ALOPECIA AREATA (1) Treatment with contact sensitizers (2) Antigen sources (3) Famvir (4) PUVA (5) Rogaine (6) Miscellaneous (5) Role of trauma in the etiology of alopecia areata? (6) Immune modulation (7) Melatonin (8) Itramuscular triamcinalone (9) Intralesional triamcinalone (10) Thymus extract (11) Angst associated with treating alopecia areata (12) Dye and alopecia areata (13) Cases (14) Proscar (15) Squaric Acid ------------------------------------------------------ ---------------------------------- TREATMENT WITH CONTACT SENSITIZERS ---------------------------------- While the subject is up, I'd again like to inquire if anyone out there is willing to share their approach to using squaric acid or DCP as a contact sensitizer for AA. I have used DNCB for warts, but have no experience with these agents. Mark Ling, M.D., Ph.D. Emory University ---------------- We did a study on about 20 patients with AA on SADBE. Please note that Squaric Acid is different from Squaric Acid Dibutyl Ester (SADBE). Squaric Acid is not a potent sensitizer but SADBE is. We sensitize, an AA patch with 2% SADBE in Acetone (freshly prepared). 2 weeks later we do a patch test on the arm with serial dilutions of SADBE (0.001% to 1%) to determine the concentration that evoke just enough contact dermatitis. Then we painted the AA patches with that concentration weekly for about 6-12 weeks Patient will experience some itch and pigmentation. If you paint with too strong a concentration of SADBE, you will get severe acute dermatitis. You patient will run away. Results were very good. But about 20-30% patients relapse when you stop the application. Our findings will be published in Int J Derm soon. We are currently conducting a study using the same procedure to treat viral wart (comparing SADBE with liquid nitrogen application). Impression: Not effective. We are waiting to analyse the date on completion of study. Dr C L Goh National Skin Centre Singapore --------- I have experience with squaric acid for alopecia areata. Sensitize with 2% on the arm or somewhere Do test patches with 0.001, 0.01, 0.05, 0.1, and 1% to find a good erythemic dose but not vesicular. Then apply once weekly, then twice weekly, and working up to daily. Caution the patient to use gloves to apply, and expect adenopathy. the drug needs to be refrigerated and in a glass bottle. Squaric acid is available from Sigma Chemical, their catalog #S2756...5 grams is $19.60. Have your pharmacist mix it in acetone. Hope this helps. Jay Barnett, MD --------------- I sensitize them with a 2 cm by 2 cm patch of 2% DPC in petrolatum which is washed off the next day, then after a couple of weeks if they have reacted I apply 0.01% to the areas of hair loss, re-applying once or twice a week and increasing the concentration if there is not a moderate degree of erythema and pruritus. Should say I USED TO, because the results weren't good anough to justify the hassle [impetiginization, lymphadenopathy, and one case of dermographism that to months to settle down]. KC Smith, MD FRPCP Niagara Falls Ontario ---------------------- Perhaps you could drop a line to Dr. Jerry Shapiro, at the University of British Columbia Division of Dermatology. He has had extensive experience with the usage of DPCP for alopecia areata, totalis, and some universalis. Dr. Gordon E. Searles, OD, MD, MSc, FRCPC University of Alberta --------------------- --------------- ANTIGEN SOURCES --------------- Hollister Steir allergy labs has been a source for rhus antigen. They produce 1:100, 1:50, and 1:25 dilutions in a kit for oral desensitization. The dilutent is corn oil so you can customize your own dilutions. L.J. Gregg MD ------------- I have SADBE that I have used for AA from recalcitrant patches to totalis. A nearby pharmacist obtains SADBE and prepares both the sensitizing solution that I apply and also the compounded forms the patient applies. Why not have a pharmacist near you do the same thing? You may contact me directly or have your pharmacist do so. NGUZICK@eworld.com ------------------ ------ FAMVIR ------ Anecdotally, the one kid with alopecia totalis [the only patient with a good enough drug plan] is growing back his hair with Famvir 500 tid [to knock off possible CMV]. The photos are impressive. I need another few cases before I'll be convinced In the last month I've had a few patients come back who I gave up on a couple of years ago, and they are growing hair too! KC Smith, MD FRPCP Niagara Falls Ontario ---------------------- That's quite interesting about the famvir...I tried 500mg tid for a month in a patient with waxing/waning alopecia areata with no results...should I use it longer/larger doses? Steve Emmet MD -------------- This kid has been on it for about 4 months now - I want to take him off it to see how he does, if the mom will let me. KC Smith MD FRCPC Niagara Falls ON ---------------- ---- PUVA ---- Have you tried PUVA? I once grew a full head of hair on a man, not even realizing he had a.a.; I just thought he was bald. I put him in the PUVA box for severe vitiligo. The vitiligo did not improve a bit over several months, but he was one happy patient with his luxurious new scalp growth. Daniel F. Mitchell MD --------------------- I've tried PUVA for AA about 6 times - all failures, but desperate cases so maybe it would work in milder cases. I put a lady on 5% cytovene [to knock off CMV in the affected skin] in Moisturel Cream bid this week - keep you posted on her progress. Kevin Smith MD -------------- I had one pt with alopecia totalis who grew a full head of hair with PUVA. Safer than prednisone, and possibly more effective. Dan Mitchell, MD ----------------- I have several patients who did great using topical puva. Overall, my average is 60% in severe patients Guy Webster MD -------------- I'm aware of success stories too, but I recall an article a couple years ago I think in the Archives with a meta-analysis suggesting no statistically significant effect of PUVA for AA. Beware the placebo effect. Mark Ling, M.D., Ph.D. ---------------------- The article on PUVA and AA was in the Br. J. Derm. about 3 yrs ago. Its hard to argue that PUVA doesn't work in at least some bad AAs. I use topical PUVA and think that I get better results than with the po form. Guy Webster MD -------------- Jerry Shapiro, MD, the Director of tha Adult Hair Clinic, Division of Dermatology, Univ of British Columbia, 855 W. 10th Ave, Vancouver, BC, Canada V5Z 1L7 wrote a great review of Alopecia Areata Therapy in Dermatologic Clinics in January 1993. I don't know his Email address, but he was very helpful to me when I wanted to use topical immunotherapy on a patient like yours. My first therapeutic suggestion for your patient would be PUVA. When I explained the various options to my patient with alopecia almost universalis whom I wanted to treat with PUVA or topical immunotherapy, he decided it wasn't worth the trouble; I see him occasionally for atopic dermatitis, and he is still bald! Yelva Lynfield, MD ------------------ ------- ROGAINE ------- Before the patient gives up on Rogaine, have his mix it 50/50 with Retin-A solution; I've had two patients who seemed to respond to that , but who did not seem to do well on the straight commercial product. John Uhlemann MD ---------------- ------------- MISCELLANEOUS ------------- I encountered a patient who is currently 35F married who developed progressive hair loss starting at age 7. At present she is totally devoid of hair except for a few strands of white hair on the scalp. She has not been treated by anyone else. We ordered a series of labs but we feel that they will all come out normal. She has no family history of Alopecia. We thought of starting her on Predisone. Any comments? Has anybody heard of the use of thymus peptide extract in the treatment of alopecia areata? Supposedly it acts by increasing the oxygenation of the hair follicle? Jonathan Yu, MD --------------- Cyclosporine would probably be safer than prednisone if you want a systemic agent. It it were my patient, I'd try diphenylcyclorpropenone [DPC] 1st. KC Smith, MD, FRCPC ------------------- Anecdote in re hair loss, for what it's worth: A male patient in his 70s averred that while doing his water exercises in the local indoor pool, he, as well as a half dozen other exercisers, noted loss of body hair! Arms and legs and thighs. The women in the group were delighted! This apparently got worse and persisted. Could it have been excess chlorine? Bromine? He never did find out but he will investigate it. Jerry Litt ---------- ------------------------------------------------------ THE ROLE OF TRAUMA IN THE ETIOLOGY OF ALOPECIA AREATA? ------------------------------------------------------ I have recently developed several spots of alopecia areata of my left parietal and left occipital scalp regions. I attribute this to bumping my head on overhead compartments in planes. (I have been flying a lot lately.) I also have a patient -- a nurse -- who, whenever she bumps her head on her kitchen cupboard door, develops alopecia areata in exactly the area she had bumped. This has happened on several occasions with her. Any suggestions or thoughts on the matter? Any anecdotes to substantiate trauma in the etiology of alopecia areata? I'm beginning to look like a moth-eaten syphilitic! Jerry Litt MD ------------- I have recently seen several cases of alopecia areata develop in sites of recent insect bites, and in one basketball player who was elbowed during a game. I think there are some references which describe postinflammatory alopecia. My recollection is they usually spontaneously resolve. As to the mechanism, I presume that the inflammatory infiltrate is to blame, but I don't know the specific subpopulation (Th1 or Th2, or perhaps Ts cells). Any takers on a study? Dr. Gordon E. Searles, OD, MD, MSc, FRCPC University of Alberta --------------------- ------------ PIGMENT LOSS ------------ A colleague of mine has an alopecia areata patient who has responded nicely to treatment with intralesional triamcinolone 3mg/cc. The patient is very pleased except the newly regrowing hair is depigmented. I recall that there is an increased incidence of vitiligo with alopecia areata. How common is hair depigmentation at recovering sites of alopecia areata? What is the long term prognosis for this depigmentation? This patient has no evidence of vitiligo elsewhere, so far. -------------------- I've found this depigmentation is not uncommon in newly regrown hair in alopecia areata. In most of my patients after a few months, the color returns. Jere J. Mammino, D.O. --------------------- I find it very common to see depigmentation of hair after regrowth and it sometimes comes back and sometimes does not. I have had female patients complain that the white hair does not color as well as before the AA. L.J. Gregg,MD ------------- ----------------- IMMUNE MODULATION ----------------- My patient is a 41 y/o white male with a 25 yr h/o recurrent alopecia areata of scalp who has now lost all eyelashes, most eyebrows and nasal hair, and much body hair. He works with the public and fears that he will "look like a freak" and compromise his ability to make sales for his aerospace company. W/U is in progress, but thusfar appears to be healthy with normal thyroid fxn. Is there some immunologic manipulation I can initiate? Any references? Allan L. Kayne, M.D. -------------------- Regarding the question about progressive universal alopecia, there is a very good review by Wilma Bergfeld in the past several years in JAAD. She puts all of her patients on cimetidine as an immunomodulator and with the eyelash problems you a pretty well looking at systemic tx with corticosteroids with appropriate warnings of relapse. L.J. Gregg, MD -------------- Why cimetidine...? I seem to recall immunology literature suggesting that cimetidine is a weak enhancer of the immune response. If this is the case and AA is an autoimmune disease wouldn't you want to suppress the immune response? If cimetidine really does work, why not melatonin? Their is some literature on Buspar (buspirone) as an immunomodulator, it is safe, why not Buspar. Maybe Buspar, Melatonin and cimetidine (all safe) should be tried in combination? Richard J. Sharpe, M.D. ----------------------- There have been several rxderm exchanges on immunotherapy in AA. I was intrigued enough by the references to cimetidine to look up the basic immunology work on its effects and was surprised enough to find a strong scientific basis to its use. There are trials in a number of poorly treated carcinomas in conjunction with vaccines and/or cytokines. I will post some of the relevant references. Basically it appears to: 1) inhibit histamine H2-mediated release of pro-inflammatory and chemotactic cytokines (IL-1,6, GM-CSF, TNF-a,), see JBC 269:9952, 1994, JEM 174:281, 1991; 2) increase IL-2 production and synergistically with IL-2, NK & LAK cell activity; 3) inhibit Tsuppressor activity (Int Arch Allerg Immunol 97:8, 1992); 4) inhibit substance P induced inflammatory responses; 5) increase DTH responses mediated by IgE and IgG1 (JI 146:3929, 1991), and the induction of allergic contact (JID 94:441, 1990); 6) inhibit bone marrow/stem cell granulocyte production via cytokine effects. For immunomodulatory effects: cimetidine>ranitidine>famotidine. Some cimetidine immunological activity (increased NK and PBL cytotoxicity, mitogenesis) may not be duplicated with the others even after accounting for H2-binding/potency (2 or 3 reports), although no good explanation for this is evident other than non-H2 related pharmacologic actions. Note: In allotransplanted rats, cimetidine shortened graft survival, presumably by inhibiting tolerogenic/suppressive mechanisms. A renal transplant patient was reported to have granulocytopenia with NK lymphocytosis attributed in part to cimetidine, consistent with no.s 1, 2, 6, above. Also cimetidine enhanced GVH reactions in transplanted rats, synergistic with BCG stimulation. Estrogen blocks some cimetidine immunological effects, reversible by tamoxifen. These reports are something to think about when using cimetidine in cancer, allograft, BMT, AIDS, autoimmune patients that may also be on other immunomodulatory meds/tx. It also makes synergistic treatments with cimetidine attractive when these effects are therapeutic. I believe Dr. Smith's post on psoriasis therapy was supposed to be Ranitidine 300 mg BID (vs 30), but would await his/her reply. Cimetidine has been use at 400-800+ mg BID. Obviously diphencyprone or squaric acid are valid immunotherapies for AA totalis, universalis when things like cimetidine or a steroid course have not brought about a long term remission. DPCP is much easier in Canada than the US, but is being done. I have seen some great DPCP results in patients of George Cotsarelis at U. Penn.. Maria Turner has started a DPCP protocol at NIH (with Len Sperling, WRAMC) with one aim of expediting FDA approval and making people more comfortable medically and legally with using this. David J. Altman, MD, PhD ------------------------ --------- MELATONIN --------- Two questions regarding the recent post suggesting empiric trial of Melatonin for Alopecia Areata: (1) What is the rationale for use? (2) How do we really know it is safe? My understanding is that melatonin is readily available in health food stores; with all due respect, I wonder how rigorous the quality control and testing is for some of the products sold under these circumstances. As an aside, I remember quite distinctly my psychiatry attending in med school advocating the use of tryptophan for insomnia--it was supposedly a "safe", "natural" alternative to benzodiazepines. Tryptophan was also readily available in health food stores, and was quite the rage for a while. Marty Okun MD -------------- The reports on melatonin are in back line journals from S. American and Italian groups mostly. They suggest that melatonin is "immunoenhancing" based on increased ADCC activity, and may increase NK, and antibody T-dependent responses in cytoxan treated animals. It is suggested that this is due to a decrease in steroid receptors in T cells, and may decrease stress-induced immune suppression from increased endog steroids. This does not work with exogenous steroids and possibly not in winter or different times of day either, and regular visible light exposure produced similar findings. Trials in Italy on terminal cancer patients found IL-2+melatonin gave more partial responses than no treatment at all...no comparison seen with IL-2 alone! Other reports suggest melatonin enhances anti-collagen II induced arthritis in mice, and increases pro-inflammatory IL-1a,b from monocytes tx with LPS (JI 153:2671, 1994). Buspirone is really sparse. A couple of reports from a group in Spain showing that 5-HT-1A anxiolytics at low doses injected i.p. were "immunoenhancing" by decreasing the stress (loud noise) induced increase in influenza titers in mice and augmenting phagocytosis and NKCC, but double the dose caused significant immunosuppression. Commercial melatonin varies greatly in bioavailability, absorption, fillers, shelf life, as there is no regulation or guidelines. Given the above my _opinion_ is these are next to " laetrile" at this point. Marty's point on the effects of contaminants in L-tryptophan are especially noteworthy given this variability in preparations. It may be that seeing some sunlight, having any anxiolytic, or perhaps a well deserved cocktail may do as much "immunoenhancing" in response to stress. I will try it out and post the results another time! David J. Altman, MD, PhD Dermatology Branch, NCI, NIH ---------------------------- --------------------------- INTRAMUSCUALR TRIAMCINALONE --------------------------- Alopecia totalis or universalis patients deserve a three or four month trial of injectable triamcinolone, 40mg each month. I did this on a lady who had been totally bald for 7 years (in 1976) I still see her today. She had complete hair regrowth, never lost it again. Other patients have had poor response, but the several who have done spectacularly well are worth the try. Haines Ely MD, Grass Valley, Ca. ----------------- I would concur with Haines Ely that IM TMC40 is a worthy trial as I have had two successes such as his, both is women who had universalis for >3 years L.J. Gregg,MD ------------- ------------------------- INTLESIONAL TRIAMCINALONE ------------------------- I also use Kenalog 3 mg/ml in the eyebrows [and scalp] with usually good results, and occasionally a bit of atrophy. It's good to photograph them before you start treatment, so patients and myself can see hou they're progressing. KC Smith MD FRCPC Niagara Falls ON ---------------- I have had to inject the eyebrows of one of my AA patients every 6 weeks for the past 4 years. The results have been good with occasiona reversible atrophy. The growth is about 80% and sometimes a little patchy. I use triamcianalone acet. 3mg ml, about 0.5 cc per brow. William Liss MD --------------- We have been using Kenalog 5mg/ml mixed with aristospan 5 mg/ml with regrowth usually within one month. we also noticed that the regrowth is usually depigmented but usually in the next hair cycle the hair is pigmented but thinner in texture. The use of Aristospan enables us to inject the patient q 4 to 6 weeks instead of the plain Kenalog q 2 weeks. Jonathan Yu MD -------------- -------------- THYMUS EXTRACT -------------- Has anybody heard of the use of thymus peptide in preventing loss or thinning hair? A company Pentapharm LTD (Switzerland) sent me a paper which sites the use of thymus extract. Its role is to improve cell respiration and cell's ability to obtain and utilize oxygen. They proposed that one cause of increased hair loss and insufficient hair growth was inadequate oxygen supply. Any comments? Jonathan Yu, MD -------------- -------------------------------------------------- THE ANGST ASSOCIATED WITH TREATING ALOPECIA AREATA -------------------------------------------------- In our therapeutic discussion on alopecia totalis (AT) or universalis we tend to forget that this is a condition unlike most other skin diseases, from the cosmetic point of view.It may be devastating psychologically to lose hair but it is equally unacceptable to regrow some hair here and there on the scalp and lose it again. One cannot adjust to functioning in a wig, then to living without it because there was some regrowth, only to be resigned to it again because the hair fell out after all. In other words a therapeutic success would have to be complete and permanent or it should not be called a success. As physicians we may be excited that certain esoteric methods are "promising" and work "great" for rare patients but, in my experience,from most patients' point of view it is easier to get adjusted to no hair whatsoever than to cosmetic "four seasons" taking turns on one's scalp. A truly effective treatment for alopecia totalis should work "great" like an airplane - on ALL flights. Such therapy does not exist at the present time. It might be fair to admit to ourselves and to our patients with AT that cases of long term cosmetically acceptable regrowth (defined as almost all hair back)are so rare that the financial and psychological cost of a long and fancy treatment may not be justified. Of course, in limited alopecia areata, like in psoriasis and many other skin conditions, any improvement will be appreciated by the patient and few methods, no matter how controversial, are not worth trying. But this is a different category. Chris Dabski, M.D. ------------------ While what you say has much merit, I would be cautious as a physician about issuing a general proclamation to patients on what they should or should not be "allowed" to do in the interests of what might be considered cosmetic disease. While cycles of hair growth and alopecia are far from ideal, some patients are willing, with full insight into the risks of subsequent loss, to undergo what might be considered experimental therapies. Ultimately such complex decisions must involve the patient's desires, not just our preconceived notions of what they should do ("just learn to live with a wig"). To take your own analogy, I treat many of my severe psoriatics with all kinds of potentially toxic therapies, none of which CURE the disease. In many cases they will continue to flare and remit over time, though hopefully not too often. To say that this up and down course is worse than simply learning to "live with the disease" seems contrary to much of what we do as dermatologists. Mark Ling, M.D., Ph.D. ---------------------- In psoriasis, like in many other dermatoses any improvement is appreciated and should be attempted. We as physicians have the duty to make those attempts even though there are no guarantees of success. However alopecia totalis is in a different class.In my opinion a partial success or a temporary success is of little value. Ask any of your patients with no hair if they are willing to go through months of PUVA, consultations in dermatology clinics sometimes in far away cities etc. to grow a couple of random,ugly looking patches of hair on their scalp with an almost 100% chance of losing even them without regular injections or other heroic measures.Psoriasis is usually hidden under your shirt, alopecia is right on top of your scalp and it is difficult to hide it. this is the difference. Chris Dabski, M.D. ------------------ I certainly agree that a few whisps of hair are not an acceptable result warranting long term, costly, repeated treatments, and we should be realistic with the patients. However, I disagree that this is any different than psoriasis is (truly a heartbreak in those severely affected). Before UVB, PUVA, etretinate, MTX were accepted/standard therapies this same discussion would have occurred. These therapies exist because curious, intellectual, investigative clinicians and clinician-scientists working with affected, hopeful patients went ahead in trying _rational_ therapies in the _hope_ of ameliorating their disease, but without a promise of cure or even permanent results. Because of our different backgrounds and experiences there are different ideas of "rational", "accepted", and "standard", but our peers and profession will provide judgement ultimately on appropriate investigational therapies whether it is DAB-IL-2 for MF or psoriasis, DPCP for AA, or other genetic, immunosuppressive or cytotoxic agents. I recognize Dr. Dabski's concerns, but if we freeze our therapeutic choices, or stop trying to better treat non-lethal disease, we surrender to the very ideas the worst in managed care are trying to institutionalize and nurse-practitioners, or computer programs, will be able to do the job. The "job" just will not be worth doing, nor will it be the practice or art of medicine. David J. Altman, MD, PhD ------------------------ ----------------------- DYE AND ALOPECIA AREATA ----------------------- Have a lady whose alopecia areata is growing back with white hair. I suggested she dye the hair a dark shade to get better cosmetic coverage, but some of the hair is not taking up dye properly. Anyone seen this before? Any ideas why this is happening? Sorry I don't know what type of dye she's using. KC Smith MD FRCPC ----------------- One would suspect that this is due to structural abnormalities in the regrowing hair, which is clearly not normal as yet. Since I don't know what structure of the hair actually takes up dye, it would be sheer speculation to guess what that means. This may be a clue to some of the structural abnormalities in alopecia areata. A brief search of MEDLINE did not find any reports that involved "hair dyes" and "alopecia areata" so it might even be reportable. Mark Naylor MD -------------- I have seen this with several patients but the color returned to normal with time. They also complained that the hair wouldn't take dye. Roger Ceily MD -------------- Permanent oxidative hair dyes penetrate the hair shaft and covalently polymerize in the shaft. The polymers formed by oxidative products of paraphenylenediamine are too large to diffuse out of the hair shaft. It is probable that most of the polymerized product is deposited in the medulla. If the patient with alopecia areata had vellous hairs, with a minimal medulla, this may explain the poor result with hair dyes. Semi-permanent, and temporary hair dyes are deposited on the exterior of the hair shaft and should not have this problem. Richard Kalish MD ----------------- ----- CASES ----- I was asked by another doc if I could put a name to this: 12-year old boy with alopecia areata (heading toward totalis), nail pitting (apparently classic for aa), atopic dermatitis, psoriasis (by biopsy), and an undetermined myeloproliferative disorder, initially thought to be leukemia. Curiously, the boy's father has alopecia totalis, and the mother has hypothyroidism and vitiligo. My first thought was some environmental factor producing this conglomeration of immune-based diseases. Anyone out there have a more definite answer? Chris Scholes ------------- Whatever the gene is for autoimmune diseases like alopecia areata and vitiligo, your poor boy has a double dose. I would refer the family (or consult) one of the big academic centers where they can study them further; the Alopecia Areata Foundation can put you on the right track, if none of our Rx-Derm group voluinteers. Yelva Lynfield, MD ------------------ Is the syndrome Polyglandular autoimmune syndrome type I or II or III? According to Harrison's, Type I may be associated with hypothyroidism, hypoPTH, alopecia, vitiligo whereas type II may be associated with autoimmune thyroid disease, vitiligo and alopecia. If we assume a relative common association of atopic dermatitis with alopecia areata, and possibly a mundane association of psoriasis which can occur in up to 2% of the general population, then one of these syndromes may indeed fit with the patient. If that is the case, the child and parents should be evaluated for other underlying endocrine dysfunction, diabetes, pernicious anemia and celiac disease, and possibly myasthenia gravis. I saw a patient last year referred to the immunodermatology clinic for an ugly fingernail. On history, he had a thymoma about 12 years prior and what struck me most on physical exam, aside from the yellow fingernail (culture candida albicans), was a bizarre inequality in the appearance of his eyelids. Evaluation revealed hypothyroidism and the neurologist felt there were early signs of myasthenia gravis. All these signs were subtle. Polyglandular autoimmune syndrome was the final diagnosis. (Fitzpatrick calls it CMC with myasthenia gravis). But, what was so striking to me about this case was the subtlety of all signs. This was an elderly male, in good health with one ugly fingernail, a funny looking right eyelid, and some skin flaking. PGA does not have to be obvious, but the constellation of findings in this patient and his parent do suggest it. Warren Winkelman, MD, FRCPC --------------------------- I have a patient who I have know for quite some time. She always had a glorious head of thick blond hair. About 8 months ago she suddenly began losing her hair diffusely on the scalp. No pregnancy, no bcp's, no recent surgery or fevers however she was getting divorced and having some additional stress on her job. The loss of her hair, which is extremely important to her self image, was also contributing to her stress. Her hx and phys exam was unremarkable except for her hair loss. Initial work-up, including scalp bx, revealed nothing unusual and a working dx of telogen effluvium was established. She was given continual reassurance that this process would reverse. About one month ago her hair began to grow and we were seeing mulitple short hairs sprouting everywhere. Today she calls saying that over the past few days she has begun rapidly losing all of these short hairs. Some additional hx also revealed itself. Her mother began losing her hair in a similar manner at the same time as she did and the only commonality was they were together on her brother's ranch in Washington state. The water supply there is well water. There were no unusual activities, no medications, etc. However her sister in law and brother do not report hair loss. Could this be due to heavy metals in the water? If so what testing would you do to detect this best (ie urine, hair, blood). Any other thoughts on dx or rx? Jeff Marmelzat, M.D. -------------------- If it is really stress related, this makes me think of alopecia areata totalis in an atopic (if she is). This might also help explain a familial link, but I would be concerned that the coincident loss in her mother is suggesting exposure to a toxin, and I would not rule out the possibility that this was deliberate. Mark Naylor, M.D. ----------------- I think you are compelled to check it all out, especially since Dr.Naylor has metamorphed into Miss Marple and has astutely pointed out the possibility of deliberate poisoning. Did you notice any lateral brow loss? Thallium is a biggee in well water. Remember sometimes the criminal poisons herself a smidge as well to avoid suspicion. Paticia Cornwall Thaler ----------------------- I'd vote for a repeat biopsy with transverse sections, read by a dermpath who reads these on a regular basis. You should at least be able to address the issues of chronic TE and diffuse AA. Mark Ling, M.D., Ph.D. ---------------------- I like the idea of a biopsy in terms of a well rounded workup, but I think a gentle pull, or pluck, can differentiate between TE and AA. Diane Thaler ------------ Another thought: Chronic and recurrent telogen effluvium isn't all that rare. James R. (Jay) McCarty, M.D. ---------------------------- I agree. I'd tug 10 hairs. If more than two or three come out with a fairly gentle tug, she probably has telogen effluvium. Dan Mitchell, MD ---------------- ------- PROSCAR ------- Has anyone used Proscar (oral) for male alopecia? Is it safe? Are there any legal ramifications as a non FDA approved drug for alopecia? Dose???? Ken Edelson ----------- Proscar is a Type-II 5-alpha-reductase inhibitor; the type found in the prostate. The type found in the scalp is a Type-I isoenzyme. When at LSUMC in Shreveport, I was a P.I. for two studies using finasteride for male pattern baldness. Studies showed growth at around 2mg/day but this was vertex growth (like Rogaine) and not bifrontal (like Rogaine). Also, Merck is still trying to enter data into the halls of the FDA on even lower doses, so I, personally, am not extemporaneously compounding or prescribing it, YET! Studies show growth but how much, how long, how satisfying, etc. is not known yet. Patrick R. Carrington --------------------- Actually Vera Price has had a study on low-dose Proscar for male alopecia. I spoke with her a year or so ago and she said that she felt it worked well. "Only" problem was impotence reported in a low percentage. She said patients were very enthusiastic. Just a reminder before everyone gets very creative with this drug: Proscar (finasteride) is FDA Pregnancy Category X, and its use is absolutely contraindicated both in males and females of child-bearing capacity. Barbara R. Reed, MD ------------------- Both type I and type II isoforms of 5-alpha-reductase are found in the hair follicles of the scalp. Probably the best study was by Eichler et al. in British Journal of Dermatolgy (133:371; 1995) They localized type I to the dermal papilla, matrix cells, and outer root sheath. Type II was primarily in the inner root sheath and matrix cells. Both types were in the sebaceous gland. Type I localization more or less parallels testosterone receptor localization, presumably because 5-alpha-reductase converts testosterone to dihydrotestosterone (DHT) that subsequently binds to the receptor with high affinity. What all of this means with respect to androgen-mediated follicle miniaturization that is the tell-tale sign of androgenetic alopecia is unclear at this point. However, Merck does claim to achieve "60-70%" response rates using finasteride in patients with androgenetic alopecia, and they also claim that 0.5 mg per day (and possibly less, even 0.1mg) works just as well as 5 mg/day (the dose for benign prostatic hypertrophy). As far as I know, none of this work has been published, except in abstract form. I would also be interested in hearing about anyone's experience with this drug in treating male pattern alopecia (keep in mind that women with child-bearing potential should not take finasteride, because male fetuses may have ambiguous genitalia if mom takes it while pregnant!). George Cotsarelis, M.D. ----------------------- I know one 40 year old male who used proscar for one year for male pattern hair loss (2.5mg/day). No regrowth of hair or sideeffects were seen. William Liss ------------ Merck is deep into the long-term extension phase of their Phase III trials with finasteride for MPB. The data from the pivotal initialk 9 month trial are back in-house, and presumably being analyzed now. The trial is currently planned to extend at least two years beyond termination of the initial 9 month phase. It's way to soon (without breaking the blind) what the results will be but keep tuned since I'd guess they will begin to release data by the end of the year. BTW, the final finasteride dose chosen for the study was 1 mg. qd. Finally, this is a drug with potential impact on male sexual function (which is an important part of the clinical trial). Furthermore there is at least a theoretical risk of feminization of the embryo even if it is the male using the drug, based on transfer of drug via semen. I'm usually pretty aggressive about off-label drug use, but this is one where at the very least I'll wait for the data from the 9 month trial. Mark Ling, M.D., Ph.D. ---------------------- ------------ SQUARIC ACID ------------ I saw a pt with recurrent alopecia areata today. Her doctor had prescribed squaric acid to apply to the scalp. She has the typical loss and regrowth, loss and regrowth pattern so common to aa, so it is not possible to know if it helps her. Does anyone have experience with squaric acid in this condition? Jerry Eisner ------------ I've definitely used it with success. This issue is just getting them sensitized. In patchy AA, it would be very difficult to estimate success vs. spontaneous resolution (of course, that might be the same for all our other measures too), but in totalis/universalis, it can be dramatic when you get significant growth in the area sensitized. Eliot N. Mostow, MD, MPH ------------------------ Squaric acid dibutyl ester has been used for alopecia areata as a sensitizer. I have no experience using it due to its high expense, but it presumably works in a similar fashion to DNCB which I have used with amazing results, even in cases of alopecia totalis. Ben Treen --------- "To evaluate the possibility that aberrant T-cell-mediated immunity might be the cause of alopecia areata, thymopentin was compared with and found to be equivalent to such topical sensitizing therapies as squaric acid dibutylester and diphencyprone (Tosti et al. 1988). However, thymopentin was not effective in patients with alopecia totalis who were not responsive to sensitizing therapy (Tosti et al. 1991). Thymopentin, administered intravenously three times a week, was effective in treating four patients with Sezary syndrome (a form of cutaneous T-cell lymphoma). A 50-mg dose reduced itching, edema, scaling, and thickening, and it cleared erythroderma (Bernengo et al. 1988, 1992). " (From A Review of the Pharmacology, Clinical Applications, and Toxicology of Thymopentin . J. Steve Christian Asheville, North Carolina) Giorgio Rialdi -------------- I saw a pt with recurrent alopecia areata today. Her doctor had prescribed squaric acid to apply to the scalp. She has the typical loss and regrowth, loss and regrowth pattern so common to aa, so it is not possible to know if it helps her.Does anyone have experience with squaric acid in this condition? Jerry Eisner ------------ The group in Madison that was using it several years ago when they were quite excited about it is no longer using it. It didn't work well enough. Diane Thaler ------------- We have used cyclosporine for 6 months in 8 patients with severe chronic AA. It produced cosmetically acceptable results in 2/8 but had some serious side effects in many of our patients. Treatment had to be continued to maintain hair growth and we could not go less than 3.5 mg/kg/d for maintenance. This will be published fully in JAAD next year. Overall, the success rate is low and side effect profile high. Jerry Shapiro, MD, FRCPC ------------------------