Nivolumab-Induced Alopecia Areata: A Case Report and Literature Review

Abstract

Nivolumab (anti-PD-1) currently used in many cancers. With the usage of nivolumab increased, many cutaneous side effects were reported including maculopapular rash, lichenoid reactions, vitiligo, bullous disorders, psoriasis exacerbation, and alopecia areata (AA). Here, we report AA after nivolumab for treatment of hepatocellular carcinomas (HCC). A 55-year-old male presented with multiple hairless patch from 1 month ago. He suffered HCC and treated with nivolumab for 6 months after hepatectomy. He treated for hair loss with triamcinolone intra-lesional injection without improvement. We performed skin biopsy on the scalp. Histopathologic findings revealed decreased of hair follicles on the horizontal section with lymphocyte infiltration on the perifollicular area on the vertical section. Clinicopathologic findings were agreed with AA. Considering lack of previous history of AA and hairless patches with 6 months after nivolumab injection, we diagnosed him as nivolumab induced AA. Treatment included topical steroid, and minoxidil. No regrowth of hair was noted after 4 months of follow-up. Nivolimumab induced AA is rare side effect. Pathogenesis of nivolumab induced AA remain unclear. But our case is likely related to nivolumab, known to induce immune related adverse events, and given in the delay of a few months between introduction and the occurrence of the hair loss. Here, we reports nivolmumab induced AA; rare side effect.

Keywords: Alopecia areata; Nivolumab.

Fig. 1. Multiple hairless patches on the vertex without eyebrow, eyelash, or other body hair involvement (A: vertex; B: occiput; C: left temporal area of the scalp). We received the patient's consent form about publishing all photographic materials.

Fig. 2. (A) Decrease of hair follicles with inflammatory cell infiltrations in the perifollicular area. Nearly all follicles were in the telogen stage (H&E, ×40). (B) Mild lymphocyte infiltration in the perifollicular area (H&E, ×100).

Fig. 3. After 2 months of topical treatment, patient hair loss was aggravated and progressed to alopecia totalis (A: vertex; B: occiput; C: left temporal area of the scalp).