An Updated Review on Current Treatment of Alopecia Areata and Newer Therapeutic Options
Keywords:
Alopecia areata, immunosuppressant, management, new drugs, therapy
Abstract:
Alopecia areata (AA) is a dermatological disease that causes nonscarring hair loss. It can occur at any age and has an unpredictable and variable evolution in individuals. The aim of this review is to provide an update on the novel therapies currentl
Article:
INTRODUCTION
Alopecia areata (AA) is an immune-mediated disease that produces nonscarring hair loss. AA may occur as an acute self-limiting disorder with one to five patches that resolve within 6–12 months, as a chronic disorder with multiple patches relapsing and remitting over many years, or as total hair loss of the scalp or universal loss of every terminal hair on the body.[1] AA has a reported incidence of 0.1%–0.2%, with a lifetime risk of 1.7%.[2]
The onset of AA typically occurs before 40 years of age; however, late onset is also well described.[3] Men and women appear to be equally affected, and there is no known racial predisposition.
The response of AA to treatment is unpredictable. Some patients regrow spontaneously without medical intervention within 12 months. Even during a course of successful treatment, minor relapses can occur. It is not uncommon for a patient to develop a new lesion of AA on one part of the scalp while simultaneously experiencing regrowth in a recently treated patch of AA on another part of the scalp.[4]
TREATMENT OF ALOPECIA AREATA
AA is a benign condition in majority of the affected individuals, and spontaneous remission is common. Treatment is mainly directed toward halting the disease activity as there is no evidence that the treatment modalities influence the ultimate natural course of the disease. Treatment modalities depend upon the extent of hair loss and the patient’s age. The management of AA should focus on both regrowth and maintenance of hair growth. The outcome is unpredictable because of frequent relapses. Given the chronic nature of AA, most therapies lose efficacy after being discontinued.
CURRENT TREATMENTS
The need for new therapies for AA exists due to the limited efficacy provided by most currently available treatments, especially in cases of extensive hair loss.
TOPICAL THERAPY
Topical corticosteroids
The first-line treatment for most patients with patchy AA is a topical corticosteroid. Addressing the impressive inflammatory process occurring in AA, corticosteroids have by far been the most commonly used treatment modality.[5] They are a good option in children because of their painless application and wide safety margin.[6] Treatment must be continued for a minimum of 3 months before regrowth can be expected, and maintenance therapy often is sometimes necessary. Topical corticosteroids have limited benefits in patchy AA and can be associated with folliculitis.[7] A study conducted by Das et al. revealed 70% hair regrowth at the end of 3 months with the use of topical steroids.[8]
Intralesional corticosteroids
Intralesional corticosteroids are widely used in the treatment of AA. In fact, they are the first-line treatment in localized conditions involving <50% of the scalp.[9] Hydrocortisone acetate (25 mg/ml) and triamcinolone acetonide (5–10 mg/ml) are commonly used. Intralesional triamcinolone acetonide 5–10 mg/ml is injected locally every 4–6 weeks in multiple 0.1 ml injections approximately 1 cm apart. The solution is injected in or just beneath the dermis, and a maximum of 3 ml on the scalp in one visit is recommended. It results in localized hair growth in about 60% of treated sites.[10]
Lower concentrations of 2.5 mg/ml are used for eyebrows and face. Regrowth usually is seen within 4–6 weeks in responsive patients. Skin atrophy at the sites of injection is a common side effect, particularly if triamcinolone is used, but this usually resolves after a few months. Relapses often occur.[11]
Repeated injections at the same site or the use of higher concentrations of triamcinolone should be avoided as this may lead to prolonged skin atrophy. Pain limits the practicality of this treatment method in children who are <10 years of age. Severe cases of AA, alopecia totalis, alopecia universalis, as well as rapidly progressive AA, respond poorly to this form of treatment.[12] A study by Ganjoo and Thappa revealed 47% regrowth at 12 weeks and 95% regrowth at 24 weeks with intralesional triamcinolone acetonide at intervals of 4 weeks.[13]
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