Clinical-epidemiologic study of alopecia areata

A "hair-raising" history of alopecia areata

A 3500-year-old papyrus from ancient Egypt provides a list of treatments for many diseases including "bite hair loss," most likely alopecia areata (AA). The treatment of AA remained largely unchanged for over 1500 years. In 30 CE, Celsus described AA presenting as scalp alopecia in spots or the "windings of a snake" and suggested treatment with caustic compounds and scarification. The first "modern" description of AA came in 1813, though treatment still largely employed caustic agents. From the mid-19th century onwards, various hypotheses of AA development were put forward including infectious microbes (1843), nerve defects (1858), physical trauma and psychological stress (1881), focal inflammation (1891), diseased teeth (1902), toxins (1912) and endocrine disorders (1913). The 1950s brought new treatment developments with the first use of corticosteroid compounds (1952), and the first suggestion that AA was an autoimmune disease (1958). Research progressively shifted towards identifying hair follicle-specific autoantibodies (1995). The potential role of lymphocytes in AA was made implicit with immunohistological studies (1980s). However, studies confirming their functional role were not published until the development of rodent models (1990s). Genetic studies, particularly genome-wide association studies, have now come to the forefront and open up a new era of AA investigation (2000s). Today, AA research is actively focused on genetics, the microbiome, dietary modulators, the role of atopy, immune cell types in AA pathogenesis, primary antigenic targets, mechanisms by which immune cells influence hair growth, and of course the development of new treatments based on these discoveries.

Epidemiology of alopecia areata, ophiasis, totalis, and universalis: A systematic review and meta-analysis

BACKGROUND

Alopecia areata (AA) is a common autoimmune alopecia with heterogeneous severity and distribution. Previous studies found conflicting results about AA epidemiology.

OBJECTIVE

To determine the prevalence, incidence, and predictors of AA, alopecia totalis, alopecia ophiasis, and alopecia universalis.

METHODS

A systematic review of all published cohort and cross-sectional studies that analyzed AA and its subtypes. MEDLINE, Embase, LILACS, Scopus, Cochrane Library, and GREAT were searched. At least 2 reviewers performed study title/abstract review and data extraction. Random-effects meta-analysis was used because of significant heterogeneity (I² = 99.97%).

RESULTS

Ninety-four studies met the inclusion criteria. The pooled prevalence (95% confidence interval, N) of AA overall was 2.11% (1.82-2.42, N = 302,157,365), with differences of population-based (0.75% [0.49-1.06%], N = 301,173,403) and clinic-based (3.47% [3.01-3.96], N = 983,962) studies. The prevalences of alopecia totalis, ophiasis, and universalis were 0.08% (0.04-0.13, N = 1,088,149), 0.02% (0.00-0.06, N = 1,075,203), and 0.03% (0.01-0.06, N = 1,085,444), respectively. AA prevalence (95% confidence interval) increased over time (<2000: 1.02% [0.85-1.22]; 2000-2009: 1.76% [1.51-2.03]; >2009: 3.22% [2.59-3.92]; P < .0001) and differed by region. AA prevalence was significantly lower in adults (1.47% [1.18-1.80]) than children (1.92% [1.31-2.65]; P < .0001).

CONCLUSIONS

AA affects 2% of the global population. AA prevalence is lower in adults than children, is increasing over time, and significantly differs by region.

HLA antigens in individuals with down syndrome and alopecia areata

AIM: To describe human leukocyte antigen (HLA) alleles in individuals with Down syndrome and alopecia areata.

METHODS: A cross-sectional study was conducted, which evaluated 109 individuals. Ten with down syndrome (DS) and alopecia areata (AA), ten with DS without AA and ten with AA without DS, and their families. The individuals were matched by gender and age. The following data were computed: gender, age, ethnic group, karyotype, clinical presentation and family history of alopecia areata. Descriptive analysis: measures of central tendency and frequency distribution. Inferential analysis: Fisher’s exact test to compare categorical data between the three groups and Kruskal-Wallis ANOVA test for numerical data.

RESULTS: Seventy per cent of evaluated individuals in the DS and AA group were male; presented mean age of 18.6 (SD ± 7.2) years and 70% were Caucasian. We observed involvement of the scalp, with a single lesion in 10% and multiple in 90% of subjects. It was observed that there is no significant difference in the frequency distributions of the alleles HLA loci A, B, C, DRB1 and DQB1 of subjects studied. However, according to Fisher’s exact test, there is a trend (P = 0.089) of DS group to present higher proportions of HLA-A 36 and HLA-B 15 than the AA group and AA and DS group.

CONCLUSION: There was a tendency for the DS group, to present proportion of HLA-A 36 and HLA-B 15 higher than the AA group and group of individuals with AA and DS. However, there was no significant difference in the frequency distribution of the alleles.

Total serum immunoglobulin E in patients with alopecia areata

Context:

Alopecia areata (AA) is a common form of localized, non-scarring hair loss. The pathogenesis of the disease is unknown. Previous evidence suggested the involvement of Th2 cytokines in disease pathogenesis.

Aim:

To determine serum level of total IgE, this is mainly influenced by Th2 cytokines, in Egyptian patients with AA.

Materials and Methods:

Fifty subjects with AA (28 males and 22 females) were selected from Dermatology Outpatient Clinic, Menoufiya University Hospital from February 2012 to December 2012. Subjects with other conditions that might elevate serum IgE were excluded from the study. Fifty age- and sex-matched healthy subjects were selected as a control group. Venous blood samples were taken from cases and controls for measurement of total serum IgE by enzyme-linked immunosorbent assay. Skin biopsy was taken from every case from an active area of hair loss.

Results:

Total serum IgE was elevated in 27 (54%) cases. Its values among patients ranged from 13.5 IU/ml to 780 IU/ml. There was a statistically significant difference between cases and controls with regard to mean value of serum IgE (P < 0.05). Mean value of IgE did not vary significantly with disease severity, patients’ age, patients’ gender, disease duration, site of lesions, and positive family history of AA. No correlation was found between serum IgE levels and histopathological changes detected in examined cases.

Conclusions:

Total serum IgE is elevated in AA. This elevation is not related to age, gender, disease duration, disease severity, site of affection or family history of AA.

The quality of nutrition and cancer reviews: a systematic assessment

The methodological quality of published reviews of nutrition and cancer (2008-2009) and of the carcinogenicity of acrylamide (1999-2009) was systematically assessed. Each review was examined with respect to four characteristics: whether the purpose of the review was explicitly stated, whether a methods section (detailing the methods used to "weigh" the evidence) was included, whether "weight of evidence" methods were described elsewhere in the paper (e.g., in the discussion), and finally, whether references to recognized "weight of evidence" methods were included. In this study, ninety per cent of a systematically selected sample of recent reviews on nutrition and cancer published in 2008-2009 and 74% of reviews on acrylamide on cancer published in 1999-2009 were found to be methodologically troublesome or frankly unsound. Failure of peer review and editorial oversight are possible explanations, suggesting a broad lack of concern about this issue in the scientific community. If peer reviewers in the nutrition and cancer community do not require "weight of evidence" methods, then these methods may not appear in the published reviews. Similarly, if journal editors (or editorial policies) do not require methods sections in literature reviews, then these sections may not appear. The prerogative of the author(s) seems the most likely determinant of whether a systematic approach is used or not in nutrition and cancer reviews.

Heat treatment increases the incidence of alopecia areata in the C3H/HeJ mouse model

Alopecia areata (AA) is a common autoimmune disease characterized by non-scarring hair loss. Previous studies have demonstrated an association between AA and physiological/psychological stress. In this study, we investigated the effects of heat treatment, a physiological stress, on AA development in C3H/HeJ mice. Whereas this strain of mice are predisposed to AA at low incidence by 18 months of age, we observed a significant increase in the incidence of hair loss in heat-treated 8-month-old C3H/HeJ mice compared with sham-treated mice. Histological analysis detected mononuclear cell infiltration in anagen hair follicles, a characteristic of AA, in heat-treated mouse skin. As expected, increased expression of induced HSPA1A/B (formerly called HSP70i) was detected in skin samples from heat-treated mice. Importantly, increased HSPA1A/B expression was also detected in skin samples from C3H/HeJ mice that developed AA spontaneously. Our results suggest that induction of HSPA1A/B may precipitate the development of AA in C3H/HeJ mice. For future studies, the C3H/HeJ mice with heat treatment may prove a useful model to investigate stress response in AA.

Serum Interleukin-4 and Total Immunoglobulin E in Nonatopic Alopecia Areata Patients and HLA-DRB1 Typing

Background. Interleukin-4 (IL-4), a Th₂ cytokine, can stimulate immunoglobulin E (IgE) transcription. No previous studies evaluated the genetic mechanisms in nonatopic AA patients with elevated serum IgE. Objective. To compare serum IL-4 and total IgE levels between Egyptian nonatopic AA patients and healthy subjects and to investigate a possible relation to HLA-DRB1 alleles. Results. Serum IL-4 and total IgE were measured by ELISA in 40 controls and 54 nonatopic AA patients. Patients' HLA-DRB1 typing by sequence specific oligonucleotide probe technique was compared to normal Egyptian population. We found significantly elevated serum IL-4 and total IgE in AA patients (particularly alopecia universalis, AU, and chronic patients) (P < .01). HLA-DRB1*11 is a general susceptibility/chronicity allele. DRB1*13 is a protective allele. DRB1*01 and DRB1*07 are linked to chronicity. Localized AA showed decreased DRB1*03 and DRB1*07. Extensive forms showed increased DRB1*08 and decreased DRB1*04. Elevated IL4 and IgE were observed in patients with DRB1*07 and DRB1*11 not DRB1*04. Conclusion. Serum IL-4 and IgE are elevated in nonatopic AA patients, particularly AU and chronic disease. Relevant susceptibility, chronicity, and severity HLADRB1 alleles may have a role in determining type, magnitude, and duration of immune response in AA favouring increased IL4 and IgE.

Topical immunomodulator therapy with squaric acid dibutylester (SADBE) is effective treatment for severe alopecia areata (AA): Results of an open‐label, paired‐comparison, clinical trial

Severe alopecia areata (AA) may have a chronic relapsing course and is often resistant to current treatments.

OBJECTIVES

The aim of our study was to evaluate whether topical immunotherapy with squaric acid dibutylester (SADBE) is able to improve the course of severe AA and to reduce the severity of relapses.

METHODS

Fifty-four patients affected by severe AA treated with SADBE who were followed for a period of at least 2 years were selected as the study group. Data collected were compared with those of a matched control group of 54 patients who did not receive any treatment. Student's t-test, analysis of variance (ANOVA) and Pearson's chi-squared test were utilized for data analysis.

RESULTS

At the end of therapy, in comparison with the control group, the treatment group showed a statistically significant (p < 0.001) improvement. At follow-up, there was no significant change in relapse rate (treated 44% vs control 52%). However, relapses in the treated group were significantly less severe compared with the control group (p < 0.001).

CONCLUSIONS

Our data suggest that topical SADBE represents a valid therapeutic option in severe AA, and may prove to be disease modifying.

Evaluation of the profile of alopecia areata and the prevalence of thyroid function test abnormalities and serum autoantibodies in Iranian patients

BACKGROUND

The study aimed at evaluating the prevalence of thyroid function abnormalities in patients with alopecia areata (AA) and its association with other autoimmune diseases and various autoimmune antibodies.

METHOD

We retrospectively analyzed medical records of 123 patients with AA. The main site of involvement, pattern, and extent of alopecia as well as presence of the similar disease in first-degree family members and serologic status of patients were recorded.

RESULTS

Participating in the study were 57 males and 66 females (6 to 59 years old). In the majority of patients (69.9%) the disease was manifested in the first two decades of life. Patients with family members having alopecia were recorded in 24.4%. Thyroid function abnormalities were found in 8.9% of patients. Positive autoimmune antibodies were associated with AA in 51.4% of patients with no significant association between the severity and duration of disease and presence of these antibodies.

CONCLUSION

The incidence of positive auto-immune antibodies in Iranian patients is higher than previous reports. Concerning the female:male ratio, thyroid function tests and the prevalence of alopecia in first-degree relatives, our results are compatible with previous data obtained from different ethnic populations. Previous reports documented that a greater severity and longer duration of AA were seen in the early onset forms; however our result are relatively different which could be explained by differences in genetic factors.

Genetics of alopecia areata

Alopecia areata is a common disorder with a genetic predisposition where interaction with environmental factors leads to episodes of terminal hair loss. In this review article, we examine the evidence for a genetic basis to this disorder and discuss the prospects for future research into genetic susceptibility areas and the problems that are likely to be encountered in such research.

Simultaneous onset of alopecia areata and idiopathic thrombocytopenic purpura: A potential association?

Alopecia areata (AA) has been associated with a variety of autoimmune diseases. Immune thrombocytopenic purpura (ITP) is an autoimmune disease marked by isolated thrombocytopenia. We present a young girl with the simultaneous onset of AA and ITP. To the best of our knowledge, this association has not previously been reported. We hypothesize that ITP may be one of many autoimmune diseases associated with AA via antibodies that cross-react between platelet membrane glycoproteins and follicular glycoproteins.