TREATMENT OF SELECTED CASES OF ALOPECIA AREATA BY PSORALEN AND SUNLIGHT.

Background: Psoralin and ultraviolet light A is used in the treatment of alopecia areata.Response rates have varied in literatures . Patients and methods: The thirty patients with chronic alopecia areata recalcitrant involved in this study Their age ranged between 18-50 years were prolong complain with no response to treatment of (3-10 years) . Patients were given tripsoralen (trimethyl psoralen) tablets, Then after two hours the patients were instructed to expose to sun light for 20 minutes. Treatment was given three times per week (every other day). Result: 18 patients(60%) showed a response with complete hair regrowth , while 4 patients (13.3%) showed partial regrowth of hair which was cosmetically acceptable , 4 patients (13.3%) the growth was only of villus hair and 4 patients (13.3%)did not show any response after 30 sessions. Only few minor side effects were observed

Since Iraq is country of sunny climate ,in the current study the natural sunlight and psoralen used in the treatment of recalcitrant cases of alopecia areata.

Objectives:-
The present work was carried out aiming to test the effectiveness and safety of natural sun light instead of UVA lamps in the treatment of extensive alopecia areata in combination with oral psoralen.

Patients and methods:-
The current work represents a non randomized interventional trail. Atotal of 45 patients with chronic and extensive alopecia areata was included in the study, were 15 patients defaulter for unknown reasons , while thirty patients were able to complete the study,17 males (56.7%)and 13 females(43.3%).All cases were chronic alopecia areata recalcitrant to different modalities of treatment ,while some patients had ophiasis of marginal scalp , and some with eyebrows and lashes , other with alopecia totals and universalis. The treatment regimen included the administration of trimethyl psoralen (trisolen) orally , two hours later patient instructed to exposing to sunlight for 20 minutes in an open area. This is an open labeled therapeutic trial . the study was conducted in the department of dermatology and venereology of Al yarmouk teaching hospital during period from june2010 to October 2012. Pregnant and lactating women:-Photography was tacking before and after treatment. Monitoring complete blood picture, renal and liver function tests, ophthalmological examination was performed befor treatment and after 3 months from lasts sessions of therapy.
Patients were given tripsoralen (trimethyl psoralen) tablets, each containing 5 mg were given orally 2-3 tablets. Then after two hours the patients were instructed to expose the whole body to sun light and wear goggles to protect the eyes from irradiation of sun. Genetalia should also be protected during the period of exposure.
Treatment was given three times per week (every other day) gradually until reach 20 minutes then continuous 20 minutes for rest of session.
The time of exposure should be between 03:00-0.4:00 pm then after exposure patients should stay in door for the remainder of day .
Patients continued the treatment in this regimen until obvious improvement occurred then we reduced to treatment sessions gradually were tapered and eventually session , one every 3 weeks for 3 months , if there was no improvement after 30 session , the treatment was stopped.
Fallow up:-After the last session, patients were examined every two weeks for one month , and every month for next 6 moths.

Result:-
A 60% showed improvement with complete hair growth , while 13.3% showed partial growth of hair which was cosmetically acceptable.In 13.3 of patients the growth was only of villous hair .While 13.3% did not show any response after 30 sessions. The thirty patients were 17 males (56.7%) and 13 females (43.3%).
Their age ranged between 18-50 years with a mean 34.8+ _ 6.5 years.
The duration of their alopecia areata lesion ranged from 3-10 years.
The number of treatment sessions required to obtain response ranged from 12-30 sessions with mean of 23.6+_6.9 years.
Those thirty patients , 18 patients(60%) showed a response with complete hair regrowth , while 4 patients (13.3%) showed partial regrowth of hair which was cosmetically acceptable , 4 patients (13.3%) the growth was only of villus hair and 4 patients (13.3%)did not show any response after 30 sessions.
Only few minor side effects were observed 3 patients (10%) experienced nausea after trisoralen tablets in initial phase of treatment, however this did not necessities any special antiemetic and subside spontaneously during the course of treatment .
Pruritus was observed in 2 patients (6.7%) and it was relieved by using emollient .
Headache occurred in one patient (3.3%) , and localized erythematic in 2 patients (6.7%).These side effect resolved spontaneously during the course of therapy .
After 6 months of last session , patients examined for any relapse , 14 out of 18 patients (77.8%) without relapse of alopecia areata after 6 months , these four patients showed relapse of hair fall in some patches only and not complete hair fall.

Discussion:-
Alopecia areata is an autoimmune disorder effect the hair follicle that lead to patchy hair loss of all scalp and body hair (6). 24% experienced spontaneous complete or nearly complete regrowth at some stage during the observation period of 3-3.5 years (11) .
The sad fact that there is no universally proven treatment for alopecia areata which evident from the multiplicity of claims for therapeutic success. The range of therapeutic success in alopecia areata is so wide depending on the therapy used and type of alopecia areata (4) . The time needed to induce hair regrowth in alopecia areata varies also , it is ranging between weeks to years.
Oral corticosteroids decrease the hair loss, but only for the period during which they are taken (10) In the current study sunlight and psoralen therapy of alopecia areata were uses most therapies employs the use psoralen and UVA lamp causing a variety of side effects (7) , and recurrence rate. In our study PUVA sol was gives. Tolerated with minimal side effects in addition to relapse rate only 4 patients who showed incomplete hair loss in some areas but remained cosmetically acceptable .
PUVA sol put into practice the interaction UVA and UVB and visible light and drug.
The mode of action is believed through the photo immunologic action , it may affect T-cells function and antigen presentation , it possibly inhibit local immunological action against hair follicles by depleting langerhans cells (8) . Dermoscop used in evaluation of hair loss (12) . The presence of sun light approximately all over the year in our country encourages us to use sun light instead of UVA lamps which is easier and cheaper for patients.

Conclusion:-
PUVA sol is an effective method of treatment in alopecia areata with minimal side effects.