Means and methods of external treatment of circular alopecia areata

1. Glucocorticosteroid hormones

Mechanism of action: local immunosuppressive effect

Methods of use:

Applications and occlusive dressings.

Indications: progressive stage of focal alopecia with less than 50% of the scalp affected.

Good results have been reported with long-term use of strong glucocorticosteroids (fluocinolone, dexamethasone, etc.) in the form of lotions, creams, and ointments. However, most dermatologists believe that this treatment is ineffective and that permanent hair restoration is observed only in cases where spontaneous hair growth could be expected.

Side effects: skin atrophy, steroid dermatitis (erythema, telangiectasia, dyschromia), increased sensitivity to UV radiation, folliculitis. With prolonged use of steroids under occlusion, a systemic side effect may develop - suppression of the pituitary-adrenal system, which is manifested by a decrease in the level of cortisol in the plasma.

Introduction into the affected areas. Indications: single, cosmetically difficult to conceal bald spots: maintaining eyebrow growth.

For intralesional administration, a crystalline suspension of triamcinolone acetonide in lidocaine is most often used. The concentration range varies from 2.5 to 10 mg/ml. The suspension is administered intradermally at 0.1 ml at a distance of 1 cm from each other with a maximum total dose of 2 ml. The treatment procedure is repeated every 2-4 weeks. When treating eyebrows, the concentration of triamcinolone should not exceed 2.5 mg/ml. Hair growth usually resumes after 4 weeks; a cosmetically satisfactory result is achieved after 3-4 months. Often, hair loss returns several months after stopping treatment.

Side effects: pain and skin atrophy at injection sites. Serious eye complications (secondary glaucoma, cataract) may occur when maintaining eyebrow growth.

Frequent administration of maximum doses of steroids is fraught with the development of serious systemic complications.

2. Contact allergens

Substances such as dinitrochlorobenzene (DNCB), dibutyl salicylate (DBESA), diphenylcyclopropenol (DPCP) and Primula obconica cause allergic contact dermatitis and have been used in the treatment of OC for over 30 years.

To explain the mechanism of their action, two concepts have been proposed:

1. The immunogen attracts an additional population of T cells to the area being treated, resulting in the activation of the process of removal of the suspected antigen from the hair follicle.
2. According to the concept of "antigenic competition", the recruitment of non-specific T-suppressors to the skin area being treated leads to suppression of the autoimmune reaction to the putative antigen.

Indications: focal and subtotal alopecia, torpid to other methods of therapy. In total and universal forms of the disease, the use of contact allergens is ineffective. It is not recommended to use contact sensitizers in patients with atopic disease both due to their insignificant effectiveness and because of the possible exacerbation of atopy manifestations.

Methods of using DNHB:

1. Sensitization is caused by applying 24% DNHC solution to the skin of the baldness lesion. Subsequent application after 10 days of 0.1% solution of this allergen provokes an immune inflammatory reaction in sensitized patients - allergic contact dermatitis. Then, to maintain a moderate inflammatory reaction to the baldness lesion, a very low concentration DNHC solution (up to 0.0001%) is applied weekly.
2. A 2% solution of DNCB is first applied to the skin of the forearm, and after 10 days, allergic contact dermatitis is induced at the same site by applying a 1% solution of the drug. Subsequently, a low-concentration DNCB solution (0.0001%) is applied weekly to the bald spots.

The duration of treatment is 3-12 months.

Side effects:

• expected - discomfort caused by manifestations of allergic dermatitis (erythema, itching, rarely - blisters, secondary infection).
• potential mutagenic properties due to poor purification from chloronitrobenzenes
• development of cross-sensitization to chloramphenicol and some other chemical preparations.

DFCP and DBESC are safer but less effective than DNCB. These drugs do not have a teratogenic, mutagenic or carcinogenic effect; they are not capable of inducing cross-reactions to other chemicals. The methods of their application are the same as DNCB.

Sometimes, during the treatment of DFC, a tolerance phenomenon is observed, when, in order to achieve a moderate inflammatory reaction, it becomes necessary to constantly increase the concentration of the drug (up to 2%), which ultimately leads to the loss of all re-grown hair.

Applications of DBESC should not be combined with PUVA therapy due to a decrease in the effectiveness of treatment, presumably due to the supposed suppression of the functional activity of Langerhans cells by PUVA.

3. Irritants

• hydroxyantrones (dithranol 0.1%-1% and anthralin 0.1%-1%)
• 10% red pepper tincture
• badyaga
• fresh juice of onion, garlic, horseradish, radish
• tinctures of lemongrass, zamaniha, eucalyptus, aralia, calendula
• 20% solution of turpentine in castor oil
• burdock oil
• 30% propolis ointment
• other

Indications: focal form of circular alopecia after hair loss has stopped (in the stationary stage).

Irritants have long been used to treat circular alopecia; the mechanism of action and efficacy of most of them have not been verified in modern comparative studies. In essence, irritants cause artificial dermatitis, manifested by erythema and, sometimes, swelling of the skin at the site of contact, as well as subjective sensations (itching, burning). It is possible that irritants provoke an inflammatory reaction around the hair follicles, which partially distracts immune cells from the follicles.

Nowadays, modern irritants from the group of synthetic hydroxyantrones are more often used: dithranol and anthralin, which is close to it in chemical composition.

Dithranol (1-8-dihydroxy-9-anthrone) is a chemical analogue of the natural substance chrysarobin.

Mechanism of action: The drug has a pronounced cytotoxic and cytostatic local irritant effect. At the site of application, manifestations of artificial dermatitis and skin discoloration in a yellow-brown color occur. It is assumed that in dermatitis caused by hydroxyantrones, other mediators play a dominant role than in dermatitis after the use of other irritants. The non-specific immunomodulatory effect is proven by hair growth without clinical manifestations of dermatitis.

Dithranol is available in the form of ointments, pomades (cygnoderm, dithranol). The addition of paraffin allows for more precise application, which is convenient when applied to small bald spots.

Anthralin. Similar in chemical composition and mechanism of action to dithranol.

Method of use: Apply the product for 30 minutes; then, depending on individual tolerance, gradually increase the exposure. Efficiency increases with increasing concentration of the product. For rinsing, use shampoos containing zinc pyrithione. Patients are warned about the need to wash their hands after applying dithranol (anthralin) and protect the treated skin from exposure to sunlight. Long-term use of the product on large lesions during pregnancy is not recommended. Hair growth is observed after 3 months, cosmetically satisfactory effect - after 6 months.

4. Hair growth stimulating products

Indications: all forms of circular alopecia, regardless of stage.

• Minoxidil (Regaine)
• Lotion 101-G and others

Difference: in case of circular alopecia, external treatment can be stopped once a cosmetically satisfactory effect is achieved.

5. Preparations that improve tissue trophism:

Indications: all forms of circular alopecia, regardless of stage

Containing pantothenic acid

• Bepanten (cream, ointment) - contains pantothenic acid
• Panthenol (aerosol) - contains dexpanthenol
• Tricostim - contains pantothenic acid, Sabal palm fruit extract, essential oils, vitamins, zinc sulfate, amino acids.

Mechanism of action: pantothenic acid is a part of coenzyme A, plays an important role in the process of acetylation and oxidation, participates in carbohydrate and fat metabolism and in the synthesis of acetylcholine; has some anti-inflammatory effect.

Method of use: apply (spray) to affected areas 1-2 times a day.

Side effects: allergic reactions to the components of the drugs are possible.

Contraindications: hypersensitivity to the components of the drug.

Preparations from calf blood

• Actovegin (gel, ointment).
• Solcoseryl (gel, ointment).

Mechanism of action: activates metabolism in tissues, promotes the absorption of oxygen and nutrients by tissues, accelerates ATP synthesis, stimulates angiogenesis.

Directions for use: Apply to the affected area 1-2 times a day

Side effects: a burning sensation may occur, which does not require discontinuation of treatment.

Contraindications: hypersensitivity to the components of the drug.

6. Preparations that improve microcirculation

Indications: all forms of circular alopecia, regardless of stage.

Hepatrombin (gel, ointment) is a combination drug containing sodium heparin, allantoin, and dexpanthenol.

Mechanism of action: heparin has a local antithrombotic, anti-inflammatory effect, improves blood flow. Allantoin has an anti-inflammatory effect, stimulates metabolic processes. Dexpanthenol - pantothenic acid is part of coenzyme A. plays an important role in the process of acetylation and oxidation, participates in carbohydrate, fat metabolism and in the synthesis of acetylcholine; has some anti-inflammatory effect.

Directions for use: Apply to bald spots 1-3 times a day, rubbing in lightly with massaging movements.

Side effects: local allergic reactions are possible.

Contraindications: hypersensitivity to the components of the drug.

Heparin ointment is a combination drug containing heparin sodium, benzocaine, and benzyl nicotinate.

Mechanism of action: antithrombotic, local anesthetic, anti-inflammatory.

Method of use: apply to the affected area 2-3 times a day.

Side effects: allergic reactions are possible.

Contraindications: decreased blood clotting, thrombocytopenia

7. Biologically active preparations from placenta with photosensitizing effect

Indications: all forms of circular alopecia after hair loss has stopped.

Melagenin-1 - lotion; applied to the skin of the affected area with subsequent light rubbing 3 times a day after 8 hours. After daytime rubbing, the area is irradiated with infrared rays for 11 minutes.

Pyloactive Melagenin (Antialopecium) - lotion; applied to the skin of lesions once a day. After rubbing - irradiation with infrared rays.

Mechanism of action: stimulation of protein synthesis, improvement of blood flow, normalization of sebaceous gland function.

8. Silicon-containing preparations that improve hair structure

Silocast is a combination drug consisting of 1-chloromethyl silatrane (3 g), dimexide (65 ml) and castor oil (up to 100 ml); available in 100 ml glass bottles.

Mechanism of action: promotes hair growth

Indications: focal alopecia after hair loss has stopped.

Method of use: apply (shake before use) 1 bald spots with a cotton swab soaked in the preparation by lightly blotting (do not rub!) 2 times a day, morning and evening. Daily dose from 1 to 5 ml of solution depending on the duration and severity of the disease, as well as the age of the patient. Duration of the course of treatment is 3 months.

Side effects: a burning and itching sensation may occur 3-5 minutes after application of the drug, which disappears within 15-20 minutes.

9. Keratinocyte proliferation stimulants

Ethonium is a bis-quaternary ammonium compound.

Release form: powder for the preparation of 1% solution (based on isotonic sodium chloride solution) and 2% ointment (based on petroleum jelly and lanolin).

Mechanism of action: has antimicrobial and local anesthetic effects, stimulates keratinocyte proliferation.

Method of use: apply to the lesion 1-2 times a day. There is a method of simultaneous use of 1-1.5% ethonium solution (2 times a day) and 5% acyclidine ointment (cholinomimetic) for a long time until hair regrowth.

10. Traditional medicine used for alopecia of various origins

This section includes therapy with any herbal preparations, including those already listed in the irritant group. Recently, herbal preparations have become increasingly popular due to their relative harmlessness and availability.

A. A variant of complex therapy used in the treatment of both focal and androgenic alopecia.

Herbal collection:

• St. John's wort 15.0
• Sage herb 15.0
• Calendula flowers 15.0
• Oregano herb 10.0
• Nettle leaves 20.0
• Burdock root 15.0
• Hop cones 10.0

1 tbsp of the herbal mixture is poured with 1 glass of water and boiled for 5 minutes, infused for 2 hours, filtered and taken warm, 1/2 glass 2 times a day before meals. The course is 2-3 months.

Saparal

• tab. 0.05 g No. 50
• 2 tablets in the morning and afternoon before meals. Course 2-3 months.

The preparation consists of the sum of ammonium bases of salts of triterpene glycosides obtained from the roots of Manchurian aralia. It has a tonic effect.

Contraindications: epilepsy, hyperkinesis, increased excitability.

To avoid sleep disturbance, do not administer in the evening hours.

Biosed injections

• 1 ml intramuscularly No. 30

The drug is an aqueous extract of herbs.

Action: biostimulator, enhances metabolic and regenerative processes, has a general tonic and anti-inflammatory effect.

Contraindications: achylia, peptic ulcer, malignant neoplasms.

Alopecia areas are lubricated with St. John's wort tincture mixed with table vinegar in a 1:1 ratio 2 hours before UFO exposure.

UFO up to 1.5 biodoses, 15 sessions per course.

Tincture of valerian, eleutherococcus extract, chokeberry water, rotokan (a mixture of liquid extracts of chamomile, calendula, yarrow 2:1:1), maraslavin, Kalanchoe or plantain juice are rubbed into the bald spots every evening, alternating every 5 days.

B. Other folk remedies.

• drink tea from the herb Veronica officinalis 15 g per 1 liter of water
• They drink tea from dead nettle, wild pansy, succession and strawberry leaves. The dose is arbitrary.
• burdock root decoction - 10 g per 1 glass of water - take orally during the day
• Wash your hair with a decoction of cuckoo flax; for the decoction, take 20 g of the herb, boil in 300 ml of water, evaporate to 1/3 of the original volume of liquid. The decoction can be sweetened with honey and drunk as tea with the addition of red wine.
• wash your hair 3 times a week with a strong decoction of a mixture of nettle and coltsfoot herbs (1:1)
• rinse your hair after washing with an infusion of young blackcurrant leaves
• Hair is moistened with a tincture of the roots of the hellebore: 1 part of the rhizomes 120 parts of vodka or 70° alcohol, leave for 2 weeks, strain
• rub an infusion of paniculate wormwood into the scalp - 2 tablespoons per 1 glass of boiling water
• a mixture of burdock roots 20 g, calendula flowers 10 g per 1 liter of water, boil for 20 minutes and wash your hair at least 2 times a week
• rinse your scalp weekly with a strong decoction of calamus roots and calendula flowers, do not wipe off, but let it dry on its own, a course of 5-7 procedures
• an infusion of calamus rhizomes (10 g per 1 glass of boiling water) is used to wash the head and rubbed into the hair roots
• a decoction of birch leaves or buds, black elder flowers in equal proportions, rub into the scalp
• hot infusion of cornflower flowers - 1 tablespoon of flowers per 1 glass of boiling water, rub into the scalp
• hot infusion of tansy or chamomile flower baskets in vinegar and water (2 tablespoons of raw materials per 200 ml of apple cider vinegar and 200 ml of water) for daily rubbing on light hair
• a strong decoction of coltsfoot leaves is used to wash the scalp
• a decoction of horsetail (15 g per 200 ml of water), thickened by evaporation in a water bath to half, is rubbed into the scalp
• infusion of sage herb (10 g per 200 ml of water) is rubbed into the scalp daily
• tincture of black poplar buds (10 g per 100 ml of vodka, infused for 7-10 days), for rubbing into the scalp every other day for 7-20 days.
• wash your hair with a strong decoction of equal parts willow and burdock roots
• wash your hair with a decoction of yellow water lily rhizomes in beer
• The crushed plant of the cocklebur is used to lubricate the bald spot after removing the thorns
• an alcohol tincture of birch buds (10 g per 200 ml of vodka) is rubbed into the scalp every other evening
• a decoction of honeysuckle stems (any dose) is used to rinse hair after washing
• 1 tablespoon of burdock roots, calamus rhizomes, calendula flowers, hop cones; brew in 1 liter of boiling water, leave for 30 minutes and wet your head at night 2-3 times a week
• crushed fresh root of white water lily mixed with spruce or pine resin is applied to bald areas after washing the head with a decoction of plants. Pine resin is not recommended for patients with atopic disease due to the turpentine it contains, which has a sensitizing effect.
• wash your hair and rub in decoctions of rhizomes and roots of burdock, common burdock, goat willow, thistle, black poplar buds (20 g per 200 ml of water) after washing, evaporate the decoction to half and, heating, mix in half with internal fat (22)

General treatment methods and means

There are basic therapy agents aimed at correcting concomitant diseases and background disorders identified in patients, and pathogenetic therapy agents that have an immunosuppressive effect.

A. Basic therapy means

The selection of drugs in this group is determined by the spectrum of background disorders identified during the patient’s examination.

In case of vegetative-vascular insufficiency, it is recommended to use vasodilators (xanthinol nicotinate - complamine, tinikol), which help improve peripheral blood circulation, including in the area of hair follicles. The course duration is 1-1.5 months, the dosages are normal.

Adenosine triphosphate (ATP) has a pronounced vasoactive effect due to stimulation of the formation of adenosine monophosphate (AMP). The drug also has a membrane-stabilizing effect. ATP is prescribed at 1.0 intramuscularly every other day, No. 15 per course; a repeat course - after 2-3 months.

When hemorheological and coagulological changes are detected (increased blood and plasma viscosity, increased erythrocyte aggregation and decreased deformability), corresponding to the “hyperviscosity” syndrome, their targeted correction is necessary.

The basic treatment for hyperviscosity syndrome is rheopolyglucin, a low-molecular dextran preparation. Rheopolyglucin reduces blood viscosity through hemodilution, causes disaggregation of erythrocytes, mobilizes endogenous heparin, and inhibits the formation of thrombin thromboplastin. The preparation is administered intravenously by slow drip (40 drops per minute) at 400 ml with an interval of no more than 2 days; 6-8 infusions per course.

A combination of rheopolyglucin (400 ml) with pentoxifylline (100-200 mg) and no-shpa (4 ml) is advisable, which allows for enhancing the effectiveness of each of the drugs.

Pentoxifylline has a vasodilatory effect, improving microcirculation and rheological properties of blood. The drug is not prescribed for acute myocardial infarction, bleeding, severe atherosclerotic cerebral vascular disease, heart rhythm disturbances, pregnancy and lactation.

The optimal method of reocorrection is alternating infusions of rheopolyglucin with pentoxifylline and intravenous administrations of isotonic sodium chloride solution (250 ml) and solcoseryl (4 ml); 6-8 infusions per course. Solcoseryl is a deproteinized extract from calf blood. The drug stimulates angiogenesis, promotes tissue revascularization, stimulates energy metabolism, and improves the rheological properties of blood. The drug is not used for intravenous administration in case of heart failure, pulmonary edema, oliguria, or hyperhydration. Solcoseryl can also be prescribed intramuscularly daily at 5 ml for 4-6 weeks.

To correct the rheological and coagulological properties of blood, piyavit can also be used - a preparation containing the secretion of the salivary glands of leeches - 0.3 g (2 capsules) 3 times a day for 10 days.

Treatment with all drugs in this group is carried out under the control of a coagulogram.

In case of hydrocephalic syndrome (increased intracranial pressure, cerebral vasospasm, impaired cerebrospinal fluid dynamics and hemocirculation), dehydrating agents (veroitiron, diacarb, triampur) and nootropics are used along with sedatives. Treatment courses are repeated 3-4 times a year; the duration of dehydrating agents is no more than 3 weeks. Therapy for hydrocephalic syndrome should be agreed upon with a neurologist.

For intracranial hypertension, patients are also prescribed a 25% solution of magnesium sulfate, 3-6 ml intramuscularly No. 6-10, which also has a sedative effect.

Since any type of alopecia (circular, androgenic, diffuse) is accompanied by a decrease in the level of calcium, magnesium, zinc, selenium and silicon in the hair shaft, it is necessary to prescribe drugs containing these microelements. One of the most effective drugs of this series is HSN (hair, skin, nails), which contains a complex of essential microelements.

Traditionally, zinc oxide is prescribed in powder form at 0.05 g 3 times a day for 3 months. After a month's break, the course is resumed, 3-4 such courses are conducted. In between taking zinc oxide, agents containing calcium, phosphorus, magnesium, and iron are used. It is believed that the use of zinc preparations is effective in the complex therapy of severe forms of alopecia areata, especially in patients with immunodeficiency after discontinuation of glucocorticosteroid therapy.

It is possible to use zinctheral, 1 tablet of which contains 200 mg of zinc sulfate (1 tablet 3 times a day before meals). The maximum daily dose is 6 tablets. Taking the listed zinc preparations can cause nausea, vomiting, and abdominal pain.

Acceleration of regeneration processes is achieved by prescribing biogenic stimulants (aloe extract, placenta extract, eppenin, apilak, a non-steroidal drug with anabolic action - potassium orotate), which improve cellular metabolism, trophism and tissue regeneration. The drugs are prescribed in normal therapeutic doses for a month. According to the type of action, riboxin, which is capable of increasing the activity of a number of enzymes of the Krebs cycle, stimulating nucleotide synthesis, improving metabolic processes in tissues, also belongs to anabolics; it is prescribed at 0.1 g 3 times a day for a month.

The use of dalargin, a synthetic analogue of leuenkephalin, in the treatment of mild forms of CO in the progressive stage deserves attention. The drug has an immunocorrective and anti-stress effect, prevents the development of trophic disorders. A side effect of dalargin is a decrease in blood pressure.

In the treatment of focal circular alopecia, glycyram, an extract of licorice root, has found application, moderately stimulating the function of the adrenal cortex, the hormones of which promote the resumption of hair growth. Glycyram is taken 2 tablets 3 times a day for 2 months. Licorice root is also part of the elixir "Amber Plus", which is prescribed 3 tablets in the morning for a month.

Even in the absence of anamnestic indications of stress as a possible trigger for the disease, sedatives and anxiolytics (sibazon, atarax, etc.) should be included in the treatment complex, since sudden hair loss inevitably causes neurosis, hypochondria, and depression in patients.

Treatment with sedatives is recommended to be combined with central amino acid metabolites and nootropics (cerebrolysin, aminalon nootropil, pantogam), which improve brain function by affecting microcirculation (suppression of platelet aggregation, restoration of the configuration of rigid erythrocytes), energy and protein metabolism.

B. Pathogenetic therapy

• Glucocorticosteroids

In many cases of circular alopecia, including total alopecia, general treatment with corticosteroids helps restore normal hair growth: hair loss stops, hair quickly becomes pigmented and thickens.

An analysis of numerous publications allows us to identify 3 main methods of treatment with corticosteroids.

1. Short-term administration of prednisolone (5 days - 15 mg/day, 5 days - 10 mg/day, 5 days - 5 mg/day) in the progressive stage of the disease as part of complex therapy.
2. Prednisolone pulse therapy
   • at least 4 monthly courses of prednisolone at a dose of 300 mg per month (10 mg per day) with an interval of 4 weeks between courses.
   • at least 4 monthly courses of prednisolone at a dose of 1000 mg per month (32 mg per day) with an interval of 4 weeks between courses.
3. Permanent treatment with prednisolone for up to 6 months: 20 to 40 mg of prednisolone per day for 1-2 months, followed by a reduction in the dose to a maintenance dose. Corticosteroid therapy is recommended to be combined with external use of minoxidil.
   • long-term use of small doses of dexamethasone (1-1.5 mg/day) as part of complex therapy.

However, despite the good immediate treatment results and serious theoretical prerequisites for the use of GCS (immune or autoimmune pathogenesis of the disease), there is no consensus on the advisability of their use. Restoring the normal cycle of the hair follicle, corticosteroids, unfortunately, cause a number of common serious complications, the most severe of which can lead to the death of the patient. The main complications of steroid therapy include: exogenous Itsenko-Cushing syndrome, immunodepressive state, gastric ulcer and duodenal ulcer, diabetes mellitus, mental disorder of the patient, muscle atrophy, vascular fragility, water-salt imbalance, hypoproteinemia, hypercoagulation syndrome.

Another strong argument against the use of these potentially dangerous drugs for circular alopecia are relapses of the disease, which occur in 2/3 of patients after corticosteroids are discontinued, and sometimes during the process of reducing their dose. It has been suggested that a stable positive effect is achieved in those patients who would have recovered without the use of corticosteroids, but would have recovered more slowly. There is no consensus on the method and duration of corticosteroid use.

• Cyclosporine A

The identification of the role of the immune system in the development of circular alopecia led to attempts to treat this disease with an immunosuppressive drug - cyclosporine A, or sandimmune. The drug reduces the activity of T-lymphocytes in the skin, but unlike cytostatics and other immunosuppressants, it does not affect the basic functions of macrophages and granulocytes, does not cause lymphocytolysis, selectively acting at the level of cytokines, disrupting the cooperation of immunocompetent cells.

Side effects: usually depend on the dose and decrease with its reduction. The most frequently observed are renal, hepatic and gastrointestinal dysfunction (nausea, vomiting, diarrhea), hypertrichosis, tremor, gingival hypertrophy; less frequently - headaches, mild anemia, hyperkalemia, weight gain, edema, paresthesia, dysmenorrhea.

The article presents observations of 6 patients with long-standing (on average, 8 years) total alopecia, who received cyclosporine A at 6 mg/kg (i.e., more than the maximum permissible dose of 5 mg/kg). Cosmetically acceptable hair regrowth was observed in 3 of 6 patients. A clear correlation was noted between clinical improvement and a decrease in the number of infiltrating immune cells in the scalp due to a significant decrease in T-helpers. A positive clinical effect was noted 2-4 weeks after the start of therapy, but the disease relapsed 3 months after cessation of therapy.

Other immunosuppressants were used with similar results: inosiplex (groprinosin), thymopentin (the active part of thymopoietin), levamisole.

Thus, the temporary positive effect of immunosuppressant therapy is more of a theoretical value, confirming the role of the immune system in the development of circular alopecia. Due to high nephro- and hepatotoxicity, the listed drugs cannot be recommended for widespread use.

• Photochemotherapy (PTC, PUVA therapy)

FTX (PUVA) therapy is a combined use of photosensitizers and UVA radiation with a wavelength range of 320-400 nm. The most commonly used photosensitizers are drugs from the psoralens group, intended for both oral administration (8-methoxypsoralen and 5-methoxypsoralen, 8-MOP and 5-MOP, respectively) and for external use (1% oil emulsion 8-MOP or 1% methoxypsoralen ointment). FTX therapy units have various modifications that allow irradiation of the entire skin surface and the head separately.

Mechanism of action: The immunosuppressive effect of PTX therapy is realized by acting on T-lymphocytes and suppressing the antigen-presenting function of Langerhans cells in the skin. It is believed that photochemotherapy also provides general immunosuppression through direct or indirect (via interleukin 1) stimulation of prostaglandins.

It is necessary to take into account numerous contraindications for photochemotherapy, which include benign and malignant tumors, tuberculosis, gastrointestinal diseases, diabetes mellitus, thyrotoxicosis, hypertension, diseases of the liver, kidneys, heart, central nervous system, pregnancy, cachexia, cataracts, etc.

Nearest side effects: dyspeptic disorders, headache, palpitations; dryness, itching and soreness of the skin, acute photodermatitis.

Remote side effects: systemic immunosuppression; induction of photoimmune processes, skin cancer, keratoses; uneven pigmentation, lentigo, onycholysis.

Methods of application:

1. Local FTX therapy.

The photosensitizer is used externally 30 minutes before irradiation. Local UVA irradiation is performed 4-5 times a week, for a course of 20-40 procedures. Repeated courses are prescribed after 1-3 months, depending on the clinical effect.

2. General FTX therapy.

The photosensitizer is taken orally (0.6 mg/kg) in tablets 2 hours before irradiation; a combination with external application of the drug is possible. General UVA irradiation is performed 4-5 times a week, for a course of 20-40 procedures.

Furalen, beroxan, and ammifurin can also be used as photosensitizers. When hair growth appears, PUVA therapy is stopped.

The accumulated experience of using FTX therapy for circular alopecia allows us to state that hair growth is restored mainly in patients with focal alopecia (up to 60% of patients); in the total form of the disease, the method is not very effective. The best results are achieved with general FTX therapy. Stopping treatment leads to a relapse of the disease in 50-90% of patients. Thus, FTX therapy cannot be considered a safe and effective method for treating circular alopecia and recommended for widespread use.

Physiotherapeutic methods for the treatment of circular alopecia

Physiotherapy procedures are a necessary addition to the complex therapy of patients with circular alopecia. Physiotherapy methods are as diverse as medications.

Reflex action methods are used in the progressive stage of the disease:

• D'Arsonvalization of the collar zone
• Ultratone therapy of the collar zone
• Galvanic collar according to Shcherbak
• Impact on the cervical sympathetic and parasympathetic ganglia (amplipulse, diadynamic therapy, etc.)
• Static field exposure (electrotrichogenesis, general franklinization)
• Reflexotherapy (acupuncture, electropuncture, exposure to various types of electromagnetic radiation - laser, microwave).

Local methods of action are used in the stationary stage of alopecia:

• Massage (manual, vacuum, cryomassage)
• Irrigation with ethyl chloride
• Paraffin (ozokerite) applications
• D'Arsonval current therapy
• Ultratone therapy
• UFO

Since both reflex and local physiotherapeutic procedures have a general effect on the patient’s body, the choice of method should be agreed upon with a physiotherapist.

Tactics of managing patients with circular alopecia

In focal alopecia of the usual type with a total lesion area not exceeding 25% of the scalp area (S1B0), examination and treatment of the patient can be carried out on an outpatient basis. During examination, the main attention is traditionally paid to the search for and sanitation of foci of chronic infection (odontogenic infection, diseases of the ear, throat, nose, etc.). In the progressive stage of circular alopecia, among local treatments, glucocorticosteroids (occlusive dressings and intralesional administration) give the best results. Physiotherapeutic methods of reflex action are used. In the stationary stage of circular alopecia, irritants are used externally; drugs that improve tissue trophism and microcirculation; agents that stimulate hair growth; biologically active drugs from the placenta; traditional medicine. The choice of the agent and method of external treatment is not fundamental, since spontaneous hair restoration is characteristic of this form of the disease. Any methods of local and reflex physiotherapeutic influence are effective.

In case of focal alopecia with the same affected area (S1В0), but with a pronounced tendency to progression (hair is easily epilated over the entire surface of the scalp), it is advisable to conduct examination and treatment of the patient in a dermatological hospital. In addition to foci of chronic infection, such patients often have endocrine diseases and various background disorders. The spectrum of detected changes determines the choice of general therapy. Correction of concomitant diseases (conditions) has a favorable effect on the compensatory reactions of the body and brings real benefits, even if the hair in the affected area does not begin to grow in the near future. When prescribing treatment, only those agents should be used that do not lead to functional disorders of other important organs and systems and do not reduce the protective reactions of the patient's body. Thus, in case of atopic disease, antibiotics and contact sensitizers should be avoided, in case of peptic ulcer disease, the use of corticosteroids, etc.

General treatment with corticosteroids and other immunosuppressants is only permissible in a hospital setting in exceptional cases of a combination of circular alopecia with a severe disease that poses a danger to the patient's health, for which the use of these drugs is indicated.

In ophiasis, total or universal (malignant) alopecia, which began in prepubertal age in a patient with atopy and a family history of the disease, i.e. with an obviously unfavorable prognosis, long-term use of expensive medications that are unsafe for the patient's body cannot be justified. It is advisable to rationally use basic therapy, as well as psychological assistance in adapting the patient to his condition and the need to wear a wig.

The main thing for a doctor is not to forget that circular alopecia is only a cosmetic defect, and to carefully weigh the real benefits and harms of the therapy being carried out.

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