Original Paper
Dermatology 2013;227:37–44 Received: January 4, 2013
DOI: 10.1159/000351559
Pulse Corticosteroid Therapy for Alopecia
Areata in Children: A Retrospective Study
Rivka Friedland a Rotem Tal c Moshe Lapidoth a, b, e Alex Zvulunov d
Dan Ben Amitai d, e
a
Department of Dermatology and b Laser Unit, Department of Dermatology, Rabin Medical Center,
c
Day Care Unit and d Pediatric Dermatology Unit, Schneider Children’s Medical Center of Israel, Petach Tikva,
and e Sackler Faculty of Medicine, Tel Aviv University, Tel Aviv, Israel
Key Words
Childhood · Alopecia areata · Corticosteroids · Pulse therapy
Abstract
Background/Objective: Alopecia areata may occur at any
age, though usually before the age of 20 years. Treatment
often consists of systemic steroids administered as high-
dose bolus infusions. This study sought to investigate the
effectiveness and side effects of intravenous high-dose pulse
corticosteroids in children with alopecia areata and to iden-
tify prognostic factors for successful treatment. Methods:
Patients treated with pulse corticosteroids for alopecia area-
ta in 2001–2008 at the day care unit of a tertiary pediatric
medical center were identified by computerized file search
and clinical treatment and outcome data were collected.
Results: The sample included 24 children (16 female, 8 male)
with a mean age of 8.5 ± 4.6 years at diagnosis; 8 (33%) had
multifocal disease,10 (42%) multifocal disease with ophiasis,
4 (17%) alopecia totalis and 2 (8%) alopecia universalis. Nail
involvement was noted in 9 patients (38%). Mean duration
of disease was 22 ± 27 months. Patients were treated with
8 mg/kg body weight intravenous methylprednisolone on 3
consecutive days at 1-month intervals. After a mean of 5.65
± 1.95 courses, 9 patients (38%) had a complete response, 7
© 2013 S. Karger AG, Basel
1018–8665/13/2271–0037$38.00/0
E-Mail karger@karger.com
www.karger.com/drm
Accepted after revision: April 19, 2013
Published online: August 31, 2013
(29%) a partial response and 8 (33%) no response. Of the 16
responders, 13 (81%) relapsed at 9.5 ± 12 months after the
last course; 3 patients had side effects, none of which were
severe. Three positive prognostic factors were identified:
short disease duration (≤6 months), younger age at disease
onset (<10 years) and multifocal disease (as opposed to se-
vere, diffuse variants). Conclusions: Careful patient selection
is necessary to achieve maximal benefit from pulse cortico-
steroid treatment for alopecia areata in children.
© 2013 S. Karger AG, Basel
Introduction
Alopecia areata (AA) is characterized by sudden,
patchy nonscarring hair loss, usually on the scalp although
any hair-bearing skin may be involved. The hairless patch-
es are typically round or oval, smooth and well circum-
scribed. They may present in the frontal or parietal scalp
or in the form of a band that extends from the posterior
occiput to the temporal areas bilaterally (ophiasis). AA
may progress from single or multifocal patches to com-
plete loss of scalp hair (alopecia totalis, AT) or further, to
loss of all body hair, including eyebrows, eyelashes, other
facial hair and pubic hair (alopecia universalis, AU).
203.64.11.45 - 2/23/2015 1:53:16 AM
Moshe Lapidoth, MD, MPH
Laser Unit, Department of Dermatology
Kainan University
Rabin Medical Center
Downloaded by:
Petach Tikva 49202 (Israel)
E-Mail alapidot @ netvision.net.il
 The estimated life-time risk of AA in the general pop- Table 1. Baseline characteristics of children with AA treated with
ulation is 1.7% [1, 2]. Though AA may occur at any age, high-dose pulse methylprednisolone
onset is usually (60% of cases) before the age of 20 years
Characteristics
[2]. The pathogenesis is still unknown, but increasing ev-
idence points to a reversible tissue-restricted autoim- Sex
mune process [3–5]. A hallmark of the acute phase of AA Female 16 (66.6)
is a peribulbar lymphocytic infiltrate, rich in helper T Male 8 (33.3)
lymphocytes [6]. The hair follicle is not destroyed, there- Ethnicity
Jewish 12 (50)
fore, so there is a potential for regrowth. Arab 11 (46)
Patients usually have several episodes of hair loss and Bedouin 1 (4)
regrowth during their lifetime. Recovery may be com- Age at onset, years 8.5 ± 4.6 (2.7 – 17.2)
plete, partial or absent [7]. The prognosis depends on sev- Severity
eral factors. Poor prognostic factors include the early on- Multifocal 8 (33)
Ophiatic 10 (42)
set of disease, ophiasis, diffuse disease, positive family his- AT 4 (17)
tory and atopic dermatitis. AU 2 (8)
Systemic corticosteroids are one of the various treat- Duration of disease, months 22 ± 27 (0 – 103)
ment approaches described to induce remission in pa- Comorbidities
tients with AA. To avoid side effects, the drug is admin- Hypothyroidism 1 (4)
Atopic dermatitis 1 (4)
istered as high-dose bolus infusions [8–10]. The aim of Asthma 1 (4)
the present study was to investigate the effectiveness and Psoriasis 1 (4)
safety of high-dose pulse corticosteroid therapy in chil- Family history
dren with AA and to identify prognostic factors for suc- AA 2 (8)
cessful treatment. Asthma 3 (12.5)
Atopic diathesis 3 (12.5)
Hypothyroidism 2 (8)
Vitiligo 1 (4)
Methods Values are presented as number with percentage or mean ± SD
with range.
A computerized file search was conducted in the day care unit
of a tertiary university-affiliated pediatric medical center to iden-
tify all patients treated for AA with methylprednisolone from 2001
to 2008. Patient referral to the day care unit was from the pediatric
dermatology unit. The range of years was limited in order to allow
a significant long-term follow-up. All patients were treated with a
protocol of 8–10 mg/kg body weight (up to 500 mg/dose) intrave- Results
nously on 3 consecutive days at 1-month intervals. All patients
underwent thyroid function tests and a subdermal screening test A total of 24 children met with the study criteria. Their
for tuberculosis infection (Mantoux test). Patients were clinically demographic and clinical data are summarized in table 1.
assessed by a pediatric dermatologist every 1–2 months. The group included 16 girls and 8 boys (female:male ratio
Medical charts were reviewed and data on clinical characteris-
tics, number of steroid courses, response to treatment, and follow- 2:1) with a mean age of 8.5 ± 4.6 years (range 2.7–17.2)
up were recorded. Complete response was defined as full hair re- at diagnosis; 12 (50%) were Jewish, 11 (46%) Arab and
growth at all alopecic sites, partial response as hair regrowth in part 1 (4%) Bedouin. Associated comorbidities included hypo-
of the alopecic areas, and no response as absence of all evidence of thyroidism, asthma, atopic dermatitis and psoriasis, in
hair regrowth. Mild relapse was defined as hair loss of up to 10% 1 patient (4%) each. Of the 24 patients, 5 (20%) had a fam-
of scalp hair and severe relapse as loss of all hair regrowth or worse.
The study was approved by the local institutional review board. ily history of autoimmune diseases, 2 of AA (8%), 2 of
hypothyroidism (8%) and 1 of vitiligo (4%); 6 patients
Statistical Analysis (24%) had a family history of atopic diseases – asthma and
The distribution of response to treatment by demographic and atopic dermatitis (3/24, 12% each).
clinical variables was analyzed with the χ2 test. Variables associ- At the time of referral for pulse corticosteroid therapy,
ated with complete response on univariate analysis (p < 0.2) were
entered into a multivariate logistic regression model with complete 8 patients (33%) had multifocal disease without ophiasis,
response as the binary outcome. All analyses were performed with 10 (42%) had multifocal disease with ophiasis, 4 (17%)
the SPSS for Windows, version 13 (SPSS Inc.). had AT and 2 (8%) had AU. There was no significant dif-
203.64.11.45 - 2/23/2015 1:53:16 AM

38 Dermatology 2013;227:37–44 Friedland /Tal /Lapidoth /Zvulunov /

       

DOI: 10.1159/000351559 Ben Amitai  

Kainan University
Downloaded by:
Table 2. Treatment-associated parameters

Patient Sex Age at presen- Previous Treatment Pulses, Regrowth F-U, Relapse Delay to re-
No. tation, years treatment delay, months n with pulses, n months lapse, months

Multifocal
1 F 3.9 TS 3 3 CR (2) 1 No –
2 M 3.8 TS, PM, TC, SA 0 5 CR (5) 40 Yes 3
3 M 9.3 TS, PM, TC, SA 2 3 CR (2) 6 Yes 4.5
4 F 10.8 TS 31 6 CR (6) 24 Yes 8
5 F 5.3 TS, IL 22 6 CR (6) 29 Yes 24
6 F 16.1 TS, IL, DT 4 9 PR (2) 25 Yes 7
7 F 17.2 TS, DT 2 6 NR 7 – –
8 F 14.2 TS, PM, SA, DT 11 8 NR 38 – –
Multifocal + ophiasis
9 F 4.7 TS, TC, DT 1 4 CR (2) 43 Yes 1
10 M 4.9 TS 48 6 CR (3) 12 Yes 8
11 M 5.6 TS, PM 6 8 CR (2) 68 Yes 36
12 F 14.0 TS, IL, DT 10 3 PR (3) 1 No
13 F 10.5 TS, IL, DT 1 7 PR (4) 43 Yes 24
14 F 3.3 TS, IL, DT 70 5 PR (2) 42 Yes 2
15 M 9.9 TS, TC 26 10 PR (5) No Yes 0
16 F 5.0 TS, IL 60 10 NR 17 – –
17 F 4.0 TS 103 2 NR No – –
18 F 2.7 TS, IL, TC 26 5 NR No – –
AT
19 F 6.3 No 4 4 CR (4) 1 Yes 1
20 M 10.9 TS, IL 56 10 PR (10) 26 No –
21 F 3.5 TS 6 3 NR No – –
22 M 11.8 TS 38 8 NR No – –
AU
23 M 11.3 TS, IL, DT 14 7 PR (4) No Yes 0
24 F 14.7 TS 13 2 NR No – –

CR = Complete regrowth; F-U = follow-up period after treatment; NR = no response; PR = partial regrowth; TS = topical corticoste-
roids; IL = intralesional injection of corticosteroids; DT = dithranol; SA = squaric acid; TC = tacrolimus; PM = pimecrolimus.

ference in age at diagnosis between patients with multi-
focal AA or more severe clinical variants (p = 0.181); 9
patients (38%) had nail involvement (6 with ophiatic AA,
2 with AT and 1 with AU). None of the patients with
multifocal disease without ophiasis had nail involve-
ment.
Table  2 summarizes data regarding treatment, re-
sponse and follow-up. Mean duration of disease until
pulse corticosteroid therapy initiation was 23 ± 27 months
(range 0–103). All patients also underwent thyroid func-
tion tests and a subdermal screening test for tuberculosis
infection (Mantoux test), and were then treated with a
protocol of intravenous methylprednisolone (8 mg/kg
body weight – up to 500 mg/dose) on 3 consecutive days
at 1-month intervals. Blood pressure and heart rate were
monitored on days 1–3 of each therapy course before and
immediately after intravenous application of corticoste-
roids. Weight and height were also measured during
treatment courses. After a mean of 5.83 ± 1.95 treatment
courses (range 2–10), 9 patients (38%) had a complete
response, 7 (29%) a partial response and 8 (33%) no re-
sponse. Response to treatment was first documented after
a mean of 3.87 ± 2.19 cycles (range 2–10). In 3 of the 16
responders there was no relapse; 1 patient was free of dis-
ease during a follow-up period of 26 months; 2 patients
enjoyed remission for 1 month before they were lost to
follow-up. In 13 of the 16 responders (81%), the disease
relapsed at a mean of 9.5 ± 12 months (range 0–36) after
the last treatment course; 2 patients had a mild relapse
and were treated with topical steroids and 8 patients pre-
203.64.11.45 - 2/23/2015 1:53:16 AM

Pulse Corticosteroids for Pediatric Dermatology 2013;227:37–44 39

Alopecia Areata DOI: 10.1159/000351559
Kainan University
Downloaded by:
 Color version available online
sented with severe relapse; 6 of them were referred for
another course of intravenous pulse methylprednisolone, 100

Complete recovery rate (%)

1 was treated with intralesional injections of corticoste- 90
80
roids and 1 refused further treatment. Data were missing 70
for 3 patients. Among the 6 patients who were treated 60
50
with a second course of pulse intravenous methylpred- 40
nisolone, 4 had a good response to the second course (3 30
20
after 3 months of treatment and 1 after 2 months) and 10
1 had a partial response (after 3 months of treatment). 0
Age <10, Age <10, Age –10, Age –10,
Among the 5 responders of the second course, there was multifocal AA other AA multifocal AA other AA
follow-up for another 2 years for only 1 patient; 5 months (n = 4) (n = 10) (n = 4) (n = 5)
after the end of the second course a relapse was noted, and
he was treated topically with dithranol and tacrolimus Fig. 1. Complete recovery rates and 95% CIs (Fisher’s exact test) of
with no response. Data were missing for another patient; AA, according to type and age at onset (years).
3 patients had side effects of methylprednisolone, none of
which were severe (verrucae, gastritis, abdominal pain).
Table 3 summarizes the distribution of selected patient
Table 3. Prognostic factors for complete response to treatment:
characteristics according to response to treatment. On univariate analysis
univariate analysis, there was no effect of any of the de-
mographic or clinical parameters on response rate. Fur- Complete recovery rate p value
ther analysis of complete response versus partial and no n %
response revealed an association of short disease duration
(<6 months vs. ≥6 months) with an increased likelihood Sex 0.397
of complete response (p = 0.033). Male 5/15 33.3
The rate of complete response was highest in the sub- Female 4/8 50.0
Age at onset, years 0.072
group of patients with multifocal disease (5/8, 62%), fol- ≤4 4/8 50.0
lowed by the more severe variants of ophiatic AA (3/10, 5–9 4/6 66.7
33%), AT (1/4, 25%) and AU (0). These differences were ≥10 1/9 11.1
not significant on univariate analysis (p = 0.214). How- Ethnicity 0.379
ever, after adjusting for age at onset on multivariate logis- Jewish 5/12 41.7
Arab 3/10 30.0
tic regression (fig. 1), multifocal AA was found to be as- Bedouin 1/1 100.0
sociated with a significantly increased likelihood of com- Severity of disease 0.310
plete recovery compared to the other types of alopecia Multifocal 5/8 62.5
(odds ratio (OR) = 48.82, 95% CI: 0.95–2,517.65, p = Ophiatic 3/9 33.3
0.05). Younger age at onset (<10 years) was also associ- AT 1/4 25.0
AU 0/2 0.0
ated with significantly higher chances of complete re-
Nail change 0.371
sponse (fig. 1), with an OR of 0.62 per year (95% CI: 0.41– Yes 7/14 50.0
0.95, p = 0.03). No other variables were significantly as- No 2/9 22.2
sociated with complete response in the multivariate AA duration, months 0.033
model. ≤6 6/10 60.0
>6 2/12 16.7

Discussion

AA is a cosmetically disturbing disease that affects
young people. Therefore, many treatment modalities
have been applied such as topical, intralesional or sys-
temic corticosteroids, psoralen and ultraviolet A, contact
immunotherapy, anthralin, minoxidil, topical calcineu-
rin inhibitors and cyclosporine [11, 12]. All of them are
palliative, not curative. There is no evidence from ran-
domized controlled trials that steroids, whether topical,
intralesional or systemic, are of benefit in treating AA [4].
Nevertheless, systemic corticosteroids have been consid-
ered to be the most effective treatment and the treatment
of choice for AA [11], but their prolonged administration
203.64.11.45 - 2/23/2015 1:53:16 AM

40 Dermatology 2013;227:37–44 Friedland /Tal /Lapidoth /Zvulunov /

       

DOI: 10.1159/000351559 Ben Amitai  

Kainan University
Downloaded by:
 a b

Fig. 2. Alopecia subtotalis. a Before treatment. b After 6 sessions.

Table 4. Clinical data on 39 children, previously reported, treated with corticosteroid pulse therapy for AA

Seiter [4], 2001 Kiesch [14], 1997 Hubiche [18], 2008 Sharma [20], 1998 Summary

Number of patients 4 7 12 16 39
Female 3 3 8 11 25
Male 1 4 4 5 14
Age, years 14 – 16 (15) 4 – 10 (7.7) 1 – 15 (6.75) 3 – 18 (11)
Duration of disease, months ND 3 – 44 1 – 96 (28.7) 2 – 96 (20.3)
Scalp affected, % 60 – 100 (80) 30 – 100 (57.8) 20 – 100 (64) 30 – 100 (50.6)
Treatment IV MP IV MP IV MP oral P
Number of pulses ND ND 2 – 3 (2.58) 1 – 8 (4.1)
Response, n
Excellent 2 5 7 9 23 (59%)
Good 3 1 4 (10%)
None 2 1 2 5 10 (26%)
Side effects ND 6 none none 14 none
1 abdominal pain 1 headache
1 epigastric pain
Follow-up, months 12 12 12 – 83 (44.2) 6 – 60 (25)
Relapse none 1 relapse all relapsed 5 relapsed 18/22 (81.8%)
(10 – 100%) (4 patches, 1 total)

Values in parentheses are means unless otherwise indicated. ND = No data; P = Prednisolone; MP = methylprednisolone.

is associated with severe adverse effects. In 1975 Burton
and Shuster [13] were the first to administer a single
2-gram intravenous methylprednisolone pulse in 22 pa-
tients with AA; however, only 3 (14%) had satisfacto-
ry hair regrowth. Thereafter, several additional studies
showing a beneficial effect of pulse corticosteroids, either
intravenous [4, 10, 14–19] or oral [9, 20–22], were pub-
lished. Four of these studies [4, 14, 18, 20] concern a pe-
diatric population (a total of 39 patients) (table 4). In the
present study, 16 patients (67%) exhibited terminal hair
regrowth, but only 38% had a complete response (equiva-
lent to a cosmetically acceptable appearance) (fig. 2, 3).
203.64.11.45 - 2/23/2015 1:53:16 AM

Pulse Corticosteroids for Pediatric Dermatology 2013;227:37–44 41

Alopecia Areata DOI: 10.1159/000351559
Kainan University
Downloaded by:
 a b
Fig. 3. AA. a Before treatment. b After 6 sessions.
The wide range of treatment success rates in the litera-
ture is probably attributable to differences in the proto-
cols used and in patient selection methods. Be that as it
may, it is likely that outcome was affected by the presence
of certain factors. Short disease duration (≤6 months)
was a positive prognostic factor in our study and was also
associated with favorable results in previous studies in
both adults [19] and children older than 12 years [20].
The better response associated with early disease may be
explained by findings of fewer functional follicular struc-
tures and some follicular scarring in patients with long-
standing AA [23]. Therefore, selecting patients in the ear-
ly stages of disease may be crucial to their ability to re-
spond to corticosteroid pulse therapy. It should be noted,
however, that Seiter et al. [4] reported higher response
rates in patients with long-term disease than in patients
treated during their first episodes of AA. Younger age at
disease onset (<10 years) was also associated with a better
prognosis in our cohort. Similarly, Sharma and Muralid-
har [20] observed a better response to therapy in their
group aged 3–11 years (71%) than in patients aged 12–18
years (50%). However, Im et al. [19] did not find any ef-
fect of age on outcome. These epidemiological studies in
large populations are needed to clarify the impact of both
disease duration and age.
AA is classified into several clinical subtypes: multifo-
cal and ophiatic AA, AT and AU. The more severe AT/
42 Dermatology 2013;227:37–44
DOI: 10.1159/000351559
AU subtype is associated with earlier age at onset, longer
duration of disease, susceptibility to autoimmune diseas-
es and low probability of response to treatment [24]. In
our study disease severity was found to predict therapeu-
tic response, as patients with multifocal disease had a
higher likelihood to respond to treatment than patients
with ophiatic AA, AT or AU. A poor treatment response
in patients with the severe variants has also been suggest-
ed by previous studies [4, 10, 15, 17, 19].
The safety of high-dose corticosteroids in children is
an important consideration. Concerns have been raised
that corticosteroids may expose patients with AA to a risk
of deleterious side effects without altering the long-term
course of the disease [25]. Prolonged use of corticoste-
roids can lead to Cushingoid habitus, electrolyte distur-
bances, cardiovascular effects, glucose intolerance, diabe-
tes mellitus, loss of bone density and osteoporosis with
concomitant vertebral fracture, muscular weakness, de-
layed healing, peptic ulcer, cataract, glaucoma, psychiat-
ric disturbances and increased risk of infections [26]. In
children, corticosteroids can also lead to growth retarda-
tion [27]. Discontinuation of therapy is followed by a pe-
riod of compensatory growth [28].
Pulse therapy by the administration of suprapharma-
cological doses of corticosteroid is cumulatively less toxic
than sustained steroid treatment at lower quantitative
dosage [29], but is still associated with a spectrum of ad-
203.64.11.45 - 2/23/2015 1:53:16 AM
Friedland /Tal /Lapidoth /Zvulunov /
Ben Amitai  
Kainan University
Downloaded by:
verse reactions in children, among which volatile behav-
ior is the most frequent. The nonbehavioral adverse reac-
tions include headache, abdominal complaints, pruritus,
vomiting and hypertension [30]. Most symptoms were
transient in duration, mild in severity, and required no
medical treatment [31]. In the group described in the
present study, only 3 patients had adverse effects of treat-
ment, all of which were mild, and none required cessation
of treatment. Previous studies reported similar findings
[4, 8, 9, 15–17, 19–22].
Considering the risks related to high-dose pulse corti-
costeroids, clinicians should consider risk-efficacy ratio
regarding the number of cycles that the patient received
before determining treatment failure. Surprisingly, we
did not find any consideration for this practical question
in the literature. In our cohort, initial hair growth was
documented after a mean of 3.87 ± 2.19 cycles (range
2–10). Based on this limited data, it seems reasonable to
offer a patient up to 6 cycles and to withdraw the treat-
ment if there is no response.
Pulse corticosteroids are effective in patients with AA,
but their benefit is maintained only as long as the patient
continues treatment [18]. In the present study, the major-
ity of responders (81%) relapsed after treatment was dis-
continued. Other studies in which patients were treated
with intravenous pulse methylprednisolone reported re-
lapse rates of 16.7–38% within 4–70 months of follow-up
[4, 17, 19]. Findings for oral pulse prednisolone were sim-
ilar [9, 21]. The highest reported relapse rate (74%) was
found in 2006 by Kurosawa et al. [16] in patients treated
with daily oral dexamethasone. Thus, as in other chronic
autoimmune/inflammatory skin diseases, maintenance
treatment is needed in severe AA after the success of ini-
tial intervention. Friedli et al. [10] report that a second
pulse given several months after the first one might be ef-
fective when relapse occurs, even in a previously partially
responding patient. Indeed, in our cohort, 4/6 patients
benefited from a second course. Combining pulse thera-
py with low-dose oral cyclosporine [32] or methotrexate
[33, 34] may also increase probability of long-term remis-
sion.
In conclusion, this retrospective study confirms the ef-
fectiveness of pulse corticosteroids in the treatment of
children with AA. Careful patient selection is necessary
to achieve the maximal benefit of treatment. Success rates
are higher in patients with a short duration of disease (≤6
months), young age at onset and multifocal AA as op-
posed to ophiatic AA, AT or AU. These findings may help
clinicians identify responders to corticosteroid pulse
therapy. The present study also adds evidence for short-
term safety, but the long-term safety is still unknown.
More information is needed to define the optimal timing
and course of steroid pulses to avoid chronic toxicity and
obtain maximum benefit. Given the high relapse rates
found after cessation of treatment, we suggest that pa-
tients and parents be informed of the option to combine
other immunosuppressive drugs to achieve long-term re-
mission.
Disclosure Statement
The authors have no conflicts of interest. No funding was re-
ceived for this study.

References
1 Safavi KH, Muller SA, Suman VJ, et al: Inci-
dence of alopecia areata in Olmsted County,
Minnesota, 1975 through 1989. Mayo Clin
Proc 1995;70:628–633.
2 Price VH: Alopecia areata: clinical aspects. J
Invest Dermatol 1991;96:68S.
3 Perret C, Weisner-Menzel L, Happle R: Im-
munohistochemical analysis of T-cell subsets
in the peribulbar and intrabulbar infiltrates of
alopecia areata. Acta Derm Venereol 1984:64:
26–30.
4 Seiter S, Ugurel S, Tilgen W, et al: High-dose
corticosteroid therapy in the treatment of se-
vere alopecia areata. Dermatology 2001; 202:
230–234.
5 Gilhar A, Ullmann Y, Berkutzki T, et al: Au-
toimmune hair loss (alopecia areata) trans-
ferred by T lymphocytes to human scalp ex-
plants on SCID mice. J Clin Invest 1998; 101:
62–67.
6 Gilhar A, Shalaginov R, Assy B, Serafimovich
S, Kalish RS: Alopecia areata is a T-lympho-
cyte mediated autoimmune disease: lesional
human T-lymphocytes transfer alopecia area-
ta to human skin grafts on SCID mice. J Inves-
tig Dermatol Symp Proc 1999;4:207–210.
7 Madani S, Shapiro J: Alopecia areata update.
J Am Acad Dermatol 2000;42:549–566.
8 Perriard-Wolfensberger J, Pasche-Koo F,
Mainetti C, et al: Pulse of methylprednisolone
in alopecia areata. Dermatology 1993; 187:
282–285.
9 Sharma VK: Pulsed administration of cortico-
steroids in the treatment of alopecia areata.
Int J Dermatol 1996;35:133–136.
10 Friedli A, Labarthe MP, Engelhardt E, et al:
Pulse methylprednisolone therapy for severe
alopecia areata: an open prospective study of
45 patients. J Am Acad Dermatol 1998; 39:
597–602.
11 Alkhalifah A, Alsantali A, Wang E, et al: Alo-
pecia areata update. J Am Acad Dermatol
2010;62:191–202.
12 Messenger AG, McKillop J, Farrant P, et al:
British Association of Dermatologists’ guide-
lines for the management of alopecia areata
2012. Br J Dermatol 2012;166:916–926.
203.64.11.45 - 2/23/2015 1:53:16 AM

Pulse Corticosteroids for Pediatric Dermatology 2013;227:37–44 43

Alopecia Areata DOI: 10.1159/000351559
Kainan University
Downloaded by:
13 Burton JL, Shuster S: Large doses of glucocor-
ticoid in the treatment of alopecia areata. Acta
Derm Venereol 1975;55:493–496.
14 Kiesch N, Stene JJ, Goens, et al: Pulse steroid
therapy for children’s severe alopecia areata?
Dermatology 1997;194:395–397.
15 Tsai YM, Chen W, Hsu ML, et al: High-dose
steroid pulse therapy for the treatment of se-
vere alopecia areata. J Formos Med Assoc
2002;101:223–226.
16 Kurosawa M, Nakagawa S, Mizuashi M, et al:
A comparison of efficacy, relapse rate and side
effects among three modalities of systemic
corticosteroid therapy for alopecia areata.
Dermatology 2006;212:361–365.
17 Nakajima T, Inui S, Itami S: Pulse corticoste-
roids therapy for alopecia areata: study of 139
patients. Dermatology 2007;215:320–324.
18 Hubiche T, Leaute-Labreze C, Taieb A, et al:
Poor long-term outcome of severe alopecia
areata in children treated with high dose pulse
corticosteroid therapy. Br J Dermatol 2008;
158:1136–1137.
19 Im M, Lee SS, Lee Y, et al: Prognostic factors
in methylprednisolone pulse therapy for alo-
pecia areata. J Dermatol 2011;38:767–772.
20 Sharma VK, Muralidhar S: Treatment of
widespread alopecia areata in young patients
with monthly oral corticosteroid pulse. Pedi-
atr Dermatol 1998;15:313–317.
44 Dermatology 2013;227:37–44
DOI: 10.1159/000351559
21 Kar BR, Handa S, Dogra S, et al: Placebo-con-
trolled oral pulse prednisolone therapy in alo-
pecia areata. J Am Acad Dermatol 2005; 52:
287–290.
22 Agarwal A, Nath J, Barua KN: Twice weekly
5 mg betamethasone oral pulse therapy in the
treatment of alopecia areata. J Eur Acad Der-
matol Venereol 2006;20:1375–1376.
23 Abell E, Gruber HM: A histopathologic reap-
praisal of alopecia areata. J Cutan Pathol 1987;
14:347.
24 Tosti A, Bellavista S, Iorizzo M: Alopecia
areata: a long-term follow-up study of 191 pa-
tients. J Am Acad Dermatol 2006; 55: 438–
441.
25 Winter RJ, Kern F, Blizzard RM: Prednisone
therapy for alopecia areata. A follow-up re-
port. Arch Dermatol 1976;112:1549–1552.
26 Frauman AG: An overview of the adverse re-
actions to adrenal corticosteroids. Adverse
Drug React Toxicol Rev 1996;15:203–206.
27 Allen DB, Mullen M, Mullen B: A meta-anal-
ysis of the effect of oral and inhaled cortico-
steroids on growth. J Allergy Clin Immunol
1994;93:967–976.
28 Guilbert TW, Mauger DT, Allen DB, et al:
Growth of preschool children at high risk for
asthma 2 years after discontinuation of fluti-
casone. J Allergy Clin Immunol 2011; 128:
956–963.
29 Sinha A, Bagga A: Pulse steroid therapy. In-
dian J Pediatr 2008;75:1057–1066.
30 Klein-Gitelman MS, Pachman LM: Intrave-
nous corticosteroids: adverse reactions are
more variable than expected in children. J
Rheumatol 1998;25:1995–2002.
31 Baethge BA, Lidsky MD, Goldberg JW: A
study of adverse effects of high-dose intrave-
nous (pulse) methylprednisolone therapy in
patients with rheumatic disease. Ann Phar-
macother 1992;26:316–320.
32 Shaheedi-Dadras M, Karami A, Mollaei M, et
al: The effect of methylprednisolone pulse
therapy plus oral cyclosporine in the treat-
ment of alopecia totalis and universalis. Arch
Iranian Med 2008;11:90–93.
33 Chartaux E, Joly P: Long-term follow-up of
the efficacy of methotrexate alone or in com-
bination with low doses of oral corticoste-
roids in the treatment of alopecia totalis or
universalis. Ann Dermatol Venereol 2010;
137:507–513.
34 Droitcourt C, Milpied B, Ezzedine K, et al: In-
terest of high-dose pulse corticosteroid ther-
apy combined with methotrexate for severe
alopecia areata: a retrospective case series.
Dermatology 2012;224:369–373.
203.64.11.45 - 2/23/2015 1:53:16 AM
Friedland /Tal /Lapidoth /Zvulunov /
Ben Amitai  
Kainan University
Downloaded by: