|Year : 2013 | Volume
| Issue : 1 | Page : 47-49
Alopecia areata treated with phenolisation and intravenous dexamethasone pulses
Sumit Kar, Neha Singh
Department of Dermatology, Venereology and Leprosy, Mahatma Gandhi Institute of Medical Sciences, Sewagram, Wardha, Maharashtra, India
|Date of Web Publication||6-Jul-2013|
Department of Dermatology, Venereology and Leprosy, Sewagram - 442 102, Wardha, Maharashtra
Source of Support: None, Conflict of Interest: None
| Abstract|| |
Phenol is an aromatic hydrocarbon derived from coal tar or manufactured from monochlorobenzene. Alopecia areata is a common non scarring autoimmune condition characterised by patchy loss of hair without atrophy. Various treatment modalities have been proposed and used for the treatment of alopecia areata, which is indeed a difficult condition to treat. Variable results have been documented using intralesional corticosteroid injections, topical minoxidil, topical anthralin ointment, topical contact sensitizers like diphencyprone, dinitrochlorobenzene or squaric acid dibutyl ester, and oral mini pulse with betamethasone. The use of 88% phenol for the treatment of alopecia areata has been documented in literature, but it has failed to secure a place in the priority list. Herein we have reported a case of a young girl who was treated with short-time aggressive therapy using 88% phenol and dexamethasone pulse therapy and who responded well to the treatment with no recurrence in the last 6 months of follow-up.
Keywords: Alopecia areata, chemical peeling, dexamethasone pulses, phenol
|How to cite this article:|
Kar S, Singh N. Alopecia areata treated with phenolisation and intravenous dexamethasone pulses. Int J Trichol 2013;5:47-9
| Introduction|| |
Alopecia areata can affect any hair-bearing area. It is a lymphocyte cell-mediated inflammatory type of hair loss, although the exact pathogenesis is unclear.  Phenol, also known as carbolic acid, is well known as an antiseptic agent. It is also attributed to have antipruritic properties.  It is a bactericide (>1%), fungicide (>1.3%), and a local anaesthetic. At concentrations over 80%, phenol coagulates proteins. Pertaining to its easy availability and affordability, it finds great usefulness in being used in many office procedures in dermatology clinics. The mechanism of action is based on its irritating property that leads to tissue necrosis.  Phenol has the property of penetrating into the layers of skin, and this is inversely proportional to its concentration. The application of pure, undiluted 88% phenol to the skin causes rapid and complete coagulation of epidermal keratin protein and produces a partial blockade for further chemical penetration. The more dilute solution of 50% has greater penetration and, thus, peel potency than the full strength of 88% straight phenol preparation. There is a risk of systemic absorption leading to toxicity that can be averted by dividing the desired area into small areas and using a gap of 15 min while applying phenol to each of the affected areas. 
| Case Report|| |
A 13 year old girl presented to us with diffuse hair loss over the scalp involving more than 50% of the scalp [Figure 1] for the past 6 months. She had consulted many dermatologists in the past 6 months since the onset of her complains, but none of the treatment brought relief. Therefore, it was not only the disease entity that we needed to consider but also the financial and psychosocial impact on the patient. She had no associated hair loss over any other body site. There was no history suggestive of any associated complaints. Her nails were normal on examination. There was no history of similar complains in the family. After taking a prior informed consent, phenolisation was done over the bald patches with 88% phenol until a uniform ivory white frost appeared. Phenol was applied all over the bald patches, covering more than 50% of scalp surface; 1 ml of phenol was taken in a container and applied to the scalp by dipping a bud in phenol. We assume that out of 1 ml, some amount of phenol was left in the bud. Thus, the total application of phenol was below the safe limit. No neutralization was done. The patient did complain of burning sensation and was given 5 mg diazepam orally. She underwent 5 such sittings at an interval of 15 days each. She was also given dexamethasone pulse therapy for 4 months. Dexamethasone was given in the dose of 60 mg intravenously in 5% dextrose. She was given dexamethasone and phenolisation at an interval of 15 days. She began to show response to therapy after the 2 nd sitting when vellus hair regrowth was evident diffusely all over the bald patches. After five sessions done with 88% phenolisation and 4 pulses of dexamethasone intravenous therapy, she showed marked improvement with well-marked hair growth over the patches. Phenolisation is painful and therefore she was given intravenous diazepam prior to the procedure. There were no reported side effects in the present case.
| Discussion|| |
Phenol has been used for the treatment of various conditions like vitiligo, molluscum contagiosum, epidermal cysts, acne scars, and facial rejuvenation. Diuresis is known to promote metabolism and excretion of phenol. Hence, it is important to advise the patient to take plenty of fluids. The mechanism by which phenol acts in alopecia areata is unclear; however, various mechanisms have been proposed such as the release of various growth factors during the wound repair process that stimulate the follicles. Also, various cytokines released during wound healing neutralise the peribulbar infiltrates, causing re-growth of hair through immunomodulation. Lastly most of the follicles in alopecia areata are in the telogen phase and thus lie in the dermis. Therefore, it is proposed that phenol passes through the follicular opening and directly stimulates the germinal centre. 
Alopecia areata is an organ-specific autoimmune disease directed against various cellular components of hair follicles, thus dexamethasone pulse has a profound but transient action on the perifollicular lymphocytes that restores normal hair cycle. , Therefore, repeated dexamethasone pulses are effective in treating the condition.
Use of phenol in the concentration of 20% alone or in combination with oral mini pulse with betamethasone or 2% minoxidil has been reported previously,  and it was reported that combination therapy is better than use of single agent. This could probably be because concentration of phenol used was low as compared to that in this study. We combined the above two modalities to get the desired result. The rationale for combining phenol and Dexa pulse is to get a fast and better result. The two known modalities of treatment were combined.
The patient has shown marked improvement with 5 sessions of phenol and 4 monthly pulses of dexamethasone over a period of 4 months and has not shown any relapse even after 6 months of follow-up. Keeping the safe limit in consideration, extensive lesions can be treated with 88% phenol. She has achieved good hair growth with the said treatment [Figure 2].
| References|| |
|1.||Ehsani AH, Toosi S, Seirafi H, Akhyani M, Hosseini M, Azadi R, et al. Capsaicin vs. clobetasol for the treatment of localized alopecia areata. J Eur Acad Dermatol Venereol 2009; 23:1451-3. |
|2.||Savant SS, Shenoy S. Chemical peeling with phenol: For the treatment of stable vitiligo and alopecia areata. Indian J Dermatol Venereol Leprol 1999; 65: 93-8. |
|3.||Satoskar RS, Bhandarkar SD. Antiseptics, disinfectants, insecticides and pharmacotherapy of skin diseases. In: Satoskar RS, Bhandarkar SD, eds. Pharmacology and Pharmacotherapeutics. Bombay: Popular Prakashan, 1993: 734-59. |
|4.||Shulshil Pande, Nischal KC. Commonly used chemical agents in dermatological practice. In: Uday Khopkar, eds. Handbook of drug therapy. Gurgaon: Elsevier, 2010: 348-9. |
|5.||Sharma VK. Pulsed administration of corticosteroids in the treatment of alopecia areata. Int J Dermatol 1996; 35: 133-6. |
|6.||Perriard-Wolfensberger J, Pasche-Koo F, Mainette C, Labarthe MP, Salomon D, Saurat JH. Pulse of methylprednisolone in alopecia areata. Dermatology 1993; 187: 282-5. |
|7.||Mehta BA, Raka A, Bharmbhatt V. Comparative study of various regimens in alopecia areata. Internet J Dermatol 2012; 9. |
[Figure 1], [Figure 2]