Which agent is most preferred in first-line treatment of paediatric alopecia areata?

In the treatment of paediatric alopecia areata (AA), an autoimmune, nonscarring hair loss disorder with a variable disease course and significant psychosocial impact, the most preferred first-line agent is topical corticosteroids, followed by contact immunotherapy, according to a study.

“Although topical corticosteroids remain the preferred first-line treatment for paediatric AA, randomized controlled trials (RCTs), and prospective comparative studies are needed to help define treatment guidelines,” the researchers said.

A systematic review was conducted to evaluate the evidence of current treatment modalities for paediatric AA. The researchers explored the database of PubMed in October 2019 for all published articles involving patients aged <18 years. Articles discussing AA treatment in paediatric patients and those focusing both on paediatric and adult patients were included if data on individual paediatric patients were available.

Overall, 122 reports, involving a total of 1,032 patients, met the eligibility criteria. Reports consisted of two RCTs, four prospective comparative cohorts, 83 case series, two case-control studies, and 31 case reports. [J Am Acad Dermatol 2022;86:1318-1334]

The said studies evaluated the use of aloe, apremilast, anthralin, anti-interferon gamma antibodies, botulinum toxin, corticosteroids, contact immunotherapies, cryotherapy, hydroxychloroquine, hypnotherapy, imiquimod, Janus kinase inhibitors, laser and light therapy, methotrexate, minoxidil, phototherapy, psychotherapy, prostaglandin analogues, sulfasalazine, topical calcineurin inhibitors, topical nitrogen mustard, and ustekinumab.

“Topical corticosteroids are the preferred first-line treatment for paediatric AA, as they hold the highest level of evidence, followed by contact immunotherapy,” the researchers said, noting a limited number of trials in these patients. [Int J Dermatol 2017;56:1487-1488; JAMA Dermatol 2014;150:47-50]

Potent treatments

Intralesional corticosteroids are recommended for patchy AA in adults, but their use in children is constrained because of pain. Systemic steroids are also effective, particularly in patients with a shorter disease duration, those who are young at disease onset, and those with multifocal disease, but their use is limited by side effects. [Dermatology 2013;227:37-44; J Am Acad Dermatol 2016;74:372-374; Dermatoendocrinol 2009;1:310-313; Br J Dermatol 2012;166:916-926]

Other treatment options include contact immunotherapy with diphenylcyclopropenone or squaric acid dibutyl ester, but the evidence in children is limited to case series. [J Eur Acad Dermatol Venereol 2013;27:e400-e405; Arch Dermatol 2012;148:1084-1085; Indian J Dermatol Venereol Leprol 2007;73:432-433; Clin Exp Dermatol 2007;32:48-51; Br J Dermatol 1996;135:581-585]

Of note, minoxidil is the “go-to” secondary agent in clinical practice in terms of topical adjuvant therapy, but current evidence does not support its use as a first-line agent. In addition, topical calcineurin inhibitors are not effective. [Clin Exp Dermatol 2007;32:456-457; J Am Acad Dermatol 2005;52:138-139; Am J Clin Dermatol 2019;20:237-250; J Investig Dermatol Symp Proc 2003;8:207-211]

“More clinical trials and comparative studies are needed to further guide management of paediatric AA and to promote the potential use of pre-existing, low-cost, and novel therapies, including Janus kinase inhibitors,” the researchers said. “Additionally, a better understanding of prognostic markers in AA would be valuable.”