Prague, Czech Republic — An ongoing clinical evaluation suggests that methotrexate-based, steroid-sparing therapy has induced hair growth in more than 90 percent of patients with alopecia universalis, reports news source MedPage Today.

Results of the evaluation so far were presented at the International Congress of Dermatology, held in Prague recently.

MedPage Today quotes Kiumars Pirkalani, M.D., of Tehran, Iran, as saying that based on evidence implicating autoimmunity in hair loss, the therapy begins with methotrexate and triamcinolone and then progresses through some of the same drugs used to treat rheumatoid arthritis. The goal is to lessen — and eventually eliminate — steroid use.

"We have shown that although this seems to involve many drugs, it will be potentially curative with short courses of therapy with the fewest side effects, if used intelligently," says Dr. Pirkalani.

He adds that conventional therapies for alopecia areata and its variants have proved unsatisfactory, noting that local irritants, such as diphencyprone and dithranol, induce hair growth in no more than half of patients and are often hard to tolerate. Also, systemic corticosteroids can raise the response rate to about 70 percent, but side effects and frequent relapse post-treatment make that therapy less than ideal.

The investigators say the link to autoimmunity provides a rationale to use conventional immunomodulators, such as methotrexate and azathioprine, either alone or in combination with novel therapies — such as atorvastatin (Lipitor) and vitamin B6 — that have demonstrated evidence of immune-modulating effects.

Over the course of several years, the investigators developed a multistep approach to treating alopecia universalis, employing two or more drugs. Treatment begins with triamcinolone (40 mg a week) and methotrexate (10 mg/week). Patients also receive 70 mg of alendronate weekly and levamisole 150 mg the day before administration of the steroid and methotrexate. Treatment continues for 12 to 20 weeks.

Patients who respond to therapy continue methotrexate, and the steroid dose is lessened. If the treatment is unsuccessful, patients are switched to another drug or combination. Switches have included sulfasalazine, hydroxychloroquine, azathioprine, pentoxyphylline, vitamin B6 and atorvastatin. According to Dr. Pirkalani, some patients have received as many as four drugs at a time, and continue a drug or combination for 12 weeks after a switch, unless unacceptable toxicity occurs.

The evaluation shows that 102 of 109 patients have responded to weekly dosages of triamcinolone and methotrexate, and that combining triamcinolone with other drugs typically results in higher response rates than those observed with triamcinolone monotherapy: hydroxychloroquine, 93 percent; sulfasalazine, 92 percent; azathioprine, 85 percent; atorvastatin, 83 percent; and vitamin B6, 81 percent. Results to date show that the same drugs have attained modest results as monotherapy, with response rates ranging from 15 percent to 36 percent.

MedPage Today quotes Dr. Pirkalani as saying, “All of these responses remained incomplete, but some cosmetically acceptable results also were seen. Many patients were satisfied because some protocols without steroids were identified and found to be effective.”