Clinical trial NCT01898806
Conditions: Alopecia Areata
Keywords: Alopecia Areata Kenalog Triamcinolone
Sponsor: Columbia University
Start date: 2011-09-01; Completion date: 2018-01-01
Enrollment: 11 participants; Allocation: RANDOMIZED; Intervention model: PARALLEL

Brief summary:
This study aims to determine the frequency of response to treatment with 3 concentrations of IL TAC, 2.5mg/ml, 5mg/ml or 10mg/ml as well as the duration of response and incidence of side effects compared to treatment with placebo (sterile saline solution). After the 1st 6 months, nonresponders or partial responders may be treated for 6 months with open label triamcinolone at the dose deemed appropriate by the investigator.

The investigators will also perform skin biopsies of the scalp and draw blood at selected time points in order to examine the immunohistochemical/pathological response in scalp hair follicles and the systemic circulation to treatment with IL TAC for alopecia areata.

Detailed description:
Alopecia areata (AA) is a major medical problem and is the most prevalent autoimmune disease in the US. AA represents the second most common form of hair loss and causes significant disfigurement and psychological distress to affected individuals. AA affects more individuals than most other autoimmune diseases combined, including lupus erythematosus, type 1 diabetes, psoriasis, multiple sclerosis and rheumatoid arthritis. In contrast to these conditions, research into the pathogenesis and the development of innovative therapies in AA has lagged behind.

Alopecia areata is a common form of hair loss which reportedly occurs in up to 1.7% of the population at some time in their life. Alopecia areata is apparently triggered when the individual's own immune system attacks hair follicles on the scalp or body resulting in hair loss ranging from single patches on the scalp (patch type alopecia areata) to loss of every hair on the scalp and body (alopecia universalis). Currently, there are limited treatment options for alopecia areata and unfortunately, the treatments utilized have never been rigorously tested in a placebo controlled trial.

Triamcinolone (Kenalog) is a steroid solution that has been used as a treatment for alopecia areata for over 50 years. It is administered via injection into the scalp and appears to have some efficacy for patients with mild to moderate alopecia areata. The investigators currently do not have objective data on the frequency of occurrence of successful regrowth, the duration of response or the incidence of side effects. Intralesional triamcinolone (IL TAC) is arguably the most commonly used treatments for AA, especially in patients with less than 50% hair loss. Despite this, there are no adequately powered, randomized controlled clinical trials (RCTs) examining the efficacy, safety, and duration of effect of IL TAC. In addition, the dosage or strength used varies among practitioners and the efficacy and safety of alternate doses of IL TAC has never been examined in a well designed RCT. Quantitative biomarkers for AA are a crucial step toward translational research aimed at clinical trials in AA.

Arms: arm 1: Intralesional Triamcinolone 2.5 mg/ml (IL TAC 2.5 mg/ml):

Patients will receive intradermal injection of study medication once per month to all, or as many as possible, areas of hair loss up to the maximum dose of 30 mg IL TAC per month, for a total of 6 months. Injections will be performed at baseline, weeks 4, 8, 12, 16 and 20 arm 2: Intralesional Triamcinolone 5mg/ml (IL TAC 5 mg/ml):

Patients will receive intradermal injection of study medication once per month to all, or as many as possible, areas of hair loss up to the maximum dose of 30 mg IL TAC per month, for a total of 6 months. Injections will be performed at baseline, weeks 4, 8, 12, 16 and 20. arm 3: Intralesional Triamcinolone 10mg/ml (IL TAC 10 mg/ml):

Patients will receive intradermal injection of study medication once per month to all, or as many as possible, areas of hair loss up to the maximum dose of 30 mg IL TAC per month, for a total of 6 months. Injections will be performed at baseline, weeks 4, 8, 12, 16 and 20. arm 4: Intralesional Saline (Placebo):

Patients will receive intradermal injection of study medication once per month to all, or as many as possible, areas of hair loss for a total of 6 months. Injections will be performed at baseline, weeks 4, 8, 12, 16 and 20. Open label treatment with IL kenalog at the dose deemed most appropriate may be administered after the 1st 6 months in nonresponders or partial responders.
Interventions: intervention 1: Intralesional Triamcinolone 2.5 mg/ml intervention 2: Intralesional Triamcinolone 5 mg/ml intervention 3: Intralesional Triamcinolone 10 mg/ml intervention 4: Intralesional Saline
Intervention descriptions: intervention 1: Intralesional Triamcinolone at a strength of 2.5 mg/ml. Patients will receive intradermal injection of study medication once per month to all, or as many as possible, areas of hair loss up to the maximum dose of 30 mg IL TAC per month, for a total of 6 months. intervention 2: Intralesional Triamcinolone at a strength of 5 mg/ml. Patients will receive intradermal injection of study medication once per month to all, or as many as possible, areas of hair loss up to the maximum dose of 30 mg IL TAC per month, for a total of 6 months. intervention 3: Intralesional Triamcinolone at a strength of 10 mg/ml. Patients will receive intradermal injection of study medication once per month to all, or as many as possible, areas of hair loss up to the maximum dose of 30 mg IL TAC per month, for a total of 6 months. intervention 4: Intralesional Saline (Placebo). Patients will receive intradermal injection of study medication once per month to all, or as many as possible, areas of hair loss for a total of 6 months.

Protocol documents:
Prot_SAP_000.pdf: 
Columbia university 
IL TAC in AA 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
A PHASE 4 RANDOMIZED, PLACEBO CONTROLLED 
TRIAL OF 3 DOSES OF INTRALESIONAL 
TRIAMCINOLONE (KENALOG®) IN THE TREATMENT OF 
MILD TO MODERATE PATCH TYPE ALOPECIA AREATA 
[IL TAC in AA] 
 
Julian Mackay-Wiggan, M.D., M.S. 
Angela Christiano, Ph.D. 
Raphael Clynes, M.D., Ph.D. 
Bibhas Chakraborty 
Ali Jabbari, M.D., Ph.D. 
Clinical Research Unit 
Department of Dermatology 
Columbia University Medical Center 
161 Fort Washington Ave, 12th fl, Rm 1264 
New York, NY 10032 
(212) 305-6953  
(212) 305-0286 fax 
jc299@columbia.edu 
 
Maria Hordinsky, M.D. 
Clinical Research Division 
Department of Dermatology 
University of Minnesota 
420 Delaware St SE 
MMC 98, 4-240 PWB 
Minneapolis, MN 55455 
( 612) 625-8625 
(612) 624-7484 fax 
 
Protocol version:  May 20, 2015 
 


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IL TAC in AA 
 
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GOALS 
Alopecia areata (AA) is a major cause of morbidity and is the most prevalent autoimmune 
disease in the US, affecting approximately 4.6 million people, including males and females 
across all ethnic groups, with a lifetime risk of 1.7% (1). Additionally, AA represents the 
second most common form of human hair loss, second only to androgenetic alopecia, and 
causes significant disfigurement and psychological distress to affected individuals (Figure 1). 
AA affects more individuals than most other autoimmune diseases combined, including lupus 
erythematosus (LE), type 1 diabetes (T1D), psoriasis, multiple sclerosis (MS) and rheumatoid 
arthritis (RA).  In stark contrast to these other conditions, research into the 
pathogenesis and the development of innovative therapies in AA has lagged far 
behind.  This may be due in part to the perception that AA is merely a cosmetic disorder.  In 
reality, AA carries one of the highest burdens among any skin diseases, particularly 
among children and adolescents whose self-image is so closely linked to their 
appearance (2).   
Despite its high prevalence, there are no evidence-
based treatments for AA. A comprehensive 
Cochrane analysis assessment of seventeen 
randomized clinical trials (RCTs) involving a total of 
540 participants found no treatment with proven 
efficacy for AA (3).  Each trial included from 6 to 85 
participants and assessed a range of interventions 
that included topical and oral corticosteroids, topical cyclosporine, photodynamic therapy and 
topical minoxidil. Overall, none of the interventions showed significant treatment benefit in 
terms of hair growth when compared with placebo. It was concluded that the effectiveness 
of few (if any) treatments for AA are proven. No RCTs on the use of immune modulators such 
as diphencyprone, dinitrochlorobenzene, intralesional corticosteroids or dithranol were 
found, although these drugs are commonly used for the treatment of AA. Similarly, although 
topical corticosteroids and minoxidil are widely prescribed and appear to be safe, there is no 
convincing evidence that they are beneficial in the long-term. Most trials have been poorly 
reported and/or are so small that any important clinical benefits are inconclusive.    
Intralesional corticosteroids - triamcinolone acetonide (Kenalog) (IL TAC) are arguably the 
most commonly used treatments for alopecia areata, and certainly the most commonly used 
modality for patients with less than 50% hairloss in AA(4).  Most practitioners would agree 
that many patients benefit from this treatment however there is no well controlled evidence 
to support this belief.  Despite the fact that intralesional corticosteroids have been used to 
treat AA for over 50 years(5, 6), there are no adequately powered, randomized controlled 
clinical trials examining the efficacy of this treatment(3). In addition, the dosage or strength 
used varies from practitioner to practitioner.  The relative efficacy, safety and duration of 
effect of alternate doses of IL TAC has never been examined in a well designed randomized 
clinical trial. A well designed randomized controlled study would provide immediately useful 
Figure 1. Clinical manifestations of AA.  In the upper panels (a and b), 
patients with patch type AA.  In b, the patient is in a spontaneous 
regrowth phase.  For patients with alopecia universalis, there is a 
complete lack of body hair and scalp hair (c), while patients with 
alopecia totalis lack scalp hair but not body hair.  In d, the randomness 
of hair regrowth is observed, with regrowth in the parietal region but not 
in either the occipital or temporal regions. 


Columbia university 
IL TAC in AA 
 
2 
 
information that could dramatically impact the way AA patients are currently treated.    In 
addition, quantitative biomarkers for AA are a crucial step toward translational research 
aimed at clinical trials in AA. Toward this goal, we propose: 
Specific Aim 1. To evaluate the efficacy of treating patients with mild to moderate patch type 
alopecia areata for six months with  IL TAC at a strength of 2.5mg/ml versus treatment with 
IL TAC 5mg/ml versus IL TAC 10mg/ml versus intralesional saline as placebo.  
Specific Aim 2. To identify a clinical correlation between treatment outcome and down 
modulation of key AA-associated immunohistopathological markers and biomarkers in the 
treated skin; including NKG2DL expression in the hair follicle, immune infiltration 
(CD8+NKG2D+ cells) and expression of interferon response genes.  
 
RATIONALE 
Development of an Alopecia Areata Clinical Trials Center at CUMC 
Alopecia areata has been poorly studied clinically in part because molecular mechanisms of 
pathogenesis have been poorly understood. Work here at CUMC has changed this 
landscape: GWAS studies published last year (Petukhova et al, Nature 2010) by Angela 
Christiano in our Department identified for the first time specific genes responsible for 
inherited risk and identified potential therapeutic targets. This has provided the basis for the 
initiation of a suite of new clinical research programs in alopecia areata at CUMC using 
rationally targeted therapies aimed at these genetically identified pathways.  Two such 
innovative programs have been submitted for external research funding including 1) use of 
a topical JAK inhibitor to inhibit interferon signaling in localized alopecia areata and 2) use of 
systemic anti-CTLA-4-Ig to block costimulation in severe alopecia. Further, based on these 
genetic findings, immunopathological findings and transcriptional profiling of alopecic skin, a 
biomarker platform to evaluate therapeutic responses is being developed using human blood 
and skin biosamples.  In this proposal we seek to use and refine this biomarker platform to 
evaluate the current “standard of care” intervention, topical steroids, to examine for the first 
time alopecia biomarkers during treatment.  This will provide important experience in the 
development of this platform and complete a comprehensive clinical program in alopecia 
evaluating side-by-side both novel therapeutics and current clinical practice (IL steroids) in 
alopecia areata.  
 
Clinical experience with IL TAC for AA 
One of the earliest studies of intralesional steroid was published by Richard Heffernan in 
1964. He injected patients with a variety of dermatologic disorders with TAC in varying doses 
(2.5mg/ml, 5mg/ml, 10mg/ml) or saline in a “controlled, double-blind study”.  Single discrete 
lesions were divided into 4 quadrants and equivalent volumes of the four coded suspensions 
were injected intralesionally, each suspension into a different quadrant.  A single treatment 
was given after which patients were evaluated at varying intervals.  For the single AA patient 
treated in this manner, “an equivalent degree of hair regrowth was noted in the three sites 
injected with active drug, and no regrowth of hair in the site injected [with] diluent”.  Hair 
regrowth was not present at 17 days, but was present at 34 days and 8 months(7).   
Subsequently, Abell and Munro treated 84 patients with varying types and degrees (single 
lesion to alopecia universalis) of AA using IL TAC 5mg/ml.  Injections were given at weekly 
to bi-weekly intervals on 3 occasions, followed by examinations at 6 and 12 weeks to 
determine efficacy.  Fifteen patients were injected with isotonic sterile normal saline 


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IL TAC in AA 
 
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“coincidentally with the triamcinolone therapy”.  No mention is made of randomization or 
blinding.  At follow-up satisfactory regrowth was defined as “the presence of predominantly 
pigmented terminal hair at the injection sites in significant quantity”.  “Significant quantity” 
was not further described.  Regrowth was noted to occur in tufts corresponding to the 
injection sites within 4 to 6 weeks, and was often accompanied by evidence of minimal, 
transient skin atrophy.  When divided into limited alopecia vs alopecia totalis/universalis, 71% 
of patients with limited AA had regrowth at 12 weeks vs 28% of patients with alopecia 
totalis/universalis. Seven percent of patients treated with saline had regrowth at 12 weeks, 
however the authors attributed the incidence of spontaneous recovery over the period of 
observation to be 20%.  Of note, the clinical photographs showing regrowth indicate relatively 
limited regrowth limited to small patches at injection sites.  Side effects noted were minimal 
and included: hemorrhage at injection sites, easily controlled with pressure, minimal atrophy, 
and no incidence of “sepsis”.  In one patient, plasma cortisol levels were monitored by 9am 
samples.  The pretreatment level of 14.8µg/100ml was reduced to 2.7µg/100ml the day 
following a dosage of 22.5mg of triamcinolone acetonide.  The resting level was regained by 
day 3 and remained normal over the next 10 days (8). 
 
In general practice, a concentration of 5mg/ml of TAC with a maximum volume of 6ml (30mg 
total) or 10mg/ml of TAC with a maximum volume of 3ml can be used on the scalp in one 
visit.  Multiple intradermal injections using a 30 gauge needle are administered approximately 
1 cm apart with injection of approximately 0.1ml per site.  Initial regrowth may be seen in 4 
to 8 weeks (9), (10).  Side effects include mild, transient skin atrophy, lasting 2 to 8 months 
especially if too great a volume is injected or if the injection is too superficial or too deep(11).  
Transient pain is an additional side effect which limits the use of this modality in some 
patients, especially children(4).  Ironically, younger patients (children) have been reported to 
have comparatively better hair growth in response to intralesional steroids(9).  Topical 
anesthetics may be used to decrease discomfort.  If there is no regrowth after 6 months of 
treatment, therapy with intralesional steroids should be stopped(10). 
 
Mechanism of action of intralesional steroids 
Despite the years of clinical experience of steroids in autoimmunity, the specific anti-
inflammatory mechanisms are still incompletely understood.   
 It is thought that intralesional steroids act in alopecia areata by inhibition of the T cell 
mediated attack on the hair follicle. “Glucocorticoids exert their effects by binding to the 
glucocorticoid receptor (GR), a transcription factor capable of regulating many genes in a 
positive and or negative way”(12). The immunomodulatory action of glucocorticoids is 
thought to be due to its inhibitory role on the activity of transcription factors, such as activator 
protein-1 (AP-1) and nuclear factor κ β (NFκβ), that are involved in the activation of 
proinflammatory genes(13).  Consequently, glucocorticoids suppress the production and 
effects of humoral factors involved in inflammatory responses and inhibit leukocytes’ 
migration to the inflammation sites”(14). While many patients benefit from intralesional 
steroids in AA, there is a group of patients that demonstrate a diminished response or 
resistance to this treatment modality. 
 
 


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Columbia university 
IL TAC in AA 
 
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in which fewer than 10% are expected to achieve this magnitude of hair regrowth 
spontaneously. In contrast, clinical experience would suggest that approximately 50% of 
subjects treated with either dose of IL TAC may achieve >/= 50% improvement in SALT score 
after 6 months of treatment.  The goal of this study is to validate or refute this clinical 
impression and to objectively and precisely quantify the treatment effect of 2.5mg/ml, 5mg/ml 
or 10mg/ml of IL TAC in AA. 
 
Subjects will be randomized 1:1:1:1 to the placebo or treatment arms, and will receive 6 
months of treatment with the study medication or placebo. IL TAC 2.5mg/ml, 5mg/ml, 
10mg/ml or placebo will be administered at baseline, then every 4 weeks thereafter for 5 
cycles (weeks 4, 8, 12, 16, 20) for a total treatment period of 6 months. Percent hair regrowth 
from baseline will be determined by SALT measurements following 4, 8, 12, 20 and 24 weeks 
of treatment. Punch biopsies and peripheral blood will be obtained at baseline prior to 
treatment, and then once again at a time point between weeks 4 and 20, to be determined 
by the investigator as indicated by clinical considerations such as variation in the timeline to 
regrowth from one subject to another, for immunomonitoring/biomarker studies. Additional, 
optional scalp biopsies and blood draws may be taken at other key time points in order to 
monitor response to therapy at the discretion of the investigator and with the consent of the 
study subject. Efficacy will be measured by change in hair re-growth as determined by 
physical exam and photography, as well as by patient and physician global evaluation scores.  
Physician and patient global evaluation scores will be determined based on the use of similar 
100mm Visual Analogue scales with 0 labeled as no scalp hair loss and 100 labeled as 
complete scalp hair loss.  Patients and physicians will place a vertical mark along the 
horizontal line depending on their assessment of the degree of hair loss present at the time 
of assessment. 
 
As secondary endpoints, efficacy will be measured by changes in hair re-growth as a 
continuous variable as determined by physical exam, SALT score and Canfield photography, 
as well as patient and physician global evaluation scores.  
 
To assess the durability of responses, patients who achieved 50% regrowth from baseline (a 
50% reduction in baseline SALT score) during the first 6 months, will continue to be followed 
for an additional 6 months off treatment or until it is determined that relapse has occurred.  
Percent hair regrowth from baseline will be determined by SALT measurements during the 
observational phase at weeks 28, 32, 36, 40, 44 and 48.  Relapse will be defined as any 
recurrence of hair loss in responders (subjects achieving greater than 50% decrease in SALT 
score from baseline during the first 6 months of the study) who had achieved stable regrowth 
without continued loss for at least 2 months; and loss of >/= 25% of regrowth in patients who 
had achieved 50% regrowth but still had chronic low grade hair loss.   
 
Nonresponders to 6 months study treatment (defined as failure to achieve 50% improvement 
in SALT score at week 24 compared to baseline) will not be required to participate in the 
6mth follow-up period but will be given the option of receiving monthly IL TAC 2.5mg/ml, 
5mg/ml or 10mg/ml injections for 6 months if deemed appropriate by the investigator. The 
dosage to be utilized (2.5mg/ml vs. 5mg/ml vs. 10mg/ml) will be based on clinical 
considerations, unless study data is available to support preference of one dose versus the 


Columbia university 
IL TAC in AA 
 
6 
 
other. Patients identified by unblinded study personnel as having previously been treated 
with active drug or with obvious signs of atrophy or other indications suggesting they have 
already been treated with active drug for 6 months will not be given the option of continuing 
IL TAC as it is unlikely that they will respond if they have not responded by 6 months unless 
available evidence suggests that utilization of a different dosage is more likely to be 
efficacious and safe. 
 
 
Human Subjects Involvement, Characteristics, and Design 
The use of human subjects is proposed in this application. Informed consent will be obtained 
from each subject prior to any study related procedures.  After informed consent has been 
obtained, potential subjects will be screened to ensure they meet diagnostic and safety 
criteria for inclusion in the study. Subjects will then be randomly assigned via a randomization 
list to one of three doses (2.5mg/ml versus 5mg/ml versus 10mg/ml) of IL TAC or placebo 
(intralesional saline) in a 1:1:1:1 ratio. Bacteriostatic saline is chosen as a diluent and placebo 
instead of xylocaine as the injection stings less. The concentration, frequency of injection of 
the study medication and diluents used are determined based on current standard of care in 
clinical practice for the treatment of patients with alopecia areata.  Therefore, patients being 
treated with IL TAC 2.5mg/ml will have up to a maximum of 12ml of drug injected, those 
treated with IL TAC 5mg/ml will have up to a maximum of 6ml of drug injected, while patients 
being treated with IL TAC 10mg/ml will receive a maximum of up to 3ml of drug injected.  In 
an attempt to maintain the blinding of the evaluating investigator, patients receiving saline 
placebo, will have either 3ml, 6ml, or 12ml drawn up drawn up as appropriate for the extent 
of hair loss present and at the discretion of the unblinded study staff member preparing the 
medication.   The entire syringe will be covered. After injections are completed, the unblended 
study team member will collect the used and unused syringes and calculate the total volume 
injected. This amount will be recorded and concealed to maintain integrity. During the course 
of the study, subjects will be closely monitored for efficacy and the occurrence of adverse 
events.  Determination of immunologic outcome measures will require the collection of blood 
samples (peripheral blood draws) as well as skin biopsies from the scalp. The subject 
population will consist of 68 patients with a diagnosis of patchy AA of recent onset (duration 
of at least 3 months) who have consented to participation in the trial and have met all 
inclusion and exclusion criteria.  Patients will be 18 to 75 years old, and be deemed to be in 
good general health. We do not intend to enroll patients from vulnerable populations.  
 
Inclusion criteria 
 Patients 18 to 75 years of age 
 Patients with a diagnosis of patch type alopecia areata  
 Patients will have up to 50% total scalp hair loss at baseline as measured by the Severity 
of Alopecia Tool (SALT) (2) score. 
 
 Duration of hair loss greater than 3 months without an upper limit of duration as long as 
there is reason to believe that regrowth is possible in the opinion of the investigator.  
 No evidence of active, ongoing regrowth present at baseline.  
 Patients with alopecia totalis/universalis can be included as long as the current episode 
of hair loss meets the criteria of up to 50% total hair loss (i.e. they may have had a 


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previous episode of AT or AU which demonstrated regrowth of hair, and they are not 
currently AT or AU), and as long 
 Patients with more than 50% total scalp hair loss at baseline can be included as long as 
the specified area to be treated is limited to less than 50% of total scalp area 
 
Exclusion criteria 
 Patients with a history of or existing skin diseases affecting the scalp such as psoriasis 
or seborrheic dermatitis and patients with evidence of infection or skin cancer in the 
treated areas 
 Patients in whom the diagnosis of alopecia areata is questionable 
 Patients in whom regrowth is present/evident at baseline in the areas to be treated 
 Patients with active medical conditions or malignancies (except adequately treated basal 
or squamous cell carcinoma of the skin) which in the opinion of the investigator would 
increase the risks associated with study participation, including patients with a history of 
recurrent infections 
 Women of childbearing potential who are unable or unwilling to use two forms of birth 
control for the study duration or women who are pregnant or nursing 
 Patients known to be HIV or hepatitis B or C positive or otherwise immunocompromised 
 Patients with evidence of adrenal cortex abnormality or previous significant adverse 
reaction to intralesional steroids 
 Patients unwilling or unable to discontinue treatments known to affect hair regrowth in 
alopecia areata 
 Patients who have been treated with intralesional steroids, systemic steroids, anthralin, 
squaric acid, DPCP (diphenylcycloprophenone), protopic, minoxidil or other medication 
which in the opinion of the investigator may affect hair regrowth, within one month of the 
baseline visit. 
 
Study procedures 
Screening: A complete medical history will be taken.  Patients will be specifically asked about 
renal, hepatic or adrenal abnormalities and pregnancy (women of child bearing potential 
only).  In keeping with current standard of care, no routine blood work will be done, unless it 
is deemed necessary by the investigator.  Patients will be randomly assigned to IL TAC 
2.5mg/ml, IL TAC 5mg/ml or IL TAC 10mg/ml or intralesional saline in a 1:1:1:1 ratio based 
on a computer generated randomization list. The list will be generated prior to study initiation.  
Based on the randomization list, patients will be assigned to treatment vs. placebo based on 
the order in which they are enrolled. The assignment will be made by study personnel not 
involved in making clinical assessments or evaluations.  The patient and the assessing 
physicians will remain blinded to the treatment assignment for the duration of the study.  
Baseline assessments of disease severity will be done, including SALT, Physician global 
assessment (PGA), patient global assessment and patient quality of life assessment.  
Patients will have study medication injected once per month by the study physician in 
accordance with current standard of care clinical practice.  Per current clinical practice, 
attempts will be made to treat all areas of hair loss due to AA, however (also in accordance 
with current standard of care in clinical practice) the dose of intralesional triamcinolone 
injected will be limited to a maximum of 30mg per month(16, 4). Therefore, patients being 


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8 
 
treated with IL TAC 2.5mg/ml will have up to a maximum of 12ml of drug injected, those 
treated with IL TAC 5mg/ml will have up to a maximum of 6ml of drug injected, while patients 
being treated with IL TAC 10mg/ml will receive a maximum of up to 3ml of drug injected.  In 
an attempt to maintain the blinding of the evaluating investigator, patients receiving saline 
placebo, will have either 3ml, 6ml, or 12ml drawn up at the discretion of the unblinded study 
staff member preparing the medication.  When possible, an unblinded physician investigator 
will perform study medication injections.  If the blinded evaluating investigator must perform 
injections, the syringes will be covered such that the solution contained within is not visible. 
The entire syringe will be covered. After injections are completed, the unblended study team 
member will collect the used and unused syringes and calculate the total volume injected. 
This amount will be recorded and concealed to maintain integrity. 
 
Baseline to Week 48: Patients will receive intradermal injection of study medication once per 
month to all, or as many as possible, areas of hair loss up to the maximum dose of 30mg IL 
TAC per month, for a total of 6 months.  Injections will be performed at baseline, weeks 4, 8, 
12, 16 and 20.  Injection areas will be chosen based on the investigator’s clinical assessment 
of factors including but not limited to, areas of most active shedding, areas of maximum 
medical and cosmetic benefit, avoidance of any areas of pre-existing atrophy, etc.  Patients 
will be seen at weeks 28, 32, 36, 40, 44 and 48 after end of treatment in order to assess the 
frequency and timing of relapse. Nonresponders to 6 months study treatment (defined as 
failure to achieve 50% improvement in SALT score at week 24 compared to baseline) will not 
be required to participate in the 6 month follow-up period but will be given the option of 
receiving monthly IL TAC 2.5mg/ml, 5mg/ml or 10mg/ml injections for 6 months if deemed 
appropriate by the investigator.  The dosage to be utilized (2.5mg/ml vs. 5mg/ml vs. 10mg/ml) 
will be based on clinical considerations, unless study data is available to support preference 
of one dose versus the other.  Patients identified by unblinded study personnel as having 
received TAC or with obvious signs of atrophy or other indications suggesting they have 
already been treated with active drug for 6 months will not be given the option of continuing 
IL TAC as it is unlikely that they will respond if they have not responded by 6 months unless 
available evidence suggests that utilization of a different dosage is more likely to be 
efficacious and safe. 
 
Efficacy evaluations: SALT, PGA, and Patient global assessment will be performed at every 
visit. PGA and patient evaluations will be based on similar 100mm visual analog scales. 
Patient quality of life assessments, performed at baseline, weeks 12, 24, 36, and 48, will be 
based on changes in the Dermatology Life Quality Index DLQI – adapted for hair loss, or the 
Dermatology Quality of Life Scales. Blood draws for safety assessments and immunology will 
be drawn at weeks 4, 12, 24 and 28(if needed for safety labs). Scalp biopsies for immunologic 
parameters will be obtained at baseline, and at one time point between weeks 4 and 20. 
Additional biopsies and blood draws may be obtained as clinically indicated. Since the timeline 
to regrowth may vary from subject to subject, unscheduled biopsies and blood draws will 
insure that tissue and blood samples are obtained at optimal timepoints to evaluate the 
changes occurring at the onset of growth or in the event of any unexpected clinical change. In 
addition, areas that are resistant to treatment may be biopsied to determine the cellular and 
immunologic differences of those areas compared to areas that are responding to treatment. 


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The patient will be given the option to agree to, or decline, the additional biopsies and blood 
draws. 
 
Standardized photographs of the subject’s scalp will be taken at Baseline, Week 4, 8, 12, 16, 
20, 24, 36 and 48 and will be used to support determination of percent hair regrowth.  
Photography will consist of a high resolution digital camera mounted on a stereotactic arm.  
Patients will be positioned using a fixed guide after which photographs of the entire scalp will 
be taking at standardized locations and at a fixed distance.  At a minimum, photographs of 
the crown, right and left lateral scalp and posterior scalp (views consistent with those used 
in the SALT measurement) will be taken. 
 
Visit Schedule and Assessments  
Screening assessments and all scheduled study visits are outlined in the Table of Study 
Assessments (please see below). 
 
 
Informed consent 
Written informed consent will be obtained from all patients for this study by the principal 
investigator or his/her designee prior to any protocol-specific procedures. The study will be 
conducted in accordance with the Food and Drug Administration (FDA) approved revision of 
the Declaration of Helsinki, current FDA regulations, and International Conference on 
Harmonization (ICH) guidelines.  
 
Procedures Performed Prior to Treatment Screening (Day -28 to -1):  
The following screening evaluations will be performed within 4 weeks prior to enrollment: 
 Informed consent, inclusion/exclusion criteria, prior concomitant medications 
 Medical history, physical examination, including a dermatological exam 
 Vital signs, body weight 
 Assessments of disease severity of scalp, body hair and nails will be conducted 
including SALT (Severity of Alopecia Tool) 
 Physician’s global assessment (PGA), patient global assessment, patient quality of 
life assessment 
 Clinical laboratory evaluation (complete blood count, basic metabolic profile, hepatic 
panel and urinalysis) am cortisol, urine pregnancy test and urine analysis or other, 
only if deemed necessary by the investigator. 
 
The results of all assessments/tests listed above must be reviewed prior to enrolling to 
ensure that the patient meets entry criteria and that no exclusion criteria are present. 
 
Baseline (Day 0) Procedures Performed Prior to treatment 
 Review of inclusion/exclusion criteria 
 Vital signs, body weight 
 Adverse events reporting, concomitant medication review 
 Photography 
 Physician evaluation utilizing the PGA and SALT scale 


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 Patient global assessment and quality of life assessment 
 Urine pregnancy testing 
 Blood collection for immunological studies 
 Scalp biopsy (4mm punch biopsy) 
 Non-lesional scalp biopsy may be obtained at this visit or a subsequent visit 
 Injection of study medication 
 
 
Weeks 4, 8, 12, 16, 20 - Visit days will have an acceptable window of ±7 days. 
 Vital signs, body weight 
 Adverse events reporting, concomitant medication review 
 Photography  
 Physician evaluation utilizing the PGA and SALT scale 
 Patient global assessment 
 Patient quality of life assessment (only week 12) 
 Urine pregnancy testing 
 Clinical laboratory evaluation (only weeks 4 and 12) 
 Scalp biopsy (4mm punch biopsy) and blood collection for immunological studies; 
one scalp biopsy to be obtained during this time period, at a time point determined 
by the investigator as indicated by clinical considerations such as variation in the 
timeline to regrowth from one subject to another 
 Additional scalp biopsies and blood collection optional; patient will be given the 
option to agree to, or decline, additional scalp biopsies and blood draws. 
 Injection of study medication 
 
 
Week 24 +/- 7 days – End of treatment also end of study for nonresponders not continuing 
on to open label treatment and beginning of open label treatment for nonresponders 
continuing to open label treatment 
 Vital signs, body weight 
 Physical and dermatological examination 
 Adverse events reporting, concomitant medication review 
 Photography 
 Physician evaluation utilizing the PGA and SALT scale 
 Patient global assessment and quality of life assessment 
 Urine pregnancy testing 
 Clinical laboratory evaluation 
 Optional scalp biopsy (4mm punch biopsy) and blood collection for immunological 
studies 
 IL TAC injection for qualified nonresponders continuing to open label treatment 
 
Weeks 28, 32, 36, 40, 44 and 48 +/- 7 days– Observational Period for responders or IL 
TAC Injection period for nonresponders deemed appropriate for open label injection 
 Vital signs, body weight 


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 Physical and dermatological examination (only week 48) 
 Adverse events reporting, concomitant medication review 
 Photography (weeks 36 and 48) 
 Physician evaluation utilizing the PGA and SALT scale 
 Patient global assessment 
 Patient quality of life assessment (only weeks 36 and 48) 
 Optional Scalp biopsy (4mm punch biopsy) at additional timepoints at the discretion 
of the principal investigator and with the consent of the subject, based upon 
perceived utility in context of individual patient response to therapy and durability of 
that response. 
 Optional Blood collection for immunological studies at additional timepoints at the 
discretion of the principal investigator and with the consent of the subject. 
 IL TAC injection for qualified nonresponders. 
 
Early Termination 
 Vital signs, body weight 
 Physical and dermatological examination 
 Adverse events reporting, concomitant medication review 
 Photography 
 Physician evaluation utilizing the PGA and SALT scale 
 Patient global assessment and quality of life assessment 
 Clinical laboratory evaluation 
 Scalp biopsy (4mm punch biopsy) – if indicated and if patient agreeable to biopsy 
and 2 week f/u for suture removal if deemed necessary. 
 Blood collection for immunological studies 
 
 
Unscheduled Visits 
An unscheduled visit can occur at any time during the study.  A source document must be 
maintained for these unscheduled visits. The date for the visit and any data generated must 
be recorded on the appropriate CRF.  At treatment discontinuation/early termination subjects 
will undergo off study evaluations per the Schedule of Assessments. 
 
Telephone contact/retention 
Patients will be contacted on a biweekly basis throughout the duration of the study to 
ascertain the occurrence of adverse events as well as to assess the status of hair growth or 
loss.  Any concerns or questions the patient may have will also be addressed. 
 
Assessment of efficacy 
The primary efficacy endpoint of this intention to treat trial in AAP will be the proportion of 
responders in the treated compared to the control group after 6 months of treatment, with 
response defined as 50% or greater hair re-growth from baseline as assessed by SALT 
(Severity of Alopecia Tool) (Olsen et al. 2004) score at week 24. This is a relatively strict 
definition for defining responders and non-responders and was chosen based on consensus 
of clinicians and AA experts that 50% reduction in SALT score represents clinically 


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12 
 
meaningful response and to minimize responses in the “vehicle” arm, in which fewer than 
10% are expected to achieve this magnitude of hair regrowth spontaneously. This outcome 
was also used in two recent RCT trials (Strober et al. 2009 and Price et al. 2008) evaluating 
therapies for AA. 
 
As secondary endpoints, efficacy will be measured by changes in hair re-growth as a 
continuous variable as determined by physical exam and Canfield photography, as well as 
patient and physician global evaluation scores. To assess the durability of responses, 
patients who achieve 50% reduction in baseline SALT score will continue to be followed for 
an additional 6 months off treatment.   
 
Secondary efficacy outcomes in detail: 
1. Percent hair regrowth from baseline determined by SALT measurements following 4, 8, 
12, 20 and 24 weeks of treatment and during the observational phase at weeks 28, 32, 36, 
40, 44 and 48.   
2. Comparison of the proportion of responders in each group, with response defined as 
50% change in SALT score (50% regrowth) from baseline, at weeks 12, 24, 36 and 48. 
3. Comparison of the proportion of subjects in each group attaining global overall 
improvement SALT score of A5 (100% coverage) supported by </= SALT 25 at weeks 12, 
24, 36 and 48.  
4. Change in PGA (Physician Global Assessment - (100mm Visual analogue scale)) based 
on evaluation of hair loss on clinical exam and evaluation of standardized photographs 
between baseline, week 12, 24, 36 and 48. 
5. Change in patient global assessment (100mm Visual analogue scale) between baseline, 
Week 12, 24, 36 and 48. 
6. Change in patient quality of life assessment from baseline to weeks 12, 24, 36, and 48 
(Finlay and Khan 1994). 
6. Frequency of occurrence and timing of relapse (as defined above) in responders 
followed for 6 months off therapy. 
 
PGA and patient evaluations will be based on similar 100mm visual analog scales with 0 
labeled as no scalp hair loss and 100 labeled as complete scalp hair loss (Yamada et al. 
2002). Patient quality of life assessments will be based on changes in the Dermatology Life 
Quality Index DLQI (Olsen et al. 2004) – adapted for hair loss, or the Dermatology Quality of 
Life Scales (Finlay and Khan 1994). 
 
Photography  
Photography will be performed using a high-resolution digital camera with Intelliflash system 
from Canfield Scientific, Inc., mounted on a stereotactic arm.  Patients will be positioned 
using a fixed guide, after which photographs of the entire scalp will be taken at standardized 
locations and at a fixed distance. These standardized positions will include at least four views 
of the scalp (top, both sides and back) and will be consistent with those used in the SALT 
score. The hair will be combed prior to photography to ensure maximum visualization of the 
scalp and facilitate comparisons of sequential photographs.  Close-up photographs may also 


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13 
 
be taken using an epiluminescent attachment in order to assess for the presence of early 
regrowth.   
 
Biopsy 
All punch biopsies will be performed by the study doctor according to the schedule of study 
assessments. 4mm punch biopsies will be performed using standard of care techniques.  The 
site chosen will be the leading edge (active or involved edge of a patch with some hairs still 
present) of an alopeic patch or other appropriate areas of the alopeic patch or scalp as 
determined by the investigator.  One additional scalp biopsy may be obtained from a non-
lesional area. The area will be selected at the discretion of the investigator. This non-lesional 
biopsy may be obtained during any visit. All risks and possible adverse effects from the 
procedure will be discussed in detail with the subject prior to the procedure.  The biopsy site 
will be anesthetized with an injection of 1% lidocaine with epinephrine. After approximately 1 
minute, the physician applies pressure to the biopsy site using a 4 mm skin punch (a sterile 
cylindrical tube with a sharp edge).  The punch is twisted until the blade of the skin punch 
has pierced the epidermis and dermis of the skin and enters the subcutaneous fat. Depending 
on the thickness of the skin in the area being biopsied, the cylindrical blade may be buried to 
the hub (approximately 6mm in depth).  After the blade has sufficiently cored or carved out a 
cylinder of skin, the skin punch is removed.  Nontraumatic forceps are used to gently grasp 
the cored skin, pulling upward to remove the core and reveal the subcutaneous fat. Scissors 
are used to cut the cored tissue free from the underlying subcutaneous fat.  The specimen is 
placed immediately into the appropriate media. Once the specimen has been removed, 
pressure is applied to the biopsy site with a sterile gauze. The biopsy site is then closed with 
several simple interrupted sutures. Either an absorbable or nonabsorbable suture may be 
used at the investigators discretion.  Antibiotic ointment is applied and the area is covered 
with a standard BandAid or sterile gauze and paper tape. When necessary, a small pressure 
dressing may be applied.  Subjects will be instructed in wound care and will be advised to 
call the research unit if they have any concerning signs or symptoms during healing. 
 
SALT – Severity of Alopecia Tool 
A. The proportion of scalp involvement is determined by dividing the scalp into 4 quadrants 
and estimating the percentage of the scalp surface that all the alopecic areas would occupy 
if placed 
together. The following groups will be used: 
 
S: Scalp hair loss 
_____S0 = No hair loss  
 
 
 
_____ S4 = 76%-99% hair loss 
_____S1 = less than or equal to 25% hair loss  
_____ a = 76%-95% hair loss 
_____S2 = 26%-50% hair loss 
  
 
 
_____ b = 96%-99% hair loss 
_____S3 = 51%-75% hair loss  
 
 
_____ S5 = 100% hair loss 
 


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14 
 
  
 
 
FIG. 2. Olsen/Canfield tool for determination of %scalp hair 
loss. Percentages represent scalp surface area (reprinted with 
permission). 
  
 
Figure 9. SALT score.  


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15 
 
The percentage of hair loss in any one of the four views (areas) of the scalp = the 
percentage hair loss x percent surface area of the scalp in that area. The SALT score then 
equals the sum of the scalp hair loss in each area. 
(a) Top (left side view) = 95% x .18 = 17.1 
(b) Second (right side view) = 90% x .18 = 16.2 
(c) Third (top of scalp) = 95% x .40 = 38 (realizing that most of hair loss is probably male 
pattern hair loss) 
(d) Bottom (back of scalp) = 55% x .24 = 13.2 
a+b+c+d = 17.1 + 38 + 16.2 + 13.2 = 84.5% hair loss or SALT 84.5 
 
Body hair loss 
B0 = No body hair loss 
B1 = some body hair loss 
B2 = total (100%) body hair loss 
 
Nail involvement 
N0 = No nail involvement 
N1 = some nail dystrophy 
N1a = 20 nail dystrophy 
 
 
Percentage change from baseline (% regrowth) =  
[(SALT BL – SALT F/U)/ SALT BL]  x 100% = % change from baseline 
 
Absolute regrowth = SALT BL – SALT F/U = absolute change from BL 
 
 
Study outcomes 
Primary efficacy outcome:  
1. Comparison of the proportion of responders in each group, with response defined as 50% 
change (% change NOT absolute change) in SALT score from baseline (50% regrowth 
at week 24). 
 
This is a relatively strict definition for defining responders and non-responders and was 
chosen based on consensus of clinicians and AA experts that 50% reduction in SALT score 
represents clinically meaningful response and to minimize responses in the “vehicle” arm, in 
which fewer than 10% are expected to achieve this magnitude of hair regrowth 
spontaneously. This outcome was also used in two recent RCT trials (Strober et al. 2009 and 
Price et al. 2008) evaluating therapies for AA. 
 
As secondary endpoints, efficacy will be measured by changes in hair re-growth as a 
continuous variable as determined by physical exam and Canfield photography, as well as 
patient and physician global evaluation scores. To assess the durability of responses, 
patients who achieve 50% reduction in baseline SALT score will continue to be followed for 
an additional 6 months off treatment.   
 


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16 
 
 
Secondary efficacy outcomes will include:  
1. Percent hair regrowth from baseline determined by SALT measurements following 12, 24 
weeks of treatment and at weeks 36 and 48 following discontinuation of treatment  (Price 
et al Efalizumab study) 
2. Comparison of the proportion of responders in each group, with response defined as 50% 
change in SALT score (50% regrowth) from baseline, at weeks 12, 36 and 48. 
3. Comparison of the proportion of subjects in each group attaining global overall 
improvement SALT score of A5 (100% coverage) supported by </= SALT 25 at weeks 
12, 24, 36 and 48.  
4. Change in PGA (Physician global assessment) based on evaluation of live evaluations 
and standardized photographs between baseline, week 12, 24, 36 and 48 
5. Change in patient global assessment (100mm Visual analogue scale) between baseline, 
Week 12, 24, 36 and 48 
6. Change in patient quality of life assessment (DLQI or DQLS) from baseline to weeks 12, 
24, 36 and 48. (Finlay and Khan 1994). 
7. Frequency of occurrence and timing of relapse (as defined above) in responders followed 
for 6 months off therapy. 
 
Safety and tolerability measures: 
Incidence and severity of adverse effects (AEs) including the presence and degree of skin 
atrophy. 
Incidence of treatment-emergent laboratory abnormalities. 
 
Sample size 
Power analysis is based on a chi-squared test of proportions of responders in the 4 study 
groups, where response is defined as 50% reduction in SALT score. Effect size is 
quantified in terms of Cohen’s w, a function of the response rates in the fourgroups (15). A 
minimal treatment effect size of 40% (Cohen’s w = 0.4) i.e. a 50% response rate for active 
drug (IL TAC 2.5mg/ml, 5mg/ml or 10mg/ml) versus a presumed spontaneous remission 
response rate of 10% for patients receiving inactive IL saline, would be considered clinically 
meaningful in this study. To achieve 80% power to detect the desired effect size of 40% 
with a usual 5% level of significance (alpha), we would require approximately 17 subjects 
per arm (68 subjects in total). With this sample size, an effect size of 50% (Cohen’s w = 
0.5, “large” effect) would ensure approximately 95% power.  Our postulated effect size for 
IL TAC is based on impressions due to clinical use of IL TAC in AA, however an explicit aim 
of this pilot study is to objectively and more precisely quantify the actual treatment effect of 
the various doses of IL TAC versus saline placebo. 
 
Data Analysis Plan 
The primary analysis will be a comparison of response rates in the 4 study groups, using a 
chi-squared test of proportions. If the 4-group comparison is significant, we will compare 
the efficacy and safety profiles of the three doses of intralesional triamcinolone head to 
head. For secondary outcomes that are binary (response/non-response), we will follow the 
same strategy. For secondary outcomes that are continuous (e.g. change in SALT 
measurement or PGA), we will conduct 4-group ANOVA tests, followed by pairwise 


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17 
 
comparisons, if necessary. In both cases, Bonferroni correction will be made to adjust for 
multiple testing.  To assess safety, we will summarize and test the incidence rates of 
adverse events across groups. 
 
If possible, we will attempt to stratify the patients based on baseline degree of hair loss e.g. 
0-25% vs. 26-50% hair loss in order to assess if response is correlated with degree of hair 
loss present at baseline. (Olsen E. Investigative guidelines for alopecia areata. 
Dermatologic therapy 24, 2011 311-319 
  
All outcomes will be analyzed on the intent to treat (ITT) basis. 
A 3-month interim analysis of the primary and secondary outcomes will be performed by an 
independent group in order to determine if statistical significance has been attained. A 
Haybittle-Peto rule for alpha spending (Haybittle 1971; Peto et al. 1976) will be followed for 
the interim analysis. If statistical evidence of efficacy is attained at 3 months and if the 
safety profile is acceptable, all patients will be offered the option of receiving open label 
active drug for the remaining duration of the trial. 
 
To compare the frequency of occurrence of relapse in responders (followed for 6 months off 
therapy) across the four groups, we will employ a chi-squared test for comparing multiple 
proportions.   
Furthermore, to compare the timing of relapse in responders (followed for 6 months off 
therapy) across the four groups, we will use tools from survival analysis (or, time-to-event 
analysis, with relapse as the event of interest). More specifically, first, we will conduct a 
descriptive analysis by graphically comparing the Kaplan-Meier survival (time-to-relapse) 
curves for the four groups. Next, we will use the log-rank test to formally test the null 
hypothesis of no difference between the survival functions of the four groups. 
 
Specific Aim 2. To identify a clinical correlation between treatment outcome and down 
modulation of key AA-associated immunohistopathological markers and biomarkers in the 
treated skin; including NKG2DL expression in the hair follicle, immune infiltration 
(CD8+NKG2D+ cells) and expression of interferon response genes.  
 
Rationale Establishing the genetic basis of AA marks the beginning of rationally-designed 
mechanism-driven clinical research, but it is just the beginning.  Very little is known about the 
immunopathogenesis of AA in humans. Rigorous clinical investigation of AA cannot be 
satisfied by mere clinical response evaluation.  Indeed, our study will include longitudinal 
collection of AA biospecimens that will enable temporal assessment of biomarkers of patients 
(controls and treated) providing a unique resource to characterize the natural history of this 
disease. Given the budget constraints, our mechanistic studies in this Aim are focused on 
correlating treatment and disease status with; 1) histological improvement; 2) reduced IFN 
responses; 3) reduced HF NKG2DL expression; and 4) declines in circulating and peribulbar 
CD8+NKG2D+ infiltration. Previous studies in AA have reported elevated NKG2D expression 
in circulating CD8 T cells and NK cells39, supporting the feasibility of our approach. Here we 
will be able to correlate the numbers of CD8+NKG2D+ cells in the blood with those infiltrating 
the target organ of patients with each other and as a function of disease status.  
 
Procedures 


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18 
 
i. Flow Cytometry Studies. The presence of CD8+NKG2D+ cells will be tracked in the blood 
and in the skin during treatment with IL TAC or vehicle. By assessing CD8+NKG2D+ 
involvement in longitudinally obtained skin biopsies we can correlate disease severity and 
clinical response (progression or regression) with immunopathological evidence of resolution 
of total cellular infiltration (by H&E) or loss of specific CD8+NKG2D+ cells in the skin (by IF) 
or in the blood (flow studies).  CD8+NKG2D+ frequency in the peripheral circulation will be 
quantified using freshly isolated PBMCs obtained from 30 mls of blood obtained upon entry 
into the trial and at 4 wks, 12 wks and 24 wks during treatment.   A portion of the PBMCs 
2x106 cells will be stained with anti-CD8, anti-CD25 and anti-NKG2D antibodies, stimulated 
with PMA/ionomycin in the presence of brefeldin and stained with anti-IFN- Abs. The 
remaining PBMCs will be viably frozen for future ancillary studies.  We will seek evidence of 
a comparable pathogenic T cell subset in the human that we observed in C3H mice, namely 
an activated CD25+ IFN- producing CD8+NKG2D+ T cell. 
 
ii.  Histology and Immunofluorescence Analysis. As shown in previous studies4,39 in active 
AA NKG2D ligands are upregulated on hair follicles in association with peribulbar NKG2D-
bearing CD8+ T-cells and natural killer cells. We will seek evidence of resolution of total 
cellular infiltration (by H & E) and loss of specific CD8+NKG2D+ cells (by IF) and NKG2D 
ligands by comparing baseline biopsies with biopsies obtained on treatment after 4, 12,  and 
24 weeks.  Frozen sections will be stained with anti-CD4, anti-CD8, anti-CD56 anti-NKG2D 
and anti-IFN- antibodies to visualize the total number of leukocytes, cytotoxic T-cells and 
NK cells present in the drug treated and placebo treated skin, respectively. Immunostainng 
with anti-ULBP3, anti-MICA antibodies and recombinant NKG2D soluble receptor (NKG2D-
Ig, detects all NKG2D ligands, R & D systems) will determine whether NKG2DL 
“danger/stress” signals are down modulated with Jak1/Jak2 inhibition.  Punch biopsies from 
patient skin before and after treatment will be embedded in OCT and 7-8 micron frozen 
sections will be cut. The sections will be fixed in 4% paraformaldehyde and stained overnight 
with primary antibodies for NKG2D ligands, receptor and immune markers. The following 
day, sections will be treated for 1 hr with fluorescence labeled antibody, counter-stained and 
mounted with DAPI containing media. Frozen sections will also be used to for H&E staining. 
The total number of immune cells, as well as NKG2D bearing cells, will be quantified by 
counting stained cells per magnification field using the NIH imaging software ImageJ and a 
student T-test will be carried out to determine significant changes in the number of infiltrating, 
NKG2D bearing T cells to correlate the simultaneous presence or absence of these cells in 
lesional skin and in circulation (by flow) during active disease or in remission.   
 
iii.  Analysis of Gene Expression by Quantitative RT-PCR  
We will analyze the transcriptional expression signature of IFN-response genes in the skin 
and PMBC of drug-treated AA patients using qPCR as an indirect measure of efficacy.  
Signature genes have been selected based on their differential expression in affected vs. 
unaffected C3H mice, and on published studies on human AA patients vs. controls40. The 
genes in the list represent mediators and effectors of the IFN response, which we found to 
be instrumental in disease pathology. Briefly, biopsies and peripheral blood from placebo 
control and treated patients will be collected at 0, 4, 12, and 24 week time points. Additional, 
optional scalp biopsies and peripheral blood may be taken at other time points in order to 
monitor response to therapy at the discretion of the investigator and with the consent of the 
study subject. RNA will be extracted from the tissues, and Sybr green based qPCR assays 
will be performed. Differential gene expression resulting from inhibitor treatment will be 
normalized to the expression of a housekeeping gene. We expect many of the genes on this 
list to revert to a basal level of expression, as compared in unaffected skin of an AA patient, 
or skin from a healthy control.  
 
FUTURE PLANS AND INTEGRATION 


Columbia university 
IL TAC in AA 
 
19 
 
Establishing the genetic basis of AA marks the beginning of rationally-designed mechanism-
driven clinical research, but it is just the beginning.  Very little is known about the 
immunopathogenesis of AA in humans. For example, can we identify clonal antigen specific 
T cells in the skin and blood of AA individuals? What antigens are the killer T cells recognizing 
in the hair follicle? Are there fundamental differences in the blood and skin between patients 
with mild or severe disease that would suggest different treatment approaches?  These 
questions require analysis of patient materials (blood and skin) to isolate and investigate the 
immune cells responsible.  Thus, rigorous clinical investigation of AA cannot be 
satisfied by mere clinical response evaluation.  Indeed our study will include, for the 
first time, longitudinal collection of AA biospecimens that will enable temporal 
assessment of biomarkers of patients (controls and treated) providing a unique 
resource to characterize potential biomarkers of the natural history of this disease. In 
collaboration with colleagues at other institutions, we plan to utilize the clinical and 
immunological findings of this study to facilitate the conduct and analysis of future clinical 
trials of therapies in alopecia areata.  The findings will guide us in the selection of appropriate 
immunomodulators and will allow us to objectively quantify the immunologic response to 
therapy.  We have received feedback from the NIH indicating that they consider the 
development of biomarkers of disease progression to be a crucial step in facilitating future 
trials and further that the absence of attempts to identify biomarkers will adversely affect the 
scoring of future studies submitted for funding.  In addition, this study utilizes agreed upon 
parameters proposed by experts in the field of AA for standardization of study design 
including patient selection, inclusion and exclusion criteria and evaluation of clinically 
meaningful outcomes and will help to validate and refine these parameters for future studies 
of therapies in AA. 
 
Recruitment 
Each year the Dermatology Department at CUMC sees 600 AA visits each year.Of these we 
expect roughly 20 to 30% to be eligible for this study of mild to moderate patch type alopecia.  
We also have a database of almost 400 patients evaluated at CUMC as part of the alopecia 
areata registry who have expressed an interest in being contacted for clinical trials in alopecia 
areata.  In addition, we hope to have information regarding the study posted on the website 
for the National Alopecia Areata Foundation (NAAF) the largest AA patient advocacy 
organization.  We expect to complete accrual of 68 patients within the 1 to 2 year study period 
(38 patients at CUMC and 30 at the University of Minnesota). This time frame will enable 6 
months on treatment and 6 months follow-up off drug (for patients who qualify) and 
completion of the clinical correlative portion of the study 
 
 Assessment of Safety 
Safety precautions such as the use of highly experienced investigators, frequent visits, and 
close monitoring of clinical and laboratory findings have been implemented in the protocol 
and are specified in the Schedule of Assessments.  Hematology and chemistry 
measurements, including WBC count, platelet and absolute neutrophil counts, urinalysis and 
hepatic panel may be obtained at screening and at other time points if deemed necessary by 
the investigator.   
All physical examination findings, vital sign abnormalities, and clinical laboratory 
abnormalities, will be captured as AEs when deemed medically significant by the investigator. 
A qualified physician associated with the study will be available to assess clinical signs and 
symptoms that may be indicative of an adverse event. Safety will be assessed by 


Columbia university 
IL TAC in AA 
 
20 
 
summarizing the incidence and type of AEs. The proportion of patients who discontinued 
treatment will be summarized. 
 
Methods and Timing of Safety Assessments 
Adverse Event Reporting 
An AE is any unfavorable and unintended sign, symptom, or disease temporally associated 
with the use of a study medication(s), whether or not related to the study medication(s). AEs 
that occur after randomization should be recorded on the AE page of the CRF. Recording 
should be done in a concise manner using standard, acceptable medical terms. The AE 
recorded should not be a procedure or a clinical measurement (i.e., a vital sign), but should 
reflect the reason for the procedure or the diagnosis based on the abnormal measurement. 
Any clinically significant changes in pre-existing conditions (based on medical 
history/physical examination results) will be recorded on the CRF AE pages. The intensity of 
all AEs should be classified as follows:  
Mild: A mild AE is defined as an event characterized by "awareness of symptoms which are 
easily tolerated." 
Moderate: A moderate AE is defined as an event in which "sufficient discomfort is present to 
cause interference with usual activity." 
Severe: A severe AE is defined as an event characterized by "extreme distress causing 
significant impairment of function or incapacitation." 
 
A serious adverse event (SAE) is any AE occurring at any dose that results in: 
 Death 
 A life-threatening event 
 Inpatient hospitalization or prolongation of existing hospitalization 
 Persistent or significant disability/incapacity 
 Congenital anomaly/birth defect. 
 
In addition, an important medical event that may not result in death, be life-threatening, or 
require hospitalization may be considered an SAE when, based on appropriate medical 
judgment, it may jeopardize the patient and/or may require medical or surgical intervention 
to prevent one of the outcomes listed above. 
   
An unexpected AE is any AE of which the specificity or severity is not consistent with the 
current Investigator Brochure/Package Insert.  A reasonably related AE is one that is 
possibly, probably, or definitely related to study medication (as determined by the study 
investigator). 
Immediate Reporting by Investigator  
In the event of serious adverse events that fulfill a reason for expedited reporting as outlined 
above, the investigator or designee should inform the Columbia University Medical Center 
Institutional Review Board (IRB) of any serious, unlisted/unexpected, and associated 
events within 24 hours of being aware of the event. This will be documented on a FDA 3500 
or MedWATCH form or the manner preferred by the IRB.  This form must be completed within 
24 hours/1 business day or at the latest on the following working day. The initial report must 


Columbia university 
IL TAC in AA 
 
21 
 
be as complete as possible, including details of the current illness and (serious) adverse 
event, and an assessment of the causal relationship between the event and the 
investigational product(s). Information not available at the time of the initial report (e.g., an 
end date for the adverse event received after the report) must be documented on a follow-
up MedWATCH, or otherwise appropriate, form. 
Non-Expedited Reporting 
For the 2 other types of serious events not requiring expedited reporting (serious, listed and 
associated; and serious, unlisted and not associated), the investigator should notify the 
Columbia University Medical Center Institutional Review Board (IRB) within 7 business days. 
If at any time an adverse event noted in this category changes is upgraded, the investigator 
should notify the IRB accordingly as noted in section above. 
 
Please note, this study has been deemed exempt from the need for an IND by the Columbia 
University Clinical Trials office. 
 
Institutional Review Board 
The investigator will notify the IRB of any serious, life-threatening, or unexpected adverse 
experiences, including any death, regardless of the relationship to the study medication. 
 
Protocol Amendments and Deviation  
The investigator will not deviate from the protocol without the prior written approval of IRB 
except in medical emergencies. In medical emergencies, prior approval for protocol 
deviations will not be required, but the IRB must be notified as soon as possible (within 24 
hours). All other protocol deviations require prior written approval from the IRB. The 
IRB/Ethics Committees (EC) will be informed of all protocol changes and violations by the 
investigator in accordance with the procedures established by the IRB/EC. No deviations 
from the protocol of any type will be made without complying with all of the procedures 
established by the IRB/EC. 
 
Quality Control and Assurance 
Analyses and Reporting 
Investigator responsibilities are set out in the ICH guideline for the Good Clinical Practice 
(GCP) and in the US Code of Federal Regulations. 
 
Data Collection 
All subject related information will be collected in the source document.  Study related 
parameter will then be captured in standardized case report forms (CRFs).   CRF will be used 
to collect patient data and assessments that will be used for evaluation of the patient’s 
response to treatment. Other patient data collected will include incidence and severity of 
adverse events.   
Collected data, photographs, blood and tissue specimens will be identified only by an 
assigned subject number.  All study data and specimens will be kept in secure study areas.  
In addition, the code linking the subject number to individually identifiable private information 
will be kept under lock and key in a secure study site and will be accessible only to key study 
personnel.  


Columbia university 
IL TAC in AA 
 
22 
 
A study specific database, meeting all regulatory and IRB requirements, will be created in 
order to capture securely all study data including demographics, outcome data, and adverse 
events. 
 
Data and Safety Monitoring Plan 
The performance of all aspects of the study, including the methods used to obtain informed 
consent, will be conducted in accordance with all applicable state and federal guidelines as 
well as the principles for protection of research subjects as outlined in the declaration of 
Helsinki, ICH Guidelines for Good clinical practice, applicable local health authority 
regulations and US Title 21 of the Code of Federal Regulations.  
 
Before implementing this study, the protocol, informed consent document and other 
information for subjects will be reviewed by the Columbia University IRB.  During the conduct 
of the study the principal investigator and her designee will continually monitor the study to 
ensure that the study is conducted in compliance with the IRB approved study protocol.  
Safety data will be reviewed by the PI or designee as soon as it is received.  All adverse 
events will be reported to the IRB in accordance with the above requirements.  Serious 
adverse events requiring expedited reporting will be reported to the IRB their preferred 
methods of communication within 24 hours of study personnel becoming aware of the event.  
Serious adverse events not requiring expedited reporting will be communicated within 7 
business days. The investigator will also notify the IRB of any serious deviations from the 
protocol, and any new information indicating added risks to subjects.   
 
The clinical research coordinator in the Dermatology Clinical research unit will review 100% 
of all source documentation of data collected including all safety data.  Case report forms will 
be reviewed to ensure agreement with source documentation and to ensure accurate and 
complete capture of study data. Database data capture will be double verified and response 
parameters will be included to minimize the risk of erroneous entries.   Data will be verified 
and cleaned prior to data lock. The regulatory binder will also be reviewed to ensure that it is 
complete and up to date.  The first review will occur after the first 2 patients are enrolled and 
will continue every eight weeks during the enrollment and treatment period.  Any 
discrepancies will be discussed with the PI and relevant study personnel for clarification and/ 
or correction.  A record will be maintained of all monitoring activities, findings, conclusions 
and action taken to correct deficiencies.  
 
Annual reports and any interim reports of necessary study modifications will be submitted as 
required to the IRB and funding agency.  
 
An unblinded member of the study team who is not involved in patient assessment will 
examine the efficacy and safety data available when all subjects have completed 3 months 
of study drug.  Efficacy and safety parameters will be put in place to determine if efficacy has 
been established at this time point.  If efficacy has been established and the safety profile is 
acceptable, study participants will be offered the option to continue the study in an open label 
format for the remaining duration of the study.  
 
Regulatory Considerations 


Columbia university 
IL TAC in AA 
 
23 
 
Institutional Review Board/Independent Ethics Committee Review and Approval 
The protocol for this study has been designed in accordance with the general ethical 
principles outlined in the Declaration of Helsinki.  The review of this protocol by the IRB/IEC 
and the performance of all aspects of the study, including the methods used for obtaining 
informed consent, must also be in accordance with principles enunciated in the declaration, 
as well as ICH Guidelines, applicable local health authority regulations, and US Title 21 of 
the Code of Federal Regulations (CFR), Part 50 Protection of Human Subjects and Part 56 
Institutional Review Boards.  Before implementing this study, the protocol, the proposed 
informed consent form and other information to subjects, must be reviewed by a properly 
constituted IRB/IEC.  
The investigator(s) will be responsible for preparing documents for submission to the relevant 
IRB/IEC and obtaining written approval for this study.  The approval will be obtained prior to 
the initiation of the study. The investigator is responsible for notifying the IRB/IEC of any 
serious deviations from the protocol, or anything else that may involve added risk to subjects. 
 
Informed Consent 
The investigator must obtain informed consent of a subject or his/her designee prior to any 
study related procedures according to GCP as set forth in US 21 CFR Parts 50 and 56, the 
EU Clinical Trial Directive, local health authorities, and ICH guidelines. Documentation that 
informed consent occurred prior to the subject’s entry into the study and of the informed 
consent process should be recorded in the subject’s source documents.  The original consent 
form signed and dated by the subject and by the person consenting the subject prior to the 
subject’s entry into the study must be maintained in the Investigator’s study files and a copy 
given to the subject.  In addition, if a protocol is amended and it impacts on the content of 
the informed consent, the informed consent must be revised.  Subjects participating in the 
study when the amended protocol is implemented must be re-consented with the revised 
version of the informed consent.  The revised consent form signed and dated by the subject 
and by the person consenting the subject must be maintained in the Investigator’s study files 
and a copy given to the subject. 
 
 
 
 


Columbia university 
IL TAC in AA 
 
24 
 
STUDY SCHEDULE OF ASSESSMENTS – IL TAC IN ALOPECIA AREATA 
Visit 
1 
Screening 
2 
Baseline 
 
3 
Week 
4 
4 
Week 
8 
5 
Week 
12 
6 
Week 
16 
7 
Week 
20 
8 
Week 24 
ET/ES for 
nonresponders 
not qualified 
for open label 
IL TAC 
injections 
9 
Week 
28 
10 
Week 
32 
11 
Week 
36 
12 
Week 
40 
13 
Week 
44 
14 
Week 
48 
Day 
-28 to -1 
0 
28±7 
56±7 
84±7 
112±7 
140±7 
168±7 
196±7 
224±7 
252±7 
280±7 
308±7 
336±7 
Informed Consent 
X 
 
 
 
 
 
 
 
 
 
 
 
 
 
Inclusion/Exclusion 
Criteria 
X 
X 
 
 
 
 
 
 
 
 
 
 
 
 
Medical History 
X 
 
 
 
 
 
 
 
 
 
 
 
 
 
Body Weight 
X 
X 
 
 
X 
 
 
X 
 
 
X 
 
 
X 
Physical/Cutaneous 
Exam 
X 
 
 
 
 
 
 
X 
 
 
 
 
 
X 
Vital Signs 
X 
X 
X 
X 
X 
X 
X 
X 
X 
X 
X 
X 
X 
X 
Concomitant 
Medications 
X 
X 
X 
X 
X 
X 
X 
X 
X 
X 
X 
X 
X 
X 
Adverse events 
 
X 
X 
X 
X 
X 
X 
X 
X 
X 
X 
X 
X 
X 
Photography 
 
X 
X 
X 
X 
X 
X 
X 
 
X 
 
X 
 
X 
SALT evaluation 
X 
X 
X 
X 
X 
X 
X 
X 
X 
X 
X 
X 
X 
X 
Physician global 
assessment 
X 
X 
X 
X 
X 
X 
X 
X 
X 
X 
X 
X 
X 
X 
Patient quality of 
life assessment 
X 
X 
 
 
X 
 
 
X 
 
 
X 
 
 
X 
Patient global 
assessment 
X 
X 
X 
X 
X 
X 
X 
X 
X 
X 
X 
X 
X 
X 
 
 


Columbia university 
IL TAC in AA 
 
25 
 
Visit 
1 
Screening 
2 
Baseline 
 
3 
Week 
4 
4 
Week 
8 
5 
Week 
12 
6 
Week 
16 
7 
Week 
20 
8 
Week 24 
ET/ES for 
nonresponders not 
qualified for open 
label IL TAC 
injections 
9 
Week 
28 
10 
Week 
32 
11 
Week 
36 
12 
Week 
40 
13 
Week 
44 
14 
Week 
48 
Day 
-28 to -1 
0 
28±7 
56±7 
84±7 
112±7 
140±7 
168±7 
196±7 
224±7 
252±7 
280±7 
308±7 
336±7 
Clinical laboratory 
evaluationa 
X 
 
X 
 
X 
 
 
X 
X* 
 
 
 
 
 
Hepatitis screening 
panel  
X 
 
 
 
 
 
 
 
 
 
 
 
 
 
Lipid Profile 
X 
 
 
 
 
 
 
 
 
 
 
 
 
 
Urine pregnancy 
testb 
X 
X 
X 
X 
X 
X 
X 
X 
X 
X 
X 
X 
X 
X 
Scalp Biopsyc 
 
X 
Xc 
Xc 
Xc 
Xc 
Xc 
Xc 
 
 
 
 
 
 
Nonlesional biopsyc 
 
X** 
 
 
 
 
 
 
 
 
 
 
 
 
Phlebotomy for 
immunological 
studies 
 
X 
Xc 
Xc 
Xc 
Xc 
Xc 
Xc 
 
 
 
 
 
 
Injection of study 
medication 
 
X 
X 
X 
X 
X 
X 
X (for 
nonresponders 
qualified for 
open label 
treatment) 
 
 
 
 
 
 
Injection of open 
label IL TAC for 
qualifying 
nonresponders 
 
 
 
 
 
 
 
X 
X 
X 
X 
X 
X 
X 
a  Clinical laboratory evaluation may consist of CBC, BMP, hepatic panel, and/or urinalysis or other as deemed appropriate by the investigator. Cortisol levels may be 
checked at baseline and at weeks 24, 28 and 48. 
* Week 28 evaluation will only be performed if needed to verify normalization of previously abnormal lab values and to check cortisol levels.   
b  Urine pregnancy test will be continued after week 24 only for patients receiving open label IL TAC. 


Columbia university 
IL TAC in AA 
 
26 
 
c Additional, optional scalp biopsies and blood draws may be taken at other time points in order to monitor response to therapy at the discretion of the investigator and with 
the consent of the study subject. 
 
ET = end of treatment. ES = end of study 
**Non-lesional biopsy may be obtained at the baseline visit or at subsequent visits. A subject’s choice to decline to participate in this biopsy will not affect enrollment. 


Columbia university 
IL TAC in AA 
 
 
27
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45. Gilhar, A., Kam, Y., Assy, B., and Kalish, R.S. 2005. Alopecia areata induced in C3H/HeJ 
mice by interferon-gamma: evidence for loss of immune privilege. J Invest Dermatol 
124:288-289. 
46. Mistry, N., Shapero, J., and Crawford, R.I. 2009. A review of adverse cutaneous drug 
reactions resulting from the use of interferon and ribavirin. Can J Gastroenterol 23:677-
683. 
47. Maticic, M., Poljak, M., Lunder, T., Rener-Sitar, K., and Stojanovic, L. 2008. Lichen planus 
and other cutaneous manifestations in chronic hepatitis C: pre- and post-interferon-based 
treatment prevalence vary in a cohort of patients from low hepatitis C virus endemic area. 
J Eur Acad Dermatol Venereol 22:779-788. 
48. Kartal, E.D., Alpat, S.N., Ozgunes, I., and Usluer, G. 2007. Adverse effects of high-dose 
interferon-alpha-2a treatment for chronic hepatitis B. Adv Ther 24:963-971. 
49. Kartal, E.D., Alpat, S.N., Ozgunes, I., and Usluer, G. 2007. Reversible alopecia 
universalis secondary to PEG-interferon alpha-2b and ribavirin combination therapy in a 
patient with chronic hepatitis C virus infection. Eur J Gastroenterol Hepatol 19:817-820. 
50. Demirturk, N., Aykin, N., Demirdal, T., and Cevik, F. 2006. Alopecia universalis: a rare 
side effect seen on chronic hepatitis C treatment with peg-IFN and ribavirin. Eur J 
Dermatol 16:579-580. 


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51. Yu, M.L., Dai, C.Y., Huang, J.F., Hou, N.J., Lee, L.P., Hsieh, M.Y., Chiu, C.F., Lin, Z.Y., 
Chen, S.C., Wang, L.Y., et al. 2007. A randomised study of peginterferon and ribavirin for 
16 versus 24 weeks in patients with genotype 2 chronic hepatitis C. Gut 56:553-559. 
52. Taliani, G., Biliotti, E., Capanni, M., Tozzi, A., Bresci, S., and Pimpinelli, N. 2005. 
Reversible alopecia universalis during treatment with PEG-interferon and ribavirin for 
chronic hepatitis C. J Chemother 17:212-214. 
53. Radny, P., Bauer, J., Caroli, U.M., Eigentler, T.K., Kamin, A., Metzler, G., and Garbe, C. 
2004. Alopecia areata induced by adjuvant treatment with alpha-interferon in malignant 
melanoma? Dermatology 209:249-250. 
54. Agesta, N., Zabala, R., and Diaz-Perez, J.L. 2002. Alopecia areata during interferon 
alpha-2b/ribavirin therapy. Dermatology 205:300-301. 
55. Kernland, K.H., and Hunziker, T. 1999. Alopecia areata induced by interferon alpha? 
Dermatology 198:418-419. 
56. Lang, A.M., Norland, A.M., Schuneman, R.L., and Tope, W.D. 1999. Localized interferon 
alfa-2b-induced alopecia. Arch Dermatol 135:1126-1128. 
57. Skurkovich, S., Korotky, N.G., Sharova, N.M., and Skurkovich, B. 2005. Treatment of 
alopecia areata with anti-interferon-gamma antibodies. J Investig Dermatol Symp Proc 
10:283-284. 
58. Nakamura, M., Jo, J., Tabata, Y., and Ishikawa, O. 2008. Controlled delivery of T-box21 
small interfering RNA ameliorates autoimmune alopecia (Alopecia Areata) in a C3H/HeJ 
mouse model. Am J Pathol 172:650-658. 
59. Shimizu T, Mizue Y, Abe R, Watanabe H, Shimizu H. 2002. Increased macrophage 
migration inhibitory factor (MIF) in the sera of patients with extensive alopecia areata. J 
Invest Dermatol 118:555-557. 
60. Pawlak E, Kochanowska IE, Frydecka I, Kiełbiński M, Potoczek S, Bilińska M. 2005. The 
soluble CTLA-  4 receptor: a new marker in autoimmune diseases. Arch Immunol Ther 
Exp  53:336-341.  
61. Nuckel, H., Switala, M., Sellmann, L., Horn, P.A., Durig, J., Duhrsen, U., Kuppers, R., 
Grosse-Wilde, H., and Rebmann, V. 2010. The prognostic significance of soluble NKG2D 
ligands in B-cell chronic lymphocytic leukemia. Leukemia 24:1152-1159. 
 
 
 
 
 
 
 
 


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Addendum 1 
 
 
 
 
DERMATOLOGY LIFE QUALITY INDEX (Modified for hair loss) 
 
 
 
 
 
 
 
 
 
 
 
 
 DLQI 
Hospital No: 
 
 
 
 
Date: 
 
 
 
 
 
 
Name:  
 
 
 
 
 
 
 
 
 
 
Score: 
Address: 
 
 
 
 
Diagnosis: 
 
 
 
 
 
 
The aim of this questionnaire is to measure how much your hair loss has affected your life OVER THE LAST WEEK.  Please tick one 
box for each question. 
 
1. 
Over the last week, how itchy, sore,  
 
 
 
Very much 
 
 
painful or stinging has your scalp  
  
 
 
A lot 
 
 
 
been?   
 
 
 
 
 
 
A little  
 
 
 
 
 
 
 
 
 
 
Not at all 
 
 
2. 
Over the last week, how embarrassed  
 
 
Very much 
 
 
or self conscious have you been because  
 
 
A lot 
 
 
 
of your hair loss? 
 
  
 
 
 
A little  
 
 
 
 
 
 
 
 
 
 
Not at all 
 
 
3. 
Over the last week, how much has your   
 
 
Very much 
 
 
hair loss interfered with you going 
 
  
 
A lot 
 
 
 
shopping or looking after your home or  
 
 
A little  
 
 
garden?        
 
 
 
 
 
 
Not at all 
 
Not relevant  
 
4. 
Over the last week, how much has your   
 
 
Very much 
 
 
hair loss influenced the clothes  
 
 
 
A lot 
 
 
 
you wear? 
 
 
 
 
 
 
A little  
 
 
 
 
 
 
 
 
 
 
Not at all 
 
Not relevant  
 
5. 
Over the last week, how much has your   
 
 
Very much 
 
 
hair loss affected any social or   
 
 
 
A lot 
 
 
 
leisure activities? 
 
 
 
 
 
A little  
 
 
 
 
 
 
 
 
 
 
Not at all 
 
Not relevant  
 
6. 
Over the last week, how much has your   
 
 
Very much 
 
 
hair loss made it difficult for  
 
 
 
 
A lot 
 
 


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you to do any sport? 
 
 
 
 
 
A little  
 
 
 
 
 
 
 
 
 
 
Not at all 
 
Not relevant  
 
7. 
Over the last week, has your hair loss prevented  
 
Yes 
 
 
 
you from working or studying? 
 
 
 
No 
 
 
Not relevant  
 
 
 
If "No", over the last week how much has  
 
 
A lot 
 
 
 
your hair loss been a problem at  
 
 
 
A little  
 
 
work or studying? 
 
 
 
 
 
Not at all 
 
 
8. 
Over the last week, how much has your   
 
 
Very much 
 
 
hair loss created problems with your  
 
 
 
A lot 
 
 
 
partner or any of your close friends 
 
 
 
A little  
 
 
or relatives?   
 
 
 
 
 
Not at all 
 
Not relevant  
 
9. 
Over the last week, how much has your   
 
 
Very much 
 
 
hair loss caused any sexual  
 
 
 
 
A lot 
 
 
 
difficulties? 
 
 
 
 
 
 
A little  
 
 
 
 
 
 
 
 
 
 
Not at all 
 
Not relevant  
 
10. 
Over the last week, how much of a  
 
 
 
Very much 
 
 
problem has the treatment for your 
 
 
 
A lot 
 
 
 
hair loss been, for example by making 
 
 
 
A little  
 
 
your home messy, or by taking up time?  
 
 
Not at all 
 
Not relevant  
 
 
Please check you have answered EVERY question. Thank you.  

AY Finlay, GK Khan, April 1992 www.dermatology.org.uk, this must not be copied without the permission of the authors. 
Permission granted from the authors for copying and use of this instrument. August 8, 2011. 
 
 


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Skindex29 
MMChren,1996 
 
 
 
 
 
 
 
 
DERMATOLOGY SURVEY 
 
 
 
 
 
This survey concerns the scalp/hair loss condition which has bothered you the most during the past four 
weeks.          
 
 
                                                                                                                                                                                                                   
 
 
 
 
 
 
 
 


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All answers are confidential.  Your name will NOT appear on your survey, be put in your chart or be seen by your doctor.  This research is 
part of a study being conducted by the San Francisco Veterans Affairs Medical Center.   Thank you for your participation. 
 
 


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These questions concern your feelings over the past 4 weeks about the scalp/hair loss condition 
that has bothered you the most. Check the answer that comes closest to the way you have been 
feeling. 
 
 
HOW OFTEN DURING THE PAST FOUR WEEKS  
DO THESE STATEMENTS DESCRIBE YOU? 
_________________________________________
____ 
 
NEVER         RARELY      SOMETIMES       OFTEN         ALL 
THE  
                                                                                             TIME 
_________________________________________
____ 
 
  1. My scalp/areas of hair loss hurt(s)    .    .    .   .    .    .   .    .    .     
 
   1              2              3               4              5 
 
  2. My hair loss affects how well I sleep    .    .    .    .    .    . 
 
   1              2              3               4              5 
 
  3. I worry that my hair loss may be serious    .    .    .    .    . 
 
   1              2              3               4              5 
 
  4. My hair loss makes it hard to work or do hobbies    .    . 
 
   1              2              3               4              5 
 
  5. My hair loss affects my social life   .    .    .    .    .    .    . 
 
   1              2              3               4              5 
 
  6. My hair loss makes me feel depressed    .    .    .    .    .   
 
   1              2              3               4              5 
 
  7. My scalp/areas of hair loss burns or stings    .    .    .    .    .    .     
 
   1              2              3               4              5 
 
  8. I tend to stay at home because of my hair loss    .    .    . 
 
   1              2              3               4              5 
 
  9. I worry about getting scars from my skin condition    .    .    .   
 
   1              2              3               4              5 
 
10. My scalp/areas of hair loss itches    .    .    .    .    .    .    .    .    .    
 
   1              2              3               4              5 
 
11. My hair loss affects how close I can be with those I love . 
 
   1              2              3               4              5 


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12. I am ashamed of my hair loss    .    .    .    .    .    .    .    . 
 
   1              2              3               4              5 
 
13. I worry that my hair loss may get worse    .    .    .    .    . 
 
   1              2              3               4              5 
 
14. I tend to do things by myself because of my hair loss    . 
 
   1              2              3               4              5 
 
15. I am angry about my hair loss    .    .    .    .    .    .    .    . 
 
   1              2              3               4              5 
 
16. Water bothers my hair loss (bathing, washing hands)    . 
 
   1              2              3               4              5 
 
17. My hair loss makes showing affection difficult    .    .    . 
 
   1              2              3               4              5 
 
18. I worry about side-effects from scalp/hair loss medications / 
treatments   
 
   1              2              3               4              5 
 
19. My scalp/areas of hair loss is (are) irritated    .    .    .    .    .    .     
 
   1              2              3               4              5 
 
20. My hair loss affects my interactions with others    .    .     
 
   1              2              3               4              5 
 
Please turn to next page 
 
These questions concern your feelings over the past 4 weeks about the scalp/hair loss condition 
that has bothered you the most. Check the answer that comes closest to the way you have been 
feeling. 
 
 
HOW OFTEN DURING THE PAST FOUR WEEKS  
DO THESE STATEMENTS DESCRIBE YOU? 
_________________________________________
____ 
 
NEVER         RARELY      SOMETIMES       OFTEN         ALL 
THE  
                                                                                             TIME 
_________________________________________
____ 
 
21. I am embarrassed by my hair loss    .    .    .    .    .    .    .     
 
   1              2              3               4              5 


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22. My hair loss is a problem for the people I love    .    .    .  
 
   1              2              3               4              5 
 
23. I am frustrated by my hair loss    .    .    .    .    .    .    .    .  
 
   1              2              3               4              5 
 
24. My scalp/areas of hair loss is (are) sensitive    .    .    .    .    .    .   
 
   1              2              3               4              5 
 
25. My hair loss affects my desire to be with people    .    .  
 
   1              2              3               4              5 
 
26. I am humiliated by my hair loss    .    .    .    .    .    .    .    . 
 
   1              2              3               4              5 
 
27. My scalp/areas of hair loss bleed(s)    .    .    .    .    .    .    .    .     
 
   1              2              3               4              5 
 
28. I am annoyed by my hair loss    .    .    .    .    .    .    .    .   
 
   1              2              3               4              5 
 
29. My hair loss interferes with my sex life    .    .    .    .    .  
 
   1              2              3               4              5 
 
30. My hair loss makes me tired    .    .    .    .    .    .    .    .    . 
 
   1              2              3               4              5 
 


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SKINDEX 29 SCORING (note that item #18 is not used in scoring) 
 
 
 
 
 
SCALE 
ITEMS 
 
 
Emotion 
3-6-9-12-13-15-21-23-26-28 
Symptoms 
1-7-10-16-19-24-27 
Functioning 
2-4-5-8-11-14-17-20-22-25-29-30 
 
 
 
 


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Addendum 3 – DERMATOLOGY QUALITY OF LIFE SCALES 
 
DERMATOLOGY QUALITY OF LIFE QUESTIONNAIRE – modified for hair loss 
 
 
Dermatology Quality of Life Scales (DQOLS comprise 29 patient-generated items, consisting of a 17 item psycho-social scale 
grouped into 4 sub-scales (embarrassment, despair, irritableness, distress) and 12 item physical activities scale grouped into 4 
sub-scales (everyday activities, summer, social and sexual).  The psycho-social scale asks patients to indicate, ‘the extent to which 
you generally feel this way’ using a 5-point Likert scale (very slightly to extremely).  The activities scale similarly requires 
patients to rate ‘how much your skin problem/hair loss generally affects or restricts you in these things.’ The DQOLS have a high 
level of internal consistency (Cronbach’s  alpha coefficient of 0.92 for the 17 psycho-social items and 0.83 for the 12 activity 
items), and  satisfy requirements for reliability and construct validity. 
 
 


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Psychosocial scale  
This consists of a number of words that describe different feelings and emotions.  Please read each item then 
mark the appropriate answer in the box to indicate to what extent you generally feel this way about your 
hair loss. 
 
 
very slightly 
or not at all 
a little 
moderately 
quite a bit 
extremely 
 
feel embarrassed 
 
 
 
 
 
 
 
 
feel ashamed 
 
 
 
 
 
 
 
feel depressed 
 
 
 
 
 
 
 
worry about appearance 
 
 
 
 
 
 
 
feel distressed 
 
 
 
 
 
 
 
feel suicidal 
 
 
 
 
 
 
 
feel self conscious 
 
 
 
 
 
 
 
worry about what others think 
 
 
 
 
 
 
 
feel short tempered 
 
 
 
 
 
 
 
feel lack of hope 
 
 
 
 
 
 
 
 
 
 
 
 


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feel isolated 
 
 
feel lack of understanding from 
others 
 
 
 
 
 
 
 
feel dependent 
 
 
 
 
 
 
 
worry about reactions of others 
 
 
 
 
 
 
 
feel anxious 
 
 
 
 
 
 
 
feel frustrated 
 
 
 
 
 
 
 
worry about long-term effects 
 
 
 
 
 
 
 
 
 
Physical activities scale 
Please indicate how much your hair loss generally affects or restricts you in these things 
 
 
 
very slightly 
or not at all 
a little 
moderately 
quite a bit 
extremely 
not relevant 
 
going out 
 
 
 
 
 
 
 
 
walking 
 
 
 
 
 
 
 
 
 
 
 
 
 
 


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making  
friends/meeting 
people 
 
 
choice of clothes 
 
 
 
 
 
 
 
 
summer 
activities/swimmi
ng 
 
 
 
 
 
 
 
 
going out in the 
sun 
 
 
 
 
 
 
 
 
household tasks 
 
 
 
 
 
 
 
 
sleep 
 
 
 
 
 
 
 
 
work 
 
 
 
 
 
 
 
 
sexual activities 
 
 
 
 
 
 
 
 
bathing 
 
 
 
 
 
 
 
 
sporting  
activities/exercise 
 
 
 
 
 
 
 
 
 
 
 
 


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 M Morgan/R.J.Hay, 1996.  Dermatology Quality of Life Scales (DQOLS) 
Not to be used without permission of the authors. 
Contact: Prof M Morgan, Department of Public Health Sciences, King’s College London, 
Capital House, Weston Street, London SE1 3QD 
E-mail: myfanwy.morgan@kcl.ac.uk 


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Addendum 4 – VISUAL ANALOGUE SCALE 
 
100mm VISUAL ANALOGUE SCALE 
 
 
 
 
 
 
 
 
0 
 
 
 
 
 
 
      
100 
 
 
No scalp  
 
 
 
 
 
 
 
Complete scalp 
 hairloss 
 
 
 
 
 
 
    
 hair loss 
 
 
 
 
 
 
 
 
The patient or physician will mark a vertical line somewhere on the horizontal line between 0 to 100 in the location which 
they feel best reflects the degree of hair loss present at the time of evaluation. 
 
A numerical score (between 0 and 100) will be assigned to the location of the vertical mark based on measurement with a 
standard 100mm ruler.  This score will be recorded in the source document and case report form/database as the 
Physician’s or patient’s global assessment of hair loss for that time point/visit. 
 
 
 
 
 


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Instructions for processing of blood and tissue samples for immunologic studies. 
 
Blood samples from study participants are transported at room temperature to the Christiano Lab for processing within 24 hrs of blood 
draw.  Serum will be aliquoted in 0.5 ml aliquots and stored at -80°C for cytokine/chemokine, autoantibody and other biomarker analysis.  
PBMC are isolated by density centrifugation and frozen in 10% DMSO in aliquots of 5 x 106 cells and stored in liquid N2. These storage 
conditions keep the cells viable and suitable for all planned functional and phenotypic analyses. Samples (skin biopsies and blood 
cells) for total RNA, miRNA extraction and histology will be collected in PAXgene tissue system (PreAnalytiX) for tissue stabilization 
and transported at room temperature to the lab. To minimize variation between samples coming from different sites, all tissue samples 
for RNA / miRNA extraction will be left in PAXgene at room temperature for the same amount of time (48 hrs) before further processing. 
 
Biopsies for T cell isolation are collected in tissue culture media and transported to the lab at room temperature. The biopsies are 
processed directly using a protocol developed by Clark and Kupper, who are consultants to the AACORT (J. Invest. Dermatol. 2006) 
for the efficient isolation of T cells from skin biopsies using 3 dimensional matrices. Isolated T cells will be aliquoted in 1-5 x 105 cells 
per vial, frozen in 10% DMSO and stored in liquid N2 until phenotypic and functional assays.