An overview of treatments for alopecia areata

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

  Alopecia Areata Treatment Overview
 
There is enough evidence that alopecia areata is an auto immune mediated disease. Because the pathogenesis is not well understood, an effective treatment is unlikely soon. Presently, the treatments focus on limiting the symptoms.

Treatment of alopecia areata has to be long term because the disease can last for a long time. Therefore treatments that produce side effects must be avoided. As the inflammation occurs in and around the bulbar region, any drug, administered in whichever way, must be able to penetrate into the subcutaneous fat layer. Some of the therapeutic methods being used now are given below.

Immunosupresive treatment

Corticosteroids: Besides their anti-inflammatory effects, corticosteroids inhibit the activation of T-lymphocytes and reduce the expression of MHC class molecules thus reducing anagen presentation. These reasons make it a good drug for treating alopecia areata. Corticosteroids are administered in three ways - topically, lesionally and systemically.

Topical Treatment: Creams and ointments are used here. In many cases there is absence of response, perhaps due to failure of the drug to reach the hair bulb. Topical treatment produces side effects like folliculitis, epidermal atrophy and local skin infections and therefore should be avoided as far as possible.

Intralesional Corticosteroids: Intralesional injections have been around 40 years. Hair growth takes place mostly at the site of the injection. It is therefore impracticable to treat the entire scalp with intralesional corticosteroids. The injection is painful and causes side effects like temporary or permanent atrophy of the skin. It is impossible for hair to grow on permanently atrophied skin. This treatment is effective on some selected, long existing and small bald patches, with the possibility of serious side effects.

Systemic Corticosteroids: This treatment has also been around for about 40 years. Earlier corticosteroids were applied daily or on alternate days but are now considered inadvisable. Hair re-growth requires 30 mg to 150 mg daily. Such doses are dangerous as they cause side effects like hypertension, diabetes, immuno-suppression and tendencies to thrombosis.

Now, pulsed administration of single monthly doses is done to reduce the side effects. Consequently, major side effects were absent but there were minor side effects like headache, fatigue, palpitations and giddiness. Cosmetic hair growth was seen, but such observations were unreliable since they were not made under controlled conditions. Majority of the patients had patchy alopecia areata, which causes spontaneous hair remission very similar to cosmetic growth. Other studies reported failure of hair growth. Efficacy of pulse administration is, therefore, still unproven.

PUVA: In use since 1974, here psoralen and ultra violet or PUVA is used for immuno-suppression, by causing the disappearance of Langerhan’s cell and their antigen presenting capacity. PUVA also induces apoptosis in T-lymphocytes and causes the release of cytokines.

Studies using oral applications and UVA, as well as topical application and UVA, have shown cosmetically acceptable hair growth in 40% to 50% of the patients. These studies, however, were not controlled. So the hair growth could well have been spontaneous remission. Also there were relapses in 30% to 50% of the cases once the treatment was stopped. These relapses, some believe are due to fresh hair growths preventing the UVA rays from reaching the skin. Technical improvements like comb emitting UVA light showed no results

Permanent hair growth requires long term PUVA treatment, which is not possible, since long-term exposure to ultra violet rays pose health hazards.

Immunomodulatory Treatments

Here non-mutagenic diphenylcyclopropenone (DCP) or squaric acid dibutylester (SADBE) is used.

The patient is first sensitized by applying 2% solution of DCP on a small area of the scalp. The treatment starts two weeks later by application of 0.001% of DCP solution, followed by weekly applications of increasing concentrations of DCP till a mild eczematous reaction is obtained accompanied by itching and erythema, but with no blisters or oozing. This way the correct concentration for each patient is found out. Weekly applications are then continued. Scalp can be washed two days after application.

Hair growth occurs 8 to 12 weeks later. For complete growth, weekly treatment is necessary. Then the intervals of treatment can be reduced and eventually treatment is stopped. In case of relapse, treatment must be restarted immediately.

The desired side effects, like mild eczematous reaction or enlargement of retroauricular lymph nodes, are well tolerated if the patients are told about it. Undesired effects are vesicular or bullous reactions in the early stages of the treatment and affect 2% to5%. There are some minor side effects and pigmentary problems, which can be effectively tackled. No other major long-term side effects were reported after 18 years of DCP and 21years of SADBE treatment on 10,000 patients word-wide.

Contact sensitizer studies, done under controlled conditions are more reliable. The median response rate of contact sensitizer studies was 43% making them an effective tool for treating alopecia areata.

Non-Specific Irritants

Non-specific irritant have been tried for curing alopecia areata. After largely futile experiments with croton oil, sodium lauryl sulfate and topical tretinoin, the irritant anthralin was found effective. Typically a 0.5% anthralin is applied either in liquid or cream form. After a prescribed course of application the anthralin is washed away. The exact concentration and duration of treatment depends upon the extent and nature of alopecia areata and the patient’s response to it. How it works is unknown but basically it acts by inhibiting normal cell growth and differentiation in the skin.

Vasodilators

The vasodilator Minoxidil was developed to treat high blood pressure by oral application and hair growth was observed as a side effect. Since then a topical application has been developed for treating alopecia areata. Minoxidil is now available in pre mixed solution as a non-prescriptive, over the counter medicine in 2% and 5% concentrations. For women 5% solution is not recommended because of chances of facial hair growth. Usually it is applied twice a week.

10% to 20% cases have reported growth. In 90% cases hair loss decreased. Best results are obtained when it is applied right at the onset of the disease

Gene Therapy

Currently the focus is on gene therapy to improve immunosupression and immunomodulation. It is hoped that alopecia areata would be treated, one day, by genetically engineered regulatory T-cells, directed to the hair follicle, producing locally delivered cytokines without any side effects.



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