Treatment Response to Diphenylcyclopropenone in Patients with Alopecia Totalis/Universalis

Introduction: Alopecia totalis (AT) and Alopecia universalis (AU) are forms of Alopecia areata (AA) which represent the strongest predictor of poor prognosis since spontaneous regrowth is <10%. Topical immunotherapy agent, diphenylcyclopropenone (DPCP) has shown clinical efficacy with limited side effects in severe forms of AA. However, its specific role in AT/AU characterized by complete hair loss over the scalp can help highlight the efficacy of the drug with fewer confounders. Methodology: Data were collected from 18 patients diagnosed with AT/AU and treated with topical immunotherapy with DPCP as per protocol by Happle et al. Baseline Severity of Alopecia Tool (SALT) score and subclass was recorded. In the case of AU, baseline body hair loss score was also recorded. Patients were reassessed after 6 months of treatment in terms of change in SALT score and hair regrowth was assessed using the Global Assessment Score. The side effects during treatment were also assessed and recorded. Results: Eighteen patients of whom eleven (61.1%) were diagnosed as AU and seven (38.9%) as AT were treated. The mean age was 21.6, with a male: female ratio of 3:2. The comorbidities noted were atopy in six (33.3%), atopy and hypothyroidism in one (5.5%), Down’s syndrome in two (11.1%), and hypothyroidism alone in one (5.5%) patient. The mean duration of disease at the time of presentation was 3 years and all patients had remained refractory to various other modalities of treatment. All patients had a baseline SALT score of 100 corresponding to S5. After 6 months of treatment, 27.7% of patients did not show any response (SALT score S5), 16.6% had a score of S4, 11.1% had a score of S3, 11.1% had a score of S2, 22.2% had a score of S1, and 11.1% had a score of S0. On assessing improvement in body hair loss score, 36.3% of patients showed no improvement, 36.3% showed partial improvement, and 27.2% of patients showed complete body hair regrowth. About 55.5% of patients developed notable side effects that included severe local reactions, cervical lymphadenopathy, acne and pigmentation at the site of application as well as untreated sites. Conclusion: The AT/AU subtypes of AA, was amenable to treatment with contact immunotherapeutic agent DPCP with a >75% hair regrowth in 33.3% of patients. The castling phenomenon was seen in 63.6% of AU patients. The adverse effects noted were not severe enough to deter treatment.