Alopecia totalis in a patient with Crohn's disease and its treatment with azathioprine

The Association between Alopecia and Inflammatory Bowel Disease: A Systematic Review and Meta-Analysis

IMPORTANCE

The link between autoimmune gut disorders and different types of hair loss conditions has been recently investigated with an increased interest. With acknowledgement of the connection between immune dysregulation and the gut microbiome, this pathway is now becoming recognized as playing an important role in hair growth. The inflammatory cascade that results from the disruption of gut integrity such as seen in inflammatory bowel diseases (IBD) has been associated with certain types of alopecia.

OBJECTIVE

The aim of this work was to evaluate the association between alopecia and IBD.

EVIDENCE REVIEW

A primary literature search was conducted using the PubMed, Embase, and Web of Science databases to identify articles on co-occurring alopecia and IBD from 1967 to 2020. A total of 79 studies were included in the review. A one-way proportional meta-analysis was performed on 19 of the studies to generate the pooled prevalence of alopecia and IBD.

FINDING

The pooled prevalence of non-scarring alopecia among IBD patients was 1.12% (k = 7, I2 = 98.6%, 95% CI 3.1-39.9); the prevalence of IBD among scarring and non-scarring alopecia was 1.99% (k = 12; I2 = 99%, 95% CI 6.2-34). The prevalence of non-scarring alopecia areata (AA) among IBD was compared to the prevalence of AA in the general population (0.63 vs. 0.1%; p < 0.0001). Similarly, the prevalence of IBD among the scarring and non-scarring alopecia groups was compared to the prevalence of IBD in the general population (1.99 vs. 0.396%; p = 0.0004).

CONCLUSION

IBD and alopecia, particularly AA, appear to be strongly associated. Dermatology patients with alopecia may benefit from screening for IBD.

Alopecia Universalis Associated with Ulcerative Colitis and The Role of Azathioprine

Skin manifestations can herald, co-exist, or follow the evolution of inflammatory bowel disease (IBD). We report a middle-aged man with recent onset alopecia universalis and a history of intermittent diarrheal attacks for 6 years. Colonscopy and biopsy sampling confirmed ulcerative colitis. Regrowth of hair was achieved by treating the patient with azathioprine and mesalamine. Clinicians have to be aware that a multitude of skin manifestations with history of diarrhea can be an extraintestinal manifestation of IBD such as ulcerative colitis and this warrants further investigation.

Low-Dose Systemic Methotrexate Therapy for Recalcitrant Alopecia Areata

Background

Alopecia areata (AA) is an autoimmune skin disease difficult to manage and treat. The pathogenesis of AA features a T-cell-associated autoimmune process, and systemic immunosuppressive therapy is prescribed widely for AA.

Objective

To evaluate the efficacy and tolerance of systemic low-dose methotrexate (LD-MTX) therapy in treatment of recalcitrant AA multiplex.

Methods

In a retrospective, non-controlled study, we evaluated 29 patients with recalcitrant AA treated with LD-MTX and assessed the therapeutic response according to severity of disease, disease duration, cumulative dose of MTX, and drug safety.

Results

MTX was administered twice weekly, and the mean maximum weekly dose was 14.48 mg. The response was A5 (regrowth=100.0%) in 14 (48.3%) patients and A4 (regrowth of 75%~90%) in 12 (41.4%) patients. Three patients had poor response to LD-MTX treatment (A2: n=2 [6.9%], A1: n=1 [3.4%]). All three of the patients showing a poor response had disease durations exceeding 24 months. Relapse was observed in 31% of patients with more than 75% regrowth. Common side-effects were elevated liver enzyme levels and gastrointestinal discomfort.

Conclusion

LD-MTX appears to be an effective and well-tolerated treatment for recalcitrant AA multiplex.

Symptom management in inflammatory bowel disease

Patients with inflammatory bowel disease can present with a wide variety of symptoms. Most are related to disease activity and should be managed with appropriate medical therapy for inflammatory bowel disease. However, some patients may develop symptoms due to the side effects of the medications, or due to immunosuppression. In these cases, the offending medications should be discontinued until resolution of the symptoms and a few may be able to restart therapy. Symptoms can also occur as an extraintestinal manifestation of the disease or due to concomitant autoimmune-mediated disorders. Regardless of the etiology, symptoms should be addressed promptly with immediate evaluation and appropriate therapy, as a delay may lead to permanent sequela.

Autoimmune polyglandular syndrome type 2, alopecia universalis and Crohn's disease

Autoimmune polyglandular syndromes are defined as a spectrum of association between 2 or more organ specific endocrinopaties and non-endocrine autoimmune diseases. Autoimmune polyglandular syndromes type 2 is characterized by the coexistence of adrenal failure with autoimmune thyroid disease and diabetes mellitus type 1. Inflammatory bowel diseases are rarely associated with these autoimmune disorders. Here, we report about a case of 33 years old male with known history of Crohn's colitis diagnosed in childhood. In 2003 the patient experienced sudden loss of hair, eyebrows, eyelashes, beard and body hair - alopecia universalis was diagnosed. At the age of 28, the patient was hospitalized with severe dehydration and clinical signs of ketoacidosis. Increased blood glucose (40 mmol/L), ketonuria and metabolic acidosis indicated diabetes mellitus type 1. In 2005, he had severe relapse of Crohn's disease and was treated with systemic corticosteroid. Although patient responded well to the induction therapy, fatigue, hypotension, bradycardia called for further investigations: free thyroxine - 6.99 pmol/L, thyroid-stimulating hormone >75 U/ml, anti-thyroid peroxidase antibodies >1000 U/mL, so diagnosis of Haschimoto thyroiditis was confirmed. Persistent hypotension and fatigue, recurrent hypoglycemic crises indicated a possible presence of hypo-function of adrenal glands. After complete withdrawal of corticosteroid therapy, low cortisol levels (69.4 nmol/L) and positive tetracosactide stimulation test proved adrenal cortex failure. Regardless of the intensive treatment for diabetes, hypothyroidism, adrenal insufficiency and Crohn's disease, it was extremely difficult to achieve and maintain control of all four diseases.

Severe myelosuppression following alopecia shortly after the initiation of 6-mercaptopurine in a patient with Crohn's disease

A 15-year-old, woman, Crohn's disease patient, who carried the TPMT *3C heterozygous mutant, complained of alopecia 3 days after starting 6-mercaptopurine (6-MP) and then developed severe myelosuppression 6 weeks after starting 6-MP. The alopecia involved scalp hair only (body hair preserved) and was dominant in the temporal region. Following these side effects, transient remission of Crohn's disease occurred. Myelosuppression due to 6-MP is a rare but life-threatening side effect that is difficult to predict despite continuous monitoring of complete blood cell counts. In the present case, 6-MP-induced alopecia preceded myelosuppression and progressed rapidly as the myelosuppression worsened.

Treatment of alopecia areata

Some individuals question whether any treatment is effective in severe alopecia areata. Certainly many patients, especially those with mild disease, experience spontaneous hair regrowth; however, results of double-blind studies clearly indicate that some treatments do promote hair regrowth even in those with extensive disease. Some patients never show either spontaneous or treatment-related hair regrowth; others experience hair regrowth only while maintained on treatment, repeatedly losing hair within a few weeks of discontinuing treatment and regrowing it within several weeks after restarting treatment. Some patients who have been responsive to treatment may experience exacerbation of their disease such that even high-dose systemic steroids do not prevent the development of alopecia universalis. Some treatments appear to work on some patients some or all of the time, but no treatment appears to work on all patients all of the time. We would suggest a few practical points that we find useful: To maximize the potential for cosmetic hair growth in alopecia areata that is extensive or flaring, treat the entire scalp instead of "chasing" patches. Do not change any topical treatment sooner than 3 months after starting it; early regrowth may first be present at 3 months. Cosmetic regrowth may take a year or more to achieve. Maintenance treatment increases the likelihood of maintenance of cosmetic hair growth, but patches of hair loss may still come and go. Atopic patients who experience seasonal hair loss may benefit (ie, have less severe hair loss flares or respond more readily to topical therapy) by using an antihistamine or mast cell stabilizer prophylactically. Whether one looks at the therapeutic cup as half full or half empty, most patients urge us to continue to try to find safe, effective long-term treatments for this disease.

Polymyositis, alopecia universalis, and primary sclerosing cholangitis in a patient with Crohn's disease

We report a 36-year-old man with Crohn's disease, primary sclerosing cholangitis, and alopecia universalis. Six years after the onset of intestinal disease, the patient developed severe muscular pain and weakness of the neck. Muscle biopsy revealed myositis. Immunosuppressive treatment led to a significant improvement of muscular symptoms. Myositis in inflammatory bowel disease appears to be an important differential diagnosis in corticoid myopathy. Both alopecia and polymyositis are rarely associated with inflammatory bowel disease; thus, they have to be discussed as extraintestinal manifestations.

Ulcerative colitis and total alopecia in a mother and her son

Extraintestinal autoimmune disorders are associated with ulcerative colitis in selected patients and lend support to the theory of immune-mediated injury in inflammatory bowel disease. Rarely, alopecia areata has been associated with ulcerative colitis, and familial aggregation and an HLA association have been reported for both disorders. The occurrence of both alopecia and ulcerative colitis in a mother and son are reported with a detailed investigation of antineutrophil cytoplasmic antibodies and HLA alleles in this family. Treatment with the immunosuppressive agent cyclosporine proved beneficial in the child leading to remission of the ulcerative colitis and nascent growth of scalp and body hair.