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Table of Contents
ORIGINAL ARTICLE
Year : 2017  |  Volume : 14  |  Issue : 3  |  Page : 165-170

Frequency of alopecia areata in patients with autoimmune thyroid diseases


1 Department of Dermatology and Venereal Diseases, Faculty of Medicine, Hitit University, Çorum, Turkey
2 Department of Dermatology and Venereal Diseases, Faculty of Medicine, Yildirim Beyazit University, Ankara, Turkey
3 Dermatology Clinic, Lokman Hekim Hospital, Ankara, Turkey
4 Department of Family Medicine, Faculty of Medicine, Hitit University, Çorum, Turkey

Date of Web Publication27-Oct-2017

Correspondence Address:
Aynure Oztekin
Department of Dermatology and Venereal Diseases, Faculty of Medicine, Hitit University, Çorum
Turkey
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Source of Support: None, Conflict of Interest: None


DOI: 10.4103/am.am_16_17

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  Abstract 


Background: Alopecia areata (AA) is higher in patients with thyroid dysfunctions such as Hashimoto's thyroiditis and Graves' disease than in general population. Our aim was to assess AA frequency in patients with thyroid diseases. Materials and Methods: This prospective study included 550 patients with autoimmune thyroid disease (AITD), 126 patients with non-AITD (NAITD), and 100 healthy subjects. Results: Twenty-eight (4.1%) patients were diagnosed with AA based on either medical history or physical examination (P = 0.039). AA was not determined in healthy subjects. The rate of AA was higher among the patients with NAITD than those with AITD (5.6% vs. 3.8%; P = 0.075). Among the AITD patients, 5 (23.8%) patients were diagnosed with AA after being diagnosed with thyroid disease, whereas 15 (71.4%) patients were diagnosed with AA before being diagnosed with thyroid disease. The mean ages at the diagnosis of AITD and at the onset of AA were 36.6 ± 10.8 years and 30.3 ± 13.0 years, respectively. Among the NAITD patients, the mean ages at the onset of thyroid disease and at the onset of AA were 45.3 ± 9.3 years and 37.3 ± 13.3 years, respectively. Other autoimmune-based diseases such as vitiligo, chronic urticaria, and type 1 diabetes were also detected. The patchy pattern of AA was the most common type (n = 27). Conclusions: The frequency of AA was higher in patients with NAITD and AITD compared to the healthy population. Clinicians should be aware of these findings, and accordingly, it would be suitable for them to screen AA patients for thyroid diseases.

Keywords: Alopecia areata, autoimmune thyroiditis, hair loss, Hashimoto's thyroiditis, skin


How to cite this article:
Oztekin A, Metin A, Kirbas SC, Öztekin C. Frequency of alopecia areata in patients with autoimmune thyroid diseases. Apollo Med 2017;14:165-70

How to cite this URL:
Oztekin A, Metin A, Kirbas SC, Öztekin C. Frequency of alopecia areata in patients with autoimmune thyroid diseases. Apollo Med [serial online] 2017 [cited 2019 Jan 19];14:165-70. Available from: http://www.apollomedicine.org/text.asp?2017/14/3/165/217361




  Introduction Top


Autoimmune thyroid diseases (AITD), such as Hashimoto's thyroiditis (HT) and Graves' disease (GD), are the most common organ-specific autoimmune disorders.[1] These diseases are complex and multifactorial diseases that are characterized by the presence of antibodies against thyroid antigens, such as thyroid peroxidase, thyroglobulin, and thyroid-stimulating hormone receptor. The prevalence of AITD is about 5% in the developed countries.[2],[3]

Alopecia areata (AA) is a dermatological disorder characterized by sudden hair loss, which usually improves spontaneously without scarring. The prevalence of AA is approximately 0.1%–0.2%.[4] AA accounts for 0.7%–3.8% of all patients presented to dermatology clinics.[5],[6] AA has different clinical types such as patchy alopecia, alopecia reticularis, and alopecia totalis. The etiology and pathogenesis of AA are unclear. Nevertheless, the frequency of AA is higher in patients with thyroid dysfunction as compared to the general population.[7],[8] Therefore, AA may be associated with thyroid diseases.

Nowadays, there are studies demonstrating concurrent thyroid diseases in patients with AA;[7],[8],[9],[10],[11] however, the number of studies assessing the frequency of AA in patients with thyroid diseases is limited.[12] The aim of the present study was to assess the frequency of AA among patients with thyroid diseases.


  Materials and Methods Top


The present study was performed prospectively at the Department of Endocrinology and Metabolism of the Ankara Ataturk Training and Research Hospital between April 2011 and February 2012. The present study was approved by the Local Ethics Committee (Approval Number: 2011.04.21). The participants were informed about the study, and their written informed consents were obtained prior their inclusion in the study. All procedures followed were in accordance with the ethical standards of the responsible committee on human experimentation (institutional and national) and with the Declaration of Helsinki, 1975 as revised in 2008.

The present study included 550 patients with AITD and 126 patients with non-AITD (NAITD), who were admitted to our endocrinology clinic, and 100 healthy volunteers. The NAITD group included the patients with other thyroid diseases; however, these patients were not classified according to their diagnosis. Only the diagnoses of the AITD patients regarding thyroid diseases were recorded. The control group was selected from volunteer healthcare staff who had no thyroid disease and/or family member with thyroid disease and/or history of thyroid disease both in themselves and their families. Data regarding sociodemographic characteristics and diagnosis of AITD were obtained from the database. The patients diagnosed with AA based on their medical history or physical examinations were questioned about age at disease onset and localization and type of AA. Moreover, poor prognostic factors such as extensive involvement, autoimmunity conditions, and onychodystrophy were also investigated.

Statistical analysis

Statistical analyses were performed using the Statistical Package for the Social Sciences program (SPSS Inc., version 17.0, Chicago, IL, USA). The Shapiro–Wilk test was used to test the normal distribution of the data. Descriptive analyses were expressed as median for ordinal and nonnormally distributed variables or as mean for normally distributed numerical variables. Statistical comparisons were performed using Chi-square test, Fisher's exact test, Mann–Whitney U-test, Student's t-tests, one-way analysis of variance, and Kruskal–Wallis test, depending on the type of variables and number of groups. A P< 0.05 was considered statistically significant.


  Results Top


In the present study, the data of 676 patients with thyroid diseases (550 with AITD and 126 with NAITD) and 100 healthy volunteers were evaluated. The distributions of age and gender were similar among the groups. Two different types of AITD including HT (86%) and GH (14%) were observed. The mean ages of the patients with HT and GD were similar, and the rate of females was higher among both HT and GD patients. The general characteristics of the study population are presented in [Table 1].
Table 1: Distribution of age and gender among the study groups

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Twenty-eight (4.1%) patients were diagnosed with AA based on either medical history or physical examination performed during the patient visits. These patients with AA were those who had either AITD or NAITD. AA was not determined in healthy subjects. There was a significant difference between the healthy subjects and patient groups regarding the diagnosis of AA (P = 0.039). There was no significant difference between the patients with NAITD and AITD in terms of the rate of AA (5.6% vs. 3.8%, P = 0.075). The diagnosis was established based on the medical history in 24 patients with AA. Only four patients were diagnosed based on the physical examination findings during the patient visits and all had HT. AA diagnosis duration between the groups is illustrated in [Table 2].
Table 2: Diagnosis duration of alopecia areata in the patients with thyroid dysfunction

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The mean age at the diagnosis of AITD was 36.6 ± 10.8 years, and the mean age at the onset of AA was 30.3 ± 13.0 years. The mean age at the onset of thyroid disease was 45.3 ± 9.3 years, and the mean age at the onset of AA was 37.3 ± 13.3 years in the patients with NAITD. The relationship between onset of AA and onset of thyroid disease among the groups is presented in [Table 3].
Table 3: Onset of alopecia areata according to the onset of thyroid diseases

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There was no significant difference between the patients with AITD and NAITD regarding the types of AA. Scalp was the most common localization. The types of AA are presented in [Table 4]. Other comorbid diseases associated with thyroid diseases and other accompanying autoimmune diseases in the patients with AA are presented in [Table 5] and [Table 6]. Poor prognostic factors in the patients with AA are summarized in [Table 7]. The most common poor prognostic factors in the patients with AA were the history of autoimmune disease, onychodystrophy, and history of atopy.
Table 4: Types of alopecia areata in the present study

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Table 5: Distribution of comorbid diseases according to thyroid disease groups

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Table 6: Distribution of other autoimmune related diseases with alopecia areata according to thyroid disease groups

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Table 7: Distribution of poor prognostic factors of patients with alopecia areata according to thyroid disease groups

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  Discussion Top


Although the majority of patients with AA are young, the disease is encountered in all age groups. However, the prevalence of the disease is the highest between the 2nd and 4th decades of life and equal in males and females. AA is a chronic disease usually characterized by episodic and recurrent patterns. The diagnosis is based on inspection. The etiology and pathophysiology of AA are unclear; however, many evidence suggests that AA may be encountered alone or together with an autoimmune disease characterized by T-cell infiltration.[7] Autoimmune diseases, particularly AITD, may be associated with AA.[7],[8] To the best of our knowledge, the number of studies on the frequency of AA in patients with AITD and NAITD is limited.[12]

Although the pathogenesis of AITD is unclear, certain factors are responsible for the development of autoimmunity.[13] These factors include genetic factors, immune defects, hormonal factors, and environmental factors such as infectious agents and vaccines.[14] Likewise, genetics and autoantigens are also considered responsible for the pathogenesis of AA.[15],[16],[17] AA, which is characterized by perifollicular T-cell infiltrates and cytokine production around the hair follicles that are in the anagen phase,[18],[19] is also associated with Class I and II human leukocyte antigen (HLA) as is in the other autoimmune diseases.[20],[21] These autoimmune disorders include type 1 diabetes mellitus, thyroiditis, rheumatoid arthritis, vitiligo, systemic lupus erythematosus, and pemphigus vulgaris.[12],[22],[23],[24],[25] It has been reported that the prevalence of AA is increased among patients with autoimmune diseases.[26],[27] Consequently, the relation between HLA Class II antigens and autoimmune diseases, response of patients with AA to immunosuppressive therapies, and frequency of AA being high in autoimmune diseases are significant evidence that supports the relation of AA with autoimmune diseases.[18],[28],[29],[30] In the present study, while vitiligo (14.3%), chronic urticaria (4.8%), and type 1 diabetes mellitus (4.8%) were other autoimmune-related diseases in AA patients with AITD, chronic urticaria (14.3%) and rheumatoid arthritis (14.3%) were autoimmune-related diseases in the AA patients with NAITD.

Although most of the studies evaluating the coexistence of AITD and AA are the studies that comprise AA patients, there is limited number of studies on the frequency of AA in patients with thyroid disease.[9],[10],[11],[12],[31],[32] In the studies performed on AA patients, the incidence of thyroid disease has been found between 0% and 28%.[7],[11],[15],[27],[33],[34],[35],[36],[37],[38] Kılınçet al.[31] reported the rate of coexistence of AA and AITD as 13.6%. Studies evaluating thyroid antibody positivity in AA patients have reported the rate of antibody positivity between 26% and 29%.[9],[39] In one of the studies performed on thyroid patients, AA was determined in 1.9% of the cases.[40] In other studies, this rate was reported to be 3.1%,[12] 6.34%,[41] and 22%.[42] In the present study, the frequency of AA was 4.1% in the patients with thyroid diseases including AITD and NAITD. However, AA was not determined in healthy controls. The reason for this finding might be the selection of healthy controls from a population that has a less risk of having AA. The frequency of AA was found to be higher in the patients with NAITD (5.6%) than in the patients with AITD (3.8%). This result might suggest that AA is not only related to autoimmunity but also related to the thyroid dysfunction. In addition, this might also suggest that there were some additional factors increasing the risk of AA in the NAITD group. In the NAITD group, the higher frequency of AA, presence of other comorbid autoimmune diseases, and higher mean age of the patients as compared to the other groups, even without statistically significant difference, might all be the increasing factors for the frequency of AA.

In the present study, most of the patients (71.4%) were diagnosed with AA before being diagnosed with AITD. The diagnosis of AA was established after the diagnosis of AITD in 5 (23.8%) patients. AA and AITD were simultaneously diagnosed in only one patient. The mean age at diagnosis was 30.3 ± 13.0 years in the patients with AA; however, the mean age at the onset of AITD was 36.6 ± 10.8 years. According to the literature review, although AA is encountered in all ages, it is commonly seen below the age of 20 years. Its prevalence reaches to the highest level between the 2nd and 4th decades of life.[43] In the studies conducted in Turkey, the age at the onset of disease was found to be between 16 years and 40 years in 72.8% of the cases in the study by Kılınçet al.[31] and above 18 years in 59.2% of the cases in the study by Kavaket al.[44] In different studies, the age at the onset of AA has been reported to change between 20 years and 32 years.[5],[23],[34],[39],[45] Similarly, in the present study, the age at the onset of AA was between 20 years and 40 years in the AITD group and mostly between 30 years and 40 years in the NAITD group. However, while the mean age at the onset of AA was 30 years in the AITD group, it was 37 years in the NAITD group. It was considered that this difference might be associated with autoimmunity. To our knowledge, there is no information in the literature about the age at the onset of AA in patients with AITD. Nevertheless, some studies in patients with AA have failed to establish an association between the age at the onset of AA and autoimmune diseases.[33],[46] Chuet al.[45] performed a study on 4334 cases and reported that AITD was significantly more common in the group that developed AA between the ages of 21 years and 50 years; however, they provided no information about the age at the onset of AITD.

Patchy AA is the most common type of AA.[24],[47],[48] In the previous studies, the frequency of patchy AA among patients with AA has been determined between 23% and 86%.[9],[11],[31],[39],[46] In the present study, all AA patients were diagnosed with patchy AA, except for one patient with ophiasis pattern of AA who had GD. The pattern of hair loss in the patients of the present study was different from that reported in the literature and the patchy pattern (96.4%) was more common in the present study. This rate was reported to be 43.9% by Seyrafiet al.[39] and 86% by Gönület al.[46] In the study by Gönület al.,[46] of the AA patients, 46% had multiple patchy lesions and 42% had a single patchy lesion. In another study,[9] the rate of single patchy type was found to be 23%, whereas the rate of multiple patchy types was found to be 63%. In the present study, with regard to the number of lesions, it was striking that multiple patchy lesions were more common in the patients with NAITD and single patchy lesions were more common in the AITD group (71.4% and 52.4%, respectively). This finding suggested that the development of multiple lesions would be higher in those with NAITD.

In the present study, the most frequent poor prognostic factor among AA patients was the presence of autoimmune disease. The other poor prognostic factors included onychodystrophy, history of atopy, and family history of AA. When the patients with AA were questioned in terms of the presence of atopic diseases such as atopic dermatitis, asthma, and allergic rhinitis, it was striking that 32.1% of them had any of the poor prognostic factors. In the literature, it has been expressed that atopic disease accompanies AA by 10%–60% and it has been accepted that atopic diseases might be more frequent and severe in AA patients as compared to the general population.[6],[19],[23],[32],[49],[50] In their study, Chuet al.[45] reported the presence of an atopic disorder in 24.9% of their AA patients, of whom 5% had atopic dermatitis, 5.7% had asthma, and 14.3% had allergic rhinitis.

There are some limitations in the present study. First, the number of patients in the NAITD group and the number of healthy volunteers were smaller than the number of patients in the AITD group. Second, the data of the present study were obtained by questioning the patients and by physical examinations in the outpatient clinic. The patients with thyroid diseases were examined only once, and the presence of AA was evaluated for the period before and during the patient visits. Prospective evaluation of AA was not performed. Accordingly, these may be lead to a bias in our findings.


  Conclusions Top


Our findings revealed that the frequency of AA was increased in the patients with thyroid diseases and that this frequency was higher in the patients with NAITD than in those with AITD. In addition, it was observed that, in general, the onset of AA was earlier than the onset of thyroid diseases in the patients having thyroid diseases and AA. We are in the opinion that clinicians should be aware of these findings, and accordingly, it would be suitable for them to screen AA patients for thyroid diseases.

Financial support and sponsorship

Nil.

Conflicts of interest

There are no conflicts of interest.



 
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    Tables

  [Table 1], [Table 2], [Table 3], [Table 4], [Table 5], [Table 6], [Table 7]



 

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