Alopecia Areata Treatment & ManagementMay wwork, Author: Treatment is not mandatory because the condition is benign, and spontaneous dork and recurrences are do steroid injections for alopecia work. Treatments used are believed to stimulate hair growth, but no evidence indicates they can influence the ultimate natural course of alopecia metabol steroid side effects. Treatment modalities usually are considered first according to the extent of hair loss and the patient's age. Assessment of the efficacy of a treatment must be considered with care because the condition is highly unpredictable in presentation, evolution, and response to treatment.
Intralesional Steroids for Alopecia Areata
May 08, Author: Treatment is not mandatory because the condition is benign, and spontaneous remissions and recurrences are common. Treatments used are believed to stimulate hair growth, but no evidence indicates they can influence the ultimate natural course of alopecia areata. Treatment modalities usually are considered first according to the extent of hair loss and the patient's age. Assessment of the efficacy of a treatment must be considered with care because the condition is highly unpredictable in presentation, evolution, and response to treatment.
Little data exist regarding the natural evolution of the condition. Vestey and Savin [ 21 ] reviewed 50 patients with extensive alopecia areata. The relapse rate is high in patients with severe forms of alopecia areata. Patients with alopecia totalis or alopecia universalis usually have a poorer prognosis, and treatment failure is seen in most patients with any therapy.
Because alopecia areata is believed to be an autoimmune condition, different immunomodulators have been used to treat this condition. Additional treatment options for alopecia areata include minoxidil and other treatment modalities. For intralesional steroids, few studies are available regarding efficacy; however, they are used widely in the treatment of alopecia areata. Intralesional steroids are the first-line treatment in localized conditions and are usually superior to topical corticosteroids.
Regrowth usually is seen within weeks in responsive patients. Patients with rapidly progressive, extensive, or long-standing alopecia areata tend to respond poorly. Another study showed regrowth in most patients treated with intralesional steroids, except in two patients with alopecia universalis.
Hair growth may persist for months after a single injection. Injections are administered intradermally using a 3-mL syringe and a gauge needle. Triamcinolone acetonide Kenalog is used most commonly; concentrations vary from 2. The lowest concentration is used on the face.
A study showed no difference in regrowth when using 2. Caution should be used in patients with glaucoma when treating the eyebrows. It may be best to consult with their ophthalmologists. The presence of atrophy should prompt a reduction in the triamcinolone acetonide concentration and avoidance of the atrophic site. For topical steroids, again, few studies have been performed regarding efficacy in the treatment of alopecia areata; they can however be useful, especially in children who cannot tolerate injections.
Fluocinolone acetonide cream 0. Children younger than 10 years responded better, as did patients with a duration of hair loss of less than 1 year. A study by Tosti et al [ 25 ] in patients with alopecia totalis or alopecia universalis showed that the use of 2.
Regrowth was seen weeks after the onset of therapy. Regrowth was maintained for at least 6 months after cessation of therapy in 5 Even though only Treatment must be continued for a minimum of 3 months before regrowth can be expected, and maintenance therapy often is necessary.
Despite these data, the authors do not believe that monotherapy with a topical steroid has been of great benefit in the authors' practice. The most common adverse effect is local folliculitis, which appears after a few weeks of treatment.
Telangiectases and local atrophy also have been reported. No systemic adverse effects have been reported. Topical immunotherapy [ 1 ] is defined as the induction and periodic elicitation of an allergic contact dermatitis by topical application of potent contact allergens. These are compounded investigational agents not approved by the US Food and Drug Administration for use in alopecia. Dinitrochlorobenzene DNCB has become less popular as a result of reports that it is mutagenic in the Ames assay a bacterial assay.
No rigorous toxicologic and pharmacologic studies have been performed on the use of these agents in humans. Acetone solutions and alcohol solutions of SADBE are equally stable for 2 months under storage conditions. DPCP occasionally can contain mutagenic contaminants; therefore, it should be screened periodically to ensure purity.
No formal data are available on DPCP regarding its longevity in solution. Wiseman et al [ 26 ] retrospectively reported the results of a large cohort of consecutive patients treated with DPCP. Their analysis showed that the cumulative patient response at 32 months was The response rate varied with the extent of the alopecia.
Cosmetically acceptable regrowth was seen in Age at onset was also a significant variable, with older age at onset leading to a better prognosis. A lag period of 3 months was usually present between the onset of therapy and the presence of regrowth.
The median time to achieve significant regrowth was Some patients showed regrowth on the treated side after 18 months of therapy. No benefit is achieved with continuing therapy after 24 months in the absence of regrowth. The relapse rate after reaching significant regrowth was The only variable that seemed to affect response to treatment was the baseline extent of the alopecia areata.
The type of alopecia areata before treatment, duration of the disease, and the presence of nail changes were found to predict a lower response to treatment. Age at onset and sex of the patient do not appear to influence the prognosis.
Controversy exists concerning whether atopy is an adverse prognosis factor. Topical immunotherapy has been used for almost 20 years; no serious adverse effects have been reported. The most common side effect, which is desired, is a mild contact dermatitis redness, scaling, itching.
Adverse effects include cervical lymphadenopathy and pigment changes. Vitiligo developed on the application site in 6. Transient leukoderma on a distant untreated area has been reported. Confetti-type dyschromia ie, hyperpigmentation, hypopigmentation has been described as an adverse effect of DPCP treatment and occurred in 1.
Less common adverse effects include erythema multiforme—like eruptions and urticaria, which were reported in 3 patients treated with DPCP. The mechanism of action of topical immunotherapy is unknown. Antigenic competition has been hypothesized. That is, the introduction of a second antigen can initiate a new infiltrate containing T-suppressor cells and suppressor macrophages that may modify the preexisting infiltrate and allow regrowth.
Because topical immunotherapy involves the production of contact sensitivity in a previously naive patient, it is best to seek approval for the treatment by the ethics review board and to have the patient sign an informed consent. Acetone-based solutions usually are preferred because they evaporate quickly, allowing patients to wear a hat or wig immediately after treatment.
Quick drying also decreases the chances of dissemination to other body parts by contact. The concentration is increased slowly every week as needed until a mild tolerable allergic contact dermatitis is elicited. Many concentrations are available that achieve this goal. Treating only half of the head allows the physician to use the untreated half as a control. Once regrowth occurs on the treated half, treatment can be applied to the entire scalp.
If regrowth initially occurs on both sides, spontaneous remission is likely, although treatment cannot be excluded as the cause. Avoid severe contact dermatitis. Patients are advised to avoid light exposure on the scalp for 48 hours because light degrades the chemical.
Patients also are advised not to wash the scalp for 48 hours. Initial regrowth may be seen at weeks Once cosmetically acceptable regrowth is achieved, the treatment can be tapered gradually. Almost all patients relapse if the treatment is discontinued, and maintenance treatment is needed. Both short-contact and overnight treatments have been used.
Anthralin concentrations varied from 0. A study by Tang et al [ 28 ] showed no benefit in using anthralin. The mean time to response was 11 weeks, and the mean time to cosmetic response was 23 weeks. Half the body was treated with anthralin 0. Four mice had almost complete regrowth. The untreated side showed either no regrowth or continued hair loss.
Cytokine studies performed with an RNase protection assay showed that tumor necrosis factor-alpha and -beta were inhibited in mice that responded to treatment. Most patients experienced irritant contact dermatitis. Whether the dermatitis is necessary for efficacy remains under debate.
No correlation exists between duration of the current episode and response to treatment. Adverse effects include pruritus, erythema, scaling folliculitis, local pyoderma, and regional lymphadenopathy.
Withholding treatment for a few days results in rapid disappearance of adverse effects. Treatment then can be reinstituted, but anthralin should be left on for shorter periods. Staining of clothes and skin can be a concern. The mechanism of action of anthralin is unknown. Most likely, it creates inflammation by generating free radicals, which have antiproliferative and immunosuppressive actions.
Minoxidil was of little benefit in patients with alopecia totalis or alopecia universalis.