Treatment of severe alopecia areata with intralesional steroid injections
Journal of Drugs in Dermatology, Oct, 2009 by Kyung Hee Chang, Salinee Rojhirunsakool, Lynne J. Goldberg
ABSTRACT
Background: Treatment of alopecia areata with intralesional steroid injection is generally recommended for people who have less than 50% scalp involvement. In a specialized hair loss clinic, the authors successfully treated patients with extensive alopecia areata (over 50% but under 99%) with intralesional corticosteroid injections.
Observations: A review of patients with extensive alopecia areata was done. Six out of 10 patients responded to treatment with intralesional triamcinolone acetonide. In comparison to the non-responders, the responders tended to have exclamation mark hairs and a positive hair pull test at their initial physical examination, and exhibited improvement during the initial months of treatment. Complications were negligible, with mild reversible atrophy in three patients. The treatment was well tolerated and, in some patients, pain was minimized by use of a topical anesthetic agent applied under occlusion prior to the visit.
Conclusion: Intralesional triamcinolone acetonide is a safe and effective treatment for patients with extensive alopecia areata. Patients with exclamation point hairs and a positive hair pull test may be more likely to respond.
INTRODUCTION
Alopecia areata is a common type of autoimmune hair loss that has a variable presentation and course. Some patients exhibit spontaneous remission, while others progress to develop total loss of scalp and body hair. The current therapy for alopecia areata is not curative, but rather is aimed at controlling or limiting the pathogenic process. (1), (2) The treatments available for alopecia areata are topical, intralesional and systemic steroids, anthralin, minoxidil, photochemo-therapy, oral cyclosporine and contact sensitization therapy. (3-5) These treatments have variable efficacy rates, and this unpredictability makes the initial choice of treatment challenging for individual patients.
Current algorithms for treatment rely on the extent of the alopecia and the age of the patient. (2), (5) The extent of alopecia areata is stratified depending on the percentage of scalp involved. (6) Current guidelines recommend intralesional corticosteroids as a first-line therapy only for adult patients who have less than 50% scalp involvement. (2), (5), (7) In a specialized hair loss clinic, the authors had the opportunity to successfully treat patients with extensive alopecia areata (over 50% but under 99%) with intralesional injections. The characteristics of these patients are reported, and a comparison is made with similarly treated patients who did not respond.
medical negligence claim METHODS
A retrospective review of charts from patients evaluated for alopecia areata by a single dermatologist (LJG) between June 2003 and December 2006 was done. Patients with extensive alopecia areata, defined as over 50%, but less than alopecia totalis, who were treated with intralesional triamcinolone acetonide, were selected for inclusion. This study was approved by the Institutional Review Board of Boston University School of Medicine, Boston, Massachusetts.
The following data were collected: patient age and sex, duration of alopecia areata, duration of alopecia areata current episode, the presence or absence of exclamation point hairs, results of a gentle hair pull test, steroid concentration and volume used per treatment, treatment response and adverse affects. Exclamation point hairs are short, broken hairs that taper proximally. A positive hair pull was defined as over six shed hairs with a gentle but firm pull of approximately 60 hairs.
Triamcinolone acetonide was used for all injections, administered with a 3 mL syringe with a 30-gauge needle. The initial concentration used was 5 mg/mL, which was increased incrementally depending on the treatment response to a maximum of 10 mg/mL.
Initial response was assessed in four to eight weeks following treatment. Responders were patients with no evidence of alopecia areata or near complete regrowth of cosmetically acceptable hair following treatment. Non-responders were patients exhibiting either little to no change or worsening of their alopecia areata despite treatment.
RESULTS
A total of 14 patients were initially identified. Four were lost to follow up for various reasons (pregnancy, relocation and insurance issues), leaving 10 for inclusion into the study. Patient demographics are listed in Table 1. Six of 10 responded to therapy
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