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Alopecia areata (AA) is an autoimmune disorder characterized by patches of non-scarring alopecia affecting scalp and body hair that can be psychologically devastating. AA is clinically heterogenous, and its natural history is unpredictable. There is no preventative therapy or cure. The objective of this study is to provide an evidence-based systematic review on the epidemiology and the burden of AA. A search was conducted of the published, peer-reviewed literature via PubMed, Embase, and Web of Science. Studies published in English within the last 51 years that measured AA's incidence, prevalence, distribution, disability-adjusted life years (DALYs), quality of life, and associated psychiatric and medical comorbidities were included. Two authors assessed studies and extracted the data. The lifetime incidence of AA is approximately 2% worldwide. Both formal population studies found no sex predominance. First onset is most common in the third and fourth decades of life but may occur at any age. An earlier age of first onset corresponds with an increased lifetime risk of extensive disease. Global DALYs for AA were calculated at 1,332,800 in 2010. AA patients are at risk for depression and anxiety, atopy, vitiligo, thyroid disease, and other autoimmune conditions. AA is the most prevalent autoimmune disorder and the second most prevalent hair loss disorder after androgenetic alopecia, and the lifetime risk in the global population is approximately 2%. AA is associated with psychiatric and medical comorbidities including depression, anxiety, and several autoimmune disorders, and an increased global burden of disease.
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Epidemiology and burden of alopecia areata:
a systematic review
Alexandra C Villasante Fricke
Mariya Miteva
Department of Dermatology and
Cutaneous Surgery, University of
Miami Miller School of Medicine,
Miami, FL, USA
Correspondence: Mariya Miteva
Department of Dermatology and
Cutaneous Surgery, University of Miami
Miller School of Medicine, 1600 NW
10th Avenue, Rosenstiel Medical
Science Building, Room 2023A,
33136 Miami, FL, USA
Background: Alopecia areata (AA) is an autoimmune disorder characterized by patches of
non-scarring alopecia affecting scalp and body hair that can be psychologically devastating.
AA is clinically heterogenous, and its natural history is unpredictable. There is no preventative
therapy or cure.
Objective: The objective of this study is to provide an evidence-based systematic review on
the epidemiology and the burden of AA.
Methods and selection criteria: A search was conducted of the published, peer-reviewed
literature via PubMed, Embase, and Web of Science. Studies published in English within the last
51 years that measured AAs incidence, prevalence, distribution, disability-adjusted life years
(DALYs), quality of life, and associated psychiatric and medical comorbidities were included.
Two authors assessed studies and extracted the data.
Results: The lifetime incidence of AA is approximately 2% worldwide. Both formal population
studies found no sex predominance. First onset is most common in the third and fourth decades
of life but may occur at any age. An earlier age of first onset corresponds with an increased
lifetime risk of extensive disease. Global DALYs for AA were calculated at 1,332,800 in 2010.
AA patients are at risk for depression and anxiety, atopy, vitiligo, thyroid disease, and other
autoimmune conditions.
Conclusion: AA is the most prevalent autoimmune disorder and the second most prevalent
hair loss disorder after androgenetic alopecia, and the lifetime risk in the global population is
approximately 2%. AA is associated with psychiatric and medical comorbidities including depres-
sion, anxiety, and several autoimmune disorders, and an increased global burden of disease.
Keywords: hair loss, hair, prevalence, incidence, burden of disease
Alopecia areata (AA) is a common, clinically heterogenous, immune-mediated, non-
scarring hair loss disorder.
The disease may be limited to one or more discrete, well-
circumscribed round or oval patches of hair loss on the scalp or body, or it may affect
the entire scalp (alopecia totalis) or the entire body (alopecia universalis).
the course of disease is unpredictable, with spontaneous regrowth of hair occurring
in 80% of patients within the first year, and sudden relapse at any given time.
AA, CD4+ and CD8+ T-cells violate the immune privilege of the anagen hair follicle,
leading to loss of the growing hair shaft.
CD8+ T-cells are present in significantly
greater quantities than CD4+ cells, and a subset of them known as CD8+ NKG2D+
T-cells has been found both necessary and sufficient to induce AA in C3H/HeJ mice.
A predominant Th1 cytokine profile has been discovered at the site of AA lesions.
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Recently, a genome-wide association study demonstrated a
genetic predisposition to AA.
Environmental insults, such
as viral infections, trauma, or psychosocial stress, have also
been suspected to possibly contribute to the development of
the disease.
Treatment options for AA have limited success, no cure
has been found, and no therapy has been able to prevent
disease relapse.
Treatment options include topical, locally
injected, or systemic steroids; topical immunotherapy; topical
minoxidil; topical irritants such as anthralin; and systemic
immunosuppressants such as cyclosporine or methotrexate.
Success rates vary depending on the extent and duration of
disease. Psychosocial support and therapy is also an impor-
tant part of disease management, as this often disfiguring
disease can be psychosocially burdensome.
The objectives of this review are to 1) to assess the
epidemiology of alopecia areata, including its incidence,
prevalence, and distribution by sex and age a brief descrip-
tion of the genome-wide association studies is also included;
and 2) to assess its burden of disease including its comorbid
psychiatric and medical conditions. Burden of disease is
measured by disability-adjusted life years (DALYs), which
combine years lost to disability (morbidity) and years lost
to death (mortality) so that one DALY represents 1 year of
healthy life lost.
Materials and methods
A search of the literature was performed in order to answer
the question: what is the epidemiology and burden of alopecia
areata? A search was performed first on PubMed with the
terms “alopecia areata epidemiology”, which yielded 208
results. All titles and abstracts were scanned to determine
whether each article answered the question. Further searches
were performed including: “alopecia areata prevalence”,
“alopecia areata incidence”, “alopecia areata distribution”,
“alopecia areata burden”, “alopecia areata DALY”, “alopecia
areata demographics”, “alopecia areata comorbidity”, and
“National Alopecia Areata Registry”. Similar searches were
also performed on Embase and Web of Science.
Articles chosen for inclusion were peer-reviewed with
available full-text or abstract in English, providing primary
data, and were published in the last 51 years. Additionally,
secondary data generated by the World Health Organization
(WHO) in the Global Burden of Disease Study were included.
For the purpose of defining the epidemiology of AA, we
selected articles with data on the prevalence, incidence, and
distribution by sex or age. For the burden of disease, we
selected articles with data on DALYs as well as associated
psychiatric or medical comorbidities.
Epidemiology: prevalence and incidence
Two population studies have measured the incidence and
prevalence of AA, both based in Olmsted County, Minnesota,
Mirzoyev et al analyzed data from the Rochester
Epidemiology Project, assessing 530 newly diagnosed
patients with AA from 1990 to 2009.
Estimated incidence
was 20.9 per 100,000 person-years with a cumulative lifetime
incidence of 2.1%.
The cumulative AA incidence increased
almost linearly with age.
Almost 20 years prior, Safavi et al
estimated the overall incidence of AA at 20.2 per 100,000
person-years with a lifetime incidence of 1.7% using data
from 1975 through 1989.
Three years prior to that, using
data from a survey conducted between 1971 and 1974,
prevalence was estimated at 0.1% to 0.2%, with lifetime
risk of 1.7%.
Hospital-based studies from across the world have esti-
mated the incidence of AA to be between 0.57% and 3.8%,
as detailed in Table 1.
An estimated 2.4 million doctor
office visits in the USA are for AA, which accounts for 25%
of visits for all types of alopecia.
Prevalence in Japan was
calculated to be 2.45%.
Episodes of AA last less than 6
months in the majority of patients.
Epidemiology: family history of AA
Patients with AA reporting a family history of the disease have
been estimated between 0% and 8.6%.
In children, rates
of family history of AA have been reported to be between
Table 1 Incidence of alopecia areata globally
Incidence, % Number of persons in study Country Type of study Comments References
2.1 530 patients USA Population study Lifetime incidence 10
1.7 292 patients USA Population study Lifetime incidence 11
2 n/a USA and Britain Review and hospital-based study 14
0.7 808 patients, 572 controls India Hospital-based study 15
3.8 219 patients Singapore Hospital-based study 16
0.57 187 patients Mexico Hospital-based study 13
Abbreviation: n/a, not applicable.
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Epidemiology and burden of alopecia areata
10% and 51.6%.
One study found that males were more
likely to have a family history than females were.
Epidemiology: distribution by sex
No significant difference in the incidence of AA was found
between males and females in either of the two population
Ten different hospital-based studies from across the
world, however, have cited a female predominance, ranging from
a ratio of 2.6:1 to 1.2:1.
Contrarily, four studies have
shown a male predominance ranging from 2:1 to 1.1:1.
children, there was a male predominance at 1.4:1 in two studies,
with one citing boys as having more severe involvement; a third
study reported girls as having more severe disease.
Male patients were reported as receiving a diagnosis of
AA at an earlier age than female patients.
Females were
found to have a greater likelihood of extensive AA than
Females were found to have higher rates of comorbid
nail involvement and concomitant autoimmune disease, par-
ticularly thyroid disease.
Some studies report no statistically
significant differences in the age of onset, duration, or type
of AA by sex or ethnicity.
Epidemiology: distribution by age and
body site
AA has historically been more prevalent in the younger
age groups.
The largest age group presenting for care was
21–40-years of age, followed by the 1–20-year age group, the
41–60-year age group, and finally the 61–80-year age group.
Similarly, peak in visits for AA has been reported in the
30–59-year age group and the 31–35-year age group.
Age of onset
AA sufferers experience their first onset of AA by age 40
years in 82.6%–88% of patients and by age 20 years in 40.2%
of patients.
The mean age of onset has been reported as
between 25.2 and 36.3 years, as depicted in Table 2.
Age of onset for females compared to males has been variously
reported as lower (24.2 vs 26.7 years),
the same,
and higher
(36.2 vs 31.5 years).
In children, the mean age of onset has
been reported as between ages 5 and 10 years.
Epidemiology: distribution by body site
The scalp is the most common site of involvement, with
or without involvement of other body sites (such as the
eyebrows, eyelashes, and beard).
Specifically, the most
common site was the occipital region, involved in 38.4% of
males and 33.4% of females.
Upon first presentation, 58%
of adult patients had patchy hair loss with less than half the
scalp involved.
On the other hand, in children, 80%–85%
had mild to moderate hair loss involving less than half the
A later age of onset correlated with a less exten-
sive alopecia, or in other words, onset in the first 2 decades
was more often associated with severe alopecia.
Alopecia totalis and universalis occurred in 7.3% of AA cases
and always occurred before the age of 30 years.
Nail changes occur in 10.5%–38% of AA patients, with
common findings including pitting, trachyonychia, and
longitudinal ridging.
Nail changes correlated with
disease severity, as they were found in more severe AA.
Furthermore, nail dystrophy is a poor prognostic indictor
of AA.
Results: burden of disease
Burden of disease: DALYs
In the Global Burden of Disease Study, WHO measured
the global DALYs lost to AA in 2010 to be 1,332,800.
comparison, the DALYs of psoriasis are 1,050,660, and for
diabetes mellitus they are 46,857,100.
The DALYs for AA
have been increasing linearly since 1990, when the global
DALYs were under 1 million. No deaths have been reported
from AA between 1990 and 2010. The disability weight for
AA, which ranges from 0 to 1, was 0.035.
AA is thought to
account for 0.071% of total US DALYs.
Burden of disease: quality of life
Over half of patients with AA experience poor health-related
quality of life (QOL).
Though patients of all ages and both
sexes may experience decreased QOL with AA, risk fac-
tors for poor health-related QOL include age between 20
and 50 years, female sex, lightening of skin color, hair loss
greater than 25%, family stress, and job change.
with extensive AA experienced more adverse psychological
effects than those with limited AA.
Burden of disease: psychiatric
A 66%–74% lifetime prevalence of psychiatric disorders
has been reported in AA patients, with a 38%–39% lifetime
Table 2 Age of onset of alopecia areata globally
Age of onset, years Country Type of study Reference
25.2 Singapore Hospital-based 16
28.98 People’s Republic
of China
Hospital-based 20
36.3 USA Hospital-based 32
32.2 Taiwan Hospital-based 34
33.6 USA Population 10
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Villasante Fricke and Miteva
prevalence of depression and a 39%–62% prevalence of
generalized anxiety disorder.
Adjustment disorders
are also commonly found with AA.
Table 3 outlines the
rates of psychiatric disorders in AA patients compared to
the general population. Approximately 50% of psychiatric
disorders presented earlier than did AA, with the other half
presenting after the onset of AA.
Furthermore, stressful
events preceding hair loss were recalled in 9.8% of adults
and in 9.5%–80% of children.
The rate of psychiatric
comorbidity was influenced by the age of onset of AA, with
an increased risk of depression in patients aged ,20 years
and an increased risk of anxiety and obsessive-compulsive
disorder in those aged 40–59 years.
No patients were acutely suicidal in a study of 45 AA
patients, four with alopecia totalis and 28 with alopecia
One patient in that study, however, answered yes
to “dying is the best solution for me.Four patients affirmed
that they “wish [they] were dead,” and one denied that “life
is still worth living.
A recent letter to the editor, however,
reports the death of four Australian males aged 14–17 years
who were affected by AA with no known pre-existing psy-
chological disorders, and with social withdrawal that began
after the onset of the alopecia.
Burden of disease: comorbid medical
The incidence of atopy in patients with AA has been reported
to be between 11% and 38.2%.
In children with AA,
atopy is seen in 26.6% of patients, though one study found
no significant personal history of atopy compared to con-
A personal or family history of atopy was reported in
60.7% of adults with AA and in 25% of children with AA.
Specifically, atopic dermatitis was reported in 15.6% of adults
with AA and in 39.5% of children with AA.
Five percent of patients in one study were discovered
to have subclinical hypothyroidism due to Hashimoto’s
Seventy-five percent of those discovered to
have Hashimoto’s thyroiditis had a family history of thyroid
Thyroid function abnormalities were found in
8.9% of patients with AA.
Similarly, the prevalence of
thyroid peroxidase antibodies in AA patients was reported
to be 17.7%, about double that of the general population,
with a female-to-male predominance of 6.7:1.
In general,
AA patients were significantly more likely to have a family
history of thyroid disorder.
In addition to autoimmune thyroid disease, it has been
long suspected that there is an association between AA and
other autoimmune disorders such as vitiligo, systemic lupus
erythematosus, psoriasis, inflammatory bowel disease, and
rheumatoid arthritis.
Incidence of the aforementioned
disorders in AA can be seen in Table 4. Positive autoimmune
antibodies (ANA, SMA, Anti-Tg, or PCA) were reported
in 51.4% of patients with AA.
Patients with a family his-
tory of vitiligo were more likely to develop extensive AA.
Some studies, however, did not observe a correlation with
autoimmune conditions in the AA patients or in family his-
tory of autoimmune disorders, with the exception of thyroid
Most recently, diabetes mellitus was found in 11.1% of
AA patients, as shown in Table 4.
Significant increases in
levels of insulin, c-peptide, and HOMA-IR were reported
in AA patients compared to controls, suggesting increased
insulin resistance in AA patients.
Approximately 36.6% of
AA patients in one study reported family history of diabetes
mellitus type 2.
Down syndrome was found in 1.4% of AA patients with
onset of disease before age 15 years and with extensive
involvement in all of these patients.
Summary of genome-wide
associations in AA
A review on AA would not be complete without a mention
of the current literature on genomic associations. Previously,
genes in the human leukocyte antigen (HLA) region were
implicated in AA as well as some genes outside of HLA
including PTPN22 and AIRE.
In 2010, Petukhova et al
published reports of a genome-wide association study that
Table 3 Psychiatric disorders in alopecia areata (AA) patients
compared to the general population
Disorder AA patients, % General
population, %
Major depression 8.8 1.3–1.5
Generalized anxiety disorder 18.2 2.5
Social phobias 3.5 0.9–2.2
Paranoid disorder 4.4
Notes: Data from Koo et al.
Table 4 The incidence of autoimmune disorders in alopecia
areata (AA)
Autoimmune disorder Incidence in AA, % Reference
Vitiligo 1.8–7.0 15,16,33,46,47
Thyroid disorder 2.3–14.6 16,33,34,46
Irritable bowel syndrome 2.0 46
Psoriasis ± psoriatic arthritis
1.9–6.3 34,46
Systemic lupus erythematosus 1.5 34
Rheumatoid arthritis 0.9–3.9 19,34,46
Diabetes mellitus 0.4–11.1 15,46
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Epidemiology and burden of alopecia areata
discovered 139 single nucleotide polymorphisms (SNPs)
associated with AA, mostly genes related to inflammation
and immune-modulation, HLA, and cytokines.
those SNPs include: genes that control the activation and
proliferation of regulatory T-cells; cytotoxic T lymphocyte-
associated antigen 4; interleukins 2 and 21; interleukin-2
receptor A; Eos (or Ikaros family zinc finger 4); HLA;
genes expressed within the hair follicle, including PRDX5
and STX17; and the ULBP (cytomegalovirus UL16-binding
protein) gene cluster on chromosome 6q25.1, encoding acti-
vating ligands of the natural killer cell receptor NKG2D.
Using an Immunochip, Redler et al discovered that the
strongest associations were observed for variants of the major
histocompatibility complex class II DQ beta 1 (HLA-DQB1)
and class II DQ alpha 2 (HLA-DQA2).
Examples of SNPs
associated with AA in genes that regulate T-cell function
include the promoter regions of Foxp3 and ICOSLG, and
the CTLA4 CT60 polymorphism.
Most recently, Betz
et al discovered three novel loci: ACOXL/BCL2L11(BIM)
(2q13); GARP (LRRC32) (11q13.5); and SH2B3(LNK)/
ATXN2 (12q24.12).
Discussion and conclusion
This systematic review provides a summary of the existing
data on the worldwide incidence and prevalence of AA and
its burden. Comparison between studies was attempted in
relation to geography, age, and sex. Generally, a concern with
the population studies is that their sample from a population
register may not be representative of the true population at
risk of AA. In fact, both population studies cited in the cur-
rent review were based in Minnesota.
However, there are
also concerns that hospital-based studies may fail to provide
an unbiased sample of the population at risk with respect to
exposure status. These concerns aside, our literature search
found that the estimated incidence of AA was approximately
2% in the population studies and close to 2% in hospital-
based studies globally (Table 1).
There is no clear conclusion about whether the disease
varies according to sex. There appears to be no significant
difference in the incidence of AA between males and
females as both formal population studies found none,
and hospital-based studies are mixed in citing a female vs
male predominance.
Again, hospital-based
studies depend on access to care, and in some cases, willing-
ness to participate in the study, which may bias the results.
Most patients experience their first onset of AA by
age 40 years, with a peak of incidences occurring in their
20s and 30s (Table 2).
The younger the age
of onset, the greater the lifetime likelihood of extensive
Access to care and delay in presentation
may also play a role in the age distribution seen. Family
history of AA is present in a minority of patients with AA,
and is seen more often in patients who present with AA as
The scalp is involved with or without involvement of
other body sites in almost all cases of AA, with the occipital
scalp being the most commonly involved site.
involvement can be seen in severe AA and is a poor prog-
nostic factor.
The Global Burden of Disease Study, which estimates the
DALYs for AA to be 1,332,800, or a weighted 0.035, may
underestimate the true population-based prevalence and dis-
ease burden due to patients with AA who do not present for
Furthermore, it considers the disability imposed by itch
and disfigurement, but does not take into account emotional
distress, interpersonal relationships, or financial impact.
AA leads to decreased QOL in half of its sufferers and is
associated with an approximately 70% lifetime prevalence of
psychiatric disorders, most commonly depression, anxiety,
and adjustment disorders.
It has even been implicated
in suicide.
In about half of patients, however, psychiatric
disorders presented earlier than AA, and in a portion of cases,
stressful events were recalled preceding hair loss.
AA appears to be associated with atopy and many
autoimmune diseases including vitiligo and thyroid
Some studies did not find
association with autoimmune diseases.
association studies, however, implicate genes in the HLA
region and genes involved in inflammation and immune
modulation in AA, many of which could plausibly affect
multiple autoimmune conditions.
Discrepancies in the
incidence of associated conditions seen in Table 4 may, in
part, be due to differences in the prevalence of atopy and
autoimmune diseases across the globe and over time.
Extensive AA leads to greater disfigurement and psycho-
social distress. Factors that increase the likelihood of exten-
sive AA such as alopecia totalis and/or universalis include:
younger age of onset; associated autoimmune or atopic
disease, particularly thyroid disease and atopic dermatitis;
nail changes; Down syndrome; positive family history of
vitiligo; and positive family history of AA.
In conclusion, studies on the occurrence of AA have
contributed to a greater appreciation of the disease burden.
Clinical, Cosmetic and Investigational Dermatology 2015:8
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Villasante Fricke and Miteva
The estimated high prevalence of 2% globally underscores
the importance of disease awareness, of unveiling the role
of genomics in influencing the likelihood of developing AA,
and of discovering potential molecule-oriented treatments.
Yet, epidemiological studies on AA are limited, and no clear
conclusions can be drawn. Possible sources of heterogeneity
in research results arise from 1) the different methodologies
utilized to collect the data: hospital-based medical records,
insurance databases, registries, or primary care databases,
which may under-represent patients with no access to health
care; and/or 2) case definition: self-diagnosis, primary care
physician’s diagnosis or dermatologist’s diagnosis of AA.
There is a need for international research collaborations using
standardized methodology to address those knowledge gaps.
The authors report no conflicts of interest in this work.
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... The disorder can affect one or more discrete, well-circumscribed patches of hair loss on the scalp or body, or it can affect the entire scalp or body (alopecia totalis) (alopecia universalis). The global lifetime prevalence of Alopacia areata is around 2% [1] . It affects people of all ages and both sexes. ...
... [2] In our study, the most common age group affected was 20-40 years (70%) which was in concurrence with the study done by Tan et al. and Bhat et al. [6,7] The mean age of onset has been reported as between 25.2 and 36.3 years in various studies done in other parts of the world. [8] Similar to our study, the scalp was found to be the most common site involved, with or without involvement of other body sites. [6,9] Bhat et al. [7] Trace element levels in alopecia areata Statistically significant low zinc levels in alopecia areata patients, but no significant change was observed in copper and magnesium levels. ...
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Objectives (1) The objectives of the study are as follows: To study serum zinc levels in patients with alopecia areata. (2) To study the correlation between serum zinc levels and severity of alopecia areata. Material and Methods A hospital-based and cross-sectional study was conducted in our out-patient Department of Dermatology and STD. All new cases of alopecia areata were included in this study. The patients with clinical features of Systemic Lupus Erythematosus and other autoimmune disorders were excluded from the study. After obtaining a detailed history and examination and confirmation by hair pull test and dermoscopy, the severity of alopecia was graded by Severity of Alopecia Tool score and gauging score. Serum zinc levels of the patients were then measured by calorimetric method. Results A total of 88 cases who met the criteria were chosen. Majority of patients were between 20 and 40 years of age with a male preponderance. Patchy pattern of alopecia was the most common pattern noted with scalp being the most commonly involved site. Serum zinc was deficient in around 52.2% of cases. Most of the patients had mild alopecia areata. No significant association was noted between serum zinc levels and alopecia areata. Furthermore, there was no correlation between the severity of alopecia areata and serum zinc levels. Conclusion In our study, no association was noted between serum zinc levels and alopecia areata. Furthermore, the severity of alopecia areata did not correlate with serum zinc levels.
Importance: Alopecia areata (AA) is characterized by nonscarring hair loss of the scalp, face, and/or body. Alopecia totalis (AT) and alopecia universalis (AU) involve complete loss of the scalp and body hair, respectively. The epidemiology of AA in the US remains unclear, having previously been extrapolated from older studies that were limited to specific geographic areas or clinical settings, or from self-reported data. Objective: To estimate the annual prevalence and incidence of AA and AT and/or AU (AT/AU) in the US. Design, setting, and participants: This retrospective, population-based cohort study was conducted from January 2016 to December 2019 and included enrollees in the IBM MarketScan Commercial Claims and Encounters and Medicare Supplemental databases and their dependents, with plan enrollment during each study calendar year and the year prior. Exposures: Prevalent cases were identified by 1 or more claims for AA or AT/AU (International Statistical Classification of Diseases, Tenth Revision, Clinical Modification [ICD-10-CM] codes L63.x, L63.0, L63.1) during each year of interest or the year prior. Incident cases were identified by 1 or more claims for AA or AT/AU during a specific year and no diagnosis the year prior. Main outcomes and measures: Annual incidence and prevalence rates were calculated and stratified by age, sex, and region. National employer-sponsored insurance population estimates were obtained using population-based weights. Results: Among eligible patients (2016: n = 18 368 [mean (SD) age, 40.6 (17.9) years; 12 295 women (66.9%)]; 2017: n = 14 372 [mean (SD) age, 39.6 (17.7) years; 9195 women (64.0%)]; 2018: n = 14 231 [mean (SD) age, 38.9 (17.3) years; 8998 women (63.2%)]; 2019: n = 13 455 [mean (SD) age, 39.1 (17.4) years; 8322 women (61.9%)]), AA prevalence increased from 0.199% (95% CI, 0.198%-0.200%) in 2016 to 0.222% (95% CI, 0.221%-0.223%) in 2019. Roughly 5% to 10% of prevalent and incident cases of AA were AT/AU. The prevalence of AT/AU increased from 0.012% (95% CI, 0.012%-0.013%) to 0.019% (95% CI, 0.018%-0.019%) from 2016 to 2019. Incidence of AA per 100 000 person-years ranged from 87.39 (95% CI, 86.84-87.96) in 2017 to 92.90 (95% CI, 92.35-93.45) in 2019. Incidence of AT/AU ranged from 7.09 (95% CI, 6.94-7.25) in 2017 to 8.92 (95% CI, 8.75-9.09) in 2016. Prevalence and incidence of AA and AT/AU were higher among female vs male individuals, adults vs children and adolescents, and in the Northeast vs other regions. Conclusions and relevance: The results of this cohort study suggest that these recent AA prevalence and incidence estimates could help improve current understanding of the disease burden. Further research is warranted to elucidate subpopulation differences and trends in AA in the broader US population.
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Type 1 Diabetes Mellitus (T1DM) is a common hyperglycemic disease characterized by the autoimmune destruction of insulin-producing beta cells of the pancreas. Various attempts have been made to understand the complex interplay of genetic and environmental factors which lead to the development of the autoimmune response in an individual. T1DM is frequently associated with other autoimmune illnesses, the most common being autoimmune thyroid disorders affecting more than 90% of people with T1D and autoimmune disorders. Antithyroid antibodies are present in around 20% of children with T1D at the start of the illness and are more frequent in girls. Patients with T1DM often have various other co-existing multi-system autoimmune disorders including but not limited to thyroid diseases, parathyroid diseases, celiac disease, vitiligo, gastritis, skin diseases, and rheumatic diseases. It is a consistent observation in clinics that T1DM patients have other autoimmune disorders which in turn affect their prognosis. Concomitant autoimmune illness might affect diabetes care and manifest itself clinically in a variety of ways. A thorough understanding of the complex pathogenesis of this modern-day epidemic and its association with other autoimmune disorders has been attempted in this review in order to delineate the measures to prevent the development of these conditions and limit the morbidity of the afflicted individuals as well. The measures including antibody screening in susceptible individuals, early identification and management of other autoimmune disorders, and adoption of personalized medicine can significantly enhance the quality of life of these patients. Personalized medicine has recently gained favor in the scientific, medical, and public domains, and is frequently heralded as the future paradigm of healthcare delivery. With the evolution of the ‘omics’, the individualization of therapy is not only closer to reality but also the need of the hour.
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Autoimmune diseases often present with cutaneous symptoms that contribute to dysfunction, disfigurement, and in many cases, reduced quality-of-life. Unfortunately, treatment options for many autoimmune skin diseases are limited. Local and systemic corticosteroids remain the current standard-of-care but are associated with significant adverse effects. Hence, there is an unmet need for novel therapies that block molecular drivers of disease in a local and/or targeted manner. Granzyme B (GzmB) is a serine protease with known cytotoxic activity and emerging extracellular functions, including the cleavage of cell–cell junctions, basement membranes, cell receptors, and other structural proteins. While minimal to absent in healthy skin, GzmB is markedly elevated in alopecia areata, interface dermatitis, pemphigoid disease, psoriasis, systemic sclerosis, and vitiligo. This review will discuss the role of GzmB in immunity, blistering, apoptosis, and barrier dysfunction in the context of autoimmune skin disease. GzmB plays a causal role in the development of pemphigoid disease and carries diagnostic and prognostic significance in cutaneous lupus erythematosus, vitiligo, and alopecia areata. Taken together, these data support GzmB as a promising therapeutic target for autoimmune skin diseases impacted by impaired barrier function, inflammation, and/or blistering.
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Alopecia areata (AA) is an autoimmune condition characterized by patchy, nonscarring hair loss. Few studies of AA have adequately included participants from underrepresented groups when evaluating the burden of AA in the United States. We conducted a cross-sectional study of personal/demographic factors and AA using the ongoing All of Us (AoU) Research Program. AoU enrolls adults over 18 years either as direct volunteers or through participating Health Care Provider Organizations by prioritizing recruiting underrepresented groups. We linked data from surveys and electronic health records (EHRs) to estimate the prevalence of AA by race/ethnicity, physical disability, sexual orientation/gender identity (LGBTQIA +), income, and education. The latest AoU release (version 5) includes 329,038 participants. Average age was 51.8 years (standard deviation, SD 16.7), and 60.2% of participants were female. Of these, 251,597 (76.5%) had EHR data and 752 were diagnosed with AA (prevalence, 0.30%; 95% CI 0.28–0.32). We used multivariate logistic regression adjusted for age and other factors to estimate the odds ratio (OR) and 95% confidence intervals (CIs) for prevalence of AA. Compared to Whites, Blacks and Hispanics had higher odds of AA (OR, 1.72; 95% CI 1.39–2.11 and OR, 2.13; 95% CI 1.74–2.59, respectively). Lower odds of AA were observed in participants with less than a high school degree (OR, 0.80; 95% CI 0.59–1.08), household income ≤ $35,000 (OR, 0.67; 95% CI 0.54–0.83), and no health insurance (OR 0.35; 95% CI 0.20–0.56). In this diverse population of US adults, participants with skin of color had higher prevalence of AA. Lower prevalence of AA among individuals with lower education and income levels and those lacking health insurance may reflect limited access to dermatologic care and potentially higher levels of undiagnosed AA in these groups.
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The textile industry is considered the second most polluting industry in the world. Synthetic non�biodegradable petroleum-based dyes and toxic mordants play a major part in this pollution. Almost 20% of global water pollution has been associated with the textile dyeing practices. These controversies with the current environmental regulations, lead to a great demand for natural colors in food, pharmaceuticals, cosmetics, textiles and in the printing dye industry. Recently, microbial pigments have been shown to be a promising alternative not only to synthetic dyes, but also to other biopigments derived from vegetables or animals as they are viewed as natural, non-toxic, have no seasonal production issues, offer excellent productivity, economical and most important they are ecofriendly. An environmental screening of 77 samples was carried out for pigment production. Pigmented bacteria represented 55 (68%) of total samples with the highest percentage of pigmented bacteria found in air samples and the lowest percentage from water samples. Five potential pigmented isolates were chosen for pigment extraction and used for dyeing three types of fabrics - nylon, wool, and polyester. Furthermore, stability of dyes following treatment with acid, alkaline and detergents was studied to investigate the retention of dyes. Bacterial pigments in some unmordanted fabrics were retained 100% in cases of acid treatments while a small amount of discoloration was observed when subjected to alkali, or cold water and detergent. Apart from colorant, Serratia marcescens pigments demonstrated antibacterial activity against gram positive bacteria. The current study demonstrated that coloring ability of the natural dyes can be compared to that of the synthetic dyes. Furthermore, these biochromes are also able to produce various shades similar to those of the synthetic dyes and express variable resistance to treatment with acid, alkaline and detergents.
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The genus Salmonella consists of more than 2570 antigenic types. Salmonella Paratyphi A, B, C and Salmonella typhi are known to be non-lactose fermenters and the cause of typhoid fever. The present study aimed to implement molecular (polymerase chain reaction PCR) and routine bacteriological methods to identify 5 Salmonella isolates; 3 clinical and 2 foodborne isolates (obtained from poultry) in Mosul city. Primary biochemical reactions indicated a tentative identification of the bacteria as Salmonella spp. All isolates were identified using selective media (MacConkey, Salmonella-Shigella and XLD agar) in addition to gram stain, and the biochemical tests (Oxidase, Indole, Urease, Citrate utilization, and Triple Sugar Iron agar reaction). Identification was confirmed using molecular genome with PCR. DNA was extracted directly from each sample and amplified using Salmonella- specific primers. We hereby report an unusual case of two unusual lactose fermenting strains of Salmonella, one clinical and the others from a poultry sampling. Lactose fermenting Salmonellae cultured on MacConkey agar appeared as pink colonies following a 24 hrs. incubation period at 37 ° C. Prolonged incubation (i.e. 48 hrs.) resulted in the appearance of transparent colonies. There were no former reports, as far as we know on such lac+ Salmonella strains in Mosul city. Isolation of lactose fermenting Salmonellae is critically vital because it could be overlooked or misdiagnosed. Therefore, there is a need of awareness of such unusual Salmonellae that may be misidentified as other members of Enterobacteriaceae (Escherichia coli). Identification of Salmonellae by Molecular PCR has proved to be a more convenient method that could be completed within 24-36 hrs. as compared to 3-8 days by routine bacteriologic methods.
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Alopecia areata (AA) is a prevalent autoimmune disease with 10 known susceptibility loci. Here we perform the first meta-analysis of research on AA by combining data from two genome-wide association studies (GWAS), and replication with supplemented ImmunoChip data for a total of 3,253 cases and 7,543 controls. The strongest region of association is the major histocompatibility complex, where we fine-map four independent effects, all implicating human leukocyte antigen-DR as a key aetiologic driver. Outside the major histocompatibility complex, we identify two novel loci that exceed the threshold of statistical significance, containing ACOXL/BCL2L11(BIM) (2q13); GARP (LRRC32) (11q13.5), as well as a third nominally significant region SH2B3(LNK)/ATXN2 (12q24.12). Candidate susceptibility gene expression analysis in these regions demonstrates expression in relevant immune cells and the hair follicle. We integrate our results with data from seven other autoimmune diseases and provide insight into the alignment of AA within these disorders. Our findings uncover new molecular pathways disrupted in AA, including autophagy/apoptosis, transforming growth factor beta/Tregs and JAK kinase signalling, and support the causal role of aberrant immune processes in AA.
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Alopecia areata (AA) is a common autoimmune disease resulting from damage of the hair follicle by T cells. The immune pathways required for autoreactive T cell activation in AA are not defined limiting clinical development of rational targeted therapies. Genome-wide association studies (GWAS) implicated ligands for the NKG2D receptor (product of the KLRK1 gene) in disease pathogenesis. Here, we show that cytotoxic CD8(+)NKG2D(+) T cells are both necessary and sufficient for the induction of AA in mouse models of disease. Global transcriptional profiling of mouse and human AA skin revealed gene expression signatures indicative of cytotoxic T cell infiltration, an interferon-γ (IFN-γ) response and upregulation of several γ-chain (γc) cytokines known to promote the activation and survival of IFN-γ-producing CD8(+)NKG2D(+) effector T cells. Therapeutically, antibody-mediated blockade of IFN-γ, interleukin-2 (IL-2) or interleukin-15 receptor β (IL-15Rβ) prevented disease development, reducing the accumulation of CD8(+)NKG2D(+) T cells in the skin and the dermal IFN response in a mouse model of AA. Systemically administered pharmacological inhibitors of Janus kinase (JAK) family protein tyrosine kinases, downstream effectors of the IFN-γ and γc cytokine receptors, eliminated the IFN signature and prevented the development of AA, while topical administration promoted hair regrowth and reversed established disease. Notably, three patients treated with oral ruxolitinib, an inhibitor of JAK1 and JAK2, achieved near-complete hair regrowth within 5 months of treatment, suggesting the potential clinical utility of JAK inhibition in human AA.
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Background: Alopecia areata (AA) is a skin disease characterized by the sudden appearance of areas of hair loss on the scalp and other hair-bearing areas, but its aesthetic repercussions can lead to profound changes in patient's psychological status and relationships. Aim: The goal was to investigate a possible relationship between AA and alexithymia as well as two other emotional dimensions, anxiety and depression. Materials and Methods: Fifty patients with AA seen in the Department of Dermatology of Hedi Chaker University Hospital, Sfax were included in this study. Anxiety and depression were evaluated by Hospital Anxiety and Depression scale questionnaire, alexithymia was assessed by Toronto Alexithymia scale 20, and severity of AA was measured by Severity of Alopecia Tool. Results: Patient's mean age was 32.92 years. 52% of patients were females. Depression and anxiety were detected respectively in 38% and 62% of patients. There was statistically significant difference between patients and control group in terms of depression (P = 0.047) and anxiety (P = 0.005). Forty-two percent of patients scored positive for alexithymia. No significant difference was found between patient and control groups (P = 0.683) in terms of alexithymia. Anxiety was responsible for 14.7% of variation in alexithymia (P = 0.047). Conclusions: Our study shows a high prevalence of anxiety and depressive symptoms in AA patients. Dermatologists should be aware of the psychological impact of AA, especially as current treatments have limited effectiveness.
Background: Alopecia areata patients has recently increased in number. The clinical features and therapeutic results of alopecia areata are diverse and unpredictable. Objective: We, the authors, performed a study on alopecia areata in order to evaluate the clinical manifestations and compare the efficacies of treatment with intralesional injection of triamcinolone acetonide suspension, immunotherapy with diphenylcyclopropenone(DPCP), and photochemotherapy with psoralen plus UVA(PUVA). Methods: A clinical study of 732 patients with alopecia areata including 33 cases of alopecia totalis and 46 cases of alopecia universalis was performed for 5 years, since March, 1996 to February, 2001 who visited to Alopecia Clinic at the Department of Dermatology, Collage of Medicine, Chung-Ang University. Results: 1) The age distribution showed a peak incidence in the third decade(29.1%) and the mean age was 26.8 years and 136 cases(18.6%) showed alopecia areata in patients below 10 years old. 2) Previous episodes of alopecia were observed in 173 cases(23.6%) and 58 cases(7,9%) had family history of alopecia areata. 3) The most common site was the occipital region in both male and female patients, which were 251 cases(38.4%) and 218 cases(33.4%) respectively. 4) Associated diseases with alopecia areata included seborrheic dermatitis(97 cases), allergic contact dermatitis(25 cases), liver disease(22 cases), hypertension(18 cases), diabetes mellitus(16 cases), urticaria(16 cases), atopic dermatitis(14 cases) and thyroid disease(8 cases). 5) The efficacies of treatment modality had no statistical differences in DPCP immunotherapy, intralesional triamcinolone injection or photochemothrapy. Conclusion: There was no noticeable differences compared to previous studies on alopecia areata, except that increasing tendency of severe, recurrent, and refractory alopecia areata and number of childhood patients.
Abbreviations: AA, alopecia areata; FASLG, Fas ligand (TNF superfamily, member 6); GWA, genome-wide association; HLA-DQA2, MHC class II DQ alpha 2; HLA-DQB, MHC class II DQ beta; KIAA0350/CLEC16A, C-type lectin domain family 16, member A; MHC, major histocompatibility complex; OX40L, OX40 ligand; THADA, thyroid adenoma associated; TNF, tumor necrosis factor; TNFSF4, TNF (ligand) superfamily, member 4
Alopecia areata (AA) is a common, non-scarring dermatologic condition regularly distinguished by patches of hair loss on the scalp also manifesting in other, severe forms, including alopecia totalis (total loss of hair on the scalp) and alopecia universalis (complete loss of hair on the scalp and body). AA is a clinically heterogeneous disease with greatly varying yet typical symptoms, but the etiology for AA remains an enigma. However, clinical and experimental studies have pointed to autoimmune involvement, specifically regarding immune privilege sites of the hair follicles and the infiltration of CD4 + and CD8 + T cells and a predominant Th1 cytokine profile. Environmental insults, such as viral infections, trauma and genetic predisposition are also believed to contribute to the disease process. Multiple treatment options including the use of broad acting corticosteroids appear to be relative effective in mild cases, however the clinical management of more severe forms of AA is much more difficult. Recent studies suggest that intervention of the JAK pathway may have a potential therapeutic efficacy for AA.
Importance Research prioritization should be guided by impact of disease.Objective To determine whether systematic reviews and protocol topics in Cochrane Database of Systematic Reviews (CDSR) reflect disease burden, measured by disability-adjusted life years (DALYs) from the Global Burden of Disease (GBD) 2010 project.Design, Setting, and Participants Two investigators independently assessed 15 skin conditions in the CDSR for systematic review and protocol representation from November 1, 2013, to December 6, 2013. The 15 skin diseases were matched to their respective DALYs from GBD 2010. An official publication report of all reviews and protocols published by the Cochrane Skin Group (CSG) was also obtained to ensure that no titles were missed. There were no study participants other than the researchers, who worked with databases evaluating CDSR and GBD 2010 skin condition disability data.Main Outcomes and Measures Relationship of CDSR topic coverage (systematic reviews and protocols) with percentage of total 2010 DALYs, 2010 DALY rank, and DALY percentage change from 1990 to 2010 for 15 skin conditions.Results All 15 skin conditions were represented by at least 1 systematic review in CDSR; 69% of systematic reviews and 67% of protocols by the CSG covered the 15 skin conditions. Comparing the number of reviews/protocols and disability, dermatitis, melanoma, nonmelanoma skin cancer, viral skin diseases, and fungal skin diseases were well matched. Decubitus ulcer, psoriasis, and leprosy demonstrated review/protocol overrepresentation when matched with corresponding DALYs. In comparison, acne vulgaris, bacterial skin diseases, urticaria, pruritus, scabies, cellulitis, and alopecia areata were underrepresented in CDSR when matched with corresponding DALYs.Conclusions and Relevance Degree of representation in CDSR is partly correlated with DALY metrics. The number of published reviews/protocols was well matched with disability metrics for 5 of the 15 studied skin diseases, while 3 skin diseases were overrepresented, and 7 were underrepresented. Our results provide high-quality and transparent data to inform future prioritization decisions.
Alopecia areata (AA) is a common, non-scarring, autoimmune hair-loss disorder with a complex genetic and environmental etiology. A higher incidence rate of AA in the female population is well described. It is unclear why females are more likely to be diagnosed with AA and what, if any, differences in disease phenotype exist between males and females. The identification of gender specific characteristics of disease may help clinical management and patient education in cases of AA. Accordingly, we recruited 481 North-American Caucasian AA patients (336 female, 145 male) to assess age of onset, autoimmune and atopic co-morbidity, nail involvement, family history of AA and autoimmune disease, and disease subtype. There was a female predominance (female to male ratio 2.3:1) in this AA study population. We found that male AA patients are more likely to be diagnosed in childhood (age <10 years, P= 0.067) and have a family history of AA (P= 0.004). On the other hand, female AA patients are more likely to be diagnosed in adolescence (age 10-20 years, P= 0.083), have co-morbid nail involvement (P= 0.0257), and have concomitant autoimmune disease (P= 0.014), particularly thyroid disease (P= 0.058). The clinical implications of disease heterogeneity between males and females remains to be determined. J Drugs Dermatol. 2014;13(4):409-413.
Alopecia areata is a chronic inflammatory non-scarring condition affecting the hair follicle that leads to hair loss ranging from small well defined patches to complete loss of all body hair. In about 80% of affected individuals there is spontaneous regrowth within a year. It can present at any age, although 60% of patients develop their first episode of hair loss before the age of 20. There is a family history of alopecia areata in 20% of cases indicative of a genetic basis. A positive family history is prognostic of troublesome alopecia areata, as are onset in childhood, ophiasis (involvement of the scalp hair margins), nail changes and concurrent atopic disease. However, the severity of hair loss at presentation appears to be the strongest predictor of long-term outcome. There is an association with autoimmune diseases, including vitiligo, diabetes, pernicious anaemia and thyroid disease, suggesting that alopecia areata itself is an autoimmune disease, although this is still unproven. Alopecia areata normally presents with hair loss in discrete, well circumscribed patches, which may be small (<1 cm) to very large. Close examination of the periphery of a lesion with a magnifying glass will often reveal short hairs which taper in diameter from their tip to the point at which they emerge from the skin. These 'exclamation mark' hairs are diagnostic of alopecia areata. Individuals with alopecia areata should be referred for dermatological advice if there is diagnostic uncertainty, they have extensive hair loss, they are suffering severe psychological distress or they would like a wig.