DISCUSSION
Here we report a case of complete resolution of AT following
chemotherapy. The response of this patient’s AT to chemotherapeutic
agents supports the theory that autoimmune dysfunction is a driver of
the pathogenesis of alopecia areata. The resolution and sustained
remission in this case suggests that the intensive immunosuppression
from chemotherapy may have played a role in resetting her immune system.
While it is also possible that this patient’s hair regrew as part of the
natural history of alopecia areata, most patients with AT remain stable
or worsen with time.11 This patient has no evidence of
relapse of AT 6 years following chemotherapy completion. The prolonged
remission along with the timing of hair regrowth during chemotherapy
treatment suggests the possibility of a durable cure of AT with
chemotherapy.
Prior to this case, there were two reported cases of sustained
resolution of alopecia universalis following hematopoietic stem cell
transplant (HSCT) for systemic malignancy. Seifert et
al9 described complete resolution of alopecia
universalis in a 40 year-old male patient following allogenic HSCT for
chronic myeloid leukemia. Subsequently, Feher et al10reported a similar case in a 48 year-old male patient with alopecia
universalis who was treated with chemotherapy and autologous HSCT for
follicular lymphoma. In both of these cases, the authors hypothesized
that myeloablative conditioning and autologous HSCT with immune
reconstitution resulted in remission of the autoimmunity and resolution
of this patient’s alopecia. In contrast, complete myeloablation and
immune reconstitution was not part of this patient’s leukemia treatment,
although we postulate that the standard dose chemotherapy-induced immune
suppression she received played a role in the resolution of her AT.
Chemotherapy given in the context of systemic malignancy has previously
been reported to coincide with resolution of other autoimmune
dermatologic diseases such as psoriasis12 and
hidradenitis suppurativa.13 Systemic autoimmune
conditions, such as systemic lupus erythematous14 and
rheumatoid arthritis15, have also been in remission
following chemotherapy for cancer treatment. While the risks inherent
with chemotherapy usually outweighs the morbidity of AT, the sustained
remission of the AT following chemotherapy helps shed some light into
the pathogenesis of and potential future therapeutic targets for this
cosmetically debilitating and enigmatic disease. It would be worth
reviewing the clinical course of other oncology patients who have
concomitant alopecia areata and their long-term response to
chemotherapy.
We highlight a case of sustained resolution of AT following chemotherapy
for B-ALL in a pediatric patient. This case highlights the role of
autoimmunity in the pathogenesis of AT and demonstrates that a reset of
the host immune system using chemotherapy may provide a durable cure for
AT.