Florence — Alopecia areata is a disease with important aesthetic implications that may affect the patient psychologically and socially, and treatment can be challenging, according to Ana Kaminsky, M.D., Ph.D., professor of dermatology, School of Medicine, University of Buenos Aires, Argentina.
At the 13th Congress of the European Academy of Dermatology and Venereology here, Dr. Kaminsky reviewed treatments other than immunotherapies and immunomodulators for alopecia areata.
Phototherapy, photochemotherapy "Alopecia areata is a T-cell-mediated autoimmune disease in which anagen hair bulbs are targeted by CD4+ and CD8+ lymphocytes," she says.
A retrospective review of PUVA treatment in 70 patients over a 10-year period at St. John's Institute, King's College, London, evaluated the efficacy of PUVA treatment for alopecia, excluding cases of vellus hair growth or cases in which PUVA-induced regrowth was quickly lost (Taylor and Hawk. Br J Dermatol. 1995;133:914-918). The patients evaluated in this study had all failed several previous therapies, and many were considered refractory cases.
The results of PUVA treatment were not encouraging. At best, the effective success rates were reported to be 6.3 percent for alopecia areata partialis (AP), 12.5 percent for alopecia areata totalis (AT) and 13.3 percent for alopecia areata universalis (AU), indicating that PUVA was ineffective.
Combination PUVA treatment is often given in combination with psoralen, either orally or topically.
Promising results have been reported using PUVA in combination with a dilute psoralen solution, in a treatment procedure described as "PUVA turban." A cotton towel is soaked in a dilute psoralen solution (1 mg/L 8-methoxypsoralen) at 37 C, wrung gently to remove excess solution and wrapped as a turban around the patient's head. After 20 minutes, the turban is removed and UVA radiation is immediately applied.
One report describes the results of PUVA turban therapy in a group of nine patients with severe, rapidly progressing, treatment-resistant alopecia (Behren-Williams et al. J Am Acad Dermatol. 2001; 44:248-252). PUVA therapy was administered three to four times a week. Six of the nine patients experienced hair regrowth after treatment of up to 10 weeks, leading the authors to conclude that PUVA turban treatment could be an effective alternative treatment for some patients.
Corticosteroids Although widely used, potent topical corticosteroids are generally ineffective in the treatment of AT and AU.
In some patients, intralesional injection of depot corticosteroids stimulates hair regrowth at the injection site. Corticosteroids used in this treatment include hydrocortisone (2.5 mg/ml) and triamcinolone acetonide (5-10 mg/ml). Skin atrophy can occur, particularly with triamcinolone, although the atrophy generally resolves a few months after treatment. Injection close to the eye increases the risk of cataracts and may raise intraocular pressure.
There are potentially severe side effects associated with systemic corticosteroids, particularly with long-term use.
Biologic response modifiers "Papers published to date, although involving a low number of patients, suggest that cyclosporin A may stimulate hair growth in some patients," Dr. Kaminsky says. "However, as cyclosporin A is a systemic drug, drug-related side effects must be taken into consideration."
Major side effects include hypertension, renal interstitial fibrosis and gingival hyperplasia; however, reversal of most side effects is seen after the therapy discontinuation.