Cochrane Abstracts
Interventions for alopecia areata
Abstract
Background
Alopecia areata is a disorder in which there is loss of hair causing patches of baldness but with no scarring of the affected area. It can affect the entire scalp (alopecia totalis) or cause loss of all body hair (alopecia universalis). It is a relatively common condition affecting 0.15% of the population. Although in many cases it can be a self‐limiting condition, nevertheless hair loss can often have a severe social and emotional impact.
Objectives
To assess the effects of interventions used in the management of alopecia areata, alopecia totalis and alopecia universalis.
Search methods
We searched the Cochrane Skin Group Specialised Register in February 2006, the Cochrane Central Register of Controlled Clinical Trials (The Cochrane Library Issue 1, 2006), MEDLINE (from 2003 to February 2006), EMBASE (from 2005 to February 2006), PsycINFO (from 1806 to February 2006), AMED (Allied and Complementary Medicine, from 1985 to February 2006), LILACS (Latin American and Caribbean Health Science Information database, from 1982 to February 2006), and reference lists of articles. We also searched online trials registries for ongoing trials.
Selection criteria
Randomised controlled trials that evaluated the effectiveness of both topical and systemic interventions for alopecia areata, alopecia totalis, and alopecia universalis.
Data collection and analysis
Two authors assessed trial quality and extracted the data. We contacted trial authors for more information. We collected adverse effects information from the included trials.
Main results
Seventeen trials were included with a total of 540 participants. Each trial included from 6 to 85 participants and they assessed a range of interventions that included topical and oral corticosteroids, topical ciclosporin, photodynamic therapy and topical minoxidil. Overall, none of the interventions showed significant treatment benefit in terms of hair growth when compared with placebo. We did not find any studies where the participants self‐assessed their hair growth or quality of life.
Authors' conclusions
Few treatments for alopecia areata have been well evaluated in randomised trials. We found no RCTs on the use of diphencyprone, dinitrochlorobenzene, intralesional corticosteroids or dithranol although they are commonly used for the treatment of alopecia areata. Similarly although topical steroids and minoxidil are widely prescribed and appear to be safe, there is no convincing evidence that they are beneficial in the long‐term. Most trials have been reported poorly and are so small that any important clinical benefits are inconclusive. There is a desperate need for large well conducted studies that evaluate long‐term effects of therapies on quality of life.
Considering the possibility of spontaneous remission especially for those in the early stages of the disease, the options of not being treated therapeutically or, depending on individual preference wearing a wig may be alternative ways of dealing with this condition.
Author(s)
Finola M Delamere, Michael J Sladden, Helen M Dobbins, Jo Leonardi-Bee
Abstract
Plain language summary
Treatments for alopecia areata, alopecia totalis and alopecia universalis
There is no good trial evidence that any treatments provide long‐term benefit to patients with alopecia areata, alopecia totalis and alopecia universalis.
Alopecia areata is a condition that causes patchy hair loss. The size and number of patches and progress of the disease can vary between people. It can affect the entire scalp (alopecia totalis) or cause loss of all body hair (alopecia universalis). Sometimes the condition will get better on its own, but in some cases it can get worse.
Treatments include a variety of different creams or lotions applied to the scalp such as topical or oral corticosteroids, minoxidil and some light‐based therapies. Some of the skin treatments can have unpleasant side effects such as itching or hair growth in areas of the body away from where the cream was applied. Oral steroids may cause serious side effects. Also, there is no guarantee that any hair regrown during treatment will persist once the treatment is finished.
We found 17 randomised controlled trials involving 540 participants. Only one study which compared two topical corticosteroids showed significant short‐term benefits. No studies showed long‐term beneficial hair growth. None of the included studies asked participants to report their opinion of hair growth or whether their quality of life had improved with the treatment.
Author(s)
Finola M Delamere, Michael J Sladden, Helen M Dobbins, Jo Leonardi-Bee
Reviewer's Conclusions
Authors' conclusions
Implications for practice
Few treatments for alopecia areata have been well evaluated in randomised trials: there is no RCT evidence that steroids, whether topical, intralesional or systemic, are of benefit in treating alopecia areata. Systemic steroids have the potential to produce serious side effects. Similarly, there is insufficient evidence on use of topical minoxidil, topical ciclosporin, PDT, hair growth stimulants, or other immunotherapies for the treatment of alopecia areata.
Before starting treatment for alopecia areata, and especially in the early stages of the disease people should be informed of its natural history and the possibility of spontaneous remission and the lack of evidence for different treatments. We found no RCTs on the use of diphencyprone to treat alopecia areata, but it is frequently used and recommended for the treatment of extensive alopecia areata and alopecia totalis/universalis (MacDonald Hull 2003). Similarly although topical steroids and minoxidil are widely prescribed by dermatologists for limited patchy alopecia areata, and appear to be safe, there is no convincing evidence that they are beneficial. MacDonald Hull 2003 concluded that there was poor evidence to support the use of topical steroids and topical minoxidil.
It is clinically challenging when a patient with alopecia areata is desperately seeking treatment, to tell them that the evidence suggests that current treatment confers no long‐term benefit. Considering the possibility of spontaneous remission and lack of efficacy of treatments, the option of not treating may be the best option for many patients. For some participants with extensive alopecia areata, wearing a wig might be a reasonable option. Healthcare practitioners can still play an important role in providing psycho‐social support and information, and self help groups both online and face‐to‐face can be beneficial for some people.
Implications for research
Few treatments for alopecia areata have been well evaluated in randomised trials and we found none that addressed participant‐focussed measures of success or measurements of quality of life. Addressing these deficiencies by means of high quality clinical trials has to be a priority and main conclusion from our review.
Future studies need to be much bigger than the current largely inconclusive small studies performed to date, and they should ideally include a placebo or vehicle group given the current uncertainty around whether any treatment works. In order that studies can be comparable there needs to be a clear definition of baseline measures of hair loss as well as success in terms of measuring scalp coverage, measurement of sustained hair re‐growth and participant satisfaction. Future research should incorporate outcome measures that are clinically meaningful to participants.
Future trials should be designed to recruit participants who are clinically homogeneous, for example of similar disease severity or duration, or both, so that clinically meaningful outcomes can be used to better direct clinical practice. Similarly, because short‐term interventions may not 'cure' alopecia areata or result in long‐term benefit, trials should focus on assessing safe and sustainable treatments. There have been no trials involving the use of good quality wigs or alternative supportive therapies versus pharmaceutical interventions for alopecia areata. Such trials using patient satisfaction outcomes would be invaluable. There seems little point in doing more trials on topical ciclosporin and topical minoxidil. Long‐term use of topical corticosteroids, topical tacrolimus and topical immunotherapy with diphencyprone are possible future trial priorities. Although there are 'new' topical immunomodulating drugs and biologic therapies for the treatment of other immune‐mediated inflammatory skin diseases (Price 2003; McMichael 2003), evidence from randomised controlled trials is needed to support their effectiveness in alopecia areata. However, reports of alopecia areata occurring during treatment with biologic agents (Tosti 2006; Garcia Bartels 2006) suggest that their utility will be limited.
If more high quality RCTs were to be conducted comparing the variety of possible interventions for alopecia areata, there might be consensus about which treatment would be most effective at different stages of patchy hair loss and disease severity. A pseudo (non)‐ randomised study of aromatherapy showed promise but this warrants further study in RCTs (Hay 1998)
