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Table of Contents
CASE REPORT
Year : 2021  |  Volume : 25  |  Issue : 2  |  Page : 129-130

Use of intramuscular triamcinolone acetonide in intermediate responders to janus kinase inhibition for alopecia areata: Case report


Department of Dermatology, Johns Hopkins School of Medicine, Baltimore, Maryland, USA

Date of Submission09-Apr-2020
Date of Acceptance21-Jul-2020
Date of Web Publication29-Mar-2022

Correspondence Address:
Dr. Crystal Aguh
JHOC 8th Floor, 601 N., Caroline Street, Baltimore, Maryland 21231
USA
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Source of Support: None, Conflict of Interest: None


DOI: 10.4103/jdds.jdds_38_20

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  Abstract 


Janus kinase (JAK) inhibitors have been identified as an effective treatment option for severe alopecia areata (AA), but response is variable among patients. Intramuscular triamcinolone acetonide (IMTA), which has a greater bioavailability than other forms of steroids, has been used effectively to treat refractory AA with very few side effects. However, the use of IMTA in combination with JAK inhibitors is not well characterized. We present two patients with severe patch type AA and alopecia totalis who failed to achieve substantial regrowth after at least 6 months of oral tofacitinib and were treated with a single dose of IMTA 60 mg. Both patients had more than 50% increase in hair regrowth in areas of hair loss that had persisted on tofacitinib with no reported adverse effects.

Keywords: Alopecia areata, corticosteroid therapy, intramuscular triamcinolone acetonide, Janus kinase inhibitors


How to cite this article:
Araoye EF, Aguh C. Use of intramuscular triamcinolone acetonide in intermediate responders to janus kinase inhibition for alopecia areata: Case report. J Dermatol Dermatol Surg 2021;25:129-30

How to cite this URL:
Araoye EF, Aguh C. Use of intramuscular triamcinolone acetonide in intermediate responders to janus kinase inhibition for alopecia areata: Case report. J Dermatol Dermatol Surg [serial online] 2021 [cited 2022 Jul 2];25:129-30. Available from: https://www.jddsjournal.org/text.asp?2021/25/2/129/341208




  Introduction Top


Emerging evidence continues to support the use of Janus kinase (JAK) inhibitors in treating moderate-to-severe alopecia areata (AA) and alopecia totalis (AT), however response remains variable among treated patients.[1],[2] _Patients can be characterized as strong responders (>50% response), intermediate responders (5%–50% improvement), and nonresponders (<5% improvement) within 3 months of therapy.[2] For those patients who do not experience robust response to JAK inhibitors, additional therapies are often warranted. Intramuscular triamcinolone acetonide (IMTA) can treat refractory AA with very few side effects, but its use with JAK inhibitors is not well characterized.[3] We present two cases in which IMTA was used successfully as an adjunctive treatment in patients with intermediate response to JAK inhibition.


  Case Reports Top


Case 1

Patient 1 is a 33-year-old Caucasian female with severe patch type AA diagnosed at age 29. Previous treatments included anthralin, intralesional and systemic steroids, excimer laser, diphenylcyclopropenone, and topical tofacitinib 2% among others, with continued progression of disease. She was started on tofacitinib 5 mg twice daily for 8 months with moderate improvement, however persistent patches of AA were noted requiring continued use of scalp prostheses [Figure 1]a. She then received a single course of 60 mg of IMTA with 80% improvement of remaining patches. No adverse effects were noted at 3-month follow-up [Figure 1]b.
Figure 1: (a) Patient 1 experienced moderate regrowth on JAK inhibitors but presents with persistent alopecia despite 8 months of therapy. (b) Three months after single administration of intramuscular triamcinolone acetonide

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Case 2

Patient 2 is a 23-year-old African-American female with AT diagnosed at age 13. Prior treatments included intralesional and topical steroids as well as topical tacrolimus. She was started on 5-mg tofacitinib BID and daily clobetasol topical foam 0.05%. At 6 months of JAK inhibitor use, moderate hair growth was noted along the periphery of the scalp with persistent loss at the scalp vertex [Figure 2]a. A single dose of 60 mg of IMTA was given, and greater than 50% regrowth of the remaining areas was noted at 3-month follow-up [Figure 2]b. No adverse effects were noted.
Figure 2: (a) Patient 2 with alopecia totalis after 6 months on tofacitinib with minimal-to-moderate regrowth noted mostly along the scalp periphery. (b) Accelerated hair growth noted 3 months after initial treatment with intramuscular triamcinolone acetonide was administered

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  Discussion Top


We observed rapid improvement following single-dose administration of IMTA in two patients with intermediate response to JAK inhibition. Blockade of the JAK/STAT pathway with the use of pan or directed JAK inhibitors such as tofacitinib and ruxolitinib, respectively, has been a critical therapeutic development for patients with AA and AT.[1],[2] However, while moderate improvement may be scientifically relevant, for those with prominent AA patches necessitating the use of scalp camouflage, quality of life may be unchanged. Therefore, identifying safe adjuncts to use in addition to JAK inhibitors can prove useful to patients. In addition, patients with severe disease such as severe AA, AT, or AU are less likely to see robust improvement and would be more likely to require additional therapy.[2] IMTA is an effective treatment for refractory AA.[3] Although IMTA is efficacious in a number of dermatologic conditions, its use varies among providers due to lack of guidelines for dosing and frequency of administration.[3],[4] IMTA is more bioavailable than other forms of systemic steroids and ensures compliance as it is released steadily over time.[3] Unlike other systemic steroids, the risk of adrenal insufficiency is extremely rare.[4] Side effects of systemic steroids include glucose intolerance, acne, weight gain, immunosuppression, and osteopenia/osteoporosis.[3],[4] No adverse effects were noted in our patients though dysmenorrhea and osteoporosis have been reported in female patients receiving IMTA at frequent intervals (q4 weeks), thus we recommend q12 week intervals for administration.[3] We recommend consideration of IMTA in intermediate responders to JAK inhibition as an adjunct treatment.

Financial support and sponsorship

Nil.

Conflicts of interest

There are no conflicts of interest.



 
  References Top

1.
Strazzulla LC, Wang EH, Avila L, Lo Sicco K, Brinster N, Christiano AM, et al. Alopecia areata: An appraisal of new treatment approaches and overview of current therapies. J Am Acad Dermatol 2018;78:15-24.  Back to cited text no. 1
    
2.
Crispin MK, Ko JM, Craiglow BG, Li S, Shankar G, Urban JR, et al. Safety and efficacy of the JAK inhibitor tofacitinib citrate in patients with alopecia areata. JCI insight. 2016;1.  Back to cited text no. 2
    
3.
Seo J, Lee YI, Hwang S, Zheng Z, Kim DY. Intramuscular triamcinolone acetonide: An undervalued option for refractory alopecia areata. J Dermatol 2017;44:173-9.  Back to cited text no. 3
    
4.
Reddy S, Ananthakrishnan S, Garg A. A prospective observational study evaluating hypothalamic-pituitary-adrenal axis alteration and efficacy of intramuscular triamcinolone acetonide for steroid-responsive dermatologic disease. J Am Acad Dermatol 2013;69:226-31.  Back to cited text no. 4
    


    Figures

  [Figure 1], [Figure 2]



 

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