Is there an association between alopecia areata and systemic lupus erythematosus? A population-based study

Non-scarring alopecia of lupus erythematosus: A comprehensive review

BACKGROUND

Although non-scarring alopecia (NSA) is a frequent clinical finding in patients with systemic lupus erythematosus (SLE), it has been poorly described in the literature. It is considered a nonspecific sign in the current classification of skin lesions of LE. The aim of this study was to give an updated overview of the spectrum of NSA in LE patients, with emphasis on the clinical significance thereof.

METHOD

We conducted a review of the English literature using the PubMed-Medline database using the keywords "Alopecia" + "Lupus erythematosus". Publications describing LE patients with NSA were included.

RESULTS

Data for 237 patients from 27 publications were analyzed. Ninety-one patients had diffuse NSA, 43 had patchy NSA, 83 had lupus hair, 3 had alopecia of dermal cutaneous LE, and 17 had alopecia of linear and annular lupus panniculitis of the scalp. Patients with diffuse/patchy NSA and lupus hair shared the following features: strong association with systemic activity of LE, subtle clinical/trichoscopic signs of inflammation, histological aspect consistent with lesions specific to cutaneous LE, high likelihood of response to SLE therapy, and absence of progression to scarring alopecia. Association with SLE was rare in patients with dermal cutaneous LE or linear and annular lupus panniculitis of the scalp, and skin-directed therapies were most often effective. One patient of each subtype progressed to scarring alopecia.

DISCUSSION

Diffuse/patchy NSA and lupus hair may represent a topographic variation of a single entity specific for LE. Prospective studies are warranted to further document the clinical significance of this manifestation.

Comorbid Conditions Associated with Alopecia Areata: A Systematic Review and Meta-analysis

BACKGROUND

Alopecia areata (AA) is a complex autoimmune condition resulting in nonscarring hair loss. In recent years, many studies have provided new evidence on comorbid diseases present in patients with AA. However, some studies have conflicting results, and analyses conducting a comprehensive approach are lacking.

OBJECTIVE

The aim of our study was to provide an updated systematic review and meta-analysis of medical comorbidities associated with AA.

METHODS

We searched PubMed, Embase, and Web of Science for case-control, cross-sectional, and cohort studies investigating medical comorbidities in AA published from inception through 1 February 2023.

RESULTS

We screened 3428 abstracts and titles and reviewed 345 full text articles for eligibility. Ultimately, 102 studies were analyzed, comprising 680,823 patients with AA and 72,011,041 healthy controls. Almost all included studies (100 of 102 studies) were of satisfactory to high quality (Newcastle-Ottawa scale score ≥ 4). Among patients with AA, comorbidities with the highest odds ratios (OR) compared with healthy controls and data available from more than one study included vitamin D deficiency (OR 10.13, 95% CI 4.24-24.20), systemic lupus erythematous (OR 5.53, 95% CI 3.31-9.23), vitiligo (OR 5.30, 95% CI 1.86-15.10), metabolic syndrome (OR 5.03, 95% CI 4.18-6.06), and Hashimoto's thyroiditis (OR 4.31, 95% CI 2.51-7.40). AA may be a protective factor for certain disorders, for which the AA group had lower odds compared with healthy controls, such as irritable bowel syndrome (OR 0.38, 95% CI 0.14-0.99) and colorectal cancer (OR 0.61, 95% CI 0.42-0.89).

CONCLUSION

These findings corroborate and contextualize the risks across comorbidities for patients with AA. Further work should be done to identify the underlying pathophysiology and understand appropriate screening criteria.

Alopecia areata and risk of atopic and autoimmune conditions: population-based cohort study

BACKGROUND

Alopecia areata (AA) has features of both autoimmune and atopic pathogenesis, but information on the risk of people with AA developing autoimmune and atopic conditions is limited.

OBJECTIVE

To assess the prevalence and incidence of atopic and autoimmune conditions in people with AA.

METHODS

This was a population-based cohort study of 8051 adults with newly diagnosed AA (AA group) and 32 204 adults in the matched control group, using the UK Oxford-Royal College of General Practitioners (RCGP) Research and Surveillance Centre (RSC) network primary care database, 2009-2018 (trial registration number: NCT04239521). Baseline prevalence of common atopic and autoimmune conditions, and risk of new-onset atopic and autoimmune disease, were estimated.

RESULTS

Atopic and autoimmune conditions were more prevalent in the AA group than the control group (atopic 37.2% vs. 26.7%, autoimmune 11.5% vs. 7.9%). The AA group were 43% more likely to develop any new-onset atopic condition [adjusted hazard ratio (aHR) 1.43. 95% confidence interval (CI) 1.28-1.61] and 45% more likely to develop any autoimmune condition (aHR 1.45, 95% CI 1.28-1.66) compared with the control group. When examining individual conditions, the AA group were at increased risk of atopic dermatitis (aHR 1.91, 95% CI 1.67-2.19), allergic rhinitis (aHR 1.32, 95% CI 1.14-1.54), autoimmune hypothyroidism (aHR 1.65, 95% CI 1.35-2.02), systemic lupus erythematosus (aHR 4.51, 95% CI 1.88-10.82) and vitiligo (aHR 2.39, 95% CI 1.49-3.82). There was no evidence for a higher incidence of other conditions examined.

CONCLUSION

People with AA have an increased burden of atopic and autoimmune comorbidity. This supports previous work suggesting that both T helper cell (Th)1 and Th2 immune responses may be implicated in the pathogenesis of AA.

Immune-mediated diseases and subsequent risk of alopecia areata in a prospective study of US women

INTRODUCTION

Alopecia areata (AA) is the most common form of immune-mediated hair loss. Studies have begun to establish the most frequent comorbid diseases of AA; however, results have been inconsistent with few prospective studies.

METHODS

A total of 63,692 women in the Nurses' Health Study, 53-80 years, were prospectively followed from 2002 to 2014 to determine whether history of immune-mediated disease was associated with AA risk. Hazard ratios (HRs) and 95% confidence intervals (CIs) for AA in relation to immune-mediated conditions were computed using Cox proportional hazard models, adjusted for AA risk factors.

RESULTS

133 AA cases were identified during follow-up. Personal history of any immune-mediated disease was associated with increased AA risk (HR 1.72, 95% CI 1.24-2.37). History of systemic lupus erythematosus (HR 5.43, 95% CI 2.11-13.97), multiple sclerosis (HR 4.10, 95% CI 1.40-11.96), vitiligo (HR 3.13, 95% CI 1.08-9.10), psoriasis (HR 2.01, 95% CI 1.00-4.03), hypothyroidism (HR 1.88, 95% CI 1.30-2.71), and rheumatoid arthritis (HR 1.66, 95% CI 1.09-2.52) were associated with increased AA risk. History of inflammatory bowel disease or Graves' disease/hyperthyroidism was not significantly associated with AA risk.

CONCLUSIONS

In this prospective study, personal history of immune-mediated diseases either individually or overall was associated with increased AA risk.

Mechanistic insights into the inhibitory activity of FDA approved ivermectin against SARS-CoV-2: old drug with new implications

The novel corona virus (Covid-19) has become a great challenge worldwide since 2019, as no drug has been reported yet. Different clinical trials are still under way. Among them is Ivermectin (IVM), an FDA approved drug which was recently reported as a successful candidate to reduce SARS-CoV-2 viral load by inhibiting Importin-α1 (IMP-α1) protein which subsequently affects nuclear transport of viral proteins but its basic binding mode and inhibitory mechanism is unknown. Therefore, we aimed to explore the inhibitory mechanism and binding mode of IVM with IMP-α1 via different computational methods. Initially, comparative docking of IVM was performed against two different binding sites (Nuclear Localization Signal (NLS) major and minor sites) of IMP-α1 to predict the probable binding mode of IVM. Then, classical MD simulation was performed (IVM/NLS-Major site and IVM/NLS-Minor site), to predict its comparative stability dynamics and probable inhibitory mechanism. The stability dynamics and biophysical analysis of both sites highlighted the stable binding of IVM within NLS-Minor site by establishing and maintaining more hydrophobic contacts with crucial residues, required for IMP-α1 inhibition which were not observed in NLS-major site. Altogether, these results recommended the worth of IVM as a possible drug to limit the SARS-CoV-2 viral load and consequently reduces its progression.Communicated by Ramaswamy H. Sarma.

An integrated scalp and blood biomarker approach suggests the systemic nature of alopecia areata

BACKGROUND

Alopecia areata (AA) is characterized by immune dysregulation in both scalp and blood, but a large-scale approach establishing biomarkers of AA incorporating both scalp tissue and serum compartments is lacking. We aimed to characterize the transcriptomic signature of AA lesional and nonlesional scalp compared to healthy scalp and determine its relationship with the blood proteome in the same individuals, with comparative correlations to clinical AA disease severity.

METHODS

We evaluated lesional and nonlesional scalp tissues and serum from patients with moderate-to-severe AA (n = 18) and healthy individuals (n = 8). We assessed 33,118 genes in AA scalp tissue using RNAseq transcriptomic evaluation and 340 inflammatory proteins in serum using OLINK high-throughput proteomics. Univariate and multivariate approaches were used to correlate disease biomarkers with Severity of Alopecia Tool (SALT).

RESULTS

A total of 608 inflammatory genes were differentially expressed in lesional AA scalp (fold change/FCH>1.5, false discovery rate/FDR<0.05) including Th1 (IFNG/IL12B/CXCL11), Th2 (IL13/CCL18), and T-cell activation-related (ICOS) products. Th1/Th2-related markers were significantly correlated with AA clinical severity in lesional/nonlesional tissue, while keratins (KRT35/KRT83/KRT81) were significantly downregulated in lesional compared to healthy scalp (p < .05). Expression of cardiovascular/atherosclerosis-related markers (MMP9/CCL2/IL1RL1/IL33R/ST2/AGER) in lesional scalp correlated with their corresponding serum expression (p < .05). AA scalp demonstrated significantly greater biomarker dysregulation compared to blood. An integrated multivariate approach combining scalp and serum biomarkers improved correlations with disease severity/SALT.

CONCLUSION

This study contributes a unique understanding of the phenotype of moderate-to-severe AA with an integrated scalp and serum biomarker model suggesting the systemic nature of the disease, advocating for the need for immune-based systemic treatment.

Prevalence and Risk Factors Associated with the Occurrence of Autoimmune Diseases in Patients with Alopecia Areata

BACKGROUND

Increased rates of autoimmune diseases (ADs) have been reported in association with alopecia areata (AA); however, the risk factors for coexisting ADs in AA patients have been poorly investigated.

OBJECTIVE

To evaluate the prevalence and factors associated with AD comorbidities in patients with AA.

METHODS

This case-control study included patients diagnosed with AA between January 2000 and March 2020. Individuals with AA, both with and without concomitant ADs, were statistically compared. Variables significantly associated with coexisting ADs were identified using univariate and multivariate logistic regression analyses. Multinomial logistic regression analysis was performed to identify the specific risk factors for each concomitant AD.

RESULTS

Among the 615 patients with AA, comorbid ADs were found in 76 (12.4%). Autoimmune thyroid disease (AITD) exhibited the highest frequency (n = 42, 6.8%), followed by vitiligo (n = 15, 2.4%), and systemic lupus erythematosus (SLE) (n = 12, 2.0%). Logistic regression analyses revealed that female sex (odds ratio [OR] = 2.45, 95% confidence interval [CI] = 1.24-4.82; P = 0.011), nail abnormalities (OR = 2.49, 95% CI = 1.14-5.46; P = 0.023), and atopic diseases (OR = 1.98, 95% CI = 1.09-2.43; P < 0.001) were significantly associated with coexisting ADs. Regarding each concomitant AD, nail abnormalities were an associated factor for AITD (OR = 4.65, 95% CI = 1.96-7.24; P = 0.01), whereas coexisting atopic diseases were demonstrated as a predictor of vitiligo (OR = 2.48, 95% CI = 1.43-4.58; P = 0.02). Female sex (OR = 1.61, 95% CI = 1.18-4.27; P = 0.04) and family history of AD (OR = 1.85, 95% CI = 1.26-4.19; P = 0.03) were predictors of SLE.

CONCLUSION

This study suggests that female AA patients with nail abnormalities and atopic diseases have increased rates of AD comorbidities. A thorough review of systems for associated factors can help physicians screen for concomitant ADs.

Alopecia areata is not a risk factor for heart diseases: A 10-year retrospective cohort study

Alopecia areata (AA) is an autoimmune skin disease caused by chronic inflammation of hair follicles. Chronic inflammatory skin diseases such as psoriasis and lupus erythematosus can increase the risk of cardiovascular diseases. However, the relationship between AA and heart diseases (HDs) remains unclear. Therefore, we conducted this retrospective cohort study to evaluate the risk of subsequent HDs in patients with AA. We reviewed 3770 cases of AA and from 18,850 age, sex, and income level-matched controls from the National Health Insurance Service-National Sample Cohort. In the subgroup analysis, patients who suffered from alopecia totalis, alopecia universalis, and ophiasis were designated as patients with severe AA and patients having the disease for over a year were designated as patients with long-standing AA. As a result, we found that AA was not associated with a higher risk of heart failure, angina pectoris, or myocardial infarction. There was no significant increase in the risk of overall HD associated with AA (adjusted hazard ratio: 1.17; 95% confidence interval: 0.93-1.48; p = 0.177). Neither the severity nor the duration of AA was related to an increased risk of HDs. During the study period, AA patients did not show a significantly higher cumulative incidence of HDs than controls (log-rank p = 0.157). In conclusion, AA does not increase the risk of HD.

Systemic Lupus Erythematosus Presenting as Alopecia Areata

Alopecia areata is an inflammatory, non-scarring hair loss associated with autoimmune conditions. It is more commonly seen with thyroid disorders and vitiligo, but alopecia areata has also been linked to diabetes, psoriasis, rheumatoid arthritis, and systemic lupus erythematosus. Indeed, individuals with alopecia areata have an increased risk of developing systemic lupus erythematosus. A 36-year-old woman presented with hair loss characteristic of alopecia areata. After intralesional injections with triamcinolone acetonide, the areas of hair loss exhibited near complete hair regrowth. Laboratory examination and additional history were suggestive of systemic lupus erythematosus. She was referred to a rheumatologist who confirmed the diagnosis. Awareness of the comorbidities associated with alopecia areata can uncover other autoimmune conditions, such as thyroid disorders and systemic lupus erythematosus. The diagnosis of a new-onset alopecia areata may prompt a deeper investigation of potentially associated conditions.