1. In the name of God
Alopecia areata treatment

2. Alopecia areata (AA) is a T lymphocyte-mediated autoimmune disease of the hair follicle. It is characterized by patchy hair loss developing in otherwise normal skin, with ‘exclamation mark’ hairs around margins of expanding areas. Most cases are limited to one or more coin-sized patches, but in severe cases there may be complete baldness of the scalp (alopecia totalis, AT) or of the entire body (alopecia universalis, AU). The alopecia is non-cicatrizing,and in most cases resolves spontaneously after a few months.

3. MANAGEMENT STRATEGY
Spontaneous remission often occurs. Treatment can be time-consuming, uncomfortable, and potentially toxic, and relapse after treatment. Many patients are distressed so psychological support can be helpful,and careful management of expectations’ from treatment is important.

4. Intralesional corticosteroid injections are considered first-line treatment for adult
patients when only one or two small patches of alopecia are present, but can be
used on larger areas if patients can tolerate the discomfort.
The authors most frequently use triamcinolone acetonide aqueous suspension
injected intradermally and do not inject more than 20 mg in total at one visit.
Treatment is repeated at intervals of 4–12 weeks.
The main side effect is pitting atrophy which is usually transient.

5. Topical immunotherapy is the induction of contact allergy on the Scalp.
Contact sensitizers include diphencyprone(DPCP, diphenylcyclopropenone).
DPCP can initially be applied as 2% lotion to a small area (2–4 cm2) of scalp
until the site of application becomes pruritic and erythematous.
Treatment is then continued over a larger area with weekly applications of lower
concentrations, typically ranging from 0.001% to 0.1%.
The lowest concentration that maintains mild erythema or pruritus should be used.

6. Relapse rates may be high.
Side effects:
regional lymphadenopathy
rarely autosensitization
resulting in generalized eczema or even an eruption resembling erythema
multiforme.
Vitiligo may develop,this is usually confined to the treated areas For this
reason
sensitization therapy is best avoided in patients with pigmented skin types.

7. Topical corticosteroids have demonstrated efficacy in some studies of patchy AA,
particularly those using potent steroids with occlusion.
main side effect is transient folliculitis.
Topical prostaglandin analogues have been reported as effective in treating the
eyelashes of patients affected with AU.
Irritants, including anthralin (dithranol) and retinoic acid, are safe and practical to
use, although the evidence for their efficacy is limited.

8. Topical minoxidil is a safe treatment, but most studies have failed to demonstrate
a response of cosmetic value in most patients.
Systemic corticosteroids are effective in some cases if high doses are used.
AT, AU, and ophiasiform AA do not respond well and high relapse rates.
Systemic cyclosporine and methotrexate also appear effective if given in high
dosage, but the response is not maintained on cessation of therapy.

9. Other less conventional treatments include: PUVA,nitrogen mustard, lasers, topical bexarotene, topical azelaic acid, combination of simvastatin and ezetimibe, combination of topical garlic and topical steroids,cryotherapy Treatments that do not appear to be beneficial include: topical imiquimod, topical tacrolimus, topical pimecrolimus, botulinum toxin type A, topical tri-iodothyronine ointment, photodynamic therapy, narrowband UVB, topical 5-fluorouracil, capsaicin and,so far, biologics.

10. SPECIFIC INVESTIGATIONS
CBC
thyroid function tests
serum B12
autoantibodies as a screen for associated autoimmune conditions
No routine investigation is normally necessary and the diagnosis
is essentially clinical.
in patients with symptoms or a family history of autoimmune
diseases, such as thyroiditis,pernicious anemia, or Addison disease,
autoantibody screening and further investigation may be indicated.

11. FIRST-LINE THERAPIES
Intralesional steroids
Topical immunotherapy

12. SECOND-LINE THERAPIES
Topical corticosteroids
Anthralin/dithranol
Retinoic acid
Topical minoxidil
Bimatoprost / Latanoprost eye drops (for eyelashes)
PUVA

13. THIRD-LINE THERAPIES Systemic corticosteroids Systemic cyclosporine
Oral minoxidil
Sulphasalazine
Methotrexate
Azathioprine
Nitrogen mustard
Dermatography

14. Cryotherapy
Pulsed infrared diode laser
Excimer laser
Topical bexarotene
Topical azelaic acid
Combination treatment of simvastatin and ezetimibe
Onion juice
Combination of topical garlic gel and topical betamethasone valerate

15. Fexofenadine hydrochloride enhances the efficacy of contact immunotherapy for extensive alopecia areata
Retrospective analysis of 121 cases. This retrospective study showed better response to topical immunotherapy in the atopic subgroup of patients treated with oral fexofenadine 60 mg daily for adults and 30 mg daily for children.

16. Clobetasol propionate 0
Clobetasol propionate 0.05% under occlusion in the treatment of alopecia totalis/universalis.
A group of 28 patients with AT/AU of 3–12 years’ duration who had not responded to immunotherapy were treated on half of their scalp with 2.5 g of clobetasol propionate ointment under plastic film on 6 nights per week for 6 months. Regrowth started at 6–14 weeks, and 8 patients (28.5%) achieved >75% regrowth, which was then extended to the other side of the scalp.11 patients developed painful folliculitis, After a further 6 months’follow-up 17.8% of the 28 patients retained complete regrowth.

17. Treatment of alopecia areata by anthralin-induced dermatitis.
In this study using 0.5% and 1.0% concentrations of anthralin,the mean time to response was 11 weeks and the mean time to cosmetic response was 23 weeks (range 8–60 weeks). Cosmetic response was achieved in 29% (11/38) of patients with <75% scalp hair loss and in 20% (6/30) of patients with >75% scalp hair loss.

18. Topical tretinoin as an adjunctive therapy with intralesional triamcinolone acetonide for alopecia areata
In this open study 58 patients with mainly patchy alopecia were treated with monthly triamcinolone injections; 28 patients also had daily application of 0.05% tretinoin cream. More than 90% regrowth was achieved in 66.7% of patients with triamcinolone alone, and in 85.7% of patients with both treatments, which was statistically significant.

19. Bimatoprost in the treatment of eyelash universalis alopecia areata.
In this retrospective study of 41 patients, 0.03% bimatoprost eye drops were applied to the eyelid margins once a day for 1 year. Complete regrowth of the eyelashes was noted in 24.3% of patients and moderate regrowth in 18.9% of subjects.

20. Treatment of alopecia areata with three different PUVA modalities.
76 patients with severe AA were treated with local or oral 8-methoxypsoralen and local or whole body UVA irradiation. In 43 cases (57%) a good-to-excellent result was obtained. Patients with circumscribed or ophiasic alopecia responded better than patients with AT or AU. Disease duration, onset before the age of 20 years,and atopy were poor prognostic Factors. During a follow-up period of 6–68 months, 22 patients had a relapse.

21. High-dose pulse corticosteroid therapy in the treatment of severe alopecia areata.
In this prospective open study 30 patients with >30% hair loss were treated with three courses of IV methylprednisolone (8 mg/kg) on 3 consecutive days at 4-week intervals. 12 of 18 AA patients achieved >50% regrowth. None of the four patients with AT, five with AU, or three with ophiasic AA responded.

22. Placebo-controlled oral pulse prednisolone therapy in alopecia areata.
43 patients were randomized to receive oral prednisolone 200 mg weekly (23) or placebo (20) for 3 months. All patients had more than 40% scalp hair loss, or more than ten patches of AA, for more than 9 months. 8 of 23 in the treatment group showed more than 30% regrowth, compared to none in the placebo group. More than 60% regrowth occurred in only 2 patients, both within the treatment group. Side effects occurred in 55% of the treatment group, compared to 11% in the placebo group, although all were temporary.

23. Oral cyclosporine for the treatment of alopecia areata.
6 patients with alopecia (two AA, one AT and three AU) were treated with oral cyclosporine, 6 mg/kg/day, for 12 weeks. Hair regrowth in the scalp of all patients occurred within the second and fourth weeks of therapy, but cosmetically acceptable regrowth occurred in only three patients. In no case did this persist 3 months after stopping the drug.

24. Evaluation of oral minoxidil in the treatment of alopecia areata
65 patients with severe AA were treated with oral minoxidil 5 mg twice daily. Cosmetic response was reported in 18% of patients. The drug was well tolerated at this dose, provided the recommended restriction on sodium intake (2 g daily) was observed. Higher sodium intake increased the risk of fluid retention.

25. Efficacy and tolerability of methotrexate in severe childhood alopecia areata
In this retrospective study of 14 children with AA, approximately one-third of patients experienced a clinically relevant therapeutic response. The treatment was administered once weekly with a mean maximal dose of 18.9 mg weekly and a mean duration of treatment of 14–2 months.

26. Could azathioprine be considered as a therapeutic alternative in the treatment of alopecia areata
A total of 20 patients with minimum 6 months history of AA were included in this pilot study. Azathioprine was taken at a dose of 2 mg/kg of body weight. The mean regrowth was 52.3% and the mean hair loss before treatment was 72.7% compared with 33.5% after 6 months of treatment.

27. Effect of superficial hypothermic cryotherapy with liquid nitrogen on alopecia areata
72 patients with AA involving >25% of their scalp (disease duration 3 days to 15 years) were treated with liquid nitrogen on a cotton swab for two to three seconds on a double freeze–thaw cycle. This was repeated weekly for 4 weeks. Forty comparable controls were treated with glacial acetic acid in a bland emollient vehicle three times a day for 4 weeks. More than 60% regrowth occurred in 70 (97.2%) of the active group, compared to 14 (35%) of the controls.

28. Combination of topical garlic gel and betamethasone valerate cream in the treatment of localised alopecia areata
a double-blinded randomised control study. In this double-blinded randomized control trial, 40 patients were divided into two groups of garlic gel and placebo. Garlic gel was rubbed on the alopecia patches under dressing and left for 1 hour, twice daily for 3 months in the garlic group. The same procedure was carried out in the control group with placebo gel.Both groups received topical corticosteroid (betamethasone cream 0.1% in isopropyl alcohol) twice daily. Good and moderate responses were observed in 19 (95%) patients in the group treated with garlic gel and one (5%) patient in the placebo group.