Bidirectional association between alopecia areata and major depressive disorder among probands and unaffected siblings: A nationwide population-based study

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.

Depressive Disorder and Dermatological Autoimmune Diseases

Depressive disorders are a growing problem worldwide. They are also characterized by high comorbidity, including from the circle of dermatological diseases. Autoimmune diseases seem to be particularly correlated with depressive comorbidity, raising the question of their possible common pathomechanism. The PubMed database was searched, focusing on results published after 2016. A particular reciprocal correlation of depressive disorders with psoriasis, atopic dermatitis, alopecia areata, impetigo, lupus and systemic scleroderma was found. One possible explanation for the co-occurrence of the above diseases is that the inflammatory theory may be applicable to depression, the various elements of which also apply to autoimmune diseases.

Autoimmune, Inflammatory, Atopic, Thyroid, and Psychiatric Outcomes of Offspring Born to Mothers With Alopecia Areata

Importance

Alopecia areata (AA) is associated with diverse autoimmune and psychiatric disorders. However, an investigation on the long-term outcomes for offspring born to mothers diagnosed with AA is lacking.

Objective

To investigate the risks for autoimmune, inflammatory, atopic, thyroid, and psychiatric outcomes of offspring born to mothers with AA.

Design, Setting, and Participants

This retrospective population-based birth cohort study used the linked birth registration database with the Nationwide Health Insurance Service database of Korea. The participants included all newborns born to mothers with 3 or more visits with International Classification of Diseases, Tenth Revision code of L63 and 1:10 birth year, sex, insurance, income, and location of residence-matched control offspring born to mothers without AA during the years from 2003 to 2015. The analysis was conducted from July 2022 to January 2023.

Exposure

Maternal AA.

Main Outcomes and Measures

The occurrence of the following diseases was measured in newborns from birth to December 31, 2020: AA, alopecia totalis/universalis (AT/AU), vitiligo, psoriasis, inflammatory bowel disease, rheumatoid arthritis, atopic dermatitis, allergic rhinitis, asthma, hyperthyroidism, hypothyroidism, Graves disease, Hashimoto thyroiditis, attention-deficit hyperactivity disorder, mood disorder, and anxiety disorder. Multivariable Cox proportional hazard analyses were performed with the following covariates: birth year, age, insurance type, income level, location of residence, maternal age, mode of delivery, maternal history of atopic disorders, and autoimmune disorders.

Results

In total, 67 364 offspring born to 46 352 mothers with AA and 673 640 controls born to 454 085 unaffected mothers were analyzed. The risk of AA (adjusted hazard ratio [aHR], 2.08; 95% CI, 1.88-2.30), AT/AU (aHR, 1.57; 95% CI, 1.18-2.08), vitiligo (aHR, 1.47; 95% CI, 1.32-1.63), atopic disorders (aHR, 1.07; 95% CI, 1.06-1.09), hypothyroidism (aHR, 1.14; 95% CI, 1.03-1.25), and psychiatric disorders (aHR, 1.15; 95% CI, 1.11-1.20) was significantly increased in offspring born to mothers with AA. Among them, 5088 born to mothers with AT/AU were at much greater risk for the development of AT/AU (aHR, 2.98; 95% CI, 1.48-6.00) and psychiatric disorders (aHR, 1.27; 95% CI, 1.12-1.44).

Conclusions and Relevance

In this Korean retrospective population-based birth cohort study, maternal AA was associated with the development of autoimmune/inflammatory, atopic, thyroid, and psychiatric disorders in their offspring. Clinicians and parents need to be aware of the potential for these comorbidities to occur.

The burden of alopecia areata: A scoping review focusing on quality of life, mental health and work productivity

Alopecia areata (AA) is a common inflammatory autoimmune disease of the hair which can have a significant negative impact on quality of life (QoL), mental health and productivity. The aim of this scoping review is to elucidate the burden of AA focusing on these three realms. Inclusion criteria included all original manuscripts with no restriction on study type or statistical method written in English (or having an English abstract). For QoL 40 articles were included, 85 for psychiatric comorbidities, and 9 for work/school absenteeism/presenteeism mostly consisting of cross-sectional and observational cohort studies. QoL impairment was detected in over 75% of patients and up to one-third reported extremely severe QoL impairments. Specific QoL dimensions with the greatest impact were embarrassment, social functioning, as well as shopping and/or housework. Cross-sectional studies assessing the psychological burden of adult patients with AA found that the presence of signs of anxiety and/or depression ranged from 30% to 68% and affected all age groups. Rates of work absenteeism and unemployment were significantly higher in AA patients compared to healthy controls. Up to 62% reported making major life decisions including relationships, education and career based on their AA. Additionally, the extensive camouflage techniques and time lost from work led to a strong financial burden for patients and the numerous physician visits added to the healthcare costs. The overall impact of AA stretches much further than simply being an aesthetic concern and can negatively impact every part of an individual's life. An individualized approach and effective treatments will help reduce the psychosocial consequences and distress and return patients to their normal state of health.

Exploring the overlap between alopecia areata and major depressive disorder: Epidemiological and genetic perspectives

BACKGROUND

Research suggests that Alopecia areata (AA) and Major Depressive Disorder (MDD) show substantial comorbidity. To date, no study has investigated the hypothesis that this is attributable to shared genetic aetiology.

OBJECTIVES

To investigate AA-MDD comorbidity on the epidemiological and molecular genetic levels.

METHODS

First, epidemiological analyses were performed using data from a cohort of adult German health insurance beneficiaries (n = 1.855 million) to determine the population-based prevalence of AA-MDD comorbidity. Second, analyses were performed to determine the prevalence of MDD in a clinical AA case-control sample with data on psychiatric phenotypes, stratifying for demographic factors to identify possible contributing factors to AA-MDD comorbidity. Third, the genetic overlap between AA and MDD was investigated using a polygenic risk score (PRS) approach and linkage disequilibrium score (LDSC) regression. For PRS, summary statistics from a large MDD GWAS meta-analysis (PGC-MD2) were used as the training sample, while a Central European AA cohort, including the above-mentioned AA patients, and an independent replication US-AA cohort were used as target samples. LDSC was performed using summary statistics of PGC-MD2 and the largest AA meta-analysis to date.

RESULTS

High levels of AA-MDD comorbidity were reported in the population-based (MDD in 24% of AA patients), and clinical samples (MDD in 44% of AA patients). MDD-PRS explained a modest proportion of variance in AA case-control status (R²  = 1%). This signal was limited to the major histocompatibility complex (MHC) region on chromosome 6. LDSC regression (excluding MHC) revealed no significant genetic correlation between AA and MDD.

CONCLUSIONS

As in previous research, AA patients showed an increased prevalence of MDD. The present analyses suggest that genetic overlap may be confined to the MHC region, which is implicated in immune function. More detailed investigation is required to refine understanding of how the MHC is involved in the development of AA and MDD comorbidity.

Novel potential therapeutic targets of alopecia areata

Alopecia areata (AA) is a non-scarring hair loss disorder caused by autoimmunity. The immune collapse of the hair follicle, where interferon-gamma (IFN-γ) and CD8+ T cells accumulate, is a key factor in AA. However, the exact functional mechanism remains unclear. Therefore, AA treatment has poor efficacy maintenance and high relapse rate after drug withdrawal. Recent studies show that immune-related cells and molecules affect AA. These cells communicate through autocrine and paracrine signals. Various cytokines, chemokines and growth factors mediate this crosstalk. In addition, adipose-derived stem cells (ADSCs), gut microbiota, hair follicle melanocytes, non-coding RNAs and specific regulatory factors have crucial roles in intercellular communication without a clear cause, suggesting potential new targets for AA therapy. This review discusses the latest research on the possible pathogenesis and therapeutic targets of AA.

Anxiety, depression, and quality of life in children and adults with alopecia areata: A systematic review and meta-analysis

Introduction

Alopecia areata (AA) is a non-scarring hair loss condition, subclassified into AA, alopecia universalis, and alopecia totalis. There are indications that people with AA experience adverse psychosocial outcomes, but previous studies have not included a thorough meta-analysis and did not compare people with AA to people with other dermatological diagnoses. Therefore, the aim of this systematic review and meta-analysis was to update and expand previous systematic reviews, as well as describing and quantifying levels of anxiety, depression, and quality of life (QoL) in children and adults with AA.

Methods

A search was conducted, yielding 1,249 unique records of which 93 were included.

Results

Review results showed that people with AA have higher chances of being diagnosed with anxiety and/or depression and experience impaired QoL. Their psychosocial outcomes are often similar to other people with a dermatological condition. Meta-analytic results showed significantly more symptoms of anxiety and depression in adults with AA compared to healthy controls. Results also showed a moderate impact on QoL. These results further highlight that AA, despite causing little physical impairments, can have a significant amount on patients' well-being.

Discussion

Future studies should examine the influence of disease severity, disease duration, remission and relapse, and medication use to shed light on at-risk groups in need of referral to psychological care.

Systematic review registration

[https://www.crd.york.ac.uk/prospero/], identifier [CRD42022323174].

Analysis of alopecia areata surveys suggests a threshold for improved patient-reported outcomes

BACKGROUND

Although alopecia areata (AA) greatly impacts patients' quality of life (QoL), there is no adequate validation of AA-targeted QoL surveys in clinical trials, hindering sufficient representation of patient-reported outcomes.

OBJECTIVES

Better understanding of patient-reported outcomes may guide treatment goals and future clinical trials.

METHODS

In a recent randomized controlled trial testing dupilumab in AA, patients were administered the Alopecia Areata Quality of Life Index (AA-QLI) and the Alopecia Areata Symptom Impact Scale (AASIS) surveys, specifically evaluating QoL in patients with AA. An in-depth analysis was performed to assess the utility of these questionnaires in this patient population, both at baseline and after treatment, and to determine a threshold for improved patient-reported outcomes.

RESULTS

While AASIS correlated with baseline Severity of Alopecia Tool (SALT) scores and with therapeutic response, AA-QLI showed no correlation with AA severity before or after treatment. Itch strongly correlated with serum IgE levels across both surveys. Using various approaches to estimate a discriminative threshold for decreased impact of AA on QoL (by AASIS) following treatment, a SALT score of 20 points or less post-treatment was associated with improved patient-reported outcomes, including both AA-related symptoms and items within the daily activities/feelings domain such as 'feeling sad' and 'feeling anxious or worry'.

CONCLUSIONS

AASIS is better than AA-QLI to assess patient-reported outcomes. SALT ≤ 20 following treatment should be considered as a threshold for meaningful therapeutic outcome and as a clinical endpoint in future clinical trials for AA. What is already known about this topic? Alopecia areata greatly compromises quality of life, and affected patients have increased prevalences of depression, anxiety and social phobia. Despite the significant negative impact of the disease on patients' wellbeing, validation of targeted questionnaires in alopecia areata is lacking, and a therapeutic response threshold for improved patient-reported outcomes is unknown. What does this study add? This study investigated the utility of two different alopecia areata-targeted questionnaires - Alopecia Areata Quality of Life Index and Alopecia Areata Symptom Impact Scale (AASIS) - in a clinical trial setting. AASIS was found to correlate strongly with alopecia areata severity and clinical response. What are the clinical implications of this work? Patients with ≤ 20% scalp hair loss after treatment reported improvement in multiple quality-of-life items, suggesting this as a meaningful therapeutic outcome that may guide clinicians and improve the development of future clinical trials.

Health-related quality of life in patients with alopecia areata: Results of a Japanese survey with norm-based comparisons

Alopecia areata (AA) is a non-scarring hair loss disorder affecting approximately 2% of the global population. AA is reported to have a significant negative impact on the emotional and psychological well-being of the patients. This study aimed to evaluate the health-related quality of life (HRQoL) of Japanese patients with AA in comparison to the Japanese population norms (national standard values for Japanese) using Short Form Health Survey 36 Item Version 2.0 (SF-36v2). The study also aimed to access the negative effect of AA on patients' daily lives and the proportion of patients having anxiety and/or depression. This cross-sectional, non-interventional web-based survey study included 400 participants aged 17-84 years currently suffering from medically diagnosed AA. The assessment tools integrated in the online questionnaire included SF-36v2, the Dermatology Life Quality Index (DLQI), and the Hospital Anxiety and Depression Scale (HADS). All outcome measures from the tools were evaluated across the study population. SF-36v2 subscale scores for patients with AA revealed lower scores specifically for mental health (45.7 ± 10.1 points), social functioning (45.8 ± 10.9 points), vitality (46.2 ± 9.8 points), and role emotional (46.9 ± 11.6 points) as compared to the Japanese population norms of 50 ± 10 points each. The DLQI questionnaire-based analysis indicated that 32.1% of respondents showed a moderate to extremely large effect on their lives; and HADS-A (anxiety) and HADS-D (depression) scores categorized 46.0% and 41.8% respondents as doubtful-to-definite cases, respectively. Multivariate linear regression revealed that hair loss range, age, comorbidities, and depression significantly worsened DLQI scores. In conclusion, the results of this survey demonstrated that a significant decrease in the HRQoL scores was observed in Japanese patients with AA in comparison with the national norms. Hence, emphasis on mental health is crucial for AA management.

Alopecia Areata as a Proximal Risk Factor for the Development of Comorbid Depression: A Population-based Study

Alopecia areata and depression tend to co-occur; however, their temporal association has not been comprehensively investigated. The aim of this study was to examine the temporal association between alopecia areata and depression. The study included only cases with a comorbid presentation of alopecia areata and depression (n = 1,936), extracted from the databases of the Clalit Health Services, Israel. Survival analyses were used to assess the cumulative probability of receiving alopecia areata as comorbid diagnosis in the years following depression, and vice versa, compared with the opposite trajectory. The results indicate that patients with alopecia areata had greater odds of subsequent depression within 2 years from alopecia areata diagnosis, and showed a steeper increase in cumulative probability of depression as time progressed (log-rank =336.38, p < 0.001), compared with the opposite trajectory. All patients with alopecia areata had comorbid depression within 10 years of alopecia areata, compared with 70% of depression patients receiving diagnoses of comorbid alopecia areata within the same time-frame.

Obsessive-compulsive disorder and the associated risk of autoimmune skin diseases: a nationwide population-based cohort study

BACKGROUND

The concurrent incidence of autoimmune comorbidities in obsessive-compulsive disorder (OCD) is known. However, the association between OCD and related autoimmune skin diseases (ASDs) has not been well studied.

OBJECTIVE

This study aimed to investigate the association between OCD and the risk of ASDs.

METHODS

To assess the risk of developing ASDs, we recruited 44 324 patients with OCD and 177 296 matched controls from the National Health Insurance Research Database in Taiwan. A Cox regression model was used for the analyses.

RESULTS

After adjusting for confounders, an increased risk of ASDs among the patients with OCD (adjusted hazard ratio [aHR]: 6.36; 95% confidence interval [CI]: 5.43-7.45) was found when compared to the controls. Statistically significant associations were found between OCD and seven individual ASDs, including psoriasis (aHR: 12.52; 95% CI: 8.78-17.85), lichen planus (aHR: 27.22; 95% CI: 13.09-56.60), alopecia areata (aHR: 13.69; 95% CI: 9.38-19.98), autoimmune bullous diseases (aHR: 4.30; 95% CI: 2.03-9.11), hidradenitis suppurativa (aHR: 29.95; 95% CI: 3.35-267.62), vitiligo (aHR: 9.35; 95% CI: 5.35-16.32), and lupus erythematosus (aHR: 2.10; 95% CI: 1.52-2.91).

CONCLUSIONS

Patients with OCD had an increased risk of developing ASDs compared to matched controls. Further studies are required to clarify the underlying mechanisms.

Association between alopecia areata and retinal diseases: A nationwide population-based cohort study

BACKGROUND

Growing evidence has revealed abnormalities in the retinal structures of patients with alopecia areata (AA). However, the relationship between AA and retinopathy remains unclear.

OBJECTIVE

To investigate the association between AA and retinal diseases.

METHODS

The study participants were recruited from the National Health Insurance Research Database in Taiwan. We included 9909 patients with AA and 99,090 matched controls to assess the risk of retinal diseases. A Cox regression model was used for all analyses.

RESULTS

Compared with the controls, patients with AA had an adjusted hazard ratio (aHR) of 3.10 (95% confidence interval [CI] 2.26-4.26) for retinal diseases. With respect to individual retinal diseases, Patients with AA had significantly higher risks of developing retinal detachment (aHR 3.98; 95% CI 2.00-7.95), retinal vascular occlusion (aHR 2.45; 95% CI 1.22-4.92), and retinopathy (aHR 3.24; 95% CI 2.19-4.81) than controls.

LIMITATIONS

This was a retrospective cohort study. Meanwhile, almost all the participating individuals were residents of Taiwan; therefore, the validity of our findings in other demographics remains unclear.

CONCLUSION

Patients with AA had a significantly higher risk of retinal disease than controls. Further studies are needed to clarify the pathophysiology of AA and retinal diseases.

Alopecia Areata Treatment Patterns, Healthcare Resource Utilization, and Comorbidities in the US Population Using Insurance Claims

Introduction

Alopecia areata (AA) is an autoimmune disorder causing sudden, non-scarring hair loss. There are currently no drugs approved for AA treatment. This study assessed prevalence of comorbidities, treatments, and healthcare costs and resource utilization among patients with AA in the USA.

Methods

Patients diagnosed with AA between January 2011 and December 2018 were identified in IBM MarketScan^® Research Databases. Eligible patients had no other hair loss-related disorders and were continuously enrolled with medical and pharmacy benefits at least 12 months before and after AA diagnosis. Descriptive statistics were used to summarize comorbid conditions, treatments related to AA or other autoimmune/inflammatory conditions, and all-cause and AA-specific healthcare costs and resource utilization identified from claims data.

Results

A total of 68,121 patients with AA were identified. Mean (SD) age was 40.3 (17.8) years and 61.0% were female. The most common comorbidities included hyperlipidemia (22.4%), hypertension (21.8%), thyroid disorders (13.1%), contact dermatitis or eczema (10.8%), depression (9.5%), and anxiety (8.4%). Comorbid autoimmune diseases included atopic dermatitis (2.8%), psoriasis (2.1%), chronic urticaria (1.5%), and rheumatoid arthritis (1.1%). During the 12-month follow-up period, 37,995 patients (55.8%) were prescribed treatment for their AA or other comorbid autoimmune/inflammatory disease; 44.9% of treated patients were prescribed therapy within 7 days of AA diagnosis. Of patients receiving treatment, 80.3% received topical steroids and 30.0% received oral steroids. Mean (SD) total healthcare costs were $11,241.21 ($43,839.69) for all-causes and $419.12 ($1534.99) for AA. AA-related expenses were driven by outpatient and prescription costs.

Conclusion

Patients with AA have a high comorbidity burden and lack of treatment. Current AA treatments, including systemic therapies other than oral steroids, were not frequently utilized in this study population. Healthcare costs incurred by patients with AA went beyond AA-related expenses. Longitudinal data are needed to better understand treatment trajectories and the disease burden in patients with AA.

Supplementary Information

The online version contains supplementary material available at 10.1007/s12325-021-01845-0.

Association between hepatitis C virus infection and subsequent chronic inflammatory skin disease

Hepatitis C virus (HCV) infection is associated with several cutaneous manifestations, including lichen planus and psoriasis. However, its association with other chronic inflammatory skin diseases (CISD) remains largely unknown. The aim of this study was to investigate the association between HCV infection and CISD. Participants were recruited from the National Health Insurance Research Database in Taiwan. Altogether 23 509 patients with HCV infection and 94 036 matched controls were included to assess the risk of CISD. A Cox regression model was used for the analyses. Compared with controls, patients with HCV infection had an adjusted hazard ratio (aHR) of 6.34 (95% confidence interval [CI], 5.30-7.58) for CISD after adjustment for potential confounders. Regarding individual CISD, patients with HCV infection had a significantly increased risk of developing lichen planus, psoriasis, vitiligo, alopecia areata, and cutaneous lupus erythematosus. Interferon-based antiviral therapy (IFN-based AVT) was significantly associated with a decreased risk of CISD (aHR = 0.42; 95% CI, 0.28-0.64). Patients with HCV infection had a significantly increased risk of CISD, while IFN-based AVT was associated with a decreased risk. These findings suggest monitoring of CISD in patients with HCV infection.

Use of primary care services among patients with chronic skin disease seen by dermatologists

Background

Skin diseases, such as psoriasis, hidradenitis suppurativa, acne, and alopecia areata, have increasingly been linked to systemic and mental health comorbidities, such as depression. Although identification and management of these comorbidities is typically a part of primary care, some patients might not have an established relationship with a primary care provider and may only be seeing their dermatologist.

Objective

To examine the frequency with which dermatologists are the main contact within a health care system for patients with these chronic skin conditions.

Methods

We performed a retrospective cohort study using Optum's deidentified Clinformatics Data Mart Database. The primary outcome was the proportion of patients who established care with a dermatologist and had no encounters with a primary care provider during the subsequent year after this dermatology encounter.

Results

Across each of the skin diseases evaluated, 21.6%-31.2% of men and 16.9%-26.2% of women had no primary care visits in the subsequent year after establishing care with their dermatologist.

Conclusion and Relevance

For many patients with chronic skin diseases, their dermatologist might be their only source of contact with the health care system. There may be an opportunity for dermatologists to improve the quality of care for our patients by screening for associated comorbidities.

Risk of retinal diseases in patients with psoriasis: A population-based cohort study in Taiwan

Psoriasis has been associated with the risk of several ocular complications; however, its relationship with retinal diseases remains unknown. This study aimed to investigate the risk of developing retinal diseases in patients with psoriasis. Study participants were recruited from the National Health Insurance Research Database in Taiwan. A total of 11 729 psoriasis patients and 117 290 matched controls were included, showing an incidence rate of 121.15 and 28.34 cases of retinal diseases per 100 000 person-years, respectively. Compared with controls, patients with psoriasis had an adjusted hazard ratio (aHR) of 3.40 (95% confidence interval [CI], 2.63-4.39) for retinal diseases after adjustment for potential confounders. Regarding the individual retinal disease, psoriasis patients had a significantly higher risk of developing retinal detachment (aHR, 5.07; 95% CI, 2.92-8.79), retinal vascular occlusion (aHR, 3.75; 95% CI 2.42-5.82), and retinopathy (aHR, 2.84; 95% CI, 1.99-4.05) than controls. In conclusion, patients with psoriasis had a significantly higher risk of retinal diseases than controls. Further studies are necessary to investigate the pathophysiology underlying the relationship between psoriasis and retinal diseases.

Periodontal disease and risk of mortality and kidney function decline in advanced chronic kidney disease: a nationwide population-based cohort study

OBJECTIVES

Periodontal disease is prevalent in patients with chronic kidney disease (CKD) and potentially associated with kidney function decline. However, it is uncertain whether periodontal disease affects the risk of mortality and morbidity in patients with advanced CKD.

MATERIALS AND METHODS

Taiwan's National Health Insurance Research Database was used to conduct a nationwide population-based cohort study. Propensity score matching procedures were performed to select people with stage 5 CKD and to compare the long-term risk of mortality, end-stage renal disease, and major adverse cardiovascular events (MACE) between people with and without periodontal disease. Multivariable Cox regression analyses were conducted to calculate the adjusted hazard ratio (aHR) with 95% confidence interval (CI) for the outcome of interest.

RESULTS

A total of 8119 subjects with stage 5 CKD were initially included. After matching to demographic and clinical covariates, 1254 subjects with 7099 person-years of follow-up were selected for analyses. Periodontal disease was not associated with long-term risks of all-cause mortality (aHR: 0.77, 95% CI: 0.49-1.22), progression to end-stage renal disease (aHR: 0.91, 95% CI: 0.75-1.10), or MACE (aHR: 1.18, 95% CI: 0.91-1.53). These findings were generally consistent across subgroups of age, sex, comorbid diabetes, uses of systemic antibiotic, and different dental procedures.

CONCLUSIONS

Periodontal disease is not a predictor for long-term mortality or morbidity in patients with advanced CKD.

CLINICAL RELEVANCE

These results provide important evidence to elucidate the relationship between periodontitis and critical clinical outcomes of advanced CKD.

Posttraumatic Stress Disorder and the Associated Risk of Autoimmune Skin Diseases: A Nationwide Population-Based Cohort Study

OBJECTIVE

Posttraumatic stress disorder (PTSD) is known as a risk factor for various immune-related disorders; however, the association between PTSD and related autoimmune skin diseases (ASDs) remains unclear. This study aimed to investigate the association of PTSD with the risk of related ASDs.

METHODS

Participants were recruited from the National Health Insurance Research Database in Taiwan. We included 9801 patients with PTSD and 39,204 matched controls to assess the risk of developing ASDs. Cox regression model was used for analyses.

RESULTS

After adjusting for confounders, we found an increased risk of ASDs among the patients with PTSD (adjusted hazard ratio [aHR] = 3.00, 95% confidence interval [CI] = 2.21-4.07) compared with that among matched controls. Statistically significant associations were found between PTSD and five individual ASDs, including psoriasis (aHR = 3.81, 95% CI = 1.90-7.67), lichen planus (aHR = 31.63, 95% CI = 4.00-249.91), alopecia areata (aHR = 4.77, 95% CI = 2.47-9.20), autoimmune bullous diseases (aHR = 9.55, 95% CI = 1.98-45.99), and vitiligo (aHR = 16.06, 95% CI = 4.48-57.54).

CONCLUSIONS

Patients with PTSD had an increased risk of developing ASDs compared with the matched controls. Further studies are needed for better understanding of the underlying mechanisms.

Cigarette smoking and risk of herpes zoster: a population-based cohort study in Taiwan

The effects of cigarette smoking on the risk of herpes zoster (HZ) infection remain unclear. This study aimed to examine the association between cigarette smoking and HZ. Participants were collected from four rounds (2001, 2005, 2009 and 2013) of the Taiwan National Health Interview Survey. Incident cases of HZ were identified from the Taiwanese National Health Insurance database. Of the 57 641 participants, 3346 developed HZ during the observation period. After controlling for confounders, current smokers had a lower risk of incident HZ than never-smokers (adjusted hazard ratio 0.69; 95% CI 0.62-0.77). There was a trend toward a decreased risk of HZ with increasing numbers of cigarettes per day, years of smoking and cumulative pack-years of smoking among current smokers (P_trend < 0.001). Former smoking was not associated with risk of HZ. In conclusion, current smoking was significantly associated with a decreased risk of developing HZ.

Bidirectional Association between Psoriasis and Atopic Dermatitis: A Nationwide Population-Based Cohort Study

BACKGROUND

There have been some reports on the coexistence of psoriasis and atopic dermatitis; however, the longitudinal relationship between these two diseases remains unclear.

OBJECTIVE

This study aimed to investigate the bidirectional association between psoriasis and atopic dermatitis.

METHODS

This cohort study recruited patients from the National Health Insurance Research Database in Taiwan. We included 8,206 patients with psoriasis and 32,824 matched controls to assess the risk of atopic dermatitis and 25,743 patients with atopic dermatitis and 102,972 matched controls to assess the risk of psoriasis. Cox regression model was used for the analyses.

RESULTS

After adjusting for potential confounders, patients with psoriasis had a higher risk of atopic dermatitis (adjusted hazard ratio [aHR] 13.01; 95% CI 10.23-16.56) than the controls. Patients with atopic dermatitis had a higher risk of psoriasis (aHR 10.37; 95% CI 6.85-15.69) than the controls. Stratified analyses revealed similar results in both sexes and all age groups.

CONCLUSION

Our study demonstrated a bidirectional association between psoriasis and atopic dermatitis, suggesting that psoriasis and atopic dermatitis are not mutually exclusive and may share some biological mechanisms.

Cigarette Smoking, Alcohol Consumption, and Risk of Alopecia Areata: A Population-Based Cohort Study in Taiwan

BACKGROUND

The effects of cigarette smoking and alcohol consumption on the risk of alopecia areata (AA) are unclear.

OBJECTIVE

The aim was to examine the association of cigarette smoking and alcohol consumption with AA.

METHODS

We collected participants from four rounds (2001, 2005, 2009, and 2013) of the Taiwan National Health Interview Survey. Incident AA cases were identified from the National Health Insurance database.

RESULTS

Of the 60,055 participants, 154 developed AA during the 647,902 person-years of follow-up. After controlling for confounders, current smokers had a higher risk of incident AA than never smokers [adjusted hazard ratio (aHR) 1.88; 95% confidence interval (CI) 1.22-2.88]. There was a trend toward an increased risk of AA with increasing numbers of years of smoking and cumulative pack-years of smoking among current smokers. The aHRs (95% CIs) of current smokers of > 5 and ≤ 15 cigarettes per day, > 10 and ≤ 20 years of smoking, ≤ 10, and > 10 and ≤ 20 pack-years of smoking were 2.03 (1.17-3.51), 2.25 (1.21-4.18), 1.86 (1.12-3.09), and 2.04 (1.04-4.01), respectively. Conversely, social and regular drinkers had significantly lower risks of AA than never drinkers [aHRs (95% CIs) 0.65 (0.43-0.98) and 0.49 (0.26-0.93), respectively].

CONCLUSION

Current smokers had an increased risk of developing AA, while alcohol consumption was associated with a decreased risk of AA.

Preexisting Dementia Is Associated with Increased Risks of Mortality and Morbidity Following Major Surgery: A Nationwide Propensity Score Matching Study

Patients with dementia are predisposed to multiple physiological abnormalities. It is uncertain if dementia associates with higher rates of perioperative mortality and morbidity. We used reimbursement claims data of Taiwan’s National Health Insurance and conducted propensity score matching analyses to evaluate the risk of mortality and major complications in patients with or without dementia undergoing major surgery between 2004 and 2013. We applied multivariable logistic regressions to calculate adjusted odds ratios (aORs) with 95% confidence intervals (CIs) for the outcome of interest. After matching to demographic and clinical covariates, 7863 matched pairs were selected for analysis. Dementia was significantly associated with greater risks of 30-day in-hospital mortality (aOR: 1.71, 95% CI: 1.09–2.70), pneumonia (aOR: 1.48, 95% CI: 1.16–1.88), urinary tract infection (aOR: 1.59, 95% CI: 1.30–1.96), and sepsis (OR: 1.77, 95% CI: 1.34–2.34) compared to non-dementia controls. The mortality risk in dementia patients was attenuated but persisted over time, 180 days (aOR: 1.49, 95% CI: 1.23–1.81) and 365 days (aOR: 1.52, 95% CI: 1.30–1.78) after surgery. Additionally, patients with dementia were more likely to receive blood transfusion (aOR: 1.32, 95% CI: 1.11–1.58) and to need intensive care (aOR: 1.40, 95% CI: 1.12–1.76) compared to non-dementia controls. Senile dementia and Alzheimer’s disease were independently associated with higher rates of perioperative mortality and complications, but vascular dementia was not affected. We found that preexisting dementia was associated with mortality and morbidity after major surgery.

Association between vitiligo and subsequent risk of dementia: A population-based cohort study

Increasing evidence suggests a positive association between autoimmune disorders and the subsequent risk of dementia, supporting the idea that neuroinflammation is a major contributor to dementia. However, whether or not adults with vitiligo have an increased risk of dementia remains unclear. We aimed to investigate the association between vitiligo and the subsequent risk of dementia. A total of 1320 patients with vitiligo and 5280 matched controls were identified from the Taiwan National Health Insurance Research Database between 1998 and 2011. Dementia was diagnosed by board-certificated psychiatrists or neurologists in the follow-up period. Cox proportional hazards models were used to estimate the adjusted hazard ratios (aHR) after controlling for age, sex, income-related monthly premium, residence and comorbidities associated with dementia. The incidence rate of dementia (per 100 000 person-years) was 502.8 among patients with vitiligo and 101.9 among the controls. Patients with vitiligo were more likely to develop any type of dementia (aHR, 5.30; 95% confidence interval [CI], 3.30-8.51), Alzheimer's disease (aHR, 12.22; 95% CI, 3.71-40.28) and vascular dementia (aHR, 3.99; 95% CI, 1.31-12.15) compared with the controls. In conclusion, middle-aged and old patients with vitiligo are more likely to develop dementia compared with those without vitiligo. This novel finding reminds physicians to be more careful about signs of dementia when managing patients with vitiligo and provides the basis for further investigations that clarify the underlying mechanisms.

Association between major depressive disorder and subsequent autoimmune skin diseases: A nationwide population-based cohort study

BACKGROUND

Major depressive disorder (MDD) has been implicated as a risk factor for various immune-related disorders; however, the association between MDD and subsequent autoimmune skin diseases (ASDs) remains unclear. This study aimed to investigate the association of MDD with risk of subsequent ASDs.

METHODS

Subjects were recruited from the National Health Insurance Research Database in Taiwan. We included 222,522 patients with MDD and 890,088 matched controls to assess the risk of developing ASDs.

RESULTS

After controlling for confounders, we found an increased risk of ASDs among the patients with MDD (adjusted hazard ratio [aHR], 10.41; 95% CI, 9.62-11.42) compared to matched controls. Subgroup analyses showed that MDD patients had a significantly increased risk of developing psoriasis (aHR, 12.01; 95% CI, 10.37-13.91), lichen planus (aHR, 11.84; 95% CI, 8.90-15.75), alopecia areata (aHR, 11.61; 95% CI, 9.92-13.59), morphea (aHR, 6.03; 95% CI, 2.47-14.73), autoimmune bullous diseases (aHR, 7.67; 95% CI, 5.94-9.90), hidradenitis suppurativa (aHR, 8.45; 95% CI, 3.61-19.74), vitiligo (aHR, 7.24; 95% CI, 5.65-9.28), lupus erythematosus (aHR, 11.30; 95% CI, 9.21-13.86), systemic sclerosis (aHR, 8.07; 95% CI, 4.30-15.14), Sjogren's syndrome (aHR, 6.71; 95% CI, 5.29-8.50), and dermatomyositis (aHR, 14.44; 95% CI, 5.55-37.55).

CONCLUSIONS

Patients with MDD had an increased risk of developing ASDs as compared to the controls. Further studies are needed to better understand the underlying mechanisms.

Bidirectional association between alopecia areata and thyroid diseases: a nationwide population-based cohort study

Alopecia areata (AA) has long been associated with thyroid diseases; however, the temporality of their association remains unclear. This study aimed to investigate the bidirectional association between AA and thyroid diseases. In analysis 1, we included 5929 AA patients and 59,290 matched controls to assess the risk of thyroid diseases. In analysis 2, we included 35,071 patients with thyrotoxicosis, 19,227 patients with Graves' disease, 5460 patients with thyroiditis, 3352 patients with Hashimoto's thyroiditis, and their matched controls (1:10) to assess the risk of AA. Incidence of thyroid diseases and AA were the outcomes in analysis 1 and analysis 2, respectively. After adjusting the potential confounders, AA patients had an increased risk of all thyroid diseases, including toxic nodular goiter, (aHR 10.17; 95% confidence interval [CI] 5.32-19.44), nontoxic nodular goiter (aHR 5.23; 95% CI 3.76-7.28), thyrotoxicosis (aHR 7.96; 95% CI 6.01-10.54), Graves' disease (aHR 8.36; 95% CI 5.66-12.35), thyroiditis (aHR 4.04; 95% CI 2.12-7.73), and Hashimoto thyroiditis (aHR 4.35; 95% CI 1.88-10.04). On the contrary, a significantly increased risk of developing AA was observed among patients with thyrotoxicosis (aHR 9.29; 95% CI, 7.11-12.14), Graves' disease (aHR 8.66; 95% CI 6.03-12.42), and thyroiditis (aHR 6.42; 95% CI 3.15-13.11) but not in patients with Hashimoto's thyroiditis. In conclusion, our study found a bidirectional association between AA and thyroid diseases, suggesting shared biological mechanisms underlying these two diseases.

Obesity, but Not Metabolic Diseases, Is Associated with Risk of Psoriasis: A Population-Based Cohort Study in Taiwan

<b><i>Background:</i></b> Obesity and metabolic diseases including diabetes, hyperlipidemia, and hypertension are reportedly associated with an increased risk of psoriasis. However, few prospective studies have investigated the association of obesity and metabolic diseases with the risk of psoriasis. <b><i>Objective:</i></b> To examine whether obesity or metabolic diseases increase the risk of psoriasis. <b><i>Methods:</i></b> Participants were collected from 4 rounds (2001, 2005, 2009, and 2013) of the Taiwan National Health Interview Survey. Incident cases of psoriasis were identified from the National Health Insurance database. Participants were followed from the time of the National Health Interview Survey interview until December 31, 2017, or until a diagnosis of psoriasis was made or the participant died. The Cox regression model was used for the analyses. <b><i>Results:</i></b> Of 60,136 participants, 406 developed psoriasis during 649,506 person-years of follow-up. Compared to participants with a BMI of 18.5–22.9, the adjusted hazard ratios (aHR) of psoriasis were 1.34 (95% CI 1.05–1.71) for a BMI of 25.0–29.9 and 2.70 (95% CI 1.95–3.72) for a BMI ≥30. Neither individual nor multiple metabolic diseases were associated with incident psoriasis. Participants with a BMI ≥30 were at significantly higher risk of both psoriasis without arthritis (aHR 2.60; 95% CI 1.85–3.67) and psoriatic arthritis (aHR 3.96; 95% CI 1.45–10.82). <b><i>Conclusion:</i></b> Obesity, but not metabolic diseases, significantly increased the risk of psoriasis.

Bidirectional association between alopecia areata and sleep disorders: a population-based cohort study in Taiwan

BACKGROUND

The relationship between alopecia areata (AA) and sleep disorders remains uncertain. This study aims to investigate the bidirectional association between AA and sleep disorders.

METHODS

To assess the risk of developing sleep disorders, we recruited 5648 patients with AA and 22,592 matched controls from the National Health Insurance Research Database (NHIRD) in Taiwan. Similarly, risk of developing AA was assessed in 93,130 patients with sleep disorders (including 7310 patients with obstructive sleep apnea [OSA] and 85,820 patients with non-apnea insomnia) and 372,520 matched controls. Cox regression model was used for the analysis.

RESULTS

AA patients had a significantly increased risk of developing OSA (adjusted hazard ratio [aHR] 3.80; 95% confidence interval [CI] 2.53-5.71) and non-apnea insomnia (aHR 4.20; 95% CI 3.68-4.79). Conversely, presence of sleep disorders significantly increased the risk of AA development (aHR 4.70; 95% CI 3.99-5.54). Both OSA (aHR 3.89; 95% CI 2.46-6.16) and nonapnea insomnia (aHR 4.77; 95% CI 4.03-5.64) were associated an increased risk of developing AA.

CONCLUSIONS

Patients with AA have a higher risk of developing sleep disorders compared to controls, and vice versa. Further studies are needed to investigate the shared pathogenic mechanism underlying these two conditions.