Combination therapy with zinc gluconate and PUVA for alopecia areata totalis: an adjunctive but crucial role of zinc supplementation.

Spontaneous remission occurs in less than 10% of patients suffering from alopecia areata (AA) totalis for more than 2 years. The efficacy of PUVA therapy is controversial due to recurrence of hair loss after cessation. We report two cases presenting with AA totalis and AA universalis. After hair regrowth, relapse of hair loss occurred upon cessation of PUVA and zinc gluconate combination therapy. However, hair regrowth was noted upon the reintroduction of zinc gluconate and sulfur amino acids without PUVA in the first case and with episodic PUVA in the second case. The chronology of events appears to support the notion that zinc has a significant effect. Our findings suggest the possibility of a subgroup of zinc-responsive patients, but the identification of these patients remains difficult. Metallothioneins and zinc transporters regulating the entrance and exit of zinc in cells might play a key role. Combination therapy with immunomodulators may be administered to facilitate enhanced zinc-targeted action. Taking into account the safety profile of zinc, 30-40 mg/day of zinc metal may be used during at least 1 year, although we recommend to monitor its serum and hair levels. Studies with a larger number of patients are required to further investigate the therapeutic effect of zinc.