Dexamethasone pulse therapy for extensive alopecia areata: To use or not to use

M Vijayakumar, DM Thappa

 Department of Dermatology and Venereology, JIPMER, Pondicherry-605 006, India

Correspondence Address:
M Vijayakumar
Department of Dermatology and Venereology, JIPMER, Pondicherry-605 006
India

To the Editor:

We read with great interest the article "alopecia universalis: Failure of dexamethasone pulse therapy" by Balachandran C and Davis SV (Vol. 67(2): 107, 2001) and we have a few comments to make. Though the failure of a therapy cannot be judged by a single case, we would like to bring into focus the results of our preliminary study[1] which included six patients with extensive alopecia areata (AA) involving more than 30% scalp area (of more than 1 year duration) and/or with rapid progression (of less than 1 year duration). They were given 32 mg of dexamethasone in 200 ml of 5% dextrose intravenously on three consecutive days (total 96mg) every 4 weeks. Cosmetically acceptable result (i.e., more than 50 % hair regrowth in the affected area so that the patient does not use a cap or wig to conceal the hair loss) was observed in 3 cases out of 6 cases.

Meanwhile, we have recruited 15 cases of extensive AA who have received 6 to 10 dexamethasone pulses with a follow up period of 6 to 18 months (mean 8.1 months). This included 11 cases of extensive AA, 1 alopecia totalis (AT) and 3 cases of alopecia universalis (AU). Arrest of progression of hair loss was observed in 13 cases after 2 to 3 pulses. After 6 pulses, 3 cases (1 AA, 2AU) did not show any regrowth, 4 cases (3AA,lAU) showed 25-50% hair regrowth and 8 cases (7AA, 1AT) showed> 50% hair regrowth with a cosmetically acceptable result. Three patients of AA completed 10 pulses and were followed up for 12 - 18 months with no relapse. All the patients were carefully monitored for adverse effects of dexamethasone pulse therapy. Except for one patient who developed gastritis, no other adverse effects were encountered.

The pharmacological preparation, dose of corticosteroid. number of days and frequency of pulse administration of steroids have been arbitrary. Our dose of 32 mg dexamethasone (one third of the dose used for pemphigus) on 3 successive days was higher than the 300 mg prednisolone used by Sharma[2] but lower than the 1500 mg (250mg BDx 3 days) methyl prednisolone used by Perriard - Wolfensberger et al.[3] Cosmetically acceptable regrowth was observed in 53% of our cases and if only extensive AA and AT cases are considered, 66.7% cases had excellent result. Of the 3 cases of AU, 2 cases were non responsive and one case showed some regrowth of the eyebrows and body hair and < 25% regrowth of scalp hair. The mean duration of the disease was 2.6 years. (range 1-5 years) amongst non-responders and 0.96 years (range 3 months- 2years) amongst responders. Hence, the two major factors that influence the outcome of dexamethasone pulse therapy are: (i) type of alopecia areata- AU showing poorer response and (ii) duration of disease-progressive hair loss for more than 2 years showing poor response. Similar observations have been made in other studies also.[2],[3]

With evidence mounting in support of the hypothesis that AA is an organ- specific autoimmune disease directed agonist various cellular components of hair follicles, one can imagine that dexamethasone pulse can have a profound but transient action on the perifollicular lymphocytes which restores normal hair cycle.[2],[3] Therefore, repeated dexamethasone pulses will be effective in short duration, fast evolving AA, whereas it will have partial or no effect at all in chronic long duration AA.

1.	Thappa DM, Sivaraman, Vijaikumar. Intravenous dexamethasone pulse therapy for extensive alopecia areata. Indian J Dermatol 1999;44:187-190. [Google Scholar]
2.	Sharma VK. Pulsed administration of corticosteroids in the treatment of alopecia areata. Int J Dermatol 1996;35:133-136. [Google Scholar]
3.	Perriard-Wolfensberger J, Pasche-Koo F, Mainette C, et al. Pulse methylprednisolona in alopecia areata. Dermatology 1993;187:282-285. [Google Scholar]