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CASE REPORT
Year : 2022 | Volume
: 26
| Issue : 2 | Page : 92-95
Topical immunotherapy for alopecia areata: A successful diphenylcyclopropenone protocol
Melika Motamedi1, Kush Bapujib2, Navdeep Dhaliwal1
1 Department of Medicine, Faculty of Medicine, University of Alberta, Edmonton, Alberta, Canada
2 Department of Sciences, Faculty of Sciences, University of Alberta, Edmonton, Alberta, Canada
Correspondence Address:
Dr. Navdeep Dhaliwal
University of Alberta, 116 Street and 85 Avenue, Edmonton T6G 2R3, Alberta
Canada
Source of Support: None, Conflict of Interest: None
DOI: 10.4103/jdds.jdds_21_22
Alopecia areata (AA) is an autoimmune disorder that involves the destruction of anagenic hair follicles, resulting in non-scarring patchy hair loss. The patient presented in the following case had not seen improvement by use of conventional treatments and was started on topical immunotherapy, diphenylcyclopropenone (DPCP). This agent is commonly left as a last resort due to its constant need for follow-up, clinician-required administration, and risk of adverse effects. The following case presents a titration schedule using DPCP, resulting in minimal adverse effects and dramatic improvement in hair regeneration.
Keywords: Alopecia, diphenylcyclopropenone, immunotherapy
Alopecia areata (AA) is an autoimmune disorder prevalent within all ages, gender, and ethnic groups thought to affect approximately 2% of the global population.[1] AA involves the destruction of anagenic hair follicles by an individual's immune system.[2] When seen on histology, dense lymphocytic infiltrates consisting of CD8+, and CD4 + T cells surround the bulbar region of anagen hair follicles.[3] The destruction of anagenic hair follicles presents most predominantly through characteristic non-scarred areas with no hair present.[4] The negative impacts on an individual's mental wellbeing and self-confidence reinforce the urgency of developing highly effective therapies.[5]
Topical immunotherapy utilizes a specific concentration of a contact allergen; this treatment method has been utilized in the treatment of various dermatological disorders for nearly 50 years.[1],[6] Patients afflicted with AA are first introduced to a contact allergen in hopes of sensitization1 diphenylcyclopropenone (DPCP) is a common contact allergen, unable to induce genetic mutations when applied topically, making it a primary choice as a contact sensitizer in topical immunotherapy.[6] However, the use of contact allergens involved at improper concentrations has been associated with problematic contact dermatitis, enforcing the need for proper sensitization and dose escalation.
Case ReportA healthy 46-year-old male with an unremarkable family history was referred to dermatology for patchy hair loss in the beard, which had started 30 months ago. He reported no recent infections, travel, emotional stressors, or physical trauma to the affected area.
At the time of examination, a discrete area of alopecia was seen. The hair pull test was negative, and magnification revealed the presence of normal hair shafts without trichodystrophy. No evidence of scale was present to suggest dermatophytosis.
In the first 20 months of treatment, he trialled intralesional triamcinolone, topical pimecrolimus, topical tacrolimus and oxsoralen in conjunction with ultraviolet B (UVB) and UVA light therapy. The patient noticed minimal improvement and began experiencing hair loss in his eyebrows. The patient expressed frustration due to the substantial hair loss in the vertex of the scalp. He was offered the option of using DPCP immunotherapy, administered once weekly in the clinic. After 20 months since his initial visit, the patient agreed and began the DPCP treatment. Baseline photos prior to initiation of DPCP were taken to document any changes [Figure 1].
Figure 1: Baseline photos of vertex, left eyebrow and beard prior to initiation of DCPC. Photos were taken at 20 months when the patients had exhausted traditional forms of treatment such as intralesional triamcinolone, light therapy, topical pimecrolimus and tacrolimus. DCPC: DiphenylcyclopropenonAs seen in [Table 1], the patient was started on a DPCP sensitization and titration protocol. The patient was instructed to wash each application 48 h after it was applied. He was counselled that irritation is a risk, and treatments may be held for some weeks if irritation is evident. Only the scalp was treated due to the high risk of irritation. The beard and eyebrow were continued on intralesional triamcinolone 0.2 mg every 4 weeks.
The patient was seen weekly for follow-up and treatment application. At week 31, the patient was brought in for follow-up pictures [Figure 2]. Significant hair growth on the scalp was seen. The regions of the eyebrow and beard, where DPCP was not applied, demonstrated hair regrowth that was mild compared to the scalp. The patient reported significant improvement in his mood and self-confidence with the results.
Figure 2: Results from weekly DCPC application to vertex after 11 weeks. Left eyebrow and beard were treated with intralesional triamcinolone and yielded less drastic improvement in hair re-growth. DCPC: Diphenylcyclopropenon Discussion The use of immunotherapies in treating alopecia is a known approach. However, due to the risk of irritant and contact dermatitis, this treatment method is approached with hesitation. In our case, we had reached the point of exhaustion when it came to conventional topical therapies in conjunction with intralesional corticosteroids. Furthermore, as the hair-bearing areas affected in alopecia (scalp, beard, eyebrows) are more prone to the adverse effects of corticosteroids, practitioners must be cognizant in their aggressiveness of treatment.
Previous cases involving the use of DPCP in the treatment of alopecia have resulted in negative consequences. There are two published cases on the use of DPCP to treat alopecia. In 2012 a case report indicated the DPCP might induce vitiligo at both local and distant to the site of treatment administration.[7] In 2020 a case was reported of discoid lupus erythematous (DLE), which was precipitated by topical application of DPCP for a patient with chronic alopecia.[8] In both cases, the patients had a prior history of alopecia for 5 and 14 years, respectively, prior to initiation of DPCP treatment.
Our patient had no family history of autoimmune conditions, nor did he have any underlying medical conditions himself. Although alopecia can happen at any age, it tends to present before the age of 40 and in more severe subtypes, such as alopecia universalis, it has a mean age of onset of 5–10 years old.[1] Therefore, although treatment involving DPCP may be associated with irritant dermatitis as seen in our patient's treatment, more severe adverse events involving autoimmune manifestations including DLE and vitiligo may be less likely. A possible rationale for this observation is that individuals with a pre-existing autoimmune condition treated with topical immunotherapy may be susceptible to adverse effects of immune-mediated reactions. In contrast, individuals such as our patient presenting symptoms past the age of 40 more likely to contribute to an environmental cause rather than underlying medical conditions may be better candidates for topical immunotherapy.
Topical immunotherapies, such as DPCP are sometimes avoided due to the perceived risks of adverse effects. Although each patient must be assessed as appropriate candidates, we identified that using DPCP with prior sensitization and slow titration over 7 months resulted in positive outcomes for our patient.
In conclusion, AA can create insecurities for patients and therefore, prompt treatment and resolution of the condition desired. Although the pathophysiology suggests immunosuppression being the most appropriate option, the conventional use of topical and intralesional corticosteroids are not always effective. Utilizing topical immunotherapies such as DPCP is often avoided due to adverse effects and discomfort. However, following a slow titration protocol as indicated in this paper may help expedite the regenerative hair process for patients who have not had success with conventional treatment modalities.
Statement of ethics
This retrospective review of patient data did not require ethical approval in accordance with local/national guidelines. Written informed consent was obtained from the patient for publication of this case report and any accompanying images.
Declaration of patient consent
The authors certify that they have obtained all appropriate patient consent forms. In the form, the patient has given his consent for his images and other clinical information to be reported in the journal. The patient understands that his name and initials will not be published and due efforts will be made to conceal identity, but anonymity cannot be guaranteed.
Financial support and sponsorship
Nil.
Conflicts of interest
There are no conflicts of interest
References
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