ORIGINAL ARTICLE

Combination treatment of extensive and recalcitrant

alopecia areata with oral and topical steroids with
topical minoxidil: An open‑label study of efficacy and
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safety in pediatric patients

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Vivek Kumar Dey

Department of Dermatology, People’s College of Medical Sciences and Research Centre, Bhopal, Madhya Pradesh, India

ABSTRACT

Background: Alopecia areata (AA) is an autoimmune disorder characterized by nonscarring alopecia affecting scalp and body
hair. Treatment of AA in pediatric age group is challenging because of unpredictable course, uncertain natural history, potential
side effects of medicines, and psychological morbidity. Moreover, no clear guidelines for treatment of pediatric AA are available.

Objective: The objective of this study is to assess efficacy and safety of a combination treatment of extensive and
recalcitrant AA with oral and topical steroids with topical minoxidil.

Materials and Methods: Sixteen children (nine girls and seven boys) aged 6–15 years with severe and recalcitrant AA were
included in this study. All were prescribed the regimen of combination of oral and topical steroid with topical minoxidil 2%
solution. Oral steroid was tapered over 12 weeks, and topical steroid was withdrawn at the end of 24 weeks. Patients were
maintained on topical minoxidil for next 9–12 months and closely followed up.

Results: The average age of participants was 10.81 years, and the duration of disease was ranged from 3 months to
30 months. Response to our regimen was good in cases of extensive AA and ophiasis, compared to alopecia totalis. The
participant having alopecia universalis did not respond at all to the regimen. Participants tolerated the regimen well with
mild and easy to manage side effects and only few relapses.

Conclusion: Finding an effective and safe treatment regimen for AA, especially in children is difficult. Our regimen allows
for more rapid lowering of oral doses with maintaining the cosmetic response and minimizing the side effects. Therefore,
a trial course of this regiment would seem to be a reasonable approach for nearly hopeless but highly motivated pediatric
patients of extensive and recalcitrant AA.

Key words: Alopecia areata, alopecia totalis, alopecia universalis, hair loss, hair treatment, minoxidil, nonscarring alopecia,
ophiasis

INTRODUCTION ADDRESS FOR CORRESPONDENCE

Dr. Vivek Kumar Dey,

A lopecia areata (AA) is an idiopathic nonscarring LG‑112, Minal Shopping Mall, J. K. Road, Bhopal ‑ 462 037,
Madhya Pradesh, India.
disorder with multifactorial autoimmune E‑mail: drvivekdey@yahoo.co.in
pathogenesis affecting hair resulting in patches of
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How to cite this article: Dey VK. Combination treatment of extensive

DOI: and recalcitrant alopecia areata with oral and topical steroids with topical
10.4103/2319-7250.179484 minoxidil: An open-label study of efficacy and safety in pediatric patients.
Indian J Paediatr Dermatol 2016;17:173-8.

© 2016 Indian Journal of Paediatric Dermatology | Published by Wolters Kluwer ‑ Medknow 173

 Dey: Combination treatment of childhood alopecia areata with oral and topical steroid with topical minoxidil
noncicatricial baldness on scalp, face, and other
hair‑bearing skin of the body.[1,2] This lymphocyte
mediated inflammatory process not only targets
hair follicles, but also affects the quality of life
greatly. The disease can present with one or more
well‑circumscribed focal bald patch enlarging
centrifugally.[1] Alopecia totalis (AT) and alopecia
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universalis (AU) are other extensive but less
common form which affect entire scalp hair and
all body hair, respectively.[1,3] Sometimes AA may
nYQp/IlQrHD3i3D0OdRyi7TvSFl4Cf3VC4/OAVpDDa8K2+Ya6H515kE= on 07/31/2023
present in a unique pattern of hair loss localized
to the sides and lower back of the scalp known as
ophiasis (OP).
Pediatric AA is frequently encountered in our daily
practice. Up to one‑third of newly diagnosed cases are
aged 20 years or less.[4,5] AA may be associated with
other autoimmune diseases, such as thyroid disease,
celiac disease, vitiligo, irritable bowel syndrome,
SLE, rheumatoid arthritis, diabetes mellitus, and
atopy.[3,6] Nail changes, including twenty nail
dystrophy syndrome and a positive family history,
have also been associated with pediatric AA.[2]
Factors such as unpredictable course, uncertain natural
history, frequent relapses, risk of progression to AT
or AU, significant psychosocial morbidity in children,
and possible adverse effects of medicines make the
management of pediatric AA more challenging.[2,7]
Recalcitrant and extensive AA requires even more
comprehensive approach.[8]
In this study, we used a combination of daily oral
prednisolone in tapering dose, topical mometasone
furoate, and topical minoxidil 2% lotion in extensive
and recalcitrant AA. This combination was chosen
because systemic prednisolone checks the progression
of disease activity, while topical minoxidil and
mometasone furoate supplement systemic steroids
initially and facilitate early withdrawal of systemic
steroids by maintaining hair growth and reducing
relapse.
Objective
The objective of this study is to assess efficacy and
safety of a combination treatment of extensive and
recalcitrant AA with oral and topical steroid along
with topical minoxidil.
MATERIALS AND METHODS
Subjects
Sixteen children, nine females, and seven males,
aged 6–15 years with extensive and recalcitrant
174
AA attending the hair clinic from January 2009 to
December 2011 were recruited for this study. We
labeled AA as extensive if patient had more than 50%
scalp involvement or there is a presence of OP, AT, or
AU at presentation[8] and recalcitrant if patient had
received various modalities of treatment in the form
of oral steroid, pulse therapy, levamisole, tacrolimus,
minoxidil, intralesional corticosteroid therapy, or
herbal products with poor/partial response or relapse
on discontinuing therapy. A wash‑out period of
3 months was allowed before starting these patients
on the new study regime. Any patient with a history
of uncontrolled bacterial, viral, fungal, mycobacterial,
or opportunistic infection (e.g., systemic fungal
infections or parasites) was excluded from the study.
Patients with significant pulmonary or cardiovascular
disease, liver disease, or abnormal hepatic function
were also not permitted to enter the study.
The nature of the study and possible adverse effects
of the therapy was explained and written consent
including the consent of medical photography was
taken from parents of all patients. All patients were
then treated with the study regimen of combination
therapy.
Treatment Procedure
All patients were started with once daily oral
prednisolone (1 mg/kg) along with topical mometasone
and 2% topical minoxidil solution. Oral prednisolone
was reduced to 30% of the initial dose at completion of
2 weeks, then tapered down slowly to stop completely
in 12 weeks. One milliliter of topical minoxidil was
applied to the affected scalp 12 hourly. Topical
mometasone solution was applied twice daily 2 h after
the last application of minoxidil. The dose of topical
mometasone solution was reduced according to the
response of the patient and completely withdrawn at
the end of 24 weeks. Topical minoxidil was continued
for further 12 months as maintenance therapy
which included tapering the number of applications
of topical minoxidil from twice daily to once a day
then alternate days. First 12 weeks were considered
as phase I when all the three drugs were continued.
phase II was the next 12 weeks when patients were on
topicals only without oral steroid and last 12 months
of maintenance with topical minoxidil was labeled as
Phase III.
Assessment
All patients underwent a comprehensive workup at
baseline, 1st month and at the end of the 3rd month
which included weight and growth assessment,
complete physical examination, and investigations
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 Dey: Combination treatment of childhood alopecia areata with oral and topical steroid with topical minoxidil

such as complete hemogram, blood sugar levels,

liver and renal function tests, chest X‑ray, and
ophthalmological examination. The extent of AA was
noted. After completion of the 3rd month, only hair
growth was assessed at monthly interval. The response
was classified as cosmetically acceptable, partial
response, and no response. “Cosmetically acceptable”
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has been defined as amount of terminal hair growth

sufficient to cover the scalp and conceal the areas of
residual loss or patient no longer needing a wig or
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cap to conceal hair loss,[9] but when the amount of

dense patches of terminal hair are not sufficient to Figure 1: A 9‑year‑old girl with extensive alopecia areata attained cosmetic
conceal the area of residual loss or does not obviate response at 12 weeks only
the need of a wig or cap, is taken as partial response.
Nonresponder or failure is defined as no growth or
vellus hair only, even after 24 weeks of therapy.[8]

RESULTS
Total 16 patients from age 6 to 15 years were recruited in
the study, including nine girls and seven boys (M:F ratio
was 1:1.28) average age was 10.81 years (standard
deviation = 2.73). The average duration of disease
at the time of presentation was 12 months for boys
and 9.66 months for girls, ranged from 3 months to
30 months. Among all recruited patients, 1 had AU,
3 had AT, 1 had OP, and 11 had extensive AA (more
than 50% scalp involvement). Details of all patients
are given in Table 1. Out of 11 patients with extensive
AA, 3 attained good cosmetic response at 12–14 weeks
only [Figure 1]. Cosmetically acceptable response was
attained in 56% of the patients [Figures 2 and 3], Figure 2: A 13‑year‑old girl with 5 months history of more than 50%
involvement of alopecia areata. Cosmetic response was attained
whereas 31% patients showed a partial response. Poor over 24 weeks of treatment
or no response was seen in the patient with AU and
in one of the three patients of AT. All responders were
maintained on minoxidil solution 2% and followed up for

Table 1: Details of participants (n=16)

Sex Age (years) Weight (kg) Duration (months) Type*
Female 9 27 6 AA
Male 11 36 6 AA
Female 12 40 12 AA
Female 13 43 5 AA
Male 6 20 8 AA
Female 7 22 3 AA
Male 13 45 10 AA
Female 11 40 8 AA
Female 14 41 9 AA
Male 8 25 18 AA
Female 14 43 12 AA
Female 11 35 8 AT
Male 10 29 6 AT
Female 15 45 24 AT
Male 12 33 30 AU
Male 7 21 6 OP
*AA ‑ Severe alopecia areata; AT ‑ Alopecia totalis; AU ‑ Alopecia universalis;
OP ‑ Ophiasis Figure 3: Good cosmetic response in extensive alopecia areata at week 24

Indian Journal of Paediatric Dermatology | Vol 17 | Issue 3 | Jul-Sep 2016 175

 Dey: Combination treatment of childhood alopecia areata with oral and topical steroid with topical minoxidil
next 12 months. No responder developed relapse during
treatment with oral steroids (Phase I). Relapse was seen
in one patient with AT and three patients of extensive
AA in Phase II. All were mild to moderate and treated
with addition of topical steroids. Topical steroids were
withdrawn gradually without any further relapse. Same
three responders with severe AA relapsed in Phase III
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also. Topical minoxidil solution 2% was also withdrawn
gradually over the 12 month follow-up period without
any new relapse except those three patients. Details of
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response and relapse are shown in Table 2.
Most commonly seen side effects were weight gain
and acneiform eruptions in 50% of the patients and
folliculitis on the scalp in 25%. Side effects were
mild which required no changes in the doses and
were controlled with topical therapy and planned
tapering of the doses of oral steroids. Two patients
complained of scalp pruritus in first 2 weeks of
therapy, probably caused by minoxidil solution but
subsided spontaneously.
Two of the sixteen patients had an abnormal level of
thyroid stimulating hormone and one of them also
had elevated levels of thyroid autoantibodies. Personal
history suggestive of atopy was found in one patient.
The family history of AA was found in three patients.
DISCUSSION
AA is a common human disease with a lifetime risk
of 1.7% in general population[10] and the lifetime
incidence of approximately 2% worldwide.[6] It
may be observed at any age and has no clear sex
predominance. A study done in North India showed a
preponderance in men (M:F = 2:1)[5] but in another
clinical study of childhood AA done in Chandigarh,
India, the F:M ratio was found to be 1.4:1.[11] The
same finding was seen in a studies done in Kuwait
and Singapore, where girls outnumbered boys by
a 2.5:1 and 1.3:1 ratio, respectively.[12,13] We also
found a slight female preponderance in extensive and
recalcitrant AA (F:M = 1.28:1).
Table 2: Pattern of alopecia, response, and relapse (n=16)
Response
Cosmetic response Partial response
Male Female Male Female
AA (11) 3 4 1 3
AT (3) 1 ‑ ‑ 1
AU (1) ‑ ‑ ‑ ‑
OP (1) 1 ‑ ‑ ‑
Total (16) 5 4 1 4
AA ‑ Alopecia areata; AT ‑ Alopecia totalis; AU ‑ Alopecia universalis; OP ‑ Ophiasis
176
There are several topical and systemic modalities for
treatment of AA described in literature but there is a
paucity of well‑designed randomized trials for treatment
guideline, especially for childhood AA. Many different
regimens of systemic corticosteroids, including
single‑dose, short‑term with high dose, alternate day
dosing, or tapering dosing by oral or intravenous (IV)
route have been tried with different success rates, but
long‑term safety data are not well‑established.[14‑19]
The only placebo‑controlled randomized study on
oral prednisolone was done by Kar et al. where pulse
therapy of 200 mg oral prednisolone over 3 months
showed regrowth in 60% of the patients compared
with no regrowth in the placebo arm. But relapse
was seen in 25% of the responders.[14] In two other
studies, 300 mg oral prednisolone once a month
showed cosmetically acceptable response in 82%
patients over 3–6 months,[15] and in 58% of patients
with extensive AA and AT/AU in 4 months period.[16]
Regimen using alternate day prednisolone was not
found to be substantially effective and beneficial in
the natural course of AA in long‑term. Moreover, this
regimen reported the occurrence of side effects such
as striae, acne, obesity, mild hypertension lenticular
opacities, and impaired adrenocorticotropic hormone
reserve.[17]
Large single‑dose of prednisolone was also tried and
found to be unsatisfactory in a study done by Burton
and Shuster where they used prednisolone as a single
2 g dose IV or 500 mg orally for 5 days in patients
with AT.[18]
Pulse IV methylprednisolone has been found to be
beneficial in several studies. Friedli et al. showed
50–100% regrowth in 60% patients of multifocal,
patchy AA, but this regimen was found ineffective
in patients with AT, AU, or OP.[19,20] In children
with extensive patchy AA or AT/AU, high dose
pulse methylprednisolone was shown to have a poor
long‑term outcome in one study whereas few other
studies found pulsed oral corticosteroids effective.[21‑23]
Relapse
No response
Male Female Phase I Phase II Phase III
‑ ‑ ‑ 3 3
‑ 1 ‑ 1 ‑
1 ‑ ‑ ‑ ‑
‑ ‑ ‑ ‑ ‑
1 1 ‑ 4 3
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 Dey: Combination treatment of childhood alopecia areata with oral and topical steroid with topical minoxidil
In a comparative study between dexamethasone
0.5 mg/day for 6 months, intramuscular triamcinolone
acetonide 40 mg once a month for 6 months followed
by 40 mg once every 1.5 months for 1 year and pulse
therapy with oral prednisolone at 80 mg for three
consecutive days once every 3 months, best response
was found with intramuscular triamcinolone acetonide
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in patients with multifocal AA and relapse rates were
found to be the lowest in the patient who received
pulse therapy with oral prednisolone.[24]
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In few other studies, treatment with oral prednisolone
in tapering dose was combined with or followed
by topical minoxidil daily. The tapering dose of
prednisolone offered potential for regrowth with
predictable and transient side effects and topical
minoxidil helped to limit poststeroid hair loss.[25,26] The
mechanism by which topical minoxidil stimulates hair
regrowth is unknown, but a direct follicular effect is
thought to be present.[8] When used as monotherapy,
topical minoxidil is not very effective for those with
100% scalp hair loss, but it is an effective, easy, and
safe treatment for those with AA affecting 25–99%
of the scalp.[27] Therefore, it was hypothesized that
combining minoxidil with oral steroid has synergistic
action and is more effective than monotherapy of
either.
In 1978, Unger and Schemmer suggested low‑dose
oral prednisone combined with intralesional and
topical corticosteroids in patients with AT and AU
and found virtually all scalp hair regrowth in about
46% patients and all patients were able to discontinue
oral corticosteroids without recurrence of AT or AU.[28]
In view of above studies, we proposed a combined
therapy consisting of oral and topical steroids and
topical minoxidil, with gradual tapering down of oral
steroid first followed by topical steroid and lastly
minoxidil solution as it is the least harmful drug.
In our study, the cosmetic response was seen in 56%
and partial response in 31% of the total patients. All
patients with extensive AA (excluding AT and AU)
responded to our regimen, 66.6% showed cosmetic
response whereas only partial response was achieved
in 33.3% of them. About 25% responders relapsed
in Phase I and II and could not show satisfactory
response after stopping the oral medication. Patient
with OP showed good response without any
relapse. Among the patients with AT, 66% patients
responded with the regimen but 33% relapsed in
Phase II. Relapse was managed effectively without
any further relapse in the maintenance phase.
Indian Journal of Paediatric Dermatology | Vol 17 | Issue 3 | Jul-Sep 2016
Patient with AU failed to respond our regimen. In
general, success rates are found to be much better in
multifocal extensive AA with systemic corticosteroids
compared with AT and AU.[15,18,19] We also found
the same in our study. The drawbacks of systemic
corticosteroids are their side effect profile and the fact
that they do not alter the long‑term prognosis. Side
effects of long‑term systemic steroids include growth
retardation, hyperglycemia, osteoporosis, cataracts,
immunosuppression, obesity, dysmenorrhea, acne,
weight gain, mood changes/emotional lability, and
Cushing’s syndrome,[14,24,29] but tapering course of
short‑term systemic corticosteroid does not produce
any major adverse effects even in children. In
our study, side effects were predictable, mild and
reversible, in the form of local scalp irritation, weight
gain, acneiform eruptions, and folliculitis.
A small number of patients was the major limitation in
our study, as the results of this study may not represent
the actual effect of our regimen in all pediatric patients
of AA in general population. Inability to perform
long‑term follow‑up was another major limitation as
long‑term prognosis could not be assessed. Because
of the high rate of spontaneous hair regrowth, which
is almost 50% with limited disease,[2] studies with
a large number of patients are required either after
exclusion of spontaneous remission by treating each
patient on one‑half of the scalp only or by conducting
double‑blind, placebo‑controlled studies.
CONCLUSION
AA can persist for many years or even for life.
Therefore, therapeutic approaches showing severe
side effects are inappropriate for treatment in the long
run. The actual challenge is to choose a treatment
modality suitable for long‑term treatment with least
side effects. Although there are no well‑designed
large trials examining the effects of daily systemic
corticosteroids in childhood AA, it has been shown to
be able to induce regrowth in adult AA. But serious
adverse effects of long‑term corticosteroid therapy
limit its use in children. Hence, it should be reserved
for patients with rapid onset or rapidly progressive,
extensive and active AA, and oral prednisolone
should be slowly tapered over 2 months, not
exceeding 3 months.[2] Still the maintenance of hair
growth is difficult and unpredictable. On the other
hand, alternate day steroids or pulsed dosing may be
inadequate. However, using topical corticosteroids
and minoxidil along with oral prednisolone allows for
more rapid lowering of oral doses with maintaining
177
 Dey: Combination treatment of childhood alopecia areata with oral and topical steroid with topical minoxidil
the cosmetic response and minimizing the side
effects. Therefore, a trial course of oral and topical
corticosteroid treatment with topical minoxidil would
seem to be a reasonable approach for extensive,
treatment‑resistant, and nearly hopeless but highly
motivated pediatric patients of AA.
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Declaration of Patient Consent
The authors certify that they have obtained all
appropriate patient consent forms. In the form the
nYQp/IlQrHD3i3D0OdRyi7TvSFl4Cf3VC4/OAVpDDa8K2+Ya6H515kE= on 07/31/2023
patient(s) has/have given his/her/their consent for his/
her/their images and other clinical information to be
reported in the journal. The patients understand that
their names and initials will not be published and
due efforts will be made to conceal their identity, but
anonymity cannot be guaranteed.
Financial Support and Sponsorship
Nil.
Conflicts of Interest
There are no conflicts of interest.
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