Overview of alopecia areata

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

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

The value of immunohistochemical expression of SOX9 and CD34 in alopecia areata

BACKGROUND

Alopecia areata (AA), an immune-mediated disorder, is marked by temporary, nonscarring hair loss. The bulge area is protected from immune attacks by immune privilege; however, recent studies demonstrated immune cells infiltrating the bulge area.

OBJECTIVE

This study aims to investigate the immunohistochemical expression of the sex-determining region Y-box 9 (SOX9) and cluster of differentiation 34 (CD34) in AA patients as markers of hair follicle stem cells (HFSCs) and progenitor cells, respectively.

METHODS

Immunohistochemical staining of SOX9 and CD34 was applied on skin samples of 20 AA patients and 20 healthy controls.

RESULTS

SOX9 and CD34 were significantly lower in lesional samples of cases compared to perilesional and control skin biopsies. Furthermore, SOX9 level was negatively correlated with the severity of alopecia tool score (SALT score) among the studied AA patients. Moreover, lowered SOX9 expression was present in patients with recurrent attacks.

CONCLUSIONS

The significant reduction of stem cell markers (SOX9 and CD34) in our studied AA cases signifies the pathological affection of HFSCs and their progeny in AA. This is thought to cause a loss of competence in generating new hair in some AA cases, which needs to be validated in further research.

LIMITATIONS OF THE STUDY

This study has a small sample size.

Epidemiology, Treatment Patterns, and Healthcare Resource Utilization Study of Patients With Alopecia Areata in Taiwan's National Health Insurance Research Database

OBJECTIVES

This study investigated the epidemiology, treatment patterns, and resource utilization in patients with alopecia areata (AA) in Taiwan using the National Health Insurance Research Database. AA severity was determined by treatment use and diagnostic codes in the year after enrollment (including corticosteroids, systemic immunosuppressants, topical immunotherapy, and phototherapy).

METHODS

The cross-sectional analysis was conducted to estimate the incidence and prevalence of AA from 2016 to 2020. For the longitudinal analysis, 2 cohorts were identified: mild/moderate and severe. The cohorts were matched based on age, gender, and comorbidities. Patients were enrolled upon their first claim with an AA diagnosis during the index period of 2017-2018.

RESULTS

The number of patients with AA increased from 3221 in 2016 to 3855 in 2020. The longitudinal analysis identified 1808 mild/moderate patients and 452 severe patients. Mild/moderate patients used higher levels of topical corticosteroids (82.41%) than severe patients (73.45%). Conversely, severe patients used more topical nonsteroids (41.81%) and systemic therapies (51.77%) than mild/moderate patients (0.44% and 16.15%, respectively). Oral glucocorticoids use was higher in severe patients (47.57%) relative to mild/moderate patients (14.88%), whereas the use of injectable forms was similar. The most used systemic immunosuppressants were methotrexate, cyclosporin, and azathioprine. Topical immunotherapy utilization decreased with subsequent treatment lines for severe patients. Treatment persistence at 6 months was low for all treatments. Severe patients had higher annual AA-related outpatient visits than the mild/moderate cohort.

CONCLUSIONS

These findings highlight the need for additional innovations and therapies to address the clinical and economic burden of AA.

The Epidemiology of Hospital-Treated Alopecia Areata in Denmark, 1995-2016

INTRODUCTION

Alopecia areata (AA) is an autoimmune skin disease presenting as nonscarring hair loss. Information on the epidemiology of AA, especially the occurrence of AA and its subtypes within the general population, is scarce. The study aimed to estimate the incidence rates and prevalence of hospital-treated AA and its subtypes in Denmark and to examine the demographic and clinical characteristics of patients with AA, including comorbidities and use of prescription medications.

METHODS

This was a cohort study based on data from administrative and health registers in Denmark in 1995-2016. The study included individuals who were (1) registered with a hospital inpatient or hospital-based outpatient clinic diagnosis of AA between 1995 and 2016 in the Danish National Patient Registry covering encounters at all Danish hospitals, (2) alive and resided in Denmark anytime between 1995 and 2016, (3) aged ≥ 12 years, and (4) resided uninterrupted in Denmark during the 12 months before the first AA diagnosis during the study period.

RESULTS

During the study period, 2778 individuals with an incident hospital-based diagnosis of AA were identified; 63.1% were female and 28.7% of the patients were aged ≥ 50 years. Over the study period, the overall incidence rate for any hospital-treated AA per 100,000 person-years was 2.62 (95% confidence interval [CI], 2.53-2.72), and the overall prevalence in 2016 was 71.7 (95% CI 69.4-74.1) per 100,000 persons. Both incidence rate and prevalence increased over time. Prevalence of most hospital-treated comorbidities or history of medication use was below 10% and was similar in the alopecia totalis (AT)/alopecia universalis (AU) and non-AT/AU subtypes of AA.

CONCLUSION

This cohort study reported incidence rates and prevalence over time and characteristics of individuals with hospital-treated AA in Denmark, which are in agreement with those previously reported in this population.

Patients' experiences of primary healthcare and dermatology provision for alopecia

Background

Alopecia describes a group of dermatological conditions characterised by hair loss, which are either non-scarring or scarring in nature, and range from bald patches to complete body hair loss, to general thinning. In the UK, the General Practitioner (GP) is typically the first point of contact, and some patients are referred for specialist dermatology consultation. However, little is known about how individuals with alopecia in the UK experience the care provided by the National Health Service.

Objectives

We aimed to understand patients' perceptions of primary healthcare and dermatology provision. Further, we aimed to investigate how care provision and patients' overall patient journey might be improved in the UK, and how these lessons may apply internationally.

Methods

An online mixed methods survey was distributed by Alopecia UK to UK-based individuals with alopecia. Open-ended text responses were analysed using qualitative content analysis. Quantitative data were analysed using descriptive analyses and dependent measures t-tests.

Results

A total of 291 participants completed the survey. They reported neutral-to-partial dissatisfaction with their GP appointments, with greater satisfaction in their most recent compared to their first appointment. Participants highlighted positive experiences with GPs and dermatologists as well as areas for improvement. Participants also expressed a desire for a greater degree of support and understanding about the psychological impact of alopecia.

Conclusions

Results highlight the importance of being empathic and caring healthcare professionals for patients with alopecia, the need for training for GPs on alopecia, as well as a simplified and joined up pathway between primary and secondary healthcare.

Treatment preferences of adults and adolescents with alopecia areata: A discrete choice experiment

PRODUCTS with janus kinase (JAK) inhibition have been shown to promote hair regrowth in patients with alopecia areata (AA). To guide drug-approval and treatment decisions, it is important to understand patients' willingness to accept the potential risks of JAK inhibition in exchange for potential benefits. We quantified the treatment preferences of adult (≥18 years) and adolescent patients (12-17 years) with AA in the US and Europe to determine the trade-offs they are willing to make between benefits and risks. Preferences for oral AA treatment attributes were elicited using a discrete choice experiment consisting of 12 tasks in which patients chose between two hypothetical treatment alternatives and no treatment. Benefits included the probability of 80%-100% scalp hair regrowth (Severity of Alopecia Tool score ≤ 20) and achieving moderate-to-normal eyebrow and eyelash hair. Treatment-related risks included 3-year probabilities of serious infection, cancer, and blood clots. Preference estimates were used to calculate the maximum level of each risk that patients were willing to accept for increases in treatment benefits. The most important attribute to both adults (n = 201) and adolescents (n = 120) was a 50% probability of achieving hair regrowth on most or all the scalp; however, adolescents placed greater relative importance on this attribute than did adults. Adults were averse to the risks of serious infection, cancer, and blood clots, whereas adolescents were averse to the risk of cancer. For a 20% increase in the probability of 80%-100% scalp hair regrowth, adults were willing to accept a mean (95% confidence interval) 3-year risk of serious infection, cancer, and blood clots of 7.4% (5.5-9.3), 2.5% (1.9-3.1), and 9.3% (6.4-12.2). Adolescents were willing to accept a 3-year risk of cancer of 3.3% (2.4-4.2). Patients with AA in the US and Europe are willing to accept substantial risks to obtain an effective treatment.

"Hair is your crown and glory" - Black women's experiences of living with alopecia and the role of social support

BACKGROUND

Alopecia is an autoimmune condition that results in hair loss, mainly from the scalp. There are three specific types of autoimmune alopecia: alopecia areata (AA; small patches of hair loss), alopecia totalis (AT; total hair loss from the scalp) and alopecia universalis (AU; total hair loss from the scalp and body). Whilst research has explored the experiences of White women living with alopecia, there is a lack of research exploring the impact of alopecia on women in the Black community. The current study aimed to explore Black women's experience of living with autoimmune types of alopecia with a focus on the cultural importance of hair within the Black community and the impact of social support.

PARTICIPANTS AND PROCEDURE

Seven Black women (age range: 37-68 years; mean age: 51 years) were recruited purposively through alopecia support group organisations and social media to participate in a semi-structured interview; four participants were diagnosed with AA, two participants were diagnosed with AU, and one participant was diagnosed with AT. One-to-one interviews were conducted online, and interpretative phenomenological analysis was used to guide data collection and analysis.

RESULTS

Participants discussed the significance of hair specifically within the Black community and the complex relationship between psychological wellbeing, coping and seeking support.

CONCLUSIONS

This novel area, specific to Black women's psychological experience of alopecia, acknowledges the influence of cultural and ethnic differences. The findings suggest that proactive awareness from health professionals and social support groups are needed due to the nuances of Black women's alopecia experience to provide better support and to enhance the quality of life for Black women to manage their alopecia.

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

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

CBD: A Potential Lead against Hair Loss, Alopecia, and its Potential Mechanisms

BACKGROUND

Nowadays, the majority of the population suffers from the problem of hair loss. It leads to disturbed mental health, lower self-confidence, and a lot more problems. A lot of the hair loss therapies available are not reliable and lead to recurrence and side effects after some time. Cannabinoids (CBD) have recently become quite popular for their benefits against hair loss. CBD oil preparations have been used both internally and externally for oral and topical use, respectively. Due to the presence of the endocannabinoid system (ECS) in the body, which naturally targets CB1 and CB2 receptors, the control of hair fall is possible. CBD is used topically for hair loss, whereas it is administered orally for the treatment and management of a medical condition, i.e., alopecia.

AIM/OBJECTIVE

The present review aimed to provide an in-depth study on hair loss and its management using CBD and its associated mechanisms.

METHODS

Electronic databases, such as ScienceDirect, Google Scholar, PubMed, Wiley, Springer, and Scopus, were thoroughly searched for information about how CBD is used, how it works, and what role it plays in treating alopecia and hair loss.

RESULTS

This review has highlighted the use of CBD-based hair loss therapy, and described various types of hair loss and their treatments. This review also details the phytocannabinoids and the potential mechanisms of CBD's activity against hair loss and alopecia.

CONCLUSION

The data obtained from the literature regarding CBD and hair loss provide a scientific basis for CBD use in alopecia. Additionally, a more precise and comprehensive study concerning CBD needs to be carried out at the pre-clinical and clinical levels.

Treatment of in vitro generated Langerhans cells with JAK-STAT inhibitor reduces their inflammatory potential

Alopecia areata (AA) is a condition in which hair is lost in small regions or over the entire body. It has a prevalence of 1 in 1000 and has a great impact on psychological wellbeing. AA is generally considered an autoimmune disease in which a collapse of the immune privilege system of the hair follicle has shown to play an important role, potentially driven by interferon gamma (IFN-γ). The most prominent cells located in or around the hair follicle in AA are Langerhans cells, CD4+ or CD8+ T cells, macrophages and mast cells. Langerhans cells, specialized dendritic cells, are resident in the epidermis and are known to associate with hair follicles. Therefore, we aimed to develop in vitro generated Langerhans cells contributing as an in vitro model of disease. In vitro models provide insight into the behaviour of cells and are a valuable tool before being in need of an animal model or patient samples. For this, Langerhans-like cells were generated from CD14+ monocytes in the presence of GM-CSF and TGF-β. After 10 days of cell culture, Langerhans-like cells express CD207 and CD1a but lack CD209 expression as well as Birbeck granules. Next, Langerhans-like cells were exposed to inflammatory conditions and the effect of different AA treatments was investigated. All treatments-diphencyprone contact immunotherapy, UV-B light therapy and JAK-STAT inhibition-affect the expression of costimulatory and skin-homing markers on Langerhans-like cells. Importantly, also the T cell stimulatory capacity of Langerhans-like cells was significantly reduced following treatment under inflammatory conditions. Noteworthy, JAK-STAT inhibition outperformed conventional AA treatments. In conclusion, our findings demonstrate that in vitro generated Langerhans-like cells can be used as a model of disease. Moreover, JAK-STAT inhibition may become a valuable new approach for the treatment of AA.

Prevalence of autoimmune and inflammatory diseases and mental health conditions among an alopecia areata cohort from a US administrative claims database

Alopecia areata (AA) is associated with an increased burden of autoimmune and inflammatory disease and mental health conditions that may have a negative impact on quality of life. However, the exact burden of comorbidities on US patients with AA and the clinical subtypes alopecia totalis (AT) and alopecia universalis (AU) compared with those without AA is not well understood. This retrospective cohort study aimed to assess the incidence rates and prevalence of AA and its clinical subtypes and examine the autoimmune and inflammatory disease and mental health condition diagnosis burden in US patients with AA and a matched cohort without AA. The Optum Clinformatics Data Mart database was used to select patients aged ≥12 years enrolled between October 1, 2016, and September 30, 2020, who had two or more AA diagnosis codes for the AA cohort. Three patients without AA were age-, sex-, and race-matched to each patient with AA. Autoimmune and inflammatory diseases and mental health conditions were evaluated at baseline and up to 2 years after the index date. In total, 8784 patients with AA (599 with AT/AU) and 26 352 matched patients without AA were included. The incidence rate of AA was 17.5 per 100 000 person-years (PY; AT/AU: 1.1 per 100 000 PY; non-AT/AU: 16.3 per 100 000 PY), and the prevalence was 54.9 per 100 000 persons (AT/AU: 3.8; non-AT/AU: 51.2). Patients with AA had a higher prevalence of autoimmune and inflammatory diseases than the matched non-AA cohort, including allergic rhinitis (24.0% vs 14.5%), asthma (12.8% vs 8.8%), atopic dermatitis (8.3% vs 1.8%), and psoriasis (5.0% vs. 1.6%). The proportions of anxiety (30.7% vs 21.6%) and major depressive disorder (17.5% vs 14.0%) were higher in patients with AA than those without AA. Patients with AT/AU generally had a greater prevalence of autoimmune and inflammatory disease and mental health conditions than patients with non-AT/AU AA.

Incidence Rates of Infections, Malignancies, Thromboembolism, and Cardiovascular Events in an Alopecia Areata Cohort from a US Claims Database

INTRODUCTION

Alopecia areata (AA) is an autoimmune disease with an underlying immuno-inflammatory pathogenesis. Treatments can include systemic corticosteroids and immunomodulators (such as Janus kinase inhibitors); these medications may be associated with a risk of some adverse events. However, large-scale observational studies of baseline incidence rates (IRs) of infection, cardiovascular disease, malignancy, and thromboembolism in US patients with AA, including those with alopecia totalis or alopecia universalis (AT/AU), are limited. This real-world, US claims-based study aimed to estimate the incidence of events in patients with AA compared with matched patients without AA.

METHODS

Patients aged ≥ 12 years enrolled in the Optum Clinformatics Data Mart database from 1 October 2016 to 30 September 2020, with ≥ 2 AA diagnosis codes were included in the AA cohort. Patients without AA were age-, sex-, and race-matched 3:1 to patients with AA. Baseline comorbidities were evaluated during the 12-month period pre-index date. Incident cases of serious/herpes infections, malignancies, major adverse cardiovascular events (MACE), and thromboembolic events were evaluated post-index date. Data are presented using descriptive statistics, proportional percentages, frequencies, and IRs (calculated with 95% CI).

RESULTS

Overall, 8784 patients with AA, 599 of whom had AT/AU, were matched to 26,352 patients without AA. IRs per 1000 person-years among the AA and non-AA cohorts, respectively, were 18.5 and 20.6 for serious infections, 19.5 and 9.7 for herpes simplex infections, 7.8 and 7.6 for herpes zoster infections, 12.5 and 11.6 for primary malignancies, 16.0 and 18.1 for MACE, and 4.9 and 6.1 for venous thromboembolisms. Compared with patients with non-AT/AU AA, patients with AT/AU largely had higher IRs for most baseline comorbidities and outcome events evaluated.

CONCLUSION

Patients with AA had a higher IR of herpes simplex infection than the matched non-AA cohort. Patients with AT/AU generally had higher rates of outcome events than patients without AT/AU.

Evaluation of the Awareness, Beliefs, and Psychological Impact of Patients with Alopecia Areata in Makkah City, Saudi Arabia

Methods

A descriptive cross-sectional study was conducted among patients diagnosed with AA at different hospitals. A total of 211 patients were included in the investigation between November 2021 and June 2022. The participants were subjected to a well-structured, Arabic-based, validated questionnaire.

Results

More than half of the patients were men (54.0%) and single (50.7%). The most common age groups were 30 to 44 years (46.9%) and 18 to 29 years (36.0%). More than two-thirds of the participants (67.8%) had heard of AA before their diagnosis. Of these, the level of knowledge was low among 36.4%, medium among 42.0%, and high among 21.7%. Most of the patients believed that AA may be caused by genetic, nutritional, or health factors (77.3%) and that it is a serious health problem that necessitates treatment (64.0%). The most common psychological attributes caused by AA are feeling ashamed in front of other individuals (63.0%), anxiety (47.9%), and depression (36.0%).

Conclusion

Our results show more than two-thirds of the participants were knowledgeable about AA. Most believed that the cause of AA is genetic, nutritional, or health factors and suffered negative psychological effects. According to our study, high levels of anxiety and depression are closely associated with AA patients, which affect their quality of life.

Global Guidelines in Dermatology Mapping Project (GUIDEMAP): a systematic review of alopecia areata clinical practice guidelines

INTRODUCTION

Alopecia areata (AA) is a nonscarring alopecia with an estimated global prevalence of 2% and limited data on the efficacy of current treatment. Clinical practice guidelines (CPGs) provide recommendations based on best available evidence. It is unclear how many AA CPGs are available globally.

AIM

To systematically search for and identify CPGs on AA and to critically appraise their quality using validated tools.

METHODS

We performed a literature search to identify CPGs published between October 2014 and April 2021, using the following databases: MEDLINE, Embase, National Institute for Health and Care Excellence (NICE), Guidelines International Network, Emergency Care Research Institute guidelines trust, Australian CPGs, Turning Research Into Practice database and DynaMed. The systematic review was conducted and reported in accordance with the Preferred Reporting Items for Systematic Reviews and Meta-Analyses framework. Three critical appraisal tools were used: Appraisal of Guidelines for Research and Evaluation (AGREE) II instrument, Lenzer's red flags and United States Institute of Medicine's (IOM) criteria of trustworthiness.

RESULTS

In total, six AA CPGs from seven manuscripts (one CPG was in two parts published in separate papers) were included. The majority (four of six) of the CPGs focused on treatment. Four CPGs (total of five papers) were in English and two CPGs were only available in the original language (one Russian and one Japanese). All AA CPGs demonstrated low quality in several domains in the AGREE II appraisal, including stakeholder involvement and applicability, with the latter being deemed the worst domain for all CPGs, with an average of 29%. The mean (SD) number of Lenzer's red flags for the included CPGs was 3.4 (1.5) out of a total of 8 possible red flags, while the IOM criteria showed 1.6 (0.8) 'fully met' criteria and 3.1 (1.2) 'not met' out of a total of 9 criteria.

CONCLUSION

We found a limited number of AA CPGs, all of which had significant methodological deficiencies. We encourage guideline development groups to use validated checklists/tools to develop reliable and trustworthy CPGs.

Study of the Thyroid Profile of Patients with Alopecia

Thyroid hormones are required for the physiological growth and maintenance of hair follicles. We aim to study the thyroid profile of patients with alopecia. This is a narrative review. PubMed literature was searched from 2013 to 2022. We followed different types of alopecia: alopecia areata (AA), androgenic alopecia in males and females, telogen effluvium (TE), frontal fibrosing alopecia (FFA), lichen planopilaris, and alopecia neoplastica (AN). AA shares a common autoimmune background with autoimmune thyroid diseases, either sporadic or belonging to autoimmune polyglandular syndromes. Some data suggested that AA is more severe if thyroid anomalies are confirmed, including subclinical dysfunction or positive antithyroid antibodies with normal hormone values. However, routine thyroid screening for patients with AA, if the patients are asymptomatic from a thyroid point of view and they have negative personal and family history of autoimmunity, remains controversial. TE, apart from the autoimmune type, associates thyroid anomalies of a hormonal assay (between 5.7% and 17%). FFA, mostly a postmenopausal entity (however, not exclusive), associates a higher prevalence of thyroid conditions (up to 50%) than the general population. However, these might have an age-dependent pattern, thus the association may be incidental since there are a limited number of studies. Overall, alopecia remains a very challenging condition for patients and physicians; a multidisciplinary team is required to improve the outcome and quality of life. The common autoimmune background is suggestive of some types of alopecia and thyroid disorders, yet, the underlying mechanisms are still a matter of debate. AA, TE, FFA, LPP, and, potentially, female pattern hair loss have been found to be connected with thyroid entities, thus a state of awareness from a dual perspective, of trichology and endocrinology, is helpful.

Global, regional and national burden of alopecia areata and its associated diseases, 1990-2019: A systematic analysis of the Global Burden of Disease Study 2019

BACKGROUND

No study to date has concomitantly reported the global burden of alopecia areata (AA) and its associated diseases.

METHODS

The crude and age-standardized rates of prevalence (ASPR), incidence (ASIR) and years lived with disability (YLDs) of AA were extracted from the global burden of disease, injuries and risk factors study (GBD) database between 1990 and 2019 for 204 countries and territories. We stratified the analysis by global region, nation, sex, age and sociodemographic index (SDI) to dissect the epidemiology of AA and its associated diseases.

RESULTS

Alopecia areata was responsible for 0.024% of the total DALYs. Age-standardized DALYs rate of AA was 7.51 [4.73-11.14] per 100,000. Overall ASPR, ASIR and age-standardized YLDs rates were stable from 1990 to 2019 globally. All three rates were about two times higher in females compared to males and had a bimodal distribution with peaks at age 30-34 years and 60-64 years. AA burden was positively correlated with SDI (r = .375, p < .001) and was most prevalent in high-income countries, especially North America. Countries with a high AA incidence were more likely to have high incidences of autoimmune diseases and low incidences of ischaemic heart disease and ischaemic stroke.

CONCLUSIONS

The burden of AA was prominent in females, young adults, high sociodemographic countries and North Americans. The study corroborates sex- and region-specific implications and public health measures for AA and its associated burdens. These epidemiological data on AA burden can guide future research efforts, prevention strategies and allocation of resources.

Out-of-Pocket Costs in Alopecia Areata: A Cross-Sectional Study in German-speaking Countries

Alopecia areata is a common skin disease which is associated with psychosocial and financial burden. No curative therapy exists and, hence, affected persons resort to self-financed cosmetic solutions. However, studies on the economic impact of alopecia areata on individuals are limited. To estimate annual individual out-of-pocket costs in persons with alopecia areata, a cross-sectional study using a standardized online questionnaire was performed in Germany, Austria and Switzerland. A total of 346 individuals (95.1% women, mean age: 38.5 ± 11.6 years) with alopecia areata participated between April and August 2020. Mean additional spending on everyday necessities was 1,248€ per person per year, which was significantly influenced by the duration of the illness, the treatment provider, and disease severity. Hair replacement products and cosmetics accounted for the highest monthly costs, followed by costs for physician visits, hospital treatments, and medication. Most participants (n = 255, 73.7%) were currently not undergoing treatment, due to lack of efficacy, side-effects, costs and acceptance of the disease. Sex differences in expenses were observed, with women having higher expenditures. Alopecia areata-related out-of-pocket costs place a considerable financial burden on affected individuals, are higher compared with those of other chronic diseases, and should be considered in economic assessments of the impact of this disease.

Prevalence, comorbidities, and treatment patterns of Japanese patients with alopecia areata: A descriptive study using Japan medical data center claims database

Real-world data on alopecia areata (AA) demographics, comorbidities, and treatment patterns are sparse, not only in Japan but worldwide. This cross-sectional study assessed the current prevalence of AA in Japan, including analysis of severe subsets, frequency of comorbidities, and unmet medical needs surrounding treatment. Patients registered in the Japan Medical Data Center claims database (January 2012 to December 2019) and diagnosed with AA were included. Prevalence was calculated yearly, with the most common comorbidities evaluated, and treatments described in the Japanese Dermatological Association AA management guidelines and approved in Japan were included in the analysis. In total, 61 899 patients were diagnosed with AA. Among them, 1497 were diagnosed with severe subtypes. AA prevalence in Japan has been gradually increasing (from 0.16% in 2012 to 0.27% in 2019). The most common comorbidities are allergic rhinitis, atopic dermatitis, and asthma. Depression and anxiety are frequent in these patients, as are autoimmune diseases, e.g., vitiligo, thyroid diseases, and rheumatoid arthritis. Intriguingly, the analysis found Down syndrome to be a comorbidity associated with severe AA in children. The principal treatments were topical corticosteroids, followed by carpronium chloride and cepharanthine. The use of systemic corticosteroids and antihistamines is increased in severe disease. The Japanese Dermatological Association guidelines do not support the use of oral corticosteroids in children; however, in the database, this has been prescribed in up to 2.5% and 9.8% of all pediatric and severe pediatric AA cases, respectively. Despite the limitations of using a claims database, the current study demonstrates that AA prevalence in Japan has gradually increased in recent years, with allergic diseases being the most common comorbidities. The data also imply that there is a need for effective and safe therapies, especially for severe and pediatric cases.

Alopecia Areata in Latin America: Where are We and Where are We Going?

Alopecia areata (AA) represents an underrecognized burden in Latin America (LA), severely impacting quality of life (QoL). This impact is exacerbated by limited access to specialized dermatologic care and therapies for AA within and among nations. Many of the unmet needs for AA globally also exist in LA. The region has geographic, ethnic, cultural, and economic conditions. With new AA medicines targeting immunologic pathways on the horizon, LA must prepare regarding regulatory issues, reimbursement, awareness, and education to give adequate and timely treatment for patients with AA. To address these issues, the Americas Health Foundation convened a panel of six dermatologists from Argentina, Brazil, Colombia, and Mexico who are experts in AA and its comorbidities for a 3-day virtual meeting to discuss AA diagnosis and treatment in LA and create a manuscript offering recommendations to address discussed barriers. This publication examines unmet AA needs in LA, treatment, and innovative therapies and recommends improving AA care. Access constraints to conventional and novel medicines hinder appropriate treatments for patients. Therapy initiation delays can affect QoL, mental health, and disease progression. People with AA face stigmas, discrimination, and misconceptions owing to a lack of disease awareness. With promising new treatments for AA on the horizon, all stakeholders must coordinate efforts to enhance LA's AA management landscape and improve patient outcomes.

Pediatric pulse dose corticosteroid therapy dosing and administration in the treatment of alopecia areata: A review of literature

BACKGROUND

The use of pulse dose corticosteroid therapy (PDCT) in children for treatment of alopecia areata (AA) has been reported, but dosing regimens are not well-established. We aim to evaluate the available literature regarding the utilization and various dosing regimens of PDCT, as well as associated side effects, in the treatment of AA in children.

METHODS

We performed a systematic review of studies describing the use of PDCT for the treatment of AA in children.

RESULTS

Eight relevant studies were identified, five of which administered the treatment intravenously (IV) and three of which administered the treatment orally. Protocols with IV administration included two studies which used IV dexamethasone at 1.5 mg/kg/day for 1-3 days monthly for a maximum of 12 cycles and three studies used IV methylprednisolone 8-30 mg/kg/day for 1-3 days monthly for a maximum of 3-10 cycles. The three protocols with oral administration included variable doses of prednisolone at variable intervals and cycle lengths, betamethasone and dexamethasone at a prednisolone equivalent of 5 mg/kg, and methylprednisolone 15 mg/kg for 3 days bimonthly for 12 cycles. In these studies, PDCT was generally well-tolerated and resulted in improvement of the AA.

CONCLUSION

PDCT was found to be well-tolerated with few serious side effects reported. It appears to be beneficial early in disease course, especially for those with multifocal AA.

Various Application of Tofacitinib and Ruxolitinib (Janus Kinase Inhibitors) in Dermatology and Rheumatology: A Review of Current Evidence and Future Perspective

INTRODUCTION

Janus kinase inhibitors (JAKi) are anti-inflammatory medications suppressing Janus kinase-signal transducer and activator of transcription (JAK-STAT) pathway by inhibiting various cytokines receptors on the membrane of cells. Mutations and polymorphisms on JAK and STAT proteins can cause dysregulation in the balance of immune system, and ultimately result in autoimmune disorders.

OBJECTIVES

To record and summarize the overall efficacy and safety of JAKi in various autoimmune conditions such as alopecia areata (AA), psoriasis vulgaris (PV), psoriatic arthritis (PsA), atopic dermatitis (AD), vitiligo, hidradenitis suppurative (HS), lichen planus (LP), and pyoderma gangrenosum (PG).

METHODS

A thorough review of articles was performed across PubMed and Google Scholar on meta-analyses, systematic reviews, clinical trials and case studies evaluating the treatment of autoimmune disorders such as AA, PV, PsA, AD, vitiligo, LP, HS, and PG with JAKi. Duplicated data and animal experiments or in vitro/ex vivo studies were excluded.

RESULTS

All the reviewed articles reported beneficial effects of tofacitinib and ruxolitinib application in the treatment of disorders mentioned above with the autoimmune predisposition.

CONCLUSIONS

Tofacitinib and ruxolitinib showed potential efficacy in treating several autoimmune disorders. Based on records in the reviewed studies, both medications had acceptable safety profiles; however, physicians are recommended to outweigh the risks and benefits of such treatments for each specific condition.

Economic Burden and Healthcare Resource Use of Alopecia Areata in an Insured Population in the USA

INTRODUCTION

Comparative data on the economic burden of alopecia areata relative to the general population are limited. The objective of this retrospective database analysis was to evaluate healthcare resource utilization and direct medical costs among patients with alopecia areata from the US payer perspective compared with matched controls.

METHODS

Validated billing codes were used to identify patients with alopecia areata from the IQVIA PharMetrics Plus (2016-2018) who had continuous pharmacy and medical enrollment for 365 days both before (baseline period) and after (evaluation period) the index date. Demographic and clinical characteristics were characterized, and baseline comorbidities were assessed with the Quan Charlson Comorbidity Index.

RESULTS

Using the exact matching feature from Instant Health Data, 14,340 patients with alopecia areata were matched with 42,998 control patients aged ≥ 12 years. Patients with alopecia areata had higher healthcare resource utilization and adjusted total all-cause mean medical costs versus matched controls ($8557 versus $6416; p < 0.0001), because of higher inpatient costs, emergency department visits, ambulatory visits, number of prescriptions and prescription costs, and other costs such as durable medical equipment and home healthcare. The number of inpatient visits did not significantly differ between the two groups. Mean ambulatory costs were $3640 for patients with alopecia areata and $2062 for controls, and mean pharmacy costs were $3287 and $1843, respectively (p < 0.0001 for both). Pharmacy costs related to immunologic agents represented 50.0% of the total difference in pharmacy spending between patients with alopecia areata and controls. Surgery on the integumentary system accounted for 9.5% of the total difference in ambulatory costs.

CONCLUSION

Alopecia areata is associated with significant incremental healthcare resource utilization and costs relative to matched controls due to increased spending in areas such as surgical procedures and psychological and pharmacological interventions. Costs are primarily driven by ambulatory and pharmacy spending.

The epidemiology of alopecia areata: a population-based cohort study in UK primary care

BACKGROUND

There is a lack of population-based information on the disease burden and management of alopecia areata (AA).

OBJECTIVES

To describe the epidemiology of AA, focusing on incidence, demographics and patterns of healthcare utilization.

METHODS

Population-based cohort study of 4·16 million adults and children, using UK electronic primary care records from the Oxford-Royal College of General Practitioners (RCGP) Research and Surveillance Centre (RSC) network database, 2009-2018. The incidence and point prevalence of AA were estimated. Variation in AA incidence by age, sex, deprivation, geographical distribution and ethnicity was examined. Patterns of healthcare utilization were evaluated in people with incident AA.

RESULTS

The AA incidence rate was 0·26 per 1000 person-years. AA point prevalence in 2018 was 0·58% in adults. AA onset peaked at age 25-29 years for both sexes, although the peak was broader in females. People of nonwhite ethnicity were more likely to present with AA, especially those of Asian ethnicity [incidence rate ratio (IRR) 3·32 (95% confidence interval 3·11-3·55)]. Higher AA incidence was associated with social deprivation [IRR most vs. least deprived quintile 1·47 (1·37-1·59)] and urban living [IRR 1·23 (1·14-1·32)]. People of higher social deprivation were less likely to be referred for specialist dermatology review.

CONCLUSIONS

By providing the first large-scale estimates of the incidence and point prevalence of AA, our study helps to understand the burden of AA on the population. Understanding the variation in AA onset between different population groups may give insight into the pathogenesis of AA and its management.

Epidemiology, management and the associated burden of mental health illness, atopic and autoimmune conditions, and common infections in alopecia areata: protocol for an observational study series

INTRODUCTION

Alopecia areata (AA) is a common cause of immune-mediated non-scarring hair loss. Links between AA and common mental health, autoimmune and atopic conditions, and common infections have previously been described but remain incompletely elucidated and contemporary descriptions of the epidemiology of AA in the UK are lacking.

METHODS AND ANALYSIS

Retrospective study series using a large population-based cohort (5.2 million) from the Oxford Royal College of General Practitioners (RCGP) Research and Surveillance Centre (RSC) database, exploring four themes: AA epidemiology, mental health comorbidities, autoimmune/atopic associations and common infections.In the epidemiology theme, we will describe the incidence and point prevalence of AA overall and by age, sex and sociodemographic factors. Healthcare utilisation (primary care visits and secondary care referrals) and treatments for AA will also be assessed. In the mental health theme, we will explore the prevalence and incidence of mental health conditions (anxiety, depressive episodes, recurrent depressive disorder, adjustment disorder, agoraphobia, self-harm and parasuicide) in people with AA compared with matched controls. We will also explore the mental health treatment patterns (medication and psychological interventions), time off work and unemployment rates. Within the autoimmune/atopic associations theme, we will examine the prevalence of atopic (atopic dermatitis, allergic rhinitis, asthma) and autoimmune conditions (Crohn's disease, ulcerative colitis, coeliac disease, type 1 diabetes, Hashimoto's thyroiditis, Graves' disease, rheumatoid arthritis, psoriatic arthritis, ankylosing spondylitis, systemic lupus erythematosus (SLE), polymyalgia rheumatica, Sjögren's syndrome, psoriasis, vitiligo, multiple sclerosis, pernicious anaemia) in people with AA compared with matched controls. We will also estimate the incidence of new-onset atopic and autoimmune conditions after AA diagnosis. Within the common infections theme, we will examine the incidence of common infections (respiratory tract infection, pneumonia, acute bronchitis, influenza, skin infection, urinary tract infection, genital infections, gastrointestinal infection, herpes simplex, herpes zoster, meningitis, COVID-19) in people with AA compared with matched controls.

ETHICS AND DISSEMINATION

The Health Research Authority decision tool classed this a study of usual practice, ethics approval was not required. Study approval was granted by the RCGP RSC Study Approval Committee. Results will be disseminated through peer-reviewed publications.

OBSERVATIONAL STUDY REGISTRATION NUMBER

NCT04239521.

Treatment of alopecia totalis/universalis/focalis with vitamin D and analogs: Three case reports and a literature review

BACKGROUND

Alopecia areata (AA) is an inflammatory disease with autoimmune, environmental, and inherited components directed at the hair follicle, either limited to patchy hair loss over the scalp (Focalis, AF), total loss of scalp hair (Totalis, AT), or total loss of both scalp and body hair (Universalis, AU). Despite multiple treatment modalities, no therapy exists. Vitamin D deficiency in patients with AA/AT/AF influences disease severity and duration, inversely correlating with inflammation histologically.

CASE SUMMARY

Three girls presented with AT (P1), AU (P2), and AF (P3) at the ages of 1, 5, and 5 years, respectively. For P1-P2, all available treatments implemented for 2 years had failed. We started an initial 6-mo repletion with oral cholecalciferol 2000/4000 IU/d, with no apparent effect. Then we attempted immunomodulation using oral calcitriol and its analog paricalcitol. On calcitriol, 0.5 mcg/d P1 regrew hair within 6 mo. After 4 years, a relapse with loss of eyebrow hair was resolved after doubling the calcitriol dose to 0.5 mcg × 2/d; the results have been maintained for 6 years to date. On calcitriol, 0.25 mcg × 3/d P2 led to the development of asymptomatic hypercalcemia-hypercalciuria, which was immediately resolved by switching to paricalcitol 2 mcg × 3/d; mild tolerable hypercalciuria was maintained. Hair regrowth was observed at 6 mo, stabilizing only as fur at 12 mo. AF in P3 was resolved completely within 3 mo on a daily high dose (8000 IU) of cholecalciferol.

CONCLUSION

Vitamin D may have immunomodulating therapeutic impact on AT/AU/AF, which needs to be explored with further pilot clinical trials.

Association between alopecia areata and thyroid dysfunction

Alopecia Areata is an inflammatory and T cell-mediated autoimmune reaction against unknown autoantigen of hair follicles characterized by patchy, non-scarring loss of hair follicles in the anagen phase. Although its etiology is minimally understood, genetic susceptibility, autoimmunity and stress are thought to be causative factors. It occurs in episodic and recurrent patterns with an incidence rate of 0.1-0.2% in the general population and 7-30 cases per 1000 dermatological patients with a lifetime risk of 1.7%. The lesions can be single and self-limiting or may be widespread. Autoimmune disorders such as Hashimoto's thyroiditis, Vitiligo, celiac disease, diabetes mellitus, psoriasis ad lupus erythematosus were observed as an associated comorbid disorder in AA patients, but hypothyroidism and Vitiligo have the strongest association. Its clinical course is unpredictable and shows no significant predilection to age, gender or race. AA is a heterogeneous variant of alopecia and has clinical types such as patchy alopecia, alopecia reticularis and alopecia totalis. Various epidemiological reports demonstrate an increased frequency of AA in thyroid disease patients. Contemporary research has shed spotlight on circulating auto-reactive cells in evolution of AA, which may play a role in ultimately linking these diseases. Comprehension of complex interplay between autoantigens and immune cells is still evolving. The present study will explore this association of Alopecia Areata in patients with thyroid dysfunction. This correlation was studied briefly with literature available in the medical database such as PubMed and Google Scholar.

The Physicochemical, Biopharmaceutical, and In Vitro Efficacy Properties of Freeze-Dried Dexamethasone-Loaded Lipomers

Dexamethasone-loaded polymer hybrid nanoparticles were developed as a potential tool to treat alopecia areata due to their follicular targeting ability. Freeze drying (FD) is a common technique used to improve nanoparticle stability; however, there are few studies focused on its effect on ethyl cellulose lipid-core nanoparticles. Nanoparticles were lyophilized with different cryoprotectants. Sucrose was selected because it allowed for a good resuspension and provided acceptable physicochemical parameters (374.33 nm, +34.7 mV, polydispersion 0.229%, and 98.87% encapsulation efficiency). The nanoparticles obtained were loaded into a pleasant xanthan gum hydrogel, and the rheological, release, and skin permeation profiles of different formulations were studied. The FD formulation significantly modified the particle size, and the drug release and permeation properties were also altered. In addition, analyses of the cytotoxicity and anti-inflammatory efficacy of FD and non-FD particles on human keratinocytes indicated no differences.

The association between alopecia areata and anxiety, depression, schizophrenia, and bipolar disorder: a population-based study

Although Alopecia areata (AA) has been found to be associated with psychological distress, the scope and nature of this association has not been fully delineated. The current study sought to examine the association of AA with anxiety, depression, schizophrenia, and bipolar disorder, utilizing a large-scale matched controlled cohort design. Patients suffering from AA (n = 41,055) were matched to control cases (n = 41,055) by age, sex, and socioeconomic status (SES). The prevalence of the four major mental disorders was assessed while stratifying the sample by age and sex, and after adjusting for marital status, smoking, BMI, hypertension, and diabetes. Data were accessed via the Clalit Health Services (CHS) database, a comprehensive health registry utilized by the largest managed healthcare company in Israel. Anxiety was independently and positively associated with AA (OR 1.22, 95% CI 1.13-1.31, p < 0.001), across all age groups above 30, with similar rates in males and females. Depression was also independently and positively associated with AA (OR 1.09, 95% CI 1.01-1.17, p < 0.005), particularly in the 30-49 age group, with a higher association among females. A negative association was found between AA and schizophrenia (OR 0. 71, 95% CI 0.61-0.83, p < 0.001). No association was found between AA and bipolar disease. Patients with AA are at risk for anxiety and depression, with female patients, and patients in the 30-49 age group being particularly vulnerable to develop a co-occurring mental disorder. Medical treatment should therefore include psychiatric evaluation and appropriate care.

Serial Hydrolysis for the Simultaneous Analysis of Catecholamines and Steroids in the Urine of Patients with Alopecia Areata

Catecholamines and steroids are well-known neurotransmitters and hormones that rapidly change the excitability of neurons. Alopecia areata is a disease for which the exact cause is unknown, but it is considered to be associated with stress, and so the simultaneous analysis of catecholamines and steroids is required for the diagnosis of alopecia areata. Thus, we herein report the simultaneous analysis of catecholamines and steroids bearing different functional groups for the first time, during which it was necessary to carry out a serial hydrolysis procedure. Following hydrolysis of the urine samples to produce the free forms from the urinary conjugates, ethyl acetate extractions were carried out, and chemical derivatization was performed using dansyl chloride to increase the sensitivity of the liquid chromatography-tandem mass spectrometry method. The matrix effects and recoveries of this analytical method were validated, giving values of 85.4-122.9% and 88.8-123.0%, respectively. In addition, the method accuracy and precision were assessed, giving values of 0.4-21.5% and 2.0-21.6% for the intra-day and inter-day precisions, respectively. This validated method was then applied to identify differences between patients with and without alopecia areata, wherein the metanephrine content was found to be significantly higher in the alopecia areata patient group. This quantitative profiling method can also be applied to steroid-dependent diseases, as well as catecholamine-related diseases.

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.

Cross talk between oxidative stress and inflammation in alopecia areata

BACKGROUND

Although the etiopathogenesis of alopecia areata (AA) is still unclear, inflammation, oxidative stress, and subsequent DNA damage might be considered role players in disease development.

AIM

We aimed at exploring the potential link between oxidative DNA damage and inflammation in AA patients through measuring 8-hydroxy deoxyguanosine (8-OHdG), high mobility group box 1 protein (HMGB1), and one of the inflammatory mediators, C-reactive protein (CRP).

METHODS

A total of 79 subjects (49 AA patients in addition to 30 apparently healthy control subjects) were tested for serum levels of 8-OHdG, HMBG1, and CRP.

RESULTS

Compared with the control group, serum 8-OHdG, HMBG1, and CRP levels were significantly elevated in the studied patients group (0.031, <0.001, and <0.001, respectively). Moreover, logistic regression analysis revealed that disease course, serum levels of 8-OHdG, and HMBG1 were considered independent predictors for AA severity in both uni- and multivariable analyses.

CONCLUSION

Our results suggest a possible role of oxidative stress together with proinflammatory biomarkers in development of AA and their benefit in predicting a severe form of the disease.

Burden of Illness in Alopecia Areata: A Cross-Sectional Online Survey Study

Previous QOL and disease burden studies have not captured all relevant aspects of living with alopecia areata (AA). To better understand the burden and everyday experience of living with moderate-to-severe AA, a cross-sectional, online, quantitative-qualitative survey was developed to assess symptoms, relationships, productivity, treatments, and financial burden. Adult patients were recruited from the National Alopecia Areata Foundation database. Data were analyzed descriptively. A total of 216 patients completed the survey. Most were female (83%), aged ≥45 years (59%), and white (78%). Nearly 2 of 3 respondents (62%) made different major life decisions (regarding relationships, education, or career) owing to AA. Most respondents (85%) stated coping with AA as a daily challenge, citing mental health issues, concealing hair loss, and others' reactions; 47% reported anxiety and/or depression. Many patients (75%) persistently concealed hair loss (mean time spent, 10.3 h/wk). Treatment discontinuation was common owing to lack of efficacy, side effects, and cost. Associated expenditures included buying wigs or hairpieces and psychotherapy (mean ∼$2,000/y each). Survey respondents comprised a self-selected sample, which may not reflect the entire population. The impact of AA extends beyond cosmetic concerns and carries a considerable psychosocial burden. Efficacious, less burdensome AA treatments are needed to regrow hair and alleviate psychosocial sequelae.

Current Treatment of Alopecia Areata

The number of alopecia areata (AA) clinical trials with Jak inhibitors of cytoplasmic tyrosine kinases, including Jak1, Jak2, Jak3, and tyrosine-protein kinase has increased significantly since the last Research Summit. This fact means that the conversation about current treatments for AA now also needs to include a discussion of traditionally used off-label therapies as well as evolving therapies as with Jak inhibitors.

A randomized, placebo and active controlled, split scalp study to evaluate the efficacy of platelet-rich plasma in patchy alopecia areata of the scalp

Platelet-rich plasma (PRP) is a new modality of treatment in the field of dermatology. There are paucity of studies evaluating the effects of PRP in nonscarring alopecia especially alopecia areata (AA). To compare the efficacy and safety of PRP in patchy AA of the scalp in a placebo and active controlled trial. This was a randomized, placebo and active controlled, split scalp study. Fifty patients of patchy AA of the scalp were recruited and allocated to two treatment groups. Left side of the scalp received placebo (intralesional normal saline), right side of the scalp received intralesional PRP in one group and intralesional triamcinolone acetonide in second group. Three treatment sessions were given at 4-week interval and final follow-up was done at 8 weeks later. SALT scoring, dermoscopy were the parameters used to assess the efficacy. The SALT score showed statistically significant improvement from baseline in both the treatment groups (P value <.001). The maximum absolute regrowth was shown by the steroid group followed by PRP followed by placebo group (P value .016). Improvement in dermoscopic findings were similar in both the PRP and steroid groups followed by placebo (P value .448). PRP is a promising therapy in AA as an adjuvant in those with minimal response and those not tolerating steroids or have developed adverse effects to it.

Alopecia areata treated with dimethyl fumarate: A case series

Alopecia areata is an autoimmune condition leading to non-scarring hair loss. Clinically, several presentations ranging from single or few small patches to complete hair loss are documented. The management of alopecia areata is challenging and all available treatments do not ensure a long-term remission to assess the safety and efficacy of systemic dimethyl fumarate in alopecia areata patients not responding to other systemic treatments. After obtaining informed consent, we administered off-label dimethyl fumarate to 10 adult patients with alopecia areata, for a period ranging from 4 to 37 weeks. Medical information for each patient and the severity of alopecia tool (SALT) score before and after dimethyl fumarate administration were recorded. During the treatment, 50% of patients (5 patients out of 10) had a slight improvement of hair regrowth; it was mainly as partial hair regrowth (ranging from 8% to 32%) and only one patient (10%) achieved > 50% terminal hair regrowth. Authors conclude that dimethyl fumarate is not advisable as a treatment of alopecia areata, also considering the risk of fumaric acid esters toxicity.

Hair Growth Effect of Emulsion Extracted Brevilin A, a JAK3 Inhibitor, from Centipeda minima

Janus kinase 3 (JAK3) inhibitors have been used effectively in the treatment of several cases of alopecia universalis and its variants. Our study aims to evaluate whether the emulsion extract of brevilin A from Centipeda minima (CMX) stimulates hair regrowth in a clinical trial, as a JAK3 inhibitor, combined with network pharmacology-based analysis. CMX showed potent inhibition of JAK3 in a concentration-dependent manner. Significant differences in total hair count, terminal hair count, and anagen hair count from the baseline to 24 weeks were observed between the placebo and CMX subjects. The gene set enrichment analysis showed that the targets of CMX are mainly associated with the JAK-STAT signaling pathway, cytokine–cytokine receptor interactions, and the MAPK signaling pathway. This study suggests that the medicinal herbal extract CMX is useful in the treatment of mild to moderate vertex balding that contribute to the visible improvements in hair growth observed in treated patients.

Prevalence and Clinical Characteristics of Alopecia Areata at a Tertiary Care Center in Saudi Arabia

Results

A total of 216 patients with AA were included. The overall prevalence of AA was approximately 2.3%. The mean disease duration at the time of presentation was 2 months while the mean age of onset was 25.61 years. The most common type of AA in both adult and pediatric groups was the patchy type involving the scalp. Comorbid diseases were found in 32.41% of patients. Common associated conditions included hypothyroidism, diabetes mellitus, and atopic diseases.

Conclusion

The overall prevalence of AA among a population of Saudi patients is 2.3%. AA prevalence is higher in pediatrics than adults. Common comorbid conditions include hypothyroidism, diabetes mellitus, and atopic diseases.

Ruxolitinib cream for the treatment of patients with alopecia areata: A 2-part, double-blind, randomized, vehicle-controlled phase 2 study

BACKGROUND

There are currently no treatments for alopecia areata (AA) that are universally effective or approved by the US Food and Drug Administration. Oral ruxolitinib has shown efficacy in extensive AA. Ruxolitinib cream would potentially avoid systemic adverse effects.

OBJECTIVE

To assess the efficacy and safety of 1.5% ruxolitinib cream in patients with AA who had at least 25% hair loss by Severity of Alopecia Tool score.

METHODS

This was a 2-part study. Part A was an open-label, 24-week study of 1.5% ruxolitinib cream in patients with 25% to 99% hair loss followed by a 24-week extension period. Part B was a double-blind, vehicle-controlled, 24-week study of 1.5% ruxolitinib cream in patients with 25% to 100% hair loss, followed by a crossover to ruxolitinib cream in the vehicle group for 24 weeks and additional treatment time for the ruxolitinib cream group.

RESULTS

Although Part A results suggested potential efficacy of 1.5% ruxolitinib cream, there was no significant difference in hair regrowth based on 50% improvement in Severity of Alopecia Tool scores between patients receiving 1.5% ruxolitinib cream and vehicle in part B. There were no significant safety issues with 1.5% ruxolitinib cream.

LIMITATIONS

Single strength of ruxolitinib cream.

CONCLUSIONS

The 1.5% ruxolitinib cream did not have a significant effect in patients with AA.

Familial implications of autoimmune disease: Recurrence risks of alopecia areata and associated conditions in first-degree relatives

Alopecia areata (AA), a complex autoimmune hair loss condition, affects approximately 2.1% of the population. Individuals with AA have increased susceptibility to diseases such as atopy and autoimmune disorders, but little is known about first-degree relatives' risk to develop AA and associated conditions. Genetic counseling for multifactorial conditions, including autoimmune disease is complex, but potentially valuable. Anecdotally we know patients with AA ask medical providers about recurrence risk for family members as well as question whether they and their relatives are at risk for other conditions. Data on AA recurrence risks and comorbid conditions among relatives of affected individuals comprise valuable information that may guide clinical management by genetic counselors. This study investigated the recurrence risk of AA and compared the prevalence of associated conditions among first-degree relatives to the general population. The study also assessed the validity of self-reported conditions for a subset of participants. Relatives of individuals with AA (N = 155), recruited from the National Alopecia Areata Foundation Registry, completed telephone surveys about their personal medical history for 70 medical conditions associated with AA. Medical records for 60 participants were compared to self-reported responses. One-sided proportional tests, in which it is assumed the disease prevalence in first-degree relatives is higher than for those in the general population, yielded a 7.8% estimated risk of AA versus the general population prevalence of 2.1%. Furthermore, there are increased risks of 33 associated conditions, including atopy and other autoimmune conditions. Comparison of medical reports to self-reported conditions indicated only 12% was incongruent. The findings may help genetic counselors better serve patients and their families by informing them of lifetime risk estimates of developing AA and comorbid conditions, resulting in early diagnosis of autoimmune diseases in AA families. Findings also provide evidence supporting the validity of self-report data in AA families.

A variety of processes that affect the perception of skin aging

The purpose of this paper is to discuss the most important factors affecting perceived age. Aging is an unavoidable and irreversible process, but perceived age is a modifiable psychosocial factor. Our exterior has become one of the determinants of our social position, the key to success in our professional and personal lives. Today, we see people through their appearance, we judge after the first impression. With the help of aesthetic medicine, we can change the perceived age, but we cannot stop aging. This article discusses factors affecting the perceived age, such as hair color, skin color, general appearance and environmental factors. Many cannot be avoided, but we can make changes in life to look younger and more well-groomed. Indeed, we can change our habits for the benefit of the whole body, not only for the skin.

Italian Guidelines in diagnosis and treatment of alopecia areata

Alopecia areata (AA) is an organ-specific autoimmune disorder that targets anagen phase hair follicles. The course is unpredictable and current available treatments have variable efficacy. Nowadays, there is relatively little evidence on treatment of AA from well-designed clinical trials. Moreover, none of the treatments or devices commonly used to treat AA are specifically approved by the Food and Drug Administration. The Italian Study Group for Cutaneous Annexial Disease of the Italian Society of dermatology proposes these Italian guidelines for diagnosis and treatment of Alopecia Areata deeming useful for the daily management of the disease. This article summarizes evidence-based treatment associated with expert-based recommendations.

Aggregatibacter actinomycetemcomitans Leukotoxin (LtxA; Leukothera®): Mechanisms of Action and Therapeutic Applications

Aggregatibacter actinomycetemcomitans is an oral pathogen that produces the RTX toxin, leukotoxin (LtxA; Leukothera^®). A. actinomycetemcomitans is strongly associated with the development of localized aggressive periodontitis. LtxA acts as a virulence factor for A. actinomycetemcomitans to subvert the host immune response by binding to the β₂ integrin lymphocyte function-associated antigen-1 (LFA-1; CD11a/CD18) on white blood cells (WBCs), causing cell death. In this paper, we reviewed the state of knowledge on LtxA interaction with WBCs and the subsequent mechanisms of induced cell death. Finally, we touched on the potential therapeutic applications of LtxA (trade name Leukothera^®) toxin therapy for the treatment of hematological malignancies and immune-mediated diseases.

Alopecia areata: a long-term follow-up study of 104 patients

BACKGROUND

Alopecia areata (AA) is a common autoimmune disease that considerably affects the quality of life. Although several studies have investigated the epidemiology, clinical characteristics and treatment of AA, limited recent data are available regarding its long-term course.

OBJECTIVES

To evaluate the long-term course of AA in different age groups.

METHODS

A retrospective evaluation of patients who were newly diagnosed with AA from 2008 to 2011 and had at least 7 years of follow-up. Data regarding the initial episode, treatment given, disease-free interval and relapses were analysed.

RESULTS

A total of 104 cases were analysed: 31 childhood-onset, 63 adult-onset and 10 late-onset. At first episode, 88.5% of patients had mild, 3.8% moderate and 7.7% severe AA. Full or significant re-growth was observed in 74%, 94% and 100% of childhood-onset, adult-onset and late-onset AA patients, respectively. There was no re-growth in 13%, 3% and 0% of childhood-onset, adult-onset and late-onset patients, respectively. The duration of the initial episode and the disease-free interval negatively correlated with age. Systemic steroids were the most effective treatment for the primary episode. The frequency of relapses was high overall (52%, 44% and 30% in childhood-onset, adult-onset and late-onset, respectively), but significantly declined over time with a majority (79%) occurring within the first 4 years. The disease-free interval and relapse rate were not correlated with gender, disease severity at onset or treatment given.

CONCLUSIONS

The prevalence of severe disease, duration of an initial episode and the rate of relapses decreased with an older age at onset. In addition, the outcome and the disease-free interval improved with age at onset. The frequency of relapses declined over time and most appear early on. The current treatment modalities do not seem to influence the long-term outcome.

Are Preferred Scalp Locations for Alopecia Areata Patches a Clue to Neuronal Etiology?

Background

Alopecia areata (AA) is an autoimmune disease causing hair loss in 2% of the population. Anecdotally, hair specialists report that patches localize to the scalp periphery. Changes in sensory innervation and/or scalp vasculature may play a role in the development and localization of alopecic patches.

Objective

To evaluate the most common locations of initial alopecic scalp patches.

Materials and Methods

A retrospective chart review, with comprehensive evaluation of clinical photographs, was conducted from July 2016 to June 2018 to include AA patients (n = 112). Clinical data was collected on gender, age, race, time until presentation at the clinic, and areas of hair loss on initial presentation.

Results

The most common areas of initial AA patches in both females and males were the occiput (49 vs. 48.5%), parietal (46.9 vs. 21.2%), vertex (26.5 vs. 18.2%), and frontal (24.5 vs. 18.2%) regions; 26.8% of patients present with either alopecia totalis or universalis.

Limitations

This is a single-center study with underrepresentation of minority races.

Conclusion

AA patches most commonly present on the occiput of the scalp in both female and male patients. Cervical spine nerves C3 and C2 supply sensory innervation and the occipital artery supplies blood to this area.

Sequential high- and low-dose systemic corticosteroid therapy for severe childhood alopecia areata

BACKGROUND

Given the limited number of therapeutic options, severe childhood alopecia areata (AA) poses a clinical challenge. The best and most rapid response rates can be achieved with high-dose systemic corticosteroids, however, relapse following treatment discontinuation is inevitable. Due to systemic side effects, long-term high-dose corticosteroid regimens are not feasible. Following initial pulse therapy, continuation of corticosteroid therapy at a dose below the Cushing threshold might be able to suppress disease activity without causing severe side effects.

PATIENTS AND METHODS

Thirteen children with severe AA were enrolled in our open observational study. Seven had alopecia totalis or universalis; the remaining six children had multifocal alopecia affecting more than 50 % of the scalp. The treatment regimen consisted of initial pulse therapy with prednisolone 2 mg/kg PO, which was subsequently tapered to a maintenance dose below the individual Cushing threshold within nine weeks. Children were followed-up for one to three years.

RESULTS

Sixty-two percent of individuals showed complete hair regrowth. The mean time to response was 6.6 weeks. Said response was sustained with maintenance therapy for the entire follow-up period. Noticeable side effects included weight gain (1-3 kg), which was observed in all children, and mild steroid acne in 23 % of cases.

CONCLUSIONS

Sequential high- and low-dose prednisolone therapy is an effective and safe therapeutic option for childhood AA.

Differential expression patterns of specific long noncoding RNAs and competing endogenous RNA network in alopecia areata

BACKGROUND

Long noncoding RNAs (lncRNAs) regulate gene expression by acting with microRNAs (miRNAs) and indirectly interact with messenger RNA (mRNAs). However, the roles of specific lncRNA and its related competing endogenous RNAs (ceRNA) network in alopecia areata (AA) are not fully understood.

METHODS

The blood lncRNA profiles were obtained by microarray from 10 samples, including five alopecia areata samples and five normal samples. Based on bioinformatics generated from miRcode, starBase, and miRTarBase, we constructed an lncRNA-miRNA-mRNA network (ceRNA network) in alopecia areata.

RESULTS

We found 154 differentially expressed lncRNAs and 46 differentially expressed genes (DEGs). The functional enrichment indicated that the DEGs mainly regulated the pathways of focal adhesion, Mucin type O-glycan biosynthesis, and so on. The differentially expressed lncRNA (DElncRNA) involved in the pathway of thyronamine and iodothyronamine metabolism and so on. Through integrated lncRNA-mRNA and miRNA-mRNA pairs, the ceRNA network was constructed, thereafter, six ceRNA subnetworks were identified and subnetwork 1 were found to be significantly associated with the occurrence of alopecia areata.

CONCLUSION

Our results showed blood lncRNA expression patterns and a complex ceRNA network in alopecia areata. However, futher studies on blood and tissue verification of these lncRNAs and relative pathways are needed.