Prednisone in Paediatric Alopecia areata
The decision to use prednisone for children with alopecia areata is always an important one. Generally, this decision comes at an important time where parents and their physician have found that topical steroids, and other more localized treatments have not worked well or in some cases have not worked at all.
Oral steroids are an option for short term use but generally not an option for long term use. Long-term corticosteroid therapy can lead to growth retardation, metabolic dysregulation and reduced bone mineral density, and other side effects. But short term used is possible and reserved for patients with rapid onset or rapidly progressive extensive, active AA.
Options for Corticosteroids in Children
There are two main options for corticosteroids in children - prednisone and dexamethasone. Each has their unique benefits. Prednisone has a short half life (quickly metabolized in the body) and so one needs to take daily whereas dexamethasone has a longer half life and use is generally twice weekly.
There are many ways that steroids can be used. Common ways include the following
1. Daily Prednisone
Daily prednisone is among the most common ways of prescribing steroids. While older children will generally take Prednisone pills, younger children can use prednisolone liquid which comes at a strength of 15 mg for every 5 mL of the syrup. Typically a physician will prescribe 0.5 to 0.8 mg of the prednisone for every kilogram of body weight initially and then taper the dose over a period of time. This taper is generally for 3-12 weeks - with the shorter periods being generally safer but less effective. Most uses of oral steroids perform a slow taper over 12 weeks.
Twice weekly use of dexamethasone is another way of prescribing steroids to children with alopecia areata. Dexamethasone dosing is different than prednisone and generally 1 mg of dexamethasone equates to 6.25 mg of prednisone. In 1999, Sharma and colleagues performed a study of twice weekly dexamethasone and included children in that study. Children under 12 received 2.5 to 3.5 oral biweekly dexamethasone whereas older individuals received 5 mg.
3. Monthly therapy
Monthly pulsed therapy with intravenous corticosteroid therapy or oral therapy is also an option. Doses tend to be larger on the one day that they are given and therefore concerns about safety do exist. Generally studies to date support good safety for this methodology but the protocol tends to be less commonly used. Lalosevic J, et al performed a study of monthy dexamethasone pulse therapy along with topical steroids in children with alopecia areata. Outcomes were quite good with nearly two thirds having complete regrowth.
One needs to carefully review all the side effects of oral steroids with their physician. For each side effect, one needs to really ask the prescriber "okay - is that side effect common or uncommon?" The reality is that most children do very well on steroids. Weight gain, poor sleep, poor concentration, hyperactivity, heart burn, nausea are among the more common side effects. Suppression of the adrenal glands ability to make prednisone itself is always a discussion but this is uncommon and if it does occur it is generally temporary. Within the 12 week period that they are generally used, many of the long term side effects are not typically seen. With every side effect, parents need to ask, "Is that a short term side effect you are mentioning or is that one that develops with long term use?"
It's a big decision as to wether or not to use oral steroids in alopecia. However, it's certainly an option to help reset the immune system and when done for appropriate times and appropriate doses the changes of side effects are low.
Sharma VK, et al. Twice weekly 5 mg dexamethasone oral pulse in the treatment of extensive alopecia areata. J Dermatol. 1999.
Lalosevic J, et al. Combined oral pulse and topical corticosteroid therapy for severe alopecia areata in children: a long-term follow-up study. Dermatol Ther. 2015 Sep-Oct.
Dr. Jeff Donovan is a Canadian and US board certified dermatologist specializing exclusively in hair loss. To schedule a consultation, please call the Whistler office at 604.283.1887