Corticosteroids Still Part of the Treatment Plan for AA

Corticosteroids and Alopecia Areata

I read with interest an article titled: ‘Management of alopecia areata in JAK-inhibitors era: are systemic and topical corticosteroids still useful?” It was published in the International Journal of Dermatology

The article is a nice reminder that JAK inhibitors do not always regrow hair completely in alopecia areata and do not always suppress flares.

The authors describe a 35-year-old man with alopecia areata and atopic dermatitis. Atopic dermatitis had been present for 10 years whereas his alopecia areata had been present to 3 years. He had near complete hair loss on his scalp, eyebrows, eyelashes and body hair. His SALT score was 100.

He was started on dupilumab 300 mg. He had an initial good response to dupilumab but then experienced a facial eczema flare after 24 weeks. Dupilumab was stopped and the JAK inhibitor upadacitinib was started at 15 mg twice daily.  He subsequently had a good response to his AD and AA after 4 months.  His alopecia areata flared again despite upadacitinb therapy and he was treated with triamcinolone 40 mg once weekly for 4 weeks with topical clobetasol and topical minoxidil. After 4 weeks hair regrowth was noted and the patient has been in remission for his alopecia areata for 6 months while continuing the upadacitinib.

This case is a nice example of a few key points. First, not everyone responds fully to JAK inhibitors so we need to have other tools in our tool box. It may be that we use other treatments with the JAK inhibitor or it may be that we use other treatments instead of the JAK inhibitor. Often if we have elected to use a JAK inhibitor in the first place and a response has occurred from its use, the JAK inhibitor is continued and a second treatment is brought into the treatment plan.

Second even when patient respond to JAK inhibitors, flares can occur. Increasing the dose of JAK inhibitors is one option but that comes with additional cost and additional chances of side effects like infection (herpes zoster), blood clots, and blood test abnormalities.  Periodic use of topical, intralesional steroids can be used to suppress flares. Here the authors also used intramuscular triamcinolone as yet another modality.

Bringing on board other treatments is needed. Corticosteroid remain an important treatment to reduce flares in AA.

REFERENCE

Licata G et al. Management of alopecia areata in JAK-inhibitors era: are systemic and topical corticosteroids still useful? Int J Dermatol. 2022 Nov 13.