Allergic and irritant contact dermatitis compared in the treatment of alopecia totalis and universalis. A comparison of the value of topical diphencyprone and tretinoin gel

Guidelines for the Management of Patients with Alopecia Areata in Korea: Part I Topical and Device-based Treatment

BACKGROUND

Alopecia areata (AA) is a chronic disease with an unpredictable disease course and severe psychological impact.

OBJECTIVE

To provide evidence- and consensus-based insights regarding the treatment of patients with AA in Korea.

METHODS

We searched for relevant studies on the topical and device-based treatment of AA in the literature from inception until May 2021. Evidence-based recommendations were also prepared. The evidence for each statement was graded and classified according to the strength of the recommendations. Hair experts from the Korean Hair Research Society (KHRS) voted on the statements, and an agreement of 75% or greater was considered as consensus.

RESULTS

Currently, there remains a scarcity of topical treatments, which is supported by robust evidence from a number of high-quality randomized controlled trials. Current evidence supports the efficacy of topical corticosteroids, corticosteroid intralesional injection, and contact immunotherapy in AA patients. Topical corticosteroids and contact immunotherapy are recommended for pediatric AA. A consensus was achieved in 6 out of 14 (42.8%), and 1 out of 5 (20.0%) statements pertaining to topical and device-based treatments in AA, respectively. The expert consensus was from a single country, and the study may not cover all the treatments used.

CONCLUSION

The present study provides up-to-date, evidence-based treatment guidelines for AA based on the consensus reached among experts after considering regional healthcare circumstances, adding diversity to the previous guidelines.

Application of Topical Immunotherapy in the Treatment of Alopecia Areata: A Review and Update

Treatment of extensive or recalcitrant alopecia areata (AA) is a major clinical challenge. Even after thorough investigation of several medications, its treatment outcomes have remained unsatisfactory. While there is no US Food and Drug Administration-approved medication for AA yet, topical immunotherapy has been a well-documented treatment option. Dinitrochlorobenzene, squaric acid dibutylester, and diphenylcyclopropenone are three substances that have demonstrated efficacy in the treatment of extensive or recalcitrant AA. Despite being commonly used, the mechanism underlying topical immunotherapy is not well-elucidated and a wide range of clinical efficacies have been reported in the literature. The aim of this review was to summarize and update the pharmacology, mechanism of action, therapeutic efficacy, and tolerability of topical immunotherapy in the treatment of AA.

The clonal structure and dynamics of the human T cell response to an organic chemical hapten

Diphenylcyclopropenone (DPC) is an organic chemical hapten which induces allergic contact dermatitis and is used in the treatment of warts, melanoma, and alopecia areata. This therapeutic setting therefore provided an opportunity to study T cell receptor (TCR) repertoire changes in response to hapten sensitization in humans. Repeated exposure to DPC induced highly dynamic transient expansions of a polyclonal diverse T cell population. The number of TCRs expanded early after sensitization varies between individuals and predicts the magnitude of the allergic reaction. The expanded TCRs show preferential TCR V and J gene usage and consist of clusters of TCRs with similar sequences, two characteristic features of antigen-driven responses. The expanded TCRs share subtle sequence motifs that can be captured using a dynamic Bayesian network. These observations suggest the response to DPC is mediated by a polyclonal population of T cells recognizing a small number of dominant antigens.

Madarosis

Madarosis may be a presenting feature of a number of vision and life-threatening conditions, including herpes zoster, leprosy, HIV/AIDS, trachoma, malignant eyelid tumors, discoid lupus, scleroderma, and hypothyroidism. It may occur via two broad pathogenic pathways: scarring and non-scarring, which indicates the potential for lash re-growth. Madarosis may occur as an isolated finding or together with loss of other body and scalp hair. The etiology of madarosis can be further divided into dermatological, infection, endocrine, neoplastic, drug-related, congenital, and trauma. This report includes salient points in the clinical history and examination of patients with madarosis, with an emphasis on excluding or diagnosing visual or life threatening disorders associated with madarosis.

The impact of body site, topical melatonin and brushing on hair regrowth after clipping normal Siberian Husky dogs

The aims of this study were to determine the impact of body site, vigorous brushing and topical melatonin treatment on hair regrowth after clipping normal dogs. Siberian Husky dogs were randomly assigned to three groups of eight dogs each. All dogs had the lumbosacral region and both lateral thighs clipped. The left thigh and lumbosacral area received no treatment and were compared in all 24 dogs. Eight dogs had the right thigh treated with 0.1% melatonin twice daily for 2 months, and hair regrowth was compared with the left thigh. Eight dogs had the right thigh brushed twice daily for 2 months, and hair regrowth was compared with the left thigh. Eight dogs had neither thigh treated. Hairs were plucked before and 2 months postclipping, and the proportion of hair growth from the original length was calculated and compared as described above. Biopsy samples were collected before and after treatment to determine if brushing induced dermal inflammation and melatonin increased the proportion of anagen follicles. Proportionally, left thigh hairs were significantly longer compared to lumbosacral hairs 2 months postclipping. No significant differences in hair regrowth were noted between the nontreated thigh and the thigh treated with melatonin or brushed. No significant difference in dermal inflammation was noted before and after brushing. No significant differences were observed in the proportion of anagen follicles before and after topical melatonin treatment. Our results showed that the hairs in the lumbosacral region were proportionally shorter than lateral thigh hairs 2 months postclipping. Moreover, topical melatonin and brushing had no impact on hair regrowth after clipping normal dogs.

Topical immunotherapy with contact sensitizers: a model to study the natural history of delayed hypersensitivity

So-called 'topical immunotherapy' (TI) is a well-established treatment modality based on the use of potent contact sensitizers, such as squaric acid dibutylester (SADBE), that are not found in the general or occupational environment of man, and do not induce cross-sensitization to other substances. Thus, unlike patients with sensitivity to other more or less commonplace allergens, subjects submitted to this treatment modality might provide useful data for the study of the natural course of contact sensitivity. On the basis of these premises, we have retrospectively reviewed 40 patients who had consecutively received TI with SADBE for severe alopecia areata and viral warts in the period 1993-2001, and returned to visit after a 1-7-year period since the last therapeutic challenge with the sensitizer. The chronological profile of loss of contact sensitization of this case cohort has been evaluated and compared to that of other series available in the literature. Provided more standardized TI application procedures are established, aim-oriented studies of the outcome of this treatment modality may bring useful data to be employed in construction of predictive models of decay of contact sensitization under conditions of antigen avoidance.

The therapeutic use of topical contact sensitizers in benign dermatoses

Topical therapy using contact sensitizers has been practised since the 1960s to treat conditions associated with an altered immunological state. Dinitrochlorobenzene, squaric acid dibutyl ester and diphencyprone are most commonly employed in the therapy of alopecia areata and viral warts. Few dermatology departments in the U.K. provide such treatment. This systematic review discusses the various contact sensitizers used for topical immunotherapy, the methodology of treatment, factors influencing efficacy and likely adverse effects.

Efficacy of topical sensitizers in the treatment of alopecia areata

It has been more than 2 decades since the first report of the use of dinitrochlorobenzene to induce hair growth in 2 patients with alopecia areata. Other topical sensitizers, namely squaric acid dibutylester and diphenylcyclopropenone, have been used with variable success. This article reviews the efficacy and safety of the use of topical sensitizers in the treatment of alopecia areata.

Topical immunotherapy in alopecia areata. What, how, and why?

At present the induction and elicitation of an ACD with potent contact allergens such as DCP appear to be the most effective, but still not definitively curative, approach in treating extensive forms of AA. Experimental data suggest that cytokines and growth factors such as IL 1 beta are involved in the pathogenesis of AA as well as the therapeutic effect mediated by contact sensitizers. It seems reasonable to assume that factors inherent in the late phase of ACD modulate a T-cell mediated mechanism responsible for AA, thus inducing hair regrowth. Such counteracting activities are most likely mediated by proinflammatory cytokines such as TNF-alpha, IL-10, or TGF-beta 1. This hypothesis may oversimplify the underlying immunologic mechanisms, but the effectiveness of topical immunotherapy in AA would be compatible with this concept. This mode of treatment is, however, a rather rough approach and recurrences are possible. It is hoped that advances in basic science will eventually allow us to find a more specific mode of treatment.

Treatment of chronic severe alopecia areata with topical diphenylcyclopropenone and 5% minoxidil: a clinical and immunopathologic evaluation

BACKGROUND

Topical diphenylcyclopropenone (DPCP) and minoxidil have been used in the treatment of alopecia areata with variable results.

OBJECTIVE

This study was designed to evaluate the efficacy of DPCP alone or in combination with topical 5% minoxidil for the treatment of chronic severe alopecia areata. The effect of therapy on cutaneous T-cell and Langerhans cell subpopulations and intercellular adhesion molecule-1 (ICAM-1) expression was also examined.

METHODS

Fifteen patients with chronic (more than 2 years), severe (more than 50% scalp involvement) alopecia areata participated in a 24-week trial. Half of the scalp was treated with DPCP once weekly and with either 5% minoxidil solution or a vehicle solution twice daily in a randomized double-blind design. Skin biopsy specimens from each half of the scalp were obtained before therapy and after 12 and 24 weeks of therapy for histologic and immunophenotypic analysis.

RESULTS

Thirteen patients completed the study. Five of 13 patients (38%) showed marked regrowth of coarse terminal hair after 24 weeks of treatment with DPCP. The addition of topical 5% minoxidil did not produce any significant clinical benefit in this 24-week trial. Immunophenotypic analysis showed no differences between responders and nonresponders at baseline. During treatment, Leu-4, Leu-2, Leu-3, and keratinocyte ICAM-1 expression were significantly reduced in biopsy specimens of responders versus nonresponders.

CONCLUSION

DPCP treatment showed a 38% success rate in producing cosmetically acceptable regrowth in patients with chronic severe alopecia areata.

Therapy of alopecia areata with diphencyprone

The properties of diphencyprone (DPC), its possible mechanism of action in the therapy of alopecia areata (AA), and its side-effects are summarized. The results of our own study of treatment in 45 patients with AA, with a mean treatment duration of 72 (15-146) weeks, are presented, and compared with the results of previous studies. We suggest that, in future, therapy protocols should define entry criteria and therapy results more precisely, and include follow-up assessments to establish the length of remission. In view of the low response rates and short lengths of remission, the indications for DPC therapy should be set more rigorously.

Treatment of alopecia totalis with a combination of inosine pranobex and diphencyprone compared to each treatment alone

Recent developments in alopecia areata have included the use of oral inosine pranobex and the introduction of diphencyprone as a contact sensitizer. Good results have been claimed for these treatments even in severe forms of the disease. We performed a study to investigate the efficacy of a combination of these treatments in the most severe form of alopecia areata. Thirty-three patients suffering from alopecia totalis were enrolled. Subjects were divided into three groups matched for age and sex. One group received treatment with inosine pranobex (50 mg/kg/day) for 6 months. The second was sensitized to diphencyprone and treated for 6 months by maintenance of contact allergic dermatitis on the scalp. The third received both treatments. There was no evidence of response to inosine pranobex in any of the 22 subjects who received this treatment. Only two of 22 patients responded to diphencyprone. Patients with long-standing alopecia totalis contemplating diphencyprone therapy should be advised that the chances of success are only around 10%. Inosine pranobex does not appear to improve the response rate.