Consider Cultural Practices and Barriers to Care When Treating Alopecia Areata.

Treatment of chronic severe alopecia areata with topical diphenylcyclopropenone and 5% minoxidil: A clinical and immunopathologic evaluation

Background: Alopecia areata (AA) is an autoimmune disorder characterized by nonscarring alopecia affecting scalp and body hair. Treatment of AA in pediatric age group is challenging because of unpredictable course, uncertain natural history, potential side effects of medicines, and psychological morbidity. Moreover, no clear guidelines for treatment of pediatric AA are available. Objective: The objective of this study is to assess efficacy and safety of a combination treatment of extensive and recalcitrant AA with oral and topical steroids with topical minoxidil. Materials and Methods: Sixteen children (nine girls and seven boys) aged 6–15 years with severe and recalcitrant AA were included in this study. All were prescribed the regimen of combination of oral and topical steroid with topical minoxidil 2% solution. Oral steroid was tapered over 12 weeks, and topical steroid was withdrawn at the end of 24 weeks. Patients were maintained on topical minoxidil for next 9–12 months and closely followed up. Results: The average age of participants was 10.81 years, and the duration of disease was ranged from 3 months to 30 months. Response to our regimen was good in cases of extensive AA and ophiasis, compared to alopecia totalis. The participant having alopecia universalis did not respond at all to the regimen. Participants tolerated the regimen well with mild and easy to manage side effects and only few relapses. Conclusion: Finding an effective and safe treatment regimen for AA, especially in children is difficult. Our regimen allows for more rapid lowering of oral doses with maintaining the cosmetic response and minimizing the side effects. Therefore, a trial course of this regiment would seem to be a reasonable approach for nearly hopeless but highly motivated pediatric patients of extensive and recalcitrant AA.

Treatment of severe alopecia areata with baricitinib

Alopecia areata is a common skin disorder of presumed autoimmune etiology and it usually shows an unpredictable course. Treatment of alopecia areata is challenging. There is very little information on the use of surgical therapies for the treatment of alopecia areata in the medical published work. A 24-year-old male patient was referred to a private hair transplantation clinic owned by one of the authors for the treatment of therapy-resistant alopecia areata affecting both eyebrows. He had quickly lost all body hair 4 years prior beginning from the scalp. He received psoralen and ultraviolet A (PUVA) therapy for alopecia universalis and all body hair re-grew except his eyebrows. Alopecia areata was stable for the 18 months following the last medical treatment he received. Because there was no response to various medical therapeutic agents, we decided to transplant occipital hairs to the eyebrow area. After the patient understood and accepted all risks, occipital hairs were transplanted to the eyebrows by using the follicular unit extraction technique. Postoperatively, the patient did not receive any topical or systemic therapies for alopecia areata. Although 40% hair re-growth was detected in his eyebrows at 1 year postoperation, this rate was 80% by 2 years postoperation. However, there was resistance to re-growth in the medial eyebrow regions. New eyebrows grew as occipital hairs and required trimming. His satisfaction from the surgical procedure was 90% at the end of the 24th postoperative month. Surgical treatment of diseases like alopecia areata is still controversial. Our case report offers an additional contribution to the published work on the surgical methods used in the treatment of stable alopecia areata.

IntroductionIntramuscular corticosteroids (IMC) have gained popularity for the treatment of severe alopecia areata (AA) in recent years; however, evidence on their efficacy and safety is still limited.ObjectiveTo evaluate the efficacy, relapse rate, and tolerability of IMC in the treatment of AA, as well as factors associated with treatment outcomes.MethodsTime-to-event analysis was performed on patients with severe, extensive, or rapidly progressive AA receiving IMC. The IMC regimen comprised triamcinolone acetonide 20–40 mg/mL injected every 4–6 weeks. The evaluated outcomes included initial (25% regrowth), significant (75% regrowth), and complete hair regrowth (100% regrowth). Relapse and adverse events were also noted. Factors associated with treatment outcomes and relapse were analyzed using the Cox proportional hazards model.ResultsA total of 101 patients were eligible for analysis. Significant hair regrowth was obtained in 80.2% of the patients (n = 81), in a median time of 3.4 months (95% confidence interval [CI] = 2.9–4.4). Complete hair regrowth was achieved in 48.5% of the subjects (n = 49), and relapse was observed in 47.5% (n = 48). Acneiform eruption was the most common adverse effect. Multivariable analysis revealed that nail involvement was a negative predictor of significant hair regrowth (adjusted hazard ratio [HR] = 0.04, 95% CI = 0.01–0.55; P = 0.015), whereas duration of AA longer than 6 months was associated with disease recurrence (adjusted HR = 4.02, 95% CI = 1.52–4.66; P = 0.005).ConclusionThis study demonstrated the efficacy and safety of IMC in the treatment of severe or active AA; however, the relapse rate remained relatively high after discontinuation of the therapy. Nail involvement was a negative predictor of significant hair regrowth, while disease duration longer than 6 months predicted AA relapse.

Treatment of extensive or recalcitrant alopecia areata (AA) is a major clinical challenge. Even after thorough investigation of several medications, its treatment outcomes have remained unsatisfactory. While there is no US Food and Drug Administration-approved medication for AA yet, topical immunotherapy has been a well-documented treatment option. Dinitrochlorobenzene, squaric acid dibutylester, and diphenylcyclopropenone are three substances that have demonstrated efficacy in the treatment of extensive or recalcitrant AA. Despite being commonly used, the mechanism underlying topical immunotherapy is not well-elucidated and a wide range of clinical efficacies have been reported in the literature. The aim of this review was to summarize and update the pharmacology, mechanism of action, therapeutic efficacy, and tolerability of topical immunotherapy in the treatment of AA.

Intralesional corticosteroids are the treatment of choice for adults with less than 50% of scalp area involvement with alopecia areata. The sensitivity of picking up clinical response to treatment by clinical examination is very variable and has inter individual variation. To evaluate the efficacy of intralesional triamcinolone acetonide in the treatment of alopecia areata and to use dermoscopy to identify signs of early clinical response and adverse effects. Seventy patches in 60 patients were injected with steroid at 4 weeks interval and followed up for 24 weeks. Treatment response was evaluated using regrowth scale (RGS). Heine DELTA 20; dermatoscope was used to assess disease activity, response to treatment and side effects. Twenty eight patients responded early and achieved RGS of 4 within 12 weeks and 29 patients responded late and achieved RGS of 4 within 24 weeks of initiating therapy. There were 3 patients who did not achieve RGS of 4 at 24 weeks. Late and incomplete responders showed statistically significant association with family history of alopecia areata (p < 0.0001), presence of recurrent disease (p = 0.0147) and presence of nail changes (p = 0.0007). Dermoscopically, 60 patches demonstrated regrowth of new vellus hair at 4 weeks. Tapering hair disappeared maximally at 4 weeks. At 12 weeks, complete disappearance was seen in tapering hairs, broken hairs and black dots whereas for yellow dots to disappear completely in all patches it took 16 weeks. The adverse effects were observed at an earlier stage using dermoscopy than clinically. Intralesional triamcinolone acetonide is efficacious for treatment of localized patchy alopecia areata. Dermoscopy is very useful to identify signs of early clinical response, adverse effects and markers of disease activity.

Successful treatment of corticosteroid-resistant ophiasis-type alopecia areata (AA) with platelet-rich plasma (PRP)

Alopecia areata is believed to be an autoimmune condition with a worldwide occurrence. It usually presents as patchy, nonscarring hair loss. There is a paucity of clinical data in Asians. To study the epidemiology, clinical aspects, associations, and treatment of alopecia areata in an Asian population over a 1-year period. Records of all newly diagnosed alopecia areata cases seen from May 1998 to April 1999 at the National Skin Center were collated with regard to the epidemiology, pattern of alopecia, and associations according to the investigational guidelines published by Oslen et al. The treatment and psychologic impact of alopecia areata were also assessed. Two hundred and nineteen new case referrals of alopecia areata were seen from May 1998 to April 1999. The incidence of alopecia areata was 3.8%. There were 173 Chinese (79%), 35 Indians (16%), and 11 Malays (5.0%). The male to female ratio was 1 : 1.3. The median age at presentation was 25.2 years. The majority of patients (85.5%) had their first episode of alopecia areata before the age of 40 years. Of the patients with onset of alopecia areata before the age of 40 years, 36.5% presented with extensive alopecia, compared with 5.5% above the age of 40 years (P < 0.05). Nail changes, consisting of pitting, trachyonychia, and longitudinal ridging, were reported in 23 patients (10.5%). A significant percentage of patients had an associated personal and family history of atopy (60.7%). There was no significant association between a personal history of atopy and the extent of alopecia areata. The frequencies reported for the following associated diseases were: thyroid disease, 2.3%; vitiligo, 4.1%; diabetes mellitus, 3.2%; Down's syndrome, 1.4%; and rheumatic arthritis, 0.9%. A family history of alopecia areata was reported in 4.6%. Intralesional triamcinolone acetonide was the first-line treatment for limited alopecia areata, while squaric acid dibutyl ester was used for extensive involvement. The majority of patients with limited alopecia areata (82.1%) had more than 50% improvement with intralesional triamcinolone acetonide after 3 months. The majority of patients who received squaric acid dibutyl ester (87.5%) achieved more than 50% regrowth at the end of 6 months. Poor prognostic factors for alopecia areata were extensive involvement, early age of onset, and Down's syndrome. Thirteen out of 132 respondents (9.8%) recalled stressful events preceding hair loss. Patients with extensive alopecia areata experienced more psychologic adverse effects than those with limited alopecia areata (P < 0.05). Males with extensive alopecia areata experienced more severe psychologic ill-effects, such as depression and feelings of inability to improve hair loss. Our findings are similar to those reported in the Western literature where alopecia areata is predominantly a disease of the young. A holistic approach is important in the management of alopecia areata as the disease can have a severe psychologic impact on an individual's well-being.

Alopecia areata is the third most common cause of dermatology consultations in children but the treatment of paediatric alopecia areata remains challenging. A systematic review of the literature about the treatment of alopecia areata in children (≤18years old) was performed on 11 May 2020 by searching the PubMed, Scopus and EBSCO databases. The terms used for the search were: 'alopecia areata', 'alopecia totalis' or 'alopecia universalis' combined with 'paediatric', 'children' or 'childhood'. A total of 89 articles were included in final evaluation. The most commonly assessed treatment options in paediatric alopecia areata were topical immunotherapy (response rate in monotherapy: 54%; 187/345) intralesional glucocorticosteroids (75%; 211/280), systemic glucocorticosteroids (73%; 102/140), and anthralin (42%; 31/74). Topical glucocorticosteroids (81%; 35/43), systemic Janus kinase (JAK) inhibitors (90%; 27/30), topical calcineurin inhibitors (42%; 8/19), topical JAK inhibitors (65%; 11/17), PUVA therapy (56%; 9/16) and 308-nm excimer laser (77%; 10/13) were also evaluated. Additionally, evaluation in smaller numbers of paediatric patients included methotrexate (100%; 10/10), topical minoxidil (44%; 4/9) and cyclosporine (83%; 5/6). There were limited data considering children with alopecia areata treated with azathioprine, hydroxychloroquine, topical sildenafil, topical prostaglandin analogues, fractional carbon dioxide laser, leflunomide, mesalazine, apremilast, dupilumab, ustekinumab, efalizumab, botulinum toxin, and compound glycyrrhizin. On the basis of the limited data available glucocorticosteroids (systemic, intralesional or topical) and JAK inhibitors (systemic or topical) may be considered the best documented and most effective treatment options in alopecia areata in children. There are no sufficient paediatric data to compare treatment safety and relapse rates in these therapeutic modalities.

Introduction: Alopecia areata is a common, inflammatory, non-scarring type of hair loss that affects persons of both sexes and all age groups, with prevalence in the general population of approximately 0.1–0.2%. It is characterized by variable clinical presentations, ranging from single or multiple well-circumscribed patches of hair loss to extensive involvement with complete absence of body and scalp hair. Alopecia areata is an autoimmune disease of the hair follicle. Its pathogenesis is associated with loss of follicular immune privilege and T-cell mediated inflammatory response, leading to interruption of the hair growth cycle. The diagnosis of alopecia areata is usually based on clinical manifestations in addition to using severity of alopecia tool score. Currently, there is no treatment for alopecia areata approved by the US Food and Drugs Administration. However, several treatment modalities for alopecia areata have been introduced with variable outcomes. Although topical and systemic immunomodulators are the mainstay options, there is still a lack of high-quality randomized controlled trials supporting these treatment modalities. Topical Corticosteroids are considered the first-line therapy for patch-type alopecia areata. Azelaic acid is a dicarboxylic acid, derived from the fungus Pityrosporum ovale and is regarded as an effective topical therapy for patchy alopecia areata. Aim of study: The present study aims to measure the efficacy of topical azelaic acid cream 20% in the treatment of alopecia areata. Patients and Methods: The all 30 patients were collected from Erbil Dermatology Teaching Center. They were divided into two groups: group A includes fifteen patients on topical clobetasol propionate 0.05% cream; group B includes fifteen patients on topical azelaic acid 20% cream. Both treatment groups were followed up for period of around twelve weeks with monthly check up visits. Both drugs were applied topically once daily at night. Results: the comparison between the baseline and 12 weeks visits for each study group concerning severity of alopecia tool score shows that the mean of the score for both groups at 12 weeks visit is lower than that of baseline visit in a statistically significant way (group A, p=0.007, group B, p=0.036). Conclusions: This study showed that topical azelaic acid cream 20% has an acceptable efficacy in comparison to topical clobetasol ointment 0.05% in the treatment of localized alopecia areata of scalp and can be considered as a therapeutic option for this condition.

The effectiveness of Diphencyprone (DPC) in alopecia areata (AA) was demonstrated in several studies with highly variable response rates ranging from 5% to 85%. The response rate and variable factors affecting the prognosis were studied focusing on long-term follow-up with or without maintenance therapy. A total of 135 cases of AA were treated with DPC. Patients were divided into five groups according to the area of scalp affected: Grade 1 AA: 25-49% scalp affection; Grade 2 AA: 50-74% scalp affection; Grade 3 AA: 75-99% scalp affection; alopecia totalis and alopecia universalis. An initial response was defined as appearance of new terminal hair within treated sites. Excellent response was defined as terminal hair covering >75% of the scalp. Relapse meant >25% hair loss. Maintenance therapy meant ongoing therapy once every 1-4 weeks after excellent response. Follow-up was performed to detect any relapse of AA. Ninety-seven patients continued therapy for >or=3 months. After an initial 3 month lag, cumulative excellent response was seen in 15 patients (15.4%), 47 patients (48.5%), 51 patients (52.6%) and 55 patients (55.7%) after 6, 12, 18 and 24 months respectively in a mean median time of 12 months. The only patient variable affecting the prognosis was baseline extent of AA. Excellent response was seen in 100%, 77%, 54%, 50% and 41% in Grade 1, Grade 2, Grade 3, AA totalis and AA universalis patients respectively. Side-effects were few and tolerable. Hair fall >25% occurred in 17.9% of patients on maintenance and 57.1% of patients without maintenance therapy (P-value=0.025). Diphencyprone is an effective and safe treatment of extensive AA. A long period of therapy is needed and will increase the percentage of responders especially in alopecia totalis and universalis. Maintenance therapy is recommended to reduce the risk of relapse.

Long-term prognosis of subclinical sensitization with diphenylcyclopropenone in patients with alopecia areata

Alopecia areata is an autoimmune disease resulting in partial or total nonscarring hair loss and the treatment of severe alopecia areata is difficult. The aim of this study was to evaluate the efficacy and safety of azathioprine as a systemic monotherapy for moderate to severe alopecia areata. A total of 20 patients [14 men (70%) and six women (30%)] with minimum 6 months history of alopecia areata were included. The extent of scalp hair regrowth during and after the completion of the 6 months treatment was evaluated by the Severity of Alopecia Tool (the SALT score). The daily drug intake was calculated as 2 mg/kg of body weight. Mean duration of current episode of scalp hair loss was 26.4 (26.4 ± 17) months. Mean regrowth percentage was 52.3% (52.3 ± 38.4). Mean hair loss percentage before treatment was 72.7% (72.7 ± 28.3) compared with 33.5% (33.5 ± 30.7) after 6 months of azathioprine treatment. This showed a highly significant statistical difference (Paired t-test, CI 95% =21.5-54.1). Mean hair loss score (S(0) -S(5) ) before treatment was 3.9 (3.9 ± 1.6) and after 6 months of azathioprine treatment was 1.8 (1.8 ± 1.3). Assessment showed significant difference from baseline score (sign test, P < 0.0001). No significant statistical difference was observed with respect to gender before and after azathioprine treatment. Treatment with azathioprine as a systemic monotherapy clinically produces relevant improvement in moderate-to-severe alopecia areata. Generally azathioprine is a low-cost and well-tolerated drug and with controlled studies on larger number of patients, long-term efficacy and safety of this treatment should be investigated.

Background: Alopecia areata (AA) is one of the most common autoimmune disorders and its severe types are resistant to almost all conventional therapies. Methotrexate (MTX) has been used as an adjunctive therapy in some autoimmune disorders and has been proposed to be effective in the treatment of severe alopecia areata both as a monotherapy and in combination with corticosteroids. Aim of the study: was toevaluate the outcome and safety of MTX therapy in patients with severe forms of AA, whether as monotherapy or in combination with systemic or intralesional corticosteroids; and to assess therapeutic response according to sex, age, pattern of AA, disease duration and cumulative MTX dose. Methods: 28 patients were evaluated in a retrospective, non-controlled study, with alopecia areata in current or prior treatment with methotrexate to assess the therapeutic response according to sex, age, pattern of alopecia areata, disease duration, and cumulative dose of methotrexate as well as the use of systemic corticosteroids or other treatments, and drug safety. Results: 77.8% % of patients experienced a more than 50% regrowth rate, with the best responses observed in those with Conclusion: methotrexate is a convenient and relatively inexpensive drug that could be used as a safe and well tolerated adjunctive therapy for severe alopecia areata although careful monitoring of adverse effect is necessary.