thus changing the face of AA.
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Affiliation(s)
- Yael Renert-Yuval
- Department of Dermatology, Hadassah-Hebrew University Medical Center, Jerusalem, Israel
| | - Emma Guttman-Yassky
- Department of Dermatology and the Laboratory for Inflammatory Skin Diseases, Icahn School of Medicine at Mount Sinai, New York, NY, USA.
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25
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Jaller JA, Jaller JJ, Jaller AM, Jaller-Char JJ, Ferreira SB, Ferreira R, Scheinberg M. Recovery of nail dystrophy potential new therapeutic indication of tofacitinib. Clin Rheumatol 2017; 36:971-973. [PMID: 28210825 DOI: 10.1007/s10067-017-3574-0] [Citation(s) in RCA: 12] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/26/2017] [Accepted: 02/07/2017] [Indexed: 11/28/2022]
Abstract
Nail dystrophy is a heterogeneous skin condition and in some subtypes, is associated with autoimmune diseases in particular psoriasis and psoriatic arthritis. In this report, we show that tofacitinib, a novel therapy for rheumatoid arthritis, appears to be beneficial in patients with nail disease refractory to other conventional modes of therapy.
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Affiliation(s)
- Jose A Jaller
- Clinica de la Piel, Departamento de Dermatologia, Barranquilla, Colombia
| | - Juan J Jaller
- Centro de Reumatologia y Ortopedia, Division de Reumatologia, Barranquilla, Colombia
| | - Antonio M Jaller
- Clinica de la Piel, Departamento de Dermatologia, Barranquilla, Colombia
| | - Juan J Jaller-Char
- Centro de Reumatologia y Ortopedia, Division de Reumatologia, Barranquilla, Colombia
| | | | | | - Morton Scheinberg
- Hospital Israelita Albert Einstein, Hospital AACD, São Paulo, Brazil.
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