Alopecia Areata

Abstract

Although it is clear from the foregoing that some of the drugs and chemicals used to treat severe alopecia areata are efficacious to some degree, it is impossible to draw any meaningful comparisons among the data outlined in Tables 1 and 2. Virtually all of the studies were designed differently. Differences in chronicity and extent of disease as well as history of previous treatment resistance may significantly affect efficacy data even as two investigators compare the same drug. Drug-induced hair regrowth in alopecia areata may be very slow; a cosmetic response may take 1 to 2 years to achieve. Efficacy determinations made at shorter intervals may, therefore, not reflect true therapeutic potential. Efficacy end points vary significantly and need to be standardized. From a practical standpoint, scalp hair coverage that is deemed by the patient to be cosmetically acceptable seems to be a reasonable efficacy end point to report. Maintenance of cosmetic effect with continued treatment and/or following discontinuation of treatment also is useful to document. Table 3 outlines my approach to therapy of alopecia areata. Topical treatments often must be used for as long as 3 months before evidence of regrowth can be seen. In my experience with severe disease, if topical treatments cannot control a flare or induce regrowth, then the patient will often require either lengthy or frequent courses of systemic steroids. In my experience, prednisone doses as low as 20 mg/d may be associated with aseptic neurosis of the hip or severe gastrointestinal bleeding. Severe alopecia areata is a disease for which all therapies are, at best, palliative and, at worst, potentially harmful to patients who are usually otherwise very healthy. The psychosocial significance of this disease is enormous. The insights shared by a long-time sufferer of the disease mirror those expressed by the many patients with whom I have worked during the past 12 years. Three key elements to effectively treat the patient are (1) to help the patient understand the disease; (2) to encourage the patient to share his or her feelings with the physician, family, friends, and other sufferers of the disease; and (3) to help the patient to maintain a sense of hope for future scientific knowledge and treatment of the disease. With a thorough knowledge of the potential benefits and risks of each treatment or combination treatment, the physician with the patient's understanding and cooperation may then embark on what may be in severe cases a lengthy and sometimes unproductive therapeutic process.

Acquired scalp alopecia. Part II: A review

“…Topical corticosteroids have not been well evaluated but are widely used, particularly in children, and allows a greater area to be treated and may be combined with other measures. Potent topical corticosteroids are generally beneficial but hair loss may flare despite maintenance therapy with corticosteroids, such as betamethasone dipropionate 0.05% cream applied twice daily, and long‐term treatment requires monitoring for side‐effects 31 . Systemic steroids including pulse methylprednisolone have been used, particularly in rapidly progressive and more extensive disease.…”

“…Systemic steroids including pulse methylprednisolone have been used, particularly in rapidly progressive and more extensive disease. This may reduce active hair loss; however, hair loss may recur after cessation and this therapy is not without significant risk 31 –33 …”

“…Whether clinically evident inflammation is required for therapeutic benefit has not been determined. After almost universal early irritation, the clinical level of inflammation usually settles with continuation and therapeutic benefit is maintained 31 , 34 . In psoriasis, which is also probably largely T cell mediated, dithranol has been shown to cause a change in eicosanoid production, is toxic to Langerhans cells, 35 and also reduces lymphocyte infiltration.…”

Urticaria after topical immunotherapy with diphenylcyclopropenone

“…Most of the side‐effects associated with the application of DPC do not require discontinuation of therapy (10–14). Vitiligo (15), persistent hypo/hyperpigmentation (16) and erythema multiforme‐like lesions (17,18), psoriasis of the scalp and contact urticaria (5) are rare.…”