INTRODUCTION
Alopecia areata (AA) is a form of non-scarring alopecia that results from an autoimmune process that targets hair follicles.1 The severity of the disease varies from a focal, patchy hair loss termed alopecia focalis (AF) to complete hair loss of the scalp termed alopecia totalis (AT), to the most severe form, alopecia universalis (AU), which involves total loss of hair on the body and scalp. AA affects 4.5 million people in the United States.2 It affects patients of all ages with 66% of patients being younger than age 30, and 20% being older than age 40.2
The pathophysiology of the disease has not been completely elucidated, but cytotoxic T-lymphocytes have been shown to play a key role in the disease, attacking follicular autoantigens.3 Immunosuppressive and immune-modulating therapy has shown some efficacy, further pointing to the immune-mediated aspect of the disease pathophysiology. Despite the various treatment options, response rates are variable and remain low in patients with AT and AU.1 The poor prognosis of AT and AU, in addition to the psychological distress experienced by these patients makes it imperative to find effective and safe treatment options.
Dupilumab is a human monoclonal IgG4 antibody directed against the interleukin-4 (IL-4) receptor alpha subunit resulting in an inhibition of the signaling of the type 2 cytokines IL-4 and interleukin-13 (IL-13).4 First FDA approved in 2017 for the treatment of moderate to severe atopic dermatitis, dupilumab is now also approved as an adjunct treatment in moderate to severe asthma.4 There have been several case reports documenting dupilumab's effect on patients with AA, worsening the disease in some and improving hair regrowth in others.5 We report a case of a patient with alopecia totalis who achieved nearly complete hair regrowth after starting dupilumab for atopic dermatitis.
CASE REPORT
A 49-year-old Caucasian female with history of AA since age 10, and atopic dermatitis since age 30, presented to the dermatology clinic. The patient had a family history of AA in her mother and sister, as well as atopic dermatitis in her children. Her extensive history of AA included three lifetime episodes of AT, the third of which resulted in progression to AU at one point and sustained AT for roughly ten years. Numerous treatments including methotrexate, intralesional triamcinolone injections, topical corticosteroids, bexarotene gel, tazarotene and halobetasol propionate combination lotion, topical minoxidil, bimatoprost solution, ezetimibe, and simvastatin were utilized with little to no response. Figure 1 demonstrates patients' alopecia areata when being treated with daily bexarotene, clobetasol, and minoxidil.
Regarding her atopic dermatitis, the patient first developed a pruritic eczematous eyelid dermatitis in her early thirties for which she underwent patch testing that revealed allergies to fragrance mix and glutaraldehyde. Eczematous patches progressed to involve the neck, abdomen, back, and thighs despite allergen avoidance, and she was diagnosed with atopic dermatitis. The patient was treated with oral steroids, methotrexate, and
