الفهرس 
IntroductionOnly 14 pages are availabe for public view
Abstract
Alopecia areata is a non-scarring autoimmune disease affecting hair follicles. It is seen commonly as patchy lesion of hair loss, and sometimes as extensive involvement of the whole scalp (AT) o whole body (AU). Still, there is a controversy about prediction of AA clinical course and variability of the response to treatment. However, Spontaneous remission can occur in approximately 80% of limited AA within one year.
Many treatment modalities have been used for AA. In a localized AA, intralesional corticosteroids are the first-line treatment. Topical immunotherapy is widely used in treatment of AA aiming to alter the immune response inducing hair regrowth through inducing a low-grade chronic dermatitis.
Diphenylcyclopropenone (DPCP) is among immunotherapeutic agents used for treating a chronic severe AA, with greater than 50% scalp involvement and refractory AA with response rate of 5% to 85%. Relapse can occur in 60% of patients after completion of treatment.
We aimed to evaluate the efficacy and safety of topical DPCP alone and in combination with intralesional steroids or systemic steroids for treatment of extensive and refractory AA. The study enrolled 21 adult patients with severe and extensive AA, recruited from the Outpatient Clinic of Dermatology, Ain Shams University Hospital and El-houd EL-marsoud Hospital. We subdivided the patients into three groups, seven patients in each; group I patients were treated with DPCP alone, one session per week for 16 weeks, group II treated with DPCP alone, one session per a week for 8 weeks, then they received intralesional triamcinolone acetonide every other week for a maximum of 5 sessions with continuation of DPCP sessions every week for another 8 weeks. group III was treated with DPCP alone delivered as one session per a week for 8 weeks. Then, they received a systemic steroid every 3 weeks for 12 weeks. DPCP was continued as one session per week till week 16 of the study. Assessment was done clinically, by SALT scoring, digital photography and trichoscopic documentation.
Three quarters of AA patients were males with a majority of young adults aged 15 to 50 years. The duration of the disease was more than one year and the mean age of first onset was 15 years. About half of the patients was of a refractory type. All patients recalled previous history of AA and 90% treated by combined therapy. Scalp was affected in all patients and eyebrow in half of them while nails were affected in 10%. Mean SALT score at time of presentation was 59%. Majority of the patients (95%) had dermoscopic findings of yellow dots; two third had black dots and vellous hair.
All tested treatment modalities effectively improved AA condition and reduced significantly SALT score with marked reduction among AA cases treated by group II modality (DPCP plus intralesional steroid), 76%, while the two other treatment modalities (DPCP alone and DPCP with systemic steroid) achieved lesser improvement 33% and 54% respectively. The first response needed longer time to appear (12.6 weeks) is treated with DPCP and intralesional steroid compared with 6.9 weeks and 7.4 weeks within group I and III respectively.
All patients developed at least one type of side effects, mainly blister formation (85.7%). from studied personal and clinical factors of AA patients, the age of first onset of the disease was the only significant predictive factor for hair regrowth. The younger age at the first presentation of AA, the poorer the response to treatment.
One patient developed relapse among the cases treated with DPCP alone and four AA cases were show no any response throughout the treatment course and 6 weeks afterward. The patients’ satisfaction was variable between different treatment modality groups; moderate to full in 67.2% of treated AA patients in group I, in all patients of group II and in 57% of cases in group III.
Combined DPCP and corticosteroids (whether intralesional or systemic) could be recommended for the treatment of AA especially refractory cases. It would be recommended to study the combined regimens on larger group of patients and in different types of AA. Studying different regimens with different sets of treatment parameters and protocols and to follow-up patients over extended periods of time after induction of a remission and after complete withdrawal of all treatment modalities are highly recommended.