Back to Skin Therapy Letter Home Page
Link to DermWeb at UBC
Comments or suggestions?
August 1996 Volume 1 Number 6
Contents: (Full text
available in print edition.)
Extraction - Not Effective in Acne
The manual extraction of open and closed comedones has a
long tradition in the treatment of acne and continues to be
listed amongst treatments for the disease.1,2 However, some
dermatologists questioned its utility as long ago as 1984,3 and recent
histopathological data support the assertion that extraction does
not greatly influence the course of the disease and can cause
Extraction of comedones is cosmetically gratifying and
therefore seems worthwhile in comedonal acne. Open comedones
(blackheads) are usually directly extracted with a comedo
extractor, while closed comedones (whiteheads) must usually be
punctured with a sharp blade or point before the extraction is
In a recent clinical and histopathological study4,
comedones were squeezed out with comedo extractors and studied
immediately. In addition, skin biopsies were studied after 2-20
minutes, one hour, and between 1-105 days thereafter. Despite
careful extraction, common histopathological features were
epithelial defects and inflammatory and granulomatous foreign
body reactions. Even if not clinically evident, there were always
inflammatory reactions, and scarring was often found. Comedones
started to return and became visible within 4-6 weeks, unless the
epithelial capsule was delivered during the extraction. However,
the comedonal epithelium was rarely expelled in toto or the
follicle and comedo permanently removed.
- Ho V, ed.
Acne management for the 90s: current treatment
guidelines. Can J Diagn 1995; December supplement.
- Drake LA,
et al. Guidelines for the care of acne vulgaris. J Am
Acad Dermatol 1990; 22: 676-680.
- Maddin S.
Acne surgery. In: Epstein E, ed. Controversies in
dermatology. Philadelphia: WB Saunders, 1984:
- Jansen T,
Plewig G. Komedonenentfernung: eine klinische und
histopathologische Studie. Z Hautkr 1995; 70:
Return to Article
Return to Contents
Treatment of Alopecia Areata (AA) with Special Emphasis on
Topical Immunotherapy with Diphenylcyclopropenone (DCP)
The lifetime risk of men or women developing
alopecia areata (AA) is estimated at 1.7%. Although the condition
usually resolves spontaneously, approximately 7% of patients may
suffer severe and chronic hair loss, which can be psychosocially
devastating.1 Topical immunotherapy is the best overall
treatment for chronic severe (more than 50% hair loss) AA.
Systemic steroids would be more effective, but their side effects
Treatment of Alopecia Areata3
With Dr. Jerry Shapiro as Director, The
University of British Columbia Hair Clinic (UBCHC) is an
acknowledged leader in AA therapy. The clinic's recommended
treatments, in order of preference, are:
In patients with less than
50% hair loss.
In patients with more than
50% hair loss.
- Minoxidil solution
- Minoxidil solution plus
- Minoxidil solution plus
superpotent topical corticosteroid
- Topical immunotherapy if
above do not work
Topical Immunotherapy with
(diphencyprone; DCP) treatment of AA should only be used
under the supervision of dermatologists. In a study by
van der Steen and colleagues, 139 patients with severe AA
were treated with DCP for one year. Response in 50.4% was
either excellent with total regrowth or satisfactory with
only a few remaining bald patches.6 At UBCHC, in severe AA the response rate
to DCP is 50-60%.5 The main factor influencing the
therapeutic result is the extent of hair loss.4 When treating alopecia universalis or
alopecia totalis, the success rate is only 25%.5 Response rates are lower in patients
with a long duration of the disease before therapy.4,5 While treatment results may be seen in
eight weeks, they are usually apparent in 14 weeks, but
may take up to 24 weeks.5
- Topical immunotherapy with
DCP to the whole area is the treatment of choice
at the UBCHC, according to Dr. Shapiro.
corticosteroids can be used on limited resistant
- Non-responders can receive
PUVA, although this is not always effective;
regrown hair falls out when treatment is stopped.
- Minoxidil solution, with or
without anthralin or superpotent topical
steroids. Dr Shapiro prefers 5% minoxidil to the
2% solution, especially in patients with more
than 50% hair loss.
- Systemic corticosteroids
Hair growth often remains unaffected by
gradual discontinuation of DCP treatment.6 In a study of 19 patients, 37% showed no
hair loss six months after cessation of treatment and the
appearance of the scalp was cosmetically acceptable in
68%. However, 53% developed patchy alopecia, and 10% lost
all regrown hair.8 When hair loss recurs, there is a good
chance that patients will respond to further DCP
Topical immunotherapy is not
approved by the FDA in the USA or the Health Protection
Branch of Canada. In the USA, the first official trial of
DCP for alopecia areata patients has only just been
commenced by the National Institute of Health. Since DCP
treatment is experimental, a local ethics committee
should approve the treatment protocol.9
Pregnant patients and patients with
malignancies or blood dyscrasias of any sort are excluded
from treatment. Dark-skinned patients are more difficult
to treat as they are more prone to pigment changes.5 There is little experience with DCP
treatment of children with AA; one study demonstrated
that DCP is effective, but long-term effects are unknown.
Parents must be aware of all possible side-effects.11 The UBCHC does not treat children
younger than 12 years of age.
Lymphadenopathy occurs in virtually
all patients. Other frequent side effects are more severe
eczematous reactions with blistering, spreading of the
induced contact eczema, and sleep disturbances. Vitiligo,
hyper- and hypopigmentation can also occur.5, 6 Treatment staff can also develop adverse
reactions when applying the product.10
- DCP application should be
done by trained personnel in a hospital or
university-based skin care centre. Treatment
should NEVER be self-applied.2, 5
- DCP should be applied in
well-ventilated conditions, and treatment staff
should wear protective garments to guard against
- DCP solution should not be
washed off for 48 hours.
- As DCP degrades when
exposed to light, the patient must protect the
scalp from light, preferably for 48 hours.
- Treat half the scalp first.
If regrowth occurs, then treat the other side.
- Titrate the dose to produce
redness. Without redness and itch, treatment will
not be effective.
- Use topical corticosteroids
ONLY if the skin reaction is excessive.
Patients should understand that the
allergic contact dermatitis induced by DCP is expected
and required for treatment to be successful. They should
also be informed about the experimental nature of
Supply and Cost
DCP is readily available through
chemical suppliers. Ensure that DCP does not contain
dibenzyldibromoketones, precursors of DCP that are
positive in the Ames test for mutagenicity.2 Weekly treatments applied to the whole
head cost about US$2.25 for materials.
Mechanism of Action
Antigenic competition has been
proposed as a mechanism of action. The generation of
nonspecific T suppressor cells into the area may inhibit
the autoimmune reaction to the hair-associated antigen
and, thus, allow hair to regrow.12
Alternatives to DCP
Dinitrochlorobenzene (DNCB) has
been in use since 1976.13 DNCB is rapidly absorbed and produces a
positive Ames test. Because of safety concerns, it is no
longer recommended for use in AA. Squaric acid dibutyl
ester (SADBE) is a strong topical sensitizer that is not
found naturally and is used only rarely in industry. It
is used for treating AA in some centres as an alternative
to DCP.14 It is less stable than DCP.2
KH, Muller SA, Suman VJ, et al. Incidence of
alopecia areata in Olmsted County, Minnesota,
1975 through 1989. Mayo Clin Proc 1995;
J. Topical immunotherapy in the treatment of
chronic severe alopecia areata. Dermatol
Clinics 1993; 11: 611-617.
J. Alopecia areata: update on therapy. Dermatol
Clinics 1993; 11: 35-46.
der Steen PH, van Baar HM, Happle R, et al.
Prognostic factors in the treatment of alopecia
areata with diphenylcyclopropenone. J Am Acad
Dermatol 1991; 24: 227-230.
J. Personal communication. April 1996.
der Steen PH, van Baar HM, Perret C, et al.
Treatment of alopecia areata with
diphenylcyclopropenone. J Am Acad Dermatol
1991; 24: 253-257.
Baar HM, van der Vleuten CJM, van der Kerkhof
PCM. Dapsone versus topical immunotherapy in
alopecia areata. Brit J Dermatol 1995;133:
-Hull S, Cunliffe W. Post therapy relapse rate in
alopecia areata after successful treatment with
diphencyprone. J Dermatol Treat 1989; 1:
C, Happle R. Treatment of alopecia areata. In:
Orfanos C, Happle R (eds). Hair and hair
diseases. New York: Springer-Verlag, 1990:
M, Lewis FM, Messenger AG. Hazards in the use of
diphencyprone. Brit J Dermatol 1996; 134:
SM, Pepall L, Cunliffe WJ. Alopecia areata in
children: response to treatment with
diphencyprone. Br J Dermatol 1991;
R. Antigenic competition as a therapeutic concept
for alopecia areata. Arch Dermatol Res
1981; 26: 285.
E, Drake L. Letter, Arch Dermatol 1976;
R. Personal communication. June 1996.
|Outlook for the
treatment for severe AA is very non-specific and
has considerable side effects. A lot of work is
going into researching normal hair biology
looking for the events that control the hair
cycle. Hopefully, once the trigger for AA is
found, more specific, more effective and better
tolerated treatments will be developed. Due to
the heterogeneous nature of AA, we will find that
combination treatments utilizing more than one
treatment approach will increase our success rate
in treating AA.
Shapiro, Vancouver, Canada
Dates and Comments
|Gel and solution
(both 0.1%) of this retinoid-like compound were
approved by the FDA on the May 31, 1996 for the
topical treatment of acne. Adapalene is already
available in several other countries. See the
review of adapalene in Issue
Dovonix® Scalp Solution
|Dovonex® is now
available in Canada in a scalp solution as well
as a cream and ointment. The solution formulation
is already available in the UK, Western Europe,
and Denmark, and is awaiting approval in the USA.
This non-steroidal vitamin D analogue is
indicated for the topical management of mild to
Skin Therapy Letter. (ISSN 1201-5989) Copyright 1996
by International Skin Therapy Newsletter Inc. All rights
reserved. Reproduction in whole or in part by any process
in whole or in part is strictly forbidden without prior
consent of the publisher in writing.
Published six times yearly by International Skin
Therapy Newsletter Inc., 835 West Tenth Avenue,
Vancouver, British Columbia, Canada V5Z 4E8. Tel: (604)
874-6112. Fax: (604) 873-9919.
Annual subscription: Canadian $85 individual; $155
institutional (GST included). US $60 individual; $110
institutional. Outside North America: US$80 individual;
$130 institutional. Quotes on multiple subscriptions and
student rates supplied upon request.