Author Affiliations: Division of Dermatology, Sunnybrook Health Sciences Centre, Toronto, Ontario, Canada (Drs Salsberg and Donovan); Cleveland Clinic Canada, Toronto (Dr Donovan); and Hair Club Medical Group, Toronto (Dr Donovan).
Topical diphencyprone (DPCP) immunotherapy is used to treat refractory and advanced alopecia areata. Although not approved for this indication by the US Food and Drug Administration, the safety and efficacy of DPCP in adults with alopecia areata has been evaluated in several studies. However, the use of DPCP in children has been the focus of only a limited number of studies. One study of 26 children indicated cosmetically acceptable hair regrowth in 35% of patients.1 A second study of 12 patients indicated hair regrowth in 67% of patients.2
We performed a retrospective study of children treated in our DPCP clinic over the period 2002 through 2011 to evaluate the efficacy of DPCP, the incidence of adverse effects, and factors predictive of hair regrowth and adverse effects. The study received ethical approval. All children followed the same immunotherapy protocol beginning with sensitization with DPCP, 2%, in acetone followed by a treatment with DPCP, 0.0001%, 2 weeks later. Thereafter, treatment continued on a weekly basis with increasing concentrations of DPCP if there was no significant itching, scaling, or redness.
A complete response was defined as full regrowth of scalp hair, and a partial response was defined as any hair regrowth other than full regrowth. Fisher exact and χ2 tests were used to examine relationships between clinical parameters. P = .05 was considered significant in all analyses.
A total of 108 patients, aged 4 months to 18 years (mean age, 11.7 years), were included in the study. The mean age at onset of alopecia areata was 8 years (range, 4 months to 17 years). Patients included in the study were refractory to treatment with 1 or more of the following: topical steroids (67%), intralesional steroids (34%), or minoxidil (11%); and the average duration of the disease was 3.8 years (range, 1 month to 10 years). Thirty-five children had atopy (32%); 32 had a family history of alopecia areata (30%); 26 had an ophiasis pattern of scalp involvement (24%); and 24 had nail involvement (22%).
Marked sensitization reactions, including localized edema, dermatitis, vesicles, desquamation, and urticaria, were documented in 23 children (21%). Treatment-related adverse effects, including edema, urticaria, vesicles, erosions, dermatitis, and lymphadenopathy were seen in 58 children (54%). Thirteen percent of children discontinued treatment after 2 months owing to a variety of factors, including adverse effects, difficulties commuting to the treatment center, and/or the disruption caused by weekly absences from school.
Fourteen patients showed complete hair regrowth after 6 months of treatment (13%); 27 had partial regrowth (25%). At 12 months, 12 patients had complete hair regrowth (11%), and 23 had partial regrowth (21%). The remainder did not experience any hair growth or stopped treatment (Table 1).
Twelve patients 10 years or younger had marked sensitization reactions (32%) compared with 11 patients aged 11 to 18 years (16%) (P = .07) (Table 2). Twenty-seven of 38 patients younger than 10 years had adverse effects during DPCP treatment (71%) compared with 31 of 70 patients aged 11 to 18 years (44%) (P = .01).
None of the known prognostic factors,3 including age at onset, extent of involvement, atopy, coexistent autoimmune disease, family history, ophiasis pattern, or nail involvement, was associated with greater likelihood of having partial or complete response to DPCP therapy (data not shown).
To our knowledge, this study represents one of the largest studies of treatment responses to DPCP in patients younger than 18 years. Overall, approximately one-third of children in our study showed improvement in hair density with DPCP treatment. However, the response dropped off at between 6 months and 1 year of treatment, and overall, only 10% of our patients had complete hair regrowth. Adverse effects of DPCP were slightly more common in young children than in older children. In general, adverse effects warranting discontinuation of DPCP treatment were not common.
Study limitations include the small number of patients, the retrospective nature of the study, and incomplete documentation in some cases. Although hair regrowth in a proportion of our patients could be considered spontaneous, this is unlikely for the vast majority of our patients. Our patient population was composed of children with advanced hair loss who were refractory to topical treatments, and many had the disease beyond the time at which spontaneous regrowth would be expected to occur. Further large-scale studies of DPCP use in children with alopecia areata are needed.
Correspondence: Dr Donovan, Division of Dermatology, Sunnybrook Health Sciences Centre, 2075 Bayview Ave, Ste M1-700, Toronto, ON M4N 3M5, Canada (email@example.com).
Accepted for Publication: April 19, 2012.
Author Contributions: Both authors had full access to all of the data in the study and take responsibility for the integrity of the data and the accuracy of the data analysis. Study concept and design: Donovan. Acquisition of data: Salsberg and Donovan. Analysis and interpretation of data: Salsberg and Donovan. Drafting of the manuscript: Donovan. Critical revision of the manuscript for important intellectual content: Salsberg and Donovan. Statistical analysis: Salsberg and Donovan. Administrative, technical, and material support: Salsberg and Donovan. Study supervision: Donovan.
Financial Disclosure: None reported.
Additional Contributions: The authors thank the many physicians and nurses for the care they provided the patients in the DPCP Clinic.
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