The epidemiology of alopecia areata: a population-based cohort study in UK primary care

BACKGROUND

There is a lack of population-based information on the disease burden and management of alopecia areata (AA).

OBJECTIVES

To describe the epidemiology of AA, focusing on incidence, demographics and patterns of healthcare utilization.

METHODS

Population-based cohort study of 4·16 million adults and children, using UK electronic primary care records from the Oxford-Royal College of General Practitioners (RCGP) Research and Surveillance Centre (RSC) network database, 2009-2018. The incidence and point prevalence of AA were estimated. Variation in AA incidence by age, sex, deprivation, geographical distribution and ethnicity was examined. Patterns of healthcare utilization were evaluated in people with incident AA.

RESULTS

The AA incidence rate was 0·26 per 1000 person-years. AA point prevalence in 2018 was 0·58% in adults. AA onset peaked at age 25-29 years for both sexes, although the peak was broader in females. People of nonwhite ethnicity were more likely to present with AA, especially those of Asian ethnicity [incidence rate ratio (IRR) 3·32 (95% confidence interval 3·11-3·55)]. Higher AA incidence was associated with social deprivation [IRR most vs. least deprived quintile 1·47 (1·37-1·59)] and urban living [IRR 1·23 (1·14-1·32)]. People of higher social deprivation were less likely to be referred for specialist dermatology review.

CONCLUSIONS

By providing the first large-scale estimates of the incidence and point prevalence of AA, our study helps to understand the burden of AA on the population. Understanding the variation in AA onset between different population groups may give insight into the pathogenesis of AA and its management.

Frontal Fibrosing Alopecia survey of severity assessment methods in routine clinical practice and validation of the IFFACG measurement guidance

BACKGROUND

Lack of validated and responsive outcome measures in the management of Frontal Fibrosing Alopecia (FFA) significantly limits our ability to assess disease progression and treatment response over time.

OBJECTIVES

The aim of this study was to understand how FFA extent and progression is currently assessed in UK specialist centres, validate components of the International FFA Cooperative Group (IFFACG) statement on FFA assessment, and identify pragmatic advice to improve FFA management in clinic.

METHODS

Consultant Dermatologists with a specialist interest in hair loss (n=17) were invited to take part. Preferred FFA assessment methods were explored using questionnaires and clinical scenarios. Participants were asked to identify and mark the current hairline in 10 frontal and 10 temporal hairline images, with assessment repeated 3 months later (to assess intra-individual variability) and 12 months later (to test whether inter-individual accuracy could be improved with simple instruction).

RESULTS

All 17 clinicians (100%) completed the questionnaire at each time interval. We identified a wide variation in assessment techniques between our experts. Measurements were perceived as the most accurate method of assessing frontal recession whereas photography was preferred for temporal recession. Inter-rater reliability between clinicians measuring the frontal hairline scenarios indicated a moderate strength of agreement (ICC 0.613; 95% CI: 0.398 to 0.848), yet intra-rater reliability was found to be poor with wide limits of agreement (-8.71mm to 9.92mm) on follow-up. Importantly, when clear guidance was provided on how the hairline should be identified (questionnaire 3), inter-rater reliability improved significantly, with an ICC 0.702 suggesting moderate agreement (95% CI: 0.508 to 0.890; p<0.001). A similar pattern was seen with temporal hairline measurements, which again improved in accuracy with instruction.

CONCLUSION

We show that accuracy of measurements in FFA can be improved with simple instruction and validate components of the IFFACG measurement recommendations.

Guidelines for clinical trials of frontal fibrosing alopecia: consensus recommendations from the International FFA Cooperative Group (IFFACG)

BACKGROUND

Frontal fibrosing alopecia (FFA) has become one of the most common causes of cicatricial alopecia worldwide. However, there is a lack of clear aetiology and robust clinical trial evidence for the efficacy and safety of agents currently used for treatment.

OBJECTIVES

To enable data to be collected worldwide on FFA using common criteria and assessment methods.

METHODS

A multicentre, international group of experts in hair loss was convened by email to create consensus recommendations for clinical trials. Consensus was defined at > 90% agreement on each recommended part of these guidelines.

RESULTS

Standardized diagnostic criteria, severity rating, staging, and investigator and patient assessment of scalp hair loss and other clinical features of FFA were created.

CONCLUSIONS

These guidelines should allow the collection of reliable aggregate data on FFA and advance efforts in both clinical and basic research to close knowledge gaps in this condition.

Evidence-based (S3) guideline for the treatment of androgenetic alopecia in women and in men - short version

Androgenetic alopecia is the most common hair loss disorder, affecting both men and women. Initial signs of androgenetic alopecia usually develop during teenage years leading to progressive hair loss with a pattern distribution. Moreover, its frequency increases with age and affects up to 80% Caucasian men and 42% of women. Patients afflicted with androgenetic alopecia may undergo significant impairment of quality of life. The European Dermatology Forum (EDF) initiated a project to develop evidence-based guidelines for the treatment of androgenetic alopecia. Based on a systematic literature research the efficacy of the currently available therapeutic options was assessed and therapeutic recommendations were passed in a consensus conference. The purpose of the guideline is to provide dermatologists with an evidence-based tool for choosing an efficacious and safe therapy for patients with androgenetic alopecia.

Female pattern hair loss in complete androgen insensitivity syndrome

Female pattern hair loss, also known as female androgenetic alopecia, is generally regarded as an androgen-dependent disorder representing the female counterpart of male balding. We describe female pattern hair loss occurring in a patient with complete androgen insensitivity syndrome suggesting that mechanisms other than direct androgen action contribute to this common form of hair loss in women.

The gene for hypotrichosis of Marie Unna maps between D8S258 and D8S298: exclusion of the hr gene by cDNA and genomic sequencing

Hypotrichosis of Marie Unna (MU) is an autosomal dominant hair-loss disorder with onset in childhood. A genomewide search for the gene was performed in a large Dutch family using 400 fluorescent microsatellite markers. Linkage was detected with marker D8S258, and analysis of this family and a further British kindred with additional markers in the region gave a combined maximum two-point LOD score of 13.42, with D8S560. Informative recombinants placed the MU gene in a 2.4-cM interval between markers D8S258 and D8S298. Recently, recessive mutations in the hr gene were reported in families with congenital atrichia, and this gene was previously mapped close to the MU interval. By radiation-hybrid mapping, we placed the hr gene close to D8S298 but were unable to exclude it from the MU interval. This, with the existence of the semidominant murine hr allele, prompted us to perform mutation analysis for this gene. Full-length sequencing of hr cDNA obtained from an affected individual showed no mutations. Similarly, screening of all exons of the hr gene amplified from the genomic DNA of an affected individual revealed no mutations. Analysis of expressed sequences and positional cloning of the MU locus is underway.

Is Graves' dermopathy a generalized disorder?

The pathogenesis of the extrathyroidal manifestations of Graves' disease-ophthalmopathy and pretibial myxedema (Graves' dermopathy)-involves fibroblast activation and increased mucin (glycosaminoglycan) production. It is nuclear why fibroblasts are activated at these sites and evidence for site-specific and generalized fibroblast activation is conflicting. One previous report has demonstrated an increase in glycosaminoglycan deposition in the forearm skin of patients with Graves' disease but without pretibial myxedema. We have sought to confirm the existence of subclinical dermopathy in the forearm tissue from patients with untreated (UG) and treated (TG) Graves' disease and compared the histological changes with normal controls (C), treated toxic nodular goiter (MNG) and Graves' dermopathy specimens (PTM), using stains for mucin, elastin, glycosaminoglycans (GAGs), and HLA-DR molecules. Four of 4 PTM specimens stained positive for mucin, with varying sparse, fragmented, or dense elastin fibers. Four of 5 PTM specimens stained heavily for GAGs using colloidal iron and 2 of 5 stained heavily using colloidal gold. None of the patients in groups UG, TG, MNG, or the controls, showed mucin deposition or elastin changes. Mild staining with colloidal gold for GAGs was seen in 1 each of the UG, the TG, and MNG groups, and 4 of 8 controls. Heavy staining with colloidal iron for GAGs was seen in 1 TG patient and 1 control, while moderate staining was found in several TG, UG, and controls. In 2 of 4 PTM specimens the monoclonal antibody CR3/43 (against HLA-DR) stained frequent dermal fibroblast-like cells and in 2 a lymphocytic infiltrate was seen. Only 1 of 8 UG patients had multiple CR3/43 staining cells present in the dermis: 3 of 8 TG and 1 of 8 controls had a few CR3/43 stained cells. Overall we found no evidence of dermal mucin deposition in the forearms of 16 patients with Graves' disease and a similar GAG distribution to normal controls. HLA-DR expression by fibroblast-like cells in the dermis suggests activation of these cells in the dermis of the PTM specimens, but no evidence of widespread fibroblast activation was found in the forearms of patients with Graves' disease.

The effect of angiotensin converting enzyme inhibitors on isolated glomeruli

The following study was designed to examine the effect of the angiotensin converting enzyme (ACE) inhibitors captopril and enalapril on certain biological and physiological activities of isolated preparations of glomeruli from normotensive Wistar-Kyoto (WKY) and spontaneously hypertensive SHR rats. The results suggest that the contractile response of glomeruli from SHR to exogenous angiotensin II (Ang II) is significantly enhanced by captopril whereas it has a different effect on those from normotensive (WKY) rats. These effects are unrelated to changes in glomerular Ang II binding or the level of plasma renin activity (PRA), but they do depend partially on the sodium status of the animal. Whereas captopril induced a modest increase in the basal rate of prostaglandin E2 (PGE2) synthesis by glomeruli from normotensive (WKY) but not by those from SHR, the reverse occurred in the presence of Ang II. Prostaglandin E2 synthesis was increased in both strains of rats in the presence of excess arachidonic acid. Further increases occurred with the addition of captopril, these increases being significantly greater by glomeruli from WKY rats than by those from SHR, while enalaprilat had no effect on PGE2 production. The glomerular synthesis of PGE2 was not influenced in either strain of rats by in vitro administration of captopril.

Eruptive elastolysis: a new manifestation of pancreatic carcinoma

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