Alemtuzumab hair today gone tommorrow

NeuroDoc Gnanapavan I didn't sign-up for this!

 I want my hair back ;-(

Front Neurol. 2017 Oct 30;8:569. doi: 10.3389/fneur.2017.00569. eCollection 2017.

Alopecia Universalis following Alemtuzumab Treatment in Multiple Sclerosis: A Barely Recognized Manifestation of Secondary Autoimmunity-Report of a Case and Review of the Literature.

Zimmermann J, Buhl T, Müller M.

Secondary autoimmunity is the most frequent adverse event occurring in almost every other alemtuzumab-treated multiple sclerosis patient. We report a case of a patient with relapsing-remitting multiple sclerosis who reported smooth, circular areas of complete hair loss on both thighs 6 months after the second treatment cycle with alemtuzumab. The patient was diagnosed as having alopecia areata (AA). Within 3 months, AA progressed to complete loss of all body hair (alopecia universalis). Current literature rarely connects alemtuzumab with the onset of alopecia of autoimmune origin. Here, we report a little-noticed autoimmune disease affecting the skin, very likely being associated with alemtuzumab. We emphasize the necessity of careful clinical surveillance of alemtuzumab-treated patients for yet undescribed autoimmune diseases.

Alopecia areata

Alemtuzumab (aka Campath-1H) is arguably one of the biggest early success stories in MS, but as with every cloud that has a silver lining, every silver lining also has a cloud - namely the autoimmune side effects. In the horizon, ocrelizumab and cladrabine loom as omnipresent threats; which makes acceptance of this very unpalatable cloud by the MS community essential. 

We know that reason for the autoimmune disorders following alemtuzumab is a consequence of B-cell hyper-population in the relative absence of a T cell regulation during the period of immune reconstitution. The ability to predict who develops what, however, have been largely unsuccessful to date, and yet with increased exposure to the drug, the types of autoimmune disorders described is expanding.

So what autoimmune disorders have been linked to alemtuzumab?
Around 47% exposed to alemtuzumab develop another autoimmune disorder other than their MS. Zimmerman et al. now report a case of alopecia (or hair loss), which may possibly be linked to alemtuzumab. They also point out the alopecia is not unique to alemtuzumab, and has also been reported with teriflunomide and mitoxantrone. In their case, even after cessation of treatment, there was no regrowth of hair at the 6-month follow up.

The EMA (European Medicines Agency) label does report alopecia under side effects of >0.5% in alemtuzumab 12mg treated subjects. Alopecia areata is thought to be T cell (CD8+NKG2D+) mediated damage of the hair follicles, although there may be some B cell involvement here too and has been linked to thyroid autoimmunity.

The authors' advice that those receiving alemtuzumab examine themselves on regular basis for any early signs of hair loss so that prompt steroid treatment can be started.

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