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Imiquimod in the Treatment of Alopecia Universalis

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Imiquimod in the Treatment of Alopecia Universalis Imiquimod in the Treatment of Alopecia Universalis Philip R. Letada, MD; Joshua D. Sparling, MD; Christopher Norwood, MD Imiquimod is used topically in the treatment of those prescribed for her alopecia during this time. numerous dermatologic conditions. Imiquimod Her family history was negative for alopecia, other modifies the immune response through cytokine hair disorders, and autoimmune disease. Laboratory induction of the T-cell helper subset, correlating evaluation was negative for inflammatory, thyroid with the expression of interferon a, tumor necrosis hematologic, and infectious etiologies. factor a, interferon g, and interleukins (ILs) 1 and The patient reported her first episode of spon- 12. Reciprocal inhibition of TH 2 immune response taneous hair loss at age 8. The hair loss initially occurs via up-regulation of interferon g and down- occurred in patches from the scalp and eventually led regulation of TH 2-associated cytokines, includ- to total body hair loss, including the eyebrows, over ing IL-4, IL-5, IL-6, IL-10, and IL-13. Alopecia 6 months. Throughout this episode, her overall health universalis is a severe form of alopecia thought to was unchanged, and she denied illness or increased arise from T-cell mediated autoimmune disease of stress. The patient then experienced complete spon- the hair follicle. There have been no case reports taneous hair regrowth over 18 months. Two years noting a beneficial effect of topical imiquimod later, she reported another 6-month episode of spon- in the treatment of alopecia universalis. We pre- taneous total body hair loss similar to the first episode sent a case of a 15-year-old adolescent girl with (Figure, A). The hair loss continued for approximately alopecia universalis since age 8 who experienced 2 years. During this time, tazarotene cream 0.1% transient hair growth after topical application was applied to the scalp without hair regrowth. When of imiquimod. the patient was 14 years old, topical imiquimod Cutis. 2007;79:138-140. cream 5% was applied to the scalp, initially 3 times weekly for 1 week and eventually increased to nightly for 4 months. During these 4 months, the patient noticed hair regrowth on treated areas of the scalp Case Report (Figure, B), as well as untreated areas of the body, A 15-year-old Japanese American adolescent girl pre- including the eyebrows, bilateral axillae, upper lip, sented to the dermatology clinic with a history of and pubis. The regrowth remained for approximately cyclic total body hair loss. The patient’s medical 1 year when she once again experienced spontaneous history was significant only for infantile eczema that total body hair loss, despite continued nightly use was well-treated with several short courses of topical of the topical imiquimod cream. During this time, steroids. She denied use of medications other than she reported increased stress caused by family relo- cation and had stopped application of imiquimod. Accepted for publication October 28, 2005. Three months later, she restarted applying imiqui- Drs. Letada and Norwood are from the National Naval Medical mod cream to the scalp once to twice weekly. After Center, Bethesda, Maryland. Dr. Letada is from the Transitional 2 months, there was little hair regrowth. Imiquimod Internship Program and Dr. Norwood is from the Department of cream application then was increased to twice daily Dermatology. Dr. Sparling is from the National Capitol Consortium and the patient again noted some hair regrowth on Dermatology Residency Program, Washington, DC. The authors report no conflict of interest. the scalp and untreated areas, including the eyebrows The opinions or assertions contained herein are the private and eyelashes. views of the authors and are not to be construed as official or as reflecting the views of the US Department of the Army, the Comment US Department of the Navy, or the US Department of Defense. Alopecia universalis is a condition characterized by Reprints: Joshua D. Sparling, MD, National Capitol Consortium Dermatology Residency Program, 6900 Georgia Ave NW, total body hair loss, including scalp, eyebrow, axillary, Washington, DC 20307-5001 and pubic hair. It is a severe form of alopecia areata of (e-mail: [email protected]). unknown etiology; however, autoimmune reactions 138 CUTIS® Alopecia Universalis A Patient with spontaneous hair loss on the scalp before (A) and after (B) B 4 months of treatment with topical imiquimod cream 5%. have been suspected as the cause of hair loss. Anagen published studies have observed benefit in patients hair follicles develop a TH 2 immune response– with alopecia universalis. One exception is a study mediated perifollicular T-cell infiltrate.1 This condition by Tosti and colleagues9 in which topical steroids results in abnormal keratinization of the hair follicle were used under occlusion. and leads to premature entry of the hair follicle into Imiquimod is an immune response modifier com- the telogen or late catagen phases and eventual monly used for the treatment of external genital, hair loss.2 perianal, and plantar warts, and more recently for Numerous treatment attempts aimed at immune the nonsurgical treatment of actinic keratosis and suppression have resulted in varied success. Intra- basal cell carcinoma. It is well-tolerated and has lesional corticosteroid injection,3 topical minoxidil,4 a well-documented safety profile.10,11 Imiquimod sulfasalazine,5 contact sensitizers,6 oral steroids,7 activates the innate and cell-mediated immune and oral cyclosporine8 have yielded modest results pathways. Cytokine activation eventually leads to in patients with alopecia areata. To date, few the drug’s antiviral, antitumor, and antiproliferative VOLUME 79, FEBRUARY 2007 139 Alopecia Universalis properties. One of the indirect effects of imiquimod REFERENCES resulting from topical application is the prolifera- 1. Madani S, Shapiro J. Alopecia areata update. J Am Acad tion of interferon g by TH1 and the suppression of Dermatol. 2000;42:549-566. 12 interleukins 4 and 5 by TH 2. Since alopecia areata 2. Messenger AG, Slater DN, Bleehen SS. Alopecia areata: is proposed to be mediated through TH 2 immunity, alterations in the hair growth cycle and correlation with imiquimod has been considered as a possible agent the follicular pathology. Br J Dermatol. 1986;114:337-347. for treatment. 3. Porter D, Burton JL. A comparison of intra-lesional In a case series by Sommerfeld and Poppova,13 triamcinolone hexacetonide and triamcinolone acetonide partial or total hair regrowth was observed in in alopecia areata. Br J Dermatol. 1971;85:272-273. 5 patients with alopecia areata after topical applica- 4. Price VH. Double-blind, placebo-controlled evaluation of tion of imiquimod. Poor hair growth was seen in a topical minoxidil in extensive alopecia areata. J Am Acad prospective study conducted in 2002 of 15 patients Dermatol. 1987;16:730-736. with either alopecia totalis or alopecia universalis. 5. Ellis CN, Brown MF, Voorhees JJ. Sulfasalazine for In this study, only 3 of 15 treated patients reported alopecia areata. J Am Acad Dermatol. 2002;46:541-544. growth of vellus hair with regression after suspen- 6. Rokhsar CK, Shupack JL, Vafai JJ, et al. Efficacy of topical sion of therapy.14 These are the only known reported sensitizers in the treatment of alopecia areata. J Am Acad cases of imiquimod treatment in patients with Dermatol. 1998;39:751-761. alopecia universalis. 7. Friedli A, Labarthe MP, Engelhardt E, et al. Pulse meth- In our patient, noticeable hair growth to the ylprednisolone therapy for severe alopecia areata: an open patient’s baseline occurred during 4 months of topi- prospective study of 45 patients. J Am Acad Dermatol. cal imiquimod application, with eventual hair loss 1998;39:597-602. after 1 year of continued use. Regrowth also was 8. Gupta AK, Ellis CN, Cooper KD, et al. Oral cyclosporine noted after reapplication of imiquimod subsequent for the treatment of alopecia areata: a clinical and immu- to a 3-month interruption in use. nohistochemical analysis. J Am Acad Dermatol. 1990;22: It is feasible that this patient’s hair regrowth 242-250. would have occurred regardless of treatment. 9. Tosti A, Piraccini BM, Pazzaglia M, et al. Clobetasol In fact, even before application of imiquimod, propionate 0.05% under occlusion in the treatment of the patient had experienced an episode of slow alopecia totalis/universalis. J Am Acad Dermatol. spontaneous hair regrowth after a 6-month period 2003;49:96-98. without hair. During imiquimod therapy, growth 10. Kaidbey K, Owens M, Liberda M, et al. Safety studies of also was observed in nontreated areas of the topical imiquimod 5% cream on normal skin exposed to patient’s body (ie, eyebrows, axillae, upper lip, ultraviolet radiation. Toxicology. 2002;178:175-182. and pubis); however, regrowth of hair on the scalp 11. Gilson RJ, Shupak JL, Friedman-Kien AE, et al. A random- was temporary and apparently related to restarting ized, controlled, safety study using imiquimod for the topi- topical imiquimod therapy. cal treatment of anogenital warts in HIV-infected patients. Imiquimod Study Group. AIDS. 1999;13:2397-2404. Conclusion 12. Tyring S, Conant M, Marini M, et al. Imiquimod; an inter- As observed in this patient, imiquimod is a pos- national update on therapeutic uses in dermatology. Int J sible therapeutic avenue for patients with alopecia Dermatol. 2002;41:810-816. universalis, though the effect is temporary. Because an 13. Sommerfeld B, Poppova I. Does imiquimod normalize hair effective permanent cure does not yet exist, topical growth in alopecia areata? J Eur Acad Dermatol Venereol. imiquimod offers a potential treatment for this frustrat- 2001;15(suppl 2):215-216. ing disease in some patients. Additional studies will 14. D’Ovidio R, Claudatus J, Di Prima T. Ineffectiveness of be needed to help determine the extent of efficacy of imiquimod therapy for alopecia totalis/universalis.
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