Therapeutic Modalities For Alopecia Areata

Alopecia areata is a common, autoimmune disease that can affect any hair- bearing area. Alopecia areata is a lymphocyte cell-mediated inflammatory type of hair loss, but its pathogenesis is not fully understood. The disease can present as a single patch of hair loss, multiple patches, or extensive hair loss in a form of total loss of scalp hair (alopecia totalis) or loss of entire scalp and body hair (alopecia universalis). A number of treatments can induce hair regrowth in alopecia areata but do not change the course of the disease. Treatment is more effective in patchy alopecia areata than in alopecia totalis/alopecia universalis. Therapy for alopecia areata should be tailored in light of severity of the condition and the patient’s age.

Many therapeutic modalities have been used to treat alopecia areata, with variable efficacy and safety profiles. The treatment plan is designed according to the patient’s age and extent of disease. Several studies have shown the efficacy of intralesional corticosteroid injections. For limited scalp alopecia areata, intralesional corticosteroid therapy is considered as the drug of choice by many experts. The most widely used agent is triamcinolone acetonide. The injections can be repeated at 4–6 weekly intervals. The use of mesotherapy multi-injectors with 5–7 needles is an alternative approach to decrease injection pain and to make the procedure more homogenous. Side effects include skin atrophy and telangiectasia which can be minimized by the use of smaller volumes and avoiding superficial injections.

Many forms of topical corticosteroids have been prescribed for alopecia areata, including creams, gels, ointments, lotions, and foams. Topical corticosteroids are far less effective in alopecia totalis and alopecia universalis. A highly potent topical corticosteroid under occlusion is the preferred method when using topical corticosteroids. Folliculitis is a common side effect to topical corticosteroids.

PUVA is a method of administering a dilute psoralen solution selectively to the scalp for 20 minutes using a cotton towel as a turban. The patient’s scalp is then exposed to ultraviolet A radiation. Treatment sessions are performed two or three times per week. PUVA-turban therapy lacks the systemic side effects of oral PUVA and can be considered as alternative therapy for patients with alopecia areata.

One important step that should not be overlooked during the course of management of alopecia areata is offering psychological support to foster increased self-esteem and adaptation to this disease. Helping patients with alopecia areata cope with depression and an unpredictable disease like alopecia can be achieved by several ways, including education of the patient about the nature of disease, psychotherapy, hypnotherapy, antidepressants and support groups. Hypnotherapy may significantly improve depression, anxiety, and quality of life, but not hair regrowth .

If these therapies fail or are not tolerated, third-line therapeutic options can be discussed with patients in terms of the expected outcome of therapy and possible side effects. These agents include methotrexate with or without a systemic corticosteroid, azathioprine, cyclosporine, and pulse therapy of corticosteroids. While using these drugs, close monitoring of patients is important to avoid possible side effects.

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