Treatment options of pediatric alopecia areata

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Treatment options of pediatric alopecia areata

Tips for pediatric alopecia areata treatment

  • Psychological and emotional well being of the child should be evaluated.
  • Educate the parents about the chronic relapsing nature of alopecia areata.
  • Reassure the parents that the condition is benign and does not threaten their general health.
  • The condition is highly unpredictable in presentation, evolution, and response to treatment.
  • Referral to a psychiatrist if psychiatric comorbidities were suspected.

Medical treatment options

Topical treatment options

  • Topical corticosteroids
    • High potency topical corticosteroids : first line of treatment, safe and effective.
    • Side effects include skin atrophy, telangiectasia and folliculitis.
    • Evaluate growth after three months of therapy.
    • Clobetasol propionate 0.05% cream
  • Intralesional steroids
    • The use of intralesional steroids in children is limited due the pain.
  • Topical minoxidil
    • Twice daily.
    • Excessive use may lead to systemic absorption (hypotension- palpitation- etc).
    • Minoxidil is mostly used as an adjunctive therapy.
  • Anthralin (short contact)
    • May be used twice a week to once daily.
    • Apply 0.5% to 1% anthralin cream to affected scalp once daily; leave on 20 to 30 minutes daily for 2 weeks, and then 45 minutes daily for 2 weeks, up to a maximum of 1 hour daily. Wash hands afterward, and avoid getting anthralin in the eyes.
    • Wash hands immediately after application with lukewarm water.
    • Remove from scalp with mineral oil; then wash off with soap and water.
    • Do not use on eye brows or beard.
    • Anthralin may stain the skin, clothing, and hair brown.
  • Topical immunotherapy
    • Diphenylcyclopropenone (DPCP) concentration of ( 0.0001% and 2%) or Squaric acid dibutylester (SADBE) concentration of ( 0.00001% and 1%) can be used.
    • Sensitization with DPCP 2% is followed by weekly application of the lowest concentration that can cause mild irritation.
    • The treated areas protected from the sun while the product is on it.
    • In most studies treatment was discontinued after 6 months if no response was obtained.
    • Temporary occipital and/or cervical lymphadenopathy.
    • Doctors should avoid skin contact with the allergen as possible.
    • Combination of topical immunotherapy and laser therapy could be suggested for the treatment of extensive AA in children.
  • Topical prostaglandins
    •  Topical bimatoprost 0.03% therapy.
  • Topical calcineurin inhibitors
    • Topical tacrolimus 0.1%.
  • Topical JAK inhibitors
    • Tofacitinib  2% ointment.
    • Ruxolitinib 1–2% therapy
    • Side effects include transient leukopenia and increased liver enzymes in one child.
  • Topical sildenafil
    • Sildenafil 1% cream applied twice daily for three months.

Systemic treatment options

  • Systemic Corticosteroids
    • Used for rapidly progressive alopecia areata to slow hair loss.
    • Oral, intravenous and intramuscular glucocorticosteroids have been used.
    • Pulse oral prednisolone : 5 mg/kg or 300 mg once a month.
    • Continuous oral prednisolone (0.5–2 mg/kg/day or 5–10 mg/day)
    • Intravenous methylprednisolone pulse therapy (8–30 mg/kg for three days once a month or 500 mg for one day once a month).
    • Side effects include headache, abdominal pain, weight gain, steroid acne, muscle pain, behavioral changes, Cushing syndrome, striae, increased ocular pressure, pseudoacanthosis nigricans, hypertrichosis and dysmenorrhea.
  • Methotrexate
    • 2.5–25 mg/week or 0.2 mg/kg/day.
    • Methotrexate is usually used in combination with glucocorticosteroids.
    • Side effects include nausea, vomiting, abdominal discomfort, abnormal liver function test results, neutropenia, migraine, leg weakness and tooth sensitivity.
  • Cyclosporine
    • 100–200 mg/day or 5–7.5 mg/kg/day.
    • Used alone or in combination with systemic glucocorticosteroids or PUVA therapy.
  • Azathioprine
    • 100 mg/day combined with methotrexate or anthralin.
  • Hydroxychloroquine
    • 50–400 mg daily for 4–24 month.
    • Side effects include abdominal pain, headache and viral gastroenteritis.
  • Janus kinase inhibitors
    • Used for refractory alopecia totalis or alopecia universalis.
    • oral  tofacitinib 5 mg twice daily.
    • Ruxolitinib (80 mg/day).
    • Baricitinib (7–11 mg/day).
    • Side effects include diarrhoea, upper respiratory tract infection and headaches.
  • Leflunomide
    • Leflunomide (20 mg/day) and anthralin.
  • Mesalazine
    • Mesalazine (15–30 mg/day) and topical betamethasone/minoxidil.
  • Apremilast
    • Apremilast (30 mg/day) and platelet-rich plasma.
  • Dupilumab
    • Dupilumab 300 mg s.c therapy.
  • Ustekinumab  
    • Ustekinumab therapy 90 mg Intramuscular.
  • Compound glycyrrhizin (75 mg/day) with vitamin B2 

Physical treatment options

  • Cryotherapy
    • Superficial cryotherapy in mild Alopecia areata.
    • Used in combination with topical steroids.
  • Laser therapy
    • Excimer laser 308 nm twice weekly.
      • Side effects include mild erythema, hyperpigmentation, itching, and mild peeling of the skin.
    • Fractional carbon dioxide laser (50–60 mJ/cm2) followed by the topical application of triamcinolone spray.
      • Four sessions repeated at an interval of three to four weeks. 
  • Phototherapy
    • PUVA is not recommended in children.
    • PUVA-turban therapy.

Sources :

Therapeutic management in paediatric alopecia areata: A systematic review*


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