Alopecia Areata Medication
- Author: Chantal Bolduc, MD, FRCPC; Chief Editor: Dirk M Elston, MD more...
Therapies most commonly include corticosteroid injections, corticosteroid creams, minoxidil, anthralin, topical immunotherapy, and phototherapy. The choice of one agent over the others depends on patient age (children do not always tolerate adverse effects), extent of condition (localized vs extensive), and the patient's personal preference. The University of California (San Francisco) and University of British Columbia have devised a treatment algorithm that can guide the physician in the treatment of alopecia areata (see image below).
For patients younger than 10 years, options include corticosteroid creams, minoxidil, and anthralin. For adults with less than 50% scalp involvement, the first option usually is an intralesional corticosteroid, followed by corticosteroid cream, minoxidil, and anthralin. For adults with greater than 50% scalp involvement, topical immunotherapy and phototherapy are additional options.
Because alopecia areata is believed to be an autoimmune condition, different immunomodulators have been used to treat the condition. Exact mechanism of action of topical immunotherapy is unknown. Antigenic competition was hypothesized (ie, introduction of a second antigen can initiate a new infiltrate containing T-suppressor cells and suppressor macrophages that may modify preexisting infiltrate and allow regrowth).
Commonly used agents for immunotherapy include SADBE and DPCP. These are compounded investigational agents not approved by the US Food and Drug Administration for use in alopecia.
Cyclosporine is used both topically and systemically for the treatment of alopecia areata. Topical cyclosporine has shown limited efficacy. Although systemic CsA appears to be effective in alopecia areata, the adverse effect profile, recurrence rate after treatment discontinuation, and inability to produce long-term remissions make CsA unattractive for the treatment of alopecia areata. The mechanism by which cyclosporine stimulates hair growth remains unknown. It may act through its immunosuppressive effect because patients who regrew hair had clearance of immune cells from the hair follicles and alteration in the balance of regulatory lymphocytes (ie, decreased CD4/CD8 ratio). Cyclosporine causes hypertrichosis in patients treated for conditions unrelated to hair loss.
Methoxsalen inhibits mitosis by binding covalently to pyrimidine bases in DNA when photoactivated by UV-A.
Anthralin is a synthetic derivative of a tree bark extract. Its mechanism of action in alopecia areata is unknown. Most likely, it creates inflammation by generating free radicals, which have antiproliferative and immunosuppressive actions. Both short-contact and overnight treatments have been used. High concentration (1-3%) is used for short-contact treatments. Lower concentrations (0.1-0.4%) are used for overnight treatments. Applications in excessive amounts may stain clothing.
Glucocorticoids have anti-inflammatory properties and cause profound and varied metabolic effects. In addition, these agents modify the body's immune response to diverse stimuli.
Topical corticosteroids (including intralesional corticosteroids) are safe and easy to use. They are acceptable cosmetically and allow patients to wear hats or wigs shortly after application. They also are relatively inexpensive. While the usefulness of high-potency topical corticosteroids is under debate, they remain a good (painless) option in children.
Intralesional steroids are first-line treatment in localized conditions.
Oral prednisone usually is reserved for patients with rapidly progressive alopecia areata. The relapse rate is high, and the potential for multiple severe adverse effects when used long term limits its usefulness.
Clobetasol propionate is a class I superpotent topical steroid. It suppresses mitosis and increases the synthesis of proteins that decrease inflammation and cause vasoconstriction. Treatment should continue until cosmetically acceptable regrowth is achieved or for a minimum of 3-4 months.
Prednisone is an immunosuppressant occasionally used in rapidly progressive alopecia areata in an attempt to halt the condition, but the relapse rate is high. Use of systemic steroids for the treatment of alopecia areata is under much debate. Prednisone stabilizes lysosomal membranes and suppresses lymphocytes and antibody production.
Many drug doses and regimens have been used in the treatment of alopecia areata, but no formal recommendation exists.
In alopecia areata, intralesional triamcinolone is believed to suppress the immune system locally and thereby allow hair to regrow. Injections are administered with 3-mL syringe and 30-gauge needle intralesionally.
Pediatric patients generally are less tolerant of intralesional injections because of local discomfort.
Betamethasone dipropionate is used for inflammatory dermatoses responsive to steroids. It decreases inflammation by suppressing the migration of polymorphonuclear leukocytes and reversing capillary permeability.
Vasodilators relax arteriolar smooth muscle, causing vasodilation; hair growth effects are secondary to vasodilation.
Minoxidil stimulates hair growth in general and is effective in many types of hair loss. The exact mechanism of action remains unclear, but it does not appear to have either hormonal or immunosuppressant effects. The 5% solution appears to be more effective.
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