|
Topical
corticosteroids for alopecia areata
Alopecia areata, with its recurrent episodes of erratic, unpredictable,
patchy hair loss is an insidious hair disease that disrupts the
life of young and old. In any dermatological condition, the ideal
treatment would be one that is effective, easy to apply, painless,
free of side effects, and inexpensive. Therapeutic management
should always be commenced with the treatment module that fulfills
as many of these criteria as possible, and should always be undertaken
by dermatologist or a physician with experience in the treatment
of hair diseases.
Treatment of alopecia areata patients is based on criteria like
age and extent of disease, and potentially everyone with alopecia
areata is capable of re-growing hair even after many years of
hair loss. However, although there is no strong evidence to suggest
that drug-induced remissions or therapies alter the course of
alopecia areata, it is increasingly clear that the available treatment
options at best manage to suppress the underlying process. There
are a range of therapies for which partial success has been claimed
but as soon as any of the therapies are stopped alopecia areata
returns. Current prevalent therapies used in the treatment of
alopecia areata are predominantly immunomodulating in nature.
Corticosteroids are so far the most popular form of treatment
for patchy alopecia areata. There is supporting evidence to substantiate
the theory that alopecia areata is a T-cell mediated response,
and corticosteroids are known to exert a strong inhibitory effect
on the activation of T lymphocytes. Corticosteroids also reduce
inflammation and pain, and can be administered in four different
ways; topically as a cream or lotion, intralesional as local injections
into the bald patches, and systemically either as injections into
a muscle or taken orally. Each of these methods of administration
varies in their potency, and also bears different rates of success
and side effects.
Currently, topical creams are available with several different
commercial trade names and with different concentrations of steroids.
They are applied only to the regions of hair loss and they are
the mildest form of steroid treatment. As a rule, dermatologists
will try a milder form of treatment before attempting to use stronger
forms with their greater potential for side effects.
Success rate of topical corticosteroids in alopecia areata treatment
Response to topical steroids in several therapeutic trials has
been mixed. Various studies have been carried out by different
research
teams
all over the world, and the following are their observations.
A
placebo-controlled trial using 0.2% fluocinolone acetonide in
a cream base applied
twice daily with occlusion each night
for 6 months was conducted on 28 patients with alopecia areata
with satisfactory to excellent (total to near-total) therapeutic
response to the active drug in 17 patients. The following observations
were also documented:
- Disease extent did not affect the outcome, but age and disease
duration were factors.
- Every child between the ages of 3 and
10 years showed 100 percent re-growth of hair, whereas only
approximately 50 percent of the older children and
33 percent of the adults responded.
- Results were good when the alopecia areata
process had been present for less than a year and a poor outcome
was noticed, particularly in adults,
if the disease had been present for longer periods.
- Children who had had
the disease for up to 7 years still showed a good response.
Studies were conducted on the use of 0.1% halcinonide cream
applied daily with or without occlusion, but not more that 60
g per month, to seven patients
with patchy hair loss and three patients with extensive hair loss. All patients
attained full hair re-growth, with the duration of treatment ranging from
6 to 18 months. A significant observation was made in four patients in whom
biopsies were performed - the inflammatory infiltrate seen before treatment
was not markedly reduced after treatment, despite clinical hair regrowth.
The successful use of 0.05% betamethasone dipropionate cream
in a non-optimized vehicle (Diprosone 0.05%), applied twice daily
without occlusion, was observed in children and some adults under
study. Conclusions drawn indicated at least 3 months of uninterrupted
treatment was necessary before evaluating hair re-growth, and
also that this treatment could prove helpful to individuals experiencing
actively flaring alopecia areata.
A retrospective review of 277 patients with alopecia areata
seen over a 10-year period was conducted at an academic hair center
practice. Of those patients treated with topical steroids (class
I-IV) who had more than 50 per-cent loss at baseline, 41 percent
had more than 50 percent re-growth including 15 percent with 76-99
percent re-growth and 18 percent with 100 percent re-growth. As
a comparison, these numbers were not significantly different from
those 72 patients treated for 6 to 8 weeks with tapering doses
of oral prednisone.
The presumption of the efficacy of topical steroids is that steroids
work to induce hair growth in humans with alopecia areata by restraining
the local autoimmune process inhibiting hair growth. However,
it is worth noting that topical steroids have been shown to inhibit
hair growth in normal mice. Stenn and colleagues concluded that
steroids block the expression of hair-forming genes but do not
interfere with the signal(s) that initiate those genes. Since
mouse hair, unlike human hair, grows in synchronous waves, the
relationship of this observation to corticosteroid effect in humans
is unclear.
Precautions
and side effects of topical corticosteroid treatment
When using topical steroid, it is important that the steroid
is just sufficiently potent to control the skin condition in order
to avoid significant local and systemic side effects. The minimum
effective strength or class of topical steroid in alopecia areata
has not been determined, although it would appear that 1% hydrocortisone
is too weak. The maximum effective strength remains to be determined.
Topical steroids have established a new milestone in dermatological
therapeutics; but widespread misuse has led to considerable side
effects.
For this very reason, efficacy, risks and benefits of the treatment
option must be considered before implementing any treatment regimen.
The risk of systemic absorption and the potential associated side
effects with the use of corticosteroids must be evaluated during
long-term treatment. If topical applications are applied in the
periocular area, a baseline eye exam and regular follow-up examinations
are recommended to check for glaucoma and/or cataracts. Children
with extensive alopecia areata applying more than 45 g per month
of class I or II topical steroids need to be monitored carefully
for significant systemic absorption and side effects. Side effects
of topical steroid therapy in children and adults include:
- Folliculitis (inflammation of the hair follicle).
- Hypertrichosis
(Growth of hair in excess of the normal).
- Acneiform eruption.
- The potential for developing local atrophy
(wasting) and telangiectasias (chronic dilation of groups
of capillaries causing elevated dark red blotches
on the skin).
It is important to note that there are significant problems in
defining and comparing the success rate of topical corticosteroids
with other treatment routines for alopecia areata. Many reports
on trials involve perhaps a small number of patients without any
control group for comparison. This leads to the limitation of
the inability to compare trials using different treatments. Absence
of age matched groups with alopecia areata of similar extent and
duration coupled with the different parameters individual clinicians
use to define satisfactory hair re-growth, make comparison between
different treatment types almost impossible.
Topical
corticosteroids for alopecia areata references
- Stenn KS, Paus R, Dutton T, Sarba B.
Glucocorticoid effect on hair growth initiation: a reconsideration.
Skin Pharmacol. 1993;6(2):125-34.
PMID: 8352950
- Fiedler VC. Alopecia areata. A review
of therapy, efficacy, safety, and mechanism. Arch Dermatol.
1992 Nov;128(11):1519-29.
PMID: 1444509
- Montes LF. Topical halcinonide in
alopecia areata and in alopecia totalis. J Cutan Pathol. 1977;4(2):47-50.
PMID: 915049
- Pascher F, Kurtin S, Andrade R. Assay
of 0.2 percent fluocinolone acetonide cream for alopecia areata
and totalis. Efficacy and side effects including histologic
study of the ensuing localized acneform response. Dermatologica.
1970;141(3):193-202. PMID: 4250339
|
