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Šutić Udović I, Hlača N, Massari LP, Brajac I, Kaštelan M, Vičić M. Deciphering the Complex Immunopathogenesis of Alopecia Areata. Int J Mol Sci 2024; 25:5652. [PMID: 38891839 PMCID: PMC11172390 DOI: 10.3390/ijms25115652] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/30/2024] [Revised: 05/15/2024] [Accepted: 05/22/2024] [Indexed: 06/21/2024] Open
Abstract
Alopecia areata (AA) is an autoimmune-mediated disorder in which the proximal hair follicle (HF) attack results in non-scarring partial to total scalp or body hair loss. Despite the growing knowledge about AA, its exact cause still needs to be understood. However, immunity and genetic factors are affirmed to be critical in AA development. While the genome-wide association studies proved the innate and acquired immunity involvement, AA mouse models implicated the IFN-γ- and cytotoxic CD8+ T-cell-mediated immune response as the main drivers of disease pathogenesis. The AA hair loss is caused by T-cell-mediated inflammation in the HF area, disturbing its function and disrupting the hair growth cycle without destroying the follicle. Thus, the loss of HF immune privilege, autoimmune HF destruction mediated by cytotoxic mechanisms, and the upregulation of inflammatory pathways play a crucial role. AA is associated with concurrent systemic and autoimmune disorders such as atopic dermatitis, vitiligo, psoriasis, and thyroiditis. Likewise, the patient's quality of life (QoL) is significantly impaired by morphologic disfigurement caused by the illness. The patients experience a negative impact on psychological well-being and self-esteem and may be more likely to suffer from psychiatric comorbidities. This manuscript aims to present the latest knowledge on the pathogenesis of AA, which involves genetic, epigenetic, immunological, and environmental factors, with a particular emphasis on immunopathogenesis.
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Affiliation(s)
| | | | - Larisa Prpić Massari
- Department of Dermatovenereology, Clinical Hospital Centre Rijeka, Medical Faculty, University of Rijeka, Krešimirova 42, 51000 Rijeka, Croatia; (I.Š.U.); (N.H.); (I.B.); (M.K.); (M.V.)
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Ly S, Manjaly P, Kamal K, Shields A, Wafae B, Afzal N, Drake L, Sanchez K, Gregoire S, Zhou G, Mita C, Mostaghimi A. Comorbid Conditions Associated with Alopecia Areata: A Systematic Review and Meta-analysis. Am J Clin Dermatol 2023; 24:875-893. [PMID: 37464249 DOI: 10.1007/s40257-023-00805-4] [Citation(s) in RCA: 2] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 06/18/2023] [Indexed: 07/20/2023]
Abstract
BACKGROUND Alopecia areata (AA) is a complex autoimmune condition resulting in nonscarring hair loss. In recent years, many studies have provided new evidence on comorbid diseases present in patients with AA. However, some studies have conflicting results, and analyses conducting a comprehensive approach are lacking. OBJECTIVE The aim of our study was to provide an updated systematic review and meta-analysis of medical comorbidities associated with AA. METHODS We searched PubMed, Embase, and Web of Science for case-control, cross-sectional, and cohort studies investigating medical comorbidities in AA published from inception through 1 February 2023. RESULTS We screened 3428 abstracts and titles and reviewed 345 full text articles for eligibility. Ultimately, 102 studies were analyzed, comprising 680,823 patients with AA and 72,011,041 healthy controls. Almost all included studies (100 of 102 studies) were of satisfactory to high quality (Newcastle-Ottawa scale score ≥ 4). Among patients with AA, comorbidities with the highest odds ratios (OR) compared with healthy controls and data available from more than one study included vitamin D deficiency (OR 10.13, 95% CI 4.24-24.20), systemic lupus erythematous (OR 5.53, 95% CI 3.31-9.23), vitiligo (OR 5.30, 95% CI 1.86-15.10), metabolic syndrome (OR 5.03, 95% CI 4.18-6.06), and Hashimoto's thyroiditis (OR 4.31, 95% CI 2.51-7.40). AA may be a protective factor for certain disorders, for which the AA group had lower odds compared with healthy controls, such as irritable bowel syndrome (OR 0.38, 95% CI 0.14-0.99) and colorectal cancer (OR 0.61, 95% CI 0.42-0.89). CONCLUSION These findings corroborate and contextualize the risks across comorbidities for patients with AA. Further work should be done to identify the underlying pathophysiology and understand appropriate screening criteria.
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Affiliation(s)
- Sophia Ly
- College of Medicine, University of Arkansas for Medical Sciences, Little Rock, AR, USA
- Department of Dermatology, Brigham and Women's Hospital, 221 Longwood Avenue, Boston, MA, 02115, USA
| | - Priya Manjaly
- Department of Dermatology, Brigham and Women's Hospital, 221 Longwood Avenue, Boston, MA, 02115, USA
- Boston University School of Medicine, Boston, MA, USA
| | - Kanika Kamal
- Department of Dermatology, Brigham and Women's Hospital, 221 Longwood Avenue, Boston, MA, 02115, USA
- Harvard Medical School, Boston, MA, USA
| | - Ali Shields
- Department of Dermatology, Brigham and Women's Hospital, 221 Longwood Avenue, Boston, MA, 02115, USA
- Drexel University College of Medicine, Philadelphia, PA, USA
| | - Bruna Wafae
- Department of Dermatology, Brigham and Women's Hospital, 221 Longwood Avenue, Boston, MA, 02115, USA
- Harvard Medical School, Boston, MA, USA
| | - Najiba Afzal
- Department of Dermatology, Brigham and Women's Hospital, 221 Longwood Avenue, Boston, MA, 02115, USA
- University of California, Davis School of Medicine, Sacramento, CA, USA
| | - Lara Drake
- Department of Dermatology, Brigham and Women's Hospital, 221 Longwood Avenue, Boston, MA, 02115, USA
- Tufts University School of Medicine, Boston, MA, USA
| | - Katherine Sanchez
- Department of Dermatology, Brigham and Women's Hospital, 221 Longwood Avenue, Boston, MA, 02115, USA
- Lake Erie College of Osteopathic Medicine, Erie, PA, USA
| | - Samantha Gregoire
- Department of Dermatology, Brigham and Women's Hospital, 221 Longwood Avenue, Boston, MA, 02115, USA
- University at Buffalo Jacobs School of Medicine, Buffalo, NY, USA
| | - Guohai Zhou
- Department of Dermatology, Brigham and Women's Hospital, 221 Longwood Avenue, Boston, MA, 02115, USA
| | - Carol Mita
- Countway Library of Medicine, Harvard University, Boston, MA, USA
| | - Arash Mostaghimi
- Department of Dermatology, Brigham and Women's Hospital, 221 Longwood Avenue, Boston, MA, 02115, USA.
- Harvard Medical School, Boston, MA, USA.
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Aliyeva A, Yagiz Agayarov O, Dogan EI. Assessing Auditory and Cochlear Function in Alopecia Areata Patients: Exploring the Link to Cochlear Melanocyte Damage. Cureus 2023; 15:e44882. [PMID: 37814747 PMCID: PMC10560379 DOI: 10.7759/cureus.44882] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 09/08/2023] [Indexed: 10/11/2023] Open
Abstract
Introduction Alopecia areata (AA) is an autoimmune disorder causing hair loss, including eyebrows, eyelashes, and body hair, primarily due to melanocyte impact. Though the precise AA melanocyte hearing loss mechanisms are not fully clear, it's speculated that cochlear melanocyte inflammation could disrupt endolymph production, which is necessary for sound signal transmission. Cochlear melanocytes maintain crucial potassium ion levels, which are pivotal for hearing. The potential AA-melanocyte-hearing loss link underscores the need to monitor auditory and cochlear function and consider interventions for AA-related hearing challenges. The study aimed to assess auditory and cochlear function using OAE and audiometry measurements to correlate disease severity and duration with OAE outcomes. Materials and methods In this study, we included 32 patients diagnosed with AA; the control group consisted of 29 healthy volunteers. We collected data on the patient's age, gender, onset age, family history, and disease duration. Audiological and otological evaluations were conducted, including pure tone audiometry (PTA), speech discrimination test (SD), and otoacoustic emission (DPOAE) measurements at frequencies of 500, 1000, 2000, 4000, 6000, 8000, and 10000 Hz. The patients were divided into two groups based on age: 18-25 and over 25 years old, and all parameters were compared. To examine differences between the right and left ears, gender, and age groups, we initially tested the variables for normal distribution using the Kolmogorov-Smirnov and Shapiro-Wilk tests. An independent sample t-test was conducted to compare the means for normally distributed variables. Results There were statistical differences at the 5% significance level in the mean DPOAE values of the 1 KHz SNR and 6 KHz SNR variables. According to the Mann-Whitney U test results, a significant difference was found in the gender-based DPOAE value at 2 kHz SNR (p=0.041), which was lower in men than women. Although there were no significant differences in the audiological parameters based on age, significant differences were found in the otoacoustic emission values. Variables, including 4 kHz DP1 (p=0.049), 500 Hz SNR (p=0.045), and 1 kHz SNR (p=0.023), differed significantly between age groups, with these values being lower in patients over 25 years old. Conclusion Overall, our study contributes to the growing body of evidence supporting an association between AA and auditory dysfunction, emphasizing the need for comprehensive assessment and management of hearing-related issues in individuals with AA.
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Affiliation(s)
- Aynur Aliyeva
- Department of Otolaryngology-Head and Neck Surgery, Cincinnati Children's Hospital Medical Center, Cincinnati, USA
| | - Ozlem Yagiz Agayarov
- Department of Otolaryngology-Head and Neck Surgery, Tepecik Training and Research Hospital, Health Sciences University, Izmir, TUR
| | - Esra Inan Dogan
- Department of Dermatology and Venereology, Adiyaman University Faculty of Medicine, Adiyaman, TUR
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Shakoei S, Mohammadnia E, Saedi B, Ghandi N, Khamisabadi S. Hearing impairment in patients with alopecia areata. Indian J Dermatol Venereol Leprol 2023; 0:1-5. [PMID: 37317742 DOI: 10.25259/ijdvl_416_2022] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/28/2022] [Accepted: 12/09/2022] [Indexed: 06/16/2023]
Abstract
Background Alopecia areata is an autoimmune disease that damages hair follicles and follicular melanocytes can be involved in the autoimmune process. Therefore, similar to vitiligo, there may be a relationship between sensorineural hearing loss and alopecia areata. Aims/objectives This study aimed to investigate potential hearing impairments in patients with alopecia areata. Methods A total of 42 subjects with alopecia areata and 42 healthy individuals enrolled in this cross-sectional study. The hearing was evaluated by vestibular evoked myogenic potential, otoacoustic emission and pure tone audiometry tests in the patients and control subjects. Results A normal otoacoustic emission was reported in 59.5% and 100% of subjects with alopecia areata and the controls, respectively (P = 0.02). Higher speech recognition thresholds (P = 0.02) and speech discrimination scores were reported more in subjects with alopecia areata than in controls (P < 0.001); however, the most comfortable level of speech was not significantly different between the groups (P = 0.06). The greatest increase in the hearing threshold was recorded at a frequency of 8000 Hz, while at frequencies of 500 and 1000 Hz, the patients and controls did not significantly differ (P > 0.05). About 6 (14.3%) and 2 (4.8%) of patients with unilateral and bilateral involvement, respectively, demonstrated no vestibular evoked myogenic potential response in the alopecia areata group. The patients and controls did not significantly differ in terms of amplitudes of the vestibular evoked myogenic potential test (P = 0.097). Limitation Small sample size and qualitative measurement of otoacoustic emission were limitations of our study. Conclusion Hearing loss was more common in alopecia areata patients than in healthy individuals. Follicular melanocytes may be involved in the alopecia areata inflammatory process, and destroying melanocytes may impact hearing function in the inner ear. However, there was no significant relationship between the duration and severity of alopecia areata and hearing loss.
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Affiliation(s)
- Safoura Shakoei
- Department of Dermatology, Imam Khomeini Hospital, Tehran University of Medical Sciences (TUMS), Tehran, Iran
| | - Elahe Mohammadnia
- Department of Pathology, Iran University of Medical Sciences (IUMS), Tehran, Iran
| | - Babak Saedi
- Department of Otolaryngology-Head and Neck Surgery, Otorhinolaryngology Research Center, Imam Khomeini Hospital Complex, Tehran University of Medical Sciences (TUMS), Tehran, Iran
| | - Narges Ghandi
- Department of Dermatology, Razi Hospital, Tehran University of Medical Sciences (TUMS), Tehran, Iran
| | - Saeedeh Khamisabadi
- Department of Audiology, Iran University of Medical Sciences (IUMS), Tehran, Iran
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Xie B, Sun J, Song X. Hair Follicle Melanocytes Initiate Autoimmunity in Alopecia Areata: a Trigger Point. Clin Rev Allergy Immunol 2022; 63:417-430. [PMID: 36121544 DOI: 10.1007/s12016-022-08954-w] [Citation(s) in RCA: 13] [Impact Index Per Article: 6.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 09/05/2022] [Indexed: 11/25/2022]
Abstract
Alopecia areata (AA) is characterized by common non-scarring alopecia due to autoimmune disorders. To date, the specific pathogenesis underlying AA remains unknown. Thus, AA treatment in the dermatological clinic is still a challenge. Numerous clinical observations and experimental studies have established that melanocytes may be the trigger point that causes hair follicles to be attacked by the immune system. A possible mechanism is that the impaired melanocytes, under oxidative stress, cannot be repaired in time and causes apoptosis. Melanocyte-associated autoantigens are released and presented, inducing CD8+ T cell attacks. Thereafter, amplification of the immune responses further spreads to the entire hair follicle (HF). The immune privilege of HF subsequently collapses, leading to AA. Herein, we present a narrative review on the roles of melanocytes in AA pathogenesis, aiming to provide a better understanding of this disease from the melanocyte's perspective.
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Affiliation(s)
- Bo Xie
- Department of Dermatology, Hangzhou Third People's Hospital, Hangzhou Third Hospital Affiliated to Zhejiang Chinese Medical University, Affiliated Hangzhou Dermatology Hospital, Zhejiang University School of Medicine, West Lake Ave 38, Hangzhou, 310009, People's Republic of China
| | - Jiayi Sun
- Graduate School, Zhejiang Chinese Medical University, Binwen Rd 548, Hangzhou, 310053, People's Republic of China
| | - Xiuzu Song
- Department of Dermatology, Hangzhou Third People's Hospital, Hangzhou Third Hospital Affiliated to Zhejiang Chinese Medical University, Affiliated Hangzhou Dermatology Hospital, Zhejiang University School of Medicine, West Lake Ave 38, Hangzhou, 310009, People's Republic of China.
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McKenzie PL, Rangu S, Wartinger F, Castelo-Soccio L. Evaluating for audiological differences in children with alopecia areata. J Eur Acad Dermatol Venereol 2021; 36:e221-e223. [PMID: 34661936 DOI: 10.1111/jdv.17754] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/26/2021] [Revised: 09/07/2021] [Accepted: 10/13/2021] [Indexed: 11/28/2022]
Affiliation(s)
- P L McKenzie
- Division of Pediatrics, Section␣of Dermatology, Children's Hospital of Philadelphia, Philadelphia, PA, USA.,University of Texas Southwestern Medical Center, Dallas, TX, USA
| | - S Rangu
- Division of Pediatrics, Section␣of Dermatology, Children's Hospital of Philadelphia, Philadelphia, PA, USA
| | - F Wartinger
- Center for Childhood Communication, Department of Audiology, Children's Hospital of Philadelphia, Philadelphia, PA, USA
| | - L Castelo-Soccio
- Division of Pediatrics, Section␣of Dermatology, Children's Hospital of Philadelphia, Philadelphia, PA, USA.,University of Pennsylvania Perelman School of Medicine, Philadelphia, PA, USA
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Ertugrul G, Ertugrul S, Soylemez E. There is no evidence of cochlear and vestibular melanocyte damage in patients with alopecia areata. Int J Clin Pract 2021; 75:e14040. [PMID: 33484073 DOI: 10.1111/ijcp.14040] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/13/2020] [Revised: 12/30/2020] [Accepted: 01/19/2021] [Indexed: 11/27/2022] Open
Abstract
PURPOSE Follicular melanocytes are known to be damaged in alopecia areata (AA). However, it is not clear whether melanocytes are the primary target of autoimmunity and whether melanocytes in the inner ear are affected. This study aimed to detect possible cochlear and/or vestibular melanocyte damage in AA patients. METHODS Thirty-two AA patients and 35 sex- and age-matched healthy volunteers were evaluated between November 2018 and March 2020 at the Karabük University Training and Research Hospital. The conventional pure tone audiometry test and distortion product otoacoustic emission test were performed to evaluate hearing. To evaluate the vestibular function, the following tests were performed: the vestibulospinal reflex tests (Romberg test, tandem stance test and tandem walking test); positional balance tests (Dix-Hallpike test, supine roll test and head hanging test); vestibulo-ocular reflex tests (caloric test, head shake test) and oculomotor tests (saccade, smooth pursuit and optokinetic). RESULTS The mean age of AA patients was 31.94 ± 11.86 years (range, 15-67 years). There were no significant differences in the results of the hearing and balance tests between the groups. Furthermore, disease parameters (duration of the last attack, recurrence, positive family history, positive pull test, the severity of the disease, etc) were not associated with hearing loss and vestibular damage. CONCLUSION AA patients did not exhibit hearing loss or balance abnormalities that would indicate cochlear and vestibular melanocyte damage. The lack of damage to the inner ear melanocytes in AA patients may indicate that follicular melanocytes are affected secondary to autoimmune damage in the hair bulb, and melanocytes are not the primary target in the pathogenesis of AA.
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Affiliation(s)
- Goksen Ertugrul
- Department of Dermatology, Faculty of Medicine, Karabuk University, Karabuk, Turkey
| | - Suha Ertugrul
- Department of Otorhinolaryngology, Faculty of Medicine, Karabuk University, Karabuk, Turkey
| | - Emre Soylemez
- Department of Audiology, Karabuk University, Karabuk, Turkey
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Lee S, Lee H, Lee CH, Lee WS. Comorbidities in alopecia areata: A systematic review and meta-analysis. J Am Acad Dermatol 2019; 80:466-477.e16. [DOI: 10.1016/j.jaad.2018.07.013] [Citation(s) in RCA: 52] [Impact Index Per Article: 10.4] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/25/2018] [Revised: 06/01/2018] [Accepted: 07/03/2018] [Indexed: 01/09/2023]
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Korta DZ, Christiano AM, Bergfeld W, Duvic M, Ellison A, Fu J, Harris JE, Hordinsky MK, King B, Kranz D, Mackay-Wiggan J, McMichael A, Norris DA, Price V, Shapiro J, Atanaskova Mesinkovska N. Alopecia areata is a medical disease. J Am Acad Dermatol 2018; 78:832-834. [PMID: 29548423 DOI: 10.1016/j.jaad.2017.09.011] [Citation(s) in RCA: 23] [Impact Index Per Article: 3.8] [Reference Citation Analysis] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/21/2017] [Revised: 08/18/2017] [Accepted: 09/04/2017] [Indexed: 11/27/2022]
Affiliation(s)
- Dorota Z Korta
- Department of Dermatology, University of California Irvine, Irvine, California
| | - Angela M Christiano
- Departments of Dermatology and Genetics and Development, Columbia University, New York, New York
| | - Wilma Bergfeld
- Department of Dermatology, Cleveland Clinic, Cleveland, Ohio
| | - Madeleine Duvic
- Department of Dermatology, The University of Texas MD Anderson Cancer Center, Houston, Texas
| | - Abby Ellison
- National Alopecia Areata Foundation, San Rafael, California
| | - Jennifer Fu
- Department of Dermatology, University of California San Francisco, San Francisco, California
| | - John E Harris
- Department of Dermatology, University of Massachusetts Medical School, Worcester, Massachusetts
| | - Maria K Hordinsky
- Department of Dermatology, University of Minnesota Medical School, Minneapolis, Minnesota
| | - Brett King
- Department of Dermatology, Yale School of Medicine, New Haven, Connecticut
| | - Dory Kranz
- National Alopecia Areata Foundation, San Rafael, California
| | - Julian Mackay-Wiggan
- Departments of Dermatology and Genetics and Development, Columbia University, New York, New York
| | - Amy McMichael
- Department of Dermatology, Wake Forest Baptist Medical Center, Winston-Salem, North Carolina
| | - David A Norris
- Department of Dermatology, University of Colorado Anschutz Medical Campus, Aurora, Colorado
| | - Vera Price
- Department of Dermatology, University of California San Francisco, San Francisco, California
| | - Jerry Shapiro
- The Ronald O. Perelman Department of Dermatology, New York University School of Medicine, New York, New York
| | - Natasha Atanaskova Mesinkovska
- Department of Dermatology, University of California Irvine, Irvine, California; National Alopecia Areata Foundation, San Rafael, California.
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Koçak H, Filiz Acıpayam A, Acıpayam H, Çakıl Erdoğan B, Yıldız N, Küfeciler L, Elbistanlı M, Kaya K. Is there a relationship between melanocytes and sensorineural hearing loss? Clinical evaluation of 51 patients with alopecia areata. Clin Otolaryngol 2017; 43:705-710. [DOI: 10.1111/coa.13011] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 10/12/2017] [Indexed: 12/20/2022]
Affiliation(s)
- H.E. Koçak
- Department of Otorhinolaryngology-Head and Neck Surgery; Bakırköy Dr.Sadi Konuk Training and Research Hospital; Istanbul Turkey
| | - A.Ş. Filiz Acıpayam
- Department of Dermatology; Bakırköy Dr.Sadi Konuk Training and Research Hospital; Istanbul Turkey
| | - H. Acıpayam
- Department of Otorhinolaryngology-Head and Neck Surgery; Bakırköy Dr.Sadi Konuk Training and Research Hospital; Istanbul Turkey
| | - B. Çakıl Erdoğan
- Department of Dermatology; Bakırköy Dr.Sadi Konuk Training and Research Hospital; Istanbul Turkey
| | - N.Y. Yıldız
- Department of Dermatology; Bakırköy Dr.Sadi Konuk Training and Research Hospital; Istanbul Turkey
| | - L. Küfeciler
- Department of Otorhinolaryngology-Head and Neck Surgery; Bakırköy Dr.Sadi Konuk Training and Research Hospital; Istanbul Turkey
| | - M.S. Elbistanlı
- Department of Otorhinolaryngology-Head and Neck Surgery; Bakırköy Dr.Sadi Konuk Training and Research Hospital; Istanbul Turkey
| | - K.H. Kaya
- Department of Otorhinolaryngology-Head and Neck Surgery; Bakırköy Dr.Sadi Konuk Training and Research Hospital; Istanbul Turkey
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Shaheen MA, Matta M, Abdel Rahman TT, Refaat N. Hearing threshold abnormalities in patients with alopecia areata. THE EGYPTIAN JOURNAL OF OTOLARYNGOLOGY 2015. [DOI: 10.4103/1012-5574.168374] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 12/20/2022]
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