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Dr. Christopher Tzermias

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Alopecia Areata

Alopecia Areata is an autoimmune disorder of the hair follicle. It is characterised the patchy hair thinning, which develops on normal skin, and hair look like an exclamation mark around the affected areas.

In most cases it is confined in one or more areas, but in more severe cases it may lead to complete hair thinning of the scalp (alopecia totalis) or on the whole body (alopecia universalis).

Alopecia is non-cicatricial and in most cases it resolves automatically after a few months.

Management strategy of Alopecia Areata

Treatment may be time-consuming, while treatment of relapses may be difficult. On the other hand some patients are affected to such a degree that psychological support is necessary. It has been found, also, that the contact with other patients may be really helpful.

Patients should be informed completely about the natural progress of the disease and their expectations should be realistic regarding treatment outcome.

First-line treatments continue to be the most effective and safe methods. Nevertheless, response to any type of treatment is varied and it depends greatly on the severity and the duration of hair loss. This is one more reason for which the results of studies are inconsistent is some cases. In studies focusing on patchy hair loss with recent onset, high rates of relapse may be evident, while in studies limited to serious and chronic hair loss that is resistant to treatment their effectiveness in mild alopecia is not excluded.

The term “percentage re-growth”, which is often used to describe this condition refers to the re-growth of hair at the area with alopecia as compared to the initial condition.

Intralesional corticosteroid injections are considered first-line treatment for adult patients when only one or two small patches of alopecia are present, but can be used on larger areas if patients can tolerate the discomfort. The authors most frequently use triamcinolone acetonide aqueous suspension (2.5 – 10mg/ml) injected intradermally in multiple 0.05–0.1 mL doses, and it is repeated on a monthly basis. A concentration of 5 mg/mL can be used at a dose of 3 ml maximum on the scalp during one session.

A concentration of 2.5 mg/mL can be used on the chest and on the eyebrow area. The main side effect is pitting atrophy and it is usually transient.

Topical immunotherapy is the induction of contact allergy on the scalp. Contact sensitizers include dinitrochlorobenzene (DNCB), which is considered as potentially carcinogenic and therefore no longer used, squaric acid dibutyl ester (SADBE), which has limited stability, and diphencyprone (DPCP, diphenylcyclopropenone).

The latter compound combines efficacy and safety with a practical shelf-life and has become the most widely used. DPCP can initially be applied as 2% lotion to a small area (2–4 cm2) of scalp until the site of application becomes pruritic and erythematous. Treatment is then continued over a larger area with weekly applications of lower concentrations, typically ranging from 0.001% to 0.1%. The lowest concentration that maintains mild erythema or pruritus should be used.

Usually half of their scalp is treated initially, until a favorable result means treatment can then be extended to the contralateral scalp. This is one of the best-documented therapies for AA, and is the one most likely to be effective in extensive long-standing disease. However, the timing of the response is quite unpredictable, so the authors treat patients for as long as they wish to continue. Side effects include regional lymphadenopathy and rarely autosensitization, resulting in generalized eczema or even an eruption resembling erythema multiforme.

Topical corticosteroids have demonstrated efficacy in some studies of patchy alopecia areata, particularly those using potent steroids with occlusion. They are fairly inexpensive and practical to use, and the main side effect is transient folliculitis. Results are variable, however, and they do not appear to be very effective in alopecia totalis or alopecia universalis.

Treatment with psoralen plus ultraviolet A rays (PUVA) has been studied in many clinical trials and findings are differing. Relapse rate following treatment is high and continuous treatment sessions seem to be necessary to maintain hair growth rate.

The use of irritants, including anthralin (dithranol) and retinoic acid, are safe and practical to use, although the evidence for their efficacy is limited. For patients with dark hair, anthralin has the advantage of camouflaging a pale area of scalp by staining it brown. Application needs to be frequent and at a fairly high concentration, as it needs to induce significant irritation to be effective. Retinoic acid is more practical for use in patients with fair hair.

Topical minoxidil is a safe treatment, but most studies have failed to demonstrate a response of cosmetic value in most patients.

Systemic corticosteroids administered per os are effective in some cases if high doses are used, while the use of certain intermittent administration regimens. However, alopecia totalis, alopecia universalis and ophiasiform alopecia areata do not respond well and high relapse rates make this toxic treatment hard to justify.

Systemic cyclosporine also appears effective if administered in high dosage, but the response is not maintained on cessation of therapy, and again it is difficult to justify its use.

The findings of studies using topical tacrolimus are also positive.

Another way that many patients prefer is the use of a wig, while many patients select the method of tattooing (dermatography) of the eyebrows so that to achieve a more socially acceptable image.


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