[Is alopecia areata a psychosomatic disease?]

Alopecia areata: A psychodermatological perspective

BACKGROUND

Alopecia Areata (AA) is an autoimmune dermatological disease that could be influenced by psychological factors as part of the pathophysiology of the illness.

AIMS

This review article aims to report on psychodermatological and psychopathological aspects involved in the etiopathogenesis and comorbidities of AA, as well as on the psychiatric and psychological management of affected patients.

METHODS

We conducted a literature search on PubMed and Google Scholar from January 1980 to May 2021 employing the search terms of alopecia areata, psychological factors, psychological impact, psychodermatology, and psychopathology. All lists of references from the identified articles were screened for further relevant studies. The search was limited to English and Spanish language articles and was supplemented with themed books and book chapters. No specific quality criteria were used for the studies selection.

RESULTS

Several authors have found a high comorbidity rate between AA and mental disorders, concluding that stress and psychological factors are involved in both the development and exacerbation of the illness. More evidences are needed in order to describe the associations between the immune response, stress, and the physiological factors observed in AA patients.

CONCLUSION

AA is a complex illness characterized by multifactorial etiology. An interaction between genetic, autoimmune, hormonal, neural, and psychological factors is supposed. Psychopathological aspects of illness need to be better described and considered in the clinical setting.

Alopecia areata: a review on diagnosis, immunological etiopathogenesis and treatment options

Patients suffering from alopecia areata (AA) can lose hair in focal regions, the complete scalp, including eyelashes and eyebrows, or even the entire body. The exact pathology is not yet known, but the most described theory is a collapse of the immune privilege system, which can be found in some specific regions of the body. Different treatment options, local and systemic, are available, but none of them have been proven to be effective in the long term as well for every treatment there should be considered for the possible side effects. In many cases, treated or non-treated, relapse often occurs. The prognosis is uncertain and is negatively influenced by the subtypes alopecia totalis and alopecia universalis and characteristics such as associated nail lesions, hair loss for more than 10 years and a positive familial history. The unpredictable course of the disease also makes it a mental struggle and AA patients are more often associated with depression and anxiety compared to the healthy population. Research into immunology and genetics, more particularly in the field of dendritic cells (DC), is recommended for AA as there is evidence of the possible role of DC in the treatment of other autoimmune diseases such as multiple Sclerosis and cancer. Promising therapies for the future treatment of AA are JAK-STAT inhibitors and PRP.

Headgear-induced temporary pressure alopecia

The development of hair loss associated with headgear use is a rare phenomenon. Pressure alopecia is a condition characterised by localised, non-scarring hair loss attributed to a mechanical cause. Factors such as prolonged periods of peri- and postoperative immobility have been implicated, as well as immunological and genetic predisposing factors. If the mechanical trauma is very prolonged, there is a risk of permanent follicle damage due to tissue hypoxia. A 13-year-old boy wore high-pull headgear as part of his orthodontic management. Within four weeks of headgear wear, localised areas of hair loss were seen corresponding with the areas of contact with the force delivery modules of the headgear. The patient experienced bullying at school as a result of this hair loss. Hair regrowth resumed after headgear use was discontinued, therefore confirming the diagnosis of temporary pressure alopecia. Temporary pressure alopecia is a rare side effect of orthodontic headgear. Alopecia can negatively impact an individual's psychosocial wellbeing; therefore, caution should be taken to avoid prolonged or excessive pressure in susceptible individuals and headgear patients should be regularly monitored.

Psycho-emotional conditions of patients with non-cicatrazing alopecia (circumsribed, androgenetic)

Most common psycho-emotional disorders are described with patients with circumsribed, androgenetic alopecia. Main identification methods presented. It was shown based on analysis of literary data and in order to upgrade the quality of medical help for this group of patients how important it is to identify the preoccupying, depressive and other pathological psychogenic conditions of patients chronic alopecia.

The relationship between alopecia areata and alexithymia, anxiety and depression: a case-control study

BACKGROUND

Alopecia areata (AA) is a skin disease characterized by the sudden appearance of areas of hair loss on the scalp and other hair-bearing areas, but its aesthetic repercussions can lead to profound changes in patient's psychological status and relationships.

AIM

The goal was to investigate a possible relationship between AA and alexithymia as well as two other emotional dimensions, anxiety and depression.

MATERIALS AND METHODS

Fifty patients with AA seen in the Department of Dermatology of Hedi Chaker University Hospital, Sfax were included in this study. Anxiety and depression were evaluated by Hospital Anxiety and Depression scale questionnaire, alexithymia was assessed by Toronto Alexithymia scale 20, and severity of AA was measured by Severity of Alopecia Tool.

RESULTS

Patient's mean age was 32.92 years. 52% of patients were females. Depression and anxiety were detected respectively in 38% and 62% of patients. There was statistically significant difference between patients and control group in terms of depression (P = 0.047) and anxiety (P = 0.005). Forty-two percent of patients scored positive for alexithymia. No significant difference was found between patient and control groups (P = 0.683) in terms of alexithymia. Anxiety was responsible for 14.7% of variation in alexithymia (P = 0.047).

CONCLUSIONS

Our study shows a high prevalence of anxiety and depressive symptoms in AA patients. Dermatologists should be aware of the psychological impact of AA, especially as current treatments have limited effectiveness.

Key role of CRF in the skin stress response system

The discovery of corticotropin-releasing factor (CRF) or CRH defining the upper regulatory arm of the hypothalamic-pituitary-adrenal (HPA) axis, along with the identification of the corresponding receptors (CRFRs 1 and 2), represents a milestone in our understanding of central mechanisms regulating body and local homeostasis. We focused on the CRF-led signaling systems in the skin and offer a model for regulation of peripheral homeostasis based on the interaction of CRF and the structurally related urocortins with corresponding receptors and the resulting direct or indirect phenotypic effects that include regulation of epidermal barrier function, skin immune, pigmentary, adnexal, and dermal functions necessary to maintain local and systemic homeostasis. The regulatory modes of action include the classical CRF-led cutaneous equivalent of the central HPA axis, the expression and function of CRF and related peptides, and the stimulation of pro-opiomelanocortin peptides or cytokines. The key regulatory role is assigned to the CRFR-1α receptor, with other isoforms having modulatory effects. CRF can be released from sensory nerves and immune cells in response to emotional and environmental stressors. The expression sequence of peptides includes urocortin/CRF→pro-opiomelanocortin→ACTH, MSH, and β-endorphin. Expression of these peptides and of CRFR-1α is environmentally regulated, and their dysfunction can lead to skin and systemic diseases. Environmentally stressed skin can activate both the central and local HPA axis through either sensory nerves or humoral factors to turn on homeostatic responses counteracting cutaneous and systemic environmental damage. CRF and CRFR-1 may constitute novel targets through the use of specific agonists or antagonists, especially for therapy of skin diseases that worsen with stress, such as atopic dermatitis and psoriasis.

Alexithymia in patients with alopecia areata: educational background much more important than traumatic events

BACKGROUND

Recent studies suggest a higher prevalence of alexithymia in patients with alopecia areata (AA). Some authors link alexithymia with the presence of early traumatic events, such as dysfunctional parent-child relationships. However, until today, no studies have been carried out on the association of alexithymia and early traumatic events in AA patients.

OBJECTIVE

The primary aim of this study was to explore if an association exists between the presence of traumatic childhood experiences and alexithymia in AA patients. A secondary aim was to confirm earlier observations indicating that the occurrence and/or degree of alexithymia is higher in patients with AA compared with individuals from the general population.

METHODS

We enrolled 90 patients with AA. Data on alexithymia and traumatic events were collected with two self-report questionnaires: the Toronto Alexithymia Scale-20 and the Traumatic Experiences Checklist. These data were compared with data obtained from control patients without AA randomly selected from patients presenting for dermatological surgery.

RESULTS

In adult AA patients, we found no evidence for a significant association between Toronto Alexithymia Scale (TAS) scores and emotional neglect or childhood traumatic experiences. We found a significant association with educational level, higher levels of education being associated with lower TAS-20 scores (P = 0.002). The mean TAS-20 score of 51.22 (SD 11.90) in our adult AA patient group was significantly higher compared with control patients from the same setting (44.00, SD 10.33, P < 0.001).

CONCLUSION

In adult AA patients, higher levels of education are significantly associated with lower alexithymia scores. Somewhat unexpectedly, we found no association between alexithymia score and emotional neglect or childhood traumatic experiences. Our results also confirm that alexithymia scores are significantly higher in adult patient with AA compared with control patients.

Experiências afetivo-familiares de mulheres com alopecia areata

Este estudo consistiu na análise da dinâmica emocional das experiências afetivas de mulheres com alopecia areata, tendo como eixo as relações de afeto mantidas com os pais e em suas relações conjugais. Foram entrevistadas cinco pacientes, atendidas no Instituto Lauro de Souza Lima, com idade entre 22 e 53 anos. O estudo baseou-se no método clínico de investigação e os dados foram obtidos mediante entrevistas semi-estruturadas. Nos depoimentos foram apontadas experiências dolorosas da relação conjugal e do adoecimento, que foram associadas a vivências traumáticas na infância. As associações realizadas pelas mulheres entre suas experiências passadas, relações conjugais, adoecimento e o impacto da doença na vida atual confirmaram os achados da literatura, e os dados encontrados puderam ser interpretados à luz das contribuições psicanalíticas. Os resultados obtidos podem contribuir para o esclarecimento de aspectos dinâmicos relacionados à alopecia areata e a outras psicodermatoses, bem como favorecer intervenções interdisciplinares e psicoterápicas mais efetivas com pacientes dermatológicos crônicos.

Pressure alopecia from orthodontic headgear

Pressure alopecia is a form of nonscarring hair loss that occurs because of chronic pressure. This article reports the appearance of an unusual area of pressure alopecia in a patient who wore headgear. Early diagnosis of this rare pathology is fundamental to obtaining total regression of the disease; although pressure alopecia is initially nonscarring, scarring can develop over time. Orthodontists should be aware that alopecia in predisposed patients can be caused by headgear.

Hypnotic approaches for alopecia areata

Alopecia areata (AA) is an autoimmune disease leading to loss of scalp hairs. The disease seems triggered by stress. Data on the possibility of using hypnotherapy in the treatment of AA are very limited. Twenty-eight patients with extensive AA, all refractory to previous conventional treatment, were treated with hypnosis at the Academic Hospital UZ Brussel, Brussels, Belgium. This paper describes in detail the authors' hypnotherapeutic approach combining symptom-oriented suggestions with suggestions to improve self-esteem. Twelve out of 21 patients, including 4 with total loss of scalp hair, presented a significant hair growth. All patients presented a significant decrease in scores for anxiety and depression. Although the exact mechanism of hypnotic interventions has not been elucidated, the authors' results demonstrate that hypnotic interventions may ameliorate the clinical outcome of patients with AA and may improve their psychological well-being.

Substance P as an Immunomodulatory Neuropeptide in a Mouse Model for Autoimmune Hair Loss (Alopecia Areata)

Alopecia areata (AA) is an autoimmune disorder of the hair follicle characterized by inflammatory cell infiltrates around actively growing (anagen) hair follicles. Substance P (SP) plays a critical role in the cutaneous neuroimmune network and influences immune cell functions through the neurokinin-1 receptor (NK-1R). To better understand the role of SP as an immunomodulatory neuropeptide in AA, we studied its expression and effects on immune cells in a C3H/HeJ mouse model for AA. During early stages of AA development, the number of SP-immunoreactive nerve fibers in skin is increased, compared to non-affected mice. However, during advanced stages of AA, the number of SP-immunoreactive nerves and SP protein levels in skin are decreased, whereas the expression of the SP-degrading enzyme neutral endopeptidase (NEP) is increased, compared to control skin. In AA, NK-1R is expressed on CD8+ lymphocytes and macrophages accumulating around affected hair follicles. Additional SP supply to the skin of AA-affected mice leads to a significant increase of mast cell degranulation and to accelerated hair follicle regression (catagen), accompanied by an increase of CD8+ cells-expressing granzyme B. These data suggest that SP, NEP, and NK-1R serve as important regulators in the molecular signaling network modulating inflammatory response in autoimmune hair loss.

Postoperative alopecia areata: Is pressure-induced ischemia the only cause to blame?

INTRODUCTION

Postoperative alopecia areata (PAA) following surgery has been reported, especially after certain gynecologic and cardiac procedures; however, no cases have been reported after liver transplant (LT). Localized pressure associated with prolonged anesthesia is usually blamed. Herein we report a few cases of PAA encountered especially in relation to LT procedures.

OBJECTIVE

To report our PAA cases, identifying possible contributing risk factors.

METHODS

Between April 2001 and May 2003 the data on eight PAA cases were analyzed for age, sex, type of surgery, duration of anesthesia, type of head support, periods of hypotension, and psychiatric comorbidity.

RESULTS

Median age of affected patients was 27 years (10 to 44) and the male/female ratio 3/5. The type of surgery included: two LT recipients, two LT donors, three cardiac valve replacements, and one coronary bypass surgery. Median anesthesia time was 6 hours (3 to 12). Sponge or jelly donut was used for head support with frequent change of its position as per protocol. There were no significant periods of hypotension. Surprisingly, almost all patients had a documented psychiatric comorbidity, mainly anxiety, adjustment/adaptation, or mood disorders.

CONCLUSIONS

PAA is a rare complication following certain surgeries including both donor and recipient LT procedures. Although pressure-induced ischemia is the most likely etiological factor, we believe that psychiatric comorbidity plays a major role in its development. Therefore, preoperative thorough psychiatric counseling in addition to frequent intraoperative head repositioning will help to avoid this minor but distressing postoperative complication.