Successful application of add-on high-definition transcranial direct current stimulation in a schizophrenic patient with comorbid alopecia universalis.

Sir,

High-definition transcranial direct current stimulation (HD-tDCS), an advanced version of tDCS, is found to show alleviation of auditory verbal hallucinations (AVHs) as an add-on treatment modality in schizophrenia.[1] There is a scarcity of data evaluating the utility and tolerability of the same.

Local skin-related side effects are the most common adversities reported with HD-tDCS.[2] Density of hair follicles is hypothesized to be influencing the sensory adversities related to electrical stimulation and insulation,[3] and loss of hair as seen with alopecia might pose a technical challenge. In this case report, we describe the utility and tolerability of HD-tDCS in a patient diagnosed with schizophrenia with persistent AVH with comorbid alopecia universalis (AU).

CASE REPORT

Index patient, a 24-year-old female, with a personal history of AU since birth presented with illness of 10 years duration which was insidious in onset, continuous in course, and characterized by made phenomenon, delusions and hallucinations, resulting in academic decline and impaired social functioning. The patient had shown partial response to 400 mg of amisulpride, 4 mg of risperidone, and 20 mg fluoxetine per day with remission of all psychotic symptoms, except for second- and third-person AVHs.

In view of her persistent AVH, the patient was considered for a trial of an add-on treatment with HD-tDCS after obtaining written informed consent. The patient was given ten sessions of HD-tDCS at 2 mA current. Each session lasting 20 min was administered twice a day with an intersession interval of 3 h for 5 days. Central cathode at CP5 (left temporoparietal junction) of 10–10 electroencephalography system surrounded by four return anodal ring electrodes was used.[1] Electrodes were placed in plastic holders filled with gel. A properly fitting cap was used such that electrode holders were held tight enough to avoid slippage of gel without causing undue discomfort. Sufficiently, viscous gel of 1.8–2.6 lakh centipoise (SignaGel, Parker Laboratories) was used to restrict it to the targeted foci avoiding the shortening of circuit. Side effects were closely monitored using a structured tool after every session.[1]

Auditory hallucinations score (psychotic symptom rating scale) reduced from 33 to 0 describing complete alleviation of AVH without any side effects. In parallel, risperidone was cross-tapered with aripiprazole 10 mg due to hyperprolactinemia (133.7 ng/ml). The psychotic symptoms remained remitted until the latest visit at 6th month of HD-tDCS treatment.

DISCUSSION

This case report has explored the relative effectiveness and tolerability of HD-tDCS as an add-on treatment modality for persistent AVH in schizophrenia with AU. AU is a severe form of alopecia areata which involves loss of hair from all over the body.[4] Hair is regarded as an insulator reducing the local electrical density,[3] and the absence of it did not yield in any adverse sensations. Saline or any equivalent conductive gel, if found to deviate from its locus, may lead to change in the course of the circuit path compromising the effectiveness of the stimulation. Considering AU, slippage/drifting of the gel was avoided in the index subject by using viscous gel and maintaining the properly fitting cap and electrode holders.

Reduction of excitability of left temporoparietal junction through neuroplasticity modulation by HD-tDCS is known to bring about the decline in AVH in schizophrenia. Although the reduction in AVH is reported earlier, a complete cessation, as observed in the current subject, is rarely noted.[1] The comorbidity of the two conditions in this patient could be serendipitous. However, there is involvement of inflammatory pathways in both schizophrenia and AU.[5] Therefore, along with the neuroplasticity induced by HD-tDCS, the complete cessation of AVH in this patient could be augmented by the effects of the latter on the neuroinflammatory processes.[6] Further studies are required to be able to comment on this hypotheses.

This case report highlights the utility of HD-tDCS as an add-on treatment modality in a patient with 10 years of persistent AVH. Furthermore, it suggests that HD-tDCS can be safely used in persons with AU with due technical precautions.

Declaration of patient consent

The authors certify that they have obtained all appropriate patient consent forms. In the form, the patient has given her consent for her images and other clinical information to be reported in the journal. The patient understands that her name and initials will not be published and due efforts will be made to conceal identity, but anonymity cannot be guaranteed.

Financial support and sponsorship

This work is supported by the Swarnajayanti Fellowship Grant, Department of Science and Technology, Government of India, to GV (DST/SJF/LSA-02/2014-15). RP is a clinical scientist, supported by the Nurturing Clinical Scientist Scheme, Indian Council of Medical Research. SS is supported by Wellcome Trust/DBT India Alliance (IA/R/2/502989).

Conflicts of interest

There are no conflicts of interest.