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areata treatment Alopecia areata AA is a T lymphocytemediated autoimmune disease of the hair follicle It is characterized by patchy hair loss developing

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Slide1

In the name of God

Alopecia

areata

treatment

Slide2

Alopecia areata

(AA) is a T lymphocyte-mediated

autoimmune disease

of the

hair

follicle

.

It is characterized by

patchy hair

loss

developing

in otherwise normal skin, with

exclamation

mark

’ hairs

around margins of expanding areas

.

Most cases are

limited to

one or more coin-sized patches, but in severe cases

there may be

complete

baldness of the scalp (alopecia

totalis

, AT) or of the

entire body (alopecia

universalis

, AU).

The

alopecia is

non-

cicatrizing

,and

in most cases resolves spontaneously after

a few months.

Slide3

MANAGEMENT STRATEGY

Spontaneous remission often

occurs

.

Treatment

can

be time-consuming

, uncomfortable, and potentially toxic,

and

relapse

after

treatment.

Many patients

are distressed so psychological support can be

helpful,and

careful

management

of expectations’ from treatment

is important

.

Slide4

Intralesional

corticosteroid injections

are considered

first-line treatment

for adult

patients

when only one or two small

patches of

alopecia are present, but can be

used

on larger areas if

patients can

tolerate the discomfort

.

The authors most frequently

use

triamcinolone

acetonide

aqueous

suspension

injected

intradermally

and

do

not inject more

than 20 mg in total at one visit

.

Treatment

is

repeated at

intervals of 4–12 weeks

.

The main side

effect

is pitting

atrophy which

is usually transient

.

Slide5

Topical

immunotherapy

is the induction of contact allergy on

the Scalp.

Contact sensitizers

include

diphencyprone

(DPCP

,

diphenylcyclopropenone

).

DPCP

can

initially be

applied

as 2% lotion to a small area (2–4 cm2

) of scalp

until the

site of application becomes pruritic and erythematous

.

Treatment is then

continued over a larger area with weekly

applications of

lower

concentrations

,

typically ranging from

0.001% to

0.1

%.

The lowest concentration

that

maintains mild

erythema or

pruritus should be used

.

Slide6

Relapse rates may be

high

.

Side

effects

:

regional lymphadenopathy

rarely

autosensitization

resulting

in generalized eczema or

even an eruption

resembling erythema

multiforme

.

Vitiligo

may

develop,this

is usually confined to the treated

areas

For

this

reason

sensitization

therapy is best avoided in

patients with

pigmented skin types.

Slide7

Topical

corticosteroids

have

demonstrated efficacy in some

studies of

patchy AA,

particularly

those using

potent steroids with occlusion

.

main

side effect

is

transient folliculitis

.

Topical prostaglandin analogues

have been reported as

effective in

treating the

eyelashes

of patients affected with AU

.

Irritants,

including

anthralin

(

dithranol

)

and

retinoic acid

, are safe and practical to

use, although the evidence for their efficacy is limited.

Slide8

Topical

minoxidil

is a safe treatment, but most studies

have failed

to demonstrate

a response

of cosmetic value in

most patients.

Systemic corticosteroids

are effective in some cases if

high

doses

are

used

.

AT, AU, and

ophiasiform

AA do not

respond well

and high relapse

rates.

Systemic cyclosporine and methotrexate

also appear effective

if given

in

high

dosage

, but the response is not maintained on

cessation of

therapy

.

Slide9

Other less conventional treatments include:

PUVA

,

nitrogen

mustard, lasers

,

topical

bexarotene

, topical

azelaic

acid,

combination

of

simvastatin

and

ezetimibe

,

combination of topical

garlic

and

topical

steroids,cryotherapy

Treatments that do not appear

to be beneficial

include:

topical

imiquimod

,

topical

tacrolimus

,

topical

pimecrolimus

,

botulinum

toxin

type A

,

topical

tri-

iodothyronine

ointment

,

photodynamic therapy

, narrowband UVB, topical

5-fluorouracil

, capsaicin

and,so

far

, biologics.

Slide10

SPECIFIC INVESTIGATIONS

CBC

thyroid

function

tests

serum

B12

autoantibodies

as a

screen for associated

autoimmune

conditions

No routine

investigation is normally necessary and the

diagnosis

is essentially

clinical

.

in

patients with symptoms

or a

family history of autoimmune

diseases

, such as

thyroiditis,pernicious

anemia, or Addison disease,

autoantibody

screening and

further investigation may be

indicated.

Slide11

FIRST-LINE THERAPIES

Intralesional

steroids

Topical

immunotherapy

Slide12

SECOND-LINE THERAPIES

Topical corticosteroids

Anthralin

/

dithranol

Retinoic acid

Topical

minoxidil

Bimatoprost

/

Latanoprost

eye drops (for eyelashes)

PUVA

Slide13

THIRD-LINE THERAPIES

Systemic corticosteroids

Systemic cyclosporine

Oral

minoxidil

Sulphasalazine

Methotrexate

Azathioprine

Nitrogen

mustard

Dermatography

Slide14

Cryotherapy

Pulsed infrared diode laser

Excimer

laser

Topical

bexarotene

Topical

azelaic

acid

Combination treatment of simvastatin and

ezetimibe

Onion juice

Combination of topical garlic gel and

topical betamethasone

valerate

Slide15

Fexofenadine hydrochloride enhances the efficacy of

contact immunotherapy for extensive alopecia

areata

Retrospective analysis

of 121 cases.

This retrospective study showed better response

to

topical immunotherapy

in the

atopic

subgroup

of patients treated

with oral

fexofenadine

60 mg daily for adults

and

30 mg daily

for children

.

Slide16

Clobetasol propionate 0.05% under occlusion in the

treatment of alopecia

totalis

/

universalis

.

A group of 28 patients with AT/AU of 3–12 years’ duration

who had

not responded to

immunotherapy

were treated on half

of their

scalp with 2.5 g of

clobetasol

propionate

ointment

under plastic

film on 6 nights per week for 6 months. Regrowth

started at

6–14 weeks, and

8

patients (28.5%) achieved >

75% regrowth

, which

was

then extended to the other side of the

scalp.11

patients developed painful

folliculitis

,

After a further 6

months’follow

-up

17.8% of the 28 patients retained

complete

regrowth.

Slide17

Treatment of alopecia

areata

by

anthralin

-induced

dermatitis

.

In this study using

0.5% and 1.0% concentrations

of

anthralin,the

mean time to

response

was 11 weeks and the mean time

to cosmetic

response was 23 weeks

(

range 8–60 weeks).

Cosmetic response

was achieved in 29% (11/38) of patients with

<75% scalp

hair loss and in 20% (6/30) of patients with >75%

scalp hair loss.

Slide18

Topical tretinoin

as an adjunctive therapy with

intralesional

triamcinolone acetonide for alopecia areata

In this open study 58 patients with mainly patchy

alopecia were

treated with monthly

triamcinolone

injections; 28

patients also

had daily application of

0.05%

tretinoin

cream

. More

than 90

% regrowth was achieved in 66.7% of patients

with

triamcinolone alone

, and in 85.7% of patients with both treatments, which

was statistically significant.

Slide19

Bimatoprost in the treatment of eyelash

universalis

alopecia

areata

.

In this retrospective study of 41 patients, 0.03%

bimatoprost

eye

drops were applied

to

the eyelid margins

once a day for

1 year

. Complete regrowth of the eyelashes

was

noted in 24.3%

of patients

and moderate regrowth in 18.9% of subjects.

Slide20

Treatment of alopecia areata

with three different

PUVA modalities

.

76

patients with severe AA were treated with local

or oral

8-methoxypsoralen

and

local

or whole body UVA

irradiation.

In

43 cases (57%) a good-to-excellent result was

obtained.

Patients

with circumscribed

or

ophiasic

alopecia

responded

better than

patients

with

AT or AU.

Disease

duration

,

onset before

the

age of 20

years

,and

atopy

were poor prognostic

Factors.

During

a

follow-up

period

of 6–68 months, 22 patients had a relapse.

Slide21

High-dose pulse corticosteroid therapy in the treatment of

severe alopecia

areata

.

In

this prospective open study 30 patients with >30% hair

loss were

treated with three

courses

of

IV methylprednisolone (8

mg/kg

) on 3 consecutive days at

4-week intervals

.

12

of 18

AA patients

achieved >50% regrowth. None of the four patients

with

AT

, five with

AU

, or three with

ophiasic

AA responded

.

Slide22

Placebo-controlled oral pulse prednisolone therapy in

alopecia areata.

43

patients were randomized to receive

oral

prednisolone 200

mg weekly

(

23) or placebo (20) for 3 months.

All patients

had more than 40% scalp hair loss, or

more

than

ten patches

of AA, for more than 9 months.

8

of 23 in the treatment

group showed more than 30% regrowth, compared to

none in

the placebo group.

More

than 60% regrowth occurred in

only

2

patients

, both within the treatment

group

.

Side

effects occurred

in 55%

of the treatment group, compared to 11% in the

placebo group, although all were temporary.

Slide23

Oral cyclosporine for the treatment of alopecia areata

.

6

patients with alopecia (two AA, one AT and three AU)

were treated

with oral

cyclosporine

,

6 mg/kg/day, for 12 weeks

.

Hair regrowth

in the scalp of all patients

occurred

within the

second and

fourth

weeks

of therapy, but cosmetically

acceptable regrowth occurred

in only three

patients

. In no case did this persist

3 months

after stopping the drug.

Slide24

Evaluation of oral minoxidil

in the treatment of alopecia

areata

65

patients with severe AA were treated with

oral

minoxidil

5

mg twice daily

.

Cosmetic

response was reported in

18% of

patients. The drug was well tolerated at

this

dose,

provided

the recommended

restriction on sodium intake (2 g daily) was

observed

. Higher sodium intake increased the risk of

fluid retention

.

Slide25

Efficacy and tolerability of methotrexate in severe childhood

alopecia

areata

In this retrospective study of 14 children with AA,

approximately one-third

of patients

experienced

a clinically

relevant therapeutic

response. The treatment was

administered

once weekly

with a mean maximal dose of 18.9 mg weekly

and a

mean duration

of treatment of

14–2 months

.

Slide26

Could azathioprine be considered as a therapeutic alternative

in the treatment of alopecia

areata

A

total of 20 patients with minimum 6 months history of

AA were

included in this

pilot

study. Azathioprine was taken at a

dose

of

2 mg/kg of body weight

. The

mean

regrowth was 52.3%

and the

mean hair loss before treatment was 72.7%

compared with 33.5

% after 6 months of treatment.

Slide27

Effect of superficial hypothermic cryotherapy

with

liquid nitrogen

on alopecia

areata

72

patients with AA involving >25% of their

scalp (disease

duration 3 days to

15

years) were treated with

liquid nitrogen

on a cotton swab

for two to three seconds

on

a

double freeze–thaw

cycle. This was repeated

weekly for 4 weeks

. Forty

comparable controls were treated with glacial acetic acid in

a bland

emollient

vehicle

three times a day for 4 weeks. More

than 60

% regrowth occurred in 70 (97.2%)

of

the active group,

compared to

14 (35%) of the controls.

Slide28

Combination of topical garlic gel and betamethasone valerate

cream in the treatment of

localised

alopecia

areata

a

double-blinded

randomised

control study

. In

this double-blinded randomized

control

trial, 40

patients were

divided into two groups of garlic gel

and

placebo

. Garlic

gel was

rubbed on the alopecia patches under dressing and

left

for

1 hour

, twice daily for 3 months

in the garlic group. The

same procedure

was

carried out in the control group with placebo

gel.Both

groups received

topical

corticosteroid (

betamethasone cream

0.1% in isopropyl alcohol) twice

daily

. Good and

moderate responses

were observed in 19 (95%) patients in the

group treated

with garlic gel and one (5%) patient in the placebo group.

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