Alopecia areata

DM Thappa, M Vijayikumar

 Department of Dermatology and STD, JIPMER, Pondicherry - 605006, India

Correspondence Address:
D M Thappa
Department of Dermatology and STD, JIPMER, Pondicherry - 605006
India

It is said that the only predictable thing about the progress of alopecia areata (AA) is the it is unpredictable. The first thing we tell our patient of AA is that hair regrowth may occur in about one third of the patients without any treatment. However, most of the patients are anxious, have undergone severe emotional stress, are well-motivated by the given treatment. We divide patients according to agethose less than 10 years and those of 10 years of age or more. The patients older than 10 years are further divided based on the extent and progression of hair loss those with less than 30% scalp surface area involved and those with more than 30% involvement or rapidly progressive hair loss of less than 1-year duration.

1. Patients with less than 10 years of age: We use non-specific topical irritants like tincture iodine or non- specific immunomodulators like anthralin as the first line of management. Patients are asked to apply tincture iodine on areas of hair loss overnight to elicit irritant reaction. If no regrowth occurs after 2 months of therapy, short-contact anthralin therapy is tried. Compound dithranol ointment (Derobin ointment-dithranol 1.15%, salicylic acid 1.15% and coal tar 5.3%) is applied on the leg for 30 minutes to 1 hour. If the patient is able to tolerate the drug, then application on the scalp is recommended. Usually response occurs after 2 to 3 months. We use topical corticosteroid lotion or cream (for example fluocinolone acetonide 0.05%) as second line therapy. They are applied overnight on alternate days or on five days a week to prevent atrophy of the skin. Response is expected after 6 to 8 weeks.

2. Patients older than 10 years: < 30% scalp surface involved: Short contact anthralin or topical corticosteroids are tried first. If hair regrowth does not occur after 2 to 3 months, then intralesional corticosteroids are recommended. Triamcinolone acetonide 10 mg/ml diluted with equal amount of 1% xylocaine solution can be used. It is administered as multiple intradermal injections of 0.1 ml per site, about 1cm apart using a 30-gauge needle fitted to an insulin syringe. Injections are repeated every 4 weeks. Usually patients respond by 4 to 8 weeks. If patients do not show response even after 6 months of intralesional corticosteroids, therapy is discontinued as they may lack adequate corticosteroid receptors in the scalp.

3. Patients older than 10 years, > 30% scalp involved or rapid progressive alopecia< 1-year duration: We use dexamethasone pulse therapy as the main line of treatment. It consists of 32 mg of dexamethasone in 200 ml of 5% dextrose given intravenously on three consecutive days (total 96 mg) every 4 weeks. Cosmetically acceptable results have been observed in 66% of cases of extensive alopecia areata and alopecia totalis. Arrest of progression of hair loss occurs after 2 to 3 pulses. If patient shows no response by 6 pulses, treatment is discontinued. In patients showing response, treatment is continued for up to 10 pulses. If patient is unwilling for intravenous pulse therapy, oral minipulse with 5 mg betamethasone tablets given twice weekly for up to 6 months. In our experience intravenous dexamethasone pulse therapy appears to be more effective than oral betamethasone pulses. Patients with alopecia universalis, those having progressive hair loss for more than 2 years and patients not responding to treatment are encouraged to use a wig or cap as cosmetic camouflage.