Abstract
Extensive alopecia areata including alopecia totalis and alopecia universalis is a therapeutic challenge in majority of the cases due to poor response to therapy, frequent relapses, minimal chances of spontaneous remission, and the associated psychological distress. Topical immunotherapy with diphenylcyclopropenone (DPCP) is one of the established therapeutic modalities for alopecia areata, although with a variable response rate. The use of systemic corticosteroids and other immunosuppressive drugs such as cyclosporine, azathioprine, and methotrexate is limited by their side effects. Apremilast, a phosphodiesterase-4 inhibitor, marked with a high safety profile and minimal monitoring, has been used off-label in many dermatological conditions including alopecia areata. We report three cases of extensive refractory alopecia areata with successful remission following combination therapy of DPCP and apremilast.