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Although its etiology remains unknown, evidence has accumulated to support an autoimmune pathogenesis for alopecia areata. Our review summarizes the immunologic data and also examines the role of genetics, atopy, and psychologic stress in this disorder. Until etiology is better understood, treatments for alopecia areata are likely to remain palliative. Nevertheless, newer therapies such as photochemotherapy, topical immunotherapy, and perhaps systemic immunotherapy (e.g., inosiplex) offer new hope for patients with extensive disease.

Twenty-two patients with alopecia areata were treated with a combination of topical 0.1% 8-methoxypsoralen and UVA (PUVA). Eight of the twenty-two patients (36.3%) responded with excellent regrowth (terminal hair in at least 75% of the treated scalp), and two patients (9.1%) showed good regrowth (terminal hair in 50% to 75% of the treated scalp). The mean total UVA exposure and the mean total number of treatments for the entire treatment course for these responders was 171.7 joules/cm2 and 47.4 treatments, respectively. Eight of the nine responders available for follow-up experienced some degree of relapse when PUVA treatments were tapered or during a follow-up period (mean, 8.3 months) after treatment was discontinued. Despite the failure of topical PUVA to change the long-term course of alopecia, the combination of PUVA with other therapeutic modalities may result in the prolongation of the beneficial effect in selected patients. The mechanism of action of PUVA in alopecia areata might involve an immunomodulatory effect.

Forty-five children with alopecia areata were prospectively studied by means of both clinical and laboratory evaluation for evidence of endocrine diseases and autoantibodies. Twenty-four percent had an abnormality as determined by one or more thyroid function studies (thyroxine, triiodothyronine, and thyroid-stimulating hormone) and/or elevation of microsomal antibody levels. In 16%, smooth muscle antibody was present, and in 4%, parietal cell antibody was present. Routine thyroid function testing is recommended for all children with alopecia areata.

A patient presented with a solitary plaque initially interpreted on light microscopy as benign lymphoplasia. Monoclonal antibody studies were used to define the B cell origin of the infiltrate and to characterize its probable malignant potential. Monoclonal antibody typing is a useful technique to evaluate lymphocytic infiltrates that may be difficult to categorize on the basis of routine light microscopy.

Alternaria species are common plant pathogens, but a rare cause of human infection. Previously reported cases of cutaneous alternariosis (Alternaria alternata) in both healthy and immunosuppressed hosts have been characterized by a chronic localized ulcerative eruption in exposed sites. Dermal granulomatous infiltration and variable epidermal changes, with hyphae in both the dermis and epidermis, are characteristic. We present a case with certain unique features. This is the first reported human infection with Alternaria dianthicola. In addition, our patient showed the unusual presentation of clinically noninflammatory subcutaneous nodules of the chest wall. The subcutaneous location of the granulomatous process may have been attributable to deep traumatic inoculation. The circumscribed nodular quality of the infection allowed a surgical therapeutic approach.

The efficacy of the topical allergen squaric acid dibutylester (SADBE) was investigated in the treatment of twenty-six patients with alopecia areata or alopecia totalis. The patients had their disease for a mean duration of 8.3 years (range, 3 months to 27 years). Sensitization was attempted with 2% SADBE in acetone. Five individuals could not be sensitized. The twenty-one sensitized patients were treated with topical applications of 0.001% to 1.0% SADBE in acetone adjusted to produce and maintain dermatitis for an average of 21 weeks. Eleven (52%) had excellent responses consisting of complete regrowth in six and cosmetically acceptable regrowth in five. The average treatment time for regrowth was 11 weeks (range, 5-20 weeks). Ten (48%) had no clinical response after an average of 19 weeks of therapy (range, 4-42 weeks). Topical SADBE is an effective therapy for some patients with long-standing alopecia areata.