DERMATOLOGY | CASE REPORT

A SUCCESSFUL TREATMENT OF ALOPECIA TOTALIS

TREATED WITH DAILY DOSE FOLLOWED BY ORAL
MINI-PULSE DOSE OF METHYLPREDNISOLONE
Widya Widita∗,1 and Khairuddin Djawad∗
∗ Department of Dermatology and Venereology, Faculty of Medicine, Universitas Hasanuddin, Makassar, South Sulawesi, Indonesia.

ABSTRACT Alopecia totalis (AT) is a non-scarring, autoimmune-mediated hair loss with a chronic course that affects
the entire scalp. Treatment is challenging and often incomplete. Pulse dose corticosteroids have been reported to be
successful in multiple cases but currently little is known on the optimal regimen with maximum effect and least side
effects. We report a 39-year old, otherwise healthy, female with AT who was treated with a four-week course of daily
30 mg methylprednisolone followed by three days weekly corticosteroid (oral mini-pulse dose) of the same dose. The
patient showed hair growth after four weeks and an almost complete hair growth after twelve months of treatment. No
side effects were observed in this patient. This case showed that daily dose of corticosteroid followed by mini-pulse dose
is an effective and safe treatment in AT.
KEYWORDS alopecia totalis, mini-pulse dose, corticosteroid

Introduction
Alopecia totalis (AT) is a non-scarring, autoimmune-mediated
hair loss with a chronic course that affects the entire scalp.[1] It is
the extensive clinical variant of the patchy and localized alopecia
areata.[2] This cumulative lifetime incidence of this disease is
approximately 2%, and it affects both genders equally with no
racial predilection.[3]
The autoimmunity origin of this disease first gained recogni-
tion in the 1960s and is supported by the fact that AT often occurs
with other autoimmune-mediated diseases such as vitiligo and
thyroiditis and is a response to immunomodulating agents.[4,5]
As a result, treatment of AT mainly concentrates on the use of
agents in that class such as corticosteroids, methotrexate, and
immunotherapy.
Treatment of AT is especially challenging, given its unpre-
dictable course and treatment response. Systemic corticosteroids
Copyright © 2020 by the Bulgarian Association of Young Surgeons
DOI:10.5455/IJMRCR.alopecia-totalis-prednisolone
First Received: March 16, 2020
Accepted: May 28, 2020
Associate Editor: Ivan Inkov (BG);
1
Department of Neurology Udayana University/Sanglah General Hospital, Bali,
Indonesia; Email:widita_ab@yahoo.com
have been widely used, but relapses are high and side effects
due to the required chronic nature of this treatment.[6] In order
to overcome this limitation, pulse therapy, or administrating
corticosteroids in a very high dose for a few days or single dose
and repeated after a certain period, have been attempted in
multiple events.[7] The main limitation for this approach is the
wide range of dose and regimen that complicates analysis to
determine the optimal dose and regimen.
We report a case of AT, which showed a very significant hair
growth after the initial daily dose followed by an oral mini-pulse
dose of methylprednisolone.
Case presentation
A 39-year old Indonesian female came with a chief complaint
of an abrupt, non-pruritic, painless, extensive scalp hair loss
in the past month. No hair loss occurred on other parts of the
body such as eyebrow, axilla, or pubic. Excessive sweating,
heat intolerance, weight loss, and tremor were denied. The
patient did not recall any fever or being hospitalized prior to
the complaint. The previous history of a similar complaint was
denied. History or routine medication of hypertension, diabetes,
and thyroid diseases were absent.
Physical examination showed the patient was in otherwise
good condition with normal vital signs. Dermatological exami-
nation showed diffuse hairless area all over the scalp with vellus

Widya Widita et al./ International Journal of Medical Reviews and Case Reports (2020) 4(9):32-35
Figure 1: Total hair loss of the entire scalp.

Figure 3: Follow-up after 6 months.

Figure 2: Dermoscopic examination.

hairs being present on some areas (Figure 1). No hair loss was ob-
served on other body parts. Histopathological examination was
not conducted as the patient did not give her consent. Dermo-
scopic examination showed diffuse hair loss with the appearance
of yellow dots and broken hairs. Laboratory examination com-
prising complete blood examination, random blood glucose, free
thyroxine, thyroid stimulating hormone levels, and antinuclear
antibody profile were all in normal range.
A diagnosis of alopecia totalis was established through his-
tory taking, physical examination, and dermoscopy. We admin-
istered an initial daily dose of oral 30 mg methylprednisolone
in the first four weeks, which resulted in hair growth by the
fourth week. This regimen was followed by 30 mg of methyl-
prednisolone on three consecutive days each week. Follow- Figure 4: Follow-up after 12 months.
up examination showed a significant patchy hair growth after
six months (Figure 2) and almost complete hair growth on the
twelfth month (Figure 3).

Discussion
The treatment of AT is complex and has always been challeng-
ing.[2] A multitude of treatment options has been attempted

Widya Widita et al./ International Journal of Medical Reviews and Case Reports (2020) 4(9):32-35
 Relevant medical history and interventions
The patient is a 35-year old female with otherwise insignificant medical history.
Summaries from
Date initial and follow-up Diagnostic testing Intervention
visits
Normal complete blood
examination, random
Abrupt, non-pruritic,
blood glucose, free
painless, extensive 30 mg methylprednisolone
20 March 2018 thyroxine, thyroid
scalp hair loss in the everyday
stimulating hormone
past month.
levels, and antinuclear
antibody profile
Hair growth started to 30 mg methylprednisolone on
20 April 2018 - three consecutive days every
appear
week
30 mg methylprednisolone on
18 September 2018 Patchy hair growth - three consecutive days every
week
Almost complete, 30 mg methylprednisolone on
22 March 2019 - three consecutive days every
diffuse hair growth
week

with varying results and side effects.[8] Almost all of the avail-
able agents are immunosuppressive agents such as corticos-
teroid, methotrexate, and Janus Kinase inhibitors.[6] Among
these agents, the corticosteroid is the most commonly used agent
with varied routes of administrations: topical, intralesional, oral,
and intravenous. Oral corticosteroids have been widely used
in the treatment of AT with 47% of 32 subjects showing >25%
hair regrowth and 25% of all subjects experienced >75% hair
growth.[9] However, a dilemma emerges as the majority of pa-
tients has reported hair loss recurrence four to nine weeks after
treatment cessation[6]. At the same time, long term, daily admin-
istration of corticosteroids is associated with side effects such
as hypertension, diabetes, adrenal suppression, and osteoporo-
sis[10].
To overcome this limitation, we decided to administer oral
corticosteroids three times weekly instead of the classical daily
administration. This regimen also called the ‘mini-pulse’ regi-
men, is effective in at least two studies using oral prednisolone
and betamethasone, respectively.[8, 11] Bajaj et al. reported the
earliest hair growth to occur after six weeks[8] while Khaitan et
al. reported four weeks[11].
Our regimen differed with the studies mentioned above,
where we initially administered a daily dose of 30 mg methyl-
prednisolone for four weeks to achieve a more rapid initial hair
growth. As a result, in our case, hair growth was already ob-
served after four weeks. After initial hair growth had been ob-
tained, we switched into the mini-pulse regimen, which showed
very significant and almost complete hair growth of the entire
scalp after 12 months of the administration. Various regimens
of corticosteroid pulse therapy have been reported in the liter-
ature, with most studies using a high dose of corticosteroids,
such as 100 mg intravenous prednsiolone[7], 0.1 mg/kg BW
intravenous dexamethasone[12], and 2.5-10.0 mg/kg BW intra-
venous methylprednisolone[13]. However, the high-dose pulse
has been attributed to severe side effects such as cardiovascular
events, acute liver injury, and even death.[14] As expected, the
low-dose of corticosteroids administered in this case, relative to
the classical high pulse-dose, did not result in any side effects.
Although longer follow-up is needed to observe the relapse rate,
this case showed a very satisfying and rapid result.
Conclusion
This case showed that daily dose followed by a mini-pulse dose
of corticosteroids is an effective and safe treatment for patients
with AT.
Ethics committee approval
THis case report has approved by the Research Ethics Commis-
sion of FK Udayana University/Sanglah General Hospital.
Funding
The authors declared that this study has received no financial
support.
Conflict of interest
There are no conflicts of interest to declare by any of the authors
of this study.
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