Systemic Treatments for Alopecia Areata

Prescription medications for alopecia areata are immunosuppressant drugs.

A number of different conventional treatment options are available for alopecia areata in both adults and children. These include topical and systemic drugs. Research also suggests combining systemic treatment therapies (such as methotrexate and corticosteroids) may improve outcomes.(425428)

Oral medication for alopecia areata typically involves steroids and drugs that suppress the immune system. Since long-term steroid use and immunosuppressant drugs can have serious side effects, these treatments are typically only offered for patients with severe (over 40%) hair loss. Moreover, some of the drugs that result in hair regrowth can actually cause hair loss in some people.(418430431)

The good news is research continues to find better solutions for alopecia areata. For example, drugs that are FDA-approved for cancer and other diseases have been found to quickly regrow hair in people where other treatments have failed. And using a high dose systemic steroid followed by low-dose steroids has successfully treated severe childhood alopecia areata—with reduced side effects. (418431)

Prescription Oral Drugs for Alopecia Areata

CONVENTIONAL SYSTEMIC MEDICAL TREATMENT OPTIONS FOR ALOPECIA AREATA, ALOPECIA TOTALIS, AND ALOPECIA UNIVERSALIS

AGENT

HOW IT WORKS

EVIDENCE OF BENEFIT

SIDE EFFECTS

RECOMMENDED DOSAGE OR USE

Azathioprine

Question: What is azathioprine?

Answer: Azathioprine is an immunosuppressant systemic drug commonly used to treat arthritis, inflammatory bowel disease (IBD), hepatitis, and kidney disease.(132430)

Question: Can azathioprine regrow hair?

Answer: Results from an initial clinical trial showed an average of over 52% regrowth with azathioprine treatment.(132)

Question: What are the potential side effects of azathioprine

Answer: Common side effects of azathioprine are nausea and vomiting. However, azathioprine can also cause severe suppression of bone marrow activity, pancreatitis, and even alopecia.(430)

2 mg per kg of body weight daily(132)
JAK Inhibitors

Question: What are JAK inhibitors? How does ruxolitinib work? How does tofacitinib work?

Answer: Drugs like ruxolitinib and tofacitinib inhibit various janus kinase (JAK) enzymes that generate an inflammatory immune system response.(432433)

Roxolitinib suppresses JAK1 and JAK2 enzymes, while tofacitinib inhibits JAK1 and JAK3 enzymes.(432433)

Question: Can ruxolitinib and tofacitinib regrow hair?

Answer: Case reports and a retrospective study suggest that JAK inhibitors can help a significant percentage of people with severe (over 40%) hair loss. More than half experience over 50% regrowth, with much better results in patients with AA rather than alopecia totalis or alopecia universalis.(432433)

Question: What are the potential side effects of JAK inhibitors? What are the potential side effects of ruxolitinib and tofacitinib?

Answer: JAK inhibitors appear to be well tolerated with no serious side effects.(432433)

In one comparative study, patients showed significant hair regrowth with either 20 mg of ruxolitinib or 5 mg of tofacitinib twice a day for 6 months.(434)
Methotrexate

Question: What is methotrexate?

Answer: Methotrexate is an oral drug typically used to treat severe skin diseases (such as psoriasis and atopic dermatitis) and rheumatoid arthritis. It helps suppress the immune system response.(428429)

Question: Can methotrexate regrow hair?

Answer: In a clinical trial, regrowth of over 50% in approximately 2/3rds of patients, and 75%-100% regrowth in the remaining third of patients, with more success in men than women.(428429)

Relapse occurred in a third of patients who had 50% regrowth and in 40% of those who had greater than 75% regrowth. Relapse occurred mostly in patients with multifocal alopecia areata.(428429)

Question: What are the potential side effects of methotrexate?

Answer: Short-term side effects include low blood cell counts, mild increase in liver enzymes, oral and/or GI ulcers, acne, skin rash, diarrhea, and nausea. Possible serious long-term side effects include increased risk of pulmonary fibrosis and lymphoma. However, it is generally considered safe, even in pediatric patients with AA.(428)

In clinical studies, cumulative doses of methotrexate ranged from 501 mg to over 2500 mg. Folic acid supplements were also given to patients since methotrexate interferes with the metabolism of this important nutrient.(428)
Methylprednisolone and Cyclosporine

Question: What are methylprednisolone and cyclosporine?

Answer: Methylprednisolone and cyclosporine are systemic steroids. They have anti-inflammatory and immune-modulating effects.(133)

Question: Can methylprednisolone and cyclosporine regrow hair?

Answer: In a small study involving 6 patients with alopecia totalis and 12 with alopecia universalis (male and female) the combination therapy resulted in greater than 70% regrowth in 25% of those with universalis and 50% of those with totalis. Results were sustained without significant relapse during the 18-month follow-up.(133)

The combination steroid treatment produced much better results than overall results in single therapy studies that included all types of alopecia areata, as well as those obtained from a similar treatment modality but with only one treatment session. Sustained outcomes in this study were also much better than systemic prednisone combined with topical minoxidil. In addition, the dual treatment avoided the known adverse side effects of long-term systemic steroid use.(121133)

Question: What are the potential side effects of methylprednisolone and cyclosporine?

Answer: Mild adverse side effects reported for methylprednisolone and cyclosporine include:(133)

  • Acne
  • Elevated cholesterol levels
  • Increased blood pressure
Intravenous pulses of 500 mg/day for 3 days each month plus daily oral doses of cyclosporine (2.5 mg/kg) for 5 to 8 months(133)
Sulfasalazine

Question: What is sulfasalazine?

Answer: Sulfasalazine is a systemic immune-modulating, immunosuppressant, and anti-inflammatory drug.(132)

Question: Can sulfasalazine regrow hair?

Answer: Two clinical trials reported sulfasalazine helped regrow some hair in patients with persistent alopecia areata.(132)

Question: What are the potential side effects of methylprednisolone and cyclosporine?

Answer: Mild adverse side effects reported for sulfasalazine include:(132)

  • Dizziness
  • Gastrointestinal upset
  • Headache
500 mg two times a day for 1st month, 1 g twice daily for 2nd month, 1 g three times a day thereafter(132)
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