Management of alopecia areata: Updates and algorithmic approach

Abstract

Alopecia areata is a chronic, recurrent and non-scarring alopecia. The prognoses of patients are very diverse. The larger the area of hair loss, the poorer the treatment response and greater the probability of chronic disease progression. Numerous treatments have been introduced, but curative treatments have yet to be established. The long-term efficacy of the current treatments is minimal, and the therapeutic response varies widely. Recent clinical trials have attempted to apply therapeutic metrics, such as the Severity of Alopecia Tool, and many have been designed as randomized controlled studies, enabling a more precise evaluation of existing treatments. There have been updates in practice, efficacy or indications of therapeutics that have been previously used. Moreover, the use of novel treatments such as biologics has recently been introduced. Commonly, the most important factor in determining the treatment modality for alopecia areata has been the extent of hair loss. However, if the disease activity is high and likely to progress, combination therapy with adjuvant modalities will be more desirable. This review will discuss the therapeutic effects of existing and newly-introduced treatments based on their quantity, quality of evidence and expected complications. In addition, an algorithmic approach to management of alopecia areata is proposed according to clinical subtype, severity, onset and activity of the disease.

Increased prevalence of vitamin D deficiency in patients with alopecia areata: a systematic review and meta‐analysis

“…1 The prevalence is 0.1-0.2% with the lifetime risk of 2%. 2 As AA is considered a T cell-mediated autoimmune disorder, several studies have shown that patients with AA are more likely to develop other autoimmune diseases such as rheumatoid arthritis, systemic lupus erythematosus, type I diabetes mellitus and vitiligo compared to the normal population. [3][4][5] Vitamin D is a group of fat-soluble secosteroids, synthesized in epidermal keratinocytes.…”

Is methotrexate an effective and safe treatment for maintaining hair regrowth in people with alopecia totalis? A Critically Appraised Topic

“…One retrospective case series of MTX was included that suggested useful regrowth in around 50% of patients. Lee and Lee searched PubMed until March 2017 and rated the evidence using the United States Preventive Service Task Force recommendation . MTX was listed as a third‐line therapy based on three observational studies, with a rating of ‘fair’ for quality of evidence, mid‐range for quantity of evidence and low for benefit‐to‐risk ratio.…”

“…Application of the evidence to our patient with alopecia totalis is challenging given that many patients included in the studies had AA for < 1 year, less severe disease at baseline and were treated with other forms of corticosteroid therapy. Corticosteroid monotherapy has also shown similar results; a systematic review reported complete regrowth in 43% overall; however, side‐effects are common and it is advised to avoid longer‐term use where possible . Better case series of MTX monotherapy with consecutive patients are needed to provide a clearer proof of principle before embarking on full‐scale randomized controlled trials that assess MTX alone vs. placebo, or in combination with corticosteroids vs. placebo.…”

“…Lee and Lee searched PubMed until March 2017 and rated the evidence using the United States Preventive Service Task Force recommendation. 17 MTX was listed as a thirdline therapy based on three observational studies, with a rating of 'fair' for quality of evidence, mid-range for quantity of evidence and low for benefit-to-risk ratio. A more recent appraisal of the evidence by Strazulla et al concluded that MTX 'may be effective for patients who fail standard therapy'.…”

“…Corticosteroid monotherapy has also shown similar results; a systematic review reported complete regrowth in 43% overall; however, side-effects are common and it is advised to avoid longer-term use where possible. 17 Better case series of MTX monotherapy with consecutive patients are needed to provide a clearer proof of principle before embarking on full-scale randomized controlled trials that assess MTX alone vs. placebo, or in combination with corticosteroids vs. placebo. Future studies should use validated measures for baseline severity and include outcome assessment of digital images in a blinded fashion, in addition to patient-reported outcomes and adverse effects, along with adequate follow-up during and after treatment.…”