Treatment options of pediatric alopecia areata

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 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*