The Relationship Between ADHD and Alopecia Areata

Alopecia Areata and Attention Deficit Hyperactivity Disorder: What is the Link?

Introduction

There is a close link between attention deficit hyperactivity disorder (ADHD) and alopecia areata. All of the details and mechanisms that govern the association have not been fully worked out yet, but it’s increasingly clear that there is a link.

I’d like to review four important studies that highlight this link

STUDY 1: Singam et al 2019

 In 2019, Singam et al, sought to determine whether AA is associated with any mental health disorders.

 The authors analyzed data from the 2002 to 2012 National Inpatient Sample. This is felt to be a representative cross-sectional sample of  US hospitalizations and included 87,053,155 adults and children.

 Compared with inpatients without alopecia areata, inpatients with alopecia areata were younger (mean age, 42.2 vs 47.9 years [P<0001]), more frequently female (61.7% vs 58.6% [P=0.0297]), and uninsured (8.1% vs 5.5% [P <0.0001]). In this study, patients with alopecia areata did not differ from those without AA in terms of race/ethnicity and about two-thirds of patients with and without alopecia areata were white. 

Compared to inpatients who did not have alopecia areata, inpatients with AA had higher proportions of “any mental health” diagnosis as well as a “primary mental health disorder”

For the category of “any mental health disorder”, 32.8% of patients with AA had a mental health disorder compared to 20 % without AA. For the category of “primary mental health disorder”, 5.5% of patients with AA had a primary health disorder compared to 2.2 % without AA.     

 In multivariable models, alopecia areata was associated with 13 of the 15 mental health disorders examined by the authors including any mental health disorder, adjustment disorder, anxiety disorders, ADHD, developmental disorders, impulse control disorders, mood disorders, personality disorders, schizophrenia and related disorders, alcohol related disorders, substance related disorders, suicided and self-inflicted injury.

 Of all the categories, “attention deficit, conduct and disruptive behaviour disorders had the highest adjusted odds ratio of 8.11.

 AA was also associated with primary admission to hospital for a range of mental health issues including any MH disorder, including anxiety, mood, attention-deficit/hyperactivity and conduct, and psychotic disorders

 Of all the categories associated with primary admission to hospital, “attention deficit, conduct and disruptive behaviour disorders had the highest adjusted odds ratio or 16.65.

Taken together this data suggested that alopecia areata is associated with a range of mental health issues. A particularly close link was suggested with ADHD and related disorders.

STUDY 2: Ho et al, 2021

 In 2021, Ho et al set out to examine whether the risk of alopecia areata is higher in children with ADHD than in those without ADHD. They also wanted to examined the impact of methylphenidate use on AA risk in children with ADHD.

The authors obtained data from the Taiwan Maternal and Child Health Database. This data base included 1,750,456 newborns in Taiwan from 2004 to 2017. Analysis of the data showed that 90,016 children received a diagnosis of ADHD and 1,660,440 did not. To specifically assess the risk of AA in ADHD and the impact of methylphenidate treatment on the risk of AA multiple Cox regression with adjustments for covariates (i.e., age, sex, and psychiatric comorbidities) was performed.

Results showed that there were 88 (0.098%) children with ADHD who had AA and 1191 (0.072%) children without ADHD had AA. After further statistical adjustment for the covariates, the authors found that the risk of alopecia areata was higher in children with ADHD than in those without ADHD (adjusted hazard ratio [aHR]: 1.30, 95% confidence interval [CI]: 1.04–1.64).

Interestingly, data showed that there appeared to be a trend towards some reduction in AA risk (aHR: 0.64) among children with ADHD who received methylphenidate compared to those children who did not receive methylphenidate; However, this difference was found to be nonsignificant.

 All in all, the authors of this study concluded that ADHD and AA may share some underlying mechanisms.

STUDY 3: Meaux et al, 2021

Another study in 2021 by Meaux et al set out to determine if there is an association between attention-deficit/hyperactivity disorder (ADHD),  stimulant medication (ASM) and various forms of alopecia areata.

The authors conducted a retrospective case-control medical record review of patients between the ages of 6 and 18 years seen over a 10-year period. Cases included patients diagnosed with alopecia areata (AA), alopecia totalis (AT), or alopecia universalis (AU). Cases were  matched to controls based on age and sex. ADHD medications examined included lisdexamfetamine, amphetamine/dextroamphetamine, dexmethylphenidate, and methylphenidate.  The authors identified 124 cases (110 with AA, 11 with AT, and 3 with AU) and 372 controls.

Taken together, the authors found an association only between alopecia universalis and ADHD medications use (P<0.0071). There was no relationship between ADHD medication use and the development of alopecia areata of alopecia totalis.

All in all, the authors felt that there was a significant associated  between the development of alopecia universalis and ADHD medications. They called for further study into this important issue and proposed that hair loss practitioners might consider withdrawing ADHD medications in patients with alopecia areata who are showing any signs of progression to alopecia universalis. These medications do not seem to need to be withdrawn in those with patchy alopecia areata or alopecia totalis.

STUDY 4: Joshi et al, 2023

Joshi et al sought to examine whether alopecia areata is associated with any psychiatric diseases other than the well known associations of anxiety and depression.

The authors performed a nested case-control analysis using the “All of Us Research Program” database. The authors identified 731 alopecia areata cases using ICD-9-CM code 704.01 and ICD-10-CM code L63. These cases were matched in a 1 to 4 ratio to age-, sex-, and race/ethnicity-matched controls.

The authors found AA to be significantly associated with alcohol use disorder (AUD), attention deficit/hyperactivity disorder (ADHD), and insomnia.

After adjusting for various cofounders such as age, body mass  index, income, insurance type, number of primary care physician visits within the past 12 months, race and sex,  the association of alopecia areata with  psychiatric disease persisted: there was a 2.35 fold increased risk of alcohol use disorder (OR 2.35, 95% CI 1.41-3.93), 3 fold increased risk of ADHD (OR 3.03, 95% CI 12 2.04-4.49), and 2.67 fold increased risk of insomnia.  (OR 2.67, 95% CI 2.12-3.37).

Conclusion

These four studies are important as they highlight the association between several mental health issues and alopecia areata. There seems to be a link between ADHD and alopecia areata. In fact, patients with ADHD seem to be at about a three fold increased risk of AA. Of all the mental health disorders, ADHD may have one of the closest associations to alopecia areata and for this reason alone warrants further study of the connection.

REFERENCE

Ho H-Y et al. Increased Alopecia Areata Risk in Children with Attention-Deficit/Hyperactivity Disorder and the Impact of Methylphenidate Use: A Nationwide Population-Based Cohort Study. Int J Environ Res Public Health. 2021 Feb 1;18(3):1286.

Joshi et al. Association of alopecia areata with alcohol use disorder, attention-deficit/hyperactivity disorder, and insomnia: a case control analysis using the All of Us research program. Clin Exp Dermatol. 2023 Mar 8;

Meaux TA et al. Association of Alopecia Areata With Attention-Deficit/Hyperactivity Disorder Stimulant Medication: A Case-Control Study. Ochsner J. 2021 Summer; 21(2): 139–142.

Singam V et al. Association of alopecia areata with hospitalization for mental health disorders in US adults. J Am Acad Dermatol . 2019 Mar;80(3):792-794.