Decreased lymphocyte reactivity and auto-immunity in alopecia areata

A randomized controlled clinical study of acupuncture therapy for Seborrheic alopecia in young and middle ages: Study protocol clinical trial (SPIRIT compliant)

INTRODUCTION

Seborrheic alopecia (SA) has clinical manifestations, duration of disease, and priorities. In the current situation where there are many and complicated clinical treatments, Western medicine treatment can delay and control the development of the disease and promote hair regeneration. However, some patients may aggravate symptoms after taking the drug, and the condition is easy to repeat after stopping the drug. Acupuncture is an important method for non-surgical treatment of SA, and it has various methods, low side effects, high safety, and simple and economical. Therefore, we will use a clinical randomized controlled study to explore the effect of acupuncture on SA, and provide a new idea and reference for the treatment of this disease.

METHODS/DESIGN

We will select 60 patients diagnosed with SA. They will be randomly divided into intervention group and control groups. The control group will be given conventional treatment measures. The intervention group will receive acupuncture. Efficacy will be evaluated by comparing the skin lesion score and dermatological quality of life index before and after treatment.

DISCUSSION

This trial may provide evidence regarding the clinical effectiveness, safety, and cost-effectiveness of acupuncture for patients with SA.

TRIAL REGISTRATION NUMBER

CTR2000030430.

Insignificant Correlation between Thyroid Hormone and Antithyroid Peroxidase Antibodies in Alopecia Areata Patients in Northern Rajasthan

Background

Alopecia areata (AA) is a common, recurrent form of nonscarring alopecia which often presents as circumscribed patches of spontaneous hair loss. The global prevalence of this disease varies from 0.1% to 0.2% in general population and 7-30 cases per 1000 dermatological patients. The etiology of AA still remains uncertain; however, genetic or environmental factor and autoimmunity are claimed responsible for it. Various autoimmune diseases, such as Hashimoto's thyroiditis, diabetes mellitus, vitiligo, and lupus erythematosus, have been reported in association with AA.

Aim

The index study was aimed at estimation of serum T3, T4, thyroid-stimulating hormone, and antithyroid peroxidase (TPO) antibodies.

Material and Methods

Similar age/sex-matched AA patients and controls (110 in each group). Enhanced chemiluminescence immunoassay for thyroid profile and anti-TPO antibody level estimation in veinous blood sample.

Observations

The mean/standard deviation (SD) of T3 was 3.30 ± 0.84 pg/ml in AA while 3.27 ± 0.67 pg/ml in controls (P = 0.302). Serum mean/SD of T4 level was1.23 ± 0.76 ng/dl in AA patients while 1.17 ± 0.34 ng/dl in controls (P = 0.522). The mean/SD of anti-TPO levels in AA patients was 21.52 ± 35.09 while 56.43 ± 140.72 in controls (P = 0.136).

Limitation

The limitation of this study was moderate number of AA patients and different genotype of study population.

Conclusion

Occurrence of thyroid dysfunction and evidence of anti-TPO antibodies in AA is rare event in this study population.

Acute diffuse and total alopecia: A new subtype of alopecia areata with a favorable prognosis

BACKGROUND

Alopecia areata (AA) appears in several clinical forms, all having different clinical courses and different prognoses. Acute diffuse and total alopecia (ADTA) has been reported to have a short clinical course ranging from acute hair loss to total baldness, followed by rapid recovery.

OBJECTIVE

To determine the clinical course and prognosis of ADTA through precise clinical observations.

METHODS

Thirty Korean patients who showed ADTA of the scalp within an average of 10 weeks after the onset of hair loss were studied.

RESULTS

Most patients were women who were older than 20 years of age. The histopathology of the lesion revealed infiltration of mononuclear cells around the hair follicles and prominent pigment incontinence. The patients experienced hair regrowth within about 6 months, without regard to the method of treatment.

LIMITATIONS

The duration of follow-up after remission ranged from 3 to 49 months, with a mean of 24 months.

CONCLUSIONS

These cases can be categorized as having "acute diffuse and total alopecia," a new subtype of AA that is associated with a favorable prognosis and rapid and spontaneous recovery even without treatment.

Alopecia areata update

Alopecia areata (AA) is a nonscarring hair loss condition. Among the many factors under investigation in the pathogenesis of AA, the main areas of concentration have been genetic constitution as well as nonspecific immune and organ-specific autoimmune reactions. Treatment with intralesional corticosteroid injections for localized patchy AA and topical immunotherapy for extensive AA have proven successful in the majority of patients, although all treatments are palliative and do not change the prognosis of the disease.

Immunopathology of the human hair follicle

Although patients are told that, in many instances, their hair loss is precipitated by stress, they are certainly stressed and saddened by their alopecia. They would be elated with the ability to regrow their hair. Ideally, therapy would be specific and targeted at the cascade of inflammatory, cytokine-mediated, and mesenchymal events which lead to hair loss. Such is the case with infectious folliculitides: Pityrosporum folliculitis is cleared with antifungal agents, bacterial folliculitis is cleared with antibiotics, and herpetic folliculitis is treated with antiviral agents. Future studies of the hair follicle will perhaps unlock the mechanisms that drive and maintain normal hair growth. Until that time scientists will, no doubt, continue to be fascinated by the intricate developmental and immunologic mechanisms that drive this micro-organ of the skin.

Alopecia areata associated with myasthenia gravis and thymoma: a case of alopecia with marked improvement following thymectomy and high level prednisolone administration

A 57-year-old Japanese woman who suffered from alopecia areata associated with myasthenia gravis (MG) and thymoma responded well to thymectomy and high doses of glucocorticosteroid administration. Several treatments for alopecia areata including administration of systemic prednisolone were attempted, but loss of hair on the scalp progressed. After thymectomy and high level glucocorticosteroid administration for MG, the lesions on the scalp improved within four weeks. Consequently, we suggest that this thymectomy and high level glucocorticosteroid administration assisted in improving the immune dysfunction causing the alopecic lesions in this patient.

The pathogenesis of alopecia areata

Knowledge of the disease mechanisms in alopecia areata is discussed in the light of progress in hair biology, immunology, and genetics. A disease model is presented incorporating polygenic determination of disease severity and susceptibility with largely unknown trigger factors responsible for initiating clinical disease expression. Experimental systems including animal models for alopecia areata offer new opportunities for investigation of alopecia areata and developing novel therapies.

Twenty-nail dystrophy (trachyonychia) caused by lichen planus in a patient with alopecia universalis and ichthyosis vulgaris

A 7-year-old girl with alopecia universalis had dystrophy of all 20 nails. A nail biopsy specimen disclosed features of lichen planus. The patient also had ichthyosis vulgaris and hypogammaglobulinemia. We are not aware of any previous reports of these associations, which we believe to be noncoincidental.

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.

A case of myasthenia gravis accompanied by invasive thymoma, alopecia areata and dry mouth

We report a 43-year-old man suffering from myasthenia gravis with invasive thymoma accompanied with alopecia areata and dry mouth. These complications are extremely rare and the pathogenetic etiology of these complications was thought to depend on a generalized immunological disturbance.

The aetiology and pathogenesis of alopecia areata

In common with a number of inflammatory autoimmune diseases, genetic factors including HLA class II associations have been identified in alopecia areata. No consensus has been reached on the identity of a specific disease target within the hair follicle in alopecia areata. Suggested candidate cell types include the dermal papilla cells, the keratinocytes of the matrix and presumptive cortex and the hair bulb melanocytes, but these need not be mutually exclusive. The pathogenesis is known to involve disturbance of immune function but there is no proof that an autoimmune mechanism is fundamental. We propose a pathogenetic model incorporating polygenic determination of disease susceptibility and severity with additional, possibly environmental, factors as triggers for disease expression.

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.

Simultaneously occurring alopecia areata and Hodgkin's lymphoma: complete remission of both diseases with MOPP/ABV chemotherapy

A 43-year-old man presented with simultaneously occurring alopecia areata and stage IIIB nodular sclerosing Hodgkin's disease. Systemic symptoms of Hodgkin's disease were present for 6 months, and rapidly developing patchy hair loss of the scalp was present for 2 weeks prior to presentation. The patient was treated with eight cycles of MOPP-ABV chemotherapy that resulted in complete remission of Hodgkin's-disease. Four months after the completion of chemotherapy, the patient had normal hair regrowth with no evidence of alopecia areata. Alopecia areata may be an autoimmune disease and may respond to chemotherapy.

Angiogenic activity is defective in monocytes from patients with alopecia universalis

Monocyte/macrophages are important components of cell-mediated immune responses in presentation of antigen, as regulators of lymphocyte function, and as sources of cytokines that modulate functions of cells other than those of the immune system. Their role in the pathogenesis of alopecia areata (AA) and universalis (AU) has not been explored. This study is an investigation of the function of peripheral blood monocytes from normal subjects and patients with AA, AU, and alopecia totalis (AT), with respect to the principal macrophage-derived angiogenic factor, tumor necrosis factor alpha (TNF alpha). Because neovascularization is a necessary component in the anagen phase of hair growth and may play a role in the pathology of these disorders, we asked whether monocyte/macrophage angiogenic activity was compromised in these alopecias. Purified preparations of monocytes were activated in culture. Conditioned media were assessed for angiogenic activity on the chick chorioallantoic membrane and for concentration of TNF alpha by enzyme-linked immunosorbent assay (ELISA). Both angiogenic and the TNF concentration were significantly diminished in conditioned media from AU monocytes when compared to those from normal subjects and patients with AA. These results show that the function of AU monocytes may be abnormal and that the abnormality may distinguish AU from AA. Defective monocyte/macrophage function could also play a pathogenic role via effects on neovascularization and/or modulation of the immune response.

Clinical and immunologic response to Isoprinosine in alopecia areata and alopecia universalis: association with autoantibodies

Twenty patients with alopecia universalis, alopecia semiuniversalis and alopecia areata were studied for their immune parameters. Fourteen of them received an oral treatment with Isoprinosine, a synthetic immunomodulator. Ten patients showed the presence of several autoantibodies. No significant abnormalities in various T cell rosette markers were found, but T4/T8 ratios tended to be elevated. Erythrocyte antibody complement (EAC) rosettes were usually decreased. Treatment with Isoprinosine produced a clinical response, as judged by total or partial hair growth, in nine of the fourteen patients treated. It was striking to observe that seven of the nine responders had autoantibodies prior to treatment. These autoantibodies disappeared or decreased with Isoprinosine therapy. In contrast, only one of five nonresponders had serum autoantibodies. After treatment, both groups showed an increase in blood-active T rosettes. These results suggest that alopecia is a heterogeneous disease subdivided by the presence or absence of autoantibodies since clinical response was mainly obtained in patients presenting autoantibodies.

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.

Topical therapy of alopecia areata with squaric acid dibutylester

The efficacy of the topical allergen squaric acid dibutylester (SADBE) was investigated in the treatment of twenty-six patients with alopecia areata or alopecia totalis. The patients had their disease for a mean duration of 8.3 years (range, 3 months to 27 years). Sensitization was attempted with 2% SADBE in acetone. Five individuals could not be sensitized. The twenty-one sensitized patients were treated with topical applications of 0.001% to 1.0% SADBE in acetone adjusted to produce and maintain dermatitis for an average of 21 weeks. Eleven (52%) had excellent responses consisting of complete regrowth in six and cosmetically acceptable regrowth in five. The average treatment time for regrowth was 11 weeks (range, 5-20 weeks). Ten (48%) had no clinical response after an average of 19 weeks of therapy (range, 4-42 weeks). Topical SADBE is an effective therapy for some patients with long-standing alopecia areata.

Increased ratio of helper to suppressor T cells in alopecia areata

We studied lymphocyte subsets in the blood of twenty-four patients with alopecia areata of various degrees of severity. There was an increase in the ratio of helper to suppressor cells that correlated with the extent of the disease, providing further evidence that the immune system may be involved in its pathogenesis.

Immunological profiles in alopecia areata

Cell-mediated immunity and auto-immune phenomena were investigated in sixty patients with active alopecia areata of various degrees of severity. Serum auto-antibodies to thyroid antigens were detected in twenty-three patients. Examination of T-lymphocyte populations, lymphocyte DNA synthesis, and lymphokine production in response to mitogen stimulation revealed no differences between the sixty patients and matched healthy control subjects. However, patients with thyroid auto-immunity and/or the presence of alopecia totalis or universalis showed significant reductions in interactive T lymphocytes (recognized by rosette formation with human B lymphoblastoid cells) and diminished production of leukocyte migration inhibition factor in response to stimulation with phytohaemagglutinin. This suggests that immune mechanisms may be involved in the pathogenesis of alopecia areata which is associated with thyroid auto-immunity or which progresses to total hair loss.

Response of alopecia areata to DNCB: influence of auto-antibodies and route of sensitization

The effects of treatment with topical 2,4-dinitrochlorobenzene (DNCB) were observed in fifty-one patients with alopecia areata of at least 9 months duration. Patients were sensitized either by the application of 500 micrograms of DNCB in acetone to the forearm, or by painting affected areas of the left side of the scalp with a 1% solution. A mild to moderate dermatitis was maintained by weekly applications of DNCB. When the sensitizing dose was applied directly to the scalp, significantly more patients showed poor reactivity as judged by the eczematous response obtained, although the two routes of sensitization had comparable effects upon regrowth of hair. Hair regrew significantly more frequently in females. The likelihood of regrowth was reduced in patients with hair loss of long duration and in those with immunological disturbances such as autoantibodies or low T lymphocyte numbers and responses. The relationship of these factors to the disease and to the response to DNCB treatment is discussed.