LAUSR

Dear editor, An 11-year-old boy had alopecia totalis of 1-year duration. He had a complete loss of hair over his scalp and eyebrows (Figure 1). Otherwise, his skin, nails, and mucosae were normal on examination. Review of systems was normal. His complete blood counts and antithyroid peroxidase antibodies were within normal range. There was neither a similar illness nor any other autoimmune disease in his family. He had already received oral tablets of betamethasone in the dose of 0.1 mg per kilogram, on two consecutive days per week (oral minipulse) along with topical minoxidil 5% solution and four doses of intradermal (scalp) injections of triamcinolone acetonide 10 mg/ml at monthly intervals. This treatment was continued for a period of 4 months from another institute following which, treatment was withdrawn as there was no response and he was reassured and counseled about the refractory nature of his condition. Subsequently, the boy accessed our department and he was administered apremilast in the dose of 10 mg twice daily for the initial 10 days and the dose was increased to 30 mg morning and 10 mg evening from 11th day onward. Apremilast was well tolerated and the boy did not experience any adverse effects. Additionally, autologous platelet-rich plasma therapy was undertaken as an adjuvant therapy. For platelet-rich plasma (PRP) preparation, 20 ml of venous blood was withdrawn from the child and placed in four test tubes as 5 ml each. The collected blood was centrifuged at 3,000 rpm for 10 min, using a total vibratory device and blood separated into a red inferior phase and superior plasma supernatant phase. The PRP fraction was separated in insulin syringes which contained 0.1 ml calcium bicarbonate as a platelet activator substance. Under topical anesthesia application and all aseptic precautions, PRP injections were instilled approximately 0.1 ml/cm in subfollicular plane of scalp and eyebrows were given. The session was repeated every 2 weeks and areas which were left out in the previous session were injected in the next session. No side effects were observed besides mild tenderness and erythema of transient nature and the boy and his parents were comfortable with the procedure. Interestingly, hair began to regrow between 4 and 6 weeks of the therapy. Both apremilast and PRP were continued and at the end of 6 months robust hair growth was observed over the scalp and eyebrows (Figure 2) except an ophiatic patch over the right temporal region which showed hair growth 2 months later. Severe cases, especially alopecia totalis, have a poor prognosis with chances of regrowth being meager (Spano & Jeff, 2015). Various treatments have been described including topical, intralesional, and systemic with variable efficacy and side effects (Darwin et al., 2018). On the other hand, Janus kinase inhibitors, oral and topical, have been found to successful in refractory cases of alopecia areata (Darwin et al., 2018). However, JAK inhibitors are cost prohibitive and not easily available. Nonetheless, recently, a few reports have demonstrated utility of PRP in adult F IGURE 1 Alopecia totalis demonstrating complete loss of hair over scalp and eyebrows Received: 8 August 2019 Revised: 25 August 2019 Accepted: 2 September 2019