In situ demonstration of T cells in alopecia areata

A "hair-raising" history of alopecia areata

A 3500-year-old papyrus from ancient Egypt provides a list of treatments for many diseases including "bite hair loss," most likely alopecia areata (AA). The treatment of AA remained largely unchanged for over 1500 years. In 30 CE, Celsus described AA presenting as scalp alopecia in spots or the "windings of a snake" and suggested treatment with caustic compounds and scarification. The first "modern" description of AA came in 1813, though treatment still largely employed caustic agents. From the mid-19th century onwards, various hypotheses of AA development were put forward including infectious microbes (1843), nerve defects (1858), physical trauma and psychological stress (1881), focal inflammation (1891), diseased teeth (1902), toxins (1912) and endocrine disorders (1913). The 1950s brought new treatment developments with the first use of corticosteroid compounds (1952), and the first suggestion that AA was an autoimmune disease (1958). Research progressively shifted towards identifying hair follicle-specific autoantibodies (1995). The potential role of lymphocytes in AA was made implicit with immunohistological studies (1980s). However, studies confirming their functional role were not published until the development of rodent models (1990s). Genetic studies, particularly genome-wide association studies, have now come to the forefront and open up a new era of AA investigation (2000s). Today, AA research is actively focused on genetics, the microbiome, dietary modulators, the role of atopy, immune cell types in AA pathogenesis, primary antigenic targets, mechanisms by which immune cells influence hair growth, and of course the development of new treatments based on these discoveries.

Alopecia areata

Alopecia areata (AA) is a nonscarring, autoimmune, inflammatory, hair loss on the scalp, and/or body. Etiology and pathogenesis are still unknown. The most common site affected is the scalp. Histopathology is characterized by an increased number of the catagen and telogen follicles, the presence of inflammatory lymphocytic infiltrate in the peribulbar region ("swarm of bees"). Corticosteroids are the most popular drugs for the treatment of this disease. Etiologic and pathogenic mechanisms, as well as other current treatments available will be discussed in this article.

Cutaneous manifestations in celiac disease

Celiac disease (CD) is an autoimmune gluten-dependent enteropathy characterized by atrophy of intestinal villi that improves after gluten-free diet (GFD). CD is often associated with extra-intestinal manifestations; among them, several skin diseases are described in CD patients. The present review reports all CD-associated skin manifestations described in the literature and tries to analyze the possible mechanisms involved in this association. The opportunity to evaluate the possible presence of CD in patients affected by skin disorders is discussed.

Celiac disease and alopecia areata: report of a new association

Celiac disease is frequently associated with other autoimmune disorders but has never been reported in association with alopecia areata. In a routine clinical practice, 3 patients with such an association were observed. In one of the patients, celiac disease was diagnosed after the occurrence of malabsorption symptoms. In the youngest patient, a 14-year-old boy, gluten-free diet resulted in complete regrowth of scalp and body hair. A prospective screening program for celiac disease using antigliadin and antiendomysial antibodies was therefore set up in 256 consecutive outpatients with alopecia areata. Three patients, all completely asymptomatic for intestinal diseases, were found to be positive and underwent biopsy. Histological analysis showed a flat intestinal mucosa consistent with the diagnosis of celiac disease. The results show that alopecia areata may constitute the only clinical manifestation of celiac disease and that the association between these two conditions is a real one because the observed frequency of association is much greater than can be expected by chance. It is suggested that antigliadin and antiendomysial antibodies should be included in the work-up of patients with alopecia areata.

Dapsone versus topical immunotherapy in alopecia areata

Twenty-seven patients with severe alopecia areata were treated with dapsone. The results of a mean treatment duration of 10 +/- 0.5 months are reported, and compared with the results of long-term topical immunotherapy obtained previously at the same institute. The efficacy of dapsone proved to be markedly inferior to that of topical immunotherapy. The percentage of patients showing regrowth of hair during treatment with dapsone was comparable with the occurrence of spontaneous regrowth of hair reported in the literature.

Ulcerative colitis and total alopecia in a mother and her son

Extraintestinal autoimmune disorders are associated with ulcerative colitis in selected patients and lend support to the theory of immune-mediated injury in inflammatory bowel disease. Rarely, alopecia areata has been associated with ulcerative colitis, and familial aggregation and an HLA association have been reported for both disorders. The occurrence of both alopecia and ulcerative colitis in a mother and son are reported with a detailed investigation of antineutrophil cytoplasmic antibodies and HLA alleles in this family. Treatment with the immunosuppressive agent cyclosporine proved beneficial in the child leading to remission of the ulcerative colitis and nascent growth of scalp and body hair.

Alopecia universalis treated with oral cyclosporine A and prednisolone: immunologic studies

Alopecia universalis is a refractory condition. Although the cause of this disease is unknown, immunologic abnormalities have recently been suspected. Thus, we treated six cases of refractory alopecia universalis with immunotherapy. Oral administration of cyclosporine A (2.5 mg/kg) and prednisolone (5 mg/day) resulted in marked symptomatic improvement. Cyclosporine A did not produce any side effects because the administered dosage was relatively low. At present, more than 6 months after the cessation of treatment, recurrence of alopecia has not been seen. Oral administration of low-dose cyclosporine A and prednisolone is considered to be an effective treatment for this disease. Immunologic examination of peripheral blood demonstrated improvement of immunologic function. In particular, CD8-positive T cells, NK cells, and C3, which had been reduced, were increased. A reduction in active CD4 cells, eosinophils, and circulating immune complexes was observed. Histology with fluorescent antibodies showed T-cell infiltration around the hair matrixes. This phenomenon was no longer observed after treatment. These improvements in immunologic function were seen in parallel with the resolution of the clinical symptoms, indicating that immunologic abnormalities are related to this disease.

Hair growth on nude mice due to cyclosporin A

One of the most common dermatological side effects of cyclosporin A (CsA) is dose-dependent hypertrichosis. Similar hair growth was noted in nude mice in an attempt to increase the acceptance of human xenografts with CsA in the T-cell-deficient congenitally athymic nude (nu/nu) mice. The aim of the present study was to further investigate the stimulation of hair growth on nude mice not only by oral administration of CsA but also by topical and subcutaneous administration of CsA. Young BALB/c female nude mice were treated for 3 or 4 weeks with topical, oral, or subcutaneous applications of CsA dissolved in olive oil at various doses. The hair of CsA-treated mice appeared to grow from 7 days after the treatment, even at low doses. Induced hair growth was dose-dependent and became clearly obvious 3 weeks after the treatment. The stimulation of hair growth was not restricted to the site of topical application. The distribution of the new hair depended on the natural pattern of hair growth in the mice. However, there was no hair growth in the control mice which were given only olive oil. Histological examination revealed that there were no differences in the structures of skin and hair between the control and the CsA-treated mice. Furthermore, the number of hair follicles did not remarkably increase after CsA treatment. The hair growth in the CsA-treated mice stopped after cessation of the treatment and returned to the level of the control mice on day 14 after the end of the treatment. Subsequent retreatment with CsA resulted in further regrowth of the hair.(ABSTRACT TRUNCATED AT 250 WORDS)

Immunobiological studies on the alopecic (DEBR) rat

The Dundee experimental bald rat (DEBR) has been proposed as an animal model of human alopecia areata, which is suspected of being an autoimmune disease. This study was carried out to establish whether the immunological changes observed in the lesional DEBR rat correlated with studies of human alopecia areata. The immune infiltrate was characterized using immunoperoxidase techniques on cryostat sections of vibrissa follicles. Indirect immunofluorescence was used to quantify the peripheral blood leucocytes. Some parallels were observed in the infiltration of human and DEBR rat follicles by T lymphocytes. In contrast, pre-lesional DEBR rat follicles, which are not available for investigation in human alopecia areata, were not penetrated by leucocytes and MHC class II antigens were expressed in the precortical region of the epidermal component of these follicles. Quantification of peripheral blood leucocytes showed significant increases in both T-lymphocyte subsets during lesional expression. We consider that the pre-lesional form of the rat may provide important information as a model for the pre-lesional and uninvestigated form of alopecia areata in man.

Cyclosporine in dermatology

Cyclosporine is a potent immunosuppressive agent with no appreciable effect on the bone marrow and a selective inhibitory effect on helper T cells. Oral cyclosporine was first used to prevent organ rejection but also has been reported to be effective in other disorders. In cutaneous diseases that respond to oral cyclosporine helper T cells appear to be involved in their pathogenesis. This article reviews the cutaneous diseases that have been treated with cyclosporine and its pharmacology and side effects. Two significant adverse side effects are renal dysfunction and hypertension, both of which are reversible when short-term low-dose (less than 5 mg/kg per day) oral cyclosporine is discontinued. Lymphoma is unlikely in an otherwise healthy patient who has received low-dose oral cyclosporine for limited periods. The use of oral cyclosporine in any patient should be carefully considered in terms of the risk/benefit ratio and needs to be carried out under close medical supervision. In view of the limited experience with cyclosporine in dermatology, whenever possible its use should be confined to formal clinical studies with established protocols and guidelines. Further controlled studies need to be performed to evaluate the efficacy of low-dose cyclosporine in many dermatoses and its side-effect profile, particularly over the long term.

Diphencyprone in the treatment of long-standing alopecia areata

Thirty-six patients with alopecia areata of 1-54 years duration entered a study of treatment with the contact allergen diphencyprone for 8 months. Following sensitization the diphencyprone was applied to one half of the scalp at weekly intervals, the other half acting as a control. Once hair growth was established on one side, the other side was treated. Seven patients did not continue treatment and one patient showed spontaneous regrowth. Of the remaining 28 patients who persisted with treatments, fourteen (50%) regrew hair on the treated side; eight (29%) had a cosmetically acceptable result with the regrowth of terminal hair over the whole scalp. No statistically significant differences were found in age or duration of alopecia between those who regrew and those who did not. We have found diphencyprone to be an effective stimulator of hair growth in patients with severe and long-standing alopecia areata.

Response to minoxidil in severe alopecia areata correlates with T lymphocyte stimulation

Mitogen-induced T cell blastogenesis was determined in 47 patients with severe alopecia areata, before and after treatment with topical 5% minoxidil, and compared with control values. The group of 36 responders, who demonstrated terminal hair regrowth, showed significantly increased lymphocyte stimulation with concanavalin A and PHA before treatment, which decreased towards control values following hair regrowth. Lymphocytes from non-responders showed no significant differences from controls either before or after treatment. The results suggest that enhanced T cell blastogenesis may predict the response of severe alopecia areata to topical 5% minoxidil therapy.

Abnormal expression of class I and class II major histocompatibility antigens in alopecia areata: modulation by topical immunotherapy

Fifty-eight scalp biopsies were immunohistologically investigated with monoclonal antibodies against HLA-ABC, HLA-DR, and T6 antigens. The following 3 groups were compared: control biopsies obtained from healthy volunteers (n = 5) or patients with unrelated scalp diseases (n = 6); biopsies from untreated alopecia areata (AA), obtained either from untreated patients (n = 19) or from the untreated side in patients receiving unilateral treatment with the contact allergen diphencyprone (DCP) (n = 13); biopsies obtained from the treated side in patients receiving unilateral treatment with DCP (n = 13). While HLA-ABC antigens were strongly expressed by epidermal keratinocytes and the infundibular epithelium of hair follicles in all biopsies, these antigens were either not detectable or only faintly expressed on the subinfundibular epithelium and the hair matrix in the control series. By contrast, 30 out of 32 biopsies from untreated AA showed expression of HLA-ABC antigens on hair matrix epithelium, and the subinfundibular epithelium was HLA-ABC-positive in 15 out of 32 cases. In the biopsies from treated AA, HLA-ABC antigens were expressed on hair matrix epithelium in 9 out of 13 cases, and on the subinfundibular epithelium in 1 case. In the controls and untreated AA, HLA-DR expression was confined to dendritic cells in the epidermis and the follicular infundibulum. Its expression on hair matrix epithelium was found in 15 out of 32 biopsies from untreated AA and in 4 out of 13 biopsies from treated AA. In the control series, intrabulbar T6+ dendritic cells were either absent or present in low numbers. High numbers of intrabulbar T6+ cells were present in 7 out of 32 biopsies from untreated AA and in 0 out of 13 biopsies from treated AA. The data show that abnormal expression of class I major histocompatibility (MHC) antigens on hair matrix epithelium is a constant feature in AA, whereas class II MHC antigens are less frequently expressed. Topical immunotherapy with DCP, which induced expression of HLA-DR in epidermal keratinocytes in 6 out of 13 cases, reduced the abnormal expression of both HLA-ABC and -DR antigens in the epithelium of lower hair follicles in AA.

Topical immunotherapy changes the composition of the peribulbar infiltrate in alopecia areata

It has previously been shown that, in patients with untreated progressive alopecia areata (AA), the peribulbar T4/T8 ratio is about 4:1. In the present study, the immunohistochemical findings obtained in untreated AA patients were compared to those obtained in patients who had received topical immunotherapy with diphencyprone. The untreated group consisted of 5 patients with progressive AA and 5 patients with inactive AA. The treated group consisted of 5 patients with a good response to diphencyprone and 5 patients with little or no hair regrowth after treatment. In untreated patients with progressive AA, the mean peribulbar T4/T8 ratio was 4:1, whereas in untreated patients with stable AA, the ratio was 2:1. In the treated patients with a good response to diphencyprone, the mean T4/T8 ratio was 1:1, while in the patients with poor or no response to treatment, the ratio was 0.7. In conclusion, topical immunotherapy considerably alters the peribulbar T4/T8 ratio in AA. The results are consistent with, but do not prove, the concept of topical immunomodulation.

Tissue-specific autoantibodies and autoimmune disorders in vitiligo and alopecia areata: a retrospective study

We retrospectively analyzed our laboratory reports of tissue-specific autoantibodies (TSA) in 38 patients with alopecia areata (AA) and 31 patients with vitiligo. These reports were based on standard indirect immunofluorescence (IF) procedures, employing monkey tissues as substrates. One or more TSA were detected in 39% of serum samples. Thyroid (microsomal and/or thyroglobulin) antibodies had the highest occurrence rate and, as compared with the normal population, were detected at a greater frequency in both vitiligo and AA. Over half (58%) of our patients with vitiligo had one or more detectable TSA, while only 28% of patients with AA had such antibodies. When compared with the normal population, the occurrence rate of TSA was higher in patients with vitiligo. The only remarkable finding in AA was a higher than normal occurrence rate of antithyroid antibodies.

Alopecia areata: pathogenesis and treatment

Although its etiology remains unknown, evidence has accumulated to support an autoimmune pathogenesis for alopecia areata. Our review summarizes the immunologic data and also examines the role of genetics, atopy, and psychologic stress in this disorder. Until etiology is better understood, treatments for alopecia areata are likely to remain palliative. Nevertheless, newer therapies such as photochemotherapy, topical immunotherapy, and perhaps systemic immunotherapy (e.g., inosiplex) offer new hope for patients with extensive disease.

Immunohistochemical and electron microscopic characterization of the cellular infiltrate in alopecia (areata, totalis, and universalis)

The inflammatory cell infiltrates in scalp skin of 35 patients, 20 with alopecia areata (AA), 7 with totalis, and 8 with universalis were characterized with the ANAE (alpha-naphthylacetate esterase) marker, monoclonal antibodies, and electron microscopy. As demonstrated by the ANAE staining, no clear difference in the main lymphocyte subclasses (T and B cells) or macrophages was seen between the different types of alopecia or as compared to control patients' scalp skin. However, T lymphocytes and macrophages were seen most frequently and in greater numbers perivascularly and infiltrating the hair bulb in those cases of AA where active hair loss took place. Using monoclonal OKT (OKT-3, -4, and -8) antibodies and the avidin-biotin immunoperoxidase method on frozen sections, a concentration of OKT-8 reactive cells (suppressor/cytotoxic T cells) was seen peribulbarly and invading the hair infundibulum. The cells affecting the hair infundibulum were further studied by electron microscopy. They could be classified into three main types: small lymphocytes (60%), macrophages (30%) and cells closely resembling large granular lymphocytes (LGL) (10%). LGL have previously been considered to be human natural killer (HNK) cells. Thus the hair follicle seems to be the target for the cellular immune response in alopecia. Whether HNK cells participate in the destruction of hair bulbs remains to be investigated.