Pulse steroid therapyHigh dose pulse intravenous steroids with 1 g of methylprednisolone MEP given daily, usually for three days, is an accepted practice to treat severe manifestations of systemic lupus erythematosus SLE or systemic vasculitides, despite the lack of definitive data. High dose pulse steroid therapy side effects studies addressing the efficacy of high dose glucocorticoids GCs have been uncontrolled, retrospective or did not compare different doses. A limited number of studies comparing different doses of GCs suggest that lower doses of Tablet medicine for cough given as intravenous pulse therapy might be as effective as the very high doses currently used. In addition, while early reports did not find serious adverse effects related to very high doses of steroids, several more recent studies indicate a high risk of serious infections proportional to the current or cumulative dose of GCs. While we await more conclusive studies addressing these questions, one might wonder organisches hysteroid we could be using too much of a good thing.
Pulse steroids: how much is enough? - PubMed - NCBI
Severe alopecia areata AA is resistant to conventional treatment. Although systemic oral corticosteroids are an effective treatment for patients with severe AA, those drugs have many adverse effects. Corticosteroid pulse therapy has been introduced to increase therapeutic effects and reduce adverse effects.
However, the treatment modality in severe AA is still controversial. To evaluate the effectiveness of corticosteroid pulse therapy in patients with severe AA compared with treatment with oral cyclosporine with corticosteroid. A total of 82 patients with severe AA were treated with corticosteroid pulse therapy, and 60 patients were treated with oral cyclosporine with corticosteroid.
Both groups were retrospectively evaluated for therapeutic efficacy according to AA type and disease duration. In 82 patients treated with corticosteroid pulse therapy, 53 In 60 patients treated with oral cyclosporine with corticosteroid, 30 The AA type or disease duration, however, did not significantly affect the response to treatment.
Corticosteroid pulse therapy may be a better treatment option than combination therapy in severe AA patients with the PF type. Alopecia areata AA is a relatively common nonscarring hair loss disorder. Although the exact etiology of AA is still unknown, evidence indicates that it may have an autoimmune basis 3.
Whereas patients with mild to moderate AA have a high rate of spontaneous recovery, severe AA is a refractory condition 4. Severe AA does not usually respond to conventional treatments, including topical, intralesional, and systemic steroids; topical sensitizers; anthralin; minoxidil; and photochemotherapy 5 , 6. Among these treatments, systemic oral corticosteroids have been reported to be effective in patients with extensive AA 4 , 7. Relapse after dose reduction and other adverse effects during long-term therapy, however, have restricted the use of systemic oral corticosteroids 8.
Burton and Shuster 9 introduced corticosteroid pulse therapy for treating AA to increase therapeutic effects and reduce adverse effects. Since then, physicians have tried a range of doses in corticosteroid pulse therapy. Cyclosporine, which is commonly used as an immunomodulatory agent, has a common adverse effect of dose-dependent hypertrichosis 10 , It also decreases the perifollicular lymphocytic infiltrates Several studies have shown that the combination therapy of cyclosporine and corticosteroid may be a useful treatment for severe AA 13 , The aim of this study was to evaluate the effectiveness of high-dose corticosteroid pulse therapy compared with the combination therapy of oral cyclosporine and low-dose corticosteroid in patients with severe AA.
In this study, patients who presented at the Department of Dermatology, Chung-Ang University Hospital, between January and September , with extensive AA lesions were retrospectively evaluated. A total of 82 patients with severe AA were treated with high-dose corticosteroid pulse therapy, and 60 patients were treated with oral cyclosporine with low-dose corticosteroid. The inclusion criteria were as follows: Before treatment, a complete physical examination and laboratory testing, including complete blood cell count, erythrocyte sedimentation rate, high-sensitive C-reactive protein, electrolyte, liver function test, renal function test, antithyroglobulin antibody, antinuclear antibody, electrocardiography, and chest radiography, were performed.
During infusion, electrocardiographic parameters and vital signs were consistently measured. Cimetidine was administered at a daily dose of 1, mg to prevent gastric adverse effects. The dose was then tapered to 2. The combination therapy group was treated with oral cyclosporine 2. After treatment, the doses of oral cyclosporine and methylprednisolone were gradually tapered, and the drugs were eventually discontinued. Blood pressure, pulse rate, and blood parameters e.
We examined patient characteristics such as sex, age, type of AA, and duration of disease before treatment; evaluated the therapeutic efficacy at 6 months by using the clinical record and photographs; and investigated the adverse effects after treatment. To observe the association with AA type or duration for the treatment response, we further divided the patients into five groups according to hair regrowth.
Only growth of terminal hair from the lesions was considered as regrowth grade 1: Statistical analysis was performed using SPSS version Analysis of variance and Mann-Whitney U test were used. The prevalence of the AA type was observed in the following order in both the corticosteroid pulse therapy group and the combination therapy group: The mean duration before treatment was In 82 patients treated with high-dose corticosteroid pulse therapy, 53 The outcomes did not differ significantly between any of the other groups.
In the 60 patients treated with oral cyclosporine with low-dose corticosteroid, 30 patients Similar to the patients treated with pulse therapy, the PF group showed a better response than the other groups. In addition, the recent-onset group showed a better response than the other groups. The differences, however, were not statistically significant Fig. In the comparison of therapeutic efficacy between corticosteroid pulse therapy and combination therapy of oral cyclosporine and corticosteroid, Although the patients were followed from 6 to 48 months after treatment, relapse of AA lesions occurred in 11 of the 55 However, there was no statistically significant difference.
Adverse effects, including gastrointestinal discomfort, headache, dizziness, facial flushing, and palpitation, were observed in 16 patients In the combination therapy group, adverse effects, including gastrointestinal discomfort, headache, and hypertension, were observed in 11 patients None of the patients, however, had serious adverse effects requiring cessation of treatment.
There is increasing evidence that AA is likely a tissue-specific autoimmune disease. Hair follicle-specific IgG autoantibodies have been found in the peripheral blood of AA patients The presence of inflammatory lymphocytes around affected hair follicles on biopsy of AA lesions also supports the autoimmune hypothesis Several treatment modalities have been described involving an immunomodulatory mechanism.
In , Burton and Shuster 9 first introduced corticosteroid pulse therapy in treating AA to avoid the adverse effects of prolonged corticosteroid therapy.
The clinical response was poor because of inappropriate dosage and the selection of patients with chronic severe AA. Since then, many studies have tried to induce AA remission with corticosteroid pulse therapy. The advantages of corticosteroid pulse therapy include fully ligand-occupied glucocorticoid receptors, nongenomic actions, including membrane-bound glucocorticoid receptor-mediated signaling, and direct physicochemical actions on the plasma membrane In addition, high corticosteroid levels may help correct the cytokine imbalance systemically or locally.
The standard dose of corticosteroid pulse therapy is unclear. We only performed one course of treatment because it has been shown that multiple courses have no benefit In our study, This therapeutic effect was similar to that in patients with severe AA in previous studies 15 , 16 , Some studies have evaluated the prognostic factors for the outcome of corticosteroid pulse therapy. Cyclosporine is a common therapeutic agent used in patients who had received organ transplants; this drug selectively and reversibly inhibits the T-cell-mediated immune response.
However, a common cutaneous adverse effect of cyclosporine is dose-dependent hypertrichosis due to the prolongation of the anagen phase of the hair cycle 10 , Because corticosteroids are immunosuppressive agents that inhibit the late-phase antigen-dependent inflammatory reaction, combination therapy with cyclosporine as an early immunomodulator at the induction phase may have synergistic effects on immunosuppression Combination therapy with cyclosporine and low-dose corticosteroid to treat AA has been reported as a useful treatment strategy.
Previous studies, however, in the treatment of severe AA patients showed variable treatment results for dose regimens like those of corticosteroid pulse therapy. This treatment resulted in clinical improvements for all six patients, and there was no recurrence.
Thirty-eight of 43 patients experienced considerable hair growth. There was no relation, however, between therapeutic effect and AA type or disease duration. Concerning the therapeutic efficacy of corticosteroid pulse therapy compared with that of combination therapy, the treatment responses were not significantly different.
The relapse rates of both groups were also not significantly different. Interestingly, however, AA patients with the PF type had significantly better responses to corticosteroid pulse therapy.
It was difficult to directly compare this study with previous studies because of the different treatment protocols and patient selection methods. The difference of therapeutic effects compared with previous studies might also be due to the difference of the criteria for good response and the small sample size.
None of the patients in either therapeutic modality had serious adverse effects. Particularly, pulse corticosteroid therapy was tolerable in children. Some previous studies had excluded children because of possible adverse effects such as growth retardation In conclusion, our study compares the therapeutic efficacy of corticosteroid pulse therapy and the combination therapy of oral cyclosporine and corticosteroid for severe AA patients.
Corticosteroid pulse therapy seems to be effective in severe AA patients treated within 3 months of disease onset and severe AA patients with the PF type. Especially in severe AA patients with the PF type, corticosteroid pulse therapy may be a better treatment option than combination therapy. National Center for Biotechnology Information , U. Journal List Ann Dermatol v.
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