Alefacept for Alopecia Areata

Abstract

Patient 1 is a 42-year-old white man who has had alopecia areata (AA) for 17 years. His father also has extensive AA. Early in the course of the disease, the patient intermittently received prednisone, 15 to 30 mg/d for 2 years, with 1 year being the longest duration of continuous treatment followed by an additional 7-month taper. The patient also received topical fluocinolone acetonide 0.1% (Synalar; Medicis, Scottsdale, Ariz) solution and intralesional triamcinolone acetonide (Kenalog; Bristol-MyersSquibb, New York, NY) injections for most of the duration of the disease. He typically receives intralesional triamcinolone, 10 mg/mL to his scalp and 3 to 5 mg/mL to his eyebrows, every 4 to 10 weeks. Intralesional triamcinolone was helpful, with remissions lasting 2 months. Sulfasalazine administered failed secondary to drug eruption. He has never received contact sensitizers. Patient 2 is a 37-year-old white man who has had alopecia universalis for 14 years. For the first 2 years, he received intermittent courses of prednisone, starting at 40 mg/d and tapering off for 1 to 2 weeks, together with topical corticosteroids and intralesional triamcinolone, 5 mg/mL. The prednisone led to transient hair regrowth with rapid relapse after he finished the course of steroids. The patient subsequently received squaric acid dibutyl ester 0.01% applied twice per week to his scalp in conjunction with tretinoin 0.01% gel (Retin-A; Ortho Neutrogena, Skillman, NJ). He continued to receive intralesional injections of triamcinolone, 5 mg/mL to his eyebrows and scalp, every 4 to 8 weeks. The patient began to respond after 3 months of treatment with squaric acid and had nearly total regrowth of hair on his scalp after 6 months. However, the squaric acid treatments became less effective during the next year and were discontinued. For the next 9 years, the patient received intralesional triamcinolone 5 mg/mL to his eyebrows every 4 to 8 weeks, which resulted in transient hair regrowth. His scalp went untreated and remained completely devoid of hair. A 3-month trial with tacrolimus 0.1% ointment applied twice daily to his scalp had no effect. Patient 3 is a 22-year-old Asian woman who has had alopecia universalis for 3 years. Her prior treatments include prednisone for 5 months with a maximal dose of 40 mg daily to which she had a transient response. She did not respond to diphenylcyclopropenone 2% applied weekly for 3 months. She had no response to sulfasalazine, 2 g twice daily for 1 year. She also received intralesional triamcinolone, 5 mg/mL, to her eyebrows for 11⁄2 years, which resulted in transient hair regrowth. Patient 4 is a 14-year-old white girl who has had AA for 3 years. She also has hypothyroidism, which was diagnosed 1 year ago, but has had symptoms of hypothyroidism for 5 years. Her prior treatments included class I topical corticosteroids twice daily for 3 years with no improvement and intralesional triamcinolone, 10 mg/mL, for 11⁄2 years with transient hair regrowth. A course of prednisone, 60 mg daily, tapered off for 4 weeks resulted in minimal sparse regrowth of pigmented terminal hair and improvement of her eyebrows. Treatment with diphenylcyclopropenone 0.1% to 0.5% for 9 weeks resulted in contact dermatitis but minimal sparse regrowth of pigmented terminal hair. She was unable to tolerate further treatments because of the contact dermatitis.