Oral Dexamethasone Pulsed Therapy for Alopecia Areata in Children
There are over 25 treatment options for alopecia areata. Generally speaking, topical steroids, steroid injections and minoxidil are important therapies for patchy alopecia areata (early staged disease). This is by far the most common type of alopecia areata and so these three treatments are among the most useful.
For patients with more extensive and progressive alpecia areata, a variety of treatment options can be considered including oral steroids (dexamethasone, prednisone, prednisolone), and oral immunosuppressants such as methotrexate, tofacitinib, ruxolitinib, sulfasalazine. Topical irritant and allergic therapies such as anthralin, diphencyprone and squaric acid are also important parts of the treatment ladder.
Treatment of Alopecia Areata in Children
The principles of treating alopecia areata in children is similar to treating alopecia in adults. One wants treatments that work really well and at the same time are really safe, affordable and easy to administer.
See previous article: The S.A.F.E. Principle for Treating Hair Loss
In my practice, treatment of alopecia areata in children under the age of 12 involves use of 8 main treatments. Four of them are topical and include topical steroids, minoxidil, anthralin and diphencyprone (or squaric acid). Three of them are oral treatments and include oral methotrexate, oral oral steroids, and the JAK inhibitors. The last one is neither topical nor oral - and simply involves what I call “active observation:” (or what some might call doing nothing). Many children and adults with alopecia areata regrow spontaneously so treatment is not always necessary.
Oral Dexamethasone in Alopecia Areata
Dexamethasone is an oral steroid that may be helpful in some cases of rapidly progressing alopecia areata. It has been studied in children with various medical conditions for well over 30 years. Because of the long half life of dexamethasone compared to prednisone (54 hours vs 1-2 hours), the option exists to use dexamethasone less frequently in so called “pulses” rather than daily as in the use of prednisone.
One of the important studies of dexamethasone use for treating alopecai areata was a 1999 study by Sharma and Gupta. They studied 30 patients with alopecica areata including a mix of adults and chilfren. 3 patients in the study were children under 12 and were treated with dexamethasone on two day of the week at doses of 2.5 to 3.5 mg.
Sharma’s study showed that patients who received treatment for the minimum 12 week study period had excellent growth in 63.3 % of patients. 20 % of patients had no growth. It took an average of 5 months to get to the stage of excellent regrowth indicating that the regrowth can take time in these more challenging cases. Relapse was observed in two patients after 3 and 6 months but hair did regrow with treatment. About 25 % of patients had side effects of some kind but these were generally mild.
Other studies of dexamethasone use in adults have been conducted more recently. Vano-Galvan and colleagues from Spain conducted a nice study in 2016 reviewing dexamethasone use in 31 adults with alopecia totalis (n=9) and alopecia universalis (n=22). The dose used in treatment was 0.1 mg per kg per day for the two days of the week. About 80 % of patients had some type of response and 71 % had a complete response. The mean time to see any type of hair growth happpening was about 1.5 months. Side effects were observed in 31 % of patients including weight gain, Cushing-like phenomena, striae and irritability.
Conclusion and Summary
Pulsed therapy with oral steroids is an option for children with alopecia areata. When one is deciding about which oral steroid to use, options for both prednisone and dexamethasone need to be considered. The long half life of dexamethasone and option for twice weekly dosing makes it a useful option. I generally prescribe dexamethasone on Saturday and Sundays to make it easy to parents to remember. The dose in children is according to weight but generally 2-4 mg of dexamethasone on Saturday and 2-4 mg of dexamethasone on Sunday is quite common. Because the dose is 0.1 mg per kg, it’s quite easy to calculate the appropriate dose - a 20 kg child would receive 2 mg each day of the weekend and a 30 kg child would receive 3 mg on each day of the weekend and a 40 kg child would receive 4 mg on each day of the weekend. Dexamethasone is given with calcium and vitamin D to protect bone mass. Side effects seen in children are generally mild but one must monitor for side effects carefully include irritability, weight gain, blood pressure changes. Long term use is generally discouraged and the goal of dexamethasone therapy is to help reset the immune system in some way so that minoxidil and topical steroids can once again become the mainstay of therapy for the child.
Sharma VK and Gupta S. Twice weekly 5 mg dexamethasone oral pulse in the treatment of extensive alopecia areata. J Dermatol 1999; 26: 562-5.
Vañó-Galván S et al. Pulse corticosteroid therapy with oral dexamethasone for the treatment of adult alopecia totalis and universalis. J Am Acad Dermatol. 2016 May;74(5):1005-7.
Spano F and Donovan JC. Alopecia areata: Part 1: pathogenesis, diagnosis, and prognosis. Can Fam Physician. 2015 Sep;61(9):751-5. Review.
Spano F and Donovan JC. Alopecia areata: Part 2: treatment. Can Fam Physician. 2015 Sep;61(9):757-61. Review.
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