Comorbidities in alopecia areata: A systematic review and meta-analysis

Efficacy and safety of ritlecitinib in Asian patients with alopecia areata: A subgroup analysis of the ALLEGRO phase 2b/3 trial

This subgroup analysis of the ALLEGRO phase 2b/3 study (NCT3732807) assessed the efficacy and safety of multiple doses of ritlecitinib, an oral JAK3/TEC family kinase inhibitor, in Asian patients with alopecia areata (AA). Patients aged ≥12 years with AA and ≥50% scalp hair loss received once-daily ritlecitinib 50 or 30 mg (with or without 4-week 200-mg loading dose ["200/50" or "200/30"]) or 10 mg or placebo for 24 weeks, followed by a 24-week extension, in which patients initially assigned to placebo switched to 200/50 or 50 mg. In this subgroup analysis, Asian patients with response based on achieving a Severity of Alopecia Tool (SALT) score ≤20, SALT ≤10, ≥2-grade improvement or normal score on the eyebrow assessment (EBA) scale, and ≥2-grade improvement or normal score on the eyelash assessment (ELA) scale were evaluated through week 48. Safety was monitored throughout. In total, 186 Asian patients were randomized to ritlecitinib 200/50 mg (n = 33), 200/30 mg (n = 28), 50 mg (n = 43), 30 mg (n = 34), 10 mg (n = 17), placebo to 200/50 mg (n = 14), or placebo to 50 mg (n = 17). The proportions of patients treated with ritlecitinib ≥30 mg achieving a SALT score ≤20 response were 9.1%-36.4% at week 24 vs 0% for the 10-mg group and 3.2% for placebo. At week 48, 26.5%-55.6% of patients treated with ritlecitinib ≥30 mg achieved a SALT ≤20 response. At week 48, the proportions of patients treated with ritlecitinib ≥30 mg with EBA response were 41.9%-71.1% and with ELA response were 40.7%-57.9%. The most common adverse events were nasopharyngitis, folliculitis, upper respiratory tract infection, and urticaria. No serious or opportunistic infections, major adverse cardiovascular events, thromboembolic events, malignancies, or deaths were reported. Ritlecitinib demonstrated clinical efficacy and acceptable safety over 48 weeks in Asian patients ≥12 years with AA and ≥50% hair loss. Results for the Asian subpopulation were consistent with the overall population in the ALLEGRO-2b/3 study.

Potential Causal Relationship Between Extensive Lipid Profiles and Various Hair Loss Diseases: Evidence From Univariable and Multivariable Mendelian Randomization Analyses

BACKGROUND

Hair loss disorders, including non-cicatricial forms such as alopecia areata (AA) and androgenetic alopecia (AGA), as well as cicatricial forms, represent significant dermatological concerns influenced by various factors, including lipid metabolism. While observational studies and clinical trials have suggested a link between lipid levels and hair loss, the causal relationship remains unclear.

METHODS

We conducted a comprehensive analysis of 983 lipid variables [including triglycerides (TG), fatty acids, cholesterol, cholesterol esters, phospholipids, and lipoproteins] and 4 hair loss disorders. Two-sample univariable Mendelian randomization (UVMR) and multivariable Mendelian randomization (MVMR) analyses were employed to investigate the causal effects of lipids on hair loss disorders. Sensitivity analyses were performed to ensure the robustness of our findings.

RESULTS

The UVMR analysis identified 56 significant causal associations between lipid levels and hair loss disorders, with cholesterol, high-density lipoprotein cholesterol (HDL-C), low-density lipoprotein cholesterol (LDL-C), TG, apolipoprotein A1, apolipoprotein B, and lipoprotein(a) emerging as key contributors. The MVMR analysis evaluated the independent effects of HDL-C, LDL-C, and TG on alopecia disorders, identifying significant associations only between HDL-C, TG, and AA. Sensitivity analyses confirmed the consistency and robustness of these results.

CONCLUSION

This study provides strong evidence for potential causal associations between lipids and hair loss disorders, highlighting potential therapeutic targets and the importance of lipid management in affected patients.

Evaluation of SALT score severity in correlation with trichoscopic findings in alopecia areata: a study of 303 patients

BACKGROUND

Alopecia areata (AA) is a common autoimmune non-scarring type of hair loss characterized by round patches on the scalp or body. AA is the second most common form of hair loss after male-pattern baldness in men, and female-pattern baldness in women.

AIM OF THE STUDY

This study aims to examine the correlation between trichoscopic patterns and AA severity, evaluated by the Severity of Alopecia Tool (SALT) score, and to analyze the impact of demographic and clinical factors on treatment outcomes.

PATIENTS AND METHODS

A prospective cross-sectional single-center study was conducted involving 303 patients with AA, assessing the relationships between trichoscopic findings, clinical features, treatment responses, and SALT scores.

RESULTS

Our cohort comprised 50.83% females and 49.17% males, ranging in age from 6 months to 84 years, with a mean age of 23.67 ± 14.79 years and an average disease onset at 21.68 (± 14.30) years. Localized and Multiple patchy AA were the most observed subtypes, with ophiasis, alopecia universalis, and totalis being less frequent. Small vellus hairs, exclamation mark hair, and coudability hair emerged as prevalent trichoscopic findings. A significant prevalence of comorbidities (82.18%) was observed, particularly micronutrient deficiencies, autoimmune and endocrine disorders, and atopic diseases. Key predictors of more severe AA, as indicated by higher SALT scores, include prolonged disease duration, nail involvement, and neuropsychiatric comorbidities. Shorter disease duration was correlated with active disease markers such as broken hairs, black dots, yellow dots, and exclamation mark hair. Markers like cumulus-like white dots and v-sign correlated with severe disease stages, whereas pigtail hairs, small vellus hairs, and upright regrowing hairs indicated new hair growth or positive treatment responses.

CONCLUSION

Trichoscopy proves crucial for assessing AA severity and treatment efficacy, facilitating personalized treatment approaches and improving patient management outcomes.

Association of lichen planopilaris with cardiovascular and metabolic disorders: a systematic review and meta-analysis

BACKGROUND

Lichen planopilaris (LPP) is among the most common types of immune-mediated scarring alopecia. Observational studies have reported conflicting findings regarding the association of LPP with different comorbidities.

OBJECTIVES

We conducted a systematic review and meta-analysis to elucidate the association between LPP and different cardiovascular and metabolic disorders.

METHODS

We systematically searched four electronic databases (PubMed, Web of Science, Embase and Cochrane Library) for relevant studies published from their inception to 1 August 2024. A random-effects model was used to perform a pooled analysis and calculate odds ratios or incidence rate ratios with 95% confidence intervals.

RESULTS

The meta-analysis included 10 case-control studies involving 7516 patients with LPP and 64 719 097 controls. The results demonstrated no significant associations between LPP and hypertension, diabetes mellitus or hyperlipidaemia. The results of the pooled analyses also revealed that patients with LPP did not have significantly higher risks of obesity or heart failure than did controls. All pooled analyses revealed high levels of heterogeneity across the studies, but no significant publication bias was detected.

CONCLUSIONS

LPP is not significantly associated with most cardiovascular and metabolic disorders, including hypertension, diabetes mellitus, hyperlipidaemia, obesity and heart failure.

Prevalence of Thyrotropin Receptor Antibodies and Clinical Profile of Patients with Alopecia Areata: A Cross-Sectional Study

Introduction

Alopecia areata (AA) is associated with thyroid dysfunction and abnormal levels of thyroglobulin and thyroid peroxidase autoantibodies. One study detected high prevalence of thyrotropin receptor antibodies (TRAbs) in AA patients. Our aim was to investigate the prevalence of TRAb levels in AA patients and to assess their association with thyroid hormones, other thyroid antibodies, AA severity, and other epidemiological variables.

Methods

In this observational study, 139 patients (97 females, 42 males), aged 12 and above, with newly presenting, relapsing, or treatment-resistant AA were included. Medical histories were reviewed, alopecia severity was assessed using the Severity of Alopecia Tool (SALT), and blood tests measured thyroid hormones and autoantibodies.

Results

The prevalence of TRAb was significantly higher in AA patients (23.6%) compared to the general population (1-2%) (p < 0.001). Elevated TRAb titers did not correlate with diagnosed thyroid dysfunction or treatment, abnormal thyroid function tests and autoantibodies, AA severity, duration, and onset. Male patients exhibited a significantly higher prevalence of abnormal TRAb titers compared to females (75.0% vs. 21.3%, p = 0.002).

Conclusion

A significant proportion of AA patients presented with elevated TRAb levels, independent of thyroid hormone titers, other thyroid autoantibodies, or SALT score. Prevalence of abnormal TRAb levels was higher in males.

Microneedle transdermal delivery of compound betamethasone in alopecia areata-A randomized controlled trial

BACKGROUND

Alopecia areata (AA) places a considerable burden on patients. While intralesional glucocorticoid injection is an important therapy, it can cause severe pain.

OBJECTIVE

To compare the efficacy and pain levels of microneedle transdermal delivery of compound betamethasone versus traditional intralesional injection in mild-to-moderate AA.

METHODS

We conducted a randomized controlled trial in AA patients with a Severity of Alopecia Tool (SALT) score <50. Both groups received monthly compound betamethasone injections: group A via intralesional injections and group B via transdermal microneedle delivery. The primary outcome was the reduction in SALT score after 3 months.

RESULTS

With 80 patients enrolled, baseline SALT scores were similar between group A (9.250 ± 5.300) and group B (10.65 ± 9.445). After 3 months, the mean SALT reduction was 7.000 ± 4.5017 in group A and 8.075 ± 8.014 in group B, with no statistical difference. Remission rates for SALT30/50/75/90 were 92.50/90.00/57.50/42.50% in group A and 95.00/87.50/72.50/40% in group B, with no significant difference. Group B had a significantly lower visual analog scale pain score than group A (4.000 ± 1.174 vs 5.281 ± 2.098, P = .0047).

LIMITATIONS

The study focused on mild-to-moderate patchy AA, limiting insights into severe cases.

CONCLUSION

Microneedle transdermal delivery of compound betamethasone in mild-to-moderate patchy AA demonstrates efficacy comparable to traditional intralesional injection with reduced pain.

Association Between Serum Trace Elements Level and Alopecia Areata: A Systematic Review and Meta-Analysis

BACKGROUND

Alopecia areata (AA) is a prevalent autoimmune disorder in dermatology, impacting 0.5%-2% of the general population worldwide. More and more scholars are focusing on the important role of micronutrients in the occurrence and development of AA.

AIMS

This research aimed to thoroughly and systematically assess the relationship between serum trace element levels and AA.

METHODS

The PubMed, Web of Science, EMBASE, and Cochrane Library databases were searched up to May 12, 2024. Two researchers independently screened and identified eligible studies. Depending on the heterogeneity assessed by the I2 statistic, either a random-effects model or a fixed-effects model was used to combine the effect estimates.

RESULTS

34 papers, including 4931 participants from 16 countries, were analyzed. The results of meta-analysis demonstrated patients with AA had a lower serum level of vitamin D (SMD = -0.93 ng/mL, 95% CI = 0.168-0.747, p < 0.05) and serum zinc (SMD = -0.69 μg/dL, 95% CI = -0.99 to -0.39, p < 0.05) than the healthy controls. Vitamin D deficiency was strongly associated to an elevated risk of AA (OR = 2.48, 95% CI = 1.47-4.17, p < 0.05). However, there is no significant difference in serum copper levels between AA patients and the control group.

CONCLUSIONS

Our research provided evidence that the levels of serum VD and zinc were associated with the risk of AA. Supplementation with VD and zinc may become a potential treatment for AA.

Causal Relationship and Potential Common Pathogenic Mechanisms Between Alopecia Areata and Related Cancer

Objective

Alopecia areata (AA) is an autoimmune skin disease. Observational studies have reported an association between AA and cancer. However, the causal relationship between AA and cancer has not been reported. We employed a two-sample Mendelian randomization (MR) study to assess the causality between AA and 17 subtypes of cancers.

Methods

We employed a two-sample Mendelian randomization (MR) study to assess the causality between AA and 17 subtypes of cancers. AA and cancers' association genome-wide association study (GWAS) data were collected. The inverse variance weighted (IVW) method was utilized as the principal method in our Mendelian randomization (MR) study, with additional use of the MR-Egger, weighted median, simple mode, and weighted mode methods. After that, we explored the underlying biological mechanisms by Bioinformatic Analysis.

Results

According to our MR analysis, AA has a causal relationship with hepatic bile duct cancer (HBDC, (odds ratio [OR] = 0.944, 95% confidence interval [CI] = 0.896-0.994, P-value = 0.030) and colorectal cancer (CRC, OR = 0.981, 95% CI = 0.963-0.999, P-value = 0.046). AA could decrease the risk of HBDC and CRC. No causal link between AA and other subtypes of cancers was observed. No heterogeneity or pleiotropy was observed. Furthermore, disease-related genes were obtained, Gene Ontology (GO) and Kyoto Encyclopedia of Genes and Genomes (KEGG) enrichment analysis results showed that the set of genes associated with immunity-inflammatory signaling pathway.

Conclusion

This study provided new evidence of the relationship between AA with HBDC and CRC. AA may play a protective role in both HBDC and CRC progression. This could provide newer avenues for research in search of treatment for HBDC and CRC.

Treatment patterns and healthcare resource utilization among patients with alopecia areata: A real-world chart review in South Korea

Alopecia areata (AA) is a clinically heterogeneous, immune-mediated, non-scarring hair loss disorder. This real-world chart review sought to characterize treatment patterns and healthcare resource use among patients with severe AA in South Korea. A web-based chart review of 40 dermatologists was conducted in which the medical charts of 151 adult patients diagnosed with severe AA between May 2019 and April 2021 were reviewed. Anonymized data on patient characteristics, treatment patterns, healthcare resource use, and clinical outcomes were extracted from the date of severe disease diagnosis until the date of data collection (September-November 2022). Sixty-six percent of patients were diagnosed with severe disease at initial presentation, while 34% were re-classed to severe during the disease course. Mean estimated patient age at the time of diagnosis of severe AA was 37.1 (range 22-68) years. Fifty-three percent of patients were male. Most patients (93.4%) received pharmacological treatment for their condition; 45.5% received ≥2 lines of treatment with a mean duration of 24 months. First-line treatment discontinuation due to lack of efficacy occurred in 46.0% of cases. Hair regrowth occurred in 71.0% of patients, 59.2% of whom experienced major regrowth (≥60%) during the follow-up period. Median (95% confidence interval) time to regrowth was 13.7 (11.0-20.6) months. Treatment visit rates per person-year ranged from two (phototherapy) to 10 (topical treatment), dermatologist visits occurred at a rate of 12.9 per person-year and 6.0% of patients were hospitalized due to alopecia areata. The majority of hospitalizations were related to treatment and occurred in patients who received pulse systemic corticosteroid therapy. The patient and economic burden of AA in South Korea is high and there remains a critical unmet need among patients with severe AA with respect to the effectiveness of commonly used treatment strategies.

Alopecia Areata Treatment Patterns and Satisfaction: Results of a Real-World Cross-Sectional Survey in Europe

INTRODUCTION

Alopecia areata (AA) is an autoimmune disease that causes scalp, face, and/or body hair loss. Recently, oral treatments with kinases inhibition became the first approved therapies for severe AA. An understanding of the use and effectiveness of traditional therapies in real-world treatment settings is needed to guide integration of novel therapies into the treatment paradigm. This study aimed to describe traditional treatment patterns, dermatologists' reasons for therapy choice, and dermatologists' satisfaction with disease control among patients with AA.

METHODS

Data were drawn from the 2021-2022 Adelphi Real World AA Disease Specific Programme™, a cross-sectional survey of dermatologists and adult patients with AA, conducted in France, Germany, Italy, Spain, and the UK. For each patient, using data from patient consultation and medical records, dermatologists reported % scalp hair loss (SHL), characteristics of current and prior AA therapies, and satisfaction with disease control.

RESULTS

Overall, 239 dermatologists provided data for 1720 patients with AA. Mean (SD) patient age was 35.8 (11.6) years, and 51% were male. Based on dermatologist perception, among patients with ≤ 10% SHL, 74% were experiencing mild AA, while ≥ 95% of patients with ≥ 50% SHL were experiencing severe/very severe AA. In patients with ≥ 50% SHL, the most common therapies received included systemic immunosuppressants (31%), topical corticosteroids (24%), and oral corticosteroids (24%). Among all patients who had switched therapies, 49%, 26%, and 24% switched because of worsening AA, lack of initial efficacy with prior treatment, and loss of response over time, respectively. Among those with SHL ≥ 50%, dermatologists reported satisfaction with current therapy in < 30% of patients.

CONCLUSION

Dermatologists reported low satisfaction with traditional AA therapies used in patients with extensive SHL, with some patients discontinuing treatment because of worsening disease. This suggests more effective treatments are needed for patients with severe AA.

Survey on Alopecia Areata Patients' Reported Factors that Determine Severity of Alopecia Areata: A Nationwide Multicenter Study

BACKGROUND

Alopecia areata (AA) is characterized by hair loss on the scalp and body, significantly impacting patients' quality of life based on its severity.

OBJECTIVE

This study aims to identify crucial factors influencing the perception of severe AA from the patients' viewpoint.

METHODS

A web-based survey was conducted among AA patients attending dermatology departments at 21 university hospitals in Korea. The survey comprised 17 criteria, exploring both clinical characteristics of AA patients and subjective determinants of disease severity.

RESULTS

A total of 791 AA patients and their caregivers participated in the survey. Approximately 30% of respondents developed AA during childhood, with 43.5% experiencing chronic courses lasting over 3 years. Half of the participants exhibited more than 20% scalp hair loss, and 42% reported additional hair loss on other body parts, such as eyelashes and nose hair. Most respondents agreed that patients with ≥20% scalp hair loss should be categorized as having severe AA. They also identified longer disease duration, involvement of non-scalp body hair, treatment refractoriness, and social or mental impairment requiring medical intervention as factors indicating increased disease severity.

CONCLUSION

This survey underscores the significant impact of AA on patients' quality of life and highlights existing unmet needs in current treatment modalities.

Alopecia areata exhibits cutaneous and systemic OX40 activation across atopic backgrounds

BACKGROUND

Alopecia areata (AA) is a chronic, nonscarring hair-loss disorder associated with significant quality-of-life impairment and limited treatment options. AA has been recently linked to atopy and shown to exhibit both Th1- and Th2-driven inflammation. However, a comprehensive molecular and cellular characterization across blood and scalp compartments in both atopic and nonatopic patients is lacking.

METHODS

Lesional and nonlesional scalp biopsies obtained from AA patients with (n = 16) or without (n = 20) atopic history, and 17 demographically matched healthy controls were analyzed with RNA-seq, RT-PCR, and immunohistochemistry. Flow cytometry was also performed on peripheral blood mononuclear cells (PBMCs) from a subset of patients. Differential expression was defined using |fold-change| > 1.5 and false-discovery rate <0.05.

RESULTS

AA scalp exhibited robust upregulation of Th1- (IFNG, CXCL9, CXCL10, CXCL11) and Th2-related products (CCL26, CCR4, IL10, IL13, TSLP, TNFRSF4/OX40) and shared downregulation of hair keratins, regardless of atopic background, with variable Th17/Th22 modulation. AA patients with atopy exhibited greater inflammatory tone and Th2-skewing (IL10, IL13, IL33, CCR4, CCL26). Disease severity correlated significantly with immune and hair keratin biomarkers and with perifollicular cellular infiltrates. Cutaneous OX40/OX40L upregulation was paralleled by increases in circulating OX40+ and OX40L+ leukocytes, regardless of atopic background.

CONCLUSION

Our results suggest some atopy-associated immune differences in AA and highlight the OX40 axis as a potential novel therapeutic target that may broadly benefit AA patients.

Lifetime incidence and healthcare disparities in alopecia areata: a UK population-based cohort study

BACKGROUND

Alopecia areata (AA) is an immune-mediated form of hair loss that can occur at any age, often with a significant mental health burden.

OBJECTIVES

We aimed to provide estimates of the lifetime incidence of AA, and the impacts on mental health, healthcare utilization and work-related outcomes, assessing variation across major sociodemographic subgroups.

METHODS

AA cases were identified in primary care from the UK population-based Oxford-Royal College of General Practitioners Research and Surveillance Centre database (2009-2018). Lifetime incidence of AA was estimated at age 80 years using modified time-to-event models with age as the timescale, overall and stratified by sex, ethnicity, deprivation and geography. Mental health, healthcare utilization and work-related outcomes were assessed in the 2 years after AA diagnosis compared with matched unaffected controls, and stratified by the same sociodemographic subgroups.

RESULTS

During the study period, 6961 people developed AA. Overall lifetime incidence of AA was 2.11% [95% confidence interval (CI) 2.06-2.16]. Females had a higher lifetime incidence (2.35%, 95% CI 2.28-2.43) than males (1.88%, 95% CI 1.81-1.94). Lifetime incidence was higher in those of Asian ethnicity (5.87%, 95% CI 5.51-6.24), Other (4.5%, 95% CI 3.63-5.31), Mixed (4.4%, 95% CI 3.50-5.37) and Black (3.0%, 95% CI 2.63-3.42) ethnicity, compared with White ethnicity (1.7%, 95% CI 1.68-1.80). Lifetime incidence was highest in those with the greatest deprivation: most-deprived quintile (2.92%, 95% CI 2.77-3.07) compared with least-deprived (1.68%, 95% CI 1.59-1.78). Across sociodemographic subgroups, people with AA of Black ethnicity were most likely to have anxiety (adjusted odds ratio vs. matched controls 2.92, 95% CI 1.71-4.91), and had the greatest risk of time off work (adjusted hazard ratio vs. matched controls 2.54, 95% CI 1.80-3.56).

CONCLUSIONS

AA affects around 1 in 50 people over their lifetime. The incidence and impact of AA on mental health and work outcomes is highest in ethnic groups other than White. Clinicians should be aware of the marked heterogeneity in the incidence and impact of AA, and support targeted healthcare to groups at the highest risk of alopecia and its consequences.

Vitamin D deficiency in non-scarring and scarring alopecias: a systematic review and meta-analysis

Background

Numerous studies have linked vitamin D deficiency (VDD) to the pathogenesis of various alopecia disorders.

Objective

This study aimed to investigate whether patients with alopecia are more likely to have VDD or lower vitamin D levels than controls, and the prevalence of VDD among patients with certain alopecia disorders.

Methods

Electronic searches were conducted using PubMed, Embase, Scopus, and Cochrane Library databases from the dates of their inception until September 2024. Studies that reported data allowing for the calculation of odds ratios, mean differences, or correlation coefficients related to vitamin D levels and alopecia were included, while studies without a confirmed diagnosis of alopecia or those involving patients taking vitamin D supplements were excluded.

Results

It was found that 51.94% of patients with alopecia areata (AA), 50.38% of patients with female pattern hair loss (FPHL), 47.38% of patients with male androgenic alopecia (MAGA), 53.51% of patients with telogen effluvium (TE), and 38.85% of patients with primary scarring alopecia had VDD. Compared to controls, AA patients had a pooled odds ratio (OR) of VDD of 2.84 (95% confidence interval: 1.89-4.26, I2 = 84.29%, p < 0.01) and a pooled unstandardized mean difference (UMD) of vitamin D levels of -8.20 (-10.28 - -6.12, I2 = 74.25%, p < 0.01) ng/mL. For FPHL patients, a pooled OR of VDD of 5.24 (1.50-18.33, I2 = 81.65%, p < 0.01) and a pooled UMD of vitamin D levels of -15.67 (-24.55 - -6.79, I2 = 91.60%, p < 0.01) ng/mL were found. However, for MAGA, a pooled VDD OR of 4.42 (0.53-36.61, I2 = 88.40%, p < 0.01), and a pooled UMD of vitamin D levels of -2.19 ng/mL (-4.07 - -0.31 ng/mL, I2 = 7.64%, p = 0.37) were found. For TE patients, pooled UMD of vitamin D levels of -5.71 (-10.10 - -1.32) ng/mL were found.

Conclusion

People with alopecia frequently have VDD; however, only in patients with AA or FPHL was the association of VDD and decreased vitamin D levels statistically significant compared to control. The findings indicate screening for vitamin D could benefit patients with AA or FPHL, potentially addressing vitamin D deficiency. Further study on vitamin D supplementation as a treatment for alopecia is recommended.

The toxic effects of Helicobacter pylori and benzo(a)pyrene in inducing atrophic gastritis and gut microbiota dysbiosis in Mongolian gerbils

Food chemical and microbiological contamination are major global food safety issues. This study investigated the combined effects of the food-borne pathogen Helicobacter pylori (H. pylori) and the pollutant benzo(a)pyrene (Bap) on atrophic gastritis and gut microbiota in Mongolian gerbils. The results demonstrated that simultaneous administration of H. pylori and Bap caused more severe weight loss, DNA damage, and gastritis in Mongolian gerbils compared with those exposed to H. pylori or Bap alone. The combination also significantly increased the serum level of proinflammatory cytokines, including IL-1β (p < .05), IL-6 (p < .0001), and TNF-α (p < .05). Additionally, the H. pylori and Bap combination altered the composition of gut microbiota in Mongolian gerbils: the relative abundance of Lactobacillus and Ligilactobacillus at the genus level (p < .05) was significantly reduced while the relative abundance of Allobaculum and Erysipelotrichaceae enhanced (p < .0001, p < .05). Our study revealed that the synergy of H. pylori and Bap can boost the development of atrophic gastritis and lead to gut microbiota dysbiosis in Mongolian gerbils, which provides essential implications for preventing contaminated foods to sustain life and promote well-being.

Impact of Previous Alopecia Areata Treatment on Efficacy Responses up to Week 48 Following Ritlecitinib Treatment: A Post Hoc Analysis

INTRODUCTION

Patients with alopecia areata (AA) may have received several therapies for management of AA during their lives. In the ALLEGRO phase 2b/3 (NCT03732807) study, the oral JAK3/TEC family kinase inhibitor ritlecitinib demonstrated efficacy and an acceptable safety profile in patients aged ≥ 12 years with AA and ≥ 50% scalp hair loss. This post hoc analysis investigated associations between prior use of AA therapies and Severity of Alopecia Tool (SALT) responses in patients receiving ritlecitinib for AA.

METHODS

Patients receiving ritlecitinib 30 mg or 50 mg once daily with or without an initial 4-week 200-mg daily loading dose were grouped by previous exposure to AA treatments, including topicals, intralesional corticosteroids (ILCS), topical immunotherapy, and systemic immunosuppressants or any prior AA treatment. Multivariable logistic regression analyses evaluated the association between response based on a SALT score of ≤ 20 and any prior treatment for AA at weeks 24 and 48.

RESULTS

Of 522 patients, 360 (69.0%) had previous exposure to any AA treatment. At Week 24, SALT ≤ 20 response was positively associated with prior use of ILCS (odds ratio [OR], 2.12; 95% confidence interval [CI], 1.23-3.65; P < 0.05) and negatively associated with prior use of systemic immunosuppressants (OR 0.50; 95% CI 0.28-0.88; P < 0.05). Prior use of topicals or topical immunotherapy was not associated with SALT ≤ 20 response at Week 24. By Week 48, no association was identified between SALT ≤ 20 response and prior use of topicals, ILCS, topical immunosuppressants, or systemic immunosuppressants (all P > 0.05). Previous exposure to any AA therapy was not associated with SALT ≤ 20 response at weeks 24 or 48 (all P > 0.05).

CONCLUSIONS

Prior AA treatment history had no effect on longer-term treatment response to ritlecitinib.

TRIAL REGISTRATION NUMBER

NCT03732807.

Identification of Potential Hub Genes in Alopecia Areata

Alopecia areata (AA) is an immune-mediated chronic alopecia disease, but its specific pathogenesis is unclear. Gene expression data for AA patients (AAs) and healthy controls (HCs) were retrieved from the GEO database, and the differentially expressed genes (DEGs) between AAs and HCs were identified. Then, GO, KEGG and GSEA analysis were performed. A PPI network for the DEGs was then constructed to screen for hub genes, which were validated by three additional datasets. Subsequently, the potential miRNAs interacting with the hub genes were obtained through TarBase and miRNet. The differentially expressed lncRNAs (DElncRs) were obtained for subcellular localisation analysis, and the DElncRs located in the cytoplasm were further screened to identify miRNAs that interact with them. The shared miRNAs interacting with the hub genes and lncRNAs were used to construct a network of mRNA-miRNA-lncRNA interactions. Lastly, ROC analysis was performed to evaluate the potential diagnostic value of the hub genes and DElncRs identified. A total of 173 DEGs were obtained, mainly enriched in cytokines, chemokines, hair follicle development and hair cycle related signalling pathways. Through PPI screening and validation based on 3 additional datasets, 24 hub genes were finally yielded. Of them, five hub genes were upregulated and the potential miRNAs that interact with these five hub genes were identified. Additionally, 26 DElncRs were obtained, including 9 upregulated lncRNAs located in the cytoplasm that were predicted to interact with the miRNAs. Finally, an mRNA-miRNA-lncRNA regulatory network was constructed using five hub genes, four lncRNAs and their shared five miRNAs. The regulatory relationship between CD8A, mir-185-5p and FOXD2-AS1 might be crucial in AA pathogenesis, with CD8A and FOXD2-AS1 exhibiting diagnostic potential. CD8A and FOXD2-AS1 may serve as potential therapeutic targets in AA.

Amygdalin ameliorates alopecia areata on C3H/HeJ mice by inhibiting inflammation through JAK2/STAT3 pathway

BACKGROUND

Evidence has demonstrated that Chinese medicine formula Xuefu Zhuyu decoction can markedly promote the formation of new hair in patients and mice with alopecia areata (AA). Amygdalin is one of the active components of Xuefu Zhuyu decoction, but its therapeutic effects and the underlying mechanisms on AA remains largely unrevealed.

PURPOSE

Therefore, this study aims to investigate the therapeutic effects and to probe its molecular mechanisms of inflammation and immune regulation on AA model of C3H/HeJ mice.

STUDY DESIGN

The C3H/HeJ female mice were divided into control, AA, rusolitinib (60 mg/kg), and amygdalin groups (60, 90, and 120 mg/kg, 0.2 ml/10 g, i.g.).

METHODS

The optical microscope was used to observe the feature of the local skin, and the number of lanugo and terminal hair. H&E staining was performed to determine the degree of pathological damage to the skin. ELISA was performed to detect levels of interleukin-6 (IL-6), tumor necrosis factor-α (TNF-α) and interferon-γ (IFN-γ) in mice serum. Flow cytometry was carried out to analyze the CD4+CD25+FOXP3+, CD4+ and CD8+ of skin tissue. And the levels of CD4+ and CD8+, p-JAK/JAK2, p-STAT3/STAT, and SOCS3 were detected by immunohistochemistry. Western blot and qRT-PCR were employed to examine the expression levels of IL-6, TNF-α, IFN-γ, JAK2, p-JAK, STAT, p-STAT3 and SOCS3 proteins and genes in skin tissues.

RESULTS

Compared with AA group, amygdalin immensely increased the number of vellus hairs and decreased the number of terminal hairs determined by skin microscopy and H&E staining. ELISA, Western blot and qRT-PCR data showed that the levels of IL-6, TNF-α and IFN-γ in serum and skin tissues of AA mice were significantly increased, while amygdalin administration dramatically restrained the contents of the three pro-inflammatory factors. Flow cytometry and immunohistochemistry hinted that amygdalin observably enhanced the number of CD4+CD25+FOXP3+ and CD4+ cells, while inhibited the number of CD8+ positive cells in mice with AA. Moreover, amygdalin signally reduced JAK2/STAT3 pathway-related protein and gene levels in AA mice.

CONCLUSION

Amygdalin could inhibit inflammatory response and improve immune function in the treatment of AA. The underlying molecular mechanism may be related to inhibition of JAK2/STAT3 pathway.

A retrospective analysis of disease epidemiology, comorbidities, treatment patterns, and healthcare resource utilization of alopecia areata in the United Arab Emirates using claims database

Alopecia areata (AA) is an autoimmune disorder that manifests as nonscarring hair loss and imposes a substantial disease burden. The current study, using an e-claims database, assesses the disease burden, comorbidities, treatment patterns, specialties involved in the diagnosis of AA, healthcare resource utilization (HCRU), and associated costs in privately insured patients with AA in Dubai, United Arab Emirates. The retrospective longitudinal secondary study was conducted using Dubai Real-World Database e-claims data during 01 January 2014 to 30 June 2022. Patients with at least one diagnosis claim of AA during the index period (01 January 2015-30 June 2021) with continuous enrollment (one or more AA/non-AA claim in the post-index period) were included in the analysis. The patients were stratified into subcohorts based on diagnosis code and treatment patterns, as mild, moderate-to-severe, and others. Demographics, comorbidities, treatment patterns, specialists visited, and HCRU were assessed. The study included 11 851 patients with AA (mean age: mild: 37 years; moderate-to-severe: 36 years), with a male predominance (mild: 77.6%; moderate-to-severe: 60.8%). The most prevalent comorbidities in the moderate-to-severe AA subcohort were autoimmune and T-helper 2-mediated immune disorders, including contact dermatitis and eczema (62.1%), atopic dermatitis (36.1%), and asthma (36.1%). Most patients consulted dermatologists for treatment advice (mild AA: 87.4%; moderate-to-severe AA: 47.7%) and, notably, within 1 day of AA diagnosis. Topical steroids were frequently prescribed across cohorts, regardless of disease severity. Analysis of comorbidities among patients with AA indicated an additional HCRU burden among these subsets of patients. The median disease-specific HCRU cost was higher for psychological comorbidities versus autoimmune and T-helper 2-mediated immune disorders (US $224.99 vs US $103.70). There is a substantial disease and economic burden in patients with AA and associated comorbid conditions; therefore, investing in novel therapies that target the underlying autoimmune pathway may address the gap in effective management of AA.

Immune-Mediated and Psychiatric Comorbidities Among Patients Newly Diagnosed With Alopecia Areata

Importance

Alopecia areata (AA) has been associated with multiple comorbidities, yet information regarding the timing of comorbidity development after AA diagnosis is limited.

Objective

To evaluate the prevalence and new-onset incidence of psychiatric and autoimmune comorbidities in patients with AA in the US.

Design, Setting, and Participants

This retrospective cohort analysis used data collected from January 1, 2007, to April 30, 2023, from the Merative MarketScan Research Databases, which contains medical and drug claims data from more than 46 million patients in the US. Data from adolescent and adult patients (aged 12-64 years) diagnosed with AA and patients without AA (ie, controls) were evaluated. For some analyses, patients with AA were matched (1:4) to controls based on sex, age, and geographic region.

Main Outcomes and Measures

Prevalence (at the time of AA diagnosis) and incidence (new onset after AA diagnosis) of psychiatric and autoimmune diseases were reported as percentage of patients. Risk of developing a new-onset psychiatric or autoimmune disease after AA diagnosis was calculated as adjusted hazard ratios (AHRs) with 95% CIs.

Results

At baseline, 63 384 patients with AA and 3 309 107 without AA were identified. After matching, there were 16 512 and 66 048 patients in the AA and control groups, respectively, with a mean (SD) age of 36.9 (13.4) years and 50.6% of whom were female. Compared with the unmatched controls, patients with AA had higher prevalence of psychiatric (30.9% vs 26.8%; P < .001) and autoimmune (16.1% vs 8.9%; P < .0001) comorbidities at AA diagnosis; incidence was also higher in patients with AA (without history of these comorbidities) vs the matched control group. Patients with AA vs controls had a significantly higher risk of developing a psychiatric (AHR, 1.3; 95% CI, 1.3-1.4) or autoimmune (AHR, 2.7; 95% CI, 2.5-2.8) comorbidity.

Conclusions and Relevance

In this cohort study, patients with AA had a higher prevalence of autoimmune and psychiatric comorbidities at AA diagnosis and demonstrated an elevated risk of new-onset autoimmune and psychiatric comorbidities after their diagnosis. These data highlight the most common comorbidities among patients with AA and may help physicians counsel and monitor patients newly diagnosed with AA.

Global, regional and national epidemiology of alopecia areata: a systematic review and modelling study

BACKGROUND

Alopecia areata (AA) is a chronic autoimmune disease that leads to a high psychiatric, economic and systemic disease burden. A comprehensive understanding of AA epidemiology is essential for evaluating healthcare source utilization; however, a systematic approach to summarizing epidemiological data on AA is lacking.

OBJECTIVES

To investigate systematically the global, regional and national incidence and prevalence of AA.

METHODS

A structured search was conducted using the databases MEDLINE, Embase, Cochrane Library, Web of Science, SciELO and Korean Journal Database from their date of inception to 4 October 2023. Studies that reported the prevalence or incidence of AA were included. We used a Bayesian hierarchical linear mixed model to analyse prevalence estimates. The primary outcomes of our study were the global, regional and national prevalence of physician-diagnosed AA for the overall population, for adults and for children. The incidence data were summarized descriptively.

RESULTS

In total, 88 studies from 28 countries were included in the analysis. The reported incidence of AA tended to be higher in adults aged 19-50 years, and this trend was consistent with its estimated prevalence. The reported prevalence in overall populations tended to be higher in men vs. women. The estimated lifetime prevalence rate of AA was 0.10% [95% credible interval (CrI) 0.03-0.39] in the general population worldwide, 0.12% (95% CrI 0.02-0.52) in adults and 0.03% (95% CrI 0.01-0.12) in children. The estimated prevalence of AA was highest in the Asian region and lowest in the African region.

CONCLUSIONS

In this study, 48% of the Global Burden of Disease regions had insufficient data on the prevalence or incidence of AA. Further studies are needed to provide epidemiological information on middle- and low-income countries. Our study may serve as a crucial reference in terms of healthcare policy decisions.

Interleukin-33 links asthma to alopecia areata: Mendelian randomization and mediation analysis

OBJECTIVE

The objective of this study is to elucidate the causal association between asthma and alopecia areata (AA) through the application of Mendelian randomization (MR) analysis, leveraging summary data from genome-wide association studies (GWAS). Additionally, it explores potential mediating factors.

MATERIALS AND METHODS

Mendelian randomization (MR) analysis was employed to investigate the causal relationship between asthma and AA using genetic instrumental variables (IVs) for asthma, 91 circulating inflammatory proteins, and AA extracted from large-scale GWAS. The primary analytical approach utilized the inverse-variance weighted (IVW) method, supplemented by weighted median and MR-Egger methods to assess robustness. Tests for heterogeneity and pleiotropy were conducted to ensure result reliability. Furthermore, the study examined the mediating role of circulating inflammatory proteins in the asthma-AA relationship.

RESULTS

The findings revealed an increased risk of AA among asthma patients (odds ratio (OR) = 14.070; 95% confidence interval (CI) = 1.410-140.435; P = 0.024). Interleukin-33 (IL-33) emerged as a significant mediator in the asthma-AA relationship, explaining 13.1% of the mediation effect. Bidirectional Mendelian randomization analyses did not establish a causal effect of AA on asthma occurrence.

CONCLUSION

This study, utilizing Mendelian Randomization, elucidates the causal link between asthma and AA, highlighting the mediating role of IL-33. These findings underscore the importance of considering AA risk in asthma management and offer insights for potential therapeutic strategies targeting IL-33. Future research should explore additional biomarkers and mediating mechanisms between asthma and AA to enhance treatment approaches and patient quality of life.

The Effect of an Oral Probiotic Mixture on Clinical Evolution and the Gut and Skin Microbiome in Patients with Alopecia Areata: A Randomized Clinical Trial

(1) Background: Given the autoimmune nature of Alopecia Areata (AA) and the immunomodulatory properties of probiotics, this trial was conducted to evaluate the efficacy of a probiotic mixture, consisting of Lactobacillus rhamnosus and Bifidobacterium longum strains, as an adjuvant treatment in a group of AA patients. (2) Method: This study was a 24-week, randomized, double-blind, placebo-controlled clinical trial. Twenty-six patients with AA were included in this study, and their clinical progression, along with changes in gut and skin microbiota, were analyzed. (3) Results: A higher proportion of AA patients treated with the probiotic formula showed improvement compared to the placebo group, based on both the reduction in the number of AA plaques (56% vs. 30%) and the affected scalp surface area (45% vs. 20%). For “activity”, “inactivity”, and “regrowth”, an improvement in 55%, 67%, and 55% of patients was, respectively, observed in the probiotic group, compared to 50%, 40%, and 30% in the placebo group. No changes were observed in the gut microbiota during the intervention period. Regarding skin microbiota, changes were detected in the probiotic group, with reductions in characteristic genera during the study. (4) Conclusions: To our knowledge, this is the first clinical trial assessing the efficacy of a probiotic product in patients with AA. This probiotic mixture in a routine clinical practice setting appears to improve the course of patients. In addition, the skin microbiota of scalp lesions was modified using the probiotic treatment.

Evaluation of Serum Inflammatory Markers and Their Relationship to Treatment Response in Alopecia Areata Patients

INTRODUCTION

Alopecia areata is a type of non-scarring alopecia which is thought to be associated with T-cell mediated immune response.

OBJECTIVE

This study aimed to compare the levels of serum inflammatory markers before and after treatment in patients with alopecia areata. The study explored the utility of the systemic immune-inflammation index (SII) in assessing the severity and treatment response in alopecia areata patients.

METHODS

The study included 60 alopecia areata patients and 40 control patients diagnosed with tinea unguium, aged between 18 and 65 years. Sociodemographic characteristics such as age, sex, and medical history were recorded for both groups. For alopecia areata patients, serum inflammatory markers were recorded before and at the third month of treatment. Serum inflammatory markers for the control group were also recorded. Furthermore, the Severity of Alopecia Tool (SALT) score was calculated for alopecia areata patients before and at the third month of treatment.

RESULTS

The alopecia areata group had a significantly higher neutrophil-lymphocyte ratio, mean platelet volume, and SII values compared to the control group, while high-density lipoprotein (HDL) values were significantly lower. Serum inflammatory markers, assessed at the third month of treatment in the alopecia areata group, were lower, and HDL values were significantly higher compared to pre-treatment levels. A statistically significant correlation was observed between disease severity and the SII.

CONCLUSION

The SII is a cost-effective marker that can be utilized in assessing the severity of alopecia areata and treatment response.

Italian National Registry of Alopecia Areata: an epidemiological study of 699 Italian patients

BACKGROUND

Alopecia areata (AA) is an organ-specific autoimmune disease that affects the hair follicles of the scalp and the rest of the body causing hair loss. Due to the unpredictable course of AA and the different degrees of severity of hair loss, only a few well-designed clinical studies with a low number of patients are available. Also, there is no specific cure, but topical and systemic anti-inflammatory and immune system suppressant drugs are used for treatment. The need to create a global registry of AA, comparable and reproducible in all countries, has recently emerged. An Italian multicentric electronic registry is proposed as a model to facilitate and guide the recording of epidemiological and clinical data and to monitor the introduction of new therapies in patients with AA.

METHODS

The aim of this study was to evaluate the epidemiological data of patients with AA by collecting detailed information on the course of the disease, associated diseases, concomitant and previous events, and the clinical response to traditional treatments. Estimate the impact on the quality of life of patients.

RESULTS

The creation of the National Register of AA has proven to be a valid tool for recording, with a standardized approach, epidemiological data, the trend of AA, response to therapies and quality of life.

CONCLUSIONS

AA is confirmed as a difficult hair disease to manage due to its unpredictable course and, in most cases, its chronic-relapsing course, capable of having a significant impact on the quality of life of patients.

Deciphering the Complex Immunopathogenesis of Alopecia Areata

Alopecia areata (AA) is an autoimmune-mediated disorder in which the proximal hair follicle (HF) attack results in non-scarring partial to total scalp or body hair loss. Despite the growing knowledge about AA, its exact cause still needs to be understood. However, immunity and genetic factors are affirmed to be critical in AA development. While the genome-wide association studies proved the innate and acquired immunity involvement, AA mouse models implicated the IFN-γ- and cytotoxic CD8+ T-cell-mediated immune response as the main drivers of disease pathogenesis. The AA hair loss is caused by T-cell-mediated inflammation in the HF area, disturbing its function and disrupting the hair growth cycle without destroying the follicle. Thus, the loss of HF immune privilege, autoimmune HF destruction mediated by cytotoxic mechanisms, and the upregulation of inflammatory pathways play a crucial role. AA is associated with concurrent systemic and autoimmune disorders such as atopic dermatitis, vitiligo, psoriasis, and thyroiditis. Likewise, the patient's quality of life (QoL) is significantly impaired by morphologic disfigurement caused by the illness. The patients experience a negative impact on psychological well-being and self-esteem and may be more likely to suffer from psychiatric comorbidities. This manuscript aims to present the latest knowledge on the pathogenesis of AA, which involves genetic, epigenetic, immunological, and environmental factors, with a particular emphasis on immunopathogenesis.

Dissecting hair breakage in alopecia areata: the central role of dysregulated cysteine homeostasis

In the initial stages of Alopecia Areata (AA), the predominance of hair breakage or exclamation mark hairs serves as vital indicators of disease activity. These signs are non-invasive and are commonly employed in dermatoscopic examinations. Despite their clinical salience, the underlying etiology precipitating this hair breakage remains largely uncharted territory. Our exhaustive review of the existing literature points to a pivotal role for cysteine-a key amino acid central to hair growth-in these mechanisms. This review will probe and deliberate upon the implications of aberrant cysteine metabolism in the pathogenesis of AA. It will examine the potential intersections of cysteine metabolism with autophagy, ferroptosis, immunity, and psychiatric manifestations associated with AA. Such exploration could illuminate new facets of the disease's pathophysiology, potentially paving the way for innovative therapeutic strategies.

Genetic links between atopy, allergy, and alopecia areata: insights from a Mendelian randomization study

BACKGROUND

Alopecia areata (AA), a prevalent form of autoimmune hair loss, has a not well-defined relationship with atopic and allergic disorders, including eczema, hay fever, and asthma.

OBJECTIVES

This study aims to elucidate the genetic relationship between atopy, allergies, and alopecia areata (AA) using Mendelian randomization. We hypothesize that atopic and allergic conditions contribute to the genetic predisposition of AA.

METHODS

We analyzed extensive genetic data from Genome-wide Association Studies (GWAS) involving over one million individuals. This analysis focused on assessing the genetic correlation between AA and various allergic conditions, including hay fever, eczema, asthma, and allergies to pollen, dust, and cats. The inverse variance weighted method served as our primary analytical tool, complemented by sensitivity analyses to verify the robustness of our results.

RESULTS

Our findings reveal a significant genetic correlation between atopy/allergies and an increased risk of AA. Notably, strong associations were observed for hay fever, eczema, asthma, and specific allergies (pollen, dust, and cats). The sensitivity analyses corroborated these associations, reinforcing the reliability of our primary results.

CONCLUSIONS

This study provides compelling genetic evidence of an association between atopic and allergic conditions and the development of AA. These findings suggest that individuals with such conditions may benefit from enhanced surveillance for early signs of AA.

Real world evidence: patients with alopecia areata in Italy

BACKGROUND

This real-world analysis aimed at characterizing patients hospitalized for alopecia areata (AA) in Italy, focusing on comorbidities, treatment patterns and the economic burden for disease management.

METHODS

Administrative databases of healthcare entities covering 8.9 million residents were retrospectively browsed to include patients of all ages with hospitalization discharge diagnosis for AA from 2010 to 2020. The population was characterized during the year before the first AA-related hospitalization (index-date) and followed-up for all the available successive period. AA drug prescriptions and treatment discontinuation were analyzed during follow-up. Healthcare costs were also examined.

RESULTS

Among 252 patients with AA (mean age 32.1 years, 40.9% males), the most common comorbidities were thyroid disease (22.2%) and hypertension (21.8%), consistent with literature; only 44.4% (112/252) received therapy for AA, more frequently with prednisone, triamcinolone and clobetasol. Treatment discontinuation (no prescriptions during the last trimester) was observed in 86% and 88% of patients, respectively at 12 and 24-month after therapy initiation. Overall healthcare costs were 1715€ per patient (rising to 2143€ in the presence of comorbidities), mostly driven by hospitalization and drugs expenses.

CONCLUSIONS

This first real-world description of hospitalized AA patients in Italy confirmed the youth and female predominance of this population, in line with international data. The large use of corticosteroids over other systemic therapies followed the Italian guidelines, but the high discontinuation rates suggest an unmet need for further treatment options. Lastly, the analysis of healthcare expenses indicated that hospitalizations and drugs were the most impactive cost items.

Characteristics and Management of Patients with Alopecia Areata and Selected Comorbid Conditions: Results from a Survey in Five European Countries

INTRODUCTION

Alopecia areata (AA) is an autoimmune condition that causes non-scarring hair loss and can impose a high psychosocial burden on patients. The presence of comorbid conditions may impact the management of AA in clinical practice. This analysis aims to describe disease characteristics and management of AA in patients with concomitant atopic, autoimmune, and psychiatric comorbid conditions.

METHODS

Data were collected from the Adelphi Disease Specific Programme™, a cross-sectional survey of physicians and their adult patients with AA conducted in France, Germany, Italy, Spain, and the UK between October 2021 and June 2022. Patients' disease severity was based on physician's definition. Physician-reported data on demographics, AA clinical characteristics, comorbid conditions, and information related to AA therapies were analyzed. Analyses were descriptive.

RESULTS

Overall, 239 dermatologists provided data for 2083 patients, of which 558 patients (27%) had at least one atopic, autoimmune, or psychiatric comorbid conditions. The most common comorbid conditions were atopic dermatitis, autoimmune thyroid disease, and anxiety. The mean (standard deviation) patient age for the three comorbidity groups was 37.6 years (12.1) and 56% of the patients were women (n = 313). In the three comorbidity groups, 51%, 50%, and 55% of patients with atopic, autoimmune, and psychiatric comorbidities had severe AA with disease progression reported as worsening in 30%, 28%, and 30%, respectively, whereas in the group with no comorbidities, 37% were described as having severe AA and 21% getting worse. Scalp hair loss was the primary sign reported across the three groups of comorbid conditions (atopic, 91%; autoimmune, 91%; psychiatric, 88%). Patients with preselected comorbidities presented more frequently AA-related signs and symptoms beyond scalp hair loss than patients without comorbid conditions. These patients were also more likely to receive topical calcineurin inhibitors, topical immunotherapy, conventional systemic immunosuppressants, and oral Janus kinase inhibitors for the treatment of their AA.

CONCLUSION

This analysis provided insights into the burden and management of AA in patients presenting with atopic, autoimmune, and psychiatric comorbid conditions in five European countries.

Patient-Reported Burden of Severe Alopecia Areata: First Results from the Multinational Alopecia Areata Unmet Need Survey

Purpose

Alopecia areata (AA) is an autoimmune disease characterized by hair loss that has significant psychosocial implications. This study aims to describe the patient-reported burden of severe AA, coping mechanism and information needs using data from the multinational AA Patient Satisfaction and Unmet Need Survey.

Patients and Methods

Participants with current or previous ≥50% scalp hair loss (n = 747) were recruited from 11 countries and completed a web-based survey that assessed demographics, clinical characteristics, disease burden and psychosocial impact. Data were stratified according to sex, current age, disease duration and current severity of scalp hair loss.

Results

The mean (SD) age of participants was 43.8 (7.1) years, 55.3% were women, and 63.5% reported AA symptoms within 6 months of diagnosis. Most participants had black or brown hair (88.4%), reported a disease duration of 2 years or more (75.6%) and had current scalp hair loss of ≥50% (87.4%). Severe hair loss also extended to eyebrow (46.9%), eyelash (48.7), beard (61.5%) and body hair (73.2%). Participants commonly reported comorbidities such as anxiety (26.1%), depression (18.1%) and sleep problems (28.1%). The Dermatology Life Quality Index revealed a severe impact on quality of life; 86.2% of participants scored >10. Mental health/mood was significantly affected; 55.8% of participants reported a substantial impact. Long-term effects included decreased self-esteem (32.9%), poor mental health (28.1%) and challenges in day-to-day activities (27.2%). Information needs were centered around treatment expectations, mental health, and available treatment options. More severe symptoms and a greater daily impact were reported by women and those with a longer disease duration.

Conclusion

The study emphasizes the substantial burden, including impaired quality of life and psychological well-being, of severe AA on the lives of surveyed participants. The findings highlight the importance of comprehensive disease management strategies that address both physical and psychosocial aspects of AA.

Association between non-scarring alopecia and hypothyroidism: a bidirectional two-sample Mendelian randomization study

Background

Non-scarring alopecia is typically represented by two main types: alopecia areata (AA) and androgenetic alopecia (AGA). While previous observational studies have indicated a link between non-scarring alopecia and hypothyroidism, the precise causal relationship remains uncertain. To determine the potential links between non-scarring alopecia and hypothyroidism, we conducted a bidirectional two-sample Mendelian randomization (MR) analysis.

Methods

We used independent genetic instruments from the FinnGen consortium for AA (682 cases, 361,140 controls) and AGA (195 cases, 201,019 controls) to investigate the association with hypothyroidism in the UK Biobank study (22,687 cases, 440,246 controls). The primary analysis was performed using the inverse variance-weighted method. Complementary approaches were employed to evaluate the pleiotropy and heterogeneity.

Results

Genetically predicted AA exhibited a positive causal effect on hypothyroidism (odds ratio [OR], 1.0017; 95% confidence interval [CI], 1.0004-1.0029; P = 0.0101). Additionally, hypothyroidism was found to be strongly correlated with an increase in the risk of AA (OR, 45.6839; 95% CI, 1.8446-1131.4271, P = 0.0196). However, no causal relationship was demonstrated between AGA and hypothyroidism. A sensitivity analysis validated the integrity of these causal relationships.

Conclusion

This MR study supports a bidirectional causal link between AA and hypothyroidism. Nevertheless, additional research is needed to gain a more thorough comprehension of the causal relationship between non-scarring alopecia and hypothyroidism.

Endocrine and metabolic comorbidities in primary cicatricial alopecia: A nationwide population-based study

Primary cicatricial alopecia (PCA) is a rare, scarring, hair loss disorder. Due to its low incidence, little is known about endocrine and metabolic comorbidities in patients with PCA. Thus, we aimed to investigate the association between PCA and endocrine and metabolic disorders. This nationwide, population-based, cross-sectional study included patients diagnosed with PCA or non-cicatricial alopecia (NCA) and normal individuals without history of alopecia registered in the Korean National Health Insurance Service database between January 1, 2011, and December 31, 2020. We calculated the odds ratios of endocrine and metabolic comorbidities of patients with PCA compared to all patients or age- and sex-matched patients with NCA or normal individuals using multivariable logistic regression models. A total of 3 021 483 individuals (mean age [SD], 38.7 [15.0] years, 1 607 380 [53.2%] men), including 11 956 patients with PCA, 601 852 patients with NCA, and 2 407 675 normal participants, were identified. Patients with PCA had an increased risk for dyslipidemia (adjusted odds ratio [aOR] 1.14, 95% confidence interval [CI] 1.06-1.24), diabetes (aOR 1.38, 95% CI 1.24-1.53), and hypertension (aOR 1.10, 95% CI 1.02-1.19) compared to matched patients with NCA. Regarding PCA subtypes, lichen planopilaris/frontal fibrosing alopecia was positively associated with hypothyroidism (aOR 2.03, 95% CI 1.44-2.86) compared to NCA. Folliculitis decalvans and dissecting cellulitis were positively associated with dyslipidemia (aOR 1.16, 95% CI 1.05-1.28 and aOR 1.16, 95% CI 1.04-1.29, respectively), diabetes (aOR 1.38, 95% CI 1.20-1.58 and aOR 1.52, 95% CI 1.32-1.74, respectively), and hypertension (aOR 1.10, 95% CI 1.00-1.20 and aOR 1.14, 95% CI 1.02-1.27, respectively). Similar trends were observed when each PCA subgroup was compared with the normal control group. This study demonstrates that patients with PCA are more likely to have endocrine and metabolic comorbidities than patients without PCA. Further research on these comorbidities may improve the understanding of PCA.

Incidence rate of alopecia areata in Israel: A 15-year analysis of population-based data and the emergence of young male adults as the most at-risk group

Incidence rate and temporal trends in alopecia areata (AA) vary worldwide. As a common disorder with a major impact on life quality, there is a continuous need for comprehensive epidemiological characterization and global updates of the disease burden. We sought to perform an epidemiologic characterization of AA patients and to explore temporal trends across different subgroups using long-term health data. A retrospective population-based study was conducted in a large healthcare organization in Israel. Data were analyzed for all patients with AA between 2005 and 2019. A total of 30 805 patients for 29 504 798 person-years were identified during the study period, representing an overall incidence rate of 104.4 cases per 100 000 person-years. Young adults and patients of middle socioeconomic status had the highest incidence rate compared to the whole cohort. Incidence rates in females were lower than in males (incidence rate ratio 0.72, 95% confidence interval 0.71-0.74). In a temporal trends analysis, the yearly incidence rate for the whole cohort was stable throughout the study period. Males between the ages of 18 and 30 had a significant increase in incidence during the study years, where the incidence rate increased from 119.54 to 162.36 per 100 000 person-years. Despite the limitation of lack of analysis by subgroups of disease severity and other personal data, our study clearly indicates that young male adults of middle socioeconomic status emerge as the most at risk associated with AA over a decade and a half. In an effort to delineate risk factors for this gender gap, different stressors are speculated as triggers.

Patients with autoimmune skin diseases are at increased risk of adverse pregnancy outcomes

BACKGROUND

Increased rates of adverse pregnancy outcomes have been reported in association with rheumatologic diseases such as systemic lupus erythematosus, rheumatoid arthritis, dermatomyositis. However, little is known about pregnancy outcomes in patients with autoimmune skin diseases.

OBJECTIVE

This study aimed to determine the frequency of adverse pregnancy outcomes in patients with autoimmune skin diseases. We hypothesized that similar to rheumatic diseases, the rate of adverse pregnancy outcomes in patients with autoimmune skin diseases would be higher than the general population.

STUDY DESIGN

This is a case control study using the TriNetX US Collaborative Network, which is a database of electronic medical records of >95 million patients seen at 57 healthcare organizations in the United States. All pregnant women between the ages of 15 and 44 years who were seen at a healthcare organization between January 1, 2016 and December 31, 2021 were included. Participants with autoimmune skin disease were matched to healthy controls and controls with systemic rheumatologic conditions (systemic lupus erythematosus or rheumatoid arthritis). For both the autoimmune skin disease and healthy control groups, those with systemic rheumatologic condition or hidradenitis suppurativa were excluded. The primary outcomes were adverse pregnancy outcomes defined as spontaneous abortion, gestational hypertension, preeclampsia or eclampsia, gestational diabetes mellitus, intrauterine growth restriction, preterm premature rupture of membranes, preterm birth, and stillbirth. Patients with autoimmune skin diseases and controls were 1:1 propensity score-matched by age, race, ethnicity, comorbidities, obesity, and substance use. For each outcome, odds ratio with a 95% confidence interval was calculated.

RESULTS

A total of 2788 patients with autoimmune skin diseases were matched to 2788 healthy controls. Patients with autoimmune skin diseases were at a higher risk of spontaneous abortions than controls (odds ratio, 1.54; 95% confidence interval, 1.36-1.75; P<.001). Compared with patients with systemic lupus erythematosus, patients with autoimmune skin diseases were at lower risk of having infants with intrauterine growth restriction (odds ratio, 0.59; 95% confidence interval, 0.4-0.87; P=.01), preterm birth (odds ratio, 0.68; 95% confidence interval, 0.47-0.98; P=.04), and stillbirth (odds ratio, 0.50; 95% confidence interval, 0.25-0.97; P=.04). The differences in adverse pregnancy outcomes between patients with autoimmune skin diseases and those with rheumatoid arthritis were not statistically significant.

CONCLUSION

Patients with autoimmune skin diseases are at a higher risk of spontaneous abortions than patients without autoimmune skin diseases. When analyzed by each autoimmune skin disease, patients with cutaneous lupus erythematosus or vitiligo remained at increased risk of spontaneous abortions compared with patients without autoimmune skin diseases. Patients with autoimmune skin diseases have similar risks of adverse pregnancy outcomes as patients with rheumatoid arthritis, but lower risks than patients with systemic lupus erythematosus.

Alopecia areata: What's new in the epidemiology, comorbidities, and pathogenesis?

BACKGROUND

Alopecia areata (AA) is a common, acquired, and nonscarring type of hair loss that affects people of every generation and is intractable in severe and relapsing cases. Patients with AA, especially those with greater scalp involvement, have poor health-related quality-of-life scores.

PURPOSE

Following our previous review article in the April 2017 issue of the Journal of Dermatological Science, we aim to provide a pair of review articles on recent progress in multidisciplinary approaches to AA.

MAIN FINDINGS

We found more than 1800 publications on AA from July 2016 to December 2022.

CONCLUSIONS

In this review, we focused on the latest information on the epidemiology, comorbidities, and pathogenesis of AA.

Treatments for Moderate-to-Severe Alopecia Areata: A Systematic Narrative Review

Treatments for alopecia areata (AA) have traditionally been prescribed off-label, and there has been no universal agreement on how to best manage the condition. Baricitinib is the first oral selective Janus kinase (JAK) inhibitor approved for the treatment of adults with severe AA. As a better understanding of the evidence supporting the management of AA in clinical practice is needed, we conducted a systematic literature review and subsequent narrative review to describe available evidence pertaining to the efficacy and tolerability of treatments currently recommended for adults with moderate-to-severe forms of AA. From 2557 identified records, a total of 53 records were retained for data extraction: 9 reported data from 7 randomized controlled trials (RCTs) versus placebo, and 44 reported data from unique RCTs with no placebo arm, non-randomized trials, or observational studies. Across drug classes, data were reported heterogeneously, with little consistency of data collection or clinical endpoints used. The most robust evidence was for the JAK inhibitor class, in particular the JAK1/JAK2 inhibitor baricitinib. Five RCTs (three for baricitinib) demonstrated a consistent benefit of JAK inhibitor therapy over placebo across various clinical outcomes in adult patients with at least 50% scalp hair loss. Overall, hair regrowth varied widely for the other drug classes and was generally low for patients with moderate-to-severe AA. Relapses were commonly observed during treatment and upon discontinuation. Adverse effects were generally consistent with the known safety profile of each intervention. The heterogeneity observed prevented the conduct of a network meta-analysis or an indirect comparison of different treatments. We found that the current management of patients with moderate-to-severe AA often relies on the use of treatments that have not been well evaluated in clinical trials. The most robust evidence identified supported the use of baricitinib, and other oral JAK inhibitors, in patients with severe AA.

Physician- and Patient-Reported Severity and Quality of Life Impact of Alopecia Areata: Results from a Real-World Survey in Five European Countries

INTRODUCTION

Alopecia areata (AA) can negatively affect quality of life (QoL) and is associated with increased prevalence of anxiety and depression (vs people without AA). This study compared physician-assessed and patient self-rated severity of AA in a European sample and described the patient-reported burden of AA stratified by physician-assessed severity.

METHODS

Real-world data were collected from the Adelphi Real World AA Disease Specific Programme™, a retrospective point-in-time cross-sectional survey of dermatologists and their adult patients with AA in five European countries (France, Germany, Italy, Spain, UK). Physicians provided clinical data and an AA severity assessment, according to their own definition of 'mild', 'moderate' and 'severe'. Patients were invited to provide their perception of AA severity and completed patient-reported outcome (PRO) questionnaires, including Skindex-16 for AA (Skindex-16 AA), EuroQol-5-dimension questionnaire 5-level (EQ-5D-5L), Hospital Anxiety and Depression Scale and the Work Productivity and Activity Impairment Questionnaire.

RESULTS

Data for 2083 patients were collected by 239 physicians; 561 of these patients completed PRO questionnaires. In 78.5% of cases with available data (N = 549), there was alignment between patient and physician-rated AA severity (severity was rated higher by physicians in 15.7% of cases, by patients in 5.8% of cases). Data from all PRO instruments showed an increase in patient-reported burden and work and activity impairment with increasing physician-rated AA severity. For the Skindex-16 AA, the Emotions scale had the worst scores; anxiety/depression was the EQ-5D-5L dimension with the highest percentages of patients reporting any perceived problem.

CONCLUSIONS

These data highlight the significant impact that AA can have beyond hair loss, especially for patients with severe AA. There was substantial physician-patient alignment on severity assessment. Higher physician-rated AA severity was associated with higher levels of patient-reported disease burden, including anxiety and depression, and work and activity impairment. These data may help inform appropriate treatment strategies.

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.

Inhibition of T-cell activity in alopecia areata: recent developments and new directions

Alopecia areata (AA) is an autoimmune disease that has a complex underlying immunopathogenesis characterized by nonscarring hair loss ranging from small bald patches to complete loss of scalp, face, and/or body hair. Although the etiopathogenesis of AA has not yet been fully characterized, immune privilege collapse at the hair follicle (HF) followed by T-cell receptor recognition of exposed HF autoantigens by autoreactive cytotoxic CD8+ T cells is now understood to play a central role. Few treatment options are available, with the Janus kinase (JAK) 1/2 inhibitor baricitinib (2022) and the selective JAK3/tyrosine kinase expressed in hepatocellular carcinoma (TEC) inhibitor ritlecitinib (2023) being the only US Food and Drug Administration-approved systemic medications thus far for severe AA. Several other treatments are used off-label with limited efficacy and/or suboptimal safety and tolerability. With an increased understanding of the T-cell-mediated autoimmune and inflammatory pathogenesis of AA, additional therapeutic pathways beyond JAK inhibition are currently under investigation for the development of AA therapies. This narrative review presents a detailed overview about the role of T cells and T-cell-signaling pathways in the pathogenesis of AA, with a focus on those pathways targeted by drugs in clinical development for the treatment of AA. A detailed summary of new drugs targeting these pathways with expert commentary on future directions for AA drug development and the importance of targeting multiple T-cell-signaling pathways is also provided in this review.

Utilization of Rosuvastatin and Endogenous Biomarkers in Evaluating the Impact of Ritlecitinib on BCRP, OATP1B1, and OAT3 Transporter Activity

PURPOSE

Ritlecitinib, an inhibitor of Janus kinase 3 and tyrosine kinase expressed in hepatocellular carcinoma family kinases, is in development for inflammatory diseases. This study assessed the impact of ritlecitinib on drug transporters using a probe drug and endogenous biomarkers.

METHODS

In vitro transporter-mediated substrate uptake and inhibition by ritlecitinib and its major metabolite were evaluated. Subsequently, a clinical drug interaction study was conducted in 12 healthy adult participants to assess the effect of ritlecitinib on pharmacokinetics of rosuvastatin, a substrate of breast cancer resistance protein (BCRP), organic anion transporting polypeptide 1B1 (OATP1B1), and organic anion transporter 3 (OAT3). Plasma concentrations of coproporphyrin I (CP-I) and pyridoxic acid (PDA) were assessed as endogenous biomarkers for OATP1B1 and OAT1/3 function, respectively.

RESULTS

In vitro studies suggested that ritlecitinib can potentially inhibit BCRP, OATP1B1 and OAT1/3 based on regulatory cutoffs. In the subsequent clinical study, coadministration of ritlecitinib decreased rosuvastatin plasma exposure area under the curve from time 0 to infinity (AUCinf) by  ~ 13% and maximum concentration (Cmax) by  ~ 27% relative to rosuvastatin administered alone. Renal clearance was comparable in the absence and presence of ritlecitinib coadministration. PK parameters of AUCinf and Cmax for CP-I and PDA were also similar regardless of ritlecitinib coadministration.

CONCLUSION

Ritlecitinib does not inhibit BCRP, OATP1B1, and OAT3 and is unlikely to cause a clinically relevant interaction through these transporters. Furthermore, our findings add to the body of evidence supporting the utility of CP-I and PDA as endogenous biomarkers for assessment of OATP1B1 and OAT1/3 transporter activity.

An Update on Alopecia and its Association With Thyroid Autoimmune Diseases

Alopecia is comorbid with several illnesses, including various autoimmune conditions such as thyroid disease. Leukocyte-mediated inflammation of hair follicles in alopecia was first described over a century ago. However, the high prevalence of the role of thyroid autoimmune disease in the pathogenesis of alopecia has only recently come to light, together with a strong association between the two. Therefore, this review focuses on articles published between 2011 and 2022 on alopecia's association with thyroid autoimmune disease, and the mechanism behind it. In addition, it highlights the link between alopecia and thyroid cancer, as patients with alopecia have increased risk of thyroid cancer. In conclusion, this comprehensive, focused, scoping review will serve as a reference highlighting recent information on alopecia, exploring its association with thyroid autoimmune diseases.

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.

Treatments for alopecia areata: a network meta-analysis

BACKGROUND

Alopecia areata is an autoimmune disease leading to nonscarring hair loss on the scalp or body. There are different treatments including immunosuppressants, hair growth stimulants, and contact immunotherapy.

OBJECTIVES

To assess the benefits and harms of the treatments for alopecia areata (AA), alopecia totalis (AT), and alopecia universalis (AU) in children and adults.

SEARCH METHODS

The Cochrane Skin Specialised Register, CENTRAL, MEDLINE, Embase, ClinicalTrials.gov and WHO ICTRP were searched up to July 2022.

SELECTION CRITERIA

We included randomised controlled trials (RCTs) that evaluated classical immunosuppressants, biologics, small molecule inhibitors, contact immunotherapy, hair growth stimulants, and other therapies in paediatric and adult populations with AA.

DATA COLLECTION AND ANALYSIS

We used the standard procedures expected by Cochrane including assessment of risks of bias using RoB2 and the certainty of the evidence using GRADE. The primary outcomes were short-term hair regrowth ≥ 75% (between 12 and 26 weeks of follow-up), and incidence of serious adverse events. The secondary outcomes were long-term hair regrowth ≥ 75% (greater than 26 weeks of follow-up) and health-related quality of life. We could not perform a network meta-analysis as very few trials compared the same treatments. We presented direct comparisons and made a narrative description of the findings.

MAIN RESULTS

We included 63 studies that tested 47 different treatments in 4817 randomised participants. All trials used a parallel-group design except one that used a cross-over design. The mean sample size was 78 participants. All trials recruited outpatients from dermatology clinics. Participants were between 2 and 74 years old. The trials included patients with AA (n = 25), AT (n = 1), AU (n = 1), mixed cases (n = 31), and unclear types of alopecia (n = 4). Thirty-three out of 63 studies (52.3%) reported the proportion of participants achieving short-term hair regrowth ≥ 75% (between 12 and 26 weeks). Forty-seven studies (74.6%) reported serious adverse events and only one study (1.5%) reported health-related quality of life. Five studies (7.9%) reported the proportion of participants with long-term hair regrowth ≥ 75% (greater than 26 weeks). Amongst the variety of interventions found, we prioritised some groups of interventions for their relevance to clinical practice: systemic therapies (classical immunosuppressants, biologics, and small molecule inhibitors), and local therapies (intralesional corticosteroids, topical small molecule inhibitors, contact immunotherapy, hair growth stimulants and cryotherapy). Considering only the prioritised interventions, 14 studies from 12 comparisons reported short-term hair regrowth ≥ 75% and 22 studies from 10 comparisons reported serious adverse events (18 reported zero events and 4 reported at least one). One study (1 comparison) reported quality of life, and two studies (1 comparison) reported long-term hair regrowth ≥ 75%. For the main outcome of short-term hair regrowth ≥ 75%, the evidence is very uncertain about the effect of oral prednisolone or cyclosporine versus placebo (RR 4.68, 95% CI 0.57 to 38.27; 79 participants; 2 studies; very low-certainty evidence), intralesional betamethasone or triamcinolone versus placebo (RR 13.84, 95% CI 0.87 to 219.76; 231 participants; 1 study; very low-certainty evidence), oral ruxolitinib versus oral tofacitinib (RR 1.08, 95% CI 0.77 to 1.52; 80 participants; 1 study; very low-certainty evidence), diphencyprone or squaric acid dibutil ester versus placebo (RR 1.16, 95% CI 0.79 to 1.71; 99 participants; 1 study; very-low-certainty evidence), diphencyprone or squaric acid dibutyl ester versus topical minoxidil (RR 1.16, 95% CI 0.79 to 1.71; 99 participants; 1 study; very low-certainty evidence), diphencyprone plus topical minoxidil versus diphencyprone (RR 0.67, 95% CI 0.13 to 3.44; 30 participants; 1 study; very low-certainty evidence), topical minoxidil 1% and 2% versus placebo (RR 2.31, 95% CI 1.34 to 3.96; 202 participants; 2 studies; very low-certainty evidence) and cryotherapy versus fractional CO2 laser (RR 0.31, 95% CI 0.11 to 0.86; 80 participants; 1 study; very low-certainty evidence). The evidence suggests oral betamethasone may increase short-term hair regrowth ≥ 75% compared to prednisolone or azathioprine (RR 1.67, 95% CI 0.96 to 2.88; 80 participants; 2 studies; low-certainty evidence). There may be little to no difference between subcutaneous dupilumab and placebo in short-term hair regrowth ≥ 75% (RR 3.59, 95% CI 0.19 to 66.22; 60 participants; 1 study; low-certainty evidence) as well as between topical ruxolitinib and placebo (RR 5.00, 95% CI 0.25 to 100.89; 78 participants; 1 study; low-certainty evidence). However, baricitinib results in an increase in short-term hair regrowth ≥ 75% when compared to placebo (RR 7.54, 95% CI 3.90 to 14.58; 1200 participants; 2 studies; high-certainty evidence). For the incidence of serious adverse events, the evidence is very uncertain about the effect of topical ruxolitinib versus placebo (RR 0.33, 95% CI 0.01 to 7.94; 78 participants; 1 study; very low-certainty evidence). Baricitinib and apremilast may result in little to no difference in the incidence of serious adverse events versus placebo (RR 1.47, 95% CI 0.60 to 3.60; 1224 participants; 3 studies; low-certainty evidence). The same result is observed for subcutaneous dupilumab compared to placebo (RR 1.54, 95% CI 0.07 to 36.11; 60 participants; 1 study; low-certainty evidence). For health-related quality of life, the evidence is very uncertain about the effect of oral cyclosporine compared to placebo (MD 0.01, 95% CI -0.04 to 0.07; very low-certainty evidence). Baricitinib results in an increase in long-term hair regrowth ≥ 75% compared to placebo (RR 8.49, 95% CI 4.70 to 15.34; 1200 participants; 2 studies; high-certainty evidence). Regarding the risk of bias, the most relevant issues were the lack of details about randomisation and allocation concealment, the limited efforts to keep patients and assessors unaware of the assigned intervention, and losses to follow-up.

AUTHORS' CONCLUSIONS

We found that treatment with baricitinib results in an increase in short- and long-term hair regrowth compared to placebo. Although we found inconclusive results for the risk of serious adverse effects with baricitinib, the reported small incidence of serious adverse events in the baricitinib arm should be balanced with the expected benefits. We also found that the impact of other treatments on hair regrowth is very uncertain. Evidence for health-related quality of life is still scant.

Efficacy, safety, and Pharmacoeconomics of Three Common Strategies for Pediatric Alopecia Areata Patients: A Retrospective Cohort Study

Objective

To evaluate and explore the efficacy, safety, and pharmacoeconomics of three common strategies for pediatric alopecia areata.

Methods

Chinese pediatric alopecia areata patients meeting the criteria were included and divided into three groups based on the received treatments. The efficacy, adverse events and pharmacoeconomics of these treatments were retrospectively analyzed.

Results

Twenty-four pediatric AA patients were recruited in this study. 100% (12/12) of patients from the traditional group achieved SALT100. In the tofacitinib group, 40.0% (2/5) of patients achieved SALT50. 20.0% (1/5) of patients achieved SALT75 and 40.0% (2/5) of patients achieved SALT100. In the MN group, 42.86% (3/7) of patients were non-responders. 14.28 (1/7) of patients achieved SALT75 and 42.86% (3/7) of patients achieved SALT100. The adverse effects (AEs) were mild in all three groups, and none of the patients discontinued the treatments due to the AEs. Comparing the other two groups, the MN treatment would be more time-intensive and more expensive.

Conclusion

For newly diagnosed or naive pediatric patients, the traditional treatment was the first-line approach. For long-duration, severe and refractory patients, tofacitinib and microneedling can be alternative options.

Screening for latent infectious disease in patients with alopecia areata before initiating JAK inhibitors therapy: a single-center real-world retrospective study

Introduction

Although there is growing evidence supporting the effectiveness of Janus kinase (JAK) inhibitors in treating alopecia areata, the high rate of recurrence following drug discontinuation has led to prolonged treatment courses and raised concerns about long-term safety. In clinical practice, caution should be exercised while using JAK inhibitors for various indications, and a comprehensive pre-treatment screening.

Methods

This study presents an analysis of screening data collected from real-world settings before the initiation of Janus kinase inhibitors in patients with alopecia areata. Investigators collected retrospective medical data characterizing patients' screening data. Data on demographic and clinical data, including age, sex, disease duration, severity of alopecia tool scale, history of prior treatment, and treatment regimen were recorded.

Results

In this cohort (N = 218), JAK inhibitors were initiated for 163 of 218 (74.8%) alopecia areata patients. The numbers of patients positive for antinuclear antibodies, hepatitis B surface antigen, hepatitis C virus antibodies, human immunodeficiency virus antibody, treponema pallidum hemagglutination assay, and thyroid-stimulating hormone were 32 (32/176), 10(10/218), 0 (0/218), 0 (0/218), 3 (3/218) and 9 (9/176), respectively. The number of patients with T-cell spot positive or imaging of the chest indicating tuberculosis was 37 (37/218).

Disccusion

Our data provide additional information on the safety profile of JAK inhibitors in patients with alopecia areata. As such, it is necessary and crucial to screen for JAK inhibitors before it is used, particularly for individuals with a high risk of tuberculosis, hepatitis B, and other infections.