Topical Immunotherapy: Step by Step

  • Colombina Vincenzi
  • Benedetta Marisaldi
  • Antonella Tosti


Alopecia areata (AA) is a T-cell-mediated autoimmune disease affecting genetically predisposed people of all ages (approximately 0.1–0.2% of the general population). It is a nonscarring alopecia that commonly affects the scalp with one or multiple patches, or the total scalp (alopecia totalis, AT), or the scalp and body hair (alopecia universalis, AU). There are no approved medical treatments, and the choice of treatment depends on the age of the patient, the extension, and the activity phase of the disease. Immunotherapy with squaric acid dibutylester (SADBE) or diphenylcyclopropenone (DPCP) is a topical treatment without serious side effects that can be prescribed also for children. The mechanism of action of this therapy is not fully understood, but studies have shown that the contact dermatitis induced by these sensitizers changes the perifollicular CD4+/CD8+ T-lymphocyte ratio, causes antigenic competition, leads to apoptosis of autoreactive T-lymphocytes, and modulates proinflammatory cytokines. Hair regrowth rates range from 6% to 85% as reported in different studies.


Alopecia areata Alopecia areata of the eyebrows Alopecia areata of the beard Squaric acid dibutylester Diphenylcyclopropenone Topical immunotherapy Sensitization Hair regrowth T-lymphocyte Proinflammatory cytokines 


  1. 1.
    Vedak P, Kroshinsky D. Squaric acid sensitization is not required for response in the treatment of alopecia areata. J Am Acad Dermatol. 2015;73:471–6.CrossRefGoogle Scholar
  2. 2.
    Choe SY, Lee S, Pi LQ, Keum DI, Lee CH, Kim BJ, Lee WS. Subclinical sensitization with diphenylcyclopropenone is sufficient for the treatment of alopecia areata: Retrospective analysis of 159 cases. J Am Acad Dermatol. 2018;78(3):515–21.CrossRefGoogle Scholar
  3. 3.
    Wiseman MC, Shapiro J, MacDonald N, Lui H. Predictive model for immunotherapy of alopecia areata with diphencyprone. Arch Dermatol. 2001;137(8):1063–8.Google Scholar
  4. 4.
    van der Steen PH, van Baar HM, Happle R, Boezeman JB, Perret CM. Prognostic factors in the treatment of alopecia areata with diphenylcyclopropenone. J Am Acad Dermatol. 1991;24(2 Pt 1):227–30.Google Scholar
  5. 5.
    Tosti A, Piraccini BM, Misciali C, Vincenzi C. Lentiginous eruptions due to topical immunotherapy. Arch Dermatol. 2003;139(4):544–5.Google Scholar
  6. 6.
    Rokhsar CK, Shupack JL, Vafai JJ, Washenik K. Efficacy of topical sensitizers in the treatment of alopecia areata. J Am Acad Dermatol. 1998;39(5 Pt 1):751–61.CrossRefGoogle Scholar
  7. 7.
    Ohlmeier MC, Traupe H, Luger TA, Bohm M. Topical immunotherapy with diphenylcyclopropenone of patients with alopecia areata – a large retrospective study on 142 patients with a self-controlled design. J Eur Acad Dermatol Venereol. 2012;26(4):503–7.CrossRefGoogle Scholar
  8. 8.
    Dall’Oglio F, Nasca MR, Musumed ML, La Torre G, Ricciardi G, Potenza C, Micali G. Topical immunomodulator therapy with squaric acid dibutylester (SADBE) is effective treatment for severe alopecia areata (AA): results of an open-label, paired comparison, clinical trial. J Dermatolog Treat. 2005;16:10–4.CrossRefGoogle Scholar

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© Springer Nature Switzerland AG 2020

Authors and Affiliations

  • Colombina Vincenzi
    • 1
  • Benedetta Marisaldi
    • 1
  • Antonella Tosti
    • 2
  1. 1.Dermatology, Private Hospital NigrisoliBolognaItaly
  2. 2.Fredric Brandt Endowed Professor of Dermatology, Dr. Phillip Frost Department of Dermatology and Cutaneous SurgeryUniversity of Miami Miller School of MedicineMiamiUSA

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