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imprevis&#237;vel e a resposta ao tratamento pode ser vari&#225;vel&#46; Recentemente&#44; alguns autores reconhecem a AA como condi&#231;&#227;o sist&#234;mica em decorr&#234;ncia do aumento de sua associa&#231;&#227;o com algumas comorbidades&#44; especialmente doen&#231;as metab&#243;licas e cardiovasculares&#46;<a class="elsevierStyleCrossRef" href="#bib0060"><span class="elsevierStyleSup">3</span></a></p><p id="par0010" class="elsevierStylePara elsevierViewall">O objetivo deste estudo foi identificar e analisar potenciais caracter&#237;sticas cl&#237;nicas e fatores progn&#243;sticos relacionados ao resultado do tratamento na AA de in&#237;cio precoce&#46; Este estudo retrospectivo incluiu 82 pacientes de ambos os sexos e todos os tipos de pele&#44; clinicamente diagnosticados com o primeiro epis&#243;dio de AA antes dos 18 anos na Cl&#237;nica de Doen&#231;as dos Cabelos do Hospital das Cl&#237;nicas da Universidade de S&#227;o Paulo&#44; Brasil&#44; entre 2014 e 2019&#46; Os dados dos pacientes foram obtidos dos prontu&#225;rios e avaliados por an&#225;lise multivariada&#46; Os crit&#233;rios de exclus&#227;o inclu&#237;ram outros tipos de alopecia do couro cabeludo&#46;</p><p id="par0015" class="elsevierStylePara elsevierViewall">Este estudo incluiu 43 pacientes femininas e 39 masculinos com m&#233;dia de idade atual de 20&#44;44 &#40;4&#8208;43&#41; anos e m&#233;dia de idade de in&#237;cio da doen&#231;a aos 7&#44;7 anos&#46; A dura&#231;&#227;o m&#233;dia da doen&#231;a foi de 10&#44;94 &#40;0&#44;5&#8208;36&#41; anos&#44; e o seguimento m&#233;dio foi de 24&#44;7 &#40;0&#44;5&#8208;60&#41; meses&#46; A comorbidade associada mais frequente foi hipotireoidismo &#40;24&#44;4&#37;&#41;&#59; desses&#44; por&#233;m&#44; apenas 6&#44;1&#37; apresentavam doen&#231;a de Hashimoto&#46; O tipo de AA mais frequente foi o universal &#40;n<span class="elsevierStyleHsp" style=""></span>&#61;<span class="elsevierStyleHsp" style=""></span>28&#59; 34&#44;1&#37;&#41;&#46; Quase 60&#37; &#40;n<span class="elsevierStyleHsp" style=""></span>&#61;<span class="elsevierStyleHsp" style=""></span>49&#41; dos pacientes apresentavam envolvimento de c&#237;lios&#44; sobrancelhas e&#47;ou unhas&#46; Quase todos os pacientes &#40;n<span class="elsevierStyleHsp" style=""></span>&#61;<span class="elsevierStyleHsp" style=""></span>79&#44; 96&#44;3&#37;&#41; foram submetidos &#224; terapia t&#243;pica associada ou n&#227;o a outros tratamentos&#44; que inclu&#237;ram corticoides intralesionais&#44; corticoides sist&#234;micos&#44; ciclosporina&#44; fototerapia UVB&#8208;NB e difenciprona&#46; Sessenta e dois por cento &#40;n<span class="elsevierStyleHsp" style=""></span>&#61;<span class="elsevierStyleHsp" style=""></span>51&#41; apresentaram crescimento completo ou parcial do cabelo e 23&#44;3&#37; &#40;n<span class="elsevierStyleHsp" style=""></span>&#61;<span class="elsevierStyleHsp" style=""></span>19&#41; tiveram recorr&#234;ncia ap&#243;s cinco anos&#44; a maioria apresentando&#8208;se como les&#245;es m&#250;ltiplas &#40;<a class="elsevierStyleCrossRef" href="#tbl0005">tabela 1</a>&#41;&#46;</p><elsevierMultimedia ident="tbl0005"></elsevierMultimedia><p id="par0020" class="elsevierStylePara elsevierViewall">O uso de inje&#231;&#245;es intralesionais de esteroides foi a &#250;nica vari&#225;vel estatisticamente significante relacionada a melhor resposta ao tratamento na an&#225;lise multivariada&#44; com p<span class="elsevierStyleHsp" style=""></span>&#61;<span class="elsevierStyleHsp" style=""></span>0&#44;007 &#40;OR<span class="elsevierStyleHsp" style=""></span>&#61;<span class="elsevierStyleHsp" style=""></span>4&#44;56&#44; IC95&#37; 1&#44;52&#8208;13&#44;6&#41;&#46; Inje&#231;&#245;es intralesionais de esteroides com hexacetonido de triancinolona &#40;HT&#41; na concentra&#231;&#227;o m&#233;dia de 5<span class="elsevierStyleHsp" style=""></span>mg&#47;mL &#40;2&#44;5&#8208;10<span class="elsevierStyleHsp" style=""></span>mg&#47;mL&#41; foram realizadas mensalmente em 26 pacientes com mais de 13 anos de idade&#44; e o n&#250;mero m&#233;dio de sess&#245;es foi de 8&#44;7&#46; Digno de nota&#44; os pacientes que foram submetidos a inje&#231;&#245;es de HT apresentavam&#44; em sua maioria&#44; AA universal&#44; maior m&#233;dia de idade&#44; maior idade de in&#237;cio de AA&#44; doen&#231;a mais longa e seguimento mais longo&#44; em compara&#231;&#227;o com o grupo geral&#46; Nenhum efeito colateral relevante foi relatado nesse grupo&#44; exceto dor local&#44; sangramento m&#237;nimo por pun&#231;&#227;o e atrofia transit&#243;ria da pele do couro cabeludo&#46;</p><p id="par0025" class="elsevierStylePara elsevierViewall">As evid&#234;ncias atuais sugerem que a disfun&#231;&#227;o tireoidiana e as doen&#231;as autoimunes da tireoide s&#227;o mais prevalentes em pacientes com AA&#44;<a class="elsevierStyleCrossRefs" href="#bib0065"><span class="elsevierStyleSup">4&#44;5</span></a> mas ainda faltam dados em crian&#231;as&#46; Embora quase metade dos pacientes com hipotireoidismo apresentassem AA universal ou total&#44; isso n&#227;o foi associado a resposta terap&#234;utica inferior&#46; Al&#233;m disso&#44; caracter&#237;sticas conhecidas como geralmente relacionadas a mau progn&#243;stico&#44; como AA extensa &#40;total&#47;universal&#41;&#44; envolvimento ungueal&#44; hist&#243;ria familiar de AA ou dermatite at&#243;pica&#44; n&#227;o foram relacionadas a pior resultado terap&#234;utico neste estudo&#46; Por outro lado&#44; a ades&#227;o ao tratamento foi o &#250;nico fator progn&#243;stico modificado&#44; como relatado anteriormente&#46;<a class="elsevierStyleCrossRef" href="#bib0075"><span class="elsevierStyleSup">6</span></a></p><p id="par0030" class="elsevierStylePara elsevierViewall">Embora existam muitos tratamentos para AA&#44; as op&#231;&#245;es atualmente dispon&#237;veis n&#227;o s&#227;o curativas &#8211; no m&#225;ximo controlam e limitam a doen&#231;a &#8211; e as recorr&#234;ncias s&#227;o frequentes ao longo do tempo&#46; A escolha do tratamento adequado depende da idade do paciente&#44; da extens&#227;o e dura&#231;&#227;o da doen&#231;a&#46; De acordo com o <span class="elsevierStyleItalic">AA Consensus of Experts Study</span>&#44; para pacientes com mais de 13 anos de idade com AA afetando 30&#37; a 50&#37; do couro cabeludo&#44; os corticosteroides intralesionais &#40;preferencialmente acetonido de triancinolona &#91;AT&#93;&#41; s&#227;o considerados terapia de primeira linha&#46;<a class="elsevierStyleCrossRef" href="#bib0080"><span class="elsevierStyleSup">7</span></a> O HT&#44; comercializado como suspens&#227;o est&#233;ril de 20<span class="elsevierStyleHsp" style=""></span>mg&#47;mL&#44; &#233; a op&#231;&#227;o terap&#234;utica mais dispon&#237;vel para inje&#231;&#227;o intralesional de esteroides no Brasil&#46; Embora acredite&#8208;se que o HT tenha melhor efic&#225;cia em compara&#231;&#227;o com o AT&#44;<a class="elsevierStyleCrossRef" href="#bib0085"><span class="elsevierStyleSup">8</span></a> ele &#233; um derivado do AT menos sol&#250;vel e doses mais baixas devem ser utilizadas para evitar atrofia da pele&#46;<a class="elsevierStyleCrossRef" href="#bib0090"><span class="elsevierStyleSup">9</span></a></p><p id="par0035" class="elsevierStylePara elsevierViewall">As limita&#231;&#245;es deste estudo incluem an&#225;lise retrospectiva&#44; falta de grupo controle e modalidades de tratamento escolhidas de acordo com a disponibilidade na institui&#231;&#227;o dos autores&#46;</p><p id="par0040" class="elsevierStylePara elsevierViewall">Os achados do presente estudo apoiam o fato de que inje&#231;&#245;es consecutivas de esteroides intralesionais podem ser fator modificador do curso da AA&#44; ajudando a promover o crescimento do cabelo e a ades&#227;o ao tratamento&#44; especialmente nos casos de in&#237;cio precoce&#46; Al&#233;m disso&#44; inje&#231;&#245;es intralesionais de HT podem ser consideradas terapia eficaz&#44; segura e de baixo custo para adolescentes com AA&#44; se o AT n&#227;o estiver dispon&#237;vel&#46;</p><span id="sec0005" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0005">Declara&#231;&#227;o de &#233;tica</span><p id="par0045" class="elsevierStylePara elsevierViewall">Este protocolo de estudo foi revisado e aprovado pelo Comit&#234; de &#201;tica Universit&#225;ria da Faculdade de Medicina da Universidade de S&#227;o Paulo&#44; com n&#250;mero de aprova&#231;&#227;o&#58; 4&#46;919&#46;529&#46;</p><p id="par0050" class="elsevierStylePara elsevierViewall">Todos os pacientes neste manuscrito deram seu consentimento informado por escrito para a publica&#231;&#227;o dos detalhes de seus casos&#46; Para todos os participantes menores de idade&#44; o consentimento informado por escrito foi obtido dos pais&#47;respons&#225;veis legais&#47;parentes pr&#243;ximos&#46;</p></span><span id="sec0010" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0010">Suporte financeiro</span><p id="par0055" class="elsevierStylePara elsevierViewall">Nenhum</p></span><span id="sec0015" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0015">Contribui&#231;&#227;o dos autores</span><p id="par0060" class="elsevierStylePara elsevierViewall">Isabella Doche&#58; Contribuiu com a concep&#231;&#227;o e planejamento do estudo&#44; obten&#231;&#227;o&#44; an&#225;lise e interpreta&#231;&#227;o dos dados&#59; contribuiu na reda&#231;&#227;o do manuscrito e na revis&#227;o cr&#237;tica do conte&#250;do intelectual importante&#59; participou na orienta&#231;&#227;o da pesquisa&#44; participa&#231;&#227;o intelectual em conduta terap&#234;utica de casos estudados e na revis&#227;o cr&#237;tica da literatura&#59; aprova&#231;&#227;o da vers&#227;o final do manuscrito&#46;</p><p id="par0065" class="elsevierStylePara elsevierViewall">Paula Gerlero&#58; Contribuiu com a concep&#231;&#227;o e planejamento do estudo&#44; obten&#231;&#227;o&#44; an&#225;lise e interpreta&#231;&#227;o dos dados&#59; contribuiu na reda&#231;&#227;o do manuscrito e na revis&#227;o cr&#237;tica de conte&#250;do intelectual importante&#59; participa&#231;&#227;o na orienta&#231;&#227;o da pesquisa&#44; participa&#231;&#227;o intelectual em conduta terap&#234;utica de casos estudados e na revis&#227;o cr&#237;tica da literatura&#59; aprova&#231;&#227;o da vers&#227;o final do manuscrito&#46;</p><p id="par0070" class="elsevierStylePara elsevierViewall">Tiara Magalh&#227;es&#58; Contribuiu com a concep&#231;&#227;o e planejamento do estudo&#44; obten&#231;&#227;o&#44; an&#225;lise e interpreta&#231;&#227;o dos dados&#59; participa&#231;&#227;o na orienta&#231;&#227;o da pesquisa&#44; participa&#231;&#227;o intelectual em conduta terap&#234;utica de casos estudados e na revis&#227;o cr&#237;tica da literatura&#59; aprova&#231;&#227;o da vers&#227;o final do manuscrito&#46;</p><p id="par0075" class="elsevierStylePara elsevierViewall">Chan Thien&#58; Contribuiu com a concep&#231;&#227;o e planejamento do estudo&#44; obten&#231;&#227;o&#44; an&#225;lise e interpreta&#231;&#227;o dos dados&#59; participa&#231;&#227;o na orienta&#231;&#227;o da pesquisa&#44; participa&#231;&#227;o intelectual em conduta terap&#234;utica de casos estudados e na revis&#227;o cr&#237;tica da literatura&#59; aprova&#231;&#227;o da vers&#227;o final do manuscrito&#46;</p><p id="par0080" class="elsevierStylePara elsevierViewall">Thalita Macedo&#58; Contribuiu com a concep&#231;&#227;o e planejamento do estudo&#44; obten&#231;&#227;o&#44; an&#225;lise e interpreta&#231;&#227;o dos dados&#59; participa&#231;&#227;o na orienta&#231;&#227;o da pesquisa&#44; participa&#231;&#227;o intelectual em conduta terap&#234;utica de casos estudados e na revis&#227;o cr&#237;tica da literatura&#59; aprova&#231;&#227;o da vers&#227;o final do manuscrito&#46;</p><p id="par0085" class="elsevierStylePara elsevierViewall">Maria Cec&#237;lia Rivitti&#8208;Machado&#58; Contribuiu na reda&#231;&#227;o do manuscrito e na revis&#227;o cr&#237;tica de conte&#250;do intelectual importante&#59; participa&#231;&#227;o na orienta&#231;&#227;o da pesquisa&#44; participa&#231;&#227;o intelectual em conduta terap&#234;utica de casos estudados e na revis&#227;o cr&#237;tica da literatura&#59; aprova&#231;&#227;o da vers&#227;o final do manuscrito&#59; contribuiu com a concep&#231;&#227;o e planejamento do estudo&#44; obten&#231;&#227;o&#44; an&#225;lise e interpreta&#231;&#227;o dos dados&#46;</p></span><span id="sec0020" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0020">Conflito de interesses</span><p id="par0090" class="elsevierStylePara elsevierViewall">Nenhum&#46;</p></span></span>"
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        "nota" => "<p class="elsevierStyleNotepara" id="npar0005">Como citar este artigo&#58; Doche I&#44; Gerlero P&#44; Magalh&#227;es T&#44; Thien CI&#44; Macedo T&#44; Rivitti&#8208;Machado MC&#46; Multivariate analysis of clinical characteristics and prognostic factors in early&#8208;onset alopecia areata&#58; a retrospective study with&#160;82&#160;Brazilian patients&#46; An Bras Dermatol&#46; 2023&#59;98&#58;681&#8211;4&#46;</p>"
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                  \t\t\t\t"><span class="elsevierStyleVsp" style="height:0.5px"></span></td></tr><tr title="table-row"><td class="td" title="\n
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                  \t\t\t\t  " colspan="6" align="left" valign="\n
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                  \t\t\t\t"><span class="elsevierStyleItalic">Idade na primeira consulta &#40;a&#41;</span></td></tr><tr title="table-row"><td class="td-with-role" title="\n
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                  \t\t\t\t"><span class="elsevierStyleHsp" style=""></span>Total&nbsp;\t\t\t\t\t\t\n
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                  \t\t\t\t"><span class="elsevierStyleHsp" style=""></span>Masculino&nbsp;\t\t\t\t\t\t\n
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                  \t\t\t\t\ttop\n
                  \t\t\t\t"><span class="elsevierStyleHsp" style=""></span>Feminino&nbsp;\t\t\t\t\t\t\n
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                  \t\t\t\t  " align="left" valign="\n
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                  \t\t\t\t">&#40;0&#8208;18&#41;&nbsp;\t\t\t\t\t\t\n
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                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " colspan="6" align="left" valign="\n
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                  \t\t\t\t"><span class="elsevierStyleVsp" style="height:0.5px"></span></td></tr><tr title="table-row"><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " colspan="6" align="left" valign="\n
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                  \t\t\t\t"><span class="elsevierStyleItalic">Dura&#231;&#227;o da doen&#231;a &#40;a&#41;</span></td></tr><tr title="table-row"><td class="td-with-role" title="\n
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                  \t\t\t\t"><span class="elsevierStyleHsp" style=""></span>Total&nbsp;\t\t\t\t\t\t\n
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                  \t\t\t\t  " align="left" valign="\n
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                  \t\t\t\t">8&nbsp;\t\t\t\t\t\t\n
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                  \t\t\t\t"><span class="elsevierStyleHsp" style=""></span>Masculino&nbsp;\t\t\t\t\t\t\n
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                  \t\t\t\t  " align="left" valign="\n
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                  \t\t\t\t">8&nbsp;\t\t\t\t\t\t\n
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                  \t\t\t\t">&#40;1&#8208;23&#41;&nbsp;\t\t\t\t\t\t\n
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                  \t\t\t\t\ttable-entry\n
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                  \t\t\t\t\ttop\n
                  \t\t\t\t"><span class="elsevierStyleHsp" style=""></span>Feminino&nbsp;\t\t\t\t\t\t\n
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                  \t\t\t\t  " align="left" valign="\n
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                  \t\t\t\t  " align="left" valign="\n
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                  \t\t\t\t">&#40;0&#44;5&#8208;36&#41;&nbsp;\t\t\t\t\t\t\n
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                  \t\t\t\t">10&nbsp;\t\t\t\t\t\t\n
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                  \t\t\t\t</td></tr><tr title="table-row"><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " colspan="6" align="left" valign="\n
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                  \t\t\t\t"><span class="elsevierStyleVsp" style="height:0.5px"></span></td></tr><tr title="table-row"><td class="td-with-role" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t ; entry_with_role_rowhead " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t"><span class="elsevierStyleItalic">Tempo de seguimento &#40;m&#41;</span>&nbsp;\t\t\t\t\t\t\n
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                  \t\t\t\t">&#40;0&#44;5&#8208;60&#41;&nbsp;\t\t\t\t\t\t\n
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                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t ; entry_with_role_rowhead " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t"><span class="elsevierStyleItalic">Tempo at&#233; a recorr&#234;ncia &#40;m&#41;</span>&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="left" valign="\n
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                  \t\t\t\t">87&#44;4&nbsp;\t\t\t\t\t\t\n
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                  \t\t\t\t">225&#44;1&nbsp;\t\t\t\t\t\t\n
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                  \t\t\t\t  " align="left" valign="\n
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                  \t\t\t\t">&#40;6&#8208;1220&#41;&nbsp;\t\t\t\t\t\t\n
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                  \t\t\t\t</td></tr><tr title="table-row"><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " colspan="6" align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t"><span class="elsevierStyleVsp" style="height:0.5px"></span></td></tr><tr title="table-row"><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " colspan="6" align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t"><span class="elsevierStyleItalic">Tipo de queda de cabelo</span></td></tr><tr title="table-row"><td class="td-with-role" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t ; entry_with_role_rowhead " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t"><span class="elsevierStyleHsp" style=""></span>Universal&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="" valign="\n
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                  \t\t\t\t">&nbsp;\t\t\t\t\t\t\n
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                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="" valign="\n
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                  \t\t\t\t">&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="" valign="\n
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                  \t\t\t\t">&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="" valign="\n
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                  \t\t\t\t">&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">28 &#40;34&#44;1&#41;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t ; entry_with_role_rowhead " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t"><span class="elsevierStyleHsp" style=""></span>M&#250;ltiplas placas&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
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                  \t\t\t\t">&nbsp;\t\t\t\t\t\t\n
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                  \t\t\t\t\ttable-entry\n
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                  \t\t\t\t</td><td class="td" title="\n
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                  \t\t\t\t</td><td class="td" title="\n
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                  \t\t\t\t">24 &#40;29&#44;3&#41;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t ; entry_with_role_rowhead " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t"><span class="elsevierStyleHsp" style=""></span>Placa &#250;nica&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
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                  \t\t\t\t  " align="" valign="\n
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                  \t\t\t\t">&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
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                  \t\t\t\t"><span class="elsevierStyleItalic">Fototerapia &#40;NB&#8208;UVB&#41;</span>&nbsp;\t\t\t\t\t\t\n
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                  \t\t\t\t"><span class="elsevierStyleItalic">Resposta ao tratamento &#40;crescimento parcial ou completo dos cabelos&#41;</span>&nbsp;\t\t\t\t\t\t\n
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                  \t\t\t\t"><span class="elsevierStyleItalic">Recorr&#234;ncia</span>&nbsp;\t\t\t\t\t\t\n
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                  \t\t\t\t\ttop\n
                  \t\t\t\t">&nbsp;\t\t\t\t\t\t\n
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Cartas ‐ Investigação
Análise multivariada das características clínicas e fatores prognósticos na alopecia areata de início precoce: estudo retrospectivo com 82 pacientes brasileiros
Isabella Doche, Paula Gerlero
Autor para correspondência
gerleropaula@gmail.com

Autor para correspondência.
, Tiara Magalhães, Chan I. Thien, Thalita Macedo, Maria Cecília Rivitti‐Machado
Departamento de Dermatologia, Faculdade de Medicina, Universidade de São Paulo, São Paulo, SP, Brasil
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imprevis&#237;vel e a resposta ao tratamento pode ser vari&#225;vel&#46; Recentemente&#44; alguns autores reconhecem a AA como condi&#231;&#227;o sist&#234;mica em decorr&#234;ncia do aumento de sua associa&#231;&#227;o com algumas comorbidades&#44; especialmente doen&#231;as metab&#243;licas e cardiovasculares&#46;<a class="elsevierStyleCrossRef" href="#bib0060"><span class="elsevierStyleSup">3</span></a></p><p id="par0010" class="elsevierStylePara elsevierViewall">O objetivo deste estudo foi identificar e analisar potenciais caracter&#237;sticas cl&#237;nicas e fatores progn&#243;sticos relacionados ao resultado do tratamento na AA de in&#237;cio precoce&#46; Este estudo retrospectivo incluiu 82 pacientes de ambos os sexos e todos os tipos de pele&#44; clinicamente diagnosticados com o primeiro epis&#243;dio de AA antes dos 18 anos na Cl&#237;nica de Doen&#231;as dos Cabelos do Hospital das Cl&#237;nicas da Universidade de S&#227;o Paulo&#44; Brasil&#44; entre 2014 e 2019&#46; Os dados dos pacientes foram obtidos dos prontu&#225;rios e avaliados por an&#225;lise multivariada&#46; Os crit&#233;rios de exclus&#227;o inclu&#237;ram outros tipos de alopecia do couro cabeludo&#46;</p><p id="par0015" class="elsevierStylePara elsevierViewall">Este estudo incluiu 43 pacientes femininas e 39 masculinos com m&#233;dia de idade atual de 20&#44;44 &#40;4&#8208;43&#41; anos e m&#233;dia de idade de in&#237;cio da doen&#231;a aos 7&#44;7 anos&#46; A dura&#231;&#227;o m&#233;dia da doen&#231;a foi de 10&#44;94 &#40;0&#44;5&#8208;36&#41; anos&#44; e o seguimento m&#233;dio foi de 24&#44;7 &#40;0&#44;5&#8208;60&#41; meses&#46; A comorbidade associada mais frequente foi hipotireoidismo &#40;24&#44;4&#37;&#41;&#59; desses&#44; por&#233;m&#44; apenas 6&#44;1&#37; apresentavam doen&#231;a de Hashimoto&#46; O tipo de AA mais frequente foi o universal &#40;n<span class="elsevierStyleHsp" style=""></span>&#61;<span class="elsevierStyleHsp" style=""></span>28&#59; 34&#44;1&#37;&#41;&#46; Quase 60&#37; &#40;n<span class="elsevierStyleHsp" style=""></span>&#61;<span class="elsevierStyleHsp" style=""></span>49&#41; dos pacientes apresentavam envolvimento de c&#237;lios&#44; sobrancelhas e&#47;ou unhas&#46; Quase todos os pacientes &#40;n<span class="elsevierStyleHsp" style=""></span>&#61;<span class="elsevierStyleHsp" style=""></span>79&#44; 96&#44;3&#37;&#41; foram submetidos &#224; terapia t&#243;pica associada ou n&#227;o a outros tratamentos&#44; que inclu&#237;ram corticoides intralesionais&#44; corticoides sist&#234;micos&#44; ciclosporina&#44; fototerapia UVB&#8208;NB e difenciprona&#46; Sessenta e dois por cento &#40;n<span class="elsevierStyleHsp" style=""></span>&#61;<span class="elsevierStyleHsp" style=""></span>51&#41; apresentaram crescimento completo ou parcial do cabelo e 23&#44;3&#37; &#40;n<span class="elsevierStyleHsp" style=""></span>&#61;<span class="elsevierStyleHsp" style=""></span>19&#41; tiveram recorr&#234;ncia ap&#243;s cinco anos&#44; a maioria apresentando&#8208;se como les&#245;es m&#250;ltiplas &#40;<a class="elsevierStyleCrossRef" href="#tbl0005">tabela 1</a>&#41;&#46;</p><elsevierMultimedia ident="tbl0005"></elsevierMultimedia><p id="par0020" class="elsevierStylePara elsevierViewall">O uso de inje&#231;&#245;es intralesionais de esteroides foi a &#250;nica vari&#225;vel estatisticamente significante relacionada a melhor resposta ao tratamento na an&#225;lise multivariada&#44; com p<span class="elsevierStyleHsp" style=""></span>&#61;<span class="elsevierStyleHsp" style=""></span>0&#44;007 &#40;OR<span class="elsevierStyleHsp" style=""></span>&#61;<span class="elsevierStyleHsp" style=""></span>4&#44;56&#44; IC95&#37; 1&#44;52&#8208;13&#44;6&#41;&#46; Inje&#231;&#245;es intralesionais de esteroides com hexacetonido de triancinolona &#40;HT&#41; na concentra&#231;&#227;o m&#233;dia de 5<span class="elsevierStyleHsp" style=""></span>mg&#47;mL &#40;2&#44;5&#8208;10<span class="elsevierStyleHsp" style=""></span>mg&#47;mL&#41; foram realizadas mensalmente em 26 pacientes com mais de 13 anos de idade&#44; e o n&#250;mero m&#233;dio de sess&#245;es foi de 8&#44;7&#46; Digno de nota&#44; os pacientes que foram submetidos a inje&#231;&#245;es de HT apresentavam&#44; em sua maioria&#44; AA universal&#44; maior m&#233;dia de idade&#44; maior idade de in&#237;cio de AA&#44; doen&#231;a mais longa e seguimento mais longo&#44; em compara&#231;&#227;o com o grupo geral&#46; Nenhum efeito colateral relevante foi relatado nesse grupo&#44; exceto dor local&#44; sangramento m&#237;nimo por pun&#231;&#227;o e atrofia transit&#243;ria da pele do couro cabeludo&#46;</p><p id="par0025" class="elsevierStylePara elsevierViewall">As evid&#234;ncias atuais sugerem que a disfun&#231;&#227;o tireoidiana e as doen&#231;as autoimunes da tireoide s&#227;o mais prevalentes em pacientes com AA&#44;<a class="elsevierStyleCrossRefs" href="#bib0065"><span class="elsevierStyleSup">4&#44;5</span></a> mas ainda faltam dados em crian&#231;as&#46; Embora quase metade dos pacientes com hipotireoidismo apresentassem AA universal ou total&#44; isso n&#227;o foi associado a resposta terap&#234;utica inferior&#46; Al&#233;m disso&#44; caracter&#237;sticas conhecidas como geralmente relacionadas a mau progn&#243;stico&#44; como AA extensa &#40;total&#47;universal&#41;&#44; envolvimento ungueal&#44; hist&#243;ria familiar de AA ou dermatite at&#243;pica&#44; n&#227;o foram relacionadas a pior resultado terap&#234;utico neste estudo&#46; Por outro lado&#44; a ades&#227;o ao tratamento foi o &#250;nico fator progn&#243;stico modificado&#44; como relatado anteriormente&#46;<a class="elsevierStyleCrossRef" href="#bib0075"><span class="elsevierStyleSup">6</span></a></p><p id="par0030" class="elsevierStylePara elsevierViewall">Embora existam muitos tratamentos para AA&#44; as op&#231;&#245;es atualmente dispon&#237;veis n&#227;o s&#227;o curativas &#8211; no m&#225;ximo controlam e limitam a doen&#231;a &#8211; e as recorr&#234;ncias s&#227;o frequentes ao longo do tempo&#46; A escolha do tratamento adequado depende da idade do paciente&#44; da extens&#227;o e dura&#231;&#227;o da doen&#231;a&#46; De acordo com o <span class="elsevierStyleItalic">AA Consensus of Experts Study</span>&#44; para pacientes com mais de 13 anos de idade com AA afetando 30&#37; a 50&#37; do couro cabeludo&#44; os corticosteroides intralesionais &#40;preferencialmente acetonido de triancinolona &#91;AT&#93;&#41; s&#227;o considerados terapia de primeira linha&#46;<a class="elsevierStyleCrossRef" href="#bib0080"><span class="elsevierStyleSup">7</span></a> O HT&#44; comercializado como suspens&#227;o est&#233;ril de 20<span class="elsevierStyleHsp" style=""></span>mg&#47;mL&#44; &#233; a op&#231;&#227;o terap&#234;utica mais dispon&#237;vel para inje&#231;&#227;o intralesional de esteroides no Brasil&#46; Embora acredite&#8208;se que o HT tenha melhor efic&#225;cia em compara&#231;&#227;o com o AT&#44;<a class="elsevierStyleCrossRef" href="#bib0085"><span class="elsevierStyleSup">8</span></a> ele &#233; um derivado do AT menos sol&#250;vel e doses mais baixas devem ser utilizadas para evitar atrofia da pele&#46;<a class="elsevierStyleCrossRef" href="#bib0090"><span class="elsevierStyleSup">9</span></a></p><p id="par0035" class="elsevierStylePara elsevierViewall">As limita&#231;&#245;es deste estudo incluem an&#225;lise retrospectiva&#44; falta de grupo controle e modalidades de tratamento escolhidas de acordo com a disponibilidade na institui&#231;&#227;o dos autores&#46;</p><p id="par0040" class="elsevierStylePara elsevierViewall">Os achados do presente estudo apoiam o fato de que inje&#231;&#245;es consecutivas de esteroides intralesionais podem ser fator modificador do curso da AA&#44; ajudando a promover o crescimento do cabelo e a ades&#227;o ao tratamento&#44; especialmente nos casos de in&#237;cio precoce&#46; Al&#233;m disso&#44; inje&#231;&#245;es intralesionais de HT podem ser consideradas terapia eficaz&#44; segura e de baixo custo para adolescentes com AA&#44; se o AT n&#227;o estiver dispon&#237;vel&#46;</p><span id="sec0005" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0005">Declara&#231;&#227;o de &#233;tica</span><p id="par0045" class="elsevierStylePara elsevierViewall">Este protocolo de estudo foi revisado e aprovado pelo Comit&#234; de &#201;tica Universit&#225;ria da Faculdade de Medicina da Universidade de S&#227;o Paulo&#44; com n&#250;mero de aprova&#231;&#227;o&#58; 4&#46;919&#46;529&#46;</p><p id="par0050" class="elsevierStylePara elsevierViewall">Todos os pacientes neste manuscrito deram seu consentimento informado por escrito para a publica&#231;&#227;o dos detalhes de seus casos&#46; Para todos os participantes menores de idade&#44; o consentimento informado por escrito foi obtido dos pais&#47;respons&#225;veis legais&#47;parentes pr&#243;ximos&#46;</p></span><span id="sec0010" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0010">Suporte financeiro</span><p id="par0055" class="elsevierStylePara elsevierViewall">Nenhum</p></span><span id="sec0015" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0015">Contribui&#231;&#227;o dos autores</span><p id="par0060" class="elsevierStylePara elsevierViewall">Isabella Doche&#58; Contribuiu com a concep&#231;&#227;o e planejamento do estudo&#44; obten&#231;&#227;o&#44; an&#225;lise e interpreta&#231;&#227;o dos dados&#59; contribuiu na reda&#231;&#227;o do manuscrito e na revis&#227;o cr&#237;tica do conte&#250;do intelectual importante&#59; participou na orienta&#231;&#227;o da pesquisa&#44; participa&#231;&#227;o intelectual em conduta terap&#234;utica de casos estudados e na revis&#227;o cr&#237;tica da literatura&#59; aprova&#231;&#227;o da vers&#227;o final do manuscrito&#46;</p><p id="par0065" class="elsevierStylePara elsevierViewall">Paula Gerlero&#58; Contribuiu com a concep&#231;&#227;o e planejamento do estudo&#44; obten&#231;&#227;o&#44; an&#225;lise e interpreta&#231;&#227;o dos dados&#59; contribuiu na reda&#231;&#227;o do manuscrito e na revis&#227;o cr&#237;tica de conte&#250;do intelectual importante&#59; participa&#231;&#227;o na orienta&#231;&#227;o da pesquisa&#44; participa&#231;&#227;o intelectual em conduta terap&#234;utica de casos estudados e na revis&#227;o cr&#237;tica da literatura&#59; aprova&#231;&#227;o da vers&#227;o final do manuscrito&#46;</p><p id="par0070" class="elsevierStylePara elsevierViewall">Tiara Magalh&#227;es&#58; Contribuiu com a concep&#231;&#227;o e planejamento do estudo&#44; obten&#231;&#227;o&#44; an&#225;lise e interpreta&#231;&#227;o dos dados&#59; participa&#231;&#227;o na orienta&#231;&#227;o da pesquisa&#44; participa&#231;&#227;o intelectual em conduta terap&#234;utica de casos estudados e na revis&#227;o cr&#237;tica da literatura&#59; aprova&#231;&#227;o da vers&#227;o final do manuscrito&#46;</p><p id="par0075" class="elsevierStylePara elsevierViewall">Chan Thien&#58; Contribuiu com a concep&#231;&#227;o e planejamento do estudo&#44; obten&#231;&#227;o&#44; an&#225;lise e interpreta&#231;&#227;o dos dados&#59; participa&#231;&#227;o na orienta&#231;&#227;o da pesquisa&#44; participa&#231;&#227;o intelectual em conduta terap&#234;utica de casos estudados e na revis&#227;o cr&#237;tica da literatura&#59; aprova&#231;&#227;o da vers&#227;o final do manuscrito&#46;</p><p id="par0080" class="elsevierStylePara elsevierViewall">Thalita Macedo&#58; Contribuiu com a concep&#231;&#227;o e planejamento do estudo&#44; obten&#231;&#227;o&#44; an&#225;lise e interpreta&#231;&#227;o dos dados&#59; participa&#231;&#227;o na orienta&#231;&#227;o da pesquisa&#44; participa&#231;&#227;o intelectual em conduta terap&#234;utica de casos estudados e na revis&#227;o cr&#237;tica da literatura&#59; aprova&#231;&#227;o da vers&#227;o final do manuscrito&#46;</p><p id="par0085" class="elsevierStylePara elsevierViewall">Maria Cec&#237;lia Rivitti&#8208;Machado&#58; Contribuiu na reda&#231;&#227;o do manuscrito e na revis&#227;o cr&#237;tica de conte&#250;do intelectual importante&#59; participa&#231;&#227;o na orienta&#231;&#227;o da pesquisa&#44; participa&#231;&#227;o intelectual em conduta terap&#234;utica de casos estudados e na revis&#227;o cr&#237;tica da literatura&#59; aprova&#231;&#227;o da vers&#227;o final do manuscrito&#59; contribuiu com a concep&#231;&#227;o e planejamento do estudo&#44; obten&#231;&#227;o&#44; an&#225;lise e interpreta&#231;&#227;o dos dados&#46;</p></span><span id="sec0020" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0020">Conflito de interesses</span><p id="par0090" class="elsevierStylePara elsevierViewall">Nenhum&#46;</p></span></span>"
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          "leyenda" => "<p id="spar0010" class="elsevierStyleSimplePara elsevierViewall">a&#44; anos&#59; AA&#44; alopecia areata&#59; DP&#44; desvio&#8208;padr&#227;o&#59; m&#44; meses&#59; N&#44; n&#250;mero de pacientes&#59; NB&#8208;UVB&#44; radia&#231;&#227;o ultravioleta B de banda estreita&#46;</p>"
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                  \t\t\t\t"><span class="elsevierStyleHsp" style=""></span>Feminino&nbsp;\t\t\t\t\t\t\n
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                  \t\t\t\t"><span class="elsevierStyleVsp" style="height:0.5px"></span></td></tr><tr title="table-row"><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " colspan="6" align="left" valign="\n
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                  \t\t\t\t"><span class="elsevierStyleItalic">Dura&#231;&#227;o da doen&#231;a &#40;a&#41;</span></td></tr><tr title="table-row"><td class="td-with-role" title="\n
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                  \t\t\t\t"><span class="elsevierStyleHsp" style=""></span>Total&nbsp;\t\t\t\t\t\t\n
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                  \t\t\t\t"><span class="elsevierStyleHsp" style=""></span>Masculino&nbsp;\t\t\t\t\t\t\n
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                  \t\t\t\t"><span class="elsevierStyleHsp" style=""></span>Feminino&nbsp;\t\t\t\t\t\t\n
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                  \t\t\t\t\ttable-entry\n
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                  \t\t\t\t"><span class="elsevierStyleVsp" style="height:0.5px"></span></td></tr><tr title="table-row"><td class="td-with-role" title="\n
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                  \t\t\t\t ; entry_with_role_rowhead " align="left" valign="\n
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                  \t\t\t\t"><span class="elsevierStyleItalic">Tempo de seguimento &#40;m&#41;</span>&nbsp;\t\t\t\t\t\t\n
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                  \t\t\t\t ; entry_with_role_rowhead " align="left" valign="\n
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                  \t\t\t\t"><span class="elsevierStyleItalic">Tempo at&#233; a recorr&#234;ncia &#40;m&#41;</span>&nbsp;\t\t\t\t\t\t\n
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                  \t\t\t\t">&#40;6&#8208;1220&#41;&nbsp;\t\t\t\t\t\t\n
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                  \t\t\t\t\ttable-entry\n
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                  \t\t\t\t"><span class="elsevierStyleVsp" style="height:0.5px"></span></td></tr><tr title="table-row"><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " colspan="6" align="left" valign="\n
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                  \t\t\t\t"><span class="elsevierStyleItalic">Tipo de queda de cabelo</span></td></tr><tr title="table-row"><td class="td-with-role" title="\n
                  \t\t\t\t\ttable-entry\n
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                  \t\t\t\t\ttop\n
                  \t\t\t\t"><span class="elsevierStyleHsp" style=""></span>Universal&nbsp;\t\t\t\t\t\t\n
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                  \t\t\t\t">28 &#40;34&#44;1&#41;&nbsp;\t\t\t\t\t\t\n
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                  \t\t\t\t\ttop\n
                  \t\t\t\t"><span class="elsevierStyleHsp" style=""></span>M&#250;ltiplas placas&nbsp;\t\t\t\t\t\t\n
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                  \t\t\t\t">24 &#40;29&#44;3&#41;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t ; entry_with_role_rowhead " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t"><span class="elsevierStyleHsp" style=""></span>Placa &#250;nica&nbsp;\t\t\t\t\t\t\n
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                  \t\t\t\t">15 &#40;18&#44;3&#41;&nbsp;\t\t\t\t\t\t\n
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                  \t\t\t\t ; entry_with_role_rowhead " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t"><span class="elsevierStyleHsp" style=""></span>Total&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="" valign="\n
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                  \t\t\t\t"><span class="elsevierStyleItalic">Fototerapia &#40;NB&#8208;UVB&#41;</span>&nbsp;\t\t\t\t\t\t\n
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                  \t\t\t\t"><span class="elsevierStyleItalic">Tipo de recorr&#234;ncia da queda de cabelo</span></td></tr><tr title="table-row"><td class="td-with-role" title="\n
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                  \t\t\t\t"><span class="elsevierStyleHsp" style=""></span>M&#250;ltiplas placas&nbsp;\t\t\t\t\t\t\n
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