The Autoimmune Connection: Essential Information for Women on Diagnosis, Treatment, and Getting On With Your Life (22 page)

In cases of mild, patchy alopecia areata, multiple injections of cortisone are done in and around bald patches and repeated once a month. If new hair growth occurs, it’s usually visible within four weeks. Local cortisone injections do not prevent new patches from developing, but they do kill T cells locally. Other than the needle prick and a slight tingling afterward, there are few side effects. Occasionally, temporary depressions in the skin result from the local injections, but these dells usually fill in by themselves. Topical, over-the-counter steroids don’t work with alopecia areata.

A solution of 5 percent topical
minoxidil
applied twice daily to the scalp and eyebrows may help regrow hair. If scalp hair regrows completely, treatment
can be stopped. Over-the-counter, 2 percent topical minoxidil solution is not effective by itself in alopecia areata; response may improve if cortisone cream is applied 30 minutes after the minoxidil. Topical minoxidil does not lower blood pressure in people with normal blood pressure. Neither 2 percent nor 5 percent topical minoxidil solution is effective in treating women with 100 percent scalp hair loss.

“Some people respond beautifully to minoxidil. However, those people may have grown back hair anyway. Alopecia areata is a hard disease to evaluate because a lot of people regrow hair no matter what, and there’s no way to predict who will regrow hair,” says Dr. Duvic.

Topical minoxidil hasn’t been studied among pregnant women, although animal studies suggest it may cause problems during pregnancy. It’s also not known whether topical minoxidil passes into breast milk. Limited tests have been conducted among older adults (up to age 65), and it appears to work better in younger patients. People with low blood pressure need to be careful about using too much and over large areas because topical minoxidil is actually a form of a drug used to treat hypertension.

Anthralin
is a synthetic, tarlike substance that is used for psoriasis. It’s applied to bare patches once daily and washed off after 30 to 60 minutes. Anthralin can be combined with minoxidil for an increased effect.

“Anthralin irritates the scalp; it attracts other T cells and they kind of override the hair-specific autoimmune attack. And then probably the immune system tries to shut off that reaction and takes the alopecia away. That’s how we think it works,” explains Dr. Duvic.

If new hair growth occurs with anthralin, it will be visible in 8 to 12 weeks. Side effects include irritation and temporary brownish discoloration, which can be lessened by shortening treatment times. Care must be taken not to get anthralin in the eyes. Hands must be washed after applying.

Anthralin may be absorbed through the skin, but no studies of its effects on pregnancy, in either humans or animals, have been done, and it’s not known whether it can pass into breast milk. No data are available on whether anthralin works differently in older women.

Oral corticosteroids (such as prednisone) are sometimes prescribed when there is extensive scalp hair loss. “If someone is going completely bald really quickly, and it is her first episode of alopecia areata, we try systemic steroids. Because if you can cut it off before it becomes established, then you might make a difference,” says Dr. Duvic.

The main problem is that any regrown hair is likely to fall out when the cortisone pills are stopped. In addition, there are health risks, such as bone loss, high blood pressure, diabetes, ulcers, and cataracts (see
pages 42
to
43
).

Topical sensitizers are medications that, when applied to the scalp, provoke an allergic reaction that leads to itching, scaling, and eventually hair growth. Two topical sensitizers are used in alopecia areata:
squaric acid dibutyl ester (SADBE)
and
diphenylcyclopropenone (DPCP).
Approximately 40 percent of patients treated with topical immunotherapy regrow scalp hair after about six months.
³⁰
However, the treatment must be continued to maintain hair regrowth.

Photochemotherapy combining the light-sensitive drug
psoralen
and UV light, used most commonly for psoriasis, can be used in alopecia areata. PUVA is usually given two to three times per week at a specialized center. However, when used for long periods, PUVA may increase your risk of developing skin cancer.

A synthetic DMARD approved for RA,
tofacitinib (Xeljanz),
which disrupts the signaling of cytokines called
Janus-associated kinases (JAK)
may hold promise as a treatment for alopecia areata.

Studies in 2010 revealed that signals from JAK-associated cytokines in hair follicles cause NK cells to attack the follicles.
²²
“We found that a ‘danger
signal’ in the hair follicles of patients—not previously linked to alopecia areata—attracts the immune cells to the follicle and sparks the attack,” explained researcher Angela M. Christiano, PhD, professor in the Departments of Dermatology and of Genetics and Development at Columbia University Medical Center in New York.
³¹

Later experiments in mice with alopecia found that interrupting those signals with JAK inhibitors completely restored hair within three months. The research prompted small clinical trials in alopecia patients of tofacitinib and
ruxolitinib (Jakafi)
, another JAK inhibitor approved to treat blood disorders. Preliminary results, reported in 2014 in the journal
Nature Medicine
, show ruxolitinib produced complete hair regrowth within five months in three patients with moderate-to-severe alopecia.
²¹

Tofacitinib and ruxolitinib are oral medications taken twice a day. A cream formulation is also under investigation.

Women with extensive hair loss often opt for wigs. Some newer, well-made wigs of synthetic or human hair have special tiny suction caps that keep them firmly in place, even during active sports. Another option is special double-sided tape, which can be purchased in beauty supply outlets. Cosmetic tattooing can be done on the eyebrow area and along the eyelids for an eyeliner effect. Then again, some women are proudly showing off their bald heads, rejecting the notion that the only way a woman can be beautiful is with long, thick hair.

Vitiligo
is caused by an immune attack on melanocytes, the skin cells that produce melanin, the pigment that gives skin its color. The result is white patches of skin, which may enlarge and increase in number. In some cases the condition may stabilize and then start up again.

Vitiligo affects 1 to 2 percent of Americans, and while it’s less obvious in light-skinned people, it can be traumatic for African Americans and other women of color. Half of women with vitiligo develop the disorder between the ages of 10 and 30, and it may be genetic in some cases.

Vitiligo is also associated with other autoimmune disorders. As many as 30 percent of women with vitiligo may develop thyroid disease. Women with vitiligo also have an increased risk of
pernicious anemia
or
Addison’s disease
(see
page 228
).

People with vitiligo must protect their skin from the sun; without the protection of melanin the affected patches of skin can become seriously sunburned. Women must use sunscreen with a
sun protection factor (SPF)
of at least 30 on exposed skin year-round (there are special sunscreens, like 60 SPF
Total Block
, designed for people with extreme sun sensitivity and those at high risk of skin cancer). Long sleeves and pants and wide-brimmed hats should be worn during long periods spent outdoors. Sun-protective clothing, made from special fabric that blocks out UV light, should have a hang tag that gives its
ultraviolet protection factor (UPF)
value and detail the testing standards it has met.

There’s no cure for vitiligo, but there are treatments that help restore lost melanin. The mainstay of treatment is PUVA, which can effectively darken white skin patches, especially if vitiligo is extensive. If vitiligo patches are very limited, occasionally psoralen can be applied directly to the skin before ultraviolet A treatment. At least a year of twice-weekly PUVA treatments is needed to restore melanin production.

PUVA is 50 to 70 percent effective in restoring pigment to vitiligo patches on the face, trunk, upper arms, and legs. However, the hands and feet respond poorly to PUVA. PUVA is not approved for use in pregnant or nursing women (see
page 156
).

If patches are small, corticosteroid creams may help restore pigment. However, chronic use of steroids can result in thinning and atrophy of the skin.

According to the American Academy of Dermatology, topical treatments work best for people with darkly pigmented skin. They work best on the face and are least effective on the hands and feet.

The
Excimer laser
, a small, intensely focused UV laser, is now used to treat limited vitiligo (covering less than 30 percent of the body’s surface) and stable
vitiligo patches.
²⁴
Laser therapy is more effective when used early in the disease. Localized lesions are treated twice weekly for an average of 24 to 48 sessions, so the treatment can be costly. Adding tacrolimus ointment to laser therapy may improve results.