Dermatologists from Massachusetts General Hospital were stunned when their 13-year-old patient – a girl who had suffered from severe eczema and persistent alopecia since infancy – began to regrow hair on her scalp after starting a regimen of a new immune-system-modifying drug.
Writing in the journal JAMA Dermatology, the team explains that the teen came into their care in the hopes of finding an effective treatment for her eczema, also referred to as atopic dermatitis, following years of trying various drugs and drug combinations with no improvement. The itchy red lesions characteristic of the condition covered about 70 percent of her body.
Two years of temporary successes and setbacks later, the physicians decided that she should try a brand-new drug called dupilumab. Approved in the Spring of 2017 for treatment of moderate to severe eczema, dupilumab is sold under the brand name Dupixent. It works by blocking the activation of a receptor on white blood cells involved in triggering an inflammatory allergic response. Over-activation of this receptor and several closely related receptors, through genetic variations and poorly understood environmental factors, is associated with asthma, hay fever, and food allergies, in addition to eczema.
After three injections of dupilumab over a period of six weeks, the patient’s eczema had improved significantly. And while that was exciting in itself, she was even more thrilled to notice that numerous vellus hairs – the short, fine, light-colored hairs that typically cover large areas of the body – were sprouting across her scalp. Due to her alopecia areata, the teen’s scalp had previously been completely bald (a state called alopecia totalis).
Nine months after beginning dupilumab treatment, she had grown pigmented hairs resembling normal head hairs on approximately 60 percent of her scalp.
"We were quite surprised since this patient hadn't grown scalp hair since the age of two, and other treatments that can help with hair loss did not in her case," senior author Dr Maryanne Makredes Senna said in a statement. "As far as we know, this is the first report of hair regrowth with dupilumab in a patient with any degree of alopecia areata."
Unfortunately, a snafu with insurance meant that the patient had to discontinue the pricey medication for two months, during which time her hairs fell out. But as soon as she was able to resume regular, twice-monthly dupilumab injections in April 2018, her hair growth restarted and has continued since.
As to why this remarkable side effect occurred, Dr Senna and her colleagues have a hunch.
“The dual efficacy of dupilumab for atopic dermatitis (AD) and alopecia areata (AT) may be explained by their shared immune characteristics,” they wrote. Past studies have determined AD is mediated by activity of a specific type of helper T cell (TH2), and although the mechanisms underlying AT – an autoimmune disorder wherein the body attacks its own hair follicles – are less well understood, these cells appear to play a role. “Dupilumab’s antagonism of the TH2 pathway could therefore explain its utility in both conditions.”
"Right now, it's hard to know whether dupilumab could induce hair growth in other alopecia patients, but I suspect it may be helpful in patients with extensive active eczema and active alopecia areata," Senna said. "We've submitted a proposal for a clinical trial using dupilumab in this patient population and hope to be able to investigate it further in the near future."