Psychosocial and psychiatric comorbidities and health-related quality of life in alopecia areata: A systematic review

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 phase 2a study investigating the effects of ritlecitinib on brainstem auditory evoked potentials and intraepidermal nerve fiber histology in adults with alopecia areata

Reversible axonal swelling and brainstem auditory evoked potential (BAEP) changes were observed in standard chronic (9-month) toxicology studies in dogs treated with ritlecitinib, an oral Janus kinase 3/tyrosine kinase expressed in hepatocellular carcinoma family kinase inhibitor, at exposures higher than the approved 50-mg human dose. To evaluate the clinical relevance of the dog toxicity finding, this phase 2a, double-blind study assessed BAEP changes and intraepidermal nerve fiber (IENF) histology in adults with alopecia areata treated with ritlecitinib. Patients were randomized to receive oral ritlecitinib 50 mg once daily (QD) with a 4-week loading dose of 200 mg QD or placebo for 9 months (placebo-controlled phase); they then entered the active-therapy extension and received ritlecitinib 50 mg QD (with a 4-week loading dose of 200 mg in patients switching from placebo). Among the 71 patients, no notable mean differences in change from baseline (CFB) in Waves I-V interwave latency (primary outcome) or Wave V amplitude on BAEP at a stimulus intensity of 80 dB nHL were observed in the ritlecitinib or placebo group at Month 9, with no notable differences in interwave latency or Wave V amplitude between groups. The CFB in mean or median IENF density and in percentage of IENFs with axonal swellings was minimal and similar between groups at Month 9. Ritlecitinib treatment was also not associated with an imbalanced incidence of neurological and audiological adverse events. These results provide evidence that the BAEP and axonal swelling finding in dogs are not clinically relevant in humans.

Hair Growth Promoting Effects of 15-Hydroxyprostaglandin Dehydrogenase Inhibitor in Human Follicle Dermal Papilla Cells

Prostaglandin E2 (PGE2) is known to be effective in regenerating tissues, and bimatoprost, an analog of PGF2α, has been approved by the FDA as an eyelash growth promoter and has been proven effective in human hair follicles. Thus, to enhance PGE2 levels while improving hair loss, we found dihydroisoquinolinone piperidinylcarboxy pyrazolopyridine (DPP), an inhibitor of 15-hydroxyprostaglandin dehydrogenase (15-PGDH), using DeepZema®, an AI-based drug development program. Here, we investigated whether DPP improved hair loss in human follicle dermal papilla cells (HFDPCs) damaged by dihydrotestosterone (DHT), which causes hair loss. We found that DPP enhanced wound healing and the expression level of alkaline phosphatase in DHT-damaged HFDPCs. We observed that DPP significantly down-regulated the generation of reactive oxygen species caused by DHT. DPP recovered the mitochondrial membrane potential in DHT-damaged HFDPCs. We demonstrated that DPP significantly increased the phosphorylation levels of the AKT/ERK and activated Wnt signaling pathways in DHT-damaged HFDPCs. We also revealed that DPP significantly enhanced the size of the three-dimensional spheroid in DHT-damaged HFDPCs and increased hair growth in ex vivo human hair follicle organ culture. These data suggest that DPP exhibits beneficial effects on DHT-damaged HFDPCs and can be utilized as a promising agent for improving hair loss.

Psychometric Properties of the EQ-5D-5L in Patients with Alopecia Areata

BACKGROUND

For many decision makers in Health Technology Assessment the EQ-5D-5L is the standard measure of health-related quality of life (HRQL). However, evidence has shown the limitations of the measure in certain disease areas, including dermatology. Alopecia areata (AA) is associated with a significant HRQL impact, partly due to the emotional impact of hair loss.

OBJECTIVES

This study explores the psychometric properties of the EQ-5D-5L in people with AA in reference to the short-form 36 version 2 (SF-36v2), the Alopecia Areata Patient Priority Outcomes (AAPPO), the Severity of Alopecia Tool (SALT) and the Patient Global Impressions of Change (PGI-C).

METHODS

Data from participants with AA enrolled in the ALLEGRO-2b/3 trial (NCT03732807) of ritlecitinib were analysed. Participants completed the AAPPO measure (an AA-specific measure assessing emotional symptoms and activity limitations), PGI-C, EQ-5D-5L and SF-36v2 across 48-weeks of follow up. Extent of scalp hair loss was assessed using the SALT. Ceiling effects, known groups validity, convergent validity and responsiveness were examined. Known groups were defined by SALT score and a PGI-C defined response from baseline. Exploratory factor analysis was also performed.

RESULTS

Data were available from 612 adult participants. Ceiling effects were observed for the EQ-5D-5L (55.3-61.2%) and analyses suggested that the EQ-5D did not capture important differences between patients that the SF-36v2 did. The EQ-5D-5L very weakly correlated with SALT score, whereas the AAPPO correlated more strongly with the extent of hair loss. Compared with the EQ-5D-5L, the AAPPO was better able to discriminate between known groups defined by SALT and PGI-C. An exploratory factor analysis suggested that the EQ-5D-5L had limitations in content validity compared with the AAPPO.

CONCLUSIONS

The EQ-5D-5L may not adequately measure the burden of AA on patients' HRQL. Insensitivity to the burden of AA suggests that the EQ-5D-5L may not measure treatment-related benefit with hair regrowth. Data from other measures could be considered if they are shown to be more relevant.

Gut microbiota, skin microbiota, and alopecia areata: A Mendelian randomization study

BACKGROUND

Observational studies have shown an association between skin microbiota and alopecia areata (AA), but the causal connection remains ambiguous.

METHODS

We obtained data on skin microbiota and AA from summary statistics of Genome-Wide Association Studies and applied statistical methods from Mendelian randomization (MR) to assess causal relationships. Additionally, we investigated whether the skin microbiota acts as a mediator in the pathway from gut microbiota to AA.

RESULTS

In the MR analysis of KORA FF4 and AA, the inverse-variance weighting method indicated that Corynebacterium (odds ratio [OR] = 0.82, 95% confidence interval [CI]: 0.70-0.96, p = 0.02) and asv037 (OR = 0.87, 95% CI: 0.76-0.99, p = 0.05) exerted protective effects, while Betaproteobacteria (OR = 1.21, 95% CI: 1.01-1.44, p = 0.03), asv015 (OR = 1.27, 95% CI: 1.05-1.54, p = 0.02), and Burkholderiales (OR = 1.20, 95% CI: 1.04-1.38, p = 0.01) were identified as risk factors in AA. In the MR analysis of PopGen and AA, asv001 (OR = 1.12, 95% CI: 1.01-1.24, p = 0.04), asv054 (OR = 1.13, 95% CI: 1.01-1.25, p = 0.03), and asv059 (OR = 1.14, 95% CI: 1.02-1.27, p = 0.02) were found to potentially increase the risk in AA. Furthermore, in the influence of gut microbiota on AA, the skin microbiota did not act as a mediator.

CONCLUSION

Our analysis suggests potential causal relationships between certain skin microbiota and AA, revealing insights into its pathogenesis and potential intervention strategies.

'I need to understand… so we can decide together': Difficult conversations about alopecia areata

The management of alopecia areata (AA) in pediatric patients poses unique challenges, particularly regarding treatment discussions and decision making involving both patients and their families. This commentary presents findings from unpublished research on treatment-discontinuation discussions between AA patients and their treating providers, shedding light on the hopes, expectations, and disappointments of individuals with severe AA. The study explored patient and guardian satisfaction with these discussions, emphasizing the importance of addressing psychosocial concerns, facilitating contact with support groups, and demonstrating empathy. The role of dermatologists in conversations about treatment, prognosis, and quality of life is examined, emphasizing the need for honesty, empathy, and realistic expectations. The authors propose a patient-centered approach to initiating and guiding discussions, focusing on understanding the impact of AA on patients and their families and collaboratively deciding on treatment options. The mantra: 'I need to understand how this is affecting all of you, so we can decide together what to do next' is central to this proposed approach. Special considerations for different scenarios are discussed, highlighting the importance of individualized care and effective communication. Overall, the commentary emphasizes the significance of actively listening, acknowledging emotions, and prioritizing patient and family goals to optimize care for pediatric AA patients.

Chemical Scalp Burn after Hair Coloring-Case Report with Literature Review

Hair dyeing is widely performed around the world. Chemical and thermal burns can result from the components present in brightening and coloring products, as well as the application process. We present a case of a chemical burn after applying hair dye and review the literature on similar cases, the composition of hair dyes, their mechanism of action, and the process of burns. The patient was a 17-year-old girl, who presented to the Dermatology Clinic with a 13 × 10 cm ulcer on the scalp after hair dyeing in a hairdressing salon. General and local treatment was applied, with particular emphasis on specialized dressings. The ulcer site was replaced by an area of scarring after 11 months of treatment. Based on the presented case and the review of the literature, we conclude that hair dye treatments warrant careful attention for potential scalp complications. The diagnostic and therapeutic approach demands a multidisciplinary effort, with ongoing patient-doctor cooperation throughout the treatment, which may complicate and span several months.

A Review of JAK Inhibitors for Treatment of Alopecia Areata in the Military Health Care System

INTRODUCTION

Alopecia areata (AA) is a disease that manifests as patchy hair loss on the scalp and other parts of the body; severe disease may result in disfigurement, functional impairment, and significant psychological distress. This condition is understood to be caused by autoimmunity to the hair follicle and subsequent arrest of hair growth. New medications, baricitinib and ritlecitinib, belong to the Janus kinase (JAK) inhibitor family and are among the first FDA-approved treatments for severe AA. In this manuscript, we aim to answer the question: What treatment options exist for AA in the military health care system (MHS)? In doing so, we review the pathogenesis, physical and psychosocial impact of AA, conventional treatment of AA, and the efficacy and safety of baricitinib and ritlecitinib.

METHODS

A literature search was performed using PubMed, Embase, and Ovid for the history and pathogenesis of AA, psychosocial impact of disease, functional impairments, and current treatments. Keywords "alopecia areata," "current therapy for alopecia areata," "pathogenesis alopecia areata," "baricitinib," "ritlecitinib," "JAK inhibitor alopecia," "JAK inhibitor safety," "baricitinib efficacy," "alopecia eyelash," "alopecia nails," and "psychosocial impact of alopecia" were used for the search. The TRICARE manual was searched for guidelines applicable to the treatment of AA, DoD Instruction 6130.03 Volume 2 for medical standards for military service, and the U.S. Central Command Modification 15 for fitness of deployment to Central Command area of operations.

RESULTS

Traditional treatments such as intralesional steroids may be effective for some patients, but difficulty lies in controlling extensive or refractory disease. Janus kinase inhibitors, baricitinib and ritlecitinib, are found effective at improving severe refractory disease; baricitinib induced hair regrowth in 32.6% more patients than placebo, and ritlecitinib was found to be superior to placebo by at least 24%. Currently, there is no coverage for therapeutic treatment of hair growth in the MHS. Additionally, military members are disqualified for continued service if they require immunomodulator medications such as baricitinib and ritlecitinib. Those on immunomodulators are unable to deploy worldwide.

CONCLUSIONS

Baricitinib and ritlecitinib are effective treatments for widespread, progressive, and refractory AA. Although JAK inhibitors demonstrate improved effectiveness compared to non-immunomodulator treatments, their use in the MHS for this purpose is limited.

Estimation of health utility values for alopecia areata

PURPOSE

Alopecia areata (AA) is an autoimmune-mediated inflammatory dermatological disease characterised by non-scarring hair loss affecting the scalp and sometimes other hair-bearing sites. This study aimed to elicit health state utility values (HSUVs) from the UK general population for AA using time trade off (TTO) interviews.

METHODS

Vignette descriptions of health states defined by the extent of hair loss were developed (as well as one describing caregiver burden). These were developed using data from standardised patient reported outcome (PRO) measures, a literature review and qualitative interviews. Health states were defined based on the severity of alopecia tool (SALT), which assesses extensiveness of scalp hair loss. HSUVs were then elicited for each health state in TTO interviews with the UK public.

RESULTS

One caregiver and five patient health states were developed based on the literature review findings, clinical trial PRO (Hospital Anxiety and Depression Scale and Alopecia Areata Patient Priority Outcomes Questionnaire) data and qualitative interviews with patients (N = 11), clinical experts (N = 4) and caregivers of adolescents with AA (N = 10). These data showed a more severe impact among patients with more extensive hair loss. One hundred and twenty participants evaluated the vignettes in TTO interviews. Patient HSUVs ranged from 0.502 for the most extensive hair loss health state (SALT 50-100 + eyebrow and eyelash loss) to 0.919 (SALT 0-10) for the mildest health state. The caregiver HSUV was 0.882.

CONCLUSION

Quantitative and qualitative data sources were used to develop and validate vignettes describing different AA health states. Patient and caregiver HSUVs demonstrate a large impact associated with AA, especially for states defined by more extensive hair loss.

Reduced rates of substance use disorder in patients with alopecia: An all of us case-control study

Alopecia areata (AA), depression, anxiety, and decreased quality of life are highly associated in the literature. It has been noted that there is an increased risk of substance use in those with AA to help cope with the psychological burdens and perceived stigmatization. This study aims to explore the relationship between substance use disorder (SUD) and scarring/non-scarring alopecia using the All of Us database. Of the 9,385 patients with alopecia, 8.4% had SUD of any kind. Multivariable regression revealed that alopecia is a potential protective factor against SUD when controlling for other covariates of significance, with a decreased odds of 0.73. Substance use disorder prevalence was not different between scarring and non-scarring alopecia. This may be the result of patients fearing exacerbation of hair loss, or due to increased mental health and community support in patients with alopecia. Dermatologists and primary care providers should continue to promote psychotherapy and community support to patients whose diagnosis of alopecia has a negative psychosocial impact.

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.

ADAM17 variant causes hair loss via ubiquitin ligase TRIM47-mediated degradation

Hypotrichosis is a genetic disorder characterized by a diffuse and progressive loss of scalp and/or body hair. Nonetheless, the causative genes for several affected individuals remain elusive, and the underlying mechanisms have yet to be fully elucidated. Here, we discovered a dominant variant in a disintegrin and a metalloproteinase domain 17 (ADAM17) gene caused hypotrichosis with woolly hair. Adam17 (p.D647N) knockin mice mimicked the hair abnormality in patients. ADAM17 (p.D647N) mutation led to hair follicle stem cell (HFSC) exhaustion and caused abnormal hair follicles, ultimately resulting in alopecia. Mechanistic studies revealed that ADAM17 binds directly to E3 ubiquitin ligase tripartite motif-containing protein 47 (TRIM47). ADAM17 variant enhanced the association between ADAM17 and TRIM47, leading to an increase in ubiquitination and subsequent degradation of ADAM17 protein. Furthermore, reduced ADAM17 protein expression affected the Notch signaling pathway, impairing the activation, proliferation, and differentiation of HFSCs during hair follicle regeneration. Overexpression of Notch intracellular domain rescued the reduced proliferation ability caused by Adam17 variant in primary fibroblast cells.

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.

Bilateral Association Between Atopic Dermatitis® and Alopecia Areata: A Systematic Review and Meta-Analysis

This systematic review and meta-analysis aimed to explore the association between atopic Dermatitis® (AD) and alopecia areata (AA). A comprehensive search was conducted in PubMed, Embase, Cochrane, and Web of Science from the inception of each database to November 10, 2022 for relevant studies. As there is a potential bilateral association between the 2 diseases, we assessed the prevalence/incidence of AA in patients with AD and the prevalence/incidence of AD in patients with AA. A total of 29 studies involving 11,233,448 participants were included in this analysis. AA was the exposure factor in 23 studies, AD in 7 studies, and both in 1 study. The meta-analysis revealed that the prevalence of AD was 11.2% (7.7%-15.1%) in patients with AA, and the prevalence of AA was 3.2% (95% confidence interval [CI]: 0.0%-11.5%) in patients with AD. The incidence of AD in AA patients was found to vary with age (P = 0.07). Based on 7 studies, there was a significant association between AD and AA when AA was the exposure factor [odds ratio, OR, = 4.537 (95% CI: 2.409-8.544)]; based on 10 studies, there was also a significant association between AD and AA when AD was the exposure factor [OR = 2.643 (95% CI: 1.737-3.995)]. In conclusion, this meta-analysis demonstrated the 2-way association between AD and AA, providing a clinical reference for disease prevention and control.

Novel investigational drugs for alopecia areata and future perspectives

INTRODUCTION

Alopecia areata (AA) is an immune-mediated disease that causes non-scarring hair loss. While acute, solitary patches often spontaneously remit, developing secondary patches or failure of the disease to resolve within 6-12 months predicts a poor prognosis, with an increased risk of alopecia totalis or universalis. Chronic AA increases the risk of depression and suicidality and reduces quality of life. Treatment options for chronic or acute diffuse AA were previously limited to corticosteroids and traditional immunomodulators. Two Janus Kinase (JAK) inhibitors are now approved for the treatment of chronic AA.

AREAS COVERED

The results of landmark phase 3 trials for three JAK inhibitors, baricitinib, ritlecitinib, and deuruxolitinib are discussed. Evidence for other JAK inhibitors, biologics, and phosphodiesterase-4 inhibitors are also presented. Therapies currently undergoing clinical trials are listed.

EXPERT OPINION

JAK inhibitors are a safe and efficacious treatment of moderate-to-severe AA. Early intervention, regardless of severity, allows for improved treatment efficacy. It is uncertain how long patients should remain on JAK inhibitors; discontinuation often leads to relapse. A black-box warning for JAK inhibitors was extrapolated from safety data in a rheumatoid arthritis cohort; recent meta-analyses of JAK inhibitors used in dermatology cohorts do not demonstrate the same risk profile.

Comparative efficacy and safety of JAK inhibitors in the treatment of moderate-to-severe alopecia areata: a systematic review and network meta-analysis

We performed a Bayesian network meta-analysis to indirectly compare the relative efficacy and safety of the latest JAK inhibitors for moderate-to-severe alopecia areata (AA). 13 trials totaling 3,613 patients were included. Two low-dose groups of oral formulations (ritlecitinib 10mg and ivarmacitinib 2mg) and two topical formulations (delgocitinib ointment and ruxolitinib cream) appeared to be relatively ineffective against moderate-to-severe AA. Ranking analysis suggested that brepocitinib 30mg has the best relative effect in reducing the SALT score (sucra = 0.9831), and demonstrated comparable efficacy to deuruxolitinib 12mg (sucra = 0.9245), followed by deuruxolitinib 8mg (sucra = 0.7736). Regarding the SALT50 response, brepocitinib 30mg ranked highest (sucra = 0.9567), followed by ritlecitinib 50mg (sucra = 0.8689) and deuruxolitinib 12mg (sucra = 0.7690). For achieving the SALT75 response, deuruxolitinib 12mg had the highest probability (sucra = 0.9761), followed by deuruxolitinib 8mg (sucra = 0.8678) and brepocitinib 30mg (sucra = 0.8448). Deuruxolitinib 12mg might be the most effective therapy for patients with severe AA (sucra = 0.9395), followed by ritlecitinib 50mg (sucra = 0.8753) and deuruxolitinib 8mg (sucra = 0.8070). Deuruxolitinib 12mg/8mg demonstrated notable efficacy for moderate-to-severe AA, and is expected to be a new treatment option for AA. It was worth noting that deuruxolitinib exhibit a greater likelihood of causing adverse events in comparison to other JAK inhibitors. Ritlecitinib 50mg seemed to exhibit fewer adverse effects in the high-dose groups of oral JAK inhibitors and might be an optimal choice to balance safety and efficacy. The majority of JAK inhibitors exhibited acceptable short-term safety profiles. To enhance the applicability and accuracy of our research, further head-to-head trials with longer follow-up periods are needed. Systematic Review Registration: identifier [CRD42022368012].

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.

Support Group Participation Among Patients With Alopecia Areata

This cross-sectional study describes support group use and experience among patients with alopecia areata.

Identification of SLC40A1, LCN2, CREB5, and SLC7A11 as ferroptosis-related biomarkers in alopecia areata through machine learning

Alopecia areata (AA) is a common non-scarring hair loss condition driven by the collapse of immune privilege and oxidative stress. The role of ferroptosis, a type of cell death linked to oxidative stress, in AA is yet to be explored, even though it's implicated in various diseases. Using transcriptome data from AA patients and controls from datasets GSE68801 and GSE80342, we aimed to identify AA diagnostic marker genes linked to ferroptosis. We employed Single-sample gene set enrichment analysis (ssGSEA) for immune cell infiltration evaluation. Correlations between ferroptosis-related differentially expressed genes (FRDEGs) and immune cells/functions were identified using Spearman analysis. Feature selection was done through Support vector machine-recursive feature elimination (SVM-RFE) and LASSO regression models. Validation was performed using the GSE80342 dataset, followed by hierarchical internal validation. We also constructed a nomogram to assess the predictive ability of FRDEGs in AA. Furthermore, the expression and distribution of these molecules were confirmed through immunofluorescence. Four genes, namely SLC40A1, LCN2, CREB5, and SLC7A11, were identified as markers for AA. A prediction model based on these genes showed high accuracy (AUC = 0.9052). Immunofluorescence revealed reduced expression of these molecules in AA patients compared to normal controls (NC), with SLC40A1 and CREB5 showing significant differences. Notably, they were primarily localized to the outer root sheath and in proximity to the sebaceous glands. Our study identified several ferroptosis-related genes associated with AA. These findings, emerging from the integration of immune cell infiltration analysis and machine learning, contribute to the evolving understanding of diagnostic and therapeutic strategies in AA. Importantly, this research lays a solid foundation for subsequent studies exploring the intricate relationship between AA and ferroptosis.

Machine learning application in autoimmune diseases: State of art and future prospectives

Autoimmune diseases are a group of disorders resulting from an alteration of immune tolerance, characterized by the formation of autoantibodies and the consequent development of heterogeneous clinical manifestations. Diagnosing autoimmune diseases is often complicated, and the available prognostic tools are limited. Machine learning allows us to analyze large amounts of data and carry out complex calculations quickly and with minimal effort. In this work, we examine the literature focusing on the use of machine learning in the field of the main systemic (systemic lupus erythematosus and rheumatoid arthritis) and organ-specific autoimmune diseases (type 1 diabetes mellitus, autoimmune thyroid, gastrointestinal, and skin diseases). From our analysis, interesting applications of machine learning emerged for developing algorithms useful in the early diagnosis of disease or prognostic models (risk of complications, therapeutic response). Subsequent studies and the creation of increasingly rich databases to be supplied to the algorithms will eventually guide the clinician in the diagnosis, allowing intervention when the pathology is still in an early stage and immediately directing towards a correct therapeutic approach.

Recovery Effects of Nephelium lappaceum var. pallens (Hiern) Leenh. Extract on Testosterone-Induced Inhibition of Hair Growth in C57BL/6 Mice and Human Follicular Dermal Papilla Cells

Although various hair health medicines have been developed and are used today, additional safe and effective natural hair growth therapies still need to be developed. Nephelium lappaceum var. pallens (Hiern) Leenh. extract (NLE) reportedly exhibits anticancer, antidiabetic, and antioxidant effects, which could be linked to androgenic processes; however, there are no reports of its effects on testosterone (TS)-inhibited hair growth. The present study investigated the effects of NLE on TS-induced inhibition of hair growth in C57BL/6 mice and human follicular dermal papilla cells. Oral administration of NLE restored hair growth that was suppressed following subcutaneous injection of TS more effectively than finasteride, a drug used for treating hair loss. Histological analysis demonstrated that oral NLE administration increased the number and diameter of hair follicles in the dorsal skin of C57BL/6 mice. In addition, western blot and immunofluorescence assays showed that the oral NLE administration restored TS-induced suppression of cyclin D1, proliferating cell nuclear antigen, and loricrin expression in the skin cells of the mice. Finally, TS suppression of cell proliferation in human follicular dermal papilla cells was significantly reversed by NLE pretreatment. The results suggest that NLE is a promising nutraceutical for hair growth because it promotes hair growth in androgenetic alopecia-like models.

Effectiveness and Predictive Factors of Response to Tofacitinib Therapy in 125 Patients with Alopecia Areata: A Single-centre Real-world Retrospective Study

Alopecia areata is an autoimmune disorder that greatly impacts patients' quality of life, and its management remains challenging. Tofacitinib is the first Janus kinase inhibitor to be approved for clinical use and is the most extensively studied. Several studies have demonstrated the clinical effectiveness of oral tofacitinib in treating patients with alopecia areata. However, despite being widely used in clinical practice, no prospective randomized controlled trials have been implemented and its indication criteria have not been thoroughly established. Moreover, little is known about the factors associated with response to therapy under real-world conditions. The aims of this retrospective cohort study of patients with alopecia areata treated with tofacitinib for 3 months were to assess the effectiveness of tofacitinib and to identify predictive factors of response to it. Primary outcome was the change in disease severity, as evaluated by Severity of Alopecia Tool (SALT) grade. A total of 125 patients with alopecia areata were included, the incidence of effectiveness was 83.2%, and 16.0% of patients achieved a result of complete remission. Total duration of alopecia areata and previous hair regrowth were independent predictors of response. Combined therapy was associated with relapse after discontinuation. No severe adverse event was observed. This study suggests that tofacitinib provides an effective treatment option for patients with alopecia areata, and that earlier intervention in the treatment of severe alopecia areata with tofacitinib may lead to better outcomes.

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.

Online attitudes about the first approved systemic treatment for alopecia areata: a sentiment analysis of Reddit posts

Alopecia areata (AA) is a complex inflammatory skin disease with a tremendous physical and emotional burden. Understanding patient sentiment towards AA treatment, particularly those treatments approved for AA, may help in better addressing patient needs. Here, we analysed 13 771 Reddit posts from the ‘alopecia_areata’ subreddit using sentiment analysis to evaluate online attitudes about the first approved systemic treatment for AA, baricitinib. We show that posts including baricitinib or related terms are more likely to be positive, with a higher likelihood of being positive after Food and Drug Administration approval.

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.

Real-Life Effectiveness and Tolerance of Baricitinib for the Treatment of Severe Alopecia Areata with 1-Year Follow-Up Data

INTRODUCTION

The efficacy of conventional treatments for alopecia areata (AA) has been extremely variable and disappointing, with a high rate of relapse. Recent clinical trials and real-life studies have demonstrated efficacy and safety of baricitinib (an oral Janus kinase 1 and 2 inhibitor) in alopecia areata.

METHODS

We retrospectively evaluated the effectiveness and tolerance of baricitinib in alopecia areata in a real-life Belgian monocentric adult cohort. The primary outcome was evaluated by the percentage of patients who achieved a Severity of Alopecia Tool (SALT) score of ≤ 20 at the end of the follow-up. All treatment-emergent adverse events were collected.

RESULTS

In this 19-patient series, with a median ± interquartile range (IQR) follow-up duration of 13 ± 16.2 months, we demonstrated that: (i) hair regrowth was observed in nearly 90% of patients between 4 and 16 weeks after initiation of baricitinib; (ii) at the end of the follow-up, more than 70% and, in particular, 100% of patients with patchy AA, reached the primary outcome (SALT score ≤ 20); (iii) almost half of the patients, mostly with patchy AA, showed a complete hair regrowth (SALT score = 0), within a median ± IQR treatment time of 8.5 ± 10 months; (iv) baricitinib was discontinued in three patients with total hair regrowth, two of whom relapsed; and (v) no serious adverse events were reported.

CONCLUSION

Baricitinib is effective in treating patients with alopecia areata, particularly for the patchy phenotype, but with a risk of relapse after discontinuation. Safety data are reassuring, with lipid changes being the most frequent adverse event.

Janus kinase inhibitors for alopecia areata: A narrative review

The Janus kinase (JAK) and Signal Transducer and Activator of Transcription (STAT) pathway has been identified as a key player in the pathophysiology of alopecia areata and a potential target for therapy. Here, we give a narrative review of what is known about Janus kinase inhibitors in alopecia areata. Several clinical trials as well as smaller studies have demonstrated hair regrowth and remission with oral Janus kinase inhibitors therapy, even in patients who failed conventional treatment. Baricitinib is the only US FDA-approved treatment for alopecia areata but data for other oral Janus kinase inhibitors such as tofacitinib, ruxolitinib and ritlecitinib are also promising. Fewer clinical trials have investigated topical Janus kinase inhibitors for alopecia areata, with many of them terminated early due to unfavourable results. Overall, Janus kinase inhibitors are an efficacious addition to the therapeutic arsenal for treatment-refractory alopecia areata. Further work is needed to examine the effects of long-term usage of Janus kinase inhibitors, the efficacy of topical Janus kinase inhibitors, as well as to identify biomarkers that could predict differential therapeutic responses to the various Janus kinase inhibitors.

Psychological morbidity in patients with pemphigus and its clinicodemographic risk factor: A comparative study

Due to the long disease duration, impact on appearance, social stigmatization, and numerous side effects of treatment, pemphigus, an autoimmune bullous disease, often has a significant psychological impact on patients. On the other hand, mood disorders may exacerbate the disease by affecting the patient's self-management, forming a vicious circle. To investigate anxiety and depressive disorders in patients with pemphigus, a total of 140 patients with pemphigus were recruited for this cross-sectional retrospective study between March 2020 and January 2022. A control group of 118 patients with psoriasis, a commonly known psychosomatic dermatosis, was established. Patients were evaluated at the visiting day with the Beck Anxiety Inventory and Beck Depression Inventory second edition for mood disorders, the Dermatology Life Quality Index and the EuroQol Five Dimensions Questionnaire for disease-related life quality, and the Visual Analogue Scale for pain and itching symptoms. In our cohort, 30.7% of patients with pemphigus suffered from either anxiety disorder (25%) or depressive disorders (14.3%). Propensity score matching was implemented to create a comparable cohort of pemphigus and psoriasis groups considering the baseline discrepancy. Thirty-four comparable pairs of pemphigus and psoriasis patients were extracted. The prevalence and severity of depressive disorder in pemphigus patients were significantly higher than in psoriasis patients, while anxiety disorder levels appeared to be similar in two groups. Multivariate logistic regression analysis further revealed that disease-related hospitalization history, active mucosal damage, and concomitant thyroid disease are independent risk factors for mood disorders in pemphigus patients. Our results showed that pemphigus patients had a high prevalence and severity of mood disorders. Relevant clinicodemographic indicators may be valuable for prediction and early identification of mood disorders in pemphigus. Better disease education from physicians may be important for these patients to achieve overall disease management.

Post-Traumatic Stress Disorder in Patients with Alopecia Areata: A Survey Study in the USA

Introduction

Alopecia areata (AA) is an autoimmune condition that results in nonscarring hair loss. AA is comorbid with mental health disorders including anxiety and depression. This study aimed to evaluate the presence of post-traumatic stress disorder (PTSD) in relation to hair loss in patients with AA.

Methods

A cross-sectional national survey was distributed using the National Alopecia Areata Foundation's (NAAF) email list. This study was approved by the Mass General Brigham Institutional Review Board. Participants were asked to complete the PTSD Checklist for the DSM-5 (PCL-5), a validated screening tool for PTSD in the context of their AA.

Results

Of the 1,449 completed surveys (completion rate 79.6%), most respondents were female (83.8%) and white (76.6%) with an average age of 50.6 ± 15.6 years. Respondents had AA for an average of 17.7 ± 15.8 years, with 91.4% experiencing current active hair loss. A total of 33.9% of respondents screened positively for PTSD, with an average score of 48.8 ± 12.3 on the PCL-5 in participants who screened positively. Participants with alopecia totalis have the highest average PCL-5 score of 30.1 ± 19.2, followed by participants with alopecia universalis with an average score of 26.0 ± 19.9, and lastly patchy AA with an average score of 24.5 ± 18.3 (p = 0.003). Feelings of intrusion and avoidance were the predominant reported symptoms. Total PTSD scores were significantly higher in respondents who were younger and identified as Black or African American and Hispanic when compared to white and non-Hispanic respondents, respectively.

Conclusion

These findings identify that one in 3 patients with AA in this cohort meet the screening criteria for PTSD specifically relating to their hair loss experience. These results further highlight the mental health comorbidities associated with AA and emphasize that these symptoms may persist even after hair regrowth. Limitations include the nonrandomized NAAF population with most participants being white females. Future studies should confirm these findings in other patient populations. Finally, respondent's baseline mental health was not assessed; therefore, a causal relationship between AA and PTSD cannot be deduced.

Efficacy and safety of baricitinib in patients with alopecia areata: evidence to date

Alopecia areata (AA) is a chronic, tissue-specific autoimmune disorder, characterized by non-scaring hair loss, with a global prevalence of approximately 2%. Typically, it affects a young population, with initial onset frequently occurring before the age of 30 years. Even though the exact pathogenesis of AA remains unclear, the predominant hypothesis is the breakdown of immune privilege of the hair follicle, resulting in increased self-antigen and major histocompatibility complex expression in the follicular epithelium. The relapsing nature of the disease negatively impacts patients' quality of life and makes them more susceptible to developing psychiatric comorbidities. Although many treatment modalities have been proposed, there are no currently available treatments able to induce and sustain disease remission. Traditional treatment modalities, despite being widely used, present limited results and a high risk of adverse effects. Hence, there exists an unfulfilled requirement for treatments that are both more efficient and safer. The latest understanding of the pathophysiology of AA and its connection to the JAK-STAT pathway has prompted the advancement of JAK inhibitors. These small-molecule agents function by obstructing the JAK-STAT intracellular signalling pathway. Baricitinib an orally administered, selective JAK1 and JAK2 inhibitor is a promising alternative to the available treatments, and is already approved for the treatment of AA.

Effective counseling of patients with hair loss

Effective hair loss counseling requires an understanding of patients' experiences and how they are impacted by race, ethnicity, culture, resource accessibility, and mental health. Clear communication and expectation management are critical. Physicians can empower patients through validating patient attitudes and engaging in shared decision-making to offer treatment, support, or camouflage.

Treatment Patterns and Unmet Needs in the Management of Alopecia Areata: Results of a Physician's Survey in the Middle East

INTRODUCTION

Alopecia areata (AA) is an autoimmune disease characterized by nonscarring hair loss involving the scalp, face, and/or body. Literature on the prevalence, patient characteristics, management approaches, and challenges faced by patients with AA across the Middle East is limited. Therefore, a greater understanding of the current AA landscape within the region is needed. This cross-sectional study surveyed dermatologists from four countries to assess dermatologists' perspectives on the prevalence of AA within the Middle East, as well as patient characteristics, unmet needs, and management strategies.

METHODS

This blinded, quantitative, observational study surveyed practicing dermatologists in Egypt, Lebanon, Saudi Arabia, and the United Arab Emirates. The survey was conducted between September 2021 and January 2022 and comprised 47 closed-ended, multiple-choice questions as well as Likert scale responses. These questions assessed the characteristics of physicians and the patients in their practices, physicians' familiarity with treatment, and physicians' treatment approaches.

RESULTS

The estimated prevalence of AA varied across the region. Across all age groups treated for AA, the majority of patients had AA of mild severity (pediatric: 63%; adolescent: 60%; adult: 54%) and the scalp was reported as the most affected area (65%). Potent topical corticosteroids were the most frequently used treatment for mild to moderate and severe AA (92% and 78%, respectively). There was a lack of awareness of investigative treatments, with only 33% of dermatologists aware of these options. The greatest unmet needs in treating AA included long-term disease control, improved efficacy, faster onset of action, and better safety profiles (62%, 53%, 52%, and 51%, respectively).

CONCLUSIONS

This study provided insight into the diagnosis and management of AA in the Middle East. Treatment strategies were similar regardless of the severity of AA. Long-term disease control and improved efficacy and safety profiles were identified as key unmet needs in the treatment of AA.

The Invisible Impact of a Visible Disease: Psychosocial Impact of Alopecia Areata

INTRODUCTION

The physical impact of alopecia areata (AA) is visible, but the psychological and social consequences and emotional burden are often underrecognized.

METHODS

In this cross-sectional study, 547 participants recruited via the National Alopecia Areata Foundation completed a survey encompassing demographics; AA illness characteristics; and five patient-reported outcome measures on anxiety and depression, perceived stress, psychological illness impact, stigma, and quality of life (QoL). Differences in disease severity subgroups were assessed via analysis of variance (ANOVA) and t tests.

RESULTS

Mean age was 44.6 years, and 76.6% were female. Participants with more severe hair loss tended to report longer duration of experiencing AA symptoms (P < 0.001). Overall, participants reported negative psychological impact, emotional burden, and poor QoL due to AA. Participants with 21-49% or 50-94% scalp hair loss reported greater psychological impact and poorer QoL than those with 95-100% scalp hair loss (most parameters P < 0.05). Similar results were observed for eyebrow/eyelash involvement subgroups.

CONCLUSIONS

These results suggest that participants with AA experience emotional burden, negative self-perception, and stigma, but the impact of AA is not dependent solely on the amount of hair loss. Lower impact among participants with 95-100% scalp hair loss may indicate that they have adapted to living with AA.

Overall and Racial and Ethnic Subgroup Prevalences of Alopecia Areata, Alopecia Totalis, and Alopecia Universalis

Importance

Prevalences of alopecia areata (AA), alopecia totalis (AT), and alopecia universalis (AU) are poorly established.

Objective

To estimate overall and subgroup prevalences of AA and its subtypes.

Design, Setting, and Participants

This cross-sectional study using electronic records comprising the Explorys database (Watson Health, IBM Corporation) included children, adolescents, and adults seeking healthcare across the 4 census regions in the US between January 1, 2019, and December 31, 2019. The statistical analysis was conducted between July 21, 2022, and December 22, 2022.

Main Outcomes and Measures

Prevalent cases of AA, AT, and AU.

Results

Of the 1 093 176 patients who met inclusion criteria, 1812 had at least 1 code for AA, 1216 female (67%) and 596 male (33%) patients. Overall age-and-sex standardized prevalences among adults and among children and adolescents were observed to be 0.18% and 0.10%, respectively. The age-standardized prevalence ratio in women to men was 1.32. Standardized prevalence was highest in those aged 30 to 39 (297 per 100 000; 95% CI, 263-335) and 40 to 49 (270 per 100 000; 95% CI, 240-303) years. The highest standardized prevalence was observed among Asian patients (414 per 100 000; 95% CI, 306-548), followed by patients reporting another race or multiple races (314 per 100 000; 95% CI, 266-368), Black (226 per 100 000; 95% CI, 199-255), and Hispanic/Latino (212 per 100 000; 95% CI, 129-328) patients. White patients had the lowest standardized prevalence (168 per 100 000; 95% CI, 157-179) among racial and ethnic subgroups. Relative to White patients, standardized prevalence ratios for Asian, Black, and Hispanic/Latino patients were 2.47 (95% CI, 2.17-2.81), 1.35 (95% CI, 1.26-1.44), and 1.26 (95% CI, 1.03-1.55), respectively. Cases of AT and AU comprised approximately 9% of patients diagnosed with AA.

Conclusions and Relevance

The findings of this cross-sectional study suggest that there is a significant burden of AA, AT, and AU in the US in which people of color, particularly Asian Americans, appear to be disproportionately affected.

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.

Systematic Review of Psychological Interventions for Quality of Life, Mental Health, and Hair Growth in Alopecia Areata and Scarring Alopecia

Alopecia is associated with significant psychological burden. There is limited evidence on the use of psychological interventions in conditions of hair loss. This manuscript systematically reviews the current state of literature on psychological treatments for quality of life, mental health, and hair growth in various forms of alopecia. PubMed and Embase were searched with predefined inclusion and exclusion criteria. Reference lists were also examined for relevant studies. Nine articles met our criteria and are included in this review. Eight of the articles related to alopecia areata and one related to scarring alopecia. Mindfulness-based stress reduction (MBSR) was found to improve quality of life-related subjective symptoms, relationship impacts, anxiety, phobia, distress, and psychological symptom intensity. Alopecia-specific collocated behavioral health (CLBH) treatment showed a trend for psychosocial improvement in areas such as appearance shame, activity avoidance, negative emotions, and coping. Hypnotherapy was found to improve anxiety and depression, quality of life measures, and alexithymia. There was also some evidence for significant hair growth with hypnosis, but the data are mixed. Psychotherapy combined with immunotherapy led to more hair growth, and supported self-confidence. Finally, coping strategies modulated the subjective burden of alopecia, and were associated with disease improvement. Further research will be necessary to better establish the efficacy and optimal administration of these interventions in alopecia.

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.

Quality of life in children and adolescents with alopecia areata-A systematic review

Alopecia areata (AA) is an autoimmune-mediated non-scarring hair loss whose stigmatizing effect may have a severe psychosocial impact. AA has been reported to be correlated with bullying, reduced quality of life (QoL) and psychiatric comorbidities. The effect of AA on QoL in adult patients has been systematically reviewed and found to be detrimental. No systematic evaluation of QoL in children with AA has been performed. The aim of this review is to systematically describe QoL in the child and adolescent population affected by AA. A systematic review of multiple databases and grey literature sources was conducted. Search terms included, but were not limited to, alopecia areata and quality of life. Only studies reporting results on health-related QoL in children and adolescents were included. We evaluated the studies regarding the risk of bias, and conceptual rigour concerning the quality of life and performed a descriptive synthesis of findings. Eight studies met the inclusion criteria, encompassing 358 participants with AA and 64 healthy peers. Seven studies were quantitative using four different standardized questionnaires and scores to measure QoL. One study used a qualitative design. All studies described impairment of children and adolescents' QoL by AA. The most consistently affected QoL domain was embarrassment and self-consciousness. Further psychosocial implications of AA included bullying and limiting participation in school or spare time activities. Existing evidence indicates a substantial impact of AA on QoL in children. In daily clinical practice as well as for developing new treatments QoL in paediatric AA plays a critical role. It should be considered a key outcome in clinical research and decision-making.

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.

The potential of regulatory T cell-based therapies for alopecia areata

Cytotoxic T lymphocyte has been a concern for the etiopathogenesis of alopecia areata (AA), some recent evidence suggests that the regulatory T (T_reg) cell deficiency is also a contributing factor. In the lesional scalp of AA, T_reg cells residing in the follicles are impaired, leading to dysregulated local immunity and hair follicle (HF) regeneration disorders. New strategies are emerging to modulate T_reg cells' number and function for autoimmune diseases. There is much interest to boost T_reg cells in AA patients to suppress the abnormal autoimmunity of HF and stimulate hair regeneration. With few satisfactory therapeutic regimens available for AA, T_reg cell-based therapies could be the way forward. Specifically, CAR-T_reg cells and novel formulations of low-dose IL-2 are the alternatives.

The Association of Alopecia Areata-Related Emotional Symptoms with Work Productivity and Daily Activity Among Patients with Alopecia Areata

INTRODUCTION

Patients with alopecia areata (AA) experience psychological and psychosocial symptoms including depression, anxiety, anger, social withdrawal, embarrassment, and low self-esteem. While multiple studies have measured the detrimental emotional impact of AA on patient quality of life, evidence of its effect on work productivity loss (WPL) and daily activities is limited. This study aimed to assess the extent of AA-related emotional symptom (ES) burden on work productivity and activity impairment.

METHODS

A cross-sectional survey of dermatologists and their adult patients with AA was conducted in the USA in 2019. Dermatologists provided assessments of patients' clinical characteristics, while patients completed sociodemographic questionnaires along with two validated patient-reported outcome measures of the Work Productivity and Activity Impairment (WPAI) and the AA Patient Priority Outcomes (AAPPO) ES subscale. The WPAI assessed AA-related WPL (employed respondents) and activity impairment (all respondents), and the AAPPO-ES assessed AA-related frequency of feeling self-conscious, embarrassed, sad, or frustrated. Multiple linear regression models were fitted to both WPAI scores with the AAPPO ES as an independent variable.

RESULTS

A total of 242 patients with a mean (SD) age of 39.2 (13.3) years, treated by 59 dermatologists, were evaluated. Mean (SD) ES score was 2.0 (1.1). Mean (SD) work productivity loss [n = 170] and activity impairment [n = 242] were 12.2% (17.4%) and 13.3% (18.3%), respectively. After adjusting for covariates, WPL increased by 4.1% [95% confidence interval (CI) 1.6-6.7%; p = 0.002] and activity impairment increased by 3.1% (95% CI 0.7-5.4%; p = 0.010) for every 1-point increase in ES. For an average patient, a 1-SD decrease (about 1 point) on the ES scale substantially reduced WPL and activity impairment (by at least 25%).

CONCLUSIONS

Patients with AA reported significant increases in WPL and activity impairment associated with worsening AA-related ES. These findings underscore the substantial emotional and psychosocial burden among patients with AA and a need for improved treatment options.

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].

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

INTRODUCTION

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

METHODS

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

RESULTS

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

CONCLUSIONS

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

Efficacy and safety of JAK inhibitors in the treatment of alopecia areata in children: a systematic review and meta-analysis

BACKGROUND

Alopecia areata (AA) is a non-scarring hair loss mediated by T lymphocytes. Recently, a growing number of studies have shown that Janus kinase inhibitors are effective in the treatment of AA in children.

METHODS

A systematic review and meta-analysis were performed according to the PRISMA guidelines. Good response was defined as more than 50% decrease in Severity of Alopecia Tool (SALT) score or complete regrowth or more than 50% regrowth. Partial response was defined as 5-50% decrease in SALT score. Any response to treatment was defined as more than 5% in SALT score decrease.

RESULTS

There were 81.9% responders, 68.5% good responders, and 7.7% partial responders among the 10 included studies. The treatment duration was longer in good responders than in partial responders (p = .009). Oral route was linked to a better response to topical medication, with an odds ratio of 7.8 (95%CI 1.655-36.76). In terms of toxicity, reported adverse events included only mild symptoms. Liver transaminase elevation, upper respiratory tract infection, and eosinophilia were the most common adverse events.

CONCLUSIONS

Janus kinase inhibitors demonstrated promise in the treatment of AA in children, with the most common side effects being minor and reversible.

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.

Association of mental health outcomes and lower patient satisfaction among adults with alopecia: A cross-sectional population-based study

Background

Previous studies have found the increasing use of patient satisfaction scores by patients and insurance payers. Less is known about how patient mental health affects health care satisfaction.

Objective

To examine the association between baseline mental health and health care satisfaction among adults with alopecia.

Methods

We examined 543 adults with alopecia in the 2004-2016 Medical Expenditure Panel Survey. Mental health burden was assessed by the 6-item Kessler Psychological Distress Scale (K6) and 2-item Patient Health Questionnaire (PHQ2). Patient satisfaction was determined using the Consumer Assessment of Healthcare Providers and Systems survey.

Results

Adults with versus without alopecia had higher rates of positive PHQ2 (adjusted odds ratio [95% CI], 1.37 [1.05-1.78]); positive K6 (1.57 [1.02-2.41]), and comorbid anxiety (1.85 [1.30-2.63]) and depression (1.68 [1.19-2.39]). Positive PHQ2 (2.15 [1.13, 4.11]) and positive K6 (6.04 [2.60, 14.05]) were associated with low patient satisfaction. Whereas, there were no differences in the rates of low patient satisfaction associated with comorbid anxiety (0.74 [0.33-1.67]) and depression (1.42 [0.72-2.78]).

Limitations

Data are unavailable on alopecia areata phenotypes and treatment.

Conclusions

Adults with alopecia and greater mental health symptoms report lower patient satisfaction. Clinicians may wish to adapt their communication style to support these patients and improve overall health care satisfaction.