Recovery of Alopecia Universalis with Associated Nail Dystrophy Treated with Tofacitinib: A 6-year-old Child's Case Report.

An emerging treatment modality whose established efficacy in systemic inflammatory diseases is now being actively explored for cutaneous disorders: tofacitinib, an oral Janus kinase inhibitor, is one such treatment. Alopecia universalis has been reported to improve with the use of tofacitinib in various case reports and case series. Nail dystrophy is a diverse skin disorder that has been linked to autoimmune illnesses such as psoriasis and psoriatic arthritis in certain subtypes. Alopecia areata and alopecia universalis are also commonly associated with nail dystrophy. In the present case report, we see that there are also improvements in nail dystrophy in the patient with alopecia universalis who is using tofacitinib. Copyright:

INTRODUCTION

Alopecia universalis (type of alopecia areata) is an autoimmune disease that causes hair loss on the scalp and body due to chronic hair follicle inflammation mediated by CD8+ T-cells.[1] Alopecia areata affects 1%–2% of adults and 20% of children under the age of 16.[12] Nail degeneration, including nail pitting, trachyonychia, onychorrhexis, red staining of the lunulae, onycholysis, onychomadesis, and Beau lines are common in AA and variants.[3] Inflammation caused by T cells may be reduced by Janus kinase inhibitors, which are used for rheumatoid arthritis and psoriasis.[4] Tofacitinib treatment regrows hair in alopecia areata patients by helping hair follicles revert to anagen phase.[5] Case studies[67] have shown that tofacitinib may help with nail dystrophy caused by alopecia areata. In this report, we present a patient with AA universalis and nail dystrophy who was treated with tofacitinib.

CASE REPORT

A 6-year-old girl presented to our clinic with a 2-year history of hair loss. Prior to therapy, the patient had seen three to four dermatologists but lost the records. Along with extensive hair loss on the scalp, eyelashes, and eyebrows, the patient was hyperactive and short [Figure 1a]. She had dystrophic fingernails toenails with erythematous areas (striated lunulae), pitting, and nail fragility [Figure 2a]. No other systemic abnormalities were found. Alopecia universalis with nail degeneration was diagnosed clinically. Minoxidil 2% solution was initially used with bimatoprost. After the second appointment, tofacitinib 2.5 mg daily single oral dose was administered due to lack of improvement. All examinations, including complete blood count, serum creatinine, liver function test, lipid profile, HBsAg, HCV, HIV 1 and 2, Mantoux test, tuberculosis interferon gold, and thyroid functions, were all normal prior to starting tofacitinib. Patient was also referred to a geneticist to rule out Down's syndrome. Three months into treatment, 50% of the scalp's hair grew [Figure 1b], and the nails improved [Figure 2b]. All other medications were discontinued after 3 months, except for tofacitinib. Near-complete hair growth on the scalp, eyebrows, and eyelashes was seen after 6 months of treatment [Figure 1c]. After 6 months of tofacitinib treatment, nail irregularities [Figure 2c] and pain were gone. Subsequent investigations were normal. No side effects were seen due to the medication.

Figure 1

Hair changes in patient before and after tofacitinib. (a) Before starting tofacitinib. (b) After 3 months of tofacitinib therapy. (c) After 6 months of tofacitinib therapy

Figure 2

Nail changes in patient before and after tofacitinib. (a) Before starting tofacitinib. (b) After 3 months of tofacitinib therapy. (c) After 6 months of tofacitinib therapy

DISCUSSION

In our case, nail dystrophy coexisted with alopecia universalis. The connection between nail dystrophy and alopecia areata has been extensively documented in the medical literature.[6789] Because the nail matrix, like the hair follicle, is a keratin-producing structure, decreasing the autoimmune response to the hair follicle in AU patients may also benefit the nail bed. Dhayalan and King.[6] and Jaller et al.[7] both found nail alterations in their patients with alopecia universalis. Our patient's hair regrowth was almost complete after 6 months of tofacitinib treatment, which is consistent with the case study by Jaller et al.[7] After 6 months of tofacitinib treatment, the current patient's nail dystrophy improved. Tofacitinib has also been found to aid in the treatment of alopecia and nail dystrophy (Dhalayan and King).[6]

Declaration of patient consent

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

Financial support and sponsorship

Nil.

Conflicts of interest

There are no conflicts of interest.