PUVA treatment of alopecia areata

Twenty-three patients with alopecia areata were treated with photochemotherapy combining oral or topical methoxsalen and UV-A irradiation of the scalp or of the whole body. Eleven of 17 patients with multiple plaques of alopecia areata, alopecia totalis, and alopecia universalis, who were treated with oral methoxsalen and total body irradiation, had complete or more than 90% hair regrowth. Three patients had a relapse. The mean energy required was 505 joules/sq cm. In six cases, topical applications of methoxsalen or oral methoxsalen combined with local irradiation of the scalp were treatment failures. In the patients responding to treatment, the result did not seem to depend on the age of onset or the extent or duration of disease. However, patients with long-lasting alopecia had a higher risk of recurrence notwithstanding a good initial regrowth of hair. Few side effects of psoralens and UV-A (PUVA) treatment were noted. The mean follow-up period was 18.6 months after the completion of treatment. We discuss the possible mechanisms of action of PUVA in the treatment of alopecia areata.     

Alopecia areata treatment with a phototoxic dose of UVA and topical 8-methoxypsoralen

Twenty-five patients with alopecia totalis (AT) or alopecia universalis and 124 patients with alopecia areata (AA) were treated with photochemotherapy, combining topical 8-methoxypsoralen (8-MOP) with UV irradiation of the scalp at a phototoxic dose. The mean energy required was 15 J/cm2 for AA and 42 J/cm2 for AT. Ninety-four patients had multiple bald patches and 12 with AT had complete or > 50% hair regrowth. Positive treatment results did not seem to depend on the age of onset or the duration of the disease. Few side-effects of topical psoralens plus UVA (PUVA) treatment were noted, except a for few days of slight erythema caused by the high dose of UV.     

Diphencyprone in the treatment of long-standing alopecia areata

Thirty-six patients with alopecia areata of 1-54 years duration entered a study of treatment with the contact allergen diphencyprone for 8 months. Following sensitization the diphencyprone was applied to one half of the scalp at weekly intervals, the other half acting as a control. Once hair growth was established on one side, the other side was treated. Seven patients did not continue treatment and one patient showed spontaneous regrowth. Of the remaining 28 patients who persisted with treatments, fourteen (50%) regrew hair on the treated side; eight (29%) had a cosmetically acceptable result with the regrowth of terminal hair over the whole scalp. No statistically significant differences were found in age or duration of alopecia between those who regrew and those who did not. We have found diphencyprone to be an effective stimulator of hair growth in patients with severe and long-standing alopecia areata.     

Combined oral pulse and topical corticosteroid therapy for severe alopecia areata in children: a long‐term follow‐up study

There are no widely accepted therapy protocols for severe alopecia areata (AA). We treated 65 children/adolescents with AA affecting >30% of scalp. Fourty‐three percent of patients had AA plurifocalis (AAP). Fifty‐seven percent had AA subtotalis (AAS), AAP+ophiasis (AAP+OPH), and alopecia totalis/universalis (AT/AU). Long‐term follow‐up (median 96 months) data were available for 69% of patients. Oral dexamethasone (prednisolone 5 mg/kg equivalent) was given once in 4 weeks. Patients received 6, 9, or 12 pulses. Clobetasol propionate 0.05% ointment under plastic wrap occlusion was applied 6 days a week. Hair growth was assessed on a scale ranging 0–100% of regrowth in individual AA lesions. Regrowth >50% was considered good response. Six to twelve months months after the therapy, 56.9% of patients had >75% of hair regrowth. In AAP, 65.5% had complete regrowth. 61.5% of all patients were considered good responders. Significantly, higher percentage of good responders was found in AA lasting ≤12 months. No patients had serious side effects. There was no change in stability of the hair status at the long‐term follow‐up. Most AA patients had beneficial effects with this protocol. Best results were in AAP and AAP+OPH. Combined topical and oral pulse corticosteroid therapy of AA in children shows long‐lasting results, without serious side effects.     

Systemic steroids with or without 2% topical minoxidil in the treatment of alopecia areata.

BACKGROUND AND DESIGN--Thirty-two patients with mild to extensive alopecia areata, including 16 patients with alopecia totalis or universalis, entered a randomized, controlled trial of a 6-week taper of prednisone followed by either 2% topical minoxidil or vehicle applied three times daily for an additional 14 weeks. The results of this study were compared with an open trial of 48 patients with alopecia areata treated with a similar taper of prednisone with concomitant 2% topical minoxidil applied twice daily. Only terminal hair growth was considered and was quantitated as 1% to 24%, 25% to 49%, 50% to 74%, and 75% to 100%: only those with more than 25% terminal hair regrowth were considered to have had an objective response. RESULTS--At the end of 6 weeks of prednisone, 47% (15/32) of patients had more than 25% regrowth, including nine of 20 patients who had had at least 75% hair loss at baseline. Side effects of prednisone were primarily weight gain and mood changes/emotional lability. At 3 months, six of seven minoxidil-treated patients vs one of six vehicle-treated patients who had an objective response to prednisone maintained or augmented this hair growth: at the 20-week visit, these numbers were three of seven and zero of four patients, respectively. In the open trial, objective hair growth with prednisone was 30%, related to the extent of hair loss at baseline, and this growth persisted in more than 50% of patients at 6 months with the use of 2% topical minoxidil. CONCLUSIONS--A 6-week taper of prednisone offers potential for more than 25% regrowth in 30% to 47% of patients with alopecia areata with predictable and transient side effects. Two percent topical minoxidil three times daily appears to help limit poststeroid hair loss.     

Topical photochemotherapy for alopecia areata

Twenty-two patients with alopecia areata were treated with a combination of topical 0.1% 8-methoxypsoralen and UVA (PUVA). Eight of the twenty-two patients (36.3%) responded with excellent regrowth (terminal hair in at least 75% of the treated scalp), and two patients (9.1%) showed good regrowth (terminal hair in 50% to 75% of the treated scalp). The mean total UVA exposure and the mean total number of treatments for the entire treatment course for these responders was 171.7 joules/cm2 and 47.4 treatments, respectively. Eight of the nine responders available for follow-up experienced some degree of relapse when PUVA treatments were tapered or during a follow-up period (mean, 8.3 months) after treatment was discontinued. Despite the failure of topical PUVA to change the long-term course of alopecia, the combination of PUVA with other therapeutic modalities may result in the prolongation of the beneficial effect in selected patients. The mechanism of action of PUVA in alopecia areata might involve an immunomodulatory effect.     

Severe alopecia areata treated with systemic corticosteroids

Background Treatment of severe alopecia areata is difficult, and most efforts to successfully treat this condition have been disappointing. Systemic corticosteroids have been demonstrated as an effective treatment of severe alopecia areata. Methods Eighteen patients with alopecia areata (extensive patchy and totalis universalis types) were treated with systemic corticosteroids. Results Satisfactory hair regrowth was achieved in seven patients (38.9%). Hair fall subsequently occurred in all of these patients on discontinuation or tapering of corticosteroid therapy. Conclusions Systemic corticosteroid therapy does not prevent the spread or relapse of severe alopecia areata and, when complete regrowth is obtained, it is rarely maintained off therapy.     

Seventeen cases of alopecia areata: combination of SADBE topical immunotherapy with other therapies

Topical immunotherapy is effective for severe alopecia areata. However, there are patients with alopecia areata refractory to topical immunotherapy alone. We tried SADBE (squaric acid dibutylester) topical immunotherapy combined with topical dry ice cryotherapy, carpronium chloride (a parasympathetic nerve stimulant) and/or oral cepharanthin (a biscoclaur alkaloid) in alopecia areata refractory to topical SADBE. Seventeen patients with alopecia areata (3 multiple, 3 ophiasis, 5 totalis and 6 universalis) were treated with SADBE in our department in 1999 to 2001. In 3 cases (2 multiple and 1 universalis) out of the 17 cases, cosmetically acceptable regrowth of hair was observed in several months with topical SADBE alone. In the other 14 cases, the SADBE therapy alone for several months (mean: 6.9 months) resulted in no or poor regrowth of hair. However, with subsequent combination therapy of topical SADBE for several months (mean: 7.6 months), satisfactory regrowth of hair was observed in 6 of the 14 cases. Our cases indicate that combination therapy of topical SADBE with other therapies can be a choice for alopecia areata which is refractory to topical SADBE therapy alone.     

Etanercept does not effectively treat moderate to severe alopecia areata: an open-label study

In this prospective, open-label pilot study, we evaluated the safety and efficacy of etanercept, a TNF-alpha inhibitor, in the treatment of moderate to severe alopecia areata, alopecia totalis, or alopecia universalis. Seventeen otherwise healthy adults with moderate to severe alopecia areata were enrolled. The primary outcome measure was the extent of hair regrowth during and after the end of treatment as evaluated by the Severity of Alopecia Tool (the SALT score). After between 8 and 24 weeks of continuous treatment with etanercept 50 mg given subcutaneously twice weekly, significant regrowth of hair was not shown in any of the subjects treated. Based on these results, etanercept appears to be ineffective in treating subjects with treatment-refractory, moderate to severe alopecia areata, alopecia totalis, or alopecia universalis.     

PULSED ADMINISTRATION OF CORTICOSTEROIDS IN THE TREATMENT OF ALOPECIA AREATA

Background. Widespread alopecia areata (AA) is difficult to treat and modalities such as topical and systemic steroids, topical sensitizers (e.g., squaric acid dibutylester and diphencyprone), psoralen-ultraviolet A (PUVA) therapy, minoxidil, and immunomodulators have been tried. Methods. Patients with widespread alopecia (> 40% scalp involvement), including alopecia totalis (AT) and universalis (AU), were treated with 300 mg oral prednisolone pulses at 4-week intervals, for a minimum of 4 doses or until cosmetically acceptable hair growth was obtained. Response to therapy was monitored by serial photographs and patients were examined monthly for side effects of steroids. A 1000 mg oral prednisolone pulse was administered to five patients with alopecia totalis/universalis and to three failures of the 300 mg-pulse treatment. Results. Thirty-two patients (24 men, 8 women) with a mean age of 29 years were recruited. They had alopecia for a mean period of 2.8 years. Twenty-seven patients (21 alopecia areata, 5 alopecia universalis, 1 alopecia totalis) received 300 mg pulse therapy and eight patients received 1000 mg prednisolone pulses. Fourteen (58.3%) patients (13 AA, 1 AT) out of 24 evaluated treated with 300 mg pulse therapy showed complete or cosmetically acceptable hair growth. Response was evident on average after 2.4 months and was cosmetically acceptable at 4 months. Three (AA, AT, AU-one each) out of seven patients assessed for the 1000-mg pulse had cosmetically acceptable hair growth at 6–9 month. Conclusions. An oral monthly pulse of prednisolone 300 mg is effective, safe, and can be administered on an outpatient basis. It is recommended as one of the modalities for the treatment of widespread alopecia areata.     

甲氨蝶呤是否能有效安全地维持全秃患者的头发再生? 一个经过严格评价议题

Alopecia areata (AA) is a common disorder causing hair loss, which can range from patches, to complete hair loss on the scalp (alopecia totalis), or involving all hair‐bearing sites (alopecia universalis). It can cause anxiety, depression and low self‐esteem. Treatment can be difficult – there are several options but they don't always work and can have unwanted side effects. Hair can in fact regrow without any treatment. The aim of this study was to assess the current evidence regarding use of a drug called methotrexate for getting hair to regrow, and then remain, in people with alopecia. The authors looked at 13 studies comprising 226 patients with alopecia varying from 30% hair loss to alopecia universalis at the start. Methotrexate was usually given with drugs called systemic corticosteroids to start hair regrowth rather than regrowth maintenance. Regrowth, defined as anything from 50% to complete regrowth, was reported in 20‐90% of patients. Relapse (meaning hair re‐grew but then fell out again) occurred in 20‐80%, with variable regrowth on retreatment. Unwanted side effects ranged from 7‐60%. The authors found insufficient evidence to conclude whether methotrexate is useful for maintaining regrowth in extensive alopecia areata. They found some evidence to suggest that hair regrowth may be started by methotrexate when used in combination with systemic corticosteroids, but it was difficult to say which of the treatments this was due to, or if the hair was going to regrow anyway. Further trials are needed.     

3 percent topical minoxidil compared with placebo for the treatment of chronic severe alopecia areata

The efficacy of a 3 percent topical minoxidil solution (2,4-diamino-6-piperidinopyrimidine-3-oxide) in a propylene glycol-water-ethanol base applied twice daily for one year to half the scalp was evaluated in patients with severe chronic alopecia areata. A randomized, double-blind, bilateral comparison-controlled study design was used. Of the twenty-one patients, thirteen were women and eight were men; their ages ranged from nineteen to fifty-five years. All the patients had alopecia totalis or alopecia universalis, except for two who had lost two-thirds of their scalp hair. The mean disease duration was 11.5 years (range, one to forty years). Transient regrowth of sparse vellus hair occurred in twelve patients, bilaterally in eight, but it was not significant in any. No cosmetically acceptable results were achieved. No significant side effects were noted, except for a moderately severe bilateral dermatitis in one patient. The results indicate that 3 percent topical minoxidil solution is ineffective as treatment for severe chronic alopecia areata.     

PUVA treatment of alopecia areata partialis, totalis and universalis: audit of 10 years' experience at St John's Institute of Dermatology

Our 10-year experience with PUVA treatment for alopecia areata. partialis, totalis and universalis was retrospectively reviewed using charts and follow-up questionnaires for 70 patients at St John's Institute of Dermatology. In all cases, several previous therapies were judged to be unsatisfactory prior to starting PUVA, and many cases were already deemed clinically refractory prior to referral for PUVA. If cases of vellus hair growth are excluded, and those who lost their PUVA-induced regrowth rapidly on follow-up, the effective success rate was at best 6·3% for alopecia areata partialis, 12·5% for alopecia areata totalis and 13·3% for alopecia areata universalis. We affirm that PUVA is generally not an effective treatment for alopecia areata.     

Allergic and irritant contact dermatitis compared in the treatment of alopecia totalis and universalis. A comparison of the value of topical diphencyprone and tretinoin gel

Diphencyprone is a potent topical sensitizer, but is non-mutagenic in the Ames test (unlike dinitroclorobenzene) and remains relatively stable in solution (unlike squaric acid dibutyl ester). Seventeen patients with total loss of scalp hair (eight alopecia totalis, nine alopecia universalis) were treated by maintaining on one side of the scalp an allergic contact dermatitis induced by 2,3 diphenylcyclopropenone-I ('diphencyprone'), and on the other side an irritant contact dermatitis using tretinoin gel (Retin A). After 20 weeks, treatment with tretinoin was stopped and diphencyprone was applied bilaterally for a further 10 weeks. Satisfactory regrowth of terminal hair on the scalp was achieved in only one patient. Eyebrow, eyelash and beard regrowth was achieved in one individual whilst in another, moderate, but not cosmetically satisfactory, scalp regrowth took place. In no patient did regrowth take place at tretinoin treated sites until after diphencyprone was substituted.     

Five‐year experience in the treatment of alopecia areata with DPC

Background The effectiveness of Diphencyprone (DPC) in alopecia areata (AA) was demonstrated in several studies with highly variable response rates ranging from 5% to 85%. Objective The response rate and variable factors affecting the prognosis were studied focusing on long‐term follow‐up with or without maintenance therapy. Methods 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. Results Ninety‐seven patients continued therapy for ≥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). Conclusion 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.     

Successful treatment of alopecia universalis with alefacept: a case report and review of the literature

Alopecia universalis often responds poorly to standard therapies. We report how a novel treatment option, alefacept, was successfully used in the management of a 21-year-old woman with alopecia universalis. The patient responded with complete regrowth of scalp and body hair after a single 12-week treatment course of alefacept. In addition, a review of the literature was performed pertaining to the use of biologic agents in the treatment of alopecia areata/universalis to determine which agents have a potential role in the treatment of this often refractory disease.     

Topical minoxidil for hair regrowth

Minoxidil, a potent peripheral vasodilator used orally for refractory hypertension, has produced hypertrichosis. To determine the efficacy and safety of 1% or 5% topical minoxidil for the stimulation of scalp hair regrowth, we studied fifteen normotensive patients, five with androgenic alopecia and ten with alopecia areata diagnosed clinically and by biopsy, for 12 months. Three of five patients with androgenic alopecia using 5% minoxidil for 12 months noted hair regrowth, ranging from minimally observable hair to an appreciable restoration of larger, pigmented, terminal hair in one patient. Among the patients with androgenic alopecia, regrowth response corresponded to the serum minoxidil blood levels. None of the patients with alopecia areata receiving either 1% or 5% minoxidil noted hair regrowth despite comparable minoxidil blood levels. Improved local absorption of topical minoxidil solution may promote hair regrowth in androgenic alopecia.     

The use of topical diphenylcyclopropenone for the treatment of extensive alopecia areata

BACKGROUND: Highly variable results of topical diphenylcyclopropenone (DPCP) in the treatment of alopecia areata have been reported so far. OBJECTIVE: The purposes of our study were to evaluate the efficacy and tolerability of DPCP in the treatment of chronic, extensive alopecia areata and to assess the long-term overall benefit of treatment. METHODS: Fifty-six patients with chronic, extensive alopecia areata were enrolled in an open-label clinical trial. After sensitization with 2% DPCP, progressively higher concentrations beginning at 0.001% were applied weekly for 6 to 12 months to one side of the scalp. RESULTS: Fifty-two of 56 patients completed therapy. Total regrowth of terminal hair was achieved in 25 of 52 patients (48%) at 6 months. The most frequent side effect was an eczematous reaction at the site of application. Notably, persistent response was observed in 60% of these patients after 6 to 18 months of follow-up (mean, 12 months). CONCLUSION: Topical DPCP treatment for alopecia areata is effective and well tolerated and provides prolonged therapeutic benefits.     

Use of the pulsed infrared diode laser (904 nm) in the treatment of alopecia areata.

BACKGROUND: Alopecia areata is a rapid and complete loss of hair in one or several patches, usually on the scalp, affecting both males and females equally. It is thought to be an autoimmune disease which is treated with different modalities with variable success. Laser treatment of different wavelengths has been used in the management of this problem. OBJECTIVE: To study the effect of the pulsed infrared diode laser (904 nm) in the treatment of alopecia areata.Methods. Sixteen patients with 34 resistant patches that had not responded to different treatment modalities for alopecia areata were enrolled in this study. In patients with multiple patches, one patch was left as a control for comparison. Patients were treated on a four-session basis, once a week, with a pulsed diode laser (904 nm) at a pulse rate of 40/s. A photograph was taken of each patient before and after treatment. RESULTS: The treated patients were 11 males (68.75%) and five females (31.25%). Their ages ranged between 4 and 50 years with a mean of 26.6+/-SD of +/-13.8, and the durations of their disease were between 12 months and 6 years with a mean of 13.43+/-SD of +/-18.34. Regrowth of hair was observed in 32 patches (94%), while only two patches (6%) failed to show any response. No regrowth of hair was observed in the control patches. The regrowth of hair appeared as terminal hair with its original color in 29 patches (90.6%), while three patches (9.4%) appeared as a white villous hair. In patients who showed response, the response was detected as early as 1 week after the first session in 24 patches (75%), while eight patients (25%) started to show response from the second session. CONCLUSION: The pulsed infrared diode laser is an effective mode of therapy with a high success rate for resistant patches of alopecia areata.     

Alopecia Areata

Alopecia areata is a common form of non-scarring alopecia that appears equally in males and females of any age, although children and adolescents are more commonly affected. The disorder is usually characterized by limited alopecic patches on the scalp, but more severe forms may affect the entire scalp (alopecia totalis) or body (alopecia universalis). Characteristic nail changes may also accompany hair loss. Alopecia areata has been linked with certain human leukocyte antigen (HLA) class II alleles, indicating a probable autoimmune etiology. Current research implicates T lymphocytes in the pathogenetic mechanism of disease. Other autoimmune diseases are also linked with alopecia areata. The diagnosis of alopecia areata is usually made clinically, although a biopsy is diagnostic for this condition. Treatment is challenging and aims at the regrowth of hair in affected individuals. Intralesional corticosteroid injections are widely used in mild disease. Topical anthralin and minoxidil may also be clinically efficacious. Topical sensitizers, such as squaric acid dibutlyester and diphenylcyclopropenone, are sometimes employed. Various therapies for the disease may have efficacy in different patients, making a universal treatment algorithm difficult to implement. Patients should be handled on an individual basis, with the final outcome based on the cosmetic regrowth of hair. Maintenance therapy is also important in patients that do achieve acceptable regrowth, necessitating a highly motivated patient and good rapport with the treating physician.