Treating patients with alopecia areata (AA) remains difficult, and many treatment modalities have been used, including intralesional, topical and sys¬temic corticosteroids, ultraviolet light and contact sensitizers. Of these, systemic corticosteroids are effective for the treatment of severe AA, but to maintain hair regrowth, an increase in the dosage is inevitable. A high dose of systemic corticosteroids poses a major concern because of the side effects of systemic steroid use, such as diabetic mellitus, hypertension, acne, psychological changes, osteoporosis and the suppression of the adrenocorticotropic axis.
Cyclosporine A (CsA) is a cyclic, lipophilic unde- capeptide that selectively and reversibly inhibits the T cell-mediated immune response by suppressing the phosphatase activity of calcineurin. Calcineurin regulates the nuclear factor of activated T cells (NFAT) and it also induces T cell activation by regulating the interleukin-2 (IL-2) gene expression and increasing the production of IL-2, which stimulates the secretion of interferon- у (IFN- у).
The immunologic cascade leading to AA is believed to involve these events because IL-2 and IFN- у are involved in the pathogenesis of AA. Therefore, CsA is thought to be effective for treating AA because it eliminates immune cells from the hair follicles.
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Corticosteroids are nonselective immunosuppressive agents that inhibit the late-phase antigenindependent inflammatory reaction. In addition,they decrease the availability of nuclear factor kappa B and IL-2 gene transcription. Since CsA acts as an early immune modulator at the induction phase, combination therapy with CsA and corticosteroids may have synergistic effects on immunosuppression. Although several studies have used systemic CsA in combination with corticosteroids for the treatment of severe AA, the results have been variable. Many studies that used CsA as a treatment modality recommended monitoring the peripheral blood concentration of CsA to evaluate the efficacy of treatment and avoid CsA-related toxicity.
In this study, we evaluated the efficacy of a combination therapy using CsA with low-dose corticosteroids for treating patients with severe AA and we estimated the therapeutic range of the trough concentration of CsA for this treatment.