alopecia
ALOPECIA

Alopecia is an involuntary loss of hair usually in the scalp that may occur anywhere over the body.
Scarring alopecia is severe inflammation of the hair follicle result in irreversible damage.
Non-scarring alopecias are reversible.
Alopecia may  be abrupt or gradual in onset.
Most common causes include androgenic alopecia (male & female pattern baldness) & alopecia areata.
History should be reviewed for medications, severe diet restriction, vitamin A supplementation, thyroid symptoms, concomitant illness & stress factor.

Alopecia Treatment

Principles of Therapy

Treatments for Androgenic Alopecia
  • Most effective in males aged 18-41 with Norwood/Hamilton stage II-V hair loss
  • Early intervention, when thinning is first noticed hairs are incompletely miniaturized, optimizes treatment
  • Neither Finasteride nor Minoxidil can regrow hair in areas of total hair loss
  • No well-controlled studies on combination treatment with Finasteride and Minoxidil
  • Switching treatment
    • Continue using the original medication in addition to the new agent for at least 3 months before discontinuing

Pharmacotherapy

Finasteride (Oral)
  • Recommended for treatment of male patients >18 years old with mild to moderate (Hamilton-Norwood stage II-V) androgenic alopecia
  • Effects: Studies have shown up to 66% of men show improved scalp coverage after 24 months of treatment and up to 83% showed hair loss stabilization
    • ~20-30% of patients do not respond to therapy
    • One study showed that 5 years of continuous intake showed no further visible hair loss in 90% of male subjects
  • Combination therapy with topical Minoxidil (2% or 5% solution or 5% foam) may be considered for better therapeutic effects
  • Treatment response should be evaluated at 6-12 months and if successful, therapy must be continued indefinitely to maintain benefit
  • Discontinuation of therapy leads to reversal of effect within 12 months
Dutasteride (Oral)
  • Alternative therapy for male patients >18 years old with mild to moderate (Hamilton-Norwood stage II-V) androgenic alopecia when previous treatment with Finasteride is ineffective after 12 months
Minoxidil (Topical)
  • Recommended to improve or prevent progression of androgenic alopecia in males >18 years old with mild to moderate (Hamilton-Norwood stage II-V) and females >18 years old
    • 2% solution applied twice daily was found to be effective in preventing progression and improve androgenic alopecia in the frontotemporal and vertex regions in males
    • 5% topical solution or foam applied twice daily has shown greater efficacy than 2% solution in males
    • In females, 50% have minimal regrowth and 13% moderate regrowth using 2% solution 
  • Treatment response should be evaluated at 6 months and if successful, therapy must be continued indefinitely to maintain benefit
  • Discontinuation of therapy leads to reversal of effect within 3-6 months
Cyproterone acetate
  • An oral antiandrogen that suppresses luteinizing hormone (LH) and follicle-stimulating hormone (FSH) release
  • May be used for female patients clinically diagnosed with hyperandrogenism

Spironolactone

  • An aldosterone antagonist that competitively blocks androgen receptors and inhibits androgen synthesis
  • May be used for female patients with hyperandrogenism

Platelet-rich plasma (PRP)

  • Have been utilized in the treatment of androgenic alopecia in males and females
  • More studies are needed to confirm effectivity and determine optimal regimen
Treatments for Alopecia Areata
  • Effects: The treatments used stimulate hair growth but do not prevent hair loss
    • It is unlikely that they influence the course of the disease
    • Treatment tends to be the most effective in mild disease
  • Continue treatment until remission occurs or until alopecia patches are concealed by hair regrowth (may take a month to a year)
Corticosteroids
  • Intralesional
    • Eg Triamcinolone acetonide
    • First-line treatment for adult patients with <50% (limited patchy) hair loss
    • Recommended when there is patchy hair loss of limited extent and for cosmetically sensitive sites such as eyebrows and beard
    • Effects: Patients with rapidly progressive, extensive or long standing alopecia areata responds poorly
    • Regrowth usually seen within 4-8 weeks in responsive patients
  • Intravenous (pulse therapy)
    • Studies showed that patients achieved >50% hair growth after 3 consecutive days of pulsed IV corticosteroid courses
  • Oral
    • Use of systemic corticosteroids is controversial because long-term therapy may be necessary which increases risk of adverse effects
    • Based on a small number of studies, short-taper or pulse corticosteroid delivery may be used in cases of advancing alopecia areata
    • Effects: Promotes hair growth but hair shedding occurs soon after the drug is discontinued
  • Topical
    • Eg 0.12% Betamethasone valerate, 0.05% Betamethasone dipropionate,  0.2% Fluocinolone, 0.05% Clobetasol propionate
    • May be used as initial therapy for adults and children with limited patchy alopecia areata who are intolerant of intralesional corticosteroids
    • Treatment of choice in children with alopecia areata
    • Used as 2nd line treatment for alopecia areata totalis/universalis, as an adjunct with other treatments
    • Can be combined with Minoxidil
    • Signs of regrowth can take 6 weeks to 3 months
    • High relapse rate (38-63%) during treatment and after treatment cessation
Dithranol/Anthralin (Topical)
  • Used as short-term contact immunotherapy
    • Usually discontinued after maximum response has been achieved
  • Second-line treatment for patients >10 years old with <50% hair loss who responded poorly to intralesional corticosteroid/Minoxidil/topical corticosteroid treatment
    • Administered with or without Minoxidil
  • Also used as second-line treatment for unresponsive patients >10 years old with ≥50% hair loss, given with Minoxidil and topical corticosteroids
  • Effects: Safely stimulates hair growth in patients with extensive and total scalp hair loss and is useful in children
    • Cosmetically acceptable hair growth was seen in 50-60% of patients in 6 months
    • Clinical irritation is not necessary for effectiveness
Immunotherapy (Systemic)
  • Azathioprine
    • Treatment option for patients with extensive alopecia areata
  • Cyclosporine
    • An immunosuppressant that acts on T-lymphocytes to inhibit the production of lymphokines thereby suppressing cell-mediated immune responses
    • Several studies have shown 25-76.7% success rate but with numerous noted side effects
    • Further studies are needed to establish the efficacy of Cyclosporine for alopecia areata
  • Inosiplex (Inosine pranobex/Isoprinosine)
    • Alternative treatment for patients with treatment-resistant alopecia areata
  • Janus kinase (JAK) inhibitors (eg Tofacitinib, Ruxolitinib)
    • Studies have shown its efficacy in inducing hair growth in patients with severe alopecia areata
    • More studies are needed to confirm efficacy and safety
  • Methotrexate
    • Treatment option for patients with severe alopecia areata, alopecia areata totalis or universalis
    • May be given with low-dose oral corticosteroids
  • Sulfasalazine
    • Treatment option for patients with severe alopecia areata
    • Studies have shown that 23-27% of patients on Sulfasalazine treatment exhibited hair regrowth
Immunotherapy (Topical)
  • Eg Diphenylcyclopropenone (DPCP), Squaric acid dibutyl ester
  • Recommended treatment for chronic extensive alopecia areata, alopecia areata totalis and universalis
  • First-line treatment for adult patients with >50% (extensive) hair loss
  • A contact allergen commonly used as topical immunotherapy
  • Topical immunotherapy without DPCP has shown to be effective in up to 100% of patients without<50% hair loss; 60-88% of patients with 50-99% hair loss; and 17% of patients with alopecia totalis or alopecia universalis
    • Regrowth was apparent after 3-12 months of treatment
    • No benefit is achieved with continuing therapy after 24 months in the absence of regrowth
    • Relapse rate is 62% during treatment
Minoxidil
  • Topical
    • 1%-5% solution has been shown to be the most effective in alopecia areata patients
    • Effects: Hair growth is stimulated in patients with extensive and patchy hair loss but not in patients with complete hair loss
    • Hair growth may be seen within 12 weeks and maximal growth is seen at 1 year
    • Continue application until full remission
  • Oral
    • Several studies showed significant response with Minoxidil intake
Other Eye Preparations
  • Eg Bimatoprost, Latanoprost
  • Treatment option for eyelash universalis alopecia areata
    • Further studies are needed to establish the efficacy of Bimatoprost/Latanoprost for alopecia areata

Platelet-rich plasma

  • A study has shown its effectivity in inducing hair growth
  • More studies are needed to establish efficacy in the treatment of alopecia areata

Photochemotherapy

  • UVA combined with Psoralens (PUVA) has been used for severe alopecia areata
  • Whole body UVA irradiation may also be used
  • Psoralens may be given orally or topically
  • Effects: Effectiveness varies from 20-65% although relapse rate is high
  • There is concern about the promotion of skin cancer from long-term PUVA use

Non-Pharmacological Therapy

Camouflage Cosmetics
  • Eyebrow pencil may be suggested to cover alopecia areata patches on eyebrows
  • Waterproof eyebrow pencils are highly recommended
Hairpiece/Scalp Prostheses
  • Reassure patients with >50% hair loss that this does not mean that hair will not regrow, but it may be comforting to have it available for periods of more extensive hair loss
  • Wigs, hair extensions, hairpieces, headscarves, hats, and false eyelashes have been used to cover patches/areas with hair loss
  • Wigs are highly recommended for patients with extensive patchy alopecia and alopecia areata totalis and universalis
Laser Therapy
  • Eg Infrared diode laser, 308-nm excimer laser, low-level laser
  • Produces cosmetically acceptable hair regrowth with 60% response rate

Low-level laser (light) therapy (LLLT)

  • Also known as laser phototherapy or photobiomodulation therapy
  • Stimulate cell proliferation by increasing endogenous growth factors and cutaneous microcirculation by exposing tissues to low levels of visible or near infrared light
  • May be used as an ancillary procedure for male or female patients with androgenic alopecia
  • Generally well tolerated with mild adverse effects such as scalp dryness, itching, tenderness and warm sensation
  • More studies are needed to determine optimal treatment regiment and duration of effect
Micropigmentation/Tattooing
  • Permanent/semi-permanent tattooing of the eyebrows may be suggested
  • Recoloring may be needed every 1-2 years
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