Hair & nails

Steroid-sparing agents found useful in alopecia areata


Dr Vivian Lai

Azathioprine has a high rate of continuation as a steroid-sparing agent in chronic alopecia areata suggesting reasonable patient satisfaction and a treatment response, an Australian study has found.

A retrospective analysis of 852 patients from a large Melbourne hair loss clinic found 138 had been treated with either azathioprine, cyclosporine or methotrexate, mostly concurrent with prednisolone use.

Azathioprine (52.9%) was the most widely used of the three steroid-sparing agents (SSA) followed by methotrexate (31.2%) and cyclosporine (15.9%).

Continuation rates at six and 12 months were 80.0% and 75.3% respectively for azathioprine, 72.7% and 50% for methotrexate, and 76.7% and 60.5% for cyclosporine.

The average duration of SSA treatment concurrent with prednisolone was 38.2 months.

Overall, at six months, a quarter of patients (25%) taking a SSA ceased prednisolone entirely while 75% continued to take prednisolone at an average of 7.57 mg daily.

At 12 months, 35.9% of patients taking a SSA ceased prednisolone entirely while 64.1% continued to take prednisolone at an average of 6.36 mg daily.

Adverse events resulting in cessation of SSA occurred in 15.9% of patients.

The study authors, including senior investigator Professor Rod Sinclair, said management of alopecia has been controversial and a 2019 systematic review of the evidence found no reliably effective systemic treatment.

Yet, the current study’s findings demonstrate “the real-world utility of azathioprine, methotrexate and cyclosporine as SSAs in the treatment of CAA.”

“Our clinic data highlights that azathioprine is the most well-utilised and efficacious of the SSAs.”

“In an area of practice where comparative studies between commonly used SSAs are lacking, our study provides a useful comparison between azathioprine, methotrexate and cyclosporine for clinicians to use as a point of reference.”

It noted average doses of the SSAs was relatively low e.g. 74.7 mg azathioprine daily which might explain why patients still required concurrent prednisone.

“Higher doses of SSA may be more effective at maintaining remission as a monotherapy agent,” the study said.

First author on the paper, Dr Vivien Lai from Alfred Health, told the limbic that the mean doses of prednisolone required at 6 and 12 months was quite low in the patients taking a SSA.

“So across all groups, azathioprine, methotrexate and cyclosporine, they required less than 10mg of prednisolone concurrently. Methotrexate users at 12 months for example, were requiring 5 mg prednisolone daily.”

She said being able to taper from higher doses would help prevent side effects such as osteoporosis, gastrointestinal side effects and Cushing syndrome.

“The take home message from this study is that the majority of patients with chronic alopecia areata that are started on these SSAs continue to use SSAs for at least 12 months with low dose prednisolone. And that suggests it is well tolerated and suggests that there is probably some benefit to it in at least maintaining remission of hair loss or promoting hair regrowth.”

She said hair loss was often viewed as a cosmetic problem and it was easy to forget that it does have a significant impact on a patient’s mental health.

“I guess another element to it is that people in the past haven’t been too aware of this condition and how prevalent it is and how severe it can get. Hair loss can essentially be so extensive that the entire scalp and body hair is lost and those cases are very different from the patchy AA which is very common but probably has less of an impact.”

“The fact that there still isn’t a reliable systemic treatment that consistently produces hair regrowth means that further research needs to be done to understand the underlying causes of alopecia areata and to find targets that can more reliably create hair regrowth.”

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