Topical immunotherapy with diphenylcyclopropenone in the treatment of chronic extensive alopecia areata

Diphenylcyclopropenone and platelet-rich plasma in the management of severe or recalcitrant alopecia areata

BACKGROUND

Alopecia areata (AA) is a common disease characterized by hair loss with an autoimmune background. There are many lines of therapy, but no standard line for all cases. Consequently, treating severe forms of AA is challenging.

OBJECTIVE

This study aimed to compare the efficacy and safety of the combination of diphenylcyclopropenone (DPCP) and platelet-rich plasma (PRP) with DPCP alone in treating patients with severe or refractory AA.

PATIENTS AND METHODS

Our randomized clinical trial was conducted on patients with severe and recalcitrant AA. Group A included 13 patients who received only DPCP, while Group B included 11 patients who received both DPCP and PRP. After sensitization in both groups of patients, DPCP was applied to half the scalp weekly. In addition, PRP injection in all scalp was performed once a month in group B. The patients in both groups completed the study for six months.

RESULTS

The regrowth scale results were 53.85% and 54.5% for groups A and B, respectively. Although the response rate of group B was higher than that of group A, there is no statistically significant difference between the two groups.

CONCLUSION

From our clinical trial, it can be concluded that DPCP alone or combined with PRP is an effective and safe method for treating severe or recalcitrant AA.

Diphenylcyclopropenone plays an effective therapeutic role by up-regulating the TSLP/OX40L/IL-13 pathway in severe alopecia areata

Topical immunotherapy with diphenylcyclopropenone (DPCP) is considered to be the most effective treatment of severe AA. However, the mechanism is unclear and an early predictor for the efficacy needs to be explored. The TSLP/OX40L/IL-13 pathway is an important pathway to initiate and maintain Th2 immune responses. Our previous work suggests this pathway may play a role in severe AA treated with DPCP. Thus, to further investigate the mechanism of TSLP/OX40L/IL-13 pathway in severe AA treated with DPCP and explore the predictor for the efficacy of DPCP therapy, we conducted a prospective study to compare expression levels of TSLP, OX40L, Th2 cytokines IL-4, IL-5 and IL13, and Th1 cytokine IFN-γ in severe AA patients before and after the treatment. Results showed that 21 AA patients were responsive (responders) to the DPCP therapy and 12 were not responsive (non-responders). Responders had lower levels of TSLP, OX40L and IL-13 than non-responders before the treatment. After the DPCP treatment, TSLP, IL-5 and IL-13 increased and IFN-γ decreased in responders while there were no changes of TSLP, IL-4, IL-13 and IFN-γ in non-responders. Our data suggest that the TSLP/OX40L/IL-13 pathway is down-regulated in some severe AA patients and DPCP might play a therapeutic role by up-regulating the pathway in these severe AA patients. The TSLP/OX40L/IL-13 pathway could be a predictor of response to the DPCP therapy for severe AA patients.

Therapeutic outcome of diphencyprone and its correlation with serum cytokine profile in alopecia areata

Introduction: Diphencyprone (DPCP) is considered as the first line of management in severe and extensive alopecia areata. The present study aims to evaluate the effectiveness of DPCP in alopecia areata and identify various prognostic factors and biomarkers associated with clinical response.Materials and methods: The study included participants with patchy and extensive alopecia areata (>30% scalp hair loss) treated with DPCP. Participants with Macdonald Hull and Norris grade 3 and 4 at the end of 6 months were considered as responders. We performed cytokine analysis prior and post-therapy. The protocol was registered with CTRI (REF/2017/09/015424).Results: The response rate was 54.5%. Longer disease duration, nail involvement, and high severity of alopecia tool (SALT) scores were associated with non-response. There was no significant difference in the cytokine levels among responders and non-responders before therapy. Among the responders, we found a significant decrease in IFN-γ, IL-17A, IL-9, TGF-β, and IL-13 except for IL-4, which significantly increased whereas, among the non-responders, only IL-17A and IL-13 levels have reduced considerably.Discussion: Diphencyprone reduced the level of Th1, Th17, and Th9 cytokines and increased the level of Th2 cytokines (IL-4) in the present study, which induced remission and promoted hair regrowth.

Alopecia Areata: a Comprehensive Review of Pathogenesis and Management

Alopecia areata is a common hair loss condition that is characterized by acute onset of non-scarring hair loss in usually sharply defined areas ranging from small patches to extensive or less frequently diffuse involvement. Depending on its acuity and extent, hair loss is an important cause of anxiety and disability. The current understanding is that the condition represents an organ-specific autoimmune disease of the hair follicle with a genetic background. Genome-wide association studies provide evidence for the involvement of both innate and acquired immunity in the pathogenesis, and mechanistic studies in mouse models of alopecia areata have specifically implicated an IFN-γ-driven immune response, including IFNγ, IFNγ-induced chemokines and cytotoxic CD8 T cells as the main drivers of disease pathogenesis. A meta-analysis of published trials on treatment of alopecia areata states that only few treatments have been well evaluated in randomized trials. Nevertheless, depending on patient age, affected surface area and disease duration, an empiric treatment algorithm can be designed with corticosteroids and topical immunotherapy remaining the mainstay of therapy. The obviously limited success of evidence-based therapies points to a more important complexity of hair loss. At the same time, the complexity of pathogenesis offers opportunities for the development of novel targeted therapies. New treatment opportunities based on the results of genome-wide association studies that implicate T cell and natural killer cell activation pathways are paving the way to new approaches in future clinical trials. Currently, there are ongoing studies with the CTLA4-Ig fusion protein abatacept, anti-IL15Rβ monoclonal antibodies and the Janus kinase inhibitors tofacitinib, ruxolitinib and baricitinib. Ultimately, the options available for adapting to the disease rather than treating it in an effort to cure may also be taken into consideration in selected cases of long-standing or recurrent small spot disease.

Rare Presentation of Alopecia Universalis Congenita and Twenty-nail Dystrophy in Siblings

Congenital alopecia universalis is one of the rarest anomaly which involves skin and appendages. The inheritance pattern can be autosomal recessive, X-linked recessive, or autosomal dominant. However, the most common is autosomal recessive form and it is the most severe phenotype. Twenty-nail dystrophy refers to the condition in which all the twenty nails are affected in the form of excessive ridging and nail plate roughness leading to unsightly lustureless nails. We report a rare case of two siblings with alopecia universalis congenita with twenty-nail dystrophy. To the best of our knowledge, this case is the first case to be reported with such association in both siblings. This case reports highlights the fact that alopecia areata is an autoimmune disease with a genetic predisposition as in our case both siblings had alopecia universalis and nail dystrophy. There was no evidence of any other ectodermal dyplasia and had normal teeth and seat glands. The skin biopsy ruled out congenital atrichia and was suggestive of alopecia areata.

Extensive scalp angioedema following high-dose diphenylcyclopropenone for alopecia areata

OBJECTIVE

To describe a case of an unusual adverse drug reaction to diphenylcyclopropenone for the treatment of alopecia areata.

CASE SUMMARY

A 31-year-old Caucasian male presented with extensive angioedema to the head with neck involvement 10 days following treatment with diphenylcyclopropenone 2% solution in acetone topically on his scalp to treat alopecia areata. Findings on patient presentation included edema of the soft tissues (deeper dermis and subcutaneous tissue) of the head and face with mild neck involvement, acute inflammatory changes from chemical-induced irritation, scalp erythema, and serous fluid drainage from inflamed and fissured edematous scalp. Acute treatments used for control of the reaction included intravenous steroids and antihistamines during hospitalization followed by oral steroids and antihistamines for maintenance during outpatient treatment of the resolving condition.

DISCUSSION

The role of topical diphenylcyclopropenone in this case of alopecia areata is probable according to the Naranjo criteria, with a score of 8. Diphenylcyclopropenone is not approved by the US Food and Drug Administration, but it has been used by many clinicians for the treatment of alopecia areata. Diphenylcyclopropenone causes an allergic contact dermatitis in the area of hair loss. In general, diphenylcyclopropenone is applied at a high concentration of 2% once and then at lower concentrations once weekly after the sensitization dose. This patient applied the 2% concentration on multiple consecutive days.

CONCLUSION

Frequent use of topical diphenylcyclopropenone 2% applied to the scalp may cause scalp angioedema.

Understanding dendritic cells and their role in cutaneous carcinoma and cancer immunotherapy. Clin Dev Immunol. 2013;2013:624123. [PMID: 23606870 PMCID: PMC3625554 DOI: 10.1155/2013/624123]

Dendritic cells (DC) represent a diverse group of professional antigen-presenting cells that serve to link the innate and adaptive immune systems. Their capacity to initiate a robust and antigen-specific immune response has made them the ideal candidates for cancer immunotherapies. To date, the clinical impact of DC immunotherapy has been limited, which may, in part, be explained by the complex nature of DC biology. Multiple distinct subsets of DCs have been identified in the skin, where they can be broadly subcategorized into epidermal Langerhans cells (LC), myeloid-derived dermal dendritic cells (mDC) and plasmacytoid dendritic cells (pDC). Each subset is functionally unique and may activate alternate branches of the immune system. This may be relevant for the treatment of squamous cell carcinoma, where we have shown that the tumor microenvironment may preferentially suppress the activity of mDCs, while LCs remain potent stimulators of immunity. Here, we provide an in depth analysis of DC biology, with a particular focus on skin DCs and their role in cutaneous carcinoma. We further explore the current approaches to DC immunotherapy and provide evidence for the targeting of LCs as a promising new strategy in the treatment of skin cancer.

Topical immunotherapy in alopecia areata

Alopecia Areata (AA) is a common non-scarring alopecia directed against the anagenic hair follicle. Various treatment modalities have been used for the treatment of severe AA. Topical immunotherapy is the best documented treatment so far for severe and refractory AA. Dinitrochlorobenzene (DNCB), squaric acid dibutylester (SADBE), and diphencyprone (DPCP) are the contact allergens used for this purpose. DNCB has been found to be mutagenic by the Ames test and is largely replaced by DPCP and SADBE. DPCP and SADBE are both known to be non-mutagenic compounds and have comparable efficacy results and relapse rates. SADBE requires special solvents and additives to maintain its potency and is more expensive than the rest. DPCP has a response rate varying from 60% in severe Alopecia Areata to 17% in patients with alopecia totalis or universalis, and shows about 88 to 100% high response rate in patients with patchy Alopecia Areata.