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Alopecia aeata: Clinical spectrum and its association with thyroid dysfunction in Bahawalpur.

Byline: Rabia Asgher, Naima Luqman, Uzma Almas, Faiza Akhlaq, Muhammad Khalid and Jamil Ahmed Shaheen

Keywords Alopecia areata, thyroid dysfunction, autoimmunity.

Introduction

Alopecia areata (AA) is a recurrent, non-cicatricial type of hair loss that can affect any hair-bearing area. Although benign in nature, it can cause significant emotional and psychosocial distress in affected patients and their families.1 AA usually occurs before the age of 30. However, it can strike from birth to the late decades of life at any age. As many as 44% of people with AA are younger than 20 years of age. The onset in patients over 40 years of age is seen in less than 30 percent of AA patients. Clinically, AA can manifest many different patterns ranging from mild, moderate and severe disease to alopecia totalis and universalis.2 The exact pathophysiology of AA is still unclear. However, the most commonly accepted hypothesis is that AA is a T-cell-mediated autoimmune condition that occurs in genetically predisposed individuals.3

The origin of AA is not fully understood; however, strong direct and indirect data supports the role of autoreactive T-cells directed against unknown hair follicle autoantigen. These T cells are oligoclonal and predominantly present in the inflammatory infiltrate surrounding the peribulbous region of hair follicle. AA is associated with many autoimmune disorders such as lichen planus, vitiligo, morphea, atopic dermatitis, Hashimoto's thyroiditis, endemic goiter, hypothyroidism, diabetes mellitus and others.4,5 The disease has a well known association with endocrinological disorders especially thyroid dysfunction.6 There is, however, a lack of consensus on the overall prevalence of thyroid function abnormalities in AA which varies from 8% to 28%.7,8 As no such work has been done in our region i.e. Bahawalpur so, the rationale of current study was to determine the clinical spectrum of AA and frequency of thyroid dysfunction in AA patients in this particular region.

Methods

This cross-sectional study was conducted at outpatient and inpatient departments of Dermatology, Bahawal Victoria Hospital, Bahawalpur for the duration of six months from September 2016 to March 2017. The disease was diagnosed clinically and severity was assessed by using olsen/canfield scoring system (Figure 1).9 A total of 183 patients suffering from AA of >3 months duration, of any severity, belonging to either sex and with age between 20-50 years were enrolled after the informed consent. The patients suffering from chronic renal failure or those taking medication that can affect thyroid functions (dopamine antagonists, antiepileptics, oral contraceptives, lithium, glucocorticoids) were excluded from the study. Then blood samples were taken and sent to the laboratory for analysis of TSH, free T3, free T4 and anti-thyroid peroxidase (TPO) antibodies. All this data was recorded on a predesigned proforma.

Data were entered and analyzed using the computer program SPSS version 20.0.The relationship between dysfunction of thyroid gland and AA was assessed by I2 (Chi square) test. P-value of less than 0.05 was statistically considered meaningful.

* Mild: Patients with 25% area of scalp being involved will be labeled as mild.

* Moderate: Patients with 50% area of scalp being involved will be labeled as moderate.

* Severe: Patients with 75% area of scalp being involved will be labeled as severe.

* Alopecia totalis: Presence of alopecia on whole of the scalp will be taken as positive.

Table 1 Distribution of patients according to Gender(n=183).

Gender###Frequency###%age

Male###103###56.28

Female###80###43.72

Table 2 Distribution of patients according to Age (n=183).

Age (in years)###No. of Patients###%age

20-35###97###53.01

36-50###86###46.99

Total###183###100.0

Table 3 Clinical spectrum of alopecia areata

Clinical spectrum###Frequency(%)

###Yes###no

Mild###81(44.26%)###102(55.74%)

Moderate###54(29.51%)###129(70.49%)

Severe###29(15.85%)###154(84.16%)

Alopecia totalis###19(10.38%)###164(89.62%)

Results

Out of 183 patients, 103 (56.28%) were males and 80 (43.72%) were females. Male to female ratio was 1.3:1 as shown in Table 1.

Age range in this study was from 20 to 50 years with mean age of 34.80 +- 8.36 years as shown in Table 2. The clinical spectrum of AA was seen as mild in 44.26%, moderate in 39.51%, severe in 15.85% and alopecia totalis in 10.38% patients (Table 3). The thyroid dysfunction was seen in 13(7.10%) of AA patients (Figure 2).

Discussion

Alopecia areata (AA) is a common cause of non scarring hair loss. It usually occurs as a patchy hair loss commonly involving the scalp and beard area. However it can affect any hair bearing site and can be confluent or diffuse in pattern. It can occur as a single, self-limiting episode or can be recurrent in nature.10

In the present study we determined the clinical spectrum of AA and frequency of thyroid dysfunction in alopecia areata patients. Age range in this study was from 20 to 50 years with mean age of 34.80 +-8.36 years. Majority of the patients i.e. 97(53.01%) were between 20 to 35 years of age. Out of 183 patients, 103 (56.28%) were males and 80 (43.72%) were females with male to female ratio of 1.3:1. The clinical spectrum of AA was seen as mild in 44.26%, moderate in 39.51%, severe in 15.85% and alopecia totalis in 10.38% patients. The thyroid dysfunction was seen in 13 (7.10%) of AA patients.

In a study, 112 patients comprising 67(60%) females and 45 (40%) males were enrolled. Highest number of the patients i.e. 45 (40%) had mild disease (P<0.05), followed by moderate and severe alopecia areata to alopecia totalis, universalis and ophiasis in a descending frequency. 10(8.9%) patients revealed thyroid dysfunction.11

In another study Ahmed et al12 also reported mild form of the disease as the most common presentation followed by moderate AA, other clinical presentations being less common.

Jameel et al13 and Ejaz et al14 also reported mild form of AA to be the most common presentation.

Lyakhovitsky et al15 also reported a significant relationship between AA and thyroid dysfuntion. In this study 19 (24%) patients out of 78 revealed abnormal thyroid function tests.

In still another study Gonul et al16 reviewed 110 AA patients and showed abnormal thyroid function tests in 11(10%) patients and the presence of thyroid autoantibody in 16(14.7%) patients.

In a retrospective study conducted on 1408 Korean patients, Park et al17 also showed increased incidence of thyroid dysfuntion (15.90%) and thyroid autoimmunity (18.46%) in AA patients particularly those with severe AA.

Conclusion

In the present study highest number of enrolled subjects was suffering from mild disease, followed by moderate and severe alopecia areata to alopecia totalis in a descending frequency. The finding in our study is at par with the studies conducted in past. The frequency of thyroid dysfunction in alopecia areata patients is also significantly high. So, it is recommended that there should be proper screening as well as management of the condition and thyroid dysfunction in these particular patients should be evaluated routinely in order to reduce their morbidity.

References

1. Seetharam KA. Alopecia areata: an update. Indian J Dermatol Venereol Leprol 2013; 79: 563-75.

2. Al-Mutairi N, Eldin ON. Clinical profile and impact on quality of life: Seven years experience with patients of alopecia areata. Indian J Dermatol Venereol Leprol 2011; 77: 489-93.

3. Duncan FJ, Silva KA, Johnson C, King B, Szatkiewicz JP, Kamdar S, et al. Endogenous retinoids in the pathogenesis of alopecia areata. J Invest Dermatol 2013; 133(2): 334-43.

4. Gilhar A, Ullmann Y, Berkutzki T, Assay B, Kalish RS. Autoimmune hair loss (alopecia areata) transferred by T lymphocytes to human scalp explants on SCID mice. J Clin Invest 1998; 101: 62-7.

5. Bakry OA, Basha MA, El Shafiee MK, Shehata WA. Thyroid disorders associated with alopecia areata in Egyptian patients. Indian J Dermatol 2014; 59(1): 49-55.

6. Alkhalifah A, Alsantali A, Wang E, McElwee KJ, Shapiro J. Alopecia areata update: part i. clinical picture, histopathology and pathogenesis. J Am Acad Dermatol 2010; 62: 177-88.

7. Lo SK, McGuire S, English JC. A retrospective study of thyroid structural abnormalities in alopecia patients. Dermato Endocrinol 2011; 3: 251-4.

8. Kurtipek GS, Cihan FG, Demirbas SE, Ataseven A. The frequency of autoimmune thyroid disease in alopecia areata and vitiligo patients. Bio Med Res Intl 2015; 2015: 435947.

9. Olsen EA. Investigative guidelines for alopecia areata. Dermatol Therapy 2011; 24: 311-19.

10. Brenner R. Coincidences of alopecia areata, Vitiligo, Onychodystrophy, localized scleroderma and lichen planus. Dermatologica 1979; 159: 356-8.

11. Ahmed I, Nasreen S, Jehangir U, Wahid Z. Clinical spectrum of alopecia areata and its association with thyroid dysfunction. J Pak Assoc Dermatol 2012; 22(3): 207-12.

12. Ahmed I, Wahid Z, Nasreen S. Alopeciaareata; combination therapy with minoxidil(2%) solution and isotretinoin (0.05%) gel. J Pak Assoc Dermatol 2005; 15: 140-5.

13. Jameel K, Ejaz A, Sohail M, Rahman SB. Value of transverse section scalp biopsy in alopecia areata - a clinicopathological correlation. J Coll Physicians Surg Pak. 2008; 18: 338-41.

14. Ejaz A, Jameel K, Suhail M. Pattern andprofile of alopecia areata in Pakistan. J Pak Assoc Dermatol 2009; 19: 136-40.

15. Lyakhovitsky, A., Shemer, A., and Amichai, B. Increased prevalence of thyroid disorders in patients with new onset alopecia areata. Australas J Dermatol 2015; 56: 103-106.

16. Gonul M, Gul U, Piskin E. Alopesi Areatali Hastalarin Geriye Donuk Z Degerlendirilmesi. Turkish J Dermatol 2011; 5: 43-47.

17. Park SM, Oh YJ, Lew BL, Sim WY. The association between thyroid dysfunction, thyroid autoimmunity,and clinical features of alopecia areata: a retrospective study. J Am Acad Dermatol 2019; 81: 602-605.
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Author:Rabia Asgher, Naima Luqman, Uzma Almas, Faiza Akhlaq, Muhammad Khalid and Jamil Ahmed Shaheen
Publication:Journal of Pakistan Association of Dermatologists
Date:Mar 31, 2020
Words:1772
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