COEUR D’ALENE, IDAHO – Systemic corticosteroids usually bring an impressive initial response for children with alopecia areata. The big question is, ‘What do you try next?’
Children can’t safely remain on long-term systemic steroids. And the great majority of responders will relapse once steroids are discontinued. The challenge is to find a safe, well-tolerated drug with long-term effectiveness as a maintenance therapy.
Dr. Ruth Ann Vleugels
"For me, when I look at the list of drugs for maintenance therapy in alopecia areata, which includes cyclosporine, azathioprine, and sulfasalazine, the drug I’m most comfortable giving to children for a prolonged time is methotrexate. That’s why this drug has really become my go-to maintenance therapy for patients with alopecia areata," Dr. Ruth Ann Vleugels said at the annual meeting of the Society for Pediatric Dermatology.
"I will give them 2-3 months of systemic steroids as a boost while their methotrexate kicks in; but after that, it’s maintenance therapy with methotrexate at 1 mg/kg/week," added Dr. Vleugels, director of the Autoimmune Skin Disease Program at Brigham and Women’s Hospital, Boston.
Of course, methotrexate doesn’t work as maintenance therapy for all children with alopecia areata. Patients who don’t respond to the initial several months of combination therapy with systemic steroids won’t respond to maintenance therapy with methotrexate alone.
For those few patients who need second-line maintenance therapy, Dr. Vleugels’ drug of choice is the transplant anti-rejection medication mycophenolate mofetil (CellCept), which is used off-label for alopecia areata. Mycophenolate mofetil also is her rescue agent as maintenance therapy for children with systemic lupus erythematosus, cutaneous lupus erythematosus, juvenile dermatomyositis, and linear morphea with progressive hemifacial atrophy.
In patients with progressive juvenile systemic sclerosis, Dr. Vleugels and her Boston colleagues now use mycophenolate mofetil, rather than methotrexate, as their first-line therapy based upon favorable results in their practice and prospective studies in adults (J. Rheumatol. 2012;39:1241-7).
The mycophenolate mofetil dosing in children with alopecia areata is 600 mg/m2 given twice daily, or 1 g twice daily in patients bigger than 1.5 m2. She uses half the dose for the first 2-3 weeks, then titrates up to full-dose therapy in order to minimize GI side effects, which she said are far and away the most common adverse effects. Smaller children do best with the liquid formulation.
A common clinical dilemma involves the child who experiences intolerable GI upset on mycophenolate mofetil. Dr. Vleugels offered two suggestions: One is to tell the parents to ignore the package insert and have their child take the drug with meals.
"No one can handle this drug on an empty stomach," she said.
A caveat: mycophenolate mofetil cannot be taken with antacids.
If mealtime dosing doesn’t solve the GI upset problem, the alternative is to switch to mycophenolic acid (Myfortic), which is enteric-coated, has better bioavailability, and is better tolerated. It’s also more expensive than mycophenolate mofetil and will require prior authorization from payers. The dose conversion is as follows: 500 mg mycophenolate mofetil equals 360 mg of mycophenolic acid.
Dr. Vleugels reported having no financial conflicts with regard to her presentation.