Alopecia update

Kohala Coast, HI

- Treatment options for hair loss disorders have changed little in recent years, but at least for cicatricial alopecia, recent evidence is suggesting some possible new alternatives, said Vera H. Price, M.D., at the Winter Clinical Dermatology Conference.

Dr. Price, professor of clinical dermatology, provided an update on the management of androgenetic alopecia, alopecia areata and cicatricial alopecia.

In patients who present with hair thinning and a presumed diagnosis of androgenetic alopecia, it is important to identify the age of onset of thinning because that history has implications for diagnosis and treatment selection.

Dr. Price said that individuals who show signs of thinning in their teens, 20s, 30s and 40s have hormonally mediated disease in contrast to hair loss that starts later in life, which represents so-called senescent alopecia. The idea that these are two distinct conditions is supported by recent evidence showing very different gene expression profiles in groups identified as having androgenetic versus senescent alopecia.

"We still have only two treatment options for androgenetic alopecia, oral finasteride and topical minoxidil, and these can be used alone or together. However, because senescent alopecia is not androgen mediated, finasteride does not work," Dr. Price said.

Treatments for alopecia areata have remained unchanged for about 20 years. Recent studies have investigated various biologics and topical calcineurin inhibitors, but none of those agents have demonstrated efficacy in their current formulations.

Based on experience showing that eyelash growth occurred in some patients using ophthalmic formulations of prostaglandin analogues for lowering intraocular pressure, Dr. Price and colleagues undertook studies examining two different products in patients with alopecia areata and at least 50 percent bilateral eyelash loss present for more than six months. However, after four months of treatment, neither the topical application to the eyelid margin nor into-the-eye biologic was effective for inducing lash growth.

"The treatments were safe, and there was some benefit in two patients who had less than 50 percent eyelash loss," noted Dr. Price.

She added that in December 2008, Allergan received approval for marketing a 0.03 percent bimatoprost formulation (Latisse) for application to the lid margin in the treatment of hypotrichosis of the eyelashes.

Treatment for cicatricial alopecia depends on the subtype, a classification that is based on the histology and clinical features. Immunomodulating agents are used for lymphocytic disease that is symptomatic, clinically active or showing progressive hair loss, whereas neutrophilic/plasmacytic subtypes are treated with antimicrobials.

Two studies currently in press using objective evaluation techniques provide evidence for the efficacy of hydroxychloroquine (Plaquenil) and mycophenolate mofetil (Cellcept) in decreasing symptoms in patients with the lymphocytic disorder, lichen planopilaris (LPP).

Looking ahead, findings from another recently published study involving microarray analysis of scalp biopsies and a transgenic mouse model provide evidence for a possible role of PPARgamma-targeted therapy in the treatment of cicatricial alopecia.

"We are now looking at a possible role for the oral antidiabetic glitazones that activate PPAR-gamma," Dr. Price said. DT