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The Changing Landscape of Alopecia Areata: the Therapeutic Paradigm

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The Changing Landscape of Alopecia Areata: the Therapeutic Paradigm Adv Ther (2017) 34:1594–1609 DOI 10.1007/s12325-017-0542-7 REVIEW The Changing Landscape of Alopecia Areata: The Therapeutic Paradigm Yael Renert-Yuval . Emma Guttman-Yassky Received: February 20, 2017 / Published online: June 23, 2017 Ó The Author(s) 2017. This article is an open access publication ABSTRACT provide another opportunity for important insights into the pathogenesis of AA. As reviewed Alopecia areata (AA), a prevalent inflammatory in this paper, numerous novel therapeutics are cause of hair loss, lacks FDA-approved therapeu- undergoing clinical trials for AA, emphasizing the tics for extensive cases, which are associated with potential transformation of the clinical practice of very poor rates of spontaneous hair regrowth and AA, which is currently lacking. Dermatologists are major psychological distress. Current treatments already familiar with the revolution in disease for severe cases include broad immune-suppres- management of psoriasis, stemming from better sants, which are associated with significant understanding of immune dysregulations, and adverse effects, precluding long-term use, with atopic dermatitis will soon follow a similar path. rapid hair loss following treatment termination. In light of these recent developments, the thera- As a result of the extent of the disease in severe peutic arena of AA treatments is finally getting cases, topical contact sensitizers and intralesional more exciting. AA will join the lengthening list of treatments are of limited use. The pathogenesis of dermatologic diseases with mechanism-targeted AA is not yet fully understood, but recent inves- drugs, thus changing the face of AA. tigations of the immune activation in AA skin reveal Th1/IFN-c, as well as Th2, PDE4, IL-23, and IL-9 upregulations. Tissue analyses of both animal Keywords: Alopecia areata; Abatacept; models and human lesions following broad-act- Baricitinib; Dupilumab; JAK inhibitors; PDE4; ing and cytokine-specific therapeutics (such as Ruxolitinib; Tofacitinib; Tralokinumab; JAK inhibitors and ustekinumab, respectively) Ustekinumab Enhanced content To view enhanced content for this article go to http://www.medengine.com/Redeem/ INTRODUCTION 9818F060128D216F. Alopecia areata (AA) is a prevalent autoimmune Y. Renert-Yuval disease causing loss of hair, with approximately Department of Dermatology, Hadassah-Hebrew 2% of the population suffering from the condi- University Medical Center, Jerusalem, Israel tion during their lifetime, most commonly E. Guttman-Yassky (&) starting before the age of 30 years [1, 2]. The Department of Dermatology and the Laboratory for typical lesion is a non-scarring, hairless, circular Inflammatory Skin Diseases, Icahn School of patch on the scalp, evolving to multiple patches, Medicine at Mount Sinai, New York, NY, USA e-mail: [email protected] but extensive forms can progress to total loss of Adv Ther (2017) 34:1594–1609 1595 scalp hair—alopecia totalis (AT), or complete lack of systemic therapeutics that are FDA-ap- body hair loss—alopecia universalis (AU). Spon- proved for the disease. Topical treatments are taneous hair growth is common when the disease largely not suitable for extensive cases of AA is limited, but when extensive, spontaneous because of minimal efficacy [17, 18]. These remission is rare. Relapses are common in AA include topical corticosteroids, tacrolimus, patients, and only one-third of cases achieve cryotherapy, minoxidil, anthralin, or ultraviolet long-lasting remission of 10–15 years [1]. Prog- light A combined with oral psoralens (PUVA), all nostic factors for AA include early onset, exten- of which have no robust evidence for their con- sive involvement (especially AT or AU), and rapid sistent efficacy in AA [17, 19–21]. Contact sensi- disease progression [3, 4]. tizers, such as diphenylcyclopropenone (DPCP), AA is associated with other dermatologic and considered by some as topical immunotherapy, autoimmune diseases, in particular atopic der- have some efficacy and are also abundantly used, matitis (AD) [5], as well as vitiligo, lupus ery- but may be associated with significant local thematosus, psoriasis, autoimmune thyroid adverse events, including vesicular reaction, pain, disease, and allergic rhinitis [6–8]. Concomitant and scalp and facial edema [17, 20, 21]. Intrale- atopy is associated with higher risk for severe sional injections of corticosteroids are often AA phenotype [6, 7, 9, 10]. effective but can only be considered for patients Although AA is not life threatening, psy- with limited involvement as well [22]. Since chological comorbidities are common and extensive AA, especially AT and AU, for which result in major impact on patients’ lives [11]. spontaneous regrowth is rare, is associated with Clinically, the severity of AA is commonly devastating stigmatism and mental stress, evaluated by the Severity of Alopecia Tool patients seeking treatments are willing to risk (SALT), a mathematical approach utilized to significant adverse drug effects and attempt determine hair loss and hair regrowth. The off-label use of various treatments. These include percentages of scalp hair loss in four main areas systemic corticosteroids, given as continuous or are assessed independently (each of the sides, pulse therapy, cyclosporine A, mycophenolate top, and top of the back, representing 18%, mofetil, methotrexate as a monotherapy or in 18%, 40%, and 24% of the total scalp surface conjunction with corticosteroids, and azathio- area, respectively). Relatively to their surface prine. All of these regimens are not FDA-approved area, these subscores are summed for a final for AA, and lack large, randomized placebo-con- total percentage hair loss, designated as the trolled data for efficacy and safety in AA [22–26]. SALT score [12]. Severe or extensive AA is usu- Although all are commonly used, these drugs ally defined as patients with at least 50% total have problematic safety profiles, with major sys- scalp hair loss, including those with AT and AU. temic adverse effects and variable degree of Lately, molecular tissue scores for treatment immunosuppression, as well as rapid recurrence response were also proposed, including the of hair loss following drug cessation, and are baseline and post-treatment assessment of the therefore unsuitable for the chronic nature of expression level of hair keratins and inflamma- extensive AA [4]. In sum, despite being a relatively tory factors [13–16]. This article is based on common condition, AA, including its extensive previously conducted studies and does not form, lacks good treatment options [18, 20]. Better involve any new studies of human or animal clinical management with improved therapeutic subjects performed by any of the authors. modalities for AA, and particularly for widespread disease, is therefore highly desired. CURRENT AA TREATMENT PARADIGM AA IN THE FOOTSTEPS OF PSORIASIS Extensive AA poses a huge therapeutic challenge due to the either lack of efficacy and/or side effects The understanding of immune activation, rev- of the current available treatment options, with olutionizing current dermatology by 1596 Adv Ther (2017) 34:1594–1609 introducing new treatments targeting patho- ‘‘JAK inhibitors’’, ‘‘anti-TNF’’, ‘‘PDE4’’, or ‘‘IL-23’’. genic immune pathways into daily clinical Acceleration in AA therapeutic research is well management of psoriasis [27, 28], has not been demonstrated by the fact that only ten clinical established yet for AA. Nevertheless, studies trials for AA were registered in ClinicalTrials.gov shed light on some immune markers upregu- during the years 2010–2015, whereas in the lated in AA [13, 14]. In 1998, by induction of AA following 2 years, 11 registered trials were in immune-suppressed mice injected with found. We included ongoing trials as well as autologous T cells isolated from involved AA recently terminated trials of special interest. We human scalp, it was first clearly demonstrated also review treatment options that may be that AA is mediated by T cells recognizing a beneficial for future clinical trials in AA patients follicular autoantigen [29]. About a decade later, (Table 1; Fig. 1). NKG2D? T cells were speculated to be the main This review will encompass the current drivers of the immune dysregulations in AA, understanding of the complex immune activa- associated with the collapse of hair follicle tion of AA by reviewing AA pathogenesis by immune privilege [30]. The first cytokine to be three main immune axes, with corresponding identified as AA-related was IL-1 [31], followed therapeutic approaches: broad T cell antago- by Th1/interferon (IFN)-c [14]. Studies also nism, Th-17/IL-23 inhibition, and Th2 showed that the levels of IFN-c are downregu- antagonism. lated in association with hair regrowth as a therapeutic response [14, 32]. Other immune pathways were also shown to be upregulated in BROAD T CELL ANTAGONISM AA, including Th2, IL-9, PDE4, and Th17/IL-23 [13]. The role of each immune axis in AA Since AA is associated with complex upregula- remained to be elucidated. Psoriasis, represent- tion of various cytokines that are part of diverse ing the best immune-characterized skin disease, immune pathways, broad-acting was also studied through the investigation of immune-modulating drugs, inhibiting common targeted drugs, which revealed the role of dif- components shared between several immune ferent immune components in disease patho- axes, are being tested for the treatment of genesis [27, 33]. AD, the most common extensive AA cases. Such drugs include the JAK inflammatory
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