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Systemic
corticosteroids for alopecia areata
Although research over the last few years has yielded valuable
data on the etiology and pathophysiology of the insidious form
of hair loss in alopecia areata, the exact pathogenesis of the
disease remains obscure, with the result that there is neither
a permanent cure for alopecia areata nor a universally proven
therapy for inducing remission. Early intervention is crucial,
and most patients can be offered hope and support to help them
cope with the months of treatment usually needed to achieve reduction
in disease symptoms.
Current prevalent therapies used in the treatment of alopecia
areata are predominantly immunomodulating in nature, with Corticosteroids
being 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.
Of these, systemic administration of steroids is the most powerful
form of corticosteroid treatment, but the side effects of prolonged
therapy limit their use. Systemic therapy can be carried out either
by giving injections into a muscle, or more commonly, by taking
it orally. These steroids generally promote a temporary re-growth
of hair and subsequent relapse when the treatment is stopped.
It is important to note that there are significant problems in
defining and comparing the success rate of systemic corticosteroids
with other treatment routines for alopecia areata. However, short
and long term hazards of systemic corticosteroid therapy are well
known for their potential severity, and systemic corticosteroid
treatment should be conducted only by a qualified medical practitioner
experienced in the treatment of hair loss diseases, and only as
a treatment of last resort because of the potentially serious
side effects.
Success
rate of systemic corticosteroids in alopecia areata treatment
The first therapeutic experiments in alopecia areata with orally
administered cortisone areata were carried out on 22 patients
(4 with alopecia totalis, 11 with alopecia universalis, and 7
with patchy hair loss). These patients were treated with cortisone
acetate tablets in tapered dosage. Sixteen of the 22 patients
re-grew hair, with the onset of re-growth within 3 to 6 weeks.
Conclusions drawn were that persons having a longer duration of
the last episode of alopecia areata and those having a history
of active disease during adolescence were associated with failure
to respond to oral cortisone acetate. Discontinuing therapy or
decreasing the dose below desirable levels was associated with
a relapse.
Several authors have performed pulse administration of corticosteroids
in single doses, in an effort to reduce the side effects of the
steroids to an acceptable level and produce prolonged hair re
growth. Pulse therapy involves short, intensive administration
of pharmacotherapy, usually given at intervals such as weekly
or monthly. Results of the studies show that major side effects
were not observed in pulsed administration of corticosteroids
in alopecia areata patients. Side effects that have been documented
include nausea, flush, headache, fatigue, palpitations, dyspnea
(shortness of breath) and giddiness. However, variable results
with pulse therapy have been observed in different sets of case
studies.
Many trials have been conducted to confirm the effects of oral
prednisone on alopecia areata. Although the initial re-growth
appears promising, the prednisone dose necessary to maintain cosmetic
growth is usually too high and adverse effects are inevitable.
An initial benefit may occur by using systemic prednisone in some
patients, but the relapse rate is high, and it does not appear
to alter the course of the condition. Systemic prednisone is,
therefore, not an agent of choice for alopecia areata because
of the adverse effects associated with both short-term and long-term
treatment.
The use of intramuscular steroids has also been evaluated by
many authors in the treatment of alopecia areata. In such form
of treatment, the drug is administered by intravenous (IV) or
intramuscular injection, and it works by blocking certain subsets
of activated T cells. The side effects of intramuscular steroids
are the same as those observed with the prolonged use of oral
steroids.
Because of the associated unfavorable side effects, there is
a need to get patients off systemic steroid use as soon as possible,
and this form of treatment needs to be used in conjunction with
other treatment modules to help sustain the re-growth when systemic
steroid treatment is stopped. For this reason, some medical professionals
advocate the benefits of combination therapy with topical, intralesional,
and oral corticosteroids for alopecia areata patients.
Results of research studies conducted indicate that systemic
steroid administration is a module of alopecia areata therapy
for which partial success has been claimed. In fact, the steroids
only succeed in promoting a temporary re-growth of hair and subsequent
relapse when the treatment is stopped. All in all, there is no
strong evidence to suggest that systemic drug-induced remissions
or therapies alter the course of alopecia areata, and it is increasingly
clear that the available treatment options at best manage to suppress
the underlying process.
Precautions
and side effects of systemic corticosteroid treatment
Treatment of alopecia areata patients with systemic steroids
is based on criteria like age and extent of disease. Systemic
steroids vary in strength. The beneficial effects as well as the
side effects are proportional to the dose taken. Steroid dose
is commonly classified as low dose (<10mg/day of steroid),
medium (10mg to 20mg per day) and high dose (>20mg/day). Treatment
continuing for more than 3 months is regarded as long term, and
results in the majority of undesirable side effects. Because of
its potentially hazardous side effects over long-term usage, this
mode of treatment is acceptable in those with milder forms of
the disease and is much less desirable in people with extensive
hair loss as seen in alopecia totalis or alopecia universalis.
Therapeutic management with respect to systemic steroids should
only be undertaken by dermatologist or a physician with experience
in the treatment of hair diseases. Steroid administration should
never be discontinued abruptly and doses must be tapered off.
The doses of oral systemic steroids that are required to maintain
hair growth in alopecia areata are between 30 mg and 150 mg daily,
which may give rise to unacceptable side effects including:
- Hypertension or high blood pressure
- Diabetes can be precipitated
or aggravated
- Immunosuppression, or suppression of the body’s
immune response
- Osteoporosis or thinning of the bones
- Tendency towards thrombosis
(formation of a fibrinous clot in a blood vessel or in a chamber
of the heart)
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corticosteroids for alopecia areata references
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