Alopecia areata can be a difficult condition to treat and is very distressing for patients that suffer from this disease. Has squaric acid dibutylester (SADBE) been shown to be successful in managing this condition?

If so, what dose do you recommend? How often should the patient be seen in the office? Has SADBE shown better efficacy than topical and injectable cortisones? — Andrea Brezill, PA-C, Chicago

You are absolutely correct that alopecia areata is a psychologically disturbing disease that can significantly impact a patient’s mental health and quality of life. Patients with alopecia areata should be screened for an underlying autoimmune disease, such as thyroid disease, diabetes, inflammatory bowel disease, lupus, rheumatoid arthritis, or psoriasis. Alopecia areata can wax and wane over the years, progress, or spontaneously go into remission.

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Intralesional and topical corticosteroids are traditional first-line therapy for alopecia areata. Response should be re-evaluated monthly. Patients should be reminded that regrowth occurs very slowly, and it may take up to three months of corticosteroid injections and topical creams before any progress is noted.

In one study, six out of 10 patients with extenisive alopecia areata saw regrowth with intralesional triamcinolone acetonide (Kenalog) alone (J Drugs Dermatol. 2009;8:909-912). When using intralesional steroid injections, special attention must be paid to avoid systemic absorption and such unwanted side effects such as localized atrophy or permanent indentation of the area.

Most studies of SADBE as immunotherapy for alopecia areata indicate a 30%-to-50% success rate, with a median length of time for regrowth of 12.2 months (J Am Acad Dermatol. 1998;39:751-761). The success rate varied greatly depending on the extent of hair loss and age of onset.

In general, the patient’s scalp is first sensitized with 2% SADBE and then re-examined weekly while the concentration is slowly increased until a mild, tolerable contact dermatitis is achieved. Once regrowth is observed and stabilized, larger areas can be treated. Applications can be very slowly decreased after ideal regrowth has been achieved. It is notable that the FDA has not approved SADBE for this use, and the purity of the formula is difficult to ensure. This is not a first-line therapy and should only be used under the direction of an experienced clinician after receiving full informed consent from the patient. — Abby A. Jacobson, PA-C (186-4)

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