Alopecia areata responds to skin-directed therapy

Key Points

National report - Although large, randomized, controlled trials of topical treatments for alopecia areata (AA) are lacking, experts say many such treatments provide varying degrees of success.

When it comes to AA, says Jerry Shapiro, M.D., "Some dermatologists still believe nothing works." He is adjunct professor, department of dermatology, New York University, New York.

Due to the paucity of randomized, controlled trials and appropriate measurement mechanisms in AA, he says, one large review concluded that no effective treatments for this condition exist (Delamere FM, Sladden MM, Dobbins HM, Leonardi-Bee J. Cochrane Database Syst Rev. 2008 Apr 16;(2):CD004413). "This review says to tell your patients, 'Go home, get a wig and join a support group.' That could hardly be more wrong," Dr. Shapiro says.

Among skin-directed treatments, Elise A. Olsen, M.D., says, "Topical steroids are my first choice. I believe they're very effective. It's unfortunate that the way to prove this ideally would be to perform a placebo-controlled trial, which is very difficult to do because of AA's high spontaneous remission rate." She is professor of dermatology and oncology and director of the Dermatopharmacology Study Center, Duke University Medical Center, Durham, N.C.

However, Dr. Olsen says, half-head studies, including one showing that class I topical steroids can induce hair growth on the side where the steroids were applied (Tosti A, Piraccini BM, Pazzaglia M, Vincenzi C. J Am Acad Dermatol. 2003;49(1):96-98), have provided scientific support.

For adults, she says, "I usually use clobetasol or Diprolene (betamethasone propionate, various manufacturers), both class I steroids, in liquid form. That way, as the hair starts to come in, you can still get the steroid into the scalp better than with a foam vehicle." For children, Dr. Olsen says she typically uses diprosone (a class V steroid).

Furthermore, she says that in her experience, topical steroids work for either patchy or more extensive AA.

"It takes about three months of application to see a response," she says. "That's part of the problem." Frequently, she explains, dermatologists may elect to change treatments at four- or six-week follow-up visits. "For AA, it is very important to know what each treatment agent can do, and how long it takes to do it."

Dr. Olsen recommends application of topical steroids once or twice daily. "Occlusion is good," she says, "but not necessary to get good results." Overall, she emphasizes, "Topical steroids are not necessarily less effective than systemic agents." Therefore, she says topical steroids represent a good starting point for many patients with AA.

"If I'm using oral corticosteroids, I always combine this with a topical corticosteroid because as you taper the systemic steroids, the topical steroid will help patients maintain their response," she says.

Potential side effects of topical steroids include folliculitis (a risk that increases with occlusion), Dr. Olsen says. If topical steroids drip down the face, she adds, patients could develop acneiform eruptions.

Although telangiectasias can occur, Dr. Olsen says epidermal atrophy is very uncommon with topical steroid treatment for AA used for appropriate periods of time. The potential for hypothalamic-pituitary-adrenal axis suppression is low, she says, due largely to the low concentrations, normal skin surface and small surface area involved in treating scalp AA.