A combination of treatments can be used to treat alopecia areata

Alopecia areata therapy is still at a rather unsatisfactory stage. The treatment is not specific and is directed at suppressing the symptoms because the culprit gene remains unidentified. The course of the response is unpredictable. There could be complete regrowth, partial regrowth or a relapse. Treatment prognosis is therefore rather bad.

Combination Therapy

Combination therapy is a therapy involving use of more than one therapy or one drug simultaneously.

All alopecia areata therapies attempt at either suppressing the number of causal cells or modifying their function. Such immunotherapy, involving both immune suppression and immune modulation, are satisfactory up to a point but in the long term, cause undesirable side effects. Some of these side effects are hypertension, diabetes, immunosuppression and tendency towards thrombosis. Moreover, choice of therapy depends mainly on the type, severity and spread of the disease. For these reasons combination therapy is sometimes found more suitable.

Furthermore, in its more severe forms, alopecia areata can become very difficult to treat, developing high resistance to treatment. In addition, the disorder is heterogeneous, meaning, it can affect more than one part of the scalp or the whole body. In such cases, it has been found useful to go in for more than one treatment for various affected parts i.e. go in for a combination therapy.

Clinical Studies

In the search for a universally acceptable treatment regimen for alopecia areata, several clinical studies were conducted. These included clinical trials with a combination of topical, intralesional and/or systemic steroids as well as other combination of drugs. Some of these clinical trials are briefly discussed below.

• Six patients with refractory alopecia universalis were treated with oral prednisolone 5mg/kg for two months. This was followed by the addition of oral administration of 2.5mg/kg of cyclosporine. The prednisolone treatment continued with cyclosporine treatment but it was gradually reduced after the cyclosporine was stopped. Hair growth was observed in all six patients, one month after cyclosporine treatment was introduced. The hair growth continued for more than six after discontinuation of cyclosporine treatment.
• A clinical trial of a combination therapy consisting of topical, intralesional, and oral corticosteroids was carried out on 15 patients affected by alopecia totalis or alopecia universalis. 30 mg to 40 mg of prednisone with 0.025% fluocinolone acetonide cream was daily administered, under occlusion for 12 hours per day. Seven out of 15 patients showed almost complete regrowth of their scalp hair. No relapse was observed, for an average follow up period of thirty-two months, after discontinuation of the oral corticosteroids therapy.
• A combination therapy comprising of oral cyclosporine 5 mg/kg per day and oral prednisone 5 mg was administered daily for 6 months to eight patients with alopecia areata where more than 95 percent of the scalp was affected. Two out of the eight patients showed cosmetically acceptable hair re-growth. However, relapse occurred once the therapy was discontinued. Three patients did not participate in the trials after they showed side effects like generalized edema, hypertension, abnormal liver function tests, abnormal lipid levels and hypertrichosis.
• In this study the effect of 2%, topical minoxidil on prednisone-induced hair growth was evaluated. A reducing dose of prednisone was administered for six weeks and at the end of this period, the patients were randomly given either 2% topical minoxidil or vehicle. The dosage was 1ml three times a day for patients weighing more than 40kgs and 0.5ml for patents weighing less than 40kgs. This therapy was continued for 14 weeks after the steroid therapy. It was observed that after six weeks of prednisone therapy, 47% patients showed an objective response i.e.more than 25% hair growth. At three months after discontinuation of prednisone therapy, six out of seven treated with minoxidil and one out of six given vehicle treatment and showing objective response in prednisone therapy, maintained or improved their hair growth. The results of this study were compared with an open trial of 48 patients given similar therapies. The authors of the study arrived at the conclusion that 2% minoxidil limited or slowed hair loss in alopecia areata patients, in the post-steroid phase.
• In a controlled, double-blind study in patients with severe, chronically treatment-resistant alopecia areata, comparisons were made between twice a day administration of 5% topical Minoxidil followed 30 minutes later by the application of 0.05% betamethasone dipropionate cream (Diprosone, non-optimized vehicle), either therapy alone or placebo. 13% of patients treated with placebo, 22% treated with steroid alone, 27% treated with Minoxidil alone, and 56% treated with the combination therapy showed a moderate to good hair re-growth after 16 weeks of therapy. The authors concluded that the simultaneous application of topical steroid increases the local tissue concentration of Minoxidil, probably through vasoconstriction and a secondary reduced clearance of drug.
• The effect of a combined therapy of topical 5% Minoxidil and 0.5% anthralin (Drithocreme) was examined in an open-label study of severe alopecia areata earlier shown to be resistant to oral and topical Minoxidil or only topical anthralin. 1ml of 5% topical Minoxidil was applied twice a day; anthralin was applied 2 hours after the evening Minoxidil dose and left overnight. After 11 weeks, 39 of 50 patients reported terminal hair growth. At 24 weeks 5 out of 45 patients showed cosmetically, acceptable regrowth and 4 out of these 5 maintained the growth with treatment for 84 weeks. Side effects were mild to moderate scaling and pruritis. Although Minoxidil blood levels increased with the combination therapy over topical Minoxidil alone, there was no clinical evidence of systemic Minoxidil effects.
• A combination of diphencyprone and inosiplex therapy, for alopecia totalis, was tested on 3 groups matched for age and sex. One received inosiplex 50 mg/kg per day, another was given diphencyprone topically, and the third received both treatments. The duration of therapy was 6 months. None of the 22 patients treated with inosiplex responded, and only 2 of 22 patients responded to diphencyprone alone.
• 15 patients with more than 50 percent scalp involvement were sensitized to diphencyprone. Then half the scalp of each patient was treated weekly with diphencyprone. Twice daily therapy of 5% topical Minoxidil or placebo to the treated half of the scalp was randomly assigned. After 24 weeks, Minoxidil did not improve on the success rate of diphencyprone alone.