Local injections of corticosteroids into bald patches can be used to treat alopecia areata

Alopecia areata hair loss information for men and women
Alopecia Areata 
Alopecia Areata Biology
Alopecia Areata Treatments

  Local Corticosteroid Injections for Alopecia Areata
 

Alopecia areata is a hair loss disease that is caused by the hair follicles entering into the catagen stage early in the cycle. It has been identified largely as an auto immune disease caused by the activation of the T-cell lymphocytes.

Treatment for alopecia areata remains elusive and incomplete, despite extensive research in the area. No permanent therapy has as yet emerged nor is there total remission of the disease. Of the many lines of treatment explored, corticosteroids, so far have provided the most satisfactory results for patchy alopecia areata. This is because corticosteroids inhibit the action of the T-cell lymphocytes which are supposed to initiate alopecia areata. The different ways in which corticosteroids can be applied to a patient also make it a common choice for medical practitioners. Besides, the pain and inflammation, which often accompanies alopecia areata, is reduced to a considerable extent by corticosteroids.

The common methods of corticosteroids is:

  1. Topically, as a lotion or cream
  2. Orally
  3. Intralesionally
  4. Systemically

Each of these methods has a different degree of potency and accompanying side effects. The success rate of the medicine also varies with the method of administration. Topical applications of corticosteroids are the mildest form of treatment, whereas systemic administration of corticosteroids is the most potent. In intralesional administration of corticosteroids, the drug is injected locally into the bald patches. This method has proved to be a compromise between the topical and systemic applications. Intralesional injections of corticosteroid crystal suspensions have now been in use for almost forty years.

Typically, a steroid solution of 0.1ml of triamcinolone acetomide is injected just below the epidermis with 30 gauges ½ inch or 1 inch needle and a 1ml tuberculine syringe, into the site. Several injections are made to cover the affected areas. The drug removes the confused immune cells so that the hair can grow again.

This form of application needs great care for the drug to be effective. The steroid has to be injected into the root of the hair follicles. A deeper penetration will cause the drug to reach the fatty layer which will render it ineffective and may cause atrophy. Sometimes compressed air guns are used to inject the steroid in order to make it less painful and obtain faster results. Generally, repeated injections are required over a period of up to two months for any noticeable hair growth. Intralesional corticosteroid applications are found to be rather effective for eyebrow or eyelash hair regrowth in alopecia areata patients.

Success Rate of Intralesional Corticosteroids

As with other modes of steroid applications, intralesional corticosteroids also manages to initiate hair growth and do not actually reverse the underlying process. Several studies have reported hair growth at the site of the injections in majority of cases. However, in practice it is not possible to treat the whole scalp with injections. Therefore a fair rate of success is evident, mostly in patients with long standing patchy alopecia areata. However, it shows poor response in patients with extensive alopecia areata or those with a history of the disease of two years or more. In one particular study with 84 patients, 92% of patients with patchy alopecia and 61% of those with alopecia totalis had pigmented hair regrowth. But again there was poor response to this treatment in patients with extensive alopecia, rapidly progressing alopecia or with a history of alopecia of over two years. Also, some of the patients lost the regrown hair in about twelve weeks.

Intralesional treatment is an immunomodulatory therapy, for the success of which, early detection and intervention is required. It is also important to give support and counsel to the patients as the treatment needs to be continued for an extended period of time to show results. Alternative therapies are needed essentially for children and patients of chronic alopecia areata.

Side Effects of Locally Injected Corticosteroids

The ideal mode of treatment should be one that is easy to apply, painless, free from side effects and fairly inexpensive. Intralesional corticosteroid applications do not fulfill a few of the above criteria. Drug delivery in intralesional corticosteroids is often accompanied by pain. Frequent visits to the dermatologist for repeated injections, makes the treatment complicated. Other associated complications may be transient atrophy. Use of large depot injections may cause tissue loss, along with severe depression of the skin. Unless the injections are spaced out properly and the site changed, the atrophy may become a permanent one.

If hydrocortisone suspension and methyl prednisolone acetate suspension are administered intralesionally to frontal and temporoparietal regions it has been found to lead to blood vessel occlusion and blindness. However, with the newer solutions containing micro size steroid particles, this problem is greatly reduced.

Great caution is required for the treatment of alopecia areata, requiring injections in the periocular region. It is imperative to do a baseline eye examination and regular check ups for glaucoma and cataracts, as such patients need careful handling.

Finally, with very high doses of corticosteroids injected intralesionally and at frequent intervals, there is possibility of systemic absorption of the steroid. This, again, may lead to other side effects.

Conclusion

Intralesional corticosteroids can at best be successful in milder forms of alopecia areata, which occur in patches. The success rate in extensive alopecia areata is poor. Large areas cannot be injected with the drug as that would cause, not only, considerable pain and discomfort but would also result in large amounts of corticosteroids injected into the lesions. This high dosage of medicine would lead to complicated side effects.

Intralesional corticosteroids application cannot really be compared to other modes of steroid applications as trials cannot be carried out with controlled groups. The groups on whom trials are carried out for the different treatments are not age matched, nor are the parameters for satisfactory regrowth of hair clearly defined. Different medical practitioners therefore use different parameters for considerable regrowth of hair.

It may be concluded that intralesional administrations of corticosteroids can therefore be considered as a successful treatment option only for patchy alopecia. It is impossible to treat extensive alopecia areata or alopecia totalis with this method.



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