Scholars Put Their Heads Together to Increase the Quality of Life for Children with Hair Loss
Scholars Put Their Heads Together to Increase the Quality of Life for Children with Hair Loss
  • 정리ㅣ한정선 기자·장인선 기자 번역·감수ㅣ김성혜 인턴기자·허창훈 분당서울대병원 피부과교수 (desk@k-health.com)
  • 승인 2021.03.16 11:00
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[Medical Discussion with World’s Great Scholars] ①Pediatric Alopecia Areata

· Children’s life quality is seriously disturbed… effective treatment is urgent.
· JAK inhibitors, efficacious on pediatric alopecia areata… expectations for new drugs ↑

Even amid social distancing due to COVID-19, the world is cooperating for better health care. Health Kyunghyang is the first media company to operate a multilingual edition, rapidly delivering domestic health and medical news overseas. This year, we went one step further and prepared a particular article called ‘Medical Discussion with World’s Great Scholars’. From the latest treatment for various diseases to the management of health care development in future medicine, we will communicate with distinguished researchers in the medical field to provide readers with a broader range of information. The first topic is ‘Pediatric Alopecia Areata.’ Please check out the numerous opinions of scholars from all over the world.<Editor’s Note> 

 (From the left) Choi Gwang-seong, Antonella Tosti, Manabu Ohyama
(From the left) Rodney Sinclair and  Bianca Maria Piraccin 

Alopecia areata (AA: also known as patchy hair loss) is an autoimmune disease caused by immune cells in the body attacking hair follicle cells. Unlike other types of hair loss, the early diagnosis and treatment are very essential as the speed of hair loss is very fast, and many hairs suddenly fall out at once. It is estimated that AA occurs in more than 2% of the world's population and is also commonly found in children.

There are no accurate statistics on the prevalence of pediatric alopecia areata yet. But according to a 2017 study in Florida, U.S., it accounts for 0.9 percent of patients visiting dermatologic clinics. AA also disturbs having interpersonal relationships, social developments, and academic achievements—greatly reducing the quality of life in children. This is the reason why social interests in pediatric AA and the development of effective treatments are seriously needed.

The panels of this discussion were ▲ Choi Gwang-seong (the president of the Korean Hair Research Society, a professor at Inha University, Korea) ▲Antonella Tosti (the president of the American Hair Research Society, a professor at Miami University, USA) ▲Manabu Ohyama (the president of the Society for Hair Science Research, a professor of Kyorin University, Japan) ▲Rodney Sinclair (the president of Australasian Hair and Wool Research Society, a professor at University of Melbourne, Australia) ▲Bianca Maria Piraccini (the president of the European Hair Research Society, a professor at University of Bologna, Italy).

■Major Point of Discussion

The key issue is “the latest treatment for pediatric alopecia areata.” Its treatments usually vary based on age 10. For children under the age of 10, topical treatment is used as a first-line option. Topical steroids and minoxidil solution can be used together, and phototherapy like an excimer laser can be taken into consideration, too.

If these treatments are ineffective, or the hair loss is getting worse and wider, immunotherapy using DPCP (diphenylcyclopropenone) is recommended. The intralesional steroid injections can be used in children over the age of 10, along with topical treatment. Recently, an oral JAK inhibitor, known as a rheumatoid arthritis treatment agent, has also shown effectiveness in pediatric AA, and many research and clinical trials are ongoing for government approval.

- What are the current treatments and the developments for pediatric AA in your countries?

Dr. Choi from South Korea: Studies for pediatric AA treatments in many countries are focused on the re-evaluation of existing treatment methods or combinations of them, rather than developing new methods. Currently, the most anticipated new medication is oral JAK inhibitor. It inhibits the JAK enzymes that cause inflammation on the hair follicles and suppress hair growth, promoting hair re-growth as a result. Many pharmaceutical companies are conducting clinical trials, and topical agents are also under research to reduce adverse effects.

Dr. Tosti from the USA: I think this is surely a meaningful time as we may finally offer new treatment options to this significant population of patients. Pediatric alopecia areata may lead to psychological problems such as depression as it disrupts not only physical development but also interpersonal skills, social development, and overall quality of life. The active research for developing a treatment for pediatric alopecia areata is a positive sign for meeting the need.

Dr. Ohyama from Japan: I think the strategy for treating pediatric alopecia areata is not considerably different among countries, despite differences in health care systems. Topical corticosteroids would be the first choice, along with contact immunotherapy using sensitizers like DPCP. Intralesional corticosteroid injection is effective, but hardly feasible in pediatric cases due to pain. While progress has been made in many countries, treatment options for alopecia areata—especially those for child cases—are still limited.

Dr. Sinclair from Australia: Until recently little had changed in how we treat patients with alopecia areata for over 30 years. The game-changer has been the recent discovery of the JAK inhibitors for improving alopecia areata. The first results of the phase II study investigating JAK inhibitors in patients with “hair loss affecting more than 50 percent of the scalp that had persisted for more than six months,” which I presented at the annual scientific meeting of the European Academy of Dermatology meeting in Paris in 2018, showed hair regrowth scoring almost 50 (SALT scale). Since then, we have completed the phase III studies, and once the results have been analyzed, these data will be presented to the FDA and regional regulators for assessment. If approved, these medications could be available to our patients within 12-24 months.

Dr. Piraccini from Europe: In Europe, topical steroids are the preferred therapy for children's alopecia areata. In the youngest cases, topical anthralin can be a choice, whereas, for those above the age of 14 years, intralesional corticosteroids can be tried.

©Tofacitinib for the treatment of alopecia areata in preadolescent children. Journal of the American Academy of Dermatology (J AM ACAD DERMATOL), Jul2020 83(1): 123-130. (8p)
©Tofacitinib for the treatment of alopecia areata in preadolescent children. Journal of the American Academy of Dermatology (J AM ACAD DERMATOL), Jul2020 83(1): 123-130. (8p)

- What are your opinions on the applicability and safety of oral JAK inhibitors for treating pediatric AA?

Dr. Choi from South Korea: Oral JAK inhibitor is not perfectly safe because it suppresses the immunity of the patients. However, there have been no serious side effects reported to date according to studies that applied oral JAK inhibitors on pediatric patients. Yet, we need more data on its efficacy and safety from large-scale studies. There had been a small group trial with topical JAK inhibitor; however, unfortunately, the effect was not so good compared to topical steroids. To develop topical JAK inhibitors, further studies considering various factors will be required—including the effective concentration, formulation, etc.

Dr. Tosti from the USA: JAK inhibitors are surely a suitable option for adolescents with severe alopecia areata. Various data indicate that the inhibitors are particularly well tolerated even in young children and can be considered in selected cases where common treatments do not work.

Dr. Ohyama from Japan: Based on recent publications, JAK inhibitors hold promise as a novel therapeutic option for alopecia areata, especially for severe or persistent cases. However, the data on long-term safety and efficacy for children is lacking. Drug safety is particularly significant, as discontinuation of JAK inhibitor usually results in relapse, which potentially means that medication needs to be continued for decades for severe pediatric cases. The situation can be changed once the potent topical formula of the JAK inhibitor is invented.

Dr. Sinclair from Australia: A number of studies have investigated off-label use of these agents in children and the response seems to be just as good as in adults. The regulators will require formal phase II studies in children to examine the safety before these medications are approved for pediatric use.

Dr. Piraccini from Europe: We do not have personal experience of using JAK inhibitors as the medications are hardly available in different hospitals. However, published data suggest the efficacy and safety as a pediatric alopecia areata treatment.

The efficacy of DPCP on patients with large hair loss area (A: Before treatment B: 11 months after treatment) © Therapeutic Effects of Topical Diphenylcyclopropenone (DPCP) for the Treatment of Extensive Alopecia Areata, Korean J Dermatol.. 2004;42(9):1130~1137.
The efficacy of DPCP on patients with large hair loss area (A: Before treatment B: 11 months after treatment) © Therapeutic Effects of Topical Diphenylcyclopropenone (DPCP) for the Treatment of Extensive Alopecia Areata, Korean J Dermatol., 2004;42(9):1130~1137.

- How effective is DPCP (diphenylcyclopropenone)? How commonly is it used in your country?

Dr. Choi from South Korea: DPCP immunotherapy uses intentional scalp eczema with the application of an antigen called diphenylcyclopropenone (DPCP) that causes allergic contact dermatitis. This makes the immune cells attack new skin cells instead of hair cells, and this method is one of the standard treatments for moderate and severe AA. But, DPCP is classified as a chemical agent, not medicine in Korea. Hence, active applications in Korean clinical fields are not easy. On the other hand, many other countries approve DPCP immunotherapy on humans based on its effects and safety proved by many journals and textbooks.

Dr. Tosti from the USA: DPCP is effective and safe with positive results proven in different parts of the world. However, it is not largely used outside the university settings.

Dr. Ohyama from Japan: The efficacy of DPCP can significantly vary, depending on the duration and clinical subtype (location, size of hair loss area, etc.). In one report, 13-25% of the pediatric cases achieved complete and partial hair regrowth. Still, the numerical can be greatly influenced by the nature of the patient cohort investigated and therefore hardly be accurate. In my sense, the efficacy can be higher. One important thing is that there is no good alternative option available for pediatric alopecia, especially those with the widespread lesions.

Dr. Sinclair from Australia: DPCP is an off-label topical therapy for alopecia areata first developed in the 1980s. From what I observe, while some children respond to the treatment, many do not. If it does work, the benefit can last months to years. It is a safe treatment. Side-effects are limited to worsening of atopic dermatitis and hypopigmentation. DPCP treatment is generally only available in specialist clinics.

Dr. Piraccini from Europe: DPCP is very safe and effective in chronic cases. But only trained dermatologists are able to organize the topical immunotherapy that may bring positive results.



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