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Original Investigation
October 2018

Hair Regrowth Outcomes of Contact Immunotherapy for Patients With Alopecia Areata: A Systematic Review and Meta-analysis

Author Affiliations
  • 1Institute of Hair and Cosmetic Medicine, Department of Dermatology, Yonsei University Wonju College of Medicine, Wonju, Republic of Korea
JAMA Dermatol. 2018;154(10):1145-1151. doi:10.1001/jamadermatol.2018.2312
Key Points

Question  At what rate is contact immunotherapy associated with satisfactory hair regrowth in patients with alopecia areata?

Findings  In this meta-analysis of 45 studies that included 2227 patients, any hair regrowth was observed in 74.6%, minor regrowth in 64.9%, major regrowth in 56.1%, and complete regrowth in 42.6% of patients with patchy alopecia. Any regrowth was observed in 54.5%, minor regrowth in 45.0%, major regrowth in 28.7%, and complete regrowth in 24.9% of patients with alopecia totalis/universalis.

Meaning  Hair regrowth outcomes of contact immunotherapy may be associated with various factors, and quantitative summarization may improve patient education and lead to better therapeutic adherence and hair regrowth.

Abstract

Importance  Contact immunotherapy with diphenylcyclopropenone or squaric acid dibutyl ester is a preferred treatment for severe alopecia areata; however, the defined criteria for therapeutic hair regrowth and regrowth rate have been highly heterogeneous across studies.

Objective  To summarize the clinical outcomes of contact immunotherapy for alopecia areata according to standardized criteria for therapeutic hair regrowth and several prognostic factors.

Data Source  A database search of MEDLINE, Embase, and Cochrane Library was performed for articles published before November 20, 2017, using the search terms areata, totalis, universalis, sensitizer, sensitization, immunotherapy, DPCP, diphenylcyclopropenone, diphencyprone, SADBE, and squaric.

Study Selection  Clinical trials or observational studies that investigated contact immunotherapy for alopecia areata and subgrouped the disease into patchy alopecia or alopecia totalis/universalis and reported their hair regrowth rates were included, whereas studies that investigated combination therapy or nonconventional protocol and case series or reviews were excluded.

Data Extraction and Synthesis  The following data were extracted from each of the studies included in this meta-analysis: study year and setting, sensitizer type, study population, study population composition by disease subtype, defined criteria for therapeutic hair regrowth, and regrowth rate of contact immunotherapy. The incidence of adverse effects and recurrence rate were also recorded. A random effects model was used for data synthesis because of the expected high heterogeneity of the included studies.

Main Outcomes and Measures  The main outcome was therapeutic hair regrowth rate according to the 4-grade criteria for therapeutic regrowth. Secondary outcomes included incidence of treatment-related adverse effects and recurrence rate.

Results  Forty-five studies comprising 2227 patients were analyzed. The overall rate of any hair regrowth was 65.5% among patients with alopecia areata (74.6% in the patchy alopecia and 54.5% in the alopecia totalis/universalis subgroups). However, the complete regrowth rate was 32.3% (24.9% in the patchy alopecia and 32.3% in the alopecia totalis/universalis subgroups). Disease extent of 50% or greater (odds ratio [OR], 3.05; 95% CI, 2.26-4.12), atopic history (OR, 1.61; 95% CI, 1.03-2.50), and nail involvement (OR, 2.06; 95% CI. 1.26-3.36) were associated with poorer therapeutic outcome. Recurrence rates were 38.3% among patients receiving maintenance treatment and 49.0% among those not receiving maintenance treatment.

Conclusions and Relevance  Various factors were associated with the clinical outcomes of contact immunotherapy for alopecia areata, with significant differences in hair regrowth rates according to the level of expected therapeutic regrowth. Quantitative summarization may improve patient education and lead to better therapeutic adherence and outcomes.

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