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Alopecia Areata During Treatment With Biologic Agents

Alopecia Areata During Treatment With Biologic Agents In the last few years, several biologic agents acting on tumor necrosis factor (TNF) α and intercellular adhesion molecule 1 have been considered as possible treatments for alopecia areata (AA),1 despite clinical trials of some biologic agents such as etanercept, efalizumab, and alefacept showing no significant hair regrowth in AA. We report herein 2 cases of acute AA occurring during treatment with biologic agents. Report of Cases Case 1. A 43-year-old man with psoriasis pustulosa was treated with infliximab (5 mg/kg) after several therapeutic failures with other agents. Three months later, after 4 drug injections, he developed acute AA involving 40% of the scalp. He decided to interrupt therapy with infliximab because of this adverse effect. After infliximab treatment was stopped, his alopecia was treated with topical clobetasol propionate, 0.05%, under occlusion, and he experienced complete regrowth. The patient had no personal or family history of AA. Case 2. A 57-year-old man was treated with efalizumab (1 mg/kg once a week) for psoriatic arthropathy. After 2 months, he developed acute AA that rapidly progressed to involve most (70%) of the scalp. His medical history revealed episodes of patchy hair loss since childhood, but he had never experienced severe AA in the past. Efalizumab treatment was not discontinued, and his hair loss progressed to involve the whole scalp despite treatment with topical clobetasol propionate, 0.05%, under occlusion. Comment Infliximab is a chimeric monoclonal antibody to TNF-α that kills cells having surface TNF. Infliximab binds soluble and bound TNF-α. Efalizumab is a humanized monoclonal antibody to CD11a, a component of leukocyte function–associated antigen 1 that binds to intercellular adhesion molecule 1. Both of these monoclonal antibodies are used as therapy for some autoimmune diseases and have been proposed as possible treatments for AA. Our 2 patients developed AA during treatment with biologic agents. In our first case, infliximab did not prevent development of AA in a subject who had never had this disease. In a similar case,2 therapy with efalizumab produced a severe relapse of AA. We are not aware of a previous report of AA occurring during efalizumab treatment. However, a case of AA occurring during etanercept therapy has recently been published.3 Several AA cases have also occurred during treatment with other immunosuppressive drugs such as cyclosporine A,4 although cyclosporine A at high doses may induce hair regrowth in patients with AA.5 The same dose-related phenomenon may apply to biologic agents that at the doses used for the treatment of psoriasis are not able to prevent development of AA in predisposed patients. Correspondence: Dr Tosti, Department of Dermatology, University of Bologna, Via Massarenti 1, 40138 Bologna, Italy (tosti@med.unibo.it). Financial Disclosure: None reported. References 1. Price VH Therapy of alopecia areata: on the cusp and in the future. J Investig Dermatol Symp Proc 2003;8207- 211PubMedGoogle ScholarCrossref 2. Ettefagh LNedorost SMirmirani P Alopecia areata in a patient using infliximab: new insight into the role of tumor necrosis factor on human hair follicle. Arch Dermatol 2004;1401012PubMedGoogle ScholarCrossref 3. Posten WSwan J Recurrence of alopecia areata in a patient receiving etanercept injections. Arch Dermatol 2005;141759- 760PubMedGoogle ScholarCrossref 4. Misciali CPeluso AMCameli NTosti A Occurrence of alopecia areata in a patient receiving systemic cyclosporine A. Arch Dermatol 1996;132843- 844PubMedGoogle ScholarCrossref 5. Gupta AKEllis CCooper K Oral cyclosporine for the treatment of alopecia areata: a clinical and immunohistochemical analysis. J Am Acad Dermatol 1990;22242- 250PubMedGoogle ScholarCrossref http://www.deepdyve.com/assets/images/DeepDyve-Logo-lg.png Archives of Dermatology American Medical Association

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Publisher
American Medical Association
Copyright
Copyright © 2006 American Medical Association. All Rights Reserved.
ISSN
0003-987X
eISSN
1538-3652
DOI
10.1001/archderm.142.12.1653
Publisher site
See Article on Publisher Site

Abstract

In the last few years, several biologic agents acting on tumor necrosis factor (TNF) α and intercellular adhesion molecule 1 have been considered as possible treatments for alopecia areata (AA),1 despite clinical trials of some biologic agents such as etanercept, efalizumab, and alefacept showing no significant hair regrowth in AA. We report herein 2 cases of acute AA occurring during treatment with biologic agents. Report of Cases Case 1. A 43-year-old man with psoriasis pustulosa was treated with infliximab (5 mg/kg) after several therapeutic failures with other agents. Three months later, after 4 drug injections, he developed acute AA involving 40% of the scalp. He decided to interrupt therapy with infliximab because of this adverse effect. After infliximab treatment was stopped, his alopecia was treated with topical clobetasol propionate, 0.05%, under occlusion, and he experienced complete regrowth. The patient had no personal or family history of AA. Case 2. A 57-year-old man was treated with efalizumab (1 mg/kg once a week) for psoriatic arthropathy. After 2 months, he developed acute AA that rapidly progressed to involve most (70%) of the scalp. His medical history revealed episodes of patchy hair loss since childhood, but he had never experienced severe AA in the past. Efalizumab treatment was not discontinued, and his hair loss progressed to involve the whole scalp despite treatment with topical clobetasol propionate, 0.05%, under occlusion. Comment Infliximab is a chimeric monoclonal antibody to TNF-α that kills cells having surface TNF. Infliximab binds soluble and bound TNF-α. Efalizumab is a humanized monoclonal antibody to CD11a, a component of leukocyte function–associated antigen 1 that binds to intercellular adhesion molecule 1. Both of these monoclonal antibodies are used as therapy for some autoimmune diseases and have been proposed as possible treatments for AA. Our 2 patients developed AA during treatment with biologic agents. In our first case, infliximab did not prevent development of AA in a subject who had never had this disease. In a similar case,2 therapy with efalizumab produced a severe relapse of AA. We are not aware of a previous report of AA occurring during efalizumab treatment. However, a case of AA occurring during etanercept therapy has recently been published.3 Several AA cases have also occurred during treatment with other immunosuppressive drugs such as cyclosporine A,4 although cyclosporine A at high doses may induce hair regrowth in patients with AA.5 The same dose-related phenomenon may apply to biologic agents that at the doses used for the treatment of psoriasis are not able to prevent development of AA in predisposed patients. Correspondence: Dr Tosti, Department of Dermatology, University of Bologna, Via Massarenti 1, 40138 Bologna, Italy (tosti@med.unibo.it). Financial Disclosure: None reported. References 1. Price VH Therapy of alopecia areata: on the cusp and in the future. J Investig Dermatol Symp Proc 2003;8207- 211PubMedGoogle ScholarCrossref 2. Ettefagh LNedorost SMirmirani P Alopecia areata in a patient using infliximab: new insight into the role of tumor necrosis factor on human hair follicle. Arch Dermatol 2004;1401012PubMedGoogle ScholarCrossref 3. Posten WSwan J Recurrence of alopecia areata in a patient receiving etanercept injections. Arch Dermatol 2005;141759- 760PubMedGoogle ScholarCrossref 4. Misciali CPeluso AMCameli NTosti A Occurrence of alopecia areata in a patient receiving systemic cyclosporine A. Arch Dermatol 1996;132843- 844PubMedGoogle ScholarCrossref 5. Gupta AKEllis CCooper K Oral cyclosporine for the treatment of alopecia areata: a clinical and immunohistochemical analysis. J Am Acad Dermatol 1990;22242- 250PubMedGoogle ScholarCrossref

Journal

Archives of DermatologyAmerican Medical Association

Published: Dec 1, 2006

Keywords: alopecia areata,biological products

References