Alopecia areata investigational assessment guidelines--Part II. National Alopecia Areata Foundation

Randomized comparison of topical betamethasone valerate foam, intralesional triamcinolone acetonide and tacrolimus ointment in management of localized alopecia areata

BACKGROUND

Alopecia areata (AA) is a common, non-scarring, patchy loss of hair at scalp and elsewhere. Its pathogenesis is uncertain; however, auto-immunity has been exemplified in various studies. Familial incidence of AA is 10-42%, but in monozygotic twins is 50%. Local steroids (topical / intra-lesional) are very effective in treatment of localized AA.

AIM

To compare hair regrowth and side effects of topical betamethasone valerate foam, intralesional triamcinolone acetonide and tacrolimus ointment in management of localized AA.

MATERIALS AND METHODS

105 patients of localized AA were initially registered but 27 were drop out. So, 78 patients allocated at random in group A (28), B (25) and C (25) were prescribed topical betamethasone valerate foam (0.1%) twice daily, intralesional triamcinolone acetonide (10mg/ml) every 3 weeks and tacrolimus ointment (0.1%) twice daily, respectively, for 12 weeks. They were followed for next12 weeks. Hair re-growth was calculated using "HRG Scale"; scale I- (0-25%), S II-(26-50%), S III - (51-75%) and S IV- (75-100%).

RESULTS

Hair re-growth started by 3 weeks in group B (Scale I: P<0.03), turned satisfactory at 6 weeks in group A and B (Scale I: P<0.005, Scale IV: P<0.001)), good at 9 weeks (Scale I: P<0.0005, Scale IV: P<0.00015), and better by 12 weeks of treatment (Scale I: P<0.000021, Scale IV: P<0.000009) in both A and B groups. At the end of 12 weeks follow-up hair re-growth (>75%, HRG IV) was the best in group B (15 of 25, 60%), followed by A (15 of 28, 53.6%) and lastly group-C (Nil of 25, 0%) patients. Few patients reported mild pain and atrophy at injection sites, pruritus and burning with betamethasone valerate foam and tacrolimus.

CONCLUSION

Intralesional triamcinolone acetonide is the best, betamethasone valerate foam is better than tacrolimus in management of localized AA.

Transcriptional profiling in alopecia areata defines immune and cell cycle control related genes within disease-specific signatures

Alopecia areata (AA) is a non-scarring inflammatory hair loss disease with a complex autoimmune etiopathogenesis that is poorly understood. In order to investigate the pathogenesis of AA at the molecular level, we examined the gene expression profiles in skin samples from lesional (n=10) and non-lesional sites (n=10) of AA patients using Affymetrix Hu95A-v2 arrays. 363 genes were found to be differentially expressed in AA skin compared to non-lesional skin; 97 were up-regulated and 266 were down-regulated. Functional classification of the differentially expressed genes (DEGs) provides evidence for T-cell mediated immune response (CCL5, CXCL10, CD27, ICAM2, ICAM3, IL7R, and CX3CL1), and a possible humoral mechanism (IGHG3, IGHM, and CXCR5) in AA. We also find modulation in gene expression favoring cellular proliferation arrest at various levels (FGF5, FGF18, EREG, and FOXC2) with apoptotic dysregulation (LCK, TNF, TRAF2, and SFN) and decreased expression of hair follicle structural proteins. Further analysis of patients with AAT (<1 year duration, n=4) and AAP (>1 year duration, n=6) of disease revealed 262 DEGs distinctly separating the 2 groups, indicating the existence of gene profiles unique to the initial and later stages of disease.

Revised Cutaneous Lupus Erythematosus Disease Area and Severity Index (RCLASI): a modified outcome instrument for cutaneous lupus erythematosus

BACKGROUND

In 2005, a scoring system (CLASI, Cutaneous Lupus Erythematosus Disease Area and Severity Index) was developed for patients with cutaneous lupus erythematosus (CLE) to assess disease 'activity' and 'damage'. However, the CLASI does not give an accurate assessment of the severity in all disease subtypes.

OBJECTIVES

The main objective of this study was to analyse critically the included parameters of the CLASI and to revise the activity and damage score taking into account various clinical features of the different subtypes of CLE. The revised CLASI (RCLASI) was also validated for use in clinical trials. Patients and methods A RCLASI was designed with regard to the anatomical region (i.e. face, chest, arms) and morphological aspects (i.e. erythema, scaling/hyperkeratosis, oedema/infiltration, scarring/atrophy) of skin lesions and evaluated by nine dermatologists who scored 12 patients with different subtypes of CLE to estimate inter- and intrarater reliability.

RESULTS

Reliability studies demonstrated an intraclass correlation coefficient (ICC) for an inter-rater reliability of 0.89 for the activity score [95% confidence interval (CI) 0.79-0.96] and of 0.79 for the damage score (95% CI 0.62-0.92). The ICC for intrarater reliability for the activity score was 0.92 (95% CI 0.89-0.95) and the ICC for the damage score was 0.95 (95% CI 0.92-0.98).

CONCLUSIONS

In the present study, a RCLASI was developed by experts, and reliability studies supported the validity and applicability of the revised scoring instrument for CLE. Thus, the RCLASI is a valuable instrument in multicentre studies and for the clinical evaluation of activity and damage in different disease subtypes.

Alopecia areata update: part II. Treatment

Various therapeutic agents have been described for the treatment of alopecia areata (AA), but none are curative or preventive. The aim of AA treatment is to suppress the activity of the disease. The high rate of spontaneous remission and the paucity of randomized, double-blind, placebo-controlled studies make the evidence-based assessment of these therapies difficult. The second part of this two-part series on AA discusses treatment options in detail and suggests treatment plans according to specific disease presentation. It also reviews recently reported experimental treatment options and potential directions for future disease management.

LEARNING OBJECTIVES

After completing this learning activity, participants should be able to compare the efficacy and safety of various treatment options, formulate a treatment plan tailored to individual patients, and recognize recently described treatments and potential therapeutic approaches.

The TRAF1/C5 locus confers risk for familial and severe alopecia areata

BACKGROUND

Alopecia areata (AA) is a common hair loss disorder with a complex mode of inheritance. Autoimmune mechanisms are presumed to be crucial aetiologically. It is plausible that a number of autoimmune disorders may share a common genetic background. This phenomenon has been demonstrated in previous studies, which have shown an overlap of susceptibility alleles between AA and other autoimmune disorders. Recent studies have shown that genetic variants on the TRAF1/C5 (tumor necrosis factor receptor-associated factor 1, complement component 5) locus confer susceptibility to rheumatoid arthritis (RA).

OBJECTIVES

To examine the role of the TRAF1/C5 locus in the development of AA using a large sample of 1,195 patients with AA and 1280 controls.

METHODS

We genotyped the two most significant single nucleotide polymorphisms (SNPs) (rs10818488, rs2416808) from a former RA candidate gene study. After having obtained evidence for association, we performed a fine-mapping study and genotyped the locus with an additional 27 SNPs.

RESULTS

While no significant result was obtained for the overall sample, rs2416808 showed significant associations in the analysis of the subgroups with severe AA and with a positive family history. The most significant P-value for rs2416808 was in familial cases (P = 0.004, P(corr) = 0.026). The fine mapping revealed significant associations for four additional SNPs in the analysis of subgroups, with rs2416808 remaining the most significant marker.

CONCLUSIONS

Our results point to the involvement of the TRAF1/C5 locus in the aetiology of familial and severe AA, and provide further support for a shared aetiology between AA and other autoimmune disorders.

Coudability hairs: a revisited sign of alopecia areata assessed by trichoscopy

BACKGROUND

We have previously reported several trichoscopic (dermatoscopic) characteristics, such as black dots, 'exclamation-mark' hairs, broken hairs, yellow dots and clustered short vellus hairs as being useful clinical indicators for alopecia areata (AA). 'Coudability hairs', which are normal-looking hairs tapered at the proximal end, have been previously reported as another sign of AA.

AIMS

To use trichoscopy to evaluate coudability hairs as a clinical indicator for the disease activity of AA and a substitute-marker for the hair-pull test.

METHODS

Trichoscopic examinations of hair loss and perilesional areas on the scalps of 100 East Asian patients with AA were performed using a dermatoscope. Using Spearman's rank-order correlation coefficient by rank test, we examined the correlations of scores between coudability and AA disease activity, severity or duration and other trichoscopic features, and then evaluated the coudability score as a surrogate-marker for the hair-pull test.

RESULTS

Coudability scores correlated positively with AA disease activity, hair-pull tests, short duration, black dots and exclamation-mark hairs, and correlated negatively with short vellus hairs.

CONCLUSIONS

Coudability hairs, more closely perceived by trichoscopy, are useful-markers for disease activity in AA and provide a surrogate-marker for the hair-pull test.

Phase I/II randomized bilateral half-head comparison of topical bexarotene 1% gel for alopecia areata

BACKGROUND

Alopecia areata, hair loss caused by perifollicular T-cell infiltrates, is refractory to therapy. Bexarotene, a retinoid X receptor is a selective retinoid, induces T-cell apoptosis.

OBJECTIVE

We sought to determine the safety, including the dose-limiting toxicities with adverse events, and efficacy, ie, response rate, of bexarotene in alopecia areata.

METHODS

We conducted a phase I/II randomized, half-head trial of 1% bexarotene gel applied twice daily for 6 months.

RESULTS

In all, 42 patients (11 male and 31 female) with alopecia totalis (n = 3), alopecia universalis (n = 5), or alopecia areata (n = 34) applied 1% bexarotene gel for 24 weeks. Five of 42 (12%) had 50% or more partial hair regrowth on the treated side, and 6 of 42 (14%) on both sides including 3 complete responders. In all, 31 patients had mild irritation; 4 had grade-3 irritation.

LIMITATIONS

This design cannot differentiate between drug-induced and spontaneous regrowth.

CONCLUSION

Topical bexarotene 1% application is well tolerated and possibly effective. A randomized placebo-controlled trial should be conducted.

Evaluating the severity of dermatologic disorders

Assessment of a patient's disease severity is an essential component of formulating therapeutic strategies. However, disorders of the skin are often not amenable to strict classification criteria, and the dermatologist relies upon personal thresholds of severity when assessing the patient's overall condition. A number of grading systems have arisen, primarily from the need for standardized end points in clinical trials; in some circumstances, these severity assessments may assist the clinician in the evaluation and treatment of dermatologic disease. In this review, we will summarize the results of available severity scores of frequently encountered dermatologic disorders and discuss their utility in the management of disease in a clinician's office.

Interventions for alopecia areata

BACKGROUND

Alopecia areata is a disorder in which there is loss of hair causing patches of baldness but with no scarring of the affected area. It can affect the entire scalp (alopecia totalis) or cause loss of all body hair (alopecia universalis). It is a relatively common condition affecting 0.15% of the population. Although in many cases it can be a self-limiting condition, nevertheless hair loss can often have a severe social and emotional impact.

OBJECTIVES

To assess the effects of interventions used in the management of alopecia areata, alopecia totalis and alopecia universalis.

SEARCH STRATEGY

We searched the Cochrane Skin Group Specialised Register in February 2006, the Cochrane Central Register of Controlled Clinical Trials (The Cochrane Library Issue 1, 2006), MEDLINE (from 2003 to February 2006), EMBASE (from 2005 to February 2006), PsycINFO (from 1806 to February 2006), AMED (Allied and Complementary Medicine, from 1985 to February 2006), LILACS (Latin American and Caribbean Health Science Information database, from 1982 to February 2006), and reference lists of articles. We also searched online trials registries for ongoing trials.

SELECTION CRITERIA

Randomised controlled trials that evaluated the effectiveness of both topical and systemic interventions for alopecia areata, alopecia totalis, and alopecia universalis.

DATA COLLECTION AND ANALYSIS

Two authors assessed trial quality and extracted the data. We contacted trial authors for more information. We collected adverse effects information from the included trials.

MAIN RESULTS

Seventeen trials were included with a total of 540 participants. Each trial included from 6 to 85 participants and they assessed a range of interventions that included topical and oral corticosteroids, topical ciclosporin, photodynamic therapy and topical minoxidil. Overall, none of the interventions showed significant treatment benefit in terms of hair growth when compared with placebo. We did not find any studies where the participants self-assessed their hair growth or quality of life.

AUTHORS' CONCLUSIONS

Few treatments for alopecia areata have been well evaluated in randomised trials. We found no RCTs on the use of diphencyprone, dinitrochlorobenzene, intralesional corticosteroids or dithranol although they are commonly used for the treatment of alopecia areata. Similarly although topical steroids 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 reported poorly and are so small that any important clinical benefits are inconclusive. There is a desperate need for large well conducted studies that evaluate long-term effects of therapies on quality of life. Considering the possibility of spontaneous remission especially for those in the early stages of the disease, the options of not being treated therapeutically or, depending on individual preference wearing a wig may be alternative ways of dealing with this condition.

Alopecia areata in Turkey: demographic and clinical features

BACKGROUND

Alopecia areata is a complex genetic disease with still many unknown aspects, and many studies have been tried to find some clues about it.

OBJECTIVE

We aimed to investigate the demographic and clinical characteristics of alopecia areata in Turkish patients.

METHODS

Demographic data, localization, attack number in addition to some parameters such as disease duration, severity, age of onset, family history and ophiasis pattern were evaluated in 539 alopecia areata patients.

RESULTS

The male to female ratio was 1.6:1. Occipital and beard-moustache areas were mostly affected. Positive family history was noticed in 24.1% of the patients. The age of onset was earlier in women than in men (P = 0.04). Severe forms showed more persistent (> or = 1 year) disease duration (P = 0.00). Ophiasis was more common in severe, long duration (> or = 1 year) and early onset (< or = 18 years) disease (P = 0.00 for all parameters). Childhood alopecia areata (< or = 18 years) was also associated with long duration of the disease (P = 0.016) and positive family history (P = 0.008) when compared with adult onset (> 18 years) alopecia areata.

Subcutaneous efalizumab is not effective in the treatment of alopecia areata

BACKGROUND

Alopecia areata (AA) is a T-cell-mediated autoimmune disease. Efalizumab is a T-cell-targeted therapy approved for the treatment of psoriasis.

OBJECTIVE

To assess the efficacy and safety of efalizumab in the treatment of moderate-to-severe AA.

METHODS

Sixty-two patients were enrolled into this phase II, placebo-controlled trial. The trial consisted of three 12-week periods-a double-blind treatment period, an open-label efalizumab treatment period, and a safety follow-up.

RESULTS

There were no statistical differences between treatment groups in percent hair regrowth, quality-of-life measures, or changes in biologic markers of disease severity after 12 or 24 weeks. In both groups, there was an approximately 8% response rate for hair regrowth (at 12 weeks). Efalizumab was well tolerated.

LIMITATIONS

Numbers were too small for certain analyses.

CONCLUSION

A 3- to 6-month trial of efalizumab was not effective in promoting hair regrowth in this small cohort of patients with moderate-to-severe AA.

The R620W polymorphism in PTPN22 confers general susceptibility for the development of alopecia areata

BACKGROUND

The functional R620W (c.1858C>T) variant of the protein tyrosine phosphatase nonreceptor 22 gene (PTPN22) has been associated with a variety of autoimmune disorders. A recent study has suggested that R620W also contributes to the severe form of alopecia areata (AA).

OBJECTIVES

We sought to replicate the finding of an association between PTPN22 and severe AA. In addition, we wanted to study the effect of PTPN22 on the general risk to develop AA and on other subtypes of AA (mild AA, early/late age at onset, positive/negative family history).

METHODS

The R620W variant was genotyped in a large case-control sample of Belgian-German origin with 435 patients and 628 controls.

RESULTS

Significant results were obtained for the overall collective of patients with AA (P=0.007). Subdividing the sample according to severity of AA, family history and age at onset, we detected lowest P-values for patients with the severe form of AA (Pcorr=0.036), with a positive family history (Pcorr=0.042) and with an age at onset<or=20 years (Pcorr=0.048).

CONCLUSIONS

Our results suggest the R620W variant of PTPN22 as a general risk factor in AA with the strongest effect observed among patients with a severe type of AA, a positive family history or an early onset of disease.

Loss-of-Function Mutations in the Filaggrin Gene and Alopecia Areata: Strong Risk Factor for a Severe Course of Disease in Patients Comorbid for Atopic Disease

Alopecia areata (AA) is a common dermatological disease, which affects nearly 2% of the general population. Association of AA with atopic disease has been repeatedly reported. Loss-of-function mutations in the filaggrin gene (FLG) may be considered as promising candidates in AA, as they have been observed to be a strong risk factor in atopic dermatitis. The FLG mutations R501X and 2282del4 were genotyped in a large sample of AA patients (n=449) and controls (n=473). Although no significant association was observed in the patient sample overall, FLG mutations were significantly associated with the presence of atopic dermatitis among AA patients. Furthermore, the presence of FLG mutations had a strong impact on the clinical course of AA in comorbid patients. For example, 19 of the 22 mutation carriers among AA patients with atopic dermatitis showed a severe form of the disease (P=0.003; odds ratio (OR)=5.47 (95% confidence interval (CI): 1.59-18.76)). In conclusion, our data suggest that when AA occurs in conjunction with FLG-associated atopic disorder, the clinical presentation of AA may be more severe.

Pulse corticosteroid therapy for alopecia areata: study of 139 patients

BACKGROUND/AIM

Recent reports of pulse corticosteroid therapy for alopecia areata (AA) show its efficacy for patients with a history of < or = 1 year but not for recalcitrant cases or alopecia totalis/universalis. The purpose of this study was to evaluate the efficacy and safety of pulse corticosteroid therapy for recent-onset AA patients.

METHOD

A total of 139 severe AA patients aged >15 years were included in this study. The duration from the onset of active hair loss was within 12 months for 125 (89.9%) of those patients.

RESULTS

Of the patients, 72.7% had hair loss on > 50% of their scalp area. Among the recent-onset group (duration of AA < or = 6 months), 59.4% were good responders (> 75% regrowth of alopecia lesions), while 15.8% with > 6 months duration showed a good response. Recent-onset AA patients with less severe disease (< or = 50% hair loss) responded at a rate of 88.0%, but only 21.4% of recent-onset patients with 100% hair loss responded. No serious adverse effects were observed.

Serum chemokine profiles in patients with alopecia areata

BACKGROUND

Although chemokines play an important role in various inflammatory diseases, there have been few studies about the role of chemokines in alopecia areata (AA).

OBJECTIVES

To determine serum levels of chemokines in patients with AA and their clinical correlations.

METHODS

Serum samples from 85 patients with AA, 20 patients with atopic dermatitis, 20 patients with psoriasis vulgaris and 28 normal controls were examined by the cytometric bead array assay assessing monokine induced by interferon (IFN)-gamma (MIG), RANTES, interleukin-8 (IL-8), IFN-inducible protein-10, monocyte chemoattractant protein-1, macrophage inflammatory protein (MIP)-1alpha, MIP-1beta and eotaxin levels. Secreted chemokine levels from peripheral blood mononuclear cells (PBMC) of patients with AA were also investigated.

RESULTS

Serum MIG, RANTES, IL-8 and eotaxin levels were selectively increased in patients with AA compared with normal controls. Levels of MIG, RANTES and IL-8 secreted from PBMC of patients with AA were also increased. Furthermore, elevated serum MIG and RANTES levels significantly correlated with the disease activity. RANTES levels were nonsignificantly associated with a predisposition to atopy.

CONCLUSIONS

These results suggest that MIG and RANTES play an important role in the development of AA and are useful as markers of disease activity and as therapeutic targets.

Genetik der Alopecia areata

Die Alopecia areata (AA) stellt mit einer Lebenszeitprävalenz von etwa 1–2% in beiden Geschlechtern die nach der androgenetischen Alopezie zweithäufigste Form von Haarausfall dar. Das klinische Erscheinungsbild ist typischerweise ein kreisrunder Ausfall des Kopfhaars, der Haarausfall kann aber auch an anderen Kopf- oder Körperstellen auftreten und im ungünstigsten Fall die ganze Körperbehaarung betreffen (Alopecia universalis). Der Verlauf der Erkrankung ist sehr variabel und die therapeutische Situation vielfach unbefriedigend. Das Wiederholungsrisiko bei Kindern wird mit etwa 5–6% angegeben. Die Genese der AA ist multifaktoriell mit einem signifikanten Beitrag genetischer Faktoren. Auf der pathophysiologischen Ebene werden Autoimmunmechanismen als ursächlich vermutet, die auf der Basis einer genetischen Disposition die Physiologie des Haarfollikels beeinflussen. In Übereinstimmung mit der Autoimmunhypothese sind replizierte Assoziationen mit Allelen des HLA-Komplexes sowie dem W620-Allel des PTPN22-Gens („protein tyrosine phosphatase non-receptor type 22“) berichtet worden. Eine genomweite Kopplungsuntersuchung weist auf weitere chromosomale Regionen hin, wobei dort bislang noch keine Suszeptibilitätsgene identifiziert werden konnten. Zusätzliche Hinweise auf beteiligte Gene erhofft man sich von der Untersuchung verschiedener Nagetiermodelle. Von einer umfassenden Identifizierung der krankheitsassoziierten Gene beim Menschen erhofft man sich neue Ansatzpunkte für Therapien und Möglichkeiten der Prävention.

Alopecia areata

Alopecia areata (AA) is a nonscarring, autoimmune, inflammatory, hair loss on the scalp, and/or body. Etiology and pathogenesis are still unknown. The most common site affected is the scalp. Histopathology is characterized by an increased number of the catagen and telogen follicles, the presence of inflammatory lymphocytic infiltrate in the peribulbar region ("swarm of bees"). Corticosteroids are the most popular drugs for the treatment of this disease. Etiologic and pathogenic mechanisms, as well as other current treatments available will be discussed in this article.

Efficacy and safety of a new clobetasol propionate 0.05% foam in alopecia areata: a randomized, double-blind placebo-controlled trial

BACKGROUND

Clinical efficacy of topical corticosteroids in alopecia areata (AA) is still controversial. Positive clinical results have been obtained using ointments with occlusive dressing but this approach has a low patient compliance. Recently, a new topical formulation (thermophobic foam: Versafoam) of clobetasol propionate 0.05% has been introduced on the market (Olux, Mipharm, Milan, Italy) (CF). This formulation is easy to apply. After application to the skin the foam quickly evaporates without residues and it has a good patient compliance. In vitro studies have also shown that this formulation enhances the delivery of the active compound through the skin.

AIM

To evaluate the efficacy, safety and tolerability of CF in the treatment of moderate to severe AA.

SUBJECTS AND METHODS

Thirty-four patients with moderate to severe AA (eight men, mean age 40+/-13 years) were enrolled in a randomized, double-blind, right-to-left, placebo-controlled, 24-week trial. Alopecia grading score (AGS) was calculated at baseline and after 12 and 24 weeks of treatment using a 0-5 score (0=no alopecia; 5=alopecia totalis). Clobetasol foam and the corresponding placebo foam (PF) were applied twice a day for 5 days/week for 12 weeks (phase 1) using an intrapatient design (right vs. left). From weeks 13 to 24 each enrolled patient continued only with the treatment (both on the right and left site) that was judged to have a greater efficacy than that on the contralateral side (phase 2). The primary outcome of the trial, evaluated on an intention-to-treat basis, was the hair regrowth rate, which was evaluated using a semiquantitative score (RGS) (from 0: no regrowth, to 4: regrowth of 75%).

RESULTS

At baseline the AGS was 4.1 (range: 2-5). Nine (26%) patients prematurely concluded the trial. At the end of phase 1, a greater hair regrowth was observed in 89% of the head sites treated with CF vs. 11% in the sites treated with PF. The RGS was 1.2+/-1.6 in the CF-treated sites and 0.4+/-0.8 in the PF-treated sites (P=0.001). A RGS of 2 (hair regrowth of more than 25%) was observed in 42% CF-treated sites and in 13% of PF-treated sites (P=0.027). In seven subjects (20%) a RGS of 3 to 4 (hair regrowth of 50%) was observed in CF-treated sites. In three subjects (9%) a RGS of 4 (hair regrowth of 75%) was observed in CF-treated sites. In one patient only, in a PF-treated region, a RGS of 3 was observed. The AS was reduced to 3.8 by CF treatment at the end of phase 1 and to 3.3 at the end of phase 2 (P=0.01). From weeks 12 to 24 the treatment with CF induced a further increase in the RGS (from 1.2 to 1.5+/-1.4). Forty-seven per cent of CF-treated patients had a RGS of 2 at the end of the trial. A total of eight patients (25%) at the end of the treatment with CF showed a RGS of 3. Folliculitis occurred in two patients. No significant modifications in cortisol and ACTH blood levels were observed during the trial.

CONCLUSION

This new formulation of clobetasol propionate foam is an effective, safe and well-tolerated topical treatment for AA. This formulation has a good cosmetic acceptance and patient compliance profile.

Serum anti-Fcγ receptor autoantibodies in patients with alopecia areata

Although anti-Fcgamma receptor antibodies (Abs) are detected in various autoimmune diseases, there have been no studies about the anti-Fcgamma receptor Abs in alopecia areata (AA). To detect the anti-Fcgamma receptor Abs in patients with AA and their clinical correlations, Serum samples from 72 patients with AA and 23 normal controls were examined by enzyme-linked immunosorbent assay assessing anti-Fcgamma receptor Ab levels. Anti-Fcgamma receptor I Abs were significantly frequently detected in patients with AA compared with normal controls. Furthermore, the detection of anti-Fcgamma receptor I Abs significantly inversely correlated with the disease duration. These results suggest that anti-Fcgamma receptor I Ab and Fcgamma receptor I play an important role in the regulation of AA, are useful for a marker of the disease prognosis and are worth intense research for the reasonable and specific therapy of AA.

Investigation of the functional variant c.-169T > C of the Fc receptor-like 3 (FCRL3) gene in alopecia areata

A functional variant in the Fc receptor-like 3 (FCRL3) gene has been implicated in susceptibility to autoimmune diseases such as rheumatoid arthritis, systemic lupus erythematosus and autoimmune thyroid disease. Investigating a large case-control sample of patients with alopecia areata (AA), we found no evidence for the involvement of FCRL3 in susceptibility to AA.

Investigation of the p.Ser278Arg polymorphism of the autoimmune regulator (AIRE) gene in alopecia areata

A recent study has suggested that the g.961C >G (p.Ser278Arg) variant of the autoimmune regulator (AIRE) gene contributes to susceptibility to alopecia areata (AA). We attempted to replicate this finding using a case-control sample of Belgian-German origin (273 patients and 283 controls). Despite adequate power, our study results do not support a significant association of the risk allele in our AA patient sample. This remained the case when we stratified our sample according to severity and family history of disease. Our study results do not support the hypothesis that the g.961C >G (p.Ser278Arg) polymorphism of the AIRE gene is associated with an increased risk for AA.

Alopecia areata: a long term follow-up study of 191 patients

BACKGROUND

The prognosis of alopecia areata (AA) is difficult to predict. Few studies report long-term follow-up of AA patients.

OBJECTIVE

The purpose of this study is to better assess the long-term evolution of AA and the possible relationship between disease severity and treatment response with long-term prognosis.

METHODS

One hundred ninety-one patients with AA who presented with a new diagnosis of AA between 1983 and 1990 were subsequently contacted by phone. Patients were queried regarding current disease status, treatments, and disease course.

RESULTS

Severity of AA at first consultation ranged from mild (128 patients) to severe (63 patients). Fifty-five of 191 patients were affected by concomitant autoimmune or related inflammatory disease. Sixty-six of 191 patients were presently disease free (follow-up duration, 15-22 years; mean 17.74 years). These include 41 of 60 patients with S1 disease (68.3%), 22 of 68 patients with S2 disease (32.3%), 1 of 11 patients with S3 disease (9%), 1 of 14 patients with S4 disease (7.1%), and 1 of 11 patients with alopecia totalis (AT) (9.1%). Sixty-nine of 191 patients (36-1%) were presently affected by AT or alopecia universalis. There was a statistically significant tendency of severe patterns of AA to worsen over time. In children, 18 of 39 (13 with < or =S2 disease and 5 with > or =S3 disease) with AA had developed AT or alopecia universalis at long-term follow-up. In children, however, this trend was not statistically significant. Patients with severe AA who responded to topical immunotherapy seem to have a better prognosis than nonresponders.

LIMITATIONS

Follow-up was only performed by phone.

CONCLUSIONS

Severity of AA at time of first consultation is an important prognostic factor. Response to therapy (topical immunotherapy) may be associated with better prognosis. In children, the prognosis is worse; our study found that AA worsens over time.

Familial aggregation of alopecia areata

BACKGROUND

Familial aggregation of alopecia areata (AA) has been previously described, but systematic studies with information obtained directly from family members have yet to be undertaken.

OBJECTIVE

We sought to study the pattern of familial aggregation of AA by assessing the affection status of patients' relatives. The study included 206 index patients with a total of 1029 first-degree and 2625 second-degree relatives.

METHODS

First-degree relatives were directly interviewed, whereas information on second-degree relatives was obtained by interviewing the index patients and their first-degree relatives.

RESULTS

Estimated lifetime risks were 7.1% in siblings, 7.8% in parents, and 5.7% in offspring. The risk in second-degree relatives was slightly higher than the reported population risk. Age at onset in index patients and first-degree relatives was significantly correlated.

LIMITATIONS

Using patients drawn from specialized hair clinics may have produced results showing a higher proportion of early onset and severe cases.

CONCLUSION

The familial aggregation of AA supports the role of genetic factors in the development of the disease. In addition, our data indicate genetic factors might contribute to the age at onset of AA.

Phenotypic analysis of T-cells in extensive alopecia areata scalp suggests partial tolerance

This study demonstrates the feasibility and efficacy of using flow cytometric analysis with intracellular cytokine staining for characterization of T-cell phenotype and functional status in extensive alopecia areata (EAA) scalp skin. Cell suspensions were made from scalp punch biopsies taken from 12 patients with long-standing EAA (average disease duration 14 years, 95% hair loss) and six control subjects. EAA samples had a lower percentage of CD-3-expressing cells, but CD-4/CD-8 ratios remained similar to controls. Expression of CD-69 was found only in EAA scalp biopsies, suggesting that T-cells from EAA scalp have undergone activation. No difference was found in tumor necrosis factor alpha expression. Surprisingly, EAA scalp T-cells produced less IL-2 and CD-8 T-cells produced less IFN-gamma. Immunohistochemical staining of formalin-fixed paraffin-embedded specimens demonstrated that IFN-gamma-producing cells in EAA scalp were not greater in number than in normal specimens. The few identified IFN-gamma-producing cells demonstrated no tendency to localize to the perifollicular region, and were similarly distributed as in control specimens. The abnormalities in cytokine production may explain the relative paucity of inflammatory change observed in the clinical setting and suggest that T-cell responses in EAA scalp are tightly, albeit aberrantly, regulated via mechanisms of peripheral T-cell tolerance.

Clinical Approach to the Patient With Alopecia

Hair loss, or alopecia, is a common patient complaint and a source of significant psychological and physical distress. The majority of common hair loss disorders can be accurately diagnosed in the outpatient setting with a systematic evaluation of the patient. This review will present a clinical approach to the patient with alopecia by describing the history, clinical findings, and diagnosis of various hair loss disorders.

Promoter region polymorphism of macrophage migration inhibitory factor is strong risk factor for young onset of extensive alopecia areata

We have demonstrated that serum macrophage migration inhibitory factor (MIF) was significantly elevated in patients with extensive alopecia areata (AA). Recently, functional polymorphisms have been identified in the MIF promoter region. To address the functional and prognostic relevance of the -173G/C and -794[CATT]5-8 repeat polymorphisms in MIF genes in patients with extensive AA, 113 patients with extensive AA and 194 healthy controls were genotyped. We found that MIF-173*C was a risk factor for early onset (<20 years) of extensive AA (odds ratio for GC heterozygotes with -173G/C was 4.88 (95% CI, 2.04-11.8), P=0.00038; odds ratio for CC homozygotes with -173G/C was 10.42 (95% CI, 2.56-43.5), P=0.0011). We found no statistically significant differences in the genotype frequencies of the -794[CATT]5-8 repeat polymorphism and extensive AA. These results suggest that polymorphisms within the MIF-173*C allele confer an increased risk of susceptibility to the extensive forms of AA, especially with an early onset of disease. MIF is therefore suggested to be closely implicated in the pathogenesis of the more extensive forms of AA.