Three monthly doses of corticosteroid pulse therapy yields a satisfactory but temporary response in severe alopecia areata patients

Heng-An Lu; Chao-Chun Yang; Yu-Chen Chen

doi:10.4103/1027-8117.357355

BRIEF REPORT

Year : 2022 | Volume : 40 | Issue : 3 | Page : 178-181

Three monthly doses of corticosteroid pulse therapy yields a satisfactory but temporary response in severe alopecia areata patients

Heng-An Lu¹, Chao-Chun Yang², Yu-Chen Chen³
¹ Department of Dermatology, National Cheng Kung University Hospital, College of Medicine, National Cheng Kung University, Tainan, Taiwan
² Department of Dermatology, National Cheng Kung University Hospital, College of Medicine; International Center for Wound Repair and Regeneration, National Cheng Kung University, Tainan, Taiwan
³ Department of Dermatology, National Cheng Kung University Hospital, College of Medicine, National Cheng Kung University; Department of Dermatology, An Nan Hospital, China Medical University, Tainan, Taiwan

Date of Submission	30-Sep-2021
Date of Decision	18-Apr-2022
Date of Acceptance	30-May-2022
Date of Web Publication	29-Sep-2022

Correspondence Address:
Dr. Yu-Chen Chen
Department of Dermatology, An Nan Hospital, China Medical University, No. 66, Sec. 2, Changhe Rd., Annan Dist., Tainan City 709
Taiwan

Source of Support: None, Conflict of Interest: None

DOI: 10.4103/1027-8117.357355

Abstract

Alopecia areata (AA) is a common, nonscarring type of alopecia that can cause chronic and severe hair loss in some cases. Although there is no standard established protocol for the use of corticosteroid pulse therapy, it has been reported to be an effective and well-tolerated treatment option for patients with severe AA. This study retrospectively analyzed 29 patients who were diagnosed with severe AA (>50% hair loss) from January 2010 to December 2020 and treated with 3 monthly sessions of intravenous corticosteroids. Methylprednisolone (500 mg/day) was administered for 3 consecutive days during the first session, followed by a 1-day treatment regimen for the second and third sessions. The treatment had an overall satisfactory response rate of 58.6% and a complete response rate of 13.8%. Eleven of the 13 patients who achieved a satisfactory response experienced relapse. A subgroup analysis showed that patients with a shorter duration of AA (≤6 months) had a significantly better response to corticosteroid pulse therapy. This study highlights that 3 monthly sessions of corticosteroid therapy are sufficient to induce satisfactory but temporary response.

Keywords: Alopecia areata, prognosis, steroid pulse therapy

How to cite this article:
Lu HA, Yang CC, Chen YC. Three monthly doses of corticosteroid pulse therapy yields a satisfactory but temporary response in severe alopecia areata patients. Dermatol Sin 2022;40:178-81

How to cite this URL:
Lu HA, Yang CC, Chen YC. Three monthly doses of corticosteroid pulse therapy yields a satisfactory but temporary response in severe alopecia areata patients. Dermatol Sin [serial online] 2022 [cited 2023 Jun 6];40:178-81. Available from: https://www.dermsinica.org/text.asp?2022/40/3/178/357355

Introduction

Alopecia areata (AA) is the second most common nonscarring alopecia with a lifetime prevalence of approximately 2%.^[1] AA is characterized by acute onset of patchy hair loss, which can progress to total loss of scalp hair (alopecia totalis, BRIEF REPORT) and total loss of all body hair (alopecia universalis, [AU]).^[1] It is an autoimmune disease with an unpredictable and fluctuating course.^[2] AA has been reported to be related to psychological disorders, atopy, autoimmune disorders, and endometriosis.^[3],[4] Spontaneous complete remission can be expected in most cases; however, it would be temporary in those with extensive hair loss or a longer disease duration (>6 months).^[5] For severe AA cases (>50% hair loss), corticosteroid pulse therapy has been reported to be an effective and well-tolerated treatment option.^[6],[7] There is no standardized protocol for AA treatment; the severity of disease, corticosteroid regimen, definition of treatment response, and therapeutic efficacy vary across studies.^[8] Corticosteroid pulse therapy minimizes the side effects of conventional corticosteroid treatment. Therefore, a protocol with a shorter treatment duration and fewer treatment sessions is preferred. This study aimed to retrospectively evaluate the efficacy of corticosteroid pulse therapy and identify the predictive factors for satisfactory responses.

Materials and Methods

Patients who experienced active hair loss and those diagnosed with severe AA from January 2010 to December 2020 were retrospectively recruited. Severe AA was defined as a loss of more than 50% of scalp hair.^[6] Patients with AT, AU, and AA ophiasis (AO) were also included. Only patients treated with a standardized regimen of corticosteroid pulse therapy were included in the analysis. The regimen consisted of 3 monthly sessions of corticosteroid administration. During the first session, the patient received methylprednisolone 500 mg/day (10 mg/kg/day) intravenously for 3 consecutive days and was hospitalized for monitoring of vital signs and side effects. During the second and third sessions, which took place 1 and 2 months after the first session, respectively, one bolus of methylprednisolone 500 mg (10 mg/kg) was administered to the patient. When a notable side effect, such as headache, gastrointestinal (GI) upset, or insomnia, was observed during the first session, the dosing was decreased by half for the succeeding sessions. After 3 months of corticosteroid pulse therapy, intralesional steroid injection was administered before a satisfactory response was elicited. Patients were excluded from the final analysis if they did not complete the three sessions of corticosteroid pulse therapy, had incomplete photographic records, or were not followed up within 3 months after their last dose of treatment.

The severity of hair loss was evaluated through photographic review by two independent dermatologists, and presented as percentage of scalp hair loss based on the AA Investigational Assessment Guidelines.^[6] A satisfactory response to treatment was defined as >50% hair regrowth in previously bald areas, while a complete response was defined as 100% hair regrowth. Relapse was defined as recurrent hair loss of more than 10% compared with that in previous visit in patients who had already showed a satisfactory response. Disease duration was defined as the total duration of the disease from the date of first diagnosis. Patients were divided into subgroups based on the initial extent of hair loss, age, and duration of AA to determine the factors which could predict treatment response and relapse. Subgroup analysis was performed using the Chi-square and Fisher's exact tests. This protocol was approved by the hospital's Institutional Review Board (Protocol No. A-ER-110-235).

Results

Twenty-nine patients (14 men, 15 women) were included. Their mean age was 31.8 years (range: 11–60 years). All patients had severe (>50%) hair loss with a mean severity of 67.1% prior to treatment. Male patients were associated with a greater extent of initial hair loss (74.1% in males vs. 60.5% in females, P = 0.02). The mean AA duration prior to therapy was 4.6 months. Six (20.7%) patients had a history of atopy (asthma, atopic dermatitis, or allergic rhinitis). The mean follow-up duration after initial therapy was 18.4 months (median: 11 months, range: 3.5–62 months). A summary of demographic characteristics is presented in [Table 1].

Table 1: The demographic characteristics of patients

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Overall, 17 out of 29 (58.6%) patients achieved a satisfactory response to pulse therapy, while four (13.8%) achieved a complete response. The mean duration between the initiation of treatment and a satisfactory response was 3.1 months. Six (20.7%) patients experienced minor and temporary side effects, including headache, GI discomfort, or insomnia, during or following therapy. Corticosteroid pulse therapy was significantly more effective in patients with a shorter AA duration (<6 months). Among patients with AA duration <6 months and >6 months, the satisfactory response rates were 72.7% and 14.2%, respectively [Table 2]. Patients who experienced lesser extent of hair loss had a better response rate to therapy (72.2% vs. 36.4%), although the difference was not statistically significant (P = 0.119) [Table 2].

Table 2: Satisfactory response rates (>50% hair regrowth) after pulse corticosteroid therapy

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Among the patients who achieved a satisfactory response, 11 out of 13 experienced relapse. The mean interval was 13.8 months (median: 7.3 months, range: 3.8–46.5 months). In the subgroup analysis, the relapse rate was not significantly different in patients stratified according to sex, age, extent of hair loss, and disease duration.

Discussion

The findings of our study regarding the effects of corticosteroid pulse therapy in patients with severe AA are summarized as follows: (1) The satisfactory response rate was 58.6%, occurring 3.1 months after treatment; (2) the complete response rate was 13.8%; (3) patients with a shorter AA duration (within 6 months) had a significantly better response; and (4) AA relapse was common, occurring 13.8 months after achieving a satisfactory response.

We found that early intervention in patients with AA would lead to a better response, which is line with the results of prior studies.^[8],[9] This can be explained by the prominence and paucity of perifollicular inflammation in the acute and chronic phases of AA, respectively.^[10] Previous studies have reported that patients with lesser hair loss are more likely to achieve a satisfactory treatment response.^[8],[9] Our study illustrates a similar trend; however, the result was not statistically significant, which can be attributed to the modest sample size.

Compared with previous studies, the present study shows a higher relapse rate, which can be attributed to the inconsistent definitions used for relapse and varied follow-up periods.^[7],[8],[9] In a study with a 10-year follow-up period, a high AA relapse rate (90%) was reported, which was likely due to limited sample size.^[11] Longer disease duration (>6 months) was believed to be a risk factor for relapse.^[7],[8] Regardless of relapse, patients with good initial response to corticosteroid pulse therapy had better long-term prognoses than non-responders who experienced a poor initial response.^[11]

Our treatment protocol aimed to maximize the effect of pulse therapy while minimizing the treatment duration and session number. Therefore, during the first session, a bolus corticosteroid was administered for 3 consecutive days. A previous study has shown that a 3-day regimen elicits a better response rate than a 1-day regimen.^[12] To minimize the side effects caused by long-term corticosteroid use, the total treatment duration was limited to 3 months and dosing was decreased during the second and third sessions. This resulted in a satisfactory response rate of 58.6% in patients with severe AA, which is comparable to the results of previous studies.^[7],[8]

The limitations of the study include the retrospective nature of patient recruitment, nonstandardized procedures for patient compliance and physician follow-up, and a relatively small sample size. Additionally, the Severity of Alopecia Tool was not utilized evaluate the efficacy of this study. A randomized, double-blind, placebo-controlled method is preferrable to avoid selection bias.

Conclusion

In conclusion, corticosteroid pulse therapy is an effective and well-tolerated treatment option in the acute phase of severe AA. Three monthly doses of bolus corticosteroids are sufficient to induce satisfactory but temporary response in patients with severe AA. Chronic corticosteroid administration should be avoided to minimize the side effects.

Financial support and sponsorship

Nil.

Conflicts of interest

Prof. Chao-Chun Yang, an associate editor at Dermatologica Sinica, had no role in the peer review process of or decision to publish this article. The other authors declared no conflicts of interest in writing this paper.

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