ORIGINAL RESEARCH article
Front. Med.
Sec. Dermatology
Volume 12 - 2025 | doi: 10.3389/fmed.2025.1573929
Treatment Outcomes and Considerations for Topical Immunotherapy in Patients with Alopecia Totalis and Alopecia Universalis
Provisionally accepted
Taiyo Hitaka1Sanehito Haruyama2Shun Ohmori3Natsuko Saito-Sasaki1Etsuko Okada4Motonobu Nakamura5
Yu Sawada1*- 1University of Occupational and Environmental Health Japan, Kitakyushu, Japan
- 2Haruyama Dermatology Clinic, Gyota City, Japan
- 3Kokura Daiichi Hospical, Kokura City, Japan
- 4National Hospital Organization Takasaki General Medical Center, Takasaki, Gunma, Japan
- 5Matsuoka Clinic, Osaka City, Japan
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Background: Alopecia areata (AA) is a chronic immune-mediated disorder causing nonscarring hair loss. Severe forms like alopecia totalis (AT) and alopecia universalis (AU) pose therapeutic difficult situations. Topical immunotherapy with squaric acid dibutylester (SADBE) and diphenylcyclopropenone (DPCP) is widely used but has variable efficacy.To evaluate the efficacy of topical immunotherapy in severe AA, identify factors influencing outcomes, and assess adjunctive antihistamine therapy.Methods: A retrospective analysis of 106 severe AA cases (26 AT, 80 AU) among 1,098 patients diagnosed between 2007 and 2016. Treatment efficacy was assessed using the Alopecia Areata Investigational Assessment Guidelines (AAIAG), and statistical analyses included chi-square tests and Kaplan-Meier analysis.Results: Among the 106 patients included in this study, 43% exhibited excellent or good responses to topical immunotherapy, while 75% experienced at least partial hair regrowth.Patients with alopecia totalis demonstrated slightly better outcomes than those with alopecia universalis (50% vs. 40% achieving excellent or good responses). Atopic dermatitis was significantly associated with lower treatment efficacy (54% vs. 80%, p = 0.0157). Although antihistamine use showed a trend toward improved responses (78% vs. 38%), the difference did not reach statistical significance (p = 0.0991), and multivariate analysis did not confirm its efficacy (p = 0.649). Hair regrowth was observed within four months in 90% of cases, while peak therapeutic effects were achieved within three years.Long-term treatment adherence correlated with improved outcomes, highlighting the importance of sustained therapy.Conclusions: Topical immunotherapy remains an effective treatment for severe alopecia areata, although response rates vary among patients. Individualized treatment approaches, including prolonged therapy and consideration of patient-specific factors, are essential for optimizing clinical outcomes.
Keywords: Alopecia totalis, Alopecia universalis, Topical immunotherapy, SADBE, DPCP
Received: 10 Feb 2025; Accepted: 09 Jun 2025.
Copyright: © 2025 Hitaka, Haruyama, Ohmori, Saito-Sasaki, Okada, Nakamura and Sawada. This is an open-access article distributed under the terms of the Creative Commons Attribution License (CC BY). The use, distribution or reproduction in other forums is permitted, provided the original author(s) or licensor are credited and that the original publication in this journal is cited, in accordance with accepted academic practice. No use, distribution or reproduction is permitted which does not comply with these terms.
* Correspondence: Yu Sawada, University of Occupational and Environmental Health Japan, Kitakyushu, Japan
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