Tofacitinib (Xeljanz) for Alopecia Areata: How fast does hair re-growth occur?

Speed of Regrowth in AA

Alopecia areata is an autoimmune condition. A number of treatments are available and these have been reviewed in previous articles. Among the newer options are the so called JAK inhibitors which includes tofacitinib (Xeljanz) and ruxolitinib (Jakafi/Jakavi). While not FDA approved yet for treating alopecia, they are increasing used off-label.  

I'm often asked how quickly regrowth can occur in alopecia areata patients treated with tofacitinib. The answer is that regrowth rates are variable but patients who respond well show regrowth by the first month and have significant regrowth by month 3. Patients who are not showing these types of regrowth patterns may be non-responders or may need higher doses.  If significant regrowth is not present by month 3, I may discuss the option to increase from 5 mg twice daily (i.e. 10 mg daily) to 15 mg or 20 mg daily.  The decision on whether to increase the dose depends on a number of factors including whether the patient has experienced any side effects to date. 

DOWNLOAD HANDOUT ON TOFACITINIB

DOWNLOAD HANDOUT ON RUXOLITINIB

Tofacitnib for Nail Alopecia Areata: What Do We Know So Far?

What Do We Know So Far?

The JAK inhibitors, including tofacitinib and ruxolitinib, are known to be helpful for many patients with alopecia areata. Not only can they help hair regrowth, the patients affected by nail disease can also be helped. The accompanying photo shows a patient of mine who had excellent response to tofacitinib.

Lee and colleagues from Korea set out to evaluate the relationship between nail and hair responses in patients with alopecia areata treated with tofacitinib. They performed a retrospective study of 33 adult patients with moderate-to-severe AA treated with oral tofacitinib monotherapy for at least 4 months.

15 of the 33 patients had nail involvement. Of 15 patients with nail involvement, 11 (73.3%) showed improvement. Overall, there was some delay before improvements were seen in the nail - first improvement was observed at a median of 5 months.

Interestingly, the nail improvement was associated with neither initial severity of hair loss nor hair response to tofacitinib. Nail improvement tended to occur later than hair regrowth.

This study adds to a growing body of evidence suggesting that tofacitinib helps with the nail AA as well as scalp AA. In this small study, there was no clear link between whether tofacitinib helped the scalp and whether it helped the nail.
 

REFERENCE

Lee JS, et al. Nail involvement in patients with moderate-to-severe alopecia areata treated with oral tofacitinib. J Dermatolog Treat. 2018.
 

Alopecia Areata and Vitamin D: Levels Lower in AA

Levels lower in Alopecia Areata

Accumulating studies have suggested that vitamin D levels are lower in patients with the autoimmune condition alopecia areata. Now, a large review of 14 studies including a total of 1,255 individuals with alopecia areata and 784 non-AA control were analyzed. Data showed clearly that mean serum 25-hydroxyvitamin D levels were significantly lower in individuals with AA. Although it had been suggested in previous studies that patients with more extensive hair loss were more likely to have the lowest vitamin D levels, it was difficult in the to find a clear correlation in this review.
 

Conclusion

Testing for vitamin D is an important consideration for all patients with alopecia areata. Supplementation is appropriate when levels are suboptimal.
 

Reference

Increased prevalence of vitamin D deficiency in patients with alopecia areata: A systematic review and meta-analysis.
Lee S, et al. J Eur Acad Dermatol Venereol. 2018.
 

Methotrexate for Hair Loss:

A closer look at MTX for Autoimmune Hair Loss

Methotrexate (MTX) is an immunosuppressive medication that can both be used to treat some forms of hair loss as well as cause hair loss. Methotrexate is a medication the has been used for over 60 years. It was initially developed as a cancer treatment (and continues to be used in oncology) but is also used to treat a variety of autoimmune conditions including lupus, rheumatoid arthritis, psoriasis and vasculitis.

When treating hair loss, MTX has a role in treating both scarring and non scarring conditions. Evidence supports a role of weekly oral methotrexate in treatment of lichen planopilaris, frontal fibrosing alopecia, discoid lupus and alopecia areata. In the treatment of alopecia areata, methotrexate has been used in both children and adults, often in combination with systemic corticosteroids (like dexamethasone and prednisone).

Hair Loss as a side effect of MTX

In addition to its use in treating hair loss, methotrexate can sometimes also cause hair loss. About 5-10 % of users experience hair loss and the type of hair loss includes both increased hair breakage as well as increased shedding.  Hair color changes can also occur.

MTX side effects

Anyone considering MTX needs to speak to their physician about the risks and benefits. Side effects from methotrexate include reduced blood counts, liver damage, ulcers, cough, lung irritation (rarely fibrosis or scarring in the lung), nausea and abdominal pain, fatigue, kidney damage and memory problems. Methotrexate can not be used by women trying to become pregnant or who are pregnant. 

Because methotrexate interferes with how folic acid is metabolized, the drug needs to be taken with folic acid supplements. Generally methotrexate is given only one day per week and folic acid is given the other 6 days of the week (on the days methotrexate is not taken).

Download MTX Handout for Patients. 

Oral Steroids for Paediatric Alopecia Areata

Prednisone in Paediatric Alopecia areata

The decision to use prednisone for children with alopecia areata is always an important one. Generally, this decision comes at an important time where parents and their physician have found that topical steroids, and other more localized treatments have not worked well or in some cases have not worked at all. 

Oral steroids are an option for short term use but generally not an option for long term use. Long-term corticosteroid therapy can lead to growth retardation, metabolic dysregulation and reduced bone mineral density, and other side effects. But short term used is possible and reserved for patients with rapid onset or rapidly progressive extensive, active AA.

 

Options for Corticosteroids in Children

There are two main options for corticosteroids in children - prednisone and dexamethasone. Each has their unique benefits. Prednisone has a short half life (quickly metabolized in the body) and so one needs to take daily whereas dexamethasone has a longer half life and use is generally twice weekly. 

Dosing Algorithms

There are many ways that steroids can be used. Common ways include the following 

1. Daily Prednisone

Daily prednisone is among the most common ways of prescribing steroids. While older children will generally take Prednisone pills, younger children can use prednisolone liquid which comes at a strength of 15 mg for every 5 mL of the syrup.  Typically a physician will prescribe 0.5 to 0.8 mg of the prednisone for every kilogram of body weight initially and then taper the dose over a period of time. This taper is generally for 3-12 weeks - with the shorter periods being generally safer but less effective. Most uses of oral steroids perform a slow taper over 12 weeks. 

2. Dexamethasone

Twice weekly use of dexamethasone is another way of prescribing steroids to children with alopecia areata. Dexamethasone dosing is different than prednisone and generally 1 mg of dexamethasone equates to 6.25 mg of prednisone. In 1999, Sharma and colleagues performed a study of twice weekly dexamethasone and included children in that study. Children under 12 received 2.5 to 3.5 oral biweekly dexamethasone whereas older individuals received 5 mg.

3. Monthly therapy

Monthly pulsed therapy with intravenous corticosteroid therapy or oral therapy is also an option. Doses tend to be larger on the one day that they are given and therefore concerns about safety do exist. Generally studies to date support good safety for this methodology but the protocol tends to be less commonly used. Lalosevic J, et al performed a study of monthy dexamethasone pulse therapy along with topical steroids in children with alopecia areata. Outcomes were quite good with nearly two thirds having complete regrowth. 

Side effects

One needs to carefully review all the side effects of oral steroids with their physician. For each side effect, one needs to really ask the prescriber  "okay - is that side effect common or uncommon?" The reality is that most children do very well on steroids. Weight gain, poor sleep, poor concentration, hyperactivity, heart burn, nausea are among the more common side effects.  Suppression of the adrenal glands ability to make prednisone itself is always a discussion but this is uncommon and  if it does occur it is generally temporary.  Within the 12 week period that they are generally used, many of the long term side effects are not typically seen. With every side effect, parents need to ask, "Is that a short term side effect you are mentioning or is that one that develops with long term use?"

Conclusion

It's a big decision as to wether or not to use oral steroids in alopecia. However, it's certainly an option to help reset the immune system and when done for appropriate times and appropriate doses the changes of side effects are low. 

REFERENCES
 

Sharma VK, et al. Twice weekly 5 mg dexamethasone oral pulse in the treatment of extensive alopecia areata.  J Dermatol. 1999.

Lalosevic J, et al. Combined oral pulse and topical corticosteroid therapy for severe alopecia areata in children: a long-term follow-up study.  Dermatol Ther. 2015 Sep-Oct.

Topical JAK inhibitors for Hair Loss

The Future of JAKs

The janus kinase pathway is a signaling pathway inside cells and continues to be explored in terms of its relevancy to hair disorders. Accumulating research suggests that blockade of this pathway with so called JAK inhibitors can benefit a number of hair loss conditions including alopecia areata. Both topical and oral JAK inhibitor have shown promise.  JAK inhibition may also be relevant to the treatment of androgenetic alopecia.   Another trial is evaluating the effect of two concentrations of ATI-502 on the regrowth of hair in a randomized, double-blinded, parallel-group, vehicle-controlled trial in a larger study of AA.  

Aclaris is a company which has secured the rights to study and develop the use JAK inhibitors for the treatment of alopecia areata (AA) as well as androgenetic alopecia (AGA). They have a number of JAK inhibitors they are studying and several are currently in clinical trials. This includes ATI-502 and ATI-501. Press releases from the company indicate that a number of studies are underway. This includes a trial to evaluate the effect of ATI-502 on the regrowth of scalp and eyebrow alopecia areata.  In addition to AA, it is interesting to note that trials are underway to evaluate the effect of ATI-502 on the regrowth in androgenetic alopecia (AGA). 

Comment

It's an exciting time for many new potential treatments in hair loss. The JAK inhibitors have already shown benefit in AA and additional studies will determine whether these agents receive approval and ultimately come to market. 

Alopecia Areata

Shaved scalp: Exclamation mark hairs

Many patients with advanced alopecia areata shave their scalp. For some, this allows a wig to fit better. For others, especially men, the shaving is done to reduce the appearance of hair loss. 
Even with a shaved scalp, it is sometimes possible to tell if a patient's alopecia areata is active or not. This is especially true if exclamation mark hairs can be seen. "Exclamation mark" (arrow) hairs are easy to identify with a magnifying device. They are 3-5 mm in size and wide at the top and narrow at the bottom. They signal disease activity and the need for more aggressive treatment if hair loss is to be stopped.

Other features can also be seen on a shaved scalp including yellow dots (and hair follicles lacking a hair follicle) and hair follicles with just a single hair coming out (rather than in groups of 2 and 3 haired follicles).

Alopecia Areata and Paraneoplastic Syndromes

Cancer, the Immune System and Alopecia Areata 

Alopecia areata is an autoimmune disease. Approximately 1.7 % of the world's population will be affected by alopecia areata. Studies have shown that the vast majority of patients with alopecia areata are extremely healthy. A higher incidence of eczema and thyroid problems is well known to exist in patients with alopecia areata.  Other autoimmune conditions can occur less frequently. 

70-80 % of the disease has a genetic basis and 20 % or so is influenced by environmental factors or 'triggers.' Most of the time, a trigger can not be identified in patients with alopecia areata.  There are a variety of triggers that have been studied through the years. Stress, medications, vaccines have all be proposed to play a role in a small minority of patients. It is extremely rare that cancer is a trigger, but such a phenomenon whereby a cancer triggers clinical manifestations at a site far away from the cancer itself is called a 'paraneoplastic syndrome.'

Paraneoplastic syndromes associated with Alopecia

Álvarez Otero J in 2017 reported the case of a man who developed alopecia areata two months before being diagnosed with gastric adenocarcinoma. Of course, it is challenging to know with certainly in these cases whether the alopecia is coincidental or not and this is the challenge with all paraneoplastic syndromes. However, often the timing of the alopecia, and the improvement in the hair loss with removal of the tutor lends some support to the possibility of a link.

Cancers of the gastrointestinal system have some of the most frequent reports of being associated with alopecia areata. Other cancers which may have a paraneoplastic relationship to hair loss are thymomas and Hodgkin disease. Overall though, the link is quite rare and work up an evaluation for cancer is not appropriate for most patients with alopecia areata. Nevertheless, these paraneooplastic syndromes are reminders that there can be many potential triggers of alopecia areata. 

REFERENCE

Álvarez Otero J, et al. Alopecia areata as a paraneoplastic syndrome of gastric cancer.  Rev Esp Enferm Dig. 2017

Alopecia areata as a paraneoplastic syndrome of Hodgkin's lymphoma: A case report.Gong J, et al. Mol Clin Oncol. 2014

Multiple paraneoplastic syndromes: myasthenia gravis, vitiligo, alopecia areata, and oral lichen planus associated with thymoma.Qiao J, et al. J Neurol Sci. 2011

[Alopecia areata as the initial paraneoplastic presentation of gastric adenocarcinoma].Molina Infante J, et al. Gastroenterol Hepatol. 2009. Article in Spanish.

[Gastrointestinal tumor (GIST) of the esophagus in a 34-year-old man: clubbed fingers and alopecia arealis as an early paraneoplastic phenomenon].Axel J, et al. Dtsch Med Wochenschr. 2005. Article in German.

Alopecia areata and multifocal bone involvement in a young adult with Hodgkin's disease.Mlczoch L, et al. Leuk Lymphoma. 2005

Onion extracts for alopecia Areata: Small study suggested benefit

Small study suggested benefit

When it comes to treating hair loss, I’m all for anything that works. It doesn’t matter if it’s Eastern or Western medicine, Northern or Southern. It doesn’t matter if it’s allopathic, osteopathic, naturopathic or functional medicine. If it works, it works.

In the same light, I’m against using things that don’t work. I’m against using treatments with no evidence or treatments that prey on the vulnerability of patients. I’m against treatments that waste the time, money of patients and exhaust their emotions.

Onions are on the list of treatments that work in alopecia areata. That’s not to say they are at the top of the list. But the onion made it on the list.

A 2002 study compared the benefits of onion extract in 23 patients with alopecia areata and compared it to 15 patients who used placebo (tap water). Participants applied it twice daily for 2 months. At the end of 2 months, 86.9 % of participants had regrowth compared to just 13% (2 of 15) using tap water.

Onion juice is a consideration for patients looking for simple treatments for alopecia areata. This study of course is small and has not been repeated. How best to prepare the onion extract, which onions are best to use, how often and what exact dosing schedule remain to be determined. Other similar vegetables such as garlic may also benefit.

We don’t use this treatment all that often as other treatments seem more effective for most patients. Mixing with lemon juice can cut onion odour and generally my patients apply in a mixture of essential oils such as rosemary, thyme, lavendar, cedarwood, peppermint in jojoba carrier.

Handout on Onion Juice for Hair Loss
 

Reference

Sharquie KE, et al. Onion juice (Allium cepa L.), a new topical treatment for alopecia areata.
Clinical Trial J Dermatol. 2002.

Steroid Injections: Atrophy (dents, depressions, holes)

Atrophy (dents, depressions, holes)

Steroid injections are a relatively common treatment for many inflammatory and autoimmune scalp conditions. There is rarely a day in the office that I don’t perform steroid injections. These are very valuable treatments for many patients with alopecia areata, scarring alopecias and even some forms of traction alopecia.

One of the side effects of steroid injections is atrophy. Atrophy appears as an indentation in the skin at the site of injection. The patient may refer to it as a “dimple” or a “depression.” Others may call it a “dent” or even a “hole” The indentation can often be better felt than seen.

The chance of developing indentations (atrophy) depends on the concentration of steroid the doctor uses. Higher concentrations (10 mg/mL) give a greater risk of causing atrophy than lower concentrations (2.5 or 5 mg/mL). Some studies suggested that the risk may be as high as 3 in 10 patients when a dose of 10 mg/mL is used. 
The indentations occur because the steroid affects collagen and elastin underneath the skin. The steroids inhibit the growth of fibroblasts, which are the cells that collagen and elastin. Studies have shown there is less collagen made and it’s degraded more quickly. There is a reduction in diameter of collagen fibrils. The collagen bindles become atrophic snd separated. Similar to collagen, elastin fibers become thin and fragmented.

Atrophy typically is seen by 3 weeks if it’s going to occur. An important point to be made is that the atrophy is generally reversible provided more injections aren’t given to an area already showing atrophy. The skin usually returns to normal in 3-4 months. Steroid injections should not be readministered too soon to an area that has not “recovered” as further atrophy can occur - some of which can be very long lasting.

Treatment for steroid atrophy is mainly to wait for the body to start making more collagen and elastin again in a few months. If this does not happen, saline injections, dermal fillers and fat injections can be considered.

Treating alopecia areata: More than shots?

Options for treating alopecia areata

Alopecia areata is an autoimmune condition that affects nearly 2 % of the world's population. The condition is autoimmune in nature, which means that the patient's own immune system is attacking the hairs. Treatments that reduce inflammation can often be helpful - although spontaneous regrowth can occur in some patients even without treatment. 

 

Options for Treating AA:

Steroid injections, also known as "steroid shots" are  helpful treatment for many patients with several patches of alopecia. Steroid injections are less effective for wide spread alopecia areata - and other options need to be considered in these situation. Too often I hear patients say "Is there anything else besides shots?"

Beyond Shots

Steroid injections are extremely important for many patients and if done properly present a treatment option with reasonably good efficacy and quite good safety. I think alot of people are suprised when I say there are at least 25 different treatment options for alopecia areata other than 'shots.'  Here I've listed the treatment options for alopecia areata

Topical Treatments
Topical steroids
Topical bimatoprost
Essential oils
Anthralin
Squaric acid
Diphencyprone
Minoxidil
Topical tofacitinib
Topical ruxolitinib
Onion juice
Garlic gel

Topical retinoids

Topical capsaicin 

Topical liquid nitrogen

Injection Treatments
Steroid injections
Platelet rich plasma

Dupilumab (DUPIXENT)
 

Intramuscular Treatments
Intramuscular triamcinolone 

Oral Treatments
Prednisone
Dexamethasone
Antihistamines
Simvastatin & Ezitimibe
Methotrexate
Tofacitinib, Ruxolitinib, Baricitinib
Azathioprine
Cyclosporine
Sulfasalazine
Oral minoxidil

Zinc supplements

Light and Laser Treatments
Psoralen UVA (PUVA)
308 nm Excimer Lasers

Conclusion:

There are many treatments that can be considered for patients with alopecia areata.  Steroid injections are helpful for many patients and should never be discounted. But patients who find that steroid injections did not help have numerous other options available to discuss with their dermatologists.

Correcting Vitamin D Deficiency: Do we try hard enough?

Vitamin D deficiency and Dosing Regimens

Vitamin D deficiency is common. Given that there may be some role between hair growth and vitamin D signaling inside cells, the current view is to ensure that vitamin D levels are adequate. This remains controversial from the perspective of hair loss because simply taking vitamin D tablets is not going to promote hair growth for most. Nevertheless, having low vitamin D levels could impair hair function, at least theoretically. 

Vitamin D: The 30/75 Target Number

To monitor vitamin D levels, we don't actually measure vitamin D, we measure 25 hydroxy-vitamin D (sometimes simply referred to as 25 OH D). It's important to maintain 25 hydroxy-vitamin D levels above 30 ng/mL which translates to 75 mol/L. Some countries like the United States use ng/mL as their base measure and other countries (such as Canada) use mol/L. It's important to take note of these units.  These numbers of 30/75 come from recommendations of the World Health Organization and others:

Vitamin D Deficiency is 25 OH D levels less than 20 ng/mL (50 nmol/L)

Vitamin D Insufficiency is 25 OH D levels less than 30 ng/mL (75 mol/L)

Vitamin D2 and Vitamin D3

To complicate matters slightly, there are two common forms of vitamin D supplements that can be taken. Vitamin D3, known as cholecalciferol, is the most common and available in doses of 400, 800, 1000, 2000 IU at most pharmacies and grocery stores. It is not typically available on prescription. High doses of vitamin D are available through use of vitamin  D2, which is called ergocalciferol.  It is the only form of vitamin D typically available by prescription. Vitamin D2 is available in 50,000 IU pills which makes higher dosing easier and for this reason it's the typical form using for individuals trying to correct vitamin D deficiency.  In general, vitamin D3 (cholecalciferol) is thought to be more bioavailable than vitamin D2. 

Vitamin D toxicity: A Healthy Respect

We need to respect all supplements since any supplement has the potential to be toxic.  Large doses of vitamin D can cause calcium balance to go out of whack, leading to hyperalcemia. For vitamin D3, doses up to 10,000 IU daily are generally viewed to be quite safe for most individuals. For vitamin D2 mega-doses of 50,000 IU weekly (not daily), there is good safety when taken for short periods of time.  studies have shown that individuals who mistakingly take vitamin D2 daily instead of weekly or monthly, can develop serious side effects. In other words, if anyone is going to take vitamin D, they need to know if they are taking vitamin D3 or vitamin D2 and focus on whether they are supposed to be taking it daily or weekly or monthly. 

Individuals with chronic medical conditions, including osteoporosis, diabetes, kidney disease and women who are pregnant may need to follow other doses recommendations than listed here. 

 

Correcting vitamin D deficiency: Are we taking enough?

There is a great deal of focus on the dose of vitamin D we should be taking. Depending on one's age and risk for various diseases, this may range from 400 IU daily to 2000 IU daily. But these numbers are generally for individuals who have normal levels and are trying to maintain them. The question then arises: What type of dosing is appropriate is someone  is trying to simply get their levels up to a normal range?

There are a variety of different dosing schedules. For individuals with mild vitamin D insufficiency, I typically recommend 3000-4000 IU daily for a period of 6 months and retesting the 25 OH D levels down the road.  For individuals who  have more marked deficiency, I generally follow standard protocols, and prescribe vitamin D2 in many cases:

FOR SEVERE DEFICIENCY:

Vit D2 50,000 IU weekly for 12 weeks then once monthly for 3-5 months 

FOR MODERATE DEFICIENCY

Vit D2 50,000 IU weekly for 4-8 weeks then once monthly for 2-4 months

In patients who don't respond adequately to the above regime, 50,000 IU of vitamin D2 used three times weekly for 6 weeks may be advised. 

Studies have shown that for most people a total dose of 600,000 IU is needed over a 6 month period to help get vitamin D levels up high enough.  For patients with vitamin D deficiency, I generally recommend retesting at the 6 month mark. 

Conclusion

If one has vitamin D "deficiency" or "insufficiency", taking the standard vitamin D3 doses of 400 IU or 1000 IU that are available in pharmacies is not usually enough to correct the vitamin D deficiency. It's enough to keep levels normal once they are normal, but it's not enough to get levels up to a normal range. One needs slightly different doses for shorter periods of time to bring the vitamin D levels up. 

REFERENCE
Pepper KJ et al. EVALUATION OF VITAMIN D REPLETION REGIMENS TO CORRECT VITAMIN D STATUS IN ADULTS. Endocr Pract. 2009; 15(2): 95–103. 

 

Treatment of Alopecia Areata: Is the treatment likely to help?

Is the treatment likely to help?

Alopecia areata is an autoimmune condition for which many treatments are possible. Patients with isolated patches of hair loss often begin with topical steroids, or steroid injections. Patients with more advanced and widespread hair loss may be prescribed other options such a diphencyprone. anthralin, prednisone, dexamethasone, methotrexate, sulfasalazine, tofacitinib and others.

Some treatments act rapidly (such as the use of steroid injections in an isolated patch of alopecia areata). Other treatments can be slower to show growth (such as DPCP or methotrexate in patients with alopecia totalis).

There are some signs that a clinician can see when examining the scalp that suggests a treatment is probably not going to help. For example, this photo shows many short “exclamation mark” hairs in a patient who has been receiving oral methotrexate and oral prednisone for 4 months. The persistence of these short hairs indicates that there is still a great deal of inflammation under the scalp despite these treatments. A new or modified treatment plan will be needed to try to stop this patient’s hair loss. 

EXCLAMATION MARK HAIRS IN ALOPECIA AREATA

 Variations In Size

Exclamation mark hairs are hairs that are quite short. Most exclamation mark hairs are 4-6 mm in length but rarely they can be longer depending on the amount of inflammation under the scalp beneath that specific hair. Here in this photo, we can see two exclamation mark hairs of different lengths - one is 3 mm and the other is nearly 15 mm in length. Exclamation mark hairs are seen in alopecia areata, trichotillomania and a few other conditions as well. They are important signs in alopecia areata as they indicate disease activity

Screening for thyroid disease in children with alopecia areata

Alopecia areata and Thyroid Disease

It's clear that the risk of thyroid disease is increased in individuals diagnosed with alopecia areata.   It is generally recommended that children and adults with alopecia areata undergo blood tests to determined if thyroid function is normal. 

Kurtev and colleagues performed a study in 46 children with a mean age of around 10 years.  63 % of children had enlarged thyroid glands (known as thyromegaly).  Thyroid autoantibodies were present in about 1/3 of children. Ultrasound studies showed evidence of autoimmune thyroiditis in nearly one-half of the children. 

A more recent study by Patel and colleagues examined 298 children with alopecia areata. Thyroid disease was most common in children with atopic dermatitis, children with Down syndrome and those with a family history of thyroid disease.

 

Conclusion

Thyroid disease is common in children with alopecia areata. While all children are typically screen for thyroid disease through measurement of serum TSH, this may be most important in children with atopic dermatitis, children with Down syndrome and those with a family history of thyroid disease.

REFERENCES

Patel D et al. Screening Guidelines for Thyroid Function in Children With Alopecia Areata. JAMA Dermatol. 2017;153(12):1307-1310.

Kurtev A et al. Thyroid autoimmunity in children and adolescents with alopecia areata.Int J Dermatol. 2005 Jun;44(6):457-61.

Alopecia areata: Up close

Dermatoscopic (Trichoscopic) Features of Alopecia Areata

Typical dermatoscopic findings in alopecia areata: 1) yellow dot 2) black dot 3) exclamation mark hair and 4) tapered hair. 

Alopecia areata: One of the many 'non-scarring' alopecias

Alopecia Areata is Non-scarring

It's hard to believe that there are so many different reasons for hair loss. We see about a dozen causes commonly in the office each week but many more rarer entities exist.

Hair loss is frequently divided into two big groups - "scarring" and "non-scarring." Alopecia areata is an example of a non scarring alopecia. Clinically, when one looks at the scalp up close as in the accompanying dermatoscopic image, it can be seen that the hair follicle openings are present. If one were to biopsy the scalp in this condition, there would not be scar tissue present. 

The entities in this group of "non-scarring alopecias" theoretically have the potential to regrow although regrowth is more difficult for some of the non scarring alopecias compared to others. Common non scarring alopecias include alopecia areata, androgenetic alopecia, telogen effluvium, tinea, trichotillomania, and traction alopecia.

Alopecia areata : Well demarcated

Common Clinical Features of AA

Alopecia areata is an autoimmune condition that affects 1.7 % of the world. Affected patient often develop well demarcated round or oval-shaped patches of hair loss.

Well-demarcated

The term well dermarcated means that one can often draw an imaginary line around the area of hair loss as opposed to other hair loss conditions like androgenetic alopecia where is can be challenging to determine where the hair loss starts and ends.

If one looks up close at a typical patch of alopecia areata, a number of findings are often present including (1) thin hairs or white hairs within the patch of hair loss and (2) “exclamation mark” hairs around the perimeter of the patch of hair loss. Spontaneous growth can occur in many patients. However as the size of the patch increases amd as the number of these patches increases, the chance of spontaneous regrowth diminishes. The most effective treatments for a single patch such as the one shown are topical steroids and steroid injections. I frequently add minoxidil if the patch is slower to respond to treatment.

Mononucleosis ("Mono") and Alopecia Areata - Any link?

Is mononucleosis ("mono") a trigger for alopecia areata?

Alopecia areata is an autoimmune disease. Environmental factors play a role in many patients to trigger the disease in patients who have the correct genetic predisposition to the disease.  Studies have examined whether environmental factors like stress, as well as various infections play a role in alopecia areata.

EBV: The Cause of Mono

Epstein Barr Virus (EBV) is the virus known to cause the infectious illness mononucleosis which is sometimes just called 'mono'. A 2008 study examined whether mononucleosis could be a trigger for alopecia areata. This particular study examined 6256 individuals. 1586 patients reported an environmental trigger that was thought to cause the alopecia areata - including 12 individuals who had an EBV infection within 6 months before the onset of AA.

Conclusion

The role of EBV and mononucleosis is not proven definitively but there is some evidence that it could be a trigger for a small proportion of individuals. More studies are needed.

Reference

Rodriguez TA, et al. Onset of alopecia areata after Epstein-Barr virus infectious mononucleosis. J Am Acad Dermatol. 2008.

Alopecia areata: Yellow dots

Yellow dots in AA

Alopecia areata is an autoimmune disease affecting nearly 2% of the world’s population.

This condition is potentially regrowable although some patients have more challenging types of alopecia areata to regrow than others.

The photo shows typical “yellow dots” by dermoscopy. The yellow dots represent hair follicle openings that are filled with keratin. 
Yellow dots are very common in patients with AA. Together with black dots and short vellus hairs, yellow dots are associated with disease severity.