|Year : 2010 | Volume
| Issue : 2 | Page : 106-107
Turban PUVASOL: An effective treatment in alopecia totalis
L Sornakumar, C Shanmuga Sekar, CR Srinivas
Department of Dermatology, PSG Hospitals, Coimbatore, Tamil Nadu, India
|Date of Web Publication||9-Mar-2011|
C Shanmuga Sekar
Department of Dermatology, PSG Hospitals, Peelamedu, Coimbatore - 641 004, Tamil Nadu
Source of Support: None, Conflict of Interest: None
| Abstract|| |
Alopecia areata is characterized by patchy hair loss involving the scalp, eyelashes, and beard. The disease may at times lead to complete baldness of the scalp (alopecia totalis) or of the entire body (alopecia universalis). Alopecia totalis is usually resistant to therapy. We report two cases of alopecia totalis treated with turban psoralen with sunlight exposure (PUVASOL).
Keywords: Alopecia totalis, PUVASOL, Turban
|How to cite this article:|
Sornakumar L, Sekar C S, Srinivas C R. Turban PUVASOL: An effective treatment in alopecia totalis. Int J Trichol 2010;2:106-7
| Introduction|| |
Alopecia totalis is a distressing problem which is usually resistant to various therapeutic modalities. PUVA therapy is an effective therapeutic option but is associated with side effects such as nausea, requires eye protection, and cannot be used in children. Through use of 'turban PUVASOL', it is now possible to administer a dilute bathwater solution containing 8-methoxypsoralen (8-MOP) to the scalp. We report two cases of alopecia totalis which responded to turban PUVASOL (psoralen with sunlight exposure).
| Case Reports|| |
A 41-year-old woman presented with complete loss of scalp hair since 12 months [Figure 1]. The diagnosis was confirmed by biopsy. She was treated with minoxidil 10% twice daily and 4 mg of betamethasone twice weekly for 6 months with no significant response. She was further treated with turban PUVASOL therapy as described below. After 2 months, vellus hair started growing and by 4 months, she had significant hair growth [Figure 2].
In the turban PUVASOL therapy, 1 ml of 8-methoxypsoralen (8-MOP) 1% was diluted in 2 l of water. A clean absorbent cotton cloth was soaked into the solution for 30 seconds and wrapped around the scalp in a turban-like fashion for 5 minutes. The process was repeated four times. The patients were further exposed to sunlight for 5 minutes and the time was gradually increased up to 15 minutes. The treatment was carried out thrice a week. The time of exposure was between 10:00 and 10:15 AM when the ultraviolet (UV)A : UVB ratio is maximum. The patient was advised to avoid sun exposure for few hours after treatment.
An 8-year-old boy presented with complete loss of hair over the scalp since 20 months. The diagnosis was confirmed by histopathology. He was treated for 1 year with 2 mg of betamethasone twice weekly and minoxidil 5% twice daily with no significant response. We decided to treat the patient with turban PUVASOL therapy similar to previous case. The patient started having vellus hair growth after 2 months and by 6 months there was almost complete regrowth of scalp.
| Discussion|| |
Alopecia areata (AA) is an autoimmune disease characterized by patchy, nonscarring hair loss. Although it most commonly affects the scalp, it can involve any hair-bearing area on the body. Alopecia totalis refers to complete loss of scalp hair. AA can lead to severe emotional distress. Various therapeutic modalities such as systemic steroids, contact immunotherapy, and phototherapy have been tried with partial success.
In 1974, Rollier and Warcewski  induced hair regrowth in a patient with AA using 8-MOP and natural sunlight. The first report of PUVA treatment with artificial UVA light for AA was published in 1978 by Weissman et al. who obtained encouraging results in five patients.
The turban PUVA can be considered a variation of the so called bath suit PUVA method as described by Pai and Srinivas.  It has the advantage of delivering the desired photosensitizing effect in a localized area without systemic side effects. Behrens-Williams et al.  reported hair regrowth in six of nine patients after 10 weeks of treatment. Broniarczyk-Dyla et al.  observed that turban PUVA was significantly more effective in AA vulgaris than in AA totalis or universalis and proved to be a safe, well-tolerated method without the systemic side effects of PUVA.
Our patients were not able to come regularly for turban PUVA treatment and hence we decided to modify it as turban PUVASOL. The mechanism of action of PUVA in AA is not clearly understood. There is circumstantial and indirect evidence that AA is a T cell-mediated autoimmune disease of the hair follicle. Immunohistochemical studies in human beings and animal models have demonstrated a perifollicular accumulation of dendritic cells plus CD4+ and CD8+ T lymphocytes and isolated polymorphonuclear cells.  Because dendritic cells are thought to play an important role in the initiation of AA by antigen presentation and costimulation, PUVA treatment might exert an inhibitory effect on the development of AA. Suppression of IL-2 and IL-1ß production might suppress an already present lymphocytic infiltrate in AA and induce hair growth.
The time chosen for phototherapy was between 10:00 and 10:15 AM. Balasaraswathy et al.  in a study proved that the ideal time for PUVASOL is between 9:15 and 11:15 AM, which will minimize unwanted exposure to UVB and infrared radiation and hence we regularly advise this particular time in our institute. Both our patients had significant improvement after therapy. We report this case as the effectiveness of turban PUVASOL in AA has never been reported.
| References|| |
|1.||Rollier R, Warcewski Z. Le traitement de la pelade par la meladinine. Bull Soc Fr Dermatol Syph 1974;81:97. |
|2.||Weissman I, Hofmann C, Wagner G. PUVA therapy for alopecia areata: An investigative study. Arch Dermatol Res 1978;262:333-6. |
|3.||Pai S, Srinivas CR. Bathing suit delivery of 8 - methoxypsoralen for psoriasis: A double-blind, placebo-controlled study. Int J Dermatol 1994;33:576-8. |
|4.||Behrens-Williams SC, Leiter U, Schiener R, Weidmann M, Peter RU, Kerscher M. The PUVA-turban as a new option of applying a dilute psoralen solution selectively to the scalp of patients with alopecia areata. J Am Acad Dermatol 2001;44:248-52. |
|5.||Broniarczyk - Dyla G, Wawrzycka - Kaflik A, Dubla - Berner M, Prusinska-Bratos M. Effects of psoralen-UV-A - Turban in alopecia areata. Skinmed 2006;5:64-8. |
|6.||McElwee KJ, Tobin DJ, Bystryn JC, King LE Jr, Sundberg JP. Alopecia areata: An autoimmune disease? Exp Dermatol 1999;8:371-9. |
|7.||Balasaraswathy P, Kumar U, Srinivas CR, Nair S. UVA and UVB in sunlight: Optimal utilization of UV rays in sunlight for phototherapy. Indian J Dermatol Venereol Leprol 2002;68:198-201. |
[Figure 1], [Figure 2]