Alopecia universalis in a patient with rheumatoid arthritis developed during treatment with adalimumab

Learning From Success and Failure: Biologics for Non-approved Skin Diseases

The impressive potential of biologics has been demonstrated in psoriasis, hidradenitis suppurativa, and urticaria. Numerous biologicals are entering the field for a restricted number of skin disorders. Off-label use of biologics in other recalcitrant skin diseases has increased. Mounting data point to the potential of already existing biologics acting on the IL-17/IL-23 pathway in skin disorders with epidermal hyperkeratosis (e.g., pityriasis rubra pilaris), acneiform inflammation (e.g., hidradenitis suppurativa), and loss of mucosal integrity (e.g., aphthosis). TNF-α blockers are also effective in the latter conditions but seem of particular value in granulomatous (e.g., granuloma annulare) and neutrophilic disorders (e.g., pyoderma gangrenosum). Failure of IL-17 blockade in skin diseases resulting from immune-mediated cell destruction (e.g., alopecia areata and vitiligo) illustrates its limited involvement in Th1-dependent skin immunology. Overall, disappointing results of TNF-α blockers in alopecia areata and vitiligo point to the same conclusion although promising results in toxic epidermal necrolysis suggest TNF-α exerts at least some in vivo Th1-related activities. Acting on both the Th1 and Th17 pathway, ustekinumab has a rather broad potential with interesting results in lupus and alopecia areata. The efficacy of omalizumab in bullous pemphigoid has revealed an IgE-mediated recruitment of eosinophils leading to bullae formation. Reconsidering reimbursement criteria for less common but severe diseases seems appropriate if substantial evidence is available (e.g., pityriasis rubra pilaris). For other disorders, investigator- and industry-initiated randomized clinical trials should be stimulated. They are likely to improve patient outcome and advance our understanding of challenging skin disorders.

Alopecia Universalis in a Case of Rheumatoid Arthritis after Treatment with Etanercept

Alopecia universalis (AU) is a condition which causes generalized hair loss of the body. It is postulated that autoimmunity plays an important role in its pathogenesis. It is characterized by the involvement of multiple inflammatory cytokines such as tumor necrosis factor-alpha and multiple interferons. Hence, biologics like tumor necrosis factor alpha (TNF-α) antagonist may be used to block this inflammatory process. It is not very commonly appreciated that the use of biologics can lead to alopecia areata. Here, we report a case of severe alopecia areata which progressed to AU after etanercept administration. We here describe a 23-year-old unmarried female who was a known case of rheumatoid arthritis who developed AU after 6 months of continuous treatment with etanercept. TNF-α antagonist may not play a sufficient role in the treatment of alopecia areata. There exists a strong and significant connection between TNF-α blockers and development of alopecia and specifically AU and their role in the pathophysiology of the disease should be called into question if our findings are observed again.