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Alopecia areata; combination therapy with minoxidil (2%) solution and isotretinoin (0.05%) gel
Abstract
Background: Alopecia areata is a common cause of nonscarring hair loss. The cause is unknown but it is associated with an alteration in the immunological system. Treatment for alopecia areata includes topical corticosteroids, dithranol, tretinoin, minoxidil, systemic cortisone, PUVA therapy, irritants and immunosuppressive drugs. Objective: Our objective was to assess the efficacy of combination of topical 2% minoxidil lotion and isotretinoin (0.05%) gel in the treatment of alopecia areata. Patients and methods: From 1st October 2003 till 30th September 2004, over a period of 1 year, clinically diagnosed, fresh cases of alopecia areata, fulfilling the inclusion criteria were enrolled. All the patients were advised to apply minoxidil (2%) solution in the daytime and isotretinoin (0.05%) gel in the night to avoid photosensitivity. The daily treatment was advised for a period of four months and thereafter every alternate day for another two months as a maintenance therapy. Clinical assessment was carried out by patient's self-assessment, investigator assessment and clinical evaluation on follow up visits. Results: The total number of patients studied was 54 comprising 31 males (57.4%) and 23 females (42.6%), male to female ratio being 1.3. Twenty-nine patients (53.7%) had three lesions, 18 (33.3%) had two lesions and seven (13%) only one lesion. Complete restoration of hair follicles was noted in 45 (83.3%, p<0.001) by the end of therapy. All the patients with single patch responded (100%), while 15 patients (83.3%) with 2 lesions recovered completely. Twenty-three patients (79.3%) with 3 lesions had a complete restoration of hair follicles. Conclusion: The combination therapy of minoxidil (2%) solution and isotretinoin (0.05%) gel for alopecia areata is cost effective, stimulating hair regrowth within a shorter interval and is well-tolerated.
... In patients suffering from limited patchy AA for not more than 1 year the option of leaving the disease untreated may seem logical as there is spontaneous remission in about 80% of cases 11 . Treatment options for AA are numerous which includes tacrolimus, topical and systemic steroids, topical dithranol, tretinoin, minoxidil, PUVA therapy, oral immunosuppressive drugs and contact immunotherapy 12 . Minoxidil was being used originally for treating hypertension but it had a side effect and that was extensive hair growth, and now it is being prescribed to treat alopecia by applying either 2% or 5% topically 12 . ...
... Treatment options for AA are numerous which includes tacrolimus, topical and systemic steroids, topical dithranol, tretinoin, minoxidil, PUVA therapy, oral immunosuppressive drugs and contact immunotherapy 12 . Minoxidil was being used originally for treating hypertension but it had a side effect and that was extensive hair growth, and now it is being prescribed to treat alopecia by applying either 2% or 5% topically 12 . It directly acts on hair follicles and stimulates their growth 11 . ...
... As there is no permanent cure for this type of hair loss therefore the key challenge in managing alopecia areata is to find a treatment method that really works. The present study was a step to improve the management of alopecia areata by assessing the efficacy of topical 5% minoxidil solution Minoxidil was originally approved to treat hypertension 12 . Hair growth was seen initially as a side effect of the medication, afterwards, it began to be used as a topical solution for the treatment of male-pattern baldness 12 . ...
... 11 There are a lot of treatment options for AA including topical and systemic steroids, topical minoxidil, dithranol, tacrolimus, tretinoin, PUVA therapy, contact immunotherapy and oral immunosuppressive drugs. 11,12 The minoxidil was originally invented to treat high blood pressure. 13 Hair growth was seen as a side effect of the medication, and now it is widely used as a topical 2% and 5% solution to treat alopecia. ...
... 13,14 Topical minoxidil solution especially its 5% preparation, is found highly efficacious in treating alopecia areata. [12][13][14] When it is used topically in therapeutic doses, its side effects are very rare due to minimum systemic absorption. 14 The present study was planned to see the efficacy and safety of topical 5% minoxidil solution alone and in combi-nation with topical steroids in patients of AA, because no study of this kind has been done previously in our community. ...
... Alopecia Areata (AA) is a common disorder seen in our society that causes loss of hair from the scalp and elsewhere. 12,15 Topical steroids are a common form of treatment for alopecia areata. 15,16 Moderate to highpotency topical steroids can be applied twice daily to the affected area and have an advantage in localized alopecia areata, since they're easy to use, inexpensive, painless and have no serious hazards. ...
Background: Children up to 15 years of age constitute a major portion of our population and do suffer from a wide variety of skin diseases. Pediatric dermatology is a separate subspecialty by itself hitherto non-existing in Pakistan. The current work focuses on the audit of pediatric dermatological cases presenting in the outpatient department of Dermatology and Pediatrics, Hamdard University Hospital, Karachi, during the calendar year 2005. Objective: To determine frequency of dermatoses amongst children in a hospital in Karachi. Patients and methods: All patients aged below 15 years, belonging to both sexes suffering from dermatological diseases were included in the study. After a detailed history and clinical examination, a clinical diagnosis was made in each case. The patients enrolled were investigated, as well. Results: A total of 830 cases of pediatric dermatology, 539 males (65%) and 291 females (35%) were seen during the calendar year 2005, accounting for 27.2% of all dermatological patients. The age range was 0.1-15 years with a mean age of 8.1 years. Scabies (21.7%) was the most common dermatosis reported followed by atopic eczema (21.4%), fungal infections (15.7%), urticaria (12.1%) and bacterial infections (8.2%). Hair loss (alopecia), pityriasis alba, vitiligo and a few miscellaneous disorders had a comparatively low frequency. Conclusion: Scabies remains the most common pediatric dermatosis followed by fungal infections, atopic eczema, urticaria and bacterial infections.
Background Children up to 15 years of age constitute a major portion of our population and do suffer from a wide variety of skin diseases. Pediatric dermatology is a separate subspecialty by itself hitherto non-existing in Pakistan. The current work focuses on the audit of pediatric dermatological cases presenting in the outpatient department of Dermatology and Pediatrics, Hamdard University Hospital, Karachi, during the calendar year 2005. Objective To determine frequency of dermatoses amongst children in a hospital in Karachi. Patients and methods All patients aged below 15 years, belonging to both sexes suffering from dermatological diseases were included in the study. After a detailed history and clinical examination, a clinical diagnosis was made in each case. The patients enrolled were investigated, as well. Results A total of 830 cases of pediatric dermatology, 539 males (65%) and 291 females (35%) were seen during the calendar year 2005, accounting for 27.2% of all dermatological patients. The age range was 0.1-15 years with a mean age of 8.1 years. Scabies (21.7%) was the most common dermatosis reported followed by atopic eczema (21.4%), fungal infections (15.7%), urticaria (12.1%) and bacterial infections (8.2%). Hair loss (alopecia), pityriasis alba, vitiligo and a few miscellaneous disorders had a comparatively low frequency. Conclusion Scabies remains the most common pediatric dermatosis followed by fungal infections, atopic eczema, urticaria and bacterial infections.
Alopecia areata, especially when severe, often profoundly affects the lives of those afflicted. The unpredictability of its severity and frequency of recurrence may lead to feelings of loss of control and helplessness. Severe hair loss evokes not only cosmetic concerns but may also evoke feelings of vulnerability (nakedness), loss of self-esteem, alterations in self-image, and, perhaps, even self-identity. A grief reaction often occurs with the loss of significant amounts of scalp hair. Family, friends, and, often, physicians may suggest to patients that their hair loss is a result of stress, which may further induce feelings of responsibility and guilt for the alopecia. Finally, patients are often reassured by family and friends that at least alopecia areata is not "cancer" but only a benign cosmetic problem. This later reassurance generally reinforces the patient's sense of guilt for not coping better with the situation and often precludes the patient being able to verbalize feelings that can, in time, lead to emotional
The Journal of Investigative Dermatology publishes basic and clinical research in cutaneous biology and skin disease.
This study was conducted to further evaluate the safety and efficacy of 3% topical minoxidil in the treatment of extensive alopecia areata. Patients were assigned to one of two treatment regimens in a double-blind manner. One group applied 3% minoxidil to the scalp twice daily for 64 weeks; the other group applied placebo for the initial 12 weeks and then switched to 3% minoxidil for the remaining 52 weeks. Thirty male and female subjects, ages 7 to 63 years, with extensive alopecia areata affecting 25% to 100% of the scalp were enrolled, fifteen subjects to each treatment group. Twenty-four of the thirty subjects had greater than 75% scalp hair loss. At 12 weeks the group treated with 3% minoxidil had slightly more hair growth than the placebo group, but the difference was not statistically significant. At 64 weeks, thirteen of twenty subjects (65%) who began with less than full scalp involvement (25% to 99% scalp hair loss) had terminal hair growth that was incomplete or cosmetically acceptable; of these, nine (45%) were cosmetically acceptable, a response that is significant in patients with severe alopecia areata. No hair growth or only slight growth was seen in all nine patients with 100% scalp hair loss at baseline. Thus the extent of hair loss at baseline was correlated with response at 64 weeks. Twenty-one of the patients continued treatment for a second year. Of these, thirteen showed further growth, three had no further growth, and five who had cosmetically acceptable hair growth during the first year had some hair loss.(ABSTRACT TRUNCATED AT 250 WORDS)
Topical all-trans-retinoic acid (tretinoin) alone and in combination with 0.5% minoxidil has been tested for the promotion of hair growth in 56 subjects with androgenetic alopecia. After 1 year, the combination of topical tretinoin with 0.5% minoxidil resulted in terminal hair regrowth in 66% of the subjects studied. Tretinoin was shown to stimulate some hair regrowth in approximately 58% of the subjects studied. One female subject with pronounced alopecia for more than 20 years had regrowth of hair using only tretinoin for a period of 18 months. Tretinoin has been shown to promote and regulate cell proliferation and differentiation in the epithelium and may promote vascular proliferation. These factors are important for hair growth promotion. These preliminary results indicate that more work should be done on the role of retinoids in hair growth. The synergistic effect of retinoids in combination with a low concentration of minoxidil should also be further investigated.
Minoxidil is an orally active vasodilator for treatment of severe hypertension. In combination with diuretics and beta-adrenergic blocking agents, it is effective treatment for more than 80% of patients whose blood pressure has been inadequately controlled with combinations of other been inadequately controlled with combinations of other antihypertensive drugs. Major adverse reactions include reflex activation of the adrenergic nervous system, renal sodium retention, and hypertrichosis. Despite the possibility of adverse reactions, minoxidil is indicated in patients whose blood pressure cannot be controlled with conventional therapy, in persons with major adverse reactions to other drugs, and in patients who are candidates for bilateral nephrectomy for control of hypertension.
A 1% minoxidil topical solution was used to treat 48 patients with alopecia areata, ie, 24 patients with patchy disease and 24 patients with alopecia totalis or alopecia universalis. Twenty-five patients had terminal hair regrowth; in 11 of the 25 patients, it was cosmetically acceptable. No clinical features of the disease seemed to indicate the likelihood of hair regrowth. Hair regrowth began approximately two months after the initiation of treatment and was not uniformly well maintained after the treatment was terminated. One patient had an allergic contact dermatitis reaction to the minoxidil solution; no systemic side effects were seen. No notable systemic absorption was found in 18 adult patients. Effects on cutaneous blood flow or the immune system or some direct effect on hair follicles are possible mechanisms by which minoxidil therapy might stimulate hair growth.
The treatment of alopecia areata has changed markedly in the past decade. Several options are now available to the patient. It is the dermatologist's duty to inform the patient of all the options, their side effects, and their success rates. The final selection of treatment is a team decision between the patient, the patient's family, and the physician.
Alopecia areata is a disease which occurs in 1.7% of the population (Safavi et al., 1995), often with devastating effects to patients and their families. In the past, this condition has been misunderstood and treated inadequately. New treatment modalities and support systems are offering hope to patients with alopecia areata.
Common baldness or androgenetic alopecia is a universal problem, having affected both sexes of all races to different extents for as long as mankind has existed. The progressive androgen dependent hair loss follows specific patterns and is a physiological process, which may take on disease quality due to psychosocial compontents. These should be taken into consideration when discussing the several treatment options available, particularly as a cure cannot be offered. Cosmetic measures range from back-combing over perms to hairpieces and wigs. Medical therapies include systemic antiandrogens and topical minoxidil; surgical options comprise follicular transplantation, scalp reduction and rotation. Before starting treatment, however, careful consideration should be given to the differential diagnosis which includes drug-induced hair thinning, anagen effluvium, diffuse alopecia areata, metabolic disturbances, nutritional deficiencies and acute as well as chronic telogen effluvium.
Alopecia areata is considered to be a T-cell mediated autoimmune disease of the hair follicle. Current immunosuppressive approaches and immunomodulatory treatment with contact sensitizers such as diphenylcyclopropenone and squaric acid dibutylester are dealt with in this review article. The efficacy of the various modes of treatment is evaluated by a review of literature and their mode of action is discussed. In accordance with the mechanism of autoimmune pathogenesis of AA, improved future treatments may be immunosuppressive or immunomodulatory, or they should otherwise protect the hair follicle from the injurious effects of the inflammation. Such possible future therapeutic approaches include the use of liposomes as an improved vehicle, application of immunosuppressive cytokines like TGF-beta and IL-10, inhibition of apoptosis mediated by the Fas-FasL system, inhibition of the lymphocyte homing receptor CD44v10, induction of tolerance as well as principles of gene therapy.
Topical nitrogen mustard is an alkylating agent. Its efficacy in treating alopecia areata was reported in an uncontrolled study. We present a preliminary, half-head, controlled 16-week study showing that topical nitrogen mustard was of benefit in 1 of 6 patients treated with 50% to 100% scalp involvement. Another 4 patients did not complete the trial.
A biopsy of the seemingly normal scalp of a patient who had just begun to develop alopecia areata showed distinctive changes in bulbar morphology, in addition to peribulbar lymphocytic infiltrates. One of these changes was a loss of structural integrity of the centrally located supramatrical upper bulbar region. The other was the shrinkage of hair bulbs in the direction of club shape. Uninvolved intact anagen follicles were also present among these involved follicles.