Alopecia Areata Update

Alopecia Areata Progression Index, a Scoring System for Evaluating Overall Hair Loss Activity in Alopecia Areata Patients with Pigmented Hair: A Development and Reliability Assessment

BACKGROUND

No scoring systems to evaluate overall hair loss activity in alopecia areata (AA) have been established.

OBJECTIVE

We sought to develop a measurement tool (Alopecia Areata Progression Index, AAPI) for the evaluation of overall hair loss activity in AA patients with pigmented hair.

METHODS

The scalp surface area was divided into 4 quadrants. In each quadrant, hair loss activity was scored on the basis of the percentage of alopecic area, clinical findings associated with hair loss. The AAPI was measured in 17 patients with different severities of AA.

RESULTS

Interobserver and intraobserver reliabilities were assessed by 4 investigators. A significant correlation of the total AAPI was found among the 4 investigators. In addition, intraobserver reliability was excellent, and interobserver reliability was statistically reliable.

CONCLUSION

The AAPI seems to represent a system capable of truly quantifying overall hair loss activity in AA patients with different severity, demonstrating trustworthy interobserver and intraobserver reliability.

Alopecia areata profiling shows TH1, TH2, and IL-23 cytokine activation without parallel TH17/TH22 skewing

BACKGROUND

Alopecia areata (AA) is a common T cell-mediated disorder with limited therapeutics. A molecular profile of cytokine pathways in AA tissues is lacking. Although studies have focused on TH1/IFN-γ responses, several observations support a shared genetic background between AA and atopy.

OBJECTIVE

We sought to define the AA scalp transcriptome and associated biomarkers with comparisons with atopic dermatitis (AD) and psoriasis.

METHODS

We performed microarray and RT-PCR profiling of 27 lesional and 17 nonlesional scalp samples from patients with AA for comparison with normal scalp samples (n = 6). AA gene expression was also compared with samples from patients with lesional or nonlesional AD and those with psoriasis. A fold change of greater than 1.5 and a false discovery rate of less than 0.05 were used for differentially expressed genes (DEGs).

RESULTS

We established the AA transcriptomes (lesional vs nonlesional: 734 DEGs [297 upregulated and 437 downregulated]; lesional vs normal: 4230 DEGs [1980 upregulated and 2250 downregulated]), including many upregulated immune and downregulated hair keratin genes. Equally impressive as upregulation in TH1/interferon markers (IFNG and CXCL10/CXCL9) were those noted in TH2 (IL13, CCL18, CCL26, thymic stromal lymphopoietin, and periostin), TH9/IL-9, IL-23 (p40 and p19), and IL-16 mediators (all P < .05). There were no increases in TH17/TH22 markers. Hair keratin (KRT) expressions (ie, KRT86 and KRT85) were significantly suppressed in lesional skin. Greater scalp involvement (>25%) was associated with greater immune and keratin dysregulation and larger abnormalities in nonlesional scalp samples (ie, CXCL10 and KRT85).

CONCLUSIONS

Our data associate the AA signature with TH2, TH1, IL-23, and IL-9/TH9 cytokine activation, suggesting consideration of anti-TH2, anti-TH1, and anti-IL-23 targeting strategies. Similar to psoriasis and AD, clinical trials with selective antagonists are required to dissect key pathogenic pathways.

Alopecia Areata Increases the Risk of Stroke: a 3-year Follow-Up Study

The risk for stroke in alopecia areata (AA) patients is still unknown. This study aimed to investigate the risk for subsequent risk of a stroke in AA patients in a large-scale retrospective cohort study. We identified 3231 patients with AA included in the study group from 2004 to 2011 in the “Longitudinal Health Insurance Database 2000” in Taiwan. We randomly selected 16,155 matched patients as the comparison group. We individually tracked each patient for a 3-year period to identify patients who had received a diagnosis of stroke during the follow-up period. We found that incidence rates of stroke during the 3-year follow-up periods were 5.44 (95% confidence interval (CI) = 4.03 ~ 7.20) and 2.75 (95% CI = 2.30 ~ 3.27) per 1000 person-years for patients with and those without AA, respectively. Cox proportional hazard regressions showed that the adjusted hazard ratio for stroke for those patients with AA was 1.61 (95% CI = 1.13 ~ 2.30) within the follow-up period compared to the controls. We concluded that patients with AA were associated with a higher risk of stroke in the 3-year follow-up period.

Microchimerism in alopecia areata

BACKGROUND

Autoimmunity is the main etiopathogenetic factor in alopecia areata. Microchimerism is the existence of allogeneic DNA in a living creature. There are variable studies investigating the role of microchimerism on the etiopathogenesis of autoimmune diseases. To our knowledge, no report has investigated the relationship between microchimerism and alopecia areata.

OBJECTIVE

We aimed to investigate the possible role of microchimerism on alopecia areata.

METHODS

We analyzed SRY gene levels as indicators of fetal microchimerism in our patient group. The patients were 29 women with alopecia areata, over 18 years old, who had visited our clinic between 2010 and 2013. Patients were divided into two groups; group 1 consisted of 14 patients having a son and group 2, 15 patients either nulliparous or having a daughter.

RESULTS

Seventeen of 29 patients (58.6%) and four of 103 controls (3.9%) showed presence of an SRY gene. The difference between the patient and control groups was statistically significant (P < 0.001).

CONCLUSION

As a result of our study, microchimerism may be associated with the etiopathogenesis of alopecia areata. However, we think there is a need for a larger series of studies to support this hypothesis.

Evaluation and diagnosis of the hair loss patient: part I. History and clinical examination

Hair loss (alopecia) is a common problem and is often a major source of distress for patients. The differential diagnosis of alopecia includes both scarring and nonscarring alopecias. In addition, many hair shaft disorders can produce hair shaft fragility, resulting in different patterns of alopecia. Therefore, an organized and systematic approach is needed to accurately address patients' complaints to achieve the correct diagnosis. Part 1 of this 2-part continuing medical education article on alopecia describes history taking and the clinical examination of different hair loss disorders. It also provides an algorithmic diagnostic approach based on the most recent knowledge about different types of alopecia.

Histologic features of alopecias-part I: nonscarring alopecias

The diagnosis of disorders of the hair and scalp can generally be made on clinical grounds, but clinical signs are not always diagnostic and in some cases more invasive techniques, such as a biopsy, may be necessary. This 2-part article is a detailed review of the histologic features of the main types of alopecia based on the traditional classification of these disorders into 2 major groups: scarring and nonscarring alopecias. Scarring alopecias are disorders in which the hair follicle is replaced by fibrous scar tissue, a process that leads to permanent hair loss. In nonscarring alopecias, the follicles are preserved and hair growth can resume when the cause of the problem is eliminated. In the first part of this review, we describe the histologic features of the main forms of nonscarring alopecia. Since a close clinical-pathological correlation is essential for making a correct histologic diagnosis of alopecia, we also include a brief description of the clinical features of the principal forms of this disorder.

Preferential recognition of hydroxyl radical-modified superoxide dismutase by circulating autoantibodies in patients with alopecia areata

Background

Alopecia areata (AA) is a common form of localized, non-scarring hair loss. The cause of AA is unknown but reports suggest an autoimmune etiology, where oxygen free radicals play an important role.

Objective

The aim of this study was to investigate the role of a hydroxyl radicals (·OH)-modified antioxidant enzyme, superoxide dismutase (SOD), in AA autoimmunity.

Methods

SOD was modified by ·OH radicals. Binding characteristics of autoantibodies in AA patients (n=26) against ·OH-modified SOD (·OH-SOD) were evaluated by immunoassays and the results were compared with those of healthy, age-matched controls (n=30). The effects of ·OH radicals on immunoglobulin G (IgG) isolated from AA patients were studied.

Results

Highly specific binding to ·OH-SOD was observed in 32% of the samples of patient sera, whereas normal human sera showed negligible binding with either antigen. Competitive inhibition immunoassays reiterated the results from direct binding. Protein-A-purified IgG from AA patients (AA-IgG) also showed strong binding to ·OH-SOD as compared to IgG from normal human controls (p<0.001). In addition, AA-IgG from patients with alopecia universalis recognized ·OH-SOD to a greater extent than did AA-IgG from patients with the patchy, persistent type of alopecia. Furthermore, sera from AA patients had lower levels of SOD activity as compared to control sera.

Conclusion

This is the first report showing an association between ·OH-modified SOD and AA. These novel results demonstrate that ·OH radical-mediated changes in SOD present unique neo-epitopes that might contribute to antigen-driven antibody induction in AA.

Women with alopecia exhibit a higher risk for thyroid cancer: a nationwide cohort study

BACKGROUND

Several studies have investigated the relationship between alopecia and prostate cancer. However, little information is available regarding the relationship between alopecia and the risk of cancers in women.

OBJECTIVE

The purpose of this study was to evaluate the possible association between alopecia and thyroid cancer among Taiwanese women.

METHODS

We used data from the National Health Insurance system of Taiwan. The alopecia cohort comprised 4534 women, and each woman was randomly frequency matched by age, index month, and index year with 4 women from the general population without alopecia. A Cox proportional hazard regression analysis with Bonferroni correction was conducted to estimate the effects of alopecia on the risk of thyroid cancer.

RESULTS

In women with alopecia, the overall risk for developing cancer was 22% higher than for subjects without alopecia, but the difference was not significant [hazard ratio (HR) = 1.22, 97.5% confidence interval (97.5% CI) = 0.87-1.70]. However, the risk for developing thyroid cancer among women with alopecia was significantly higher (HR = 2.39, 97.5% CI = 1.05-5.42). Further analyses determined that the alopecia group had a higher incidence of Graves' disease, but not Hashimoto thyroiditis.

CONCLUSION

Although alopecia did not significantly increase cancer risks in women, we found that Taiwanese women with alopecia had a higher risk of developing thyroid cancer that is unlikely to be related to underlying thyroid diseases.

Alternaria scalp infection in a patient with alopecia areata. Coexistence or causative relationship?

BACKGROUND

Alopecia areata is an autoimmune disease that is affecting anagen hair follicles. The triggers of autoimmunity in patients with alopecia areata remain unknown.

MAIN OBSERVATION

A 13-year-old boy developed multiple hairless patches of focal hair loss with typical clinical and trichoscopy features of alopecia areata. Mycology examination of the scalp hair and epidermal scrapings reveled massive growth of Alternaria chlamydospora.

CONCLUSION

We hypothesize that fungal antigens (e.g. antigens involved in fungal melanin synthesis) may be possible triggers, contributing to autoimmune reactions in patients with alopecia areata. We discuss research data, which may indirectly support this hypothesis, however the concept has yet to be verified.