Researchers in Japan have reported a case where a woman with patchy hair loss from the autoimmune disorder Alopecia Areata
, found her ability to walk impaired after undergoing corticosteroid treatment.
The team from Kyoto University has released this study as a warning to medical professionals involved in the treatment of hair loss
, to understand how to recognise these rare yet potential side effects.
Steroid-induced osteonecrosis of the femoral head
According to the case report, published in the Therapeutics and Clinical Risk Management
medical journal, on 14th August 2018, the woman involved was 23 years of age and had the scalp-only form of Alopecia Areata. This presents as rounded bald patches which can appear suddenly anywhere on the scalp after a disruption to the hair growth cycle
shuts down normal hair production, leaving follicles stuck lying dormant in the Telogen (resting) phase. It can affect men, women and children of any age, race and hair type, and frequently clears up naturally within 12 months, though this is not always the case. It may also recur in future
even if normal hair growth does resume.
The patient developed bilateral osteonecrosis of the femoral head (ONFH) which the Kyoto team describes as "a rare and serious complication that directly inhibits walking because of femoral head collapse"
. The femoral head is found at the top of the thigh bone and is a critical part of the hip joint.
As part of her 'repeated systemic' corticosteroid therapy treatment for extensive Alopecia Areata, the case study subject was administered several intralesional corticosteroid injections to the scalp. Also known simply as steroid injections, corticosteroids are synthetic drugs that resemble cortisol, the body's natural 'fight or flight' stress hormone which plays a crucial role in metabolism and immune system responses. As such, these are widely used for immunosuppression in cases of autoimmune disorders and inflammatory diseases, including sciatica, psoriasis
and inflammatory bowel disease. Common corticosteroids include hydrocortisone, triamcinolone and methylprednisolone and they can take a few hours to days to take effect, with this wearing off within a few months.
As with any medication, side effects are possible. In the case of corticosteroids the NHS warns that these range from short-term localised bruising, pain, mood changes and difficulty sleeping, to potentially permanent cosmetic issues such as pale skin and/or skin dimpling due to loss of fat developing around the injection site. People with diabetes or high blood pressure may also experience a spike in their blood sugar or blood pressure levels for a few days after the injection, too. If infection or swelling develops the NHS cautions that professional medical advice should be sought as quickly as possible.
What the Japanese team is wary of is that symptoms of ONFH, which can be considered a severe (and rare) side effect of corticosteroid treatment, may not be easily recognised by those designated to treat the Alopecia Areata hairloss. As the report states, "sometimes, clinicians who consider that corticosteroids are required for primary disease do not recognize steroid-induced ONFH. The final stage of ONFH is severe osteoarthritis, requiring total hip arthroplasty
" [a hip replacement].
Explaining the patient's symptoms, the study states: "While undergoing therapy, she lost her balance and complained of right groin pain when standing. The patient was subsequently diagnosed with bilateral ONFH. She recovered from AA, but she complained of persistent right hip pain, which subsequently required total hip arthroplasty. We would like to emphasize that patients on corticosteroid therapy for any common disease should be considered as having a potential risk for ONFH."
The Kyoto University team is keen to stress that early stage detection, usually in the form of MRI evaluation from someone who is able to accurately scrutinise the imaging for signs of ONFH, is crucial for its treatment. If it is caught early, joint-preservation surgery may be possible.
Alternative treatments for Alopecia Areata
There are alternative options to steroid therapy when it comes to treating Alopecia Areata
that affects the scalp only and these can be recommended, following a consultation, by a hair loss specialist.
Anyone worried about sudden hair fall, bald patches or excessive shedding should seek a professional diagnosis as soon as possible in order to ensure treatments can be swiftly recommended as well as to offer peace of mind, given this can be an incredibly stressful issue to deal with.
Where those affected are under the age of 16, or are experiencing baldness that affects areas other than the scalp - such as facial or body hairloss - their GP should be consulted in the first instance.