La artritis reumatoide es una enfermedad de tipo autoinmune. Por su carácter altamente invalidante, requiere de manejo farmacológico agresivo. Para ello, habitualmente se hace necesario el uso de drogas inmunomoduladoras agrupadas bajo el nombre de fármacos antirreumáticos modificadores de la enfermedad. Uno de los utilizados con mayor frecuencia es la leflunomida, la cual por su mecanismo de acción es capaz de suprimir ejes fundamentales en el proceso de la enfermedad. Sin embargo, su uso no se encuentra exento de efectos secundarios. Si bien existen series que reportan que los efectos adversos más prevalentes son diarrea, náuseas, exantema y alopecia, existen escasos reportes de casos de alopecia areata universal secundaria al uso de leflunomida. A propósito de un caso en el Hospital Regional de Talca, se realizó una revisión de la literatura acerca del tema.

Authors: María Ignacia Molina Molina[1], Carmen María Pinochet Paiva[2], José Ignacio Quezada Morales[1]

Affiliation:
[1] Facultad Medicina, Universidad Católica del Maule, Talca, Chile
[2] Hospital Regional de Talca, Región del Maule, Chile

E-mail: mignaciamolina@gmail.com

Author address:
[1] Avenida San Miguel 3605
Talca
Región del Maule
Chile

Citation: Molina Molina MI, Pinochet Paiva CM, Quezada Morales JI. Alopecia areata secondary to the use of leflunomide in patients with rheumatoid arthritis: a case report and literature review. Medwave 2015 Dic;15(11):e6350 doi: 10.5867/medwave.2015.11.6350

Submission date: 9/11/2015

Acceptance date: 22/12/2015

Publication date: 30/12/2015

Origin: not requested

Type of review: reviewed by one external peer reviewer, double-blind

PubMed record

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1. Cardiel MH; Latin American Rheumatology Associations of the Pan-American League of Associations for Rheumatology (PANLAR); Grupo Latinoamericano de Estudio de Artritis Reumatoide (GLADAR). First Latin American position paper on the pharmacological treatment of rheumatoid arthritis. Rheumatology (Oxford). 2006 Jun;45 Suppl 2:ii7-ii22. | PubMed |
2. Smolen JS, Emery P. Efficacy and safety of leflunomide in active rheumatoid arthritis. Rheumatology (Oxford). 2000 Jun;39 Suppl 1:48-56. | PubMed |
3. Wiacek R, Kolossa K, Jankowski T, Jeka S, Karmowski A, Karmowski M, et al. The efficacy and safety of leflunomide in patients with active rheumatoid arthritis. Adv Clin Exp Med. 2012 May-Jun;21(3):337-42. | PubMed |
4. Smolen JS, Kalden JR, Scott DL, Rozman B, Kvien TK, Larsen A, et al. Efficacy and safety of leflunomide compared with placebo and sulphasalazine in active rheumatoid arthritis: a double-blind, randomised, multicentre trial. European Leflunomide Study Group. Lancet. 1999 Jan 23;353(9149):259-66. | PubMed |
5. Alkhalifah A, Alsantali A, Wang E, McElwee KJ, Shapiro J. Alopecia areata update: part I. Clinical picture, histopathology, and pathogenesis. J Am Acad Dermatol. 2010 Feb;62(2):177-88, quiz 189-90. | CrossRef | PubMed |
6. Safavi K. Prevalence of alopecia areata in the First National Health and Nutrition Examination Survey. Arch Dermatol. 1992 May;128(5):702. | PubMed |
7. Finner AM. Alopecia areata: Clinical presentation, diagnosis, and unusual cases. Dermatol Ther. 2011 May-Jun;24(3):348-54. | CrossRef | PubMed |
8. Schneider MR, Schmidt-Ullrich R, Paus R. The hair follicle as a dynamic miniorgan. Curr Biol. 2009 Feb 10;19(3):R132-42. | CrossRef | PubMed |
9. Gilhar A, Etzioni A, Paus R. Alopecia areata. N Engl J Med. 2012 Apr 19;366(16):1515-25. | CrossRef | PubMed |
10. Ito T, Ito N, Saatoff M, Hashizume H, Fukamizu H, Nickoloff BJ, et al. Maintenance of hair follicle immune privilege is linked to prevention of NK cell attack. J Invest Dermatol. 2008 May;128(5):1196-206. | PubMed |
11. Meyer KC, Klatte JE, Dinh HV, Harries MJ, Reithmayer K, Meyer W, et al. Evidence that the bulge region is a site of relative immune privilege in human hair follicles. Br J Dermatol. 2008 Nov;159(5):1077-85. | CrossRef | PubMed |
12. Kuchabal SD, Kuchabal DS. Alopecia Areata Associated with Localized Vitiligo. Case Rep Dermatol. 2010 Mar 27;2(1):27-31. | PubMed |
13. Ito T. Recent advances in the pathogenesis of autoimmune hair loss disease alopecia areata. Clin Dev Immunol. 2013;2013:348546. | CrossRef | PubMed |
14. Gottenberg JE, Venancie PY, Mariette X. Alopecia areata in a patient with rheumatoid arthritis treated with leflunomide. J Rheumatol. 2002 Aug;29(8):1806-7. | PubMed |
15. Navarro R, Daudén E, Gallo E, Santiago Sánchez-Mateos D, García-Diez A. Alopecia areata during treatment of psoriasis with adalimumab and leflunomide: a case and review of the literature. Skin Pharmacol Physiol. 2012;25(2):107-10. | CrossRef | PubMed |
16. Chaves Y, Duarte G, Ben-Said B, Tebib J, Berard F, Nicolas JF. Alopecia areata universalis during treatment of rheumatoid arthritis with anti-TNF-alpha antibody (adalimumab). Dermatology. 2008;217(4):380. | CrossRef | PubMed |
17. Lazzarini R, Capareli GC, Buense R, Lellis RF. Alopecia universalis during treatment with leflunomide and adalimumab - case report. An Bras Dermatol. 2014 Mar-Apr;89(2):320-2. | PubMed |
18. Costa L, Atteno M, Caso F, Scarpato L, Del Puente A, Scarpa R. Alopecia areata in a patient with psoriatic arthritis and Crohn's disease receiving etanercept. Int J Rheum Dis. 2014 Feb;17(2):219-20. | CrossRef | PubMed |

Cardiel MH; Latin American Rheumatology Associations of the Pan-American League of Associations for Rheumatology (PANLAR); Grupo Latinoamericano de Estudio de Artritis Reumatoide (GLADAR). First Latin American position paper on the pharmacological treatment of rheumatoid arthritis. Rheumatology (Oxford). 2006 Jun;45 Suppl 2:ii7-ii22. | PubMed |

Smolen JS, Emery P. Efficacy and safety of leflunomide in active rheumatoid arthritis. Rheumatology (Oxford). 2000 Jun;39 Suppl 1:48-56. | PubMed |

Wiacek R, Kolossa K, Jankowski T, Jeka S, Karmowski A, Karmowski M, et al. The efficacy and safety of leflunomide in patients with active rheumatoid arthritis. Adv Clin Exp Med. 2012 May-Jun;21(3):337-42. | PubMed |

Smolen JS, Kalden JR, Scott DL, Rozman B, Kvien TK, Larsen A, et al. Efficacy and safety of leflunomide compared with placebo and sulphasalazine in active rheumatoid arthritis: a double-blind, randomised, multicentre trial. European Leflunomide Study Group. Lancet. 1999 Jan 23;353(9149):259-66. | PubMed |

Alkhalifah A, Alsantali A, Wang E, McElwee KJ, Shapiro J. Alopecia areata update: part I. Clinical picture, histopathology, and pathogenesis. J Am Acad Dermatol. 2010 Feb;62(2):177-88, quiz 189-90. | CrossRef | PubMed |

Safavi K. Prevalence of alopecia areata in the First National Health and Nutrition Examination Survey. Arch Dermatol. 1992 May;128(5):702. | PubMed |

Finner AM. Alopecia areata: Clinical presentation, diagnosis, and unusual cases. Dermatol Ther. 2011 May-Jun;24(3):348-54. | CrossRef | PubMed |

Schneider MR, Schmidt-Ullrich R, Paus R. The hair follicle as a dynamic miniorgan. Curr Biol. 2009 Feb 10;19(3):R132-42. | CrossRef | PubMed |

Gilhar A, Etzioni A, Paus R. Alopecia areata. N Engl J Med. 2012 Apr 19;366(16):1515-25. | CrossRef | PubMed |

Ito T, Ito N, Saatoff M, Hashizume H, Fukamizu H, Nickoloff BJ, et al. Maintenance of hair follicle immune privilege is linked to prevention of NK cell attack. J Invest Dermatol. 2008 May;128(5):1196-206. | PubMed |

Meyer KC, Klatte JE, Dinh HV, Harries MJ, Reithmayer K, Meyer W, et al. Evidence that the bulge region is a site of relative immune privilege in human hair follicles. Br J Dermatol. 2008 Nov;159(5):1077-85. | CrossRef | PubMed |

Kuchabal SD, Kuchabal DS. Alopecia Areata Associated with Localized Vitiligo. Case Rep Dermatol. 2010 Mar 27;2(1):27-31. | PubMed |

Ito T. Recent advances in the pathogenesis of autoimmune hair loss disease alopecia areata. Clin Dev Immunol. 2013;2013:348546. | CrossRef | PubMed |

Gottenberg JE, Venancie PY, Mariette X. Alopecia areata in a patient with rheumatoid arthritis treated with leflunomide. J Rheumatol. 2002 Aug;29(8):1806-7. | PubMed |

Navarro R, Daudén E, Gallo E, Santiago Sánchez-Mateos D, García-Diez A. Alopecia areata during treatment of psoriasis with adalimumab and leflunomide: a case and review of the literature. Skin Pharmacol Physiol. 2012;25(2):107-10. | CrossRef | PubMed |

Chaves Y, Duarte G, Ben-Said B, Tebib J, Berard F, Nicolas JF. Alopecia areata universalis during treatment of rheumatoid arthritis with anti-TNF-alpha antibody (adalimumab). Dermatology. 2008;217(4):380. | CrossRef | PubMed |

Lazzarini R, Capareli GC, Buense R, Lellis RF. Alopecia universalis during treatment with leflunomide and adalimumab - case report. An Bras Dermatol. 2014 Mar-Apr;89(2):320-2. | PubMed |

Costa L, Atteno M, Caso F, Scarpato L, Del Puente A, Scarpa R. Alopecia areata in a patient with psoriatic arthritis and Crohn's disease receiving etanercept. Int J Rheum Dis. 2014 Feb;17(2):219-20. | CrossRef | PubMed |