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
Slide2Alopecia 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.
Slide3MANAGEMENT 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
.
Slide6Relapse 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.
Slide7Topical
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.
Slide8Topical
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
.
Slide9Other 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.
Slide10SPECIFIC 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.
Slide11FIRST-LINE THERAPIES
Intralesional
steroids
Topical
immunotherapy
Slide12SECOND-LINE THERAPIES
Topical corticosteroids
Anthralin
/
dithranol
Retinoic acid
Topical
minoxidil
Bimatoprost
/
Latanoprost
eye drops (for eyelashes)
PUVA
Slide13THIRD-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
Slide15Fexofenadine 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
.
Slide16Clobetasol 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.
Slide17Treatment 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.
Slide18Topical 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.
Slide19Bimatoprost 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.
Slide20Treatment 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.
Slide21High-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
.
Slide22Placebo-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.
Slide23Oral 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.
Slide24Evaluation 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
.
Slide25Efficacy 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
.
Slide26Could 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.
Slide27Effect 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.
Slide28Combination 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.