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BJD British Journal of Dermatology British …

GUIDELINESBJDB ritish Journal of DermatologyBritish Association of Dermatologists guidelines for themanagement of alopecia Messenger, J. McKillop,* P. Farrant, McDonagh and M. Sladden Department of Dermatology , Royal Hallamshire Hospital, Sheffield S10 2JF, *Alopecia UK, 5 Titchwell Road, London SW18 3LW, Department of Dermatology , Brighton General Hospital, Elm Grove, Brighton BN2 3EW, Department of Medicine, University of Tasmania, Hobart, AustraliaCorrespondenceAndrew : for publication10 February 2012 Funding of interestNone of the authors has a financial or commercialinterest in any of the treatments discussed. acts as a consultant to pharmaceuticalcompanies who manufacture and market productsfor the treatment of hair loss is an updated guideline prepared for theBritish Association of Dermatologists (BAD)Clinical Standards Unit, made up of the Therapy& Guidelines (T&G) subcommittee.

often reveals the true diagnosis but a biopsy may be necessary in some cases. 8.0 Investigations Investigations are unnecessary in most cases of alopecia areata.

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Transcription of BJD British Journal of Dermatology British …

1 GUIDELINESBJDB ritish Journal of DermatologyBritish Association of Dermatologists guidelines for themanagement of alopecia Messenger, J. McKillop,* P. Farrant, McDonagh and M. Sladden Department of Dermatology , Royal Hallamshire Hospital, Sheffield S10 2JF, *Alopecia UK, 5 Titchwell Road, London SW18 3LW, Department of Dermatology , Brighton General Hospital, Elm Grove, Brighton BN2 3EW, Department of Medicine, University of Tasmania, Hobart, AustraliaCorrespondenceAndrew : for publication10 February 2012 Funding of interestNone of the authors has a financial or commercialinterest in any of the treatments discussed. acts as a consultant to pharmaceuticalcompanies who manufacture and market productsfor the treatment of hair loss is an updated guideline prepared for theBritish Association of Dermatologists (BAD)Clinical Standards Unit, made up of the Therapy& Guidelines (T&G) subcommittee.

2 Members ofthe Clinical Standards Unit are: J. Hughes(Chairman T&G), J. McLelland, S. Punjabi, , I. Nasr, Swale, DuarteWilliamson, McHenry, S. Wagle (BritishNational Formulary), S. Amin ( British NationalFormulary), R. Davis ( British DermatologicalNursing Group), Haveron (BAD ScientificAdministrator), Mohd Mustapa (BADC linical Standards Manager).Guidelines produced in 2003 by the BritishAssociation of Dermatologists; reviewed andupdated Evidence has accredited the process used by the British Associationof Dermatologists to produce guidelines. Accreditation is valid for threeyears from May 2010 and is applicable to guidance produced using theprocesses described in the British Association of Dermatologists guidelinesdevelopment manual (Bell & Ormerod, 2009).

3 More information onaccreditation can be viewed at and scopeThe guidelines have been revised and updated in accordancewith a predetermined scope, based on that used in the 2003guidelines. Recommendations in these guidelines supersedethose in the 2003 guidelines. The objectives of the guidelinesare to provide up-to-date recommendations for the manage-ment of alopecia areata in adults and children and a summaryof the evidence involvementThis guidance has been written by dermatologists and apatient representative. The draft guideline was made availablefor consultation and review by the British Association ofDermatologists (BAD) membership, the Primary CareDermatological Society (PCDS), the British DermatologicalNursing Group (BDNG) and the board of Alopecia UK, apatient support organization.

4 The final document was peer-reviewed by the Clinical Standards Unit of the BAD (madeup of the Therapy and Guidelines subcommittee) prior guidelines have been developed using the BAD srecommendations1and also with reference to the AGREE(Appraisal of Guidelines Research and Evaluation) , MEDLINE and EMBASE databases were searched fromJanuary 2002 to January 2012 and full relevant papers in theEnglish language obtained. Additional, targeted searches werealso carried out across these three databases, as well as asearch on the Allied and Complementary Medicine Database(AMED); details of the search strategy are available as anAppendix online (see Supporting Information).

5 The recommendations made are those that are currentlyconsidered best practice. Where possible they are based onrandomized controlled trials (RCTs). However, in view of thelimited evidence from RCTs, guidance is also based on lessrigorously controlled studies, uncontrolled studies, on clinicalexperience, and on patient experience. These recommenda-tions will be modified at intervals in light of new evidence. 2012 The Authors916 BJD 2012 British Association of Dermatologists 2012166,pp916 of the guidelinesThis document has been prepared on behalf of the BAD and isbased on the best data available when the document was pre-pared.

6 It is recognized that under certain conditions it may benecessary to deviate from the guidelines, and that the resultsof future studies may require some of the recommendationsherein to be changed. Failure to adhere to these guidelinesshould not necessarily be considered negligent, nor shouldadherence to these recommendations constitute a defenceagainst a claim of for guideline revisionThe proposed revision date for this set of recommendations isscheduled for 2017; where necessary, important interimchanges will be updated on the BAD areata is a chronic inflammatory disease that affectsthe hair follicle and sometimes the nail.

7 The onset may be atany age and there is no known race or sex areata usually presents as patches of hair loss on thescalp but any hair-bearing skin can be involved. The affectedskin may be slightly reddened but otherwise appears broken hairs (exclamation mark hairs) are frequentlyseen around the margins of expanding patches of alopeciaareata. The nails are involved in about 10% of patientsreferred for specialist follicles are preserved in alopecia areata and the po-tential for recovery of hair growth is maintained, even inlongstanding disease. One study from Japan reported thatspontaneous remission within 1 year occurred in 80% ofpatients with a small number of circumscribed patches ofhair from secondary and tertiary referral centresare less favourable indicating that 34 50% of patients willrecover within 1 year.

8 Almost all will experience more thanone episode of the disease, and 14 25% progress to totalloss of scalp hair (alopecia totalis, AT) or loss of the entirescalp and body hair (alopecia universalis, AU), from whichfull recovery is unusual (< 10%).4,5 Disease severity at pre-sentation is the strongest predictor of long-term outcome. Inan Italian study, 191 patients with alopecia areata who pre-sented to a university Dermatology clinic between 1983 and1990 were contacted by telephone in 2005 to give self-reports of their clinical with less severe dis-ease at presentation were more likely to report being free ofdisease at follow-up (68% with less than 25% hair lossinitially; 32% with 25 50% hair loss initially; 8% with morethan 50% hair loss initially).

9 Patients with more severedisease initially were also more likely to report worseningpatterns of alopecia such as AT and prognosis is also less favourable when onset occursduring childhood4,7 9and in concurrence ofatopic disease has been reported to be associated with a poorprognosis3,9but this has been 20% of people with alopecia areata have a familyhistory of the disease indicating a genetic have been reported with a variety of genes,including major histocompatibility complex (MHC) andcytokine genes, suggesting that the genetic predisposition ismultifactorial in nature.

10 A genome-wide association studyconfirmed the link with the MHC genes and also identifiedassociations with other genes involved in regulating immuneand inflammatory responses, and with some genes expressedin the hair hair follicle lesion is probablymediated by T association between alo-pecia areata and other autoimmune diseases suggests thatalopecia areata is itself an autoimmune disease although thisis unproven. It has been proposed that the hair follicle isan immunologically privileged tissue which is shelteredfrom immune surveillance by autoreactive T cells, and thatfailure of such immune privilege plays a key role in thepathogenesis of alopecia , diagnosis of alopecia areata is usually straightforwardalthough the following may cause diagnostic difficulties:1 Trichotillomania this condition probably causes most con-fusion and it is possible that it coexists with alopecia areatain some cases.


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