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SHORT COMMUNICATION
Alopecia Areata after Omalizumab Treatment for Chronic Spontaneous Urticaria
Eli MAGEN
Leumit Health Services, and Medicine C Department, Clinical Immunology and Allergy Division, Barzilai Medical Center, Ben Gurion University
of the Negev, Ashkelon, Israel. E-mail: [email protected]
Accepted Jun 17, 2019; E-published Jun 24, 2019
Omalizumab is the first targeted biologic therapy appro-
ved for the treatment of chronic spontaneous urticaria
(CSU) (1). It binds selectively to human IgE, preven-
ting binding of IgE to its high-affinity receptor (FcɛRI),
thus affecting the urticaria immunological cascade on
several levels (2). Omalizumab has a very good safety
and tolerability profile; the global pattern of side-effects
and adverse events related to the drug is similar to that
occurring in placebo-treated patients (3). The Summary
of Product Characteristics (SmPC), reports some side-
effects (muscle pain, joint swelling and hair loss), but
there is insufficient data to estimate their frequency (4).
We describe here a patient treated with omalizumab for
CSU who developed alopecia areata (AA) after 14 weeks
of first exposure.
CASE REPORT
A 27-year-old man with no significant medical history
presented with a 7-month history of poorly control-
led, antihistamine-resistant CSU. He had been treated
previously in another dermatology centre with daily
fexofenadine, 180 mg 4 times a day, and montelukast,
10 mg once a day, with only mild improvement. The la-
boratory examinations, whole blood count, liver function
tests, renal function tests, serum electrolytes, erythrocyte
sedimentation rate, CRP, thyroid function tests, C3 and
C4, were normal, antinuclear antibodies were negative
and total IgE was 74.9 kU/l (normal 2–78 kU/l). The
7-day urticaria activity score was 38.
Because high-dose antihistamines and montelukast
did not improve the patient’s condition, treatment with
omalizumab was proposed at a single dose of 300 mg/
month for 6 months. The patient improved significantly
after the first dose, and from the second month onwards,
switched from taking fexofenadine, 180 mg 4 times a
day, to use it regularly on demand. However, after 14
weeks of omalizumab treatment, he noted patches of hair
loss on his right frontal and temporal scalp (Fig. 1). He
was seen in our clinic, the pull test at the periphery of
the plaque was positive, and dermoscopy revealed black
dots. AA was diagnosed clinically (the patient refused
scalp biopsy). The patient characterized his hair loss as a
major, distressing side-effect, significantly affecting his
quality of life. He is currently being treated with intrale-
sional triamcinolone acetonide, 5 mg/ml every 4 weeks.
Fig. 1. Clinical photograph of alopecia areata after 14 weeks of
treatment with omalizumab.
DISCUSSION
We report here a chronological relationship between
omalizumab treatment and subsequent development of
AA. Although a chronological relationship cannot be
interpreted as causal, this option cannot be ruled out.
There are no reports of AA in patients on omalizumab
therapy in the existing medical literature. Although hair
loss is listed among the side-effects in the SmPC of
omalizumab, all previous reports related to diffuse and
transient types of hair loss and not to AA (5, 6). AA repre-
sents a multifactorial autoimmune organ-specific disease
and its pathogenesis involves T-cell autoantigens, type
1 T helper (Th1)/interferon-γ, Th2, PDE4, interleukin
(IL)-23 and IL-9 pathways (7). It can be speculated that
This is an open access article under the CC BY-NC license. www.medicaljournals.se/acta
Journal Compilation © 2019 Acta Dermato-Venereologica.
doi: 10.2340/00015555-3244
Acta Derm Venereol 2019; 99: 919–920