8
44 CORRESPONDENCE
4
spite of the report by Burton and Marshall of a patient
who received minoxidil and experienced hypertrichosis of
the forearms, eyebrows, temples, ears and trunk, but with
sparing of his balding scalp, topical (and to a lesser degree
oral) minoxidil is widely used in the treatment of
androgenetic alopecia. Improvements in hair density have
been reported with this agent over a 1±2-year period, but
its effects on androgenetic alopecia in the longer term are
not known.
investigate whether cyclosporin may also be of value in the
treatment of androgenetic alopecia, but reports of regrowth of
9
scalp hair have either been single case reports or small
1
0
trials. One trial using topical 5% cyclosporin showed that
one in four patients showed a significant response after 12
months. Although hair count and photography were used to
assess patients, the numbers were small with only eight
5
patients and three placebo subjects completing the trial.
Another study of 0´1% topical cyclosporin showed no change
1
1
A topical 5% cyclosporin solution has likewise been
investigated as
in hair counts after 4 months in 10 individuals. The
marked and fairly rapid progression of androgenetic alopecia
in our patient, despite continuous ingestion of oral cyclos-
porin over a 5-year period in a dose sufficient to produce
marked hypertrichosis, demonstrates that cyclosporin does
not substantially modify the natural history of androgenetic
alopecia and is unlikely to be of benefit, either topically or
orally, in the long-term treatment of androgenetic alopecia.
This observation suggests that the biological pathway that
leads to hypertrichosis is independent from the pathway that
leads to androgenetic alopecia, and that the induction of
hypertrichosis may temporarily conceal androgenetic alope-
cia, but will not arrest its progression in the long term. This is
in accordance with observations made in the stump-tail
macaque monkey of the additive effects of finasteride and
a potential treatment for androgenetic
5
alopecia, although topical cyclosporin has limited bioavail-
ability. Further efforts to develop a topical formulation of
cyclosporin are only likely to be worthwhile if oral ingestion
can be shown to arrest progression of androgenetic alopecia
or stimulate hair regrowth in the longer term.
We report a 41-year-old man with a past history of
psoriasis affecting his umbilicus, elbows, knees, scalp and
body since he was aged 8 years, and severe psoriatic
arthritis since the age of 20 years which has affected his
knees, small joints of his hands, wrists, hips and ankles. His
treatments included oral prednisolone (doses from 7´5 to
1
3´5 mg daily for 10 years), methotrexate 12´5 mg weekly
and folic acid 5 mg daily for 6 years, aldendronate sodium
0 mg daily for 2 years, and metoprolol 150 mg daily for
1
2
1
minoxidil in the treatment of androgenetic alopecia.
the past 2 years.
Cyclosporin 100 mg twice daily was commenced 5 years
ago and, within 8±12 months, he had noticed a significant
increase in the amount and length of his body hair,
particularly on his chest, shoulders and legs (Fig. 1a,b).
This has required regular cutting for control. For the last 2
years the dose has been 150 mg at night and 100 mg in the
morning. Over this period his arthritis has become well
controlled and his psoriasis has almost vanished.
Department of Medicine (Dermatology),
J.GREEN
University of Melbourne,
St Vincent's Hospital,
41 Victoria Parade,
Fitzroy 3065,
Victoria, Australia
R.D.SINCLAIR
Correspondence: Dr Rodney D.Sinclair
E-mail: sinclair@svhm.org.au
Despite this severe hypertrichosis, his androgenetic alopecia
has progressed from Hamilton/Norwood stage III vertex to
Hamilton/Norwood stage V/VI (Fig. 1c). There is a strong
family history of androgenetic alopecia affecting his two
brothers, as well as his maternal uncles and cousins. His
father has mild androgenetic alopecia while his mother is not
affected.
References
1 Sinclair RD, Banfield CC, Dawber RPR. Handbook of Diseases of the
Hair and Scalp. Oxford: Blackwell Science, 1999; 36.
2 Yamamoto S, Kato R. Hair growth-stimulating effects of
cyclosporin A and FK506, potent immunosuppressants. J Derma-
tol Sci 1994; 7 (Suppl.): S47±54.
Cyclosporin is a specific T-cell immunosuppressant that
acts primarily through inhibition of interleukin 2 gene
3
Sinclair RD. Observations on the clinical features of hypertricho-
sis. In: Hair and its Disorders: Biology, Pathology and Management
2
expression, without associated myelosuppression. It has
(Camacho FM, Randall VA, Price VH, eds.). London: Martin
Dunitz, 2000; 339±46.
been the major drug used in the prevention of organ
transplant rejection over the past two decades, and is also
widely used in the treatment of inflammatory disorders such
as rheumatoid arthritis and psoriasis.
4
5
6
7
Burton JL, Marshall A. Hypertrichosis due to minoxidil. Br J
Dermatol 1979; 101: 593±5.
Gilhar A, Pillar T, Etzioni A. Topical cyclosporine in male pattern
alopecia. J Am Acad Dermatol 1990; 22: 251±3.
Wysocki GP, Daley TD. Hypertrichosis in patients receiving
cyclosporine therapy. Clin Exp Dermatol 1987; 12: 191±6.
Paus R, Stenn KS, Link RE. The induction of anagen hair growth
in telogen mouse skin by cyclosporine A administration. Lab
Invest 1989; 60: 365±9.
Hypertrichosis is a well-recognized complication that
6
occurs in at least 60% of patients. The mechanism of this
effect is not known; although cyclosporin is able to induce
7
8
anagen hair formation in C57 BL-6 mice and nude mice by
a direct effect on the hair bulb, the precise mechanism is yet
to be clarified.
However, cyclosporin is not known to cause hirsutism.
Minoxidil, a vasodilator that in lotion form has been used to
treat androgenetic alopecia, also causes hypertrichosis rather
than hirsutism when taken orally. This has led researchers to
8
Watanabe S, Mochizuki A, Wagatsuma K et al. Hair growth on
nude mice due to cyclosporin A. J Dermatol 1991; 18: 714±19.
9 Picascia DD, Roenigk HH Jr. Cyclosporine and male pattern
alopecia. Arch Dermatol 1987; 123: 1432.
q 2001 British Association of Dermatologists, British Journal of Dermatology, 145, 838±858
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