Introduction: A number of systemic treatments are regularly used to treat chronic moderate to severe alopecia areata (AA) including alopecia totalis (AT) and alopecia universalis (AU) with variable evidence supporting efficacy.
Objective: We evaluated the evidence surrounding systemic treatments used in the management of moderate to severe AA, AT and AU.
Materials and Methods: A systematic search was conducted of the peer-reviewed literature published between 1946 and March 2018 via Medline, Embase, Amed, the Cochrane Central Register of Controlled Trials, PsychINFO and Lilacs. All randomised controlled trials (RCTs) that evaluated the effectiveness of systemic treatments for individuals with AA, AT or AU were included.
Results: Sixteen studies were included with a total of 768 participants. We found 8 placebo-controlled RCTs, 3 RCTs comparing 2 systemic treatments and 5 RCTs comparing 3 treatments. A total of 15 different systemic therapies were investigated. The most frequently investigated therapy was oral prednisolone pulse therapy and oral inosiplex in 3 studies each. There was significant variability in the definition of treatment success. Only 3 studies included psychometric questionnaires. Adverse events were reported in 13 studies and were corticosteroid-related or otherwise well tolerated. Relapse rates were considerable in the 4 studies that reported this outcome.
Conclusions: There is currently no systemic therapy supported by robust evidence from RCTs. Current evidence suggests efficacy of oral prednisolone pulse therapy and oral inosiplex. Evidence does not support oral zinc sulphate, alefacept and efalizumab. Future RCTs should be adequately powered and employ clearly defined endpoints to allow future meta-analyses.