Combination Therapy Helpful in Refractory Alopecia

By David Douglas

February 27, 2015

NEW YORK (Reuters Health) - Combination therapy with diphenylcyclopropenone (DPCP) and anthralin is more effective than DPCP alone in patients with chronic extensive alopecia areata (AA), according to Turkish researchers.

"Alopecia areata is a common autoimmune disorder characterized by noncicatricial alopecic areas. This alopecia is usually limited to a few oval bald patches, but it can spread to all the scalp (alopecia totalis) or all body hair (alopecia universalis) in some (approximately 5%) of patients. Treatment remains difficult in patients with alopecia totalis, alopecia universalis, and widespread multifocal patches," Dr. Murat Durdu, of Adana Hospital, told Reuters Health by email.

"Alopecia totalis and alopecia universalis," he added, "usually respond well to treatment with systemic steroids and cyclosporine. However, rapid recurrence may be seen frequently after terminating treatment. Use of systemic treatment for a long time can lead to several adverse events."

In fact, in a February 1 online paper in the Journal of the American Academy of Dermatology, Dr. Durdu and colleagues note that because of such limitations "combination therapies are recommended in patients with therapy-resistant extensive AA."

To gain further information on the safety and efficacy of these approaches, the team retrospectively examined data on 47 patients. Clinicians treated 22 with only DPCP, and 25 with DPCP and anthralin. Both groups received treatment for at least 30 weeks.

Complete hair regrowth was seen in 36.4% of patients given DPCP alone compared to 72% of the patients who received combination therapy. Better regrowth results were also seen for the eyebrows, eyelashes, and beards.

As Dr. Durdu pointed out, combination therapy is more effective and "complete hair regrowth duration was 4 weeks shorter with the combination therapy. Moreover, complete regrowth of the eyebrows and eyelashes was much more frequently observed in the combination therapy group. Finally, complete regrowth of the beard occurred only in the combination therapy group."

Side effects including pruritus, dermatitis, vesicles and bullae were common but did not differ between groups. However, the combination group experienced more superficial folliculitis and hyperpigmentation.

Nevertheless, fewer patients in the combination group stopped treatment (8.5%) than in the monotherapy group (18.5%), which, say the researchers "is probably related to the better treatment success rate with the combination therapy."

Commenting on the findings by email, dermatologist Dr. Robert T. Brodell, of the University of Mississippi, Jackson, told Reuters Health that the underlying cause of this autoimmune disease is unknown but stress is an aggravating factor for some patients. Fortunately," he added, "the majority of patients develop hair loss in patches that eventually grow back." However, "A small percentage of patients have the kind of persistent, extensive AA described in this article."

"For the severe cases there is no universally accepted treatment that works for everyone. Systemic steroids are generally not used because their long-term use causes many side effects" along with hair loss when treatment stops. However, Dr. Brodell continued "topical products that cause inflammation in the skin (allergy in the case of diphenylcyclopropenone) (irritation in the case of anthralin) paradoxically can halt the inflammation that induces AA."

"This article suggests that the combination works better than either one alone." But given the widespread side effects, it is clear that it is "not easy to find just the right dose that will minimize side effects and grow hair at the same time."

Dr. Brodell concluded, "I am hopeful that in the next decade major advances will be made that allow us to control this problem in a targeted fashion. Until then, this is a great example of how doctors 'practice' medicine, trying to tailor the best treatment to each individual patient while doing our best to minimize harm."

The authors report no external funding or disclosures.


J Am Acad Dermatol 2015.


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