Sulfasalazine may be effective in alopecia areata treatment

Jahrom, Iran - Many different therapies are currently being used to treat alopecia areata, however, most prove to be only marginally effective. A recent study showed that sulfasalazine is effective in the treatment of alopecia areata and can be considered as a viable therapeutic option for this disease.

Alopecia areata is a challenging disease to treat and can be often recalcitrant to the plethora of therapies currently being used, including mainstay therapies such as topical, systemic and intralesional corticosteroids, as well as trials with anthralin, minoxidil, cyclosporine, alpha-interferon and topical immunotherapy such as topical diphencyprone.

According to one expert, sulfasalazine could be a good alternative treatment for alopecia areata because of its good efficacy, good adverse event profile and steroid sparing nature.

“Sulfasalazine is a hopeful treatment approach that works similarly to other currently used medications without any serious adverse events. The drug has immunosuppressive and immunomodulatory effects, including the inhibition of inflammatory cell chemotaxis, and cytokine and antibody production and similar to cyclosporine, sulfasalazine has been shown to inhibit the release of interleukin 2,” says Shahin Aghaei, M.D., assistant professor, department of dermatology, Jahrom University of Medical Sciences, School of Medicine, Jahrom, Iran.

Clinical trial

In a recent open label, uncontrolled clinical trial, 26 patients with recalcitrant or severe alopecia areata (>40 percent scalp hair loss) were treated with sulfasalazine initially dosed at 500 mg bid for the first month, then 1 g bid for the second month, and finally with 1.5 g bid for a further three months.

Patients were grouped into three categories according to their response to treatment: no hair re-growth (<10 percent terminal hair), partial hair re-growth (10 percent to 90 percent terminal hair), and complete hair re-growth (90 percent to 100 percent terminal hair). If no re-growth was observed after six months of treatment, the patient was considered to be a non-responder and was dropped from the trial.

Twenty-two of 26 patients completed the study. Overall, results showed that 68.2 percent (15 of 22) of patients responded to therapy with 27.3 percent (six of 22 patients) and 40.9 percent (nine of 22 patients) demonstrating a complete hair re-growth and a partial hair re-growth, respectively.

Of the nine patients with partial hair growth response, five patients had 10-20 percent re-growth, two patients had 30-40 percent, one patient had 50 percent, and one patient had 60-70 percent re-growth. Results also showed that 45.5 percent (10 of 22 patients) with initially complete or partial remission suffered a partial or complete relapse either on maintenance treatment or after termination of therapy. Seven (31.8 percent) of patients had no hair re-growth and were dropped from the study.

“We saw that there was a remission in patients after the drug was either stopped or during the maintenance treatment phase. However, the relapse or partial relapse that occurs in these patients with sulfasalazine therapy is acceptable when looking at other treatment options," Dr. Aghaei says. "Topical, intralesional and especially oral corticosteroid therapy is the most common used approach and is the mainstay of therapy, however, though this approach may be effective in some patients, sulfasalazine is a good therapeutic option in lieu of the frequently encountered adverse events associated with corticosteroid therapy.”

Adverse events

The adverse events encountered in this small series of patients with sulfasalazine included gastrointestinal distress, rash, laboratory value abnormalities and headaches and was seen in 31.8 (seven of 22) percent of patients. These adverse events were all encountered within the first three months of treatment.

According to Dr. Aghaei, these side effects can be managed by lowering the dose of sulfasalazine or giving the patient a drug holiday.

Alopecia areata is a chronic disease and, therefore, a long-term therapeutic solution is needed that has less side effects than those typically seen with corticosteroid treatments. According to Dr. Aghaei, steroid sparing agents such as immunotherapy have a safer drug profile as well as a good tolerability in alopecia areata patients.

“It is clear that we need more effective therapies with minimal side effects for the treatment of alopecia areata. This study consisted of only a few patients, but I believe some inroads have been made in terms of finding alternative treatments for this disease. I think that dermatologists and dermatologic researchers could use this study as a platform to work from, and perform much larger controlled clinical trials with steroid-sparing drugs, perhaps directly comparing the therapeutic benefits of sulfasalazine to steroid and immunotherapy,” Dr. Aghaei says.