Review of treatment for alopecia totalis and alopecia universalis

Abstract

Alopecia areata (AA) is an autoimmune disease directed at the hair follicle. Although usually limited to patchy hair loss over the scalp (focalis), AA can present as total loss of scalp hair (totalis; AT) or as total loss of both scalp and body hair (universalis; AU). Management of AT and AU can be challenging, and although multiple treatment modalities have been explored, no therapy is currently FDA-approved. This review focuses on the evidence for current treatment options for AT and AU. The PubMed database was searched from January 1, 2000, to September 1, 2016, for clinical trials, retrospective studies, and case reports of treatments for AT and AU. A total of 40 studies were retrieved and analyzed. Therapies studied for AT/AU included: topical immunotherapy, steroids, photodynamic therapy, immunosuppressive agents, TNFα inhibitors, and other therapies, such as sulfasalazine, bexarotene, JAK inhibitors, and simvastatin/ezetimibe. Although certain treatments showed significant hair regrowth, no treatment was completely effective. The most promising therapies with the highest quality data include diphenylcyclopropenone, squaric acid dibutylester, photodynamic therapy, steroids, and cyclosporine in combination with methylprednisolone. High-quality randomized-controlled trials with large sample sizes are lacking. Unified outcome guidelines are encouraged to facilitate the comparison of future studies.

Alopecia totalis and universalis long‐term outcomes: a review

“…1 Diagnosis of AT and AU typically indicates poor prognosis compared to patchy AA, and patients with these diseases are more likely to have treatment failure. [4][5][6][7] The long-term recovery rate of AT and AU is often described as <10% in the literature, [8][9][10][11][12] referring to studies published decades prior. 6,13 With the discovery of new therapies, it is possible that the prognosis of AT and AU has improved.…”

Comparison of the Treatment Outcome of Oral Tofacitinib with Other Conventional Therapies in Refractory Alopecia Totalis and Universalis: A Retrospective Study

“…Steroid treatment reduces inflammation around the hair follicle, allowing it to return to its normal growth cycle. However, despite its popularity, there is limited evidence to support the efficacy of oral steroids (11)(12)(13)(14)(15)(16). The greatest barrier to using steroids is the associated adverse reactions, especially with prolonged treatment.…”

“…Clinical use of cyclosporine in combination with steroids is advised only in refractory cases, given the severity of systemic adverse effects and lack of evidence (4). Also, DPCP immunotherapy is an option for treating recalcitrant AT/AU (11). The exact therapeutic mechanism of DPCP has not yet been elucidated; however, antigenic competition and decreased production of anti-hair-follicle antibodies are thought to play important roles (22).…”

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

“…15 A systematic review of treatments for alopecia totalis or alopecia universalis by Kassira et al identified 21 clinical trials and 19 case reports or retrospective studies, comprising a total of 1254 patients with AA, of whom 485 had alopecia totalis or alopecia universalis. 16 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.…”