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Eyeing the use of cryotherapy for eyebrow alopecia areata

DII small banner By Warren R. Heymann, MD
April 5, 2017

I am always looking for alternatives to injecting eyebrow alopecia areata with triamcinolone acetonide (TAC). My protocol, based on the recommendation by Alkhalifah et al, is TAC 2.5 mg/mL, 0.5 mL to each eyebrow, every 4 to 6 weeks, as necessary (1). I always inform patients of the remote possibility of retinal artery occlusion that may occur with intralesional TAC in the periocular region (including the orbit, eyelids, maxilla, face and nose). The supraorbital artery is a branch of the ophthalmic artery proximal to the origin of the central retinal artery. The presumed mechanism by which drug suspensions gain access to the intraocular circulation is by retro-orbital flow (2). None of my patients have ever had this adverse reaction — kinehora!

Choe and Lee utilized superficial cryotherapy (SC) every other week on the right eyebrow in a total of 20 patients who had been previously treated with diphenylcyclopropenone (DPCP) immunotherapy on the scalp. No specific treatment was performed on the left eyebrows as a control. The degree of eyebrow recovery was compared in 15 patients who continued to receive more than 10 superficial cryotherapy treatments (5 months of treatment) on their right eyebrow (an eye protector was used). Hair density was significantly increased on both treated and control eyebrows after 5 months of treatment compared with the pretreatment density; moreover, the SC-treated eyebrows exhibited a significantly greater increase in density than the control eyebrows. Although hair thickness in the control eyebrows did not change significantly over the treatment period, hair thickness of the SC-treated eyebrows showed a statistically significant increase at months 3 and 5. The authors concluded that superficial cryotherapy is associated with minimal to no adverse events and exhibits high compliance and relatively good efficacy. Thus, this treatment is an important additional option for patients with AA of the eyebrow (3).

I’m not sure about their conclusion.

I am not questioning their statistical analysis (based on the use of a folliscope) — I just cannot see the clinical difference between the right and left eyebrows at 5 months (based on the photographs of the 2 patients they used as examples). As authors acknowledge themselves, perhaps improvement was based on either spontaneous improvement or a systemic effect of the DPCP.

In the most recent study of cryosurgery for alopecia areata (AA) in general, Jun et al (with the same senior author in the Choe article) retrospectively reviewed medical records of 353 AA patients. According to the response to the superficial cryotherapy, patients were categorized into four groups: “marked”, “partial”, “poor” and “no recovery”. The marked and partial recovery groups were considered as responders. Of the patients, 60.9% (22.4% marked and 38.5% partial). were classified as responders after 3 months of superficial hypothermic cryotherapy. The proportion of the responders was higher when the treatment interval was 2 weeks or less and in the incipient disease stage of disease, with statistical significance. No severe side effects other than mild pain and pruritus were reported. The authors concluded that superficial cryotherapy is an effective and safe therapeutic modality for AA (4). The one clinical image of regrowth of a large patch of AA on the parietal scalp following 12 weeks of treatment is convincing.

Why cryosurgery should work in AA is unknown, but it may be due to reactive vasodilatation and/or immunologic effects, such as diminishing Langerhans cells, T cells, or effects on melanocytes (3,4).

What I hope to see is an appropriate, prospective, randomized study of cryosurgery for AA of all types, including a study limited to the eyebrows. I need more convincing before I warm up to cryosurgery for AA.

1. Alkhalifah A, et al. Alopecia areata update: Part II. Treatment. J Am Acad Dermatol 2010; 62: 191-202.
2. Edwards AO. Central retinal artery occlusion following forehead injection with a corticosteroid suspension. Pediatr Dermatol 2008; 25; 460-1.
3. 4. Choe SJ, Lee W-S. Efficacy of superficial cryotherapy on the eyebrows of patients with alopecia universalis also treated with contact immunotherapy on the scalp: A prospective , split-face comparative study. Int J Dermatol 2017; 56: 184-9.
4. Jun M, et al. Efficacy and safety of superficial cryotherapy for alopecia areata: A retrospective, comprehensive review of 353 cases over 22 years. J Dermatol 2016; Oct 6 [Epub ahead of print].

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