Guidelines for the Management of Patients with Alopecia Areata in Korea: Part I Topical and Device-based Treatment

BACKGROUND

Alopecia areata (AA) is a chronic disease with an unpredictable disease course and severe psychological impact.

OBJECTIVE

To provide evidence- and consensus-based insights regarding the treatment of patients with AA in Korea.

METHODS

We searched for relevant studies on the topical and device-based treatment of AA in the literature from inception until May 2021. Evidence-based recommendations were also prepared. The evidence for each statement was graded and classified according to the strength of the recommendations. Hair experts from the Korean Hair Research Society (KHRS) voted on the statements, and an agreement of 75% or greater was considered as consensus.

RESULTS

Currently, there remains a scarcity of topical treatments, which is supported by robust evidence from a number of high-quality randomized controlled trials. Current evidence supports the efficacy of topical corticosteroids, corticosteroid intralesional injection, and contact immunotherapy in AA patients. Topical corticosteroids and contact immunotherapy are recommended for pediatric AA. A consensus was achieved in 6 out of 14 (42.8%), and 1 out of 5 (20.0%) statements pertaining to topical and device-based treatments in AA, respectively. The expert consensus was from a single country, and the study may not cover all the treatments used.

CONCLUSION

The present study provides up-to-date, evidence-based treatment guidelines for AA based on the consensus reached among experts after considering regional healthcare circumstances, adding diversity to the previous guidelines.

Characterizing the willingness to undergo treatment in patients with alopecia areata

Alopecia areata is an autoimmune disease that results in partial or total balding of the scalp and/or body. Treatments available are minimally effective, have severe side effects, and are often painful. Given these burdens, patients may not feel undergoing treatment is worthwhile. The purpose of this study is to characterize the willingness of patients with alopecia areata to undergo treatment. We found that few patients are willing to undergo treatment at the risk of severe health side effects. The most acceptable form of treatment administration was topical and the least acceptable was injection at the site of hair loss. A majority of patients would only undergo treatment for hair growth that is cosmetically acceptable and the most important site of hair regrowth was the scalp. The willingness to undergo treatment differed significantly by gender, age, time since disease onset, and disease severity. This study offers insight into the preferences of patients with alopecia areata and characteristics that would make treatment widely acceptable. Institutions conducting research on treatment for alopecia areata can use the results of this study to better understand the needs of their target population.

Types and Treatment of Hair Loss in Men and Women

In this article, the author focuses on 4 common hair loss disorders that occur in both men and women. The author discusses research related to androgenetic alopecia, telogen effluvium, alopecia areata, and scarring alopecia and provides details on how to approach and manage these diseases according to patient gender. There are a range of tools and tests that can assist with the diagnostic process and help ensure that relevant and high standards of patient care are maintained. In some cases, no medical intervention is always a treatment option. However, appropriate medical treatments, although still relatively limited in some cases, are safe and have proven efficacy. Hair loss has immense emotional and psychological impact in both genders, and it is always important to consider this when planning hair loss management pathways.

Types and Treatment of Hair Loss in Men and Women

In this article, the author focuses on 4 common hair loss disorders that occur in both men and women. The author discusses research related to androgenetic alopecia, telogen effluvium, alopecia areata, and scarring alopecia and provides details on how to approach and manage these diseases according to patient gender. There are a range of tools and tests that can assist with the diagnostic process and help ensure that relevant and high standards of patient care are maintained. In some cases, no medical intervention is always a treatment option. However, appropriate medical treatments, although still relatively limited in some cases, are safe and have proven efficacy. Hair loss has immense emotional and psychological impact in both genders, and it is always important to consider this when planning hair loss management pathways.

Childhood Alopecia Areata: An Overview of Treatment and Recent Patents

BACKGROUND

Alopecia Areata (AA) is a systemic autoimmune condition that usually starts in childhood.

OBJECTIVE

This article aims to review genetics, therapy, prognosis, and recent patents for AA.

METHODS

We used clinical queries and keywords "alopecia areata" AND "childhood" as a search engine. Patents were searched using the key term "alopecia areata" in Patents.google.com and freepatentsonline. com.

RESULTS

Due to an immune-mediated damage to the hair follicles, hair is lost from the scalp and other areas of the body temporarily or even permanently. Children with AA are generally healthy. Evidence of genetic association and increased predisposition for AA was found by studying families with affected members. Pathophysiologically, T- lymphocytes attack hair follicles and cause inflammation and destruction of the hair follicles and hair loss. In mild cases, there would be well-demarcated round patchy scalp hair loss. The pathognomonic "exclamation mark hairs" may be seen at the lesion periphery. In more severe cases, the hair loss may affect the whole scalp and even the whole body. The clinical course is also variable, which may range from transient episodes of recurrent patchy hair loss to an indolent gradually deteriorating severe hair loss. The treatment of AA depends on factors including patients' age, the extent of the hair loss, duration of disease, psychological impact, availability and side effect profile of the treatments. For localized patchy alopecia, topical application of corticosteroids and/or intralesional corticosteroids are the treatment of choice. Other topical treatments include minoxidil, anthralin, coal tar and immunotherapy. In severe resistant cases, systemic immunosuppressants may be considered. Although herbal medicine, acupuncture, complementary and alternative medicine may be tried on children in some Asian communities, the evidence to support these practices is lacking. To date, only a few recent patents exist in topical treatments, including Il-31, laser and herbal medications. Clinical efficacy is pending for these treatment modalities.

CONCLUSION

None of the established therapeutic options are curative. However, newer treatment modalities, including excimer laser, interleukin-31 antibodies and biologics, are evolving so that there may be significant advances in treatment in the near future. AA can be psychosocially devastating. It is important to assess the quality of life, degree of anxiety, social phobia and mood of the patients and their families. Psychological support is imperative for those who are adversely affected psychosocially.

Treatment of pediatric alopecia areata with anthralin: A retrospective study of 37 patients

BACKGROUND/OBJECTIVES

Data on treatment options in pediatric alopecia areata are limited. Topical anthralin has been demonstrated to be an effective treatment option in adults and has minimal systemic toxicity. Prior results on its efficacy in children with alopecia areata have been mixed.

METHODS

Medical records of 37 patients with alopecia areata who were started on topical anthralin before age 17 were reviewed for efficacy and safety data. Scalp regrowth was quantified by serial photography if available or by medical record documentation if photographs were unavailable. Mean duration of clinical follow-up was 2.5 years.

RESULTS

Most patients were started on anthralin while continued on prior therapies, including topical corticosteroids, minoxidil, and/or intralesional corticosteroids. Twelve patients (32%) experienced complete scalp regrowth, while 25 patients (68%) experienced at least 50% maximal scalp regrowth with using anthralin. Of the patients with at least 50% scalp regrowth, mean time to first clinically observed response was 3.4 months. Mean time to maximal response was 15 months. Four patients stopped anthralin due to skin irritation. Relapses affected 64% of those with at least 50% maximal scalp regrowth.

CONCLUSIONS

Topical anthralin provides children with alopecia areata an additional option that offers potential for significant scalp regrowth with minimal systemic effects. Treatment course may need to be continued for at least 1 year in order to achieve maximal efficacy. The efficacy of anthralin may be limited by high rate of recurrence and local adverse effects.

Treating Alopecia Areata: Current Practices Versus New Directions

Alopecia areata (AA) is non-scarring hair loss resulting from an autoimmune disorder. Severity varies from patchy hair loss that often spontaneously resolves to severe and chronic cases that can progress to total loss of scalp and body hair. Many treatments are available; however, the efficacy of these treatments has not been confirmed, especially in severe cases, and relapse rates are high. First-line treatment often includes corticosteroids such as intralesional or topical steroids for mild cases and systemic steroids or topical immunotherapy with diphenylcyclopropenone or squaric acid dibutylester in severe cases. Minoxidil and bimatoprost may also be recommended, usually in combination with another treatment. Ongoing research and new insights into mechanisms have led to proposals of innovative therapies. New directions include biologics targeting immune response as well as lasers and autologous platelet-rich plasma therapy. Preliminary data are encouraging, and it is hoped this research will translate into new options for the treatment of AA in the near future.

The comparison of treatment with clobetasol propionate 0.05% and topical pimecrolimus 1% treatment in the treatment of alopecia areata

BACKGROUND

Alopecia areata (AA) is a non-scarring hair loss.

OBJECTIVE

We aimed the comparison of clobetasol propionate and pimecrolimus efficiency and tolerability in the treatment of AA.

METHODS

The study included a total of 100 consecutive patients with AA. Patients were randomized into four groups. 30 patients used 1% pimecrolimus cream, 30 patients used 0.05% clobetasol propionate cream, 20 patients used petrolatum as placebo. Scalp of 20 patients was divided into two equal areas and one area was treated with 1% pimecrolimus cream and the other area with 0.05% clobetasol propionate cream.

RESULTS

At week 12 of treatment, the recovery rate of the pimecrolimus group was 53.73 ± 44.49 and the recovery score was 3.63 ± 2.07; that of the clobetasol propionate group was 47.00 ± 44.80 and the recovery score was 3.33 ± 2.20; that of the placebo group was 35.50 ± 40.53 and the recovery score was 2.75 ± 1.88. There was no statistically significant difference among the groups in terms of the percentage of recovery and the recovery score (p < 0.05).

CONCLUSION

In conclusion, we detected that topical pimecrolimus treatment is as effective as topical corticosteroids and is superior to topical corticosteroids in terms of side effects in the treatment of AA.

Alopecia areata update: part II. Treatment

Various therapeutic agents have been described for the treatment of alopecia areata (AA), but none are curative or preventive. The aim of AA treatment is to suppress the activity of the disease. The high rate of spontaneous remission and the paucity of randomized, double-blind, placebo-controlled studies make the evidence-based assessment of these therapies difficult. The second part of this two-part series on AA discusses treatment options in detail and suggests treatment plans according to specific disease presentation. It also reviews recently reported experimental treatment options and potential directions for future disease management.

LEARNING OBJECTIVES

After completing this learning activity, participants should be able to compare the efficacy and safety of various treatment options, formulate a treatment plan tailored to individual patients, and recognize recently described treatments and potential therapeutic approaches.

Alopecia areata

Alopecia areata (AA) is a nonscarring, autoimmune, inflammatory, hair loss on the scalp, and/or body. Etiology and pathogenesis are still unknown. The most common site affected is the scalp. Histopathology is characterized by an increased number of the catagen and telogen follicles, the presence of inflammatory lymphocytic infiltrate in the peribulbar region ("swarm of bees"). Corticosteroids are the most popular drugs for the treatment of this disease. Etiologic and pathogenic mechanisms, as well as other current treatments available will be discussed in this article.

Management of hair loss

The management of patients with hair loss requires a customized plan. Diagnosis, prognosis, psychosocial impact, treatment options, and patient preference are key determinants. This article discusses current agents for the treatment of three commonly encountered nonscarring alopecias: male- and female-pattern hair loss, telogen effluvium, and alopecia areata. Algorithmic approaches to management are provided.

Efficacy of betamethasone valerate foam formulation in comparison with betamethasone dipropionate lotion in the treatment of mild-to-moderate alopecia areata: a multicenter, prospective, randomized, controlled, investigator-blinded trial

BACKGROUND

Betamethasone valerate foam (BVF) is a new topical corticosteroid formulation. In scalp psoriasis patients BVF has induced a significantly greater clinical improvement in comparison with corticosteroid lotions. No data are available to date regarding the efficacy and safety of BVF in mild-to-moderate alopecia areata (AA).

STUDY AIM

To evaluate the efficacy, tolerability and safety of BVF treatment in patients with mild-to-moderate AA.

SUBJECTS AND METHODS

Sixty-one patients (26 men and 35 women; mean age 41 +/- 13 years) with mild-to-moderate AA (hair loss < 26%) were enrolled in a parallel-group, investigator-blinded trial. Subjects were assigned randomly to BVF (31 patients) or to betamethasone dipropionate lotion (BDL) (30 subjects). Both treatments were applied to the affected areas twice a day for 12 consecutive weeks.

OUTCOMES

The primary study outcome was to compare the hair regrowth rate. Efficacy was evaluated at weeks 8 and 12 and at follow up (week 20), using a hair regrowth score (RGS) with a scale ranging from 0 (regrowth < 10%) to 4 (regrowth > 75%).

RESULTS

Fifty-seven subjects (93%) completed the trial. At week 20, the RGS was 3.1 +/- 1.5 and 1.8 +/- 1.6 in the BVF and BDL groups, respectively (P < 0.01). A RGS > 3 was observed in 61% of patients in the BVF group (19/31) in comparison with 27% (8/30) in the BDL group (P < 0.03). No serious adverse events were observed in both groups during the study.

CONCLUSION

Betamethasone valerate foam has shown to be an effective and well-tolerated treatment of mild-to-moderate AA. Further trials are warranted to evaluate the role of this new formulation in comparison or in combination with intralesional corticosterioids in AA treatment.

Clobetasol propionate 0.05% under occlusion in the treatment of alopecia totalis/universalis

BACKGROUND

Efficacy of topical steroids in alopecia areata is still discussed.

OBJECTIVE

The purpose of this study was to evaluate the efficacy of clobetasol propionate 0.05% ointment under occlusion in 28 patients with alopecia areata totalis (AT) or AT/alopecia universalis.

METHODS

A total of 28 patients were instructed to apply 2.5 g of clobetasol propionate to the right side of the scalp every night under occlusion with a plastic film. Treatment was performed 6 days a week for 6 months. When regrowth of terminal hair occurred, treatment was extended over the entire scalp. All patients were followed up for another 6 months.

RESULTS

Of the 28 patients included in the study, 8 were treated successfully (28.5%). Regrowth of terminal hair began on the treated side 6 to 14 weeks after the start of treatment. Of these 8 patients, 3 had a relapse and were not able to maintain hair regrowth.

CONCLUSION

Our study shows that clobetasol propionate 0.05% under occlusion is effective in inducing hair regrowth in patients with AT or AT/alopecia universalis. Occurrence of hair regrowth only on the treated half of the scalp clearly shows that efficacy of treatment is a result of a local and not systemic effect of the drug. Although only 17.8% of patients had long-term benefit by treatment, our results were obtained in a population of patients with severe and refractory forms of the disease.

Alopecia areata: treatment of today and tomorrow

It is the aim of this article to review and appraise available data on treatments for alopecia areata (AA) according to the demands of evidence based medicine. Studies evaluating the efficacy of a treatment for AA should include appropriate controls, use cosmetically acceptable hair regrowth as a parameter for treatment success, include patients with AA totalis, universalis or extensive patchy AA, and exclude patients suffering from AA for less than 3 months. Moreover, the treatment must be safe over a prolonged period of time. Among the various therapeutic approaches presently available for AA, only treatment with contact sensitizers such as diphenylcyclopropenone or squaric acid dibutylester has been shown to be effective in studies that fulfill these criteria. Improved future treatments may be immunosuppressive or immunomodulatory targeting of the autoimmune pathogenesis of AA, or they may otherwise protect hair follicles from the injurious effects of inflammation. Such possible future therapeutic approaches include the incorporation of immunomodulatory agents into liposomes as an improved vehicle; inhibition of apoptosis mediated by the Fas-FasL system; inhibition of the lymphocyte homing receptor CD44v10; induction of tolerance.

Tratamento da alopecia areata com corticóide tópico: estudo prospectivo randomizado duplo cego em crianças

FUNDAMENTOS: Na alopecia areata há perda súbita e assintomática de pêlos em qualquer área pilosa do corpo. A etiologia é desconhecida, e os tratamentos propostos não costumam alterar o curso natural e imprevisível da doença. Atinge as crianças, menos responsivas às terapêuticas e mais susceptíveis às formas mais extensas. O estado atópico é considerado fator de pior prognóstico; é provável que a relação entre as duas doenças se deva às origens imunológicas, embora sejam desconhecidos seus pontos de intersecção. OBJETIVOS: Avaliar a eficácia do dipropionato de betametasona em creme a 0,05% na alopecia areata da criança e a influência da atopia na resposta terapêutica. MÉTODO: Estudo prospectivo controlado duplo cego em 35 crianças de até 12 anos portadoras de alopecia areata, atendidas no Ambulatório de Dermatologia do Instituto de Puericultura e Pediatria Martagão Gesteira - UFRJ e do Hospital Municipal Jesus, ambos no Rio de Janeiro, RJ, no período de 1996 a 1998. RESULTADOS: Das 35 crianças estudadas, 30 (85,7%) evoluíram com resposta positiva ao final de seis meses de acompanhamento. Os percentuais de resposta foram semelhantes nas terapias utilizadas - dipropionato de betametasona e placebo (p= 0,47). Dos 29 atópicos, 26 (89,6%) tiveram resposta positiva aos tratamentos. Não foi estabelecida correlação estatisticamente significativa entre a resposta terapêutica e a condição atópica (p= 0,19). CONCLUSÃO: Não houve diferença entre as respostas terapêuticas nos grupos estudados; a atopia não influenciou a resposta ao tratamento efetuado.

Optimal management of hair loss (alopecia) in children

Hair loss in children encompasses a wide range of conditions that can be congenital or acquired. A congenital hair abnormality may be an isolated finding in an otherwise healthy child or may exist as a feature of a clinical syndrome. A thorough understanding of basic hair biology and normal hair development enables accurate assessment of the child with hair loss. Knowledge of the normal range and variation observed in children's hair additionally enhances this assessment. Social and cultural factors also influence these norms. The psychological and cosmetic importance of hair is immense in our society. The clinical presentation of pediatric hair disorders ranges from subtle to disfiguring. Management of hair disorders requires a holistic approach to the child and family. Young children usually lack self-awareness and it may be the parent who, projecting their own concerns onto the child, most acutely feels any associated anxiety. In addition, parents of a child with an inherited hair condition often feel guilt, and siblings can develop unsupported fears that they may be affected. Hair loss for the older child can lead to low self-esteem, depression and humiliation. Congenital and hereditary hypotrichosis and hair shaft abnormalities often have no effective treatment. There is a variety of treatment options for alopecia areata and telogen effluvium, but no single treatment is 100% effective. Tinea capitis is an infective condition of the hair that responds readily to the appropriate medical therapy. If no effective treatment for the hair loss exists, cosmetic camouflage with wigs is the best option.

Alopecia areata. Pathogenesis, diagnosis, and therapy

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 diphenyl-cyclopropenone, 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.

Treatment of alopecia areata

Some individuals question whether any treatment is effective in severe alopecia areata. Certainly many patients, especially those with mild disease, experience spontaneous hair regrowth; however, results of double-blind studies clearly indicate that some treatments do promote hair regrowth even in those with extensive disease. Some patients never show either spontaneous or treatment-related hair regrowth; others experience hair regrowth only while maintained on treatment, repeatedly losing hair within a few weeks of discontinuing treatment and regrowing it within several weeks after restarting treatment. Some patients who have been responsive to treatment may experience exacerbation of their disease such that even high-dose systemic steroids do not prevent the development of alopecia universalis. Some treatments appear to work on some patients some or all of the time, but no treatment appears to work on all patients all of the time. We would suggest a few practical points that we find useful: To maximize the potential for cosmetic hair growth in alopecia areata that is extensive or flaring, treat the entire scalp instead of "chasing" patches. Do not change any topical treatment sooner than 3 months after starting it; early regrowth may first be present at 3 months. Cosmetic regrowth may take a year or more to achieve. Maintenance treatment increases the likelihood of maintenance of cosmetic hair growth, but patches of hair loss may still come and go. Atopic patients who experience seasonal hair loss may benefit (ie, have less severe hair loss flares or respond more readily to topical therapy) by using an antihistamine or mast cell stabilizer prophylactically. Whether one looks at the therapeutic cup as half full or half empty, most patients urge us to continue to try to find safe, effective long-term treatments for this disease.

Ulcerative colitis and total alopecia in a mother and her son

Extraintestinal autoimmune disorders are associated with ulcerative colitis in selected patients and lend support to the theory of immune-mediated injury in inflammatory bowel disease. Rarely, alopecia areata has been associated with ulcerative colitis, and familial aggregation and an HLA association have been reported for both disorders. The occurrence of both alopecia and ulcerative colitis in a mother and son are reported with a detailed investigation of antineutrophil cytoplasmic antibodies and HLA alleles in this family. Treatment with the immunosuppressive agent cyclosporine proved beneficial in the child leading to remission of the ulcerative colitis and nascent growth of scalp and body hair.

Alopecia areata: pathogenesis and treatment

Although its etiology remains unknown, evidence has accumulated to support an autoimmune pathogenesis for alopecia areata. Our review summarizes the immunologic data and also examines the role of genetics, atopy, and psychologic stress in this disorder. Until etiology is better understood, treatments for alopecia areata are likely to remain palliative. Nevertheless, newer therapies such as photochemotherapy, topical immunotherapy, and perhaps systemic immunotherapy (e.g., inosiplex) offer new hope for patients with extensive disease.