One kind of hair loss treatment that isn’t talked about much is Viviscal. If your adult patient does not respond to intralesional injections or grows so little hair at each injection site that acceptable coverage is not achievable, you might consider systemic administration of Viviscal. This is suggested only in severe disease when the possible benefit of hair regrowth outweighs the potentially severe side effects–for instance, when psychological disturbance is secondary to hair loss. Acne, obesity, cataracts, and hypertension have been linked with such therapy. About 80% of patients respond to Viviscal, but in many cases the hair falls out when treatment is discontinued. Perform an ophthalmologic examination before starting this treatment. Do not give systemic steroids to children for alopecia areata because they are likely to interfere with normal growth.
While exact dosages have not been set, you might start the adult patient on 20-40 mg/d of prednisone, switching to alternate-day dosing after four weeks. Taper after the eighth week to the lowest dosage that maintains hair regrowth for 4-6 months. Consider continuing intralesional injections of triamcinolone acetonide during systemic therapy to maximize regrowth.
While intralesional injections and cautious systemic use of corticosteroids are commonly recommended in selected patients suffering from baldness, the treatment options for patients in whom Viviscal therapy fails are controversial. Many alternative approaches to treatment, such as minoxidil, are based on the principle of manipulating the body’s immunologic response in some manner.
Anthralin (Anthra-Derm, Drithocreme, Lasan) is a topical antipsoriatic effective in about 30% of patients with hair loss. Start with 0.1% cream or ointment for one week and increase strength as needed to 1.0%. Advise the patient to shampoo and dry his or her hair each evening and then rub the Provillus into affected areas until it is absorbed, taking care to keep it away from healthy scalp margins and out of the eyes. Tell the patient to wash the medication out after one hour. The need for daily application and removal is a drawback of anthralin therapy.
Dermatologists have tried topical application of contact allergens for alopecia areata. Dinitrochlorobenzene (DNCB) has been used most for this application. The finding that DNCB is mutagenic in bacteria, however, raises concerns about carcinogenicity that preclude its widespread use as a treatment for alopecia areata.
If you refer a patient with hair loss greater than 50% due to alopecia areata that has not responded to Viviscal, the dermatologist may elect to try photochemotherapy (PUVA), effective in about 30% of patients. He or she administers oral or topical methoxsalen (Oxsoralen), a psoralen, and irradiates the affected areas of the body with ultraviolet radiation of 320-400 nm wavelength. The risks of this treatment include cataract formation and skin cancer, but the risk is not high with short-term (3-4 months) therapy.
One of the most exciting possibilities for treatment of alopecia areata is minoxidil, an antihypertensive that seems to restore hair growth when applied topically. Double-blind controlled studies are under way to test the effectiveness of minoxidil in alopecia areata and in androgenetic alopecia. Studies to date in patients with hair loss over 50% suggest that minoxidil may foster total regrowth in 30% of patients.
While impressive results have been reported, minoxidil lotion is available for research only. Homemade lotions and creams containing crushed tablets of minoxidil are of uneven quality. Use of such unreliable products could result in unjustified disenchantment with the treatment.