Treatment of Alopecia Areata, Alopecia Totalis and Alopecia Universalis with Oral ViviScal® for 12 Months
M. Majass MD*, O. Puuste MD*, B. Prästbacka (Chairman)**, Patricia Brorsdotter-Johansson (Secretary)**
*Department of Dermatology, University Central Hospital, Tallinn, Estonia
**The Swedish Association for Alopecia, Mölndal, Sweden
Address for correspondence 
M. Majass, MD Tallinn Hospital of Skin Diseases, Hiiu 39, Tallinn, EE 16, Estonia. 
SUMMARY
Altogether 97 members of the Swedish Alopecia Association (RFH) with either alopecia areata, alopecia totalis or alopecia universalis volunteered to participate in a 12 months study to evaluate the effect of oral ViviScal® on regrowth of scalp hair. Thirteen patients withdrew after 3 - 4 months because of lack of effect of the treatment. The remaining 84 patients fulfilled the treatment and were therefore evaluable. Fifty of these had alopecia areata, 12 alopecia totalis and 22 alopecia universalis. They all took two tablets of ViviScal® daily for 12 months. Before the study, after 6 and 12 months they fulfilled a questionnaire regarding the start of regrowth of scalp hair and the estimated area of the scalp with regrowth of permanent hair. In the areata group regrowth of permanent hair started to appear after approximately 6 months in 46 patients, in the totalis group in 10 patients after 4 months and in the universalis group after 5 months in 7 patients. After 12 months 7 patients in the areata group (14%) showed complete regrowth of hair, 27 patients estimated a regrowth of 70 - 95%, 10 a regrowth of 50 - 65% and 6 a regrowth less than 50%. In the totalis group 3 patients had a complete hair regrowth, 3 a regrowth of 70 - 95%, 4 a regrowth of 50 - 65% and 3 a regrowth of hair less than 50%. In the alopecia universalis group one of the patients reported complete regrowth of hair, 4 had a regrowth of 70 -95% and one a regrowth of 50 - 65%, while 16 had less than 50% regrowth of scalp hair. Better nail growth was reported by all patients with weak nails prior to the study. Overall 34 patients (68%) of the patients in the alopecia areata group, 6 of the patients (50%) of the patients in the alopecia totalis group and 5 patients (23%) in the alopecia universalis group were highly satisfied with the treatment results, while 10 (20%), 4 (33%) and 1 (5%), respectively estimated the end result as good. There was a significant correlation between the treatment results and the type of alopecia, but no significant correlation between the sex and age of the patients or duration of hair loss could be observed. No adverse reactions or unexpected events were reported by the patients. 
INTRODUCTION
The treatment of alopecia areata, totalis and universalis is usually disappointing and the treatment results are difficult to interprete because of spontaneous remissions and recurrences. Topical, intralesional or systematic cortikosteroid therapy is usually tried, but the benefit is questionable. Systemical cortikoid treatment may be effective in some cases, but the maintenance doses needed are often too high. In 1977, promising results with the use of topical dinitrochlorbencene were reported (1) . Later, it has been reported that topically used squaric acid may induce regrowth of hair in even severe cases of alopecia areata (2) . These treatments have, however, proved to be too topically irritant for practical use. Ultraviolet ligth has been recommended but its benefit has not been confirmed. However, it has been reported to stimulate regrowth of scalp hair in some patients (3) . In 1974, Rollier and Warcewski (4) first reported that methoxsalen (8-MOP) in combination with natural sunlight may induce hair growth. In 1978, Weissmann et al. (5) reported that photochemotherapy induced good regrowth of scalp hair in patients with alopecia areata. Similar results were later reported by Lassus at al. in 1980 and 1984 (6,7) . In 1992 and 1994 Lassus et al. reported excellent regrowth of hair in males with hereditary androgenic alopecia by using ViviScal®, an oral food supplement of mainly marine origin (8,9) . In an unpublished pilot study similar results could be obtained in patients with alopecia areata and alopecia totalis (10).
The present study was spontaneously initiated by the members of the Swedish Alopecia Association (RFH) in order to evaluate the effect of long-term ViviScal®treatment on alopecia areata, totalis and universalis.
PATIENTS AND METHODS
Altogether 97 patients, all members of RFH, volunteered to participate in the study. Thirteen withdrew from the study after 3 - 4 months because of lack of effect of the treatment. The remaining 84 patients continued the treatment and were thus evaluable (Table 1). All patients had earlier used conventional treatment methods without any satisfactory result. More than half of the patients suffered from alopecia areata and one fourth from alopecia universalis. Approximately one third were men. The mean duration of hair loss was especially long in the patients with alopecia universalis (Table 1) .
All evaluable patients took 2 tablets of ViviScal® for 12 months without further treatment. A questionnaire regarding patient data was filled in by the patients prior to the study, and further questionnaires regarding treatment results were filled in after 6 and 12 months of treatment. The patients themselves estimated the effect of the therapy, especially the time to first signs of regrowth of new scalp hairs, eye brows, eye lashes and body hairs. The response to the treatment was graded as complete (100% regrowth of scalp hair), excellent (70 - 95% regrowth), good (50 - 65% regrowth) and poor (less than 50% regrowth).
The collected information regarding the outcome of the study was analysed by two independent foreign dermatologists.
RESULTS
The overall results are illustrated in (Table 2) . In the alopecia areata group the mean time to signs of regrowth of permanent hair was 6 months, in the totalis group (10 patients) after 4 months and in the universalis group (7 patients) 5 months. Complete cure was observed in 7 (14%) of the patients with alopecia areata and in 3 (25%) of the patients with alopecia totalis, and one (5%) of the patients with alopecia universalis. An excellent result was obtained in 54% of the patients with alopecia areata, in 32% of the patients with alopecia totalis and in 23% of the patients with alopecia universalis. A treatment failure (poor regrowth of scalp hair) was reported by 12% of the patients with alopecia areata, 24% of the patients with alopecia totalis and in 72% of the patients with alopecia universalis.
Tables 3 and 4 show the correlation between the treatment result and the age of the patients as well as the duration of hair loss. No significant correlation could be observed.
All patients with weak and fragile nails prior to the therapy reported a complete cure or definite improvement of the nail condition after the end of the treatment.
No adverse reactions or unexpected events were reported during or after the treatment period. 
COMMENTS
The results of the present study confirm earlier results, which have shown that long-term use of ViviScal® effectively induces regrowth of hair in patients with alopecia areata and alopecia totalis (10) . The results in treatment of alopecia universalis were less encouraging. The results of this study can be criticized, because the study was carried out in an open fashion and the results were based on the patients' subjective estimation as regards hair loss and regrowth of new hair. On the other hand, the investigation clearly shows, how the patients experience the effect of ViviScal® in routine practical use. On the basis of this survey and the pilot study carried out by Lassus et al (10) ViviScal® orally used for 8 - 12 months is a recommendable mode of treatment of alopecia areata and alopecia totalis, regardless of the age of the patient or duration of the disease. It is doubtful, whether ViviScal® treatment should be used for treatment of patients with alopecia universalis.
REFERENCES
1) Happle R, Echternacht K. Alopecia areata. Erfolgreiche Halbseitungbehandlung mit DNCB. Z Hautkr 1977; 52: 1129 - 1134.
2) Happle R, Buchner U, Kalveram K-J, Echternacht-Happle K. Contact allergy as a therapeutic tool for alopecia areata: Comparison between dinitrochlorbenzene and squaric acid dibutylester. Arch Dermatol 1979; 264: 101 - 102.
3) Krook G. Treatment of alopecia areata with Kromayer's ultraviolet lamp. Acta Derm Venereol (Stockholm) 1961; 41: 178 - 181.
4) Rollier R, Warcewzki Z. Le traitement de la pelade par la meladinine. Bull Soc Fr Derm Syph 1974; 81: 97.
5) Weissmann I, Hoffmann C, Wagner G et al. PUVA-therapy for alopecia areata. An investigative study. Arch Derm Res 1978; 262: 333 - 336.
6) Lassus A, Kianto U, Johansson E, Juvakoski T. PUVA treatment for alopecia areata. Dermatologica 1980; 161: 298 - 304.
7) Lassus A, Eskelinen A, Johansson E. Treatment of alopecia areata with three different PUVA modalities. Photo-Dermatology 1984; 1: 141 -144.
8) Lassus A, Eskelinen A. A comparative study of a new food supplement, ViviScal®, with fish extract for the treatment of hereditary androgenic alopecia in young males. J Int Med Res 1992; 20: 445 - 453.
9) Lassus A, Santalahti J, Sellmann M. Traitement de l'alopécie androgénétique héréditaire chez l'adulte par administration combinée topique externe et oral de dérivés polysacharides d'origine marine. Nouv Dermatol 1994; 254 - 255.
10) Lassus A, Santalahti J, Sellmann M. Treatment of alopecia areata and alopecia totalis with ViviScal® (marine derived polysacharides). To be published. 
TABLE 1
Clinical data of 84 evaluable patients with Alopecia areata, Alopecia totalis or Alopecia universalis treated orally with ViviScal® for 12 months
	
Type of Alopecia	

Characteristics	
Areata	
Totalis	
Universalis	

No. treated	
50	
12	
22	

Females	
36	
8	
17	

Males	
14	
4	
5	

Mean age (years) 	
30.9 	
26.8 	
40.0 	

Mean duration of alopecia (years)	
6.8 	
4.9 	
13.9	

TABLE 2
Result of treatment
	
Type of Alopecia	

Characteristics 	
Areata	
Totalis	
Universalis	

No. treated	
50	
12	
22	

Mean duration to regrowth
of new scalp hair (months)	
6.3	
4.0	
5.4	

1)	
2)	
3)	

Regrowth of scalp hair (%):	

 	

- 100	
7 (14%)	
3 (25%)	
1 (5%)	

90 - 95	
11 (22%)	
1 (8%)	
2 (10%)	

80 - 85	
11 (22%)	
1 (8%)	
1 (5%)	

70 - 75	
5 (10%)	
1 (8%)	
1 (5%)	

60 - 65 	
7 (14%) 	
3 (25%) 	
0 	

50 - 55 	
3 (6%) 	
1 (8%) 	
1 (5%) 	

Less than 50 	
2 (4%) 	
1 (8%) 	
1 (5%) 	

0 	
4 (8%) 	
2 (16 %) 	
15 (68%) 	

 	

1) 46 patients 	

  	

2) 10 patients 	

  	

3) 7 patients 	

  	

TABLE 3
Correlation between age and regrowth of scalp hair
	
Regrowth of scalp hair	

Complete 	
Excellent 	
Good 	
Poor 	

TYPE OF ALOPECIA: 	

  	

ALOPECIA AREATA 	

  	

Age (years) 	

  	

-15 	
1 	
4 	
0 	
0 	

16 - 25 	
2 	
6 	
3 	
2 	

26 - 50 	
4 	
14 	
4 	
1 	

50 - 	
0 	
3 	
3 	
3 	

ALOPECIA TOTALIS 	

  	

Age (years) 	

  	

- 15 	
0 	
1 	
2 	
0 	

16 - 25 	
2 	
0 	
1 	
0 	

26 - 50 	
1 	
2 	
1 	
2 	

50 - 	
0 	
0 	
0 	
1 	

ALOPECIA UNIVERSALIS 	

  	

Age (years) 	

  	

- 15 	
0 	
0 	
0 	
2 	

16 - 25 	
1 	
0 	
0 	
2 	

26 - 50 	
0 	
3 	
1 	
8 	

50 - 	
0 	
1 	
0 	
4 	

TABLE 4:
Duration of baldness and treatment result
	
Regrowth of scalp hair	

	

	

DURATION OF ALOPECIA
(years): 	

  	

  	
Complete 	
Excellent 	
Good 	
Poor 	

ALOPECIA AREATA: 	

  	

- 5 	
5 	
17 	
6 	
1 	

6 - 10 	
1 	
6 	
4 	
2 	

10 - 	
1 	
3 	
1 	
3 	

ALOPECIA TOTALIS: 	

  	

- 5 	
1 	
2 	
2 	
1 	

6 - 10 	
1 	
1 	
2 	
0 	

10 - 	
1 	
0 	
0 	
1 	

ALOPECIA UNIVERSALIS: 	

  	

-5 	
0 	
2 	
0 	
3 	

6 -10 	
1 	
1 	
0 	
4 	

10 - 	
0 	
1 	
1 	
9