AA represents an underrecognized burden in Latin America and severely impacts quality of life |
Research on AA in Latin America is lacking |
A panel of Latin American AA professionals assembled to compile this paper outlining the challenges to AA diagnosis and treatment, as well as advice for overcoming those barriers |
Delays in access to diagnosis and treatment harm patients' quality of life, mental health, and increase disease development |
Promising new targeted therapies for AA are available, and all stakeholders must work together to enhance access and availability of prompt diagnosis and treatment |
Introduction
Materials and Methods
Box 1. Search Strategy
Results
Epidemiology
Burden of Disease and Comorbidities
Box 2. Comorbidities Associated with AA
Allergic rhinitis | Celiac disease | Systemic lupus erythematosus |
Anxiety | Depression | Systemic sclerosis |
Asthma | Pernicious anemia | Thyroid disease |
Atopic dermatitis | Rheumatoid arthritis | Type 1 diabetes mellitus |
Ulcerative colitis |
Pathophysiology
Genetic Factors
Loss of Immune Privilege and Autoimmunity
Neuroendocrine Pathways
Environmental Factors
Diagnosis
Characteristics | |
---|---|
Dermoscopy | Peladic or exclamation mark hairs Broken hairs Vellus Yellow points (empty follicles) Black points or cadaveric hairs (a follicle opening with oxidated lipids mimicking hair keratin) Coudability hairs (long bent peladic hair) Irregular constrictions of Pohl–Pinkus (pseudomonilethrix) White or dystrophic hair shafts (regrowth areas) Circular (pigtail) hairs (found in active lesions) |
Histopathology | Biopsy samples: should be taken from the margin of a patch; two samples for horizontal and vertical sections can maximize accuracy Findings: Peribulbar infiltrate of lymphocytes and Langerhans cells (in active lesions) Eosinophils, plasma cells, and mast cells HF destruction, trichomalacia, chronic infiltrate of histiocytes and giant cells (predictors of poor prognosis) *The horizontal section can examine additional indicators: Decreased anagen-to-telogen ratio Decreased terminal-to-vellus hair ratio (1:1 instead of 7:1) Decreased follicular count (seen in the subacute or chronic phases) |
Differential diagnosis | Telogen effluvium Traction alopecia Trichotillomania Syphilis Temporal alopecia triangularis Frontal fibrosing alopecia Pseudopelade of Brocq Lichen plano pilaris |
Box 3. Clinical forms of AA [53]
Prognosis and Course
Box 4. Negative Predictors for Hair Restoration
Concomitant nail lesions | Hair loss beginning before puberty |
Comorbidities of other autoimmune diseases | Lesions lasting longer than 1 year |
Down syndrome | Ophiasis pattern |
Familial history |
AA Treatment
Type of treatment | Active component | Response rate or effectivity | Used for AA Severity | Adverse effects | Availability | Accessible through public healthcare |
---|---|---|---|---|---|---|
Topical therapy | Clobetasol | Foam 0.05%: 25% had 50% response Cream under occlusion: 28.5% had at least a 50% response Cream 0.05%: 85% of children has at least a 50% response | Monotherapy in mild cases or in combination with systemic therapy in moderate–severe cases | Folliculitis, local skin atrophy, striae, acneiform rash, telangiectasias, dyschromia, adrenal suppression | ARG ✓ BRA ✓ COL ✓ MEX ✓ | ARG ✖ BRA ✖ COL ✓ MEX ✓ |
Minoxidil | 60% response with minoxidil 5% [58] | As adjuvant therapy | Hypertrichosis, local irritation [55] | ARG ✓ BRA ✓ COL ✓ MEX ✓ | ARG ✖ BRA ✓ COL ✓ MEX ✖ | |
Topical immunotherapy | Diphencyprone | 30–48% [8] global 28.3–87.9% AT and AU 72.2% for chronic extensive AA [59] | Moderate–severe | Hyperpigmentation, hypopigmentation, folliculitis lymph node enlargement, severe dermatitis, blisters, and flu-like symptoms | ARG ✓ BRA ✓ COL ✓ MEX ✖ | ARG ✖ BRA ✖ COL ✖ MEX ✖ |
Phototherapy | NB-UVB | 52.9% response week 12 (23 sessions) [60] | Mild–moderate | Pain, erythema, edema, blisters | ARG ✓* BRA ✓* COL ✓* MEX ✓* | ARG ✖ BRA ✓ COL ✓ MEX ✓ |
Excimer laser/light treatment | Satisfactory regrowth in 50.2% patients [61] | ARG ✓* BRA ✓* COL ✓* MEX ✓* | ARG ✓* BRA ✖ COL ✓* MEX ✖ | |||
Intralesional corticosteroids | Triamcinolone | 60–75% | Mild–moderate | Pain, hemorrhage at puncture sites, headache, reversible local cutaneous atrophy, dyschromia, systemic absorption | ARG ✓ BRA ✓ COL ✓ MEX ✓ | ARG ✖ BRA ✖ COL ✓ MEX ✖ |
Systemic corticosteroids | Prednisone | > 75% of regrowth with pulse therapy in 43% of total and 51% of children | Moderate–severe | Adrenal suppression, weight gain, Cushing’s syndrome, hypertension, osteoporosis, diabetes, immunosuppression, cataracts, acne | ARG ✓ BRA ✓ COL ✓ MEX ✓ | ARG ✖ BRA ✓ COL ✓ MEX ✓ |
Dexamethasone | 51.8% achieved SALT50 after 9 months of oral mini pulse (< 5 mg/d, 2 days/week) [62] | ARG ✓ BRA ✓ COL ✓ MEX ✓ | ARG ✖ BRA ✓ COL ✓ MEX ✓ | |||
Conventional systemic immunomodulators | Methotrexate | Regrowth of > 50% in 63.2% of patients [63] | Moderate–severe | Hematologic toxicity, teratogenicity, immunosuppression, hepatotoxicity, interstitial pneumonitis | ARG ✓ BRA ✓ COL ✓ MEX ✓ | ARG ✖ BRA ✖ COL ✓ MEX ✓ |
Cyclosporine | < 6 months: 74% (53–88%) ≥ 6 months: 73% (47–89%) Recurrence after monotherapy: 55% (6–96%) CsA + systemic corticosteroids: 28% (6–72%) [64] | Nephrotoxicity, immunosuppression, and arterial hypertension | ARG ✓ BRA ✓ COL ✓ MEX ✓ | ARG ✖ BRA ✖ COL ✓ MEX ✓ | ||
Azathioprine | Regrowth of 52.3% after 6 months of treatment [65] | Gastrointestinal symptoms, elevated liver enzymes, pancreatitis, hematologic toxicity | ARG ✓ BRA ✓ COL ✓ MEX ✓ | ARG ✖ BRA ✖ COL ✓ MEX ✓ | ||
JAK inhibitors | Ruxolitinib | 6 months: 95% had > 50% regrowth 12 weeks: 75% had > 50% regrowth | Moderate–severe | Mild infections, mainly of the upper respiratory tract, dyslipidemia, leukopenia, increased liver enzymes, headache, gastrointestinal complaints, fatigue, acne, weight gain, thrombosis, acne, nausea, increase in serum creatin phosphokinase, herpes zoster** | ARG ✓ BRA ✓ COL ✓ MEX ✓ | ARG ✖ BRA ✖ COL ✖ MEX ✓ |
Tofacitinib [66] | Oral 10 mg/day: Reduction in SALT 70% (50–90%) Topical twice/day: Partial regrowth in 30% of patients | ARG ✓ BRA ✓ COL ✓ MEX ✓ | ARG ✖ BRA ✖ COL ✖ MEX ✖ | |||
Ritlecitinib [54] | 50% achieve SALT 30 score and 25% SALT 90 score after 24 months | ARG ✖ BRA ✖ COL ✖ MEX ✖ | ARG ✖ BRA ✖ COL ✖ MEX ✖ | |||
Baricitinib [57] | Oral 2 mg/day: 33.3% Oral 4 mg/day: 54.4% Severity of alopecia score: < 20% at 36 weeks | ARG ✓ BRA ✓ COL ✓ MEX ✓ | ARG ✖ BRA ✖ COL ✖ MEX ✖ | |||
Biologics | Dupilumab [67] | 32.5% of patients achieved SALT 30 22.5% achieved SALT 50 15% achieved SALT 75 After 48 weeks of treatment | Moderate–severe | Conjunctivitis (in patients with atopic dermatitis) Injection-site reactions, headache, fatigue. Some reports of new onset or recurrent cases of AA after initiation for other indications [55] | ARG ✓ BRA ✓ COL ✓ MEX ✓ | ARG ✖ BRA ✖ COL ✖ MEX ✖ |
Abatacept | 3–50% hair regrowth | Infections, headache, upper respiratory tract infection, nasopharyngitis, and nausea |