Severe dermographism after topical therapy with diphenylcyclopropenone for alopecia universalis

Shedding light on dermographism: a narrative review

Dermographism is a common subtype of chronic urticaria. It generally manifests as a linear wheal after scratching or friction, with or without angioedema. The pathophysiology is not clear, but currently, we believe that the stimulation of the skin by mechanical stress leads to the activation of mast cells, which provoke the release of histamine and pro-inflammatory mediators, ultimately forming wheal along the stressed area. The gold standard for diagnosis is a medical history and provocation test or dermatographic test. As one of the subtypes of chronic urticaria, the Urticaria Control Test (UCT), Chronic Urticaria Quality of Life questionnaire (CU-Q2oL), and Dermatology Life Quality Index (DLQI) are also effective tools for evaluating disease control in dermographism patients. In addition to avoiding triggers, nonsedating H1 antihistamines are the first-line medications recommended by EAACI and other guidelines; for those who do not respond to standard doses, the recommended dosage can be increased up to 4 times. When necessary, the off-label use of omalizumab can be considered, and some drugs with potential therapeutic effects are still being explored. However, there is still a lack of biomarkers for predicting disease severity, efficacy, and prognosis. Here, we review what we know about dermographism and some points that need exploration in the future.

Use of Contact Immunotherapy in the Treatment of Skin Diseases Other than Alopecia Areata

For decades, contact immunotherapy with dinitrochlorobenzene, diphencyprone, and squaric acid dibutylester has played an important role in both clinical practice and scientific research. It is listed as the first-line treatment for extensive alopecia areata and was more recently approved for melanoma treatment as an orphan drug in the USA. Moreover, owing to the relative low cost and safety, topical immunotherapy has also been used in many infectious, neoplastic, and inflammatory dermatological diseases. It is especially valuable in vulnerable groups, for cosmetic/pain sensitive areas, or for multiple lesions. In this review, we summarize the current evidence supporting the use of contact immunotherapy for treatment of skin diseases, from articles collected from PubMed database. Owing to space limitation and already numerous studies focusing on alopecia areata, we include only skin diseases other than alopecia areata. In addition to diseases that have been reported to be treated by contact immunotherapy, the hypothesized mechanism, prognosis prediction, efficacy, and safety of these topical agents are discussed.

A retrospective comparative study of the efficacy and safety of two regimens of diphenylcyclopropenone in the treatment of recalcitrant alopecia areata

Diphenylcyclopropenone (DPCP) is an effective topical immunotherapy for recalcitrant alopecia areata (AA), which sometimes requires prolonged treatment. We developed a new treatment protocol to shorten the duration of therapy. This study aimed to compare the efficacy and safety of the new treatment protocol with the standard treatment protocol in the treatment of recalcitrant AA. We conducted a 6-year retrospective comparative study of patients with AA who received one of the DPCP treatment protocols at our institute. Patients’ information was collected and subsequent statistically analyzed. Thirtynine patients (16 in the new treatment group and 23 in the standard treatment group) were included. There were no statistically significant differences in area of hair regrowth. Mean duration to initial hair regrowth and mean duration to significant hair regrowth in the new treatment group were significantly shorter than in the standard treatment group (P=0.002 and 0.01, respectively). Adverse effects were slightly higher in the new treatment group. The present study reveals the effectiveness and safety of the new treatment protocol, which shortens the duration of DPCP treatment and could represent an alternative regimen.

Topical immunotherapy with diphenylcyclopropenone in the treatment of chronic extensive alopecia areata

Highly variable results have been described for the use of topical diphenylcyclopropenone (DPCP) in the treatment of alopecia areata (AA). We enrolled 41 patients in a prospective open clinical trial. Of these, 17 patients had either AA totalis (AAT) or AA universalis (AAU), and 24 had severe alopecia (> 50% scalp involvement). After sensitization with DPCP 2% in acetone, progressively higher concentrations were applied once a week for a period of 6-12 months. Of the 41 patients, 38 (16 with AAT or AAU and 22 with extensive AA) completed therapy. Significant hair regrowth was observed in 15 of the 38 patients (39.5%) at 6 months: 5 with AAT or AAU (31.25%) and 10 with extensive alopecia (45.4%). The above results were sustained in 66.6% of patients for a 12-month-follow up- period. In our study, topical immunotherapy with DPCP proved to be an effective treatment, with prolonged therapeutic results.