Topical Immunotherapy Remains Valuable in Alopecia Areata

Topical immunotherapy continues to have a significant role to play in treating alopecia areata (AA), even in an age of novel targeted therapies, according to a new report.

That conclusion is based on a case series involving 5 patients with chronic AA, all of whom achieved sustained disease control using a multimodal approach. The case series was published in Frontiers in Medicine.¹

Janus kinase (JAK) inhibitors have transformed the treatment landscape of AA, but access to the high-cost therapies remains a challenge, according to the study authors.

“Consequently, traditional long-standing therapies, such as immunotherapy with contact allergens, continue to play an important role in current management strategies for AA,” they wrote.

Topical immunotherapies induce a hypersensitivity reaction, distracting the immune system from the hair follicle. Those in current use include diphenylcyclopropenone (DPCP) or squaric acid dibutyl ester (SADBE), the authors explained.² They said these therapies tend to lead to responses in 50-60% of patients. The investigators said DPCP and SADBE are generally more affordable and lack the systemic side effects of some newer therapies.¹ They can also safely be used for long-term disease management.

The investigators said immunotherapy previously was used mainly as monotherapy, but they said increased understanding of the pathophysiology of AA has made it possible to use immunotherapy in combination with a range of therapies.

The new report is an attempt to document the experiences of patients who received long-term, real-world multimodal contact immunotherapy for AA.

The patients in the case series were treated with DPCP and/or SADBE in combination with adjunctive therapies, with follow-up periods ranging from 9 to 15 years. The patients were initially sensitized with 2% DPCP or SADBE on a 5 cm² area of the scalp. The immune sensitizer was removed after 8 hours, and the patient returned 3 weeks later for weekly applications of increasing concentrations of the sensitizer. When maximum regrowth was achieved, the investigators spaced out treatment to every 2-4 months, applying the contact allergen to the entire scalp. In addition, clinicians employed intralesional triamcinolone acetonide, oral dexamethasone, topical minoxidil (at concentrations from 5-10%), and high-dose oral minoxidil, the authors said. Vitamin supplements, phototherapy, and oral finasteride were also included in patient regimens, they said.

Four of the 5 patients in the case series were women. The participants ranged in age from 15 to 43 years. Three of the participants had vitiligo, and 2 had autoimmune thyroid disease. All of the patients achieved excellent cosmetic results and had occasional relapses, the investigators found. Two of the patients had isolated alopecic patches at the end of the follow-up period, and 2 had a persistent ophiasis pattern, the investigators said. In terms of Severity of Alopecia Tool (SALT) scores, 2 patients had scores of 0 at the end of the follow-up period, and the other 3 participants had scores of 1.

Given the small sample size, the authors noted that their report is not meant to propose a new therapeutic strategy, but instead to recount the long-term clinical management of patients in routine practice. The authors noted, for instance, that their case series does not directly compare the outcomes of varying types of therapeutic strategies.

The investigators concluded that the experiences of these patients show that DPCP and SADBE remain valuable therapies in AA.

“Its inclusion in multimodal regimens remains important, especially in clinical settings where biologic therapies and JAK inhibitors are unavailable, unaffordable, or contraindicated,” they concluded.

References

1. Herz-Ruelas ME, Contreras-Hernández MM, Salazar-Herz IM. Case Report: Multimodal contact immunotherapy in alopecia areata: long-term clinical experience in the JAK inhibitor era. Front Med (Lausanne). Published online February 26, 2024. doi:10.3389/fmed.2026.1757777

2. Yoshimasu T, Furukawa F. Modified immunotherapy for alopecia areata. Autoimmun Rev. 2016;15(7):664-667. doi:10.1016/j.autrev.2016.02.021