Pathogenesis of Alopecia Areata and Vitiligo: Commonalities and Differences

Both alopecia areata (AA) and vitiligo are distinct, heterogenous, and complex disease entities, characterized by nonscarring scalp terminal hair loss and skin pigment loss, respectively. In AA, inflammatory cell infiltrates are in the deep reticular dermis close to the hair bulb (swarm of bees), whereas in vitiligo the inflammatory infiltrates are in the epidermis and papillary dermis. Immune privilege collapse has been extensively investigated in AA pathogenesis, including the suppression of immunomodulatory factors (e.g., transforming growth factor-β (TGF-β), programmed death-ligand 1 (PDL1), interleukin-10 (IL-10), α-melanocyte-stimulating hormone (α-MSH), and macrophage migration inhibitory factor (MIF)) and enhanced expression of the major histocompatibility complex (MHC) throughout hair follicles. However, immune privilege collapse in vitiligo remains less explored. Both AA and vitiligo are autoimmune diseases that share commonalities in pathogenesis, including the involvement of plasmacytoid dendritic cells (and interferon-α (IFN- α) signaling pathways) and cytotoxic CD8+ T lymphocytes (and activated IFN-γ signaling pathways). Blood chemokine C-X-C motif ligand 9 (CXCL9) and CXCL10 are elevated in both diseases. Common factors that contribute to AA and vitiligo include oxidative stress, autophagy, type 2 cytokines, and the Wnt/β-catenin pathway (e.g., dickkopf 1 (DKK1)). Here, we summarize the commonalities and differences between AA and vitiligo, focusing on their pathogenesis.

C-reactive protein as a novel biomarker for vitamin D deficiency in alopecia areata

BACKGROUND

Alopecia areata (AA) is an autoimmune condition characterized by sudden and unpredictable hair loss, with a lifetime incidence of 2%. AA can be divided into three categories: patchy alopecia, alopecia totalis, and alopecia universalis. It can affect a person's psychological health and overall quality of life. Elevated C-reactive protein (CRP) levels in the liver may indicate an inflammatory response in autoimmune diseases. Vitamin D, essential for immune system control and skin health, may be related to AA. Hair follicles contain vitamin D receptors, which control immunological responses in the skin. However, no study has found a relationship between CRP and vitamin D in AA patients in our region.

SUBJECTS AND METHODS

An analytical cross-sectional study with a case-control design research investigation of 82 AA patients and 81 healthy controls was carried out. Both groups' medical histories were taken. Biochemical analysis was done for both groups as well as the serum vitamin D levels, and CRP. Genetic analysis for CDX2 rs11568820 variant detected by PCR (T-ARMS-PCR) method and vitamin D receptor (VDR) gene expression measured by real-time PCR analysis for both patients and healthy subjects.

RESULTS

CRP levels are higher in AA patients, AA patients with G/G genotypes exhibited higher concentrations of CRP when compared to those with A/A and A/G genotypes while patients with A/A genotypes have higher levels of Serum vitamin D as compared to the A/G and G/G genotypes. G allele was more abundant in AA patients. VDR gene expression was lower in AA compared to control and lower in ophiasis compared to localized and multiple patchy AA. An important inverse linear correlation was observed between vitamin D and CRP levels in ophiasis AA.

CONCLUSION

CRP concentrations were found to be elevated in AA patients. The considerable accuracy of CRP in the diagnosis of AA is substantiated by a statistically significant al. A noteworthy inverse linear association was observed between serum vitamin D and CRP concentrations in ophiasis AA.

Association of Obesity and Bariatric Surgery on Hair Health

Obesity and obesity-related conditions today constitute a public health problem worldwide. Obesity is an "epidemic" chronic disorder, which is defined by the WHO as normal or excessive fat accumulation that may impair health. It is also defined for adults as a BMI that is greater than or equal to 30. The most common obesity-related diseases are type 2 diabetes mellitus, cardiovascular diseases, metabolic syndrome, chronic kidney disease, hyperlipidemia, hypertension, nonalcoholic fatty liver disease, and certain types of cancer. It has been also proven that obesity can have a negative effect on hair. It can lead to hair thinning. Patients with obesity can undergo bariatric surgery if they meet the inclusion criteria. The four common types of weight loss surgery include a duodenal switch with biliopancreatic diversion, laparoscopic adjustable gastric banding, Roux-en-Y gastric bypass, and sleeve gastrectomy. Bariatric surgery can affect skin and hair and is associated with telogen effluvium due to weight loss, microelement deficiency, anesthesia, low calorie intake, and low protein intake. Patients who undergo bariatric surgery can experience post-bariatric surgery depression. Hair loss can have a major impact on self-esteem, negatively affecting one's self-image. The purpose of this narrative review is to critically review how obesity, obesity-related diseases, and bariatric surgery affect hair health in general and the hair development cycle, and how they influence hair loss.

Risk of Alopecia Areata After COVID-19

This cohort study examines the incidence, prevalence, and risk of alopecia areata after COVID-19.

Clinical characteristics and immune profiles of patients with immune-mediated alopecia associated with COVID-19 vaccinations

BACKGROUND

The clinical characteristics and pathomechanism for immune-mediated alopecia following COVID-19 vaccinations are not clearly characterized.

OBJECTIVE

We investigated the causality and immune mechanism of COVID-19 vaccines-related alopecia areata (AA).

STUDY DESIGN

27 new-onset of AA patients after COVID-19 vaccinations and 106 vaccines-tolerant individuals were enrolled from multiple medical centers for analysis.

RESULTS

The antinuclear antibody, total IgE, granulysin, and PARC/CCL18 as well as peripheral eosinophil count were significantly elevated in the patients with COVID-19 vaccines-related AA compared with those in the tolerant individuals (P = 2.03 × 10-5-0.039). In vitro lymphocyte activation test revealed that granulysin, granzyme B, and IFN-γ released from the T cells of COVID-19 vaccines-related AA patients could be significantly increased by COVID-19 vaccine excipients (polyethylene glycol 2000 and polysorbate 80) or spike protein (P = 0.002-0.04).

CONCLUSIONS

Spike protein and excipients of COVID-19 vaccines could trigger T cell-mediated cytotoxicity, which contributes to the pathogenesis of immune-mediated alopecia associated with COVID-19 vaccines.

[Review of the post-COVID-19 syndrome associated to acute telogen effluvium]

Coronavirus disease 2019 (COVID-19) has impacted our society in numerous ways. So far (November 2022) around 640 million SARS-CoV-2 infections have been confirmed worldwide. It is known that this disease has a main affection at the cardiopulmonary level, however, it affects almost all the organs and systems of the body, including the skin. Post-COVID-19 syndrome occurs in some patients, leaving significant sequelae that impact their quality of life. Among the most common sequelae are: cough, dyspnea, chronic fatigue, hyposmia and dysosmia. In addition to these, other sequelae not related to respiratory syndrome have been reported, such as hair loss, which has been observed in around 20% of post-COVID-19 patients, this could be attributable to acute telogen effluvium (TE). To date, no study has been conducted to determine the relationship of ET in those who have had COVID-19. Acute ET is defined as diffuse, non-scarring hair loss, usually self-limited, lasting for about 6 months. Within its etiology, severe systemic febrile illness, pregnancy, restrictive diets, severe stress and various drugs have been described. It seriously affects the quality of life of patients and is often associated with loss of confidence and low self-esteem.

Reversal of Stress-Associated Alopecia

Novel coronavirus SARS-CoV-2, designated as COVID-19 by the World Health Organization (WHO) on February 11, 2020, is one of the highly pathogenic β-coronaviruses that infects humans.1 Alopecia areata (AA) is a chronic inflammatory disease with sudden hair loss.2,3 There is strong evidence that AA is a tissue-specific autoimmune disease that develops based on genetic predisposition.4 In several patients, acute or chronic psycho-emotional stress may be causing the initiation and/or progress of AA.5 It is suggested that psychological stress can trigger or exacerbate inflammatory skin diseases through the neuroendocrine system, which is an essential connection between the brain and the skin.6,7 Hair loss has emerged as a frequently noted side effect of infection with COVID-19, and has been observed in many patients who have recovered from a documented COVID-19 illness.8,9.

Impaired autophagy promotes hair loss in the C3H/HeJ mouse model of alopecia areata

Alopecia areata (AA) involves an aberrant immune attack on the hair follicle (HF), which leads to hair loss. Previous genetic data from our lab pointed to a connection between macroautophagy/autophagy and AA pathogenesis, and GWAS identified STX17, CLEC16A and BCL2L11/BIM as risk factors for AA. Additionally, AA patients have copy number deletions in region spanning the ATG4B gene. To test whether autophagy might contribute to disease pathogenesis in AA, we investigated autophagic activity in C3H/HeJ mouse model. We found that autophagy protein SQSTM1 accumulated in HF of AA mice, while in immune cells from AA skin-draining lymph nodes SQSTM1 was not altered, suggesting that autophagic activity is inhibited in the HF of AA mice. Induction of autophagy with Tat-BECN1 peptide attenuated AA, while treatment with the autophagy blocker chloroquine promoted disease, compared to untreated AA mice. Together, our findings suggest the involvement of impaired autophagy in disease pathogenesis of AA.Abbreviations: AA: alopecia areata; CQ: chloroquine; GWAS: genome-wide association studies; HF: hair follicle; MHC: major histocompatibility complex; SDLN: skin-draining lymph nodes.

Autoantigen Discovery in the Hair Loss Disorder, Alopecia Areata: Implication of Post-Translational Modifications

Alopecia areata (AA) is a chronic, multifactorial, polygenic, and heterogeneous disorder affecting growing hair follicles in susceptible individuals, which results in a non-scarring and reversible hair loss with a highly unpredictable course. Despite very considerable research effort, the nature of the precipitating factor(s) responsible for initiating AA in any given hair follicle remains unclear, due largely to significant gaps in our knowledge of the precise sequence of the etiopathogenic events in this dermatosis. However, disease-related changes in the immune-competence of the lower growing hair follicle, together with an active immune response (humoral and cellular) to hair follicle-associated antigens, are key associated phenomena. Confirmation of the hair follicle antigen(s) implicated in AA disease onset has remained stubbornly elusive. While it may be considered somewhat philosophical by some, it is also unclear whether immune-mediated hair loss in AA results from a) an ectopic (i.e., in an abnormal location) immune response to native (unmodified) self-antigens expressed by the healthy hair follicle, b) a normal immune response against modified self-antigens (or neoantigens), or c) a normal immune response against self-antigens (modified/non-modified) that were not previously visible to the immune system (because they were conformationally-hidden or sequestered) but become exposed and presentable in an MHC-I/-II molecule-restricted manner. While some candidate hair follicle antigen target(s) in AA are beginning to emerge, with a potential role for trichohyalin, it is not yet clear whether this represents the initial and immunodominant antigenic focus in AA or is simply one of an expanding repertoire of exposed hair follicle tissue damage-associated antigens that are secondary to the disease. Confirmation of autoantigen identity is essential for our understanding of AA etiopathogenesis, and consequently for developing a more informed therapeutic strategy. Major strides have been made in autoantigen discovery in other autoimmune conditions. In particular, some of these conditions may provide insights into how post-translational modifications (e.g., citrullination, deamidation, etc.) of hair follicle-restricted proteins may increase their antigenicity and so help drive the anti-hair follicle immune attack in AA.

The Role of Autologous Micrografts Injection from The Scalp Tissue in The Treatment of Covid-19 Associated Telogen Effluvium: Clinical and Trichoscopic Evaluation

The clinical presentation of severe acute respiratory syndrome coronavirus‐2 (SARS‐CoV‐2 COVID‐19) varies from asymptomatic infection to a life‐threatening, multiorgan disease. One of these manifestations is telogen effluvium (TE) which is characterized by diffuse hair loss occurring in patients previously infected with SARS‐CoV‐2 and lasts ~3 months, after which excessive hair loss follows. Hair follicles are known to contain a well‐characterized niche for adult stem cells which is the bulge containing epithelial and melanocytic stem cells. Stem cells in the hair bulge, a demarcated structure within the lower permanent portion of hair follicles, can generate the interfollicular epidermis, hair follicle structures, and sebaceous glands. This study aims to evaluate autologous micrografts from scalp tissues as a therapeutic modality in the management of TE caused by COVID‐19. Twenty patients of previous COVID‐19 infection suffered from TE were included in this study for human follicle stem cells micrograft scalp treatment and they were evaluated after 3 months of treatment and after 6 months. There was significant improvement of the hair thickness and density compared with the start of the treatment and 6 months of follow‐up. Autologous micrograft of the scalp showed marked improvement in the treatment of COVID‐19 TE.

A Case of Late-Onset Alopecia Areata

Alopecia areata (AA) is a condition characterized by nonscarring hair loss. Cases of alopecia areata are most commonly seen in patients under age 30 and are frequently idiopathic. In this report, we discuss a woman in her 50s who developed AA shortly after receiving the Tdap vaccine and after one year of guselkumab therapy.

Platelet Rich Plasma for the Treatment of Scarring Alopecia Due to Discoid Lupus Erythematosus

Platelet-rich plasma (PRP) is an autologous concentration of plasma from a patient’s blood containing platelets up to 7 times higher than normal plasma. Originally indicated to improve connective tissue regeneration in orthopedic surgery, PRP has also proven to be advantageous in the treatment of androgenic alopecia (AGA), alopecia areata (AA), and other forms of non-scarring alopecia.

Lifestyle Factors Involved in the Pathogenesis of Alopecia Areata

Alopecia areata is a representative inflammatory skin disease that is associated with various environmental stimuli. While psychological stress is believed to be a major pathogenetic trigger in alopecia areata, infants and newborns also suffer from the disease, suggesting the possible presence of other environmental factors. Daily lifestyle is well known to be involved in various inflammatory diseases and influences the severity of inflammatory skin diseases. However, only a limited number of studies have summarized these influences on alopecia areata. In this review article, we summarize lifestyle factor-related influences on the pathogenesis of alopecia areata and focus on environmental factors, such as smoking, alcohol consumption, sleep, obesity, fatty acids, and gluten consumption.

Alopecia Areata: an Update on Etiopathogenesis, Diagnosis, and Management

Alopecia areata (AA) is a common chronic tissue-specific autoimmune disease, resulting in hair loss, that affects up to 2% of the general population. The exact pathobiology of AA has still remained elusive, while the common theory is the collapse of the immune privilege of the hair follicle caused by immunological mechanism. Multiple genetic and environment factors contribute to the pathogenesis of AA. There are several clinical treatments for AA, varying from one or multiple well-defined patches to more diffuse or total hair loss of the scalp (alopecia totalis) or hair loss of the entire body (alopecia universalis). The available treatments for AA, such as corticosteroids and other immunomodulators, minoxidil, and contact immunotherapy, are of limited efficacy with a high risk of adverse effects and high recurrence rates, especially for patients with severe AA. Recent insights into the pathogenesis of AA have led to the development of new treatment strategies, such as Janus kinase (JAK) inhibitors, biologics, and several small molecular agents. In addition, modern therapies for AA, including antihistamines, platelet-rich plasma (PRP) injection, and other novel therapies have been well explored. In this review, we discussed the recent advances in the pathogenesis, diagnosis, and treatment of AA.

A combination of herbal formulas, acupuncture, and novel pine-needle stimulation for recurrent alopecia areata: A case report

INTRODUCTION

Head hair is a symbol of vitality, and hair loss by alopecia areata (AA) presents a burden on patients. Although traditional Japanese Kampo medicine (JKM) formulas, acupuncture, and moxibustion have historically been used for treating AA, no studies have utilized a combination of these modalities.

PATIENT CONCERNS

A 34-year-old male with a history of childhood asthma presented with a sudden hair loss at the top of his head without any preceding symptoms. Except for a hairless patch of 5 cm × 6 cm, his general appearance was otherwise good. The patient underwent topical immunotherapy on visiting a dermatologist. However, the patient noticed an exacerbation of his hairless lesion.

DIAGNOSIS

The AA diagnosis was established based on clinical appearance and dermatological findings. The Severity of Alopecia Tool (SALT) score for alopecia was 19% at diagnosis.

INTERVENTIONS

The patient received 2 JKM formulas (saikokaryukotsuboreito and shichimotsukokato) in combination with acupuncture. When relapse occurred, a novel self-administration of pine-needle acupuncture was initiated in combination with the JKM formulas.

OUTCOMES

A 50% recovery from the baseline SALT score was achieved using JKM formulas in combination with acupuncture for 4 months. The patient achieved complete remission for 5 months. However, another stressful event induced an AA relapse with multiple lesions harboring a SALT score of 13%. Pine-needle acupuncture was initiated, resulting in faster resolution than the first treatment. Recoveries of 50% and 75% were achieved 3 and 4 months after relapse, respectively, and a long-lasting response without relapse was obtained for at least 3 years.

CONCLUSION

A combination of multimodal traditional therapies, including JKM formulas, acupuncture, and self-administered pine-needle stimulation, represents an effective integrative treatment for patients with AA.

Telogen Effluvium - a review of the science and current obstacles

Telogen effluvium (TE) is a common cause of diffuse non-scarring hair loss that is usually precipitated by physiological stress such as childbirth or sudden weight loss. Despite its high rate of remission, this phenomenon of sudden excessive hair loss can be very worrisome and upsetting for affected individuals and may significantly impact their quality of life. Due to the multifactorial causes and precipitants of TE, it is often challenging to diagnose and manage. Further, the mechanisms through which physiological stress influences the human hair cycle is unknown, and there are no targeted treatments for the management of TE. This review will describe the approach in making a diagnosis of TE, summarize the latest developments made in understanding the mechanisms of TE, outline the treatments tried, and recommend ways for advancing the study of this dermatological condition.

The antiinflammatory effects of Xuefu Zhuyu decoction on C3H/HeJ mice with alopecia areata

BACKGROUND

As a traditional and typical prescription of prominently activating blood circulation to remove blood stasis, Xuefu Zhuyu decoction (XZD) consists of 15 kinds of herbal medicine. Clinical investigations have showed that XZD could significantly promote the new hair generation of alopecia areata (AA) patients characterized by Qi stagnation and blood stasis.

PURPOSE

The purpose of this study was executed to determine whether the mechanisms by which XZD stimulated newborn hair were related to its anti-inflammatory effects.

METHODS

Clinical AA individuals were recruited to confirm the efficies of XZD. High performance liquid chromatography (HPLC) analysis was performed to qualitatively and quantitatively determine the contents of 15 compounds in XZD. Schrodinger molecular docking and in vivo surface plasmon resonance (SPR) techniques were used to evaluate the potential binding properties of compounds to target proteins. C3H/HeJ mice were randomly assigned to groups control, AA, and the XZD administration (6.5, 13.0 and 26.0 g/kg/d). Except for mice in control group, all the mice in the other groups were treated with a 21-day chronic unpredictable mild stress (CUMS) induced AA. Hematoxylin-eosin (H&E) staining was performed to determine the degree of pathological damage to the skin. Enzyme-linked immunosorbent assay (ELISA) was performed to detect levels of interleukin-6 (IL-6), interleukin-1 beta (IL-1β) and tumor necrosis factor alpha (TNF-α) and in serum and skin tissues. Western blot, immunohistochemistry and quantitative reverse transcription-polymerase chain reaction (qRT-PCR) were used to examine the expression levels of IL-6, IL-1β, TNF-α and osteopontin proteins and genes in skin tissues.

RESULTS

XZD could visibly promote hair regeneration of AA patients. The potential active ingredients in XZD prescription included at least amygdalin, hydroxysafflor yellow A, kaempferide, ferulic acid, catalpol, verbascoside, β-ecdysone, platycodin D, paeoniflorin, naringin, neohesperidin, liquiritin, glycyrrhizic acid, saikosaponin A and saikosaponin D. The results of molecular docking and SPR analysis showed that verbascoside, liquiritin, kaempferide and amygdalin showed the best potential binding properties with IL-6, IL-1β, TNF-α and osteopontin, respectively. Pathological evaluation showed that compared with the CUMS group, the administration of XZD significantly promoted hair regeneration, evidenced by increased number of skin hair follicles in C3H/HeJ AA mice. Compared with control group, ELISA data showed that the levels of IL-6, IL-1β and TNF-α in serum and skin tissues of CUMS induced AA mice were significantly increased, while XZD administration dramatically restrained the contents of the three pro-inflammatory factors. Western blot, immunohistochemistry, and qRT-PCR results further demonstrated that XZD administration notably down-regulated the protein and gene expression levels of osteopontin, IL-6, IL-1β and TNF-α in comparation with CUMS group.

CONCLUSION

XZD could dramatically ameliorate CUMS-induced AA damage in the skin of C3H/HeJ mice, possibly by suppressing the levels of IL-6, IL-1β, TNF-α and osteopontin.

Selenium levels and skin diseases: systematic review and meta-analysis

BACKGROUND

Several studies have investigated the association between selenium levels and skin diseases, but reached inconsistent results.

OBJECTIVE

This systematic review and meta-analysis was conducted to evaluate the association between selenium levels and skin diseases.

METHODS

A systematic search was conducted in public databases to identify all relevant studies, and study-specific standard mean differences (SMD) and 95% confidence intervals (CI) were pooled to compare the selenium levels between different groups.

RESULTS

Twenty-seven studies were identified with a total of 1315 patient and 7181 healthy controls. Compared with controls, no significant difference in selenium was found in patients with vitiligo (SMD = 0.53, 95% CI: -0.40 to 1.45), alopecia areata (SMD = 0.47, 95% CI: -2.72 and 3.65), or eczema (SMD = 0.12, 95% CI: -0.24 to 0.48). A lower selenium level was found in patients with psoriasis (SMD = -0.62, 95% CI: -1.15 to -0.10), acne vulgaris (SMD = -1.02, 95% CI: -1.45 to -0.60), chloric acne (SMD = -2.35, 95% CI: -3.15 to -1.55), and atopic dermatitis (SMD = -2.62, 95% CI: -3.00 to -2.24). As for disease severity, severe patients had a higher selenium level than mild patients in psoriasis (SMD = 0.72, 95% CI: 0.07-1.38), but no difference was found in vitiligo (SMD = -0.26, 95% CI: -2.38 to 1.85) and alopecia areata (SMD = 0.46, 95% CI: -0.34 to 1.26).

CONCLUSION

Selenium levels were associated with several skin diseases and the disease severity, and high selenium levels tended to be a protective factor in certain skin diseases.

Study on Serum Vitamin D in Alopecia Areata Patients

BACKGROUND

Alopecia areata is the commonest cause of non-scarring alopecia. Few previous studies have found correlation between AA and vitamin D deficiency, suggesting that vitamin D deficiency can be a risk factor for Alopecia areata. To compare serum vitamin D level between Alopecia areata patients and healthy controls; and to assess the relation between serum vitamin D levels and AA disease severity.

METHODS

This case control study included 30 newly diagnosed Alopecia areata patients. Thorough history was taken, detail examination was done and relevant findings were recorded in the standardized pro-forma. Their serum vitamin D (25-hydroxyvitamin D) levels were determined by competitive chemiluminescence methods; and were compared with that of age and sex matched healthy controls. Chi square test and Spearman's rho correlation test were used for the inferential statistics using SPSS version 11.5.

RESULTS

There were 30 AA patients with mean age 28.37+10.07 years. Mean Severity of Alopecia Tool score was 3.56+3.50. Prevalence of 25-hydroxyvitamin D [25(OH)D] deficiency was significantly higher in AA group (83.3%) compared to the control group (53.3%) (P=0.01). Similarly, serum 25(OH)D level was reduced more in Alopecia areata group (12.84, IQR=8.87-20.47) than the control group (29.5, IQR=19.85-41.27) (P=0.06). There was inverse co-relation between serum 25(OH)D level and SALT score.

CONCLUSIONS

Prevalence of serum 25(OH)D deficiency was significantly higher in Alopecia areata group compared to the control, with inverse co-relation between its level and Alopecia areata disease severity.

Thyroid diseases and skin autoimmunity

The skin is the largest organ of the body, at the boundary with the outside environment. Primarily, it provides a physical and chemical barrier against external insults, but it can act also as immune organ because it contains a whole host of immune-competent cells of both the innate and the adaptive immune systems, which cooperate in eliminating invading pathogens following tissue injury. On the other hand, improper skin immune responses lead to autoimmune skin diseases (AISD), such as pemphigus, bullous pemphigoid, vitiligo, and alopecia. Although the interplay among genetic, epigenetic, and environmental factors has been shown to play a major role in AISD etiology and progression, the molecular mechanisms underlying disease development are far from being fully elucidated. In this context, epidemiological studies aimed at defining the association of different AISD with other autoimmune pathologies revealed possible shared molecular mechanism(s) responsible for disease progression. In particular, over the last decades, a number of reports have highlighted a significant association between thyroid diseases (TD), mainly autoimmune ones (AITD), and AISD. Here, we will recapitulate the epidemiology, clinical manifestations, and pathogenesis of the main AISD, and we will summarize the epidemiological evidence showing the associations with TD as well as possible molecular mechanism(s) underlying TD and AISD pathological manifestations.

Alopecia Areata and Thyroid Dysfunction Association- A Study from Eastern Nepal

Background Alopecia areata (AA) is one of the non-scarring alopecia. Its etiology has not been well established till date. The most convincing hypothesis is autoimmune process for its causation. Amongst all, most frequent association was found with thyroid disorder. Objective To study the association of thyroid dysfunction in patients with alopecia areata. Method All patients of alopecia areata attending dermatology outpatient department and currently not receiving any treatment for alopecia areata were enrolled in the study. Relevant history and examination findings were recorded in the preset pro-forma. All of them were subjected for thyroid function test by chemiluminescence microparticle immunoassay method. Then thyroid function test of cases was compared with that of equal number of age and sex matched healthy controls. Result A total of 75 patients were enrolled in both case and control groups. Mean age of case and control groups were 29.40±9.90 and 28.96±9.89 years respectively (P=0.786). Median Severity of Alopecia Tool score was 2.47 (IQR=0.96-5.79). Prevalence of thyroid disorder was significantly higher in alopecia areata group (17.3%) as compared to the control group (1.3%) (P=0.001). Likewise, in individuals with abnormal thyroid function, alopecia areata disease severity grade and median severity of alopecia tool (SALT) score was higher as compared to those with normal thyroid function. Conclusion We found a significant association between alopecia areata and thyroid dysfunction. Hence thyroid function evaluation must be considered in individuals with alopecia areata. However, further studies with larger sample size are recommended before its generalization.

Building and Crossing the Translational Bridge: 2016 Alopecia Areata Research Summit Highlights

Alopecia areata (AA) is a common autoimmune skin disease that results in the loss of hair on the scalp and elsewhere on the body and affects over 146 million people worldwide at some point in their lives. Founded in 1981, the National Alopecia Areata Foundation is a nonprofit organization that supports research to find a cure or acceptable treatment for AA, supports those with the disease, and educates the public about AA. The National Alopecia Areata Foundation conducts research summits every 2 years to review progress and create new directions in its funded and promoted research. The Foundation brings together scientists from all disciplines to get a broad and varied perspective. These AA research summits are part of the Foundation's main strategic initiative, the AA Treatment Development Program, to enhance the understanding of AA and accelerate progress toward a viable treatment.

[Psychological consequences of hair loss]

Hair plays an important role in human life. Quantitative or qualitative changes of hair are therefore perceived unfavorably. The psychological consequences of hair loss are described in both androgenic alopecia and alopecia areata. Alopecia areata should be distinguished from other diagnostic units such as trichotillomania. The issue of hair disease requires a multidisciplinary collaboration, in which the dermatologist has a key role to play.

In children with autoimmune thyroid diseases the association with Down syndrome can modify the clustering of extra-thyroidal autoimmune disorders

BACKGROUND

It is known that the association with Down syndrome (DS) can affect the phenotypic expression of autoimmune thyroid diseases (AITDs), whilst is unknown whether the clustering of extra-thyroidal autoimmune diseases (ETADs) may also be atypical in DS children.

METHODS

The aim of this study was to investigate the clustering of ETADs in 832 children with AITDs divided in two groups with or without DS (A and B, respectively) and in four subgroups of patients aged either <6 or ≥6 years.

RESULTS

The rate of children with ETADs was significantly higher in Group A; in particular, alopecia areata (p=0.00001) and vitiligo (p=0.00001) were found more often in Group A irrespective of age, whilst the distribution of T1 diabetes mellitus was not different in the two groups. Celiac disease prevalence was significantly higher in DS patients only in the older subgroup.

CONCLUSIONS

The association with DS may be able to modify the clustering of ETADs in the children with AITDs by favoring the aggregation of some specific diseases such as alopecia areata and vitiligo.

Trichotillomania: Bizzare Patern of Hair Loss at 11-Year-old Girl

Trichotillomania (TTM) is defined by the Diagnostics and Statistic Manual of Mental Disorders, 4th edition (DMS-IV) as hair loss from a patient`s repetitive self-pulling of hair. The disorder is included under anxiety disorders because it shares some obsessive-compulsive features. Patients have the tendency towards feelings of unattractiveness, body dissatisfaction, and low self-esteem (1,2). It is a major psychiatric problem, but many patients with this disorder first present to a dermatologist. An 11-year-old girl came to our department with a 2-month history of diffuse hair loss on the frontoparietal and parietotemporal area (Figure 1). She had originally been examined by a pediatrician with the diagnosis of alopecia areata. The patient`s personal history included hay fever and shortsightedness, and she suffered from varicella and mononucleosis. Nobody in the family history suffered from alopecia areata, but her father has male androgenetic alopecia (Norwood/Hamilton MAGA C3F3). The mother noticed that the child had had changeable mood for about 2 months and did not want to communicate with other persons in the family. The family did not have any pet at home. At school, her favorite subjects were Math and Computer Studies. She did not like Physical Education and did not participate in any sport activities during her free time. This was very strange because she was obese (body-mass index (BMI) 24.69). She was sometimes angry with her 13-year-old sister who had better results at school. The girl had suddenly started to wear a blue scarf. The parents did not notice that she pulled out her hair at home. Dermatological examination of the capillitium found a zone of incomplete alopecia in the frontoparietal and parietotemporal area, without inflammation, desquamation, and scaring. Hairs were of variable length (Figure 1). There was a patch of incomplete alopecia above the forehead between two stripes of hair of variable length (Figure 2). The hair pull test was negative along the edges of the alopecia. Mycological examination from the skin capillitium was negative. The trichoscopy and skin biopsy of the parietotemporal region of the capillitium (Figure 3) confirmed trichotillomania. Laboratory tests (blood count, iron, ferritin, transferrin, selenium, zinc, vitamin B12, folic acid, serology and hormones of thyroid gland) were negative. We referred the girl for ophthalmologic and psychological examination. Ophthalmologic examination proved that there was no need to add any more diopters. The psychological examination provided us with a picture in which she drew her family (Figure 4). The strongest authority in the family was the mother because she looked after the girls for most of the day. She was in the first place in the picture. The father had longer working hours and spent more time outside the home. He worked as a long vehicle driver. He was in the second place in the picture. There was sibling rivalry between the girls, but the parents did not notice this problem and preferred the older daughter. She was successful at school and was prettier (slim, higher, curly brown hair, without spectacles). Our 11-years-old patient noticed all these differences between them, but at her level of mental development was not able to cope with this problem. She wanted to be her sister's equal. The sister is drawn in the picture in the third place next to father, while the patient's own figure was drawn larger and slim even though she was obese. Notably, all three female figures had very nice long brown hair. It seemed that the mother and our patient had better quality of hair and more intense color than the sister in the drawing. The only hairless person in the picture was the father. The girl did not want to talk about her problems and feelings at home. Then it was confirmed that our patient was very sensitive, anxious, willful, and withdrawn. She was interested in her body and very perceptive of her physical appearance. From the psychological point of view, the parents started to pay more interest to their younger daughter and tried to understand and help her. After consultation with the psychiatrist, we did not start psychopharmacologic therapy for trichotillomania; instead, we started treatment with cognitive behavioral therapy, mild shampoo, mild topical steroids (e.g. hydrocortisone butyrate 0.1%) in solution and methionine in capsules. With parents' cooperation, the treatment was successful. The name trichotillomania was first employed by the French dermatologist Francois Henri Hallopeau in 1889, who described a young man pulling his hair out in tufts (3-5). The word is derived from the Greek thrix (hair), tillein (to pull), and mania (madness) (5). The prevalence of TTM in the general adult population ranges from 0.6% to 4%, and 2-4% of the general psychiatric outpatient population meet the criteria for TTM (2-5). The prevalence among children and adolescents has been estimated at less than 1% (5). The disease can occur at any age and in any sex. The age of onset of hair pulling is significantly later for men than for women (3). There are three subsets of age: preschool children, preadolescents to young adults, and adults. The mean age of onset is pre-pubertal. It ranges from 8 to 13 years (on average 11.3 years) (2-5). The occurrence of hair-pulling in the first year of life is a rare event, probably comprising <1% of cases (5). The etiology of TTM is complex and may be triggered by a psychosocial stressor within the family, such as separation from an attachment figure, hospitalization of the child or parent, birth of a younger sibling, sibling rivalry, moving to a new house, or problems with school performance. It has been hypothesized that the habit may begin with "playing" with the hair, with later chronic pulling resulting in obvious hair loss (2). Environment is a factor because children usually pull their hair when alone and in relaxed surroundings. The bedroom, bathroom, or family room are "high-risk" situations for hair-pulling (5). Men and women also differed in terms of the hair pulling site (men pull hair from the stomach/back and the moustache/beard areas, while women pull from the scalp) (3). Pulling hair from siblings, pets, dolls, and stuffed animals has also been documented, often occurring in the same pattern as in the patient (5). Genetic factors contributing to the development of TTM are mutations of the SLITRK1 gene, which plays a role in cortex development and neuronal growth. The protein SAPAP3 has been present in 4.2% of TTM cases and patients with obsessive-compulsive disorder (OCD). It may be involved in the development of the spectrum of OCD. A significantly different concordance rate for TTM was found in monozygotic (38.1%) compared with dizygotic (0%) twins in 34 pairs (3). The core diagnostic feature is the repetitive pulling of hairs from one`s own body, resulting in hair loss. The targeted hair is mostly on the scalp (75%), but may also be from the eyebrows (42%), eyelashes (53%), beard (10%), and pubic area (17%) (3,5). There are three subtypes of hair pulling - early onset, automatic, and focused. Diagnostic criteria for TTM according to DSM-IV criteria are (2,3,5): 1) recurrent pulling of one`s hair resulting in noticeable hair loss; 2) an increasing sense of tension immediately prior to pulling out the hair or when attempting to resist the behavior; 3) pleasure, gratification, or relief when pulling out the hair; 4) the disturbance is not better accounted for by another mental disorder and is not due to a general medical condition (e.g., a dermatologic condition); 5) the disturbance causes clinically significant distress or impairment in social, occupational, or other important areas of functioning. The differential diagnosis includes alopecia areata (Table 1) (6), tinea capitis, telogen effluvium, secondary syphilis, traction alopecia, loose anagen syndrome, lichen planopilaris, alopecia mucinosa, and scleroderma (2-5). Biopsy of an involved area (ideally from a recent site of hair loss) can help to confirm the diagnosis (5). On histologic examination, there are typically increased numbers of catagen and telogen hairs without evidence of inflammation. Chronic hair pulling induces a catagen phase, and more hairs will be telogen hairs. Pigment casts and empty anagen follicles are often seen. Perifollicular hemorrhage near the hair bulb is an indicator of TTM (2). Complications of TTM are rare, but they comprise secondary bacterial infections with regional lymphadenopathy as a result of picking and scratching at the scalp. Many patients play with and ingest the pulled hairs (e.g. touching the hair to lips, biting, and chewing). Trichophagia (ingestion of the hair) can lead to a rare complication named trichobezoar (a "hair ball" in stomach). This habit is present in approximately 5% to 30% of adult patients, but it is less frequent in children. Patient with trichophagia present with pallor, nausea, vomiting, anorexia, and weight loss. Radiologic examination and gastroscopy should not be delayed (2,4,5). The management of the disease is difficult and requires strong cooperation between the physician, patient, and parents. The dermatologist cannot take part in the therapy, strictly speaking, but without the psychological, psychopharmacologic, and topic dermatologic treatment a vicious circle will be perpetuated.

Osteopontin: a new facilitating factor in alopecia areata pathogenesis?

Osteopontin (OPN) is a multifunctional glycophosphoprotein secreted by many cell types, including osteoblasts, lymphocites, macrophages, epithelial cells, and vascular smooth muscle cells. It has been implicated in many physiological and pathological processes, such as cell-mediated immunity, inflammation, cell survival, and tumor invasion and metastasis. Osteopontin has multiple emerging roles in cutaneous biology and pathology and OPN involvement has been emphasized in Th1-mediated diseases such as psoriasis. Alopecia areata (AA) is a form of non-scarring hair loss affecting anagen stage hair follicles with a multifactorial autoimmune pathogenesis characterized by a prevalent Th1 cytokine profile. Given the role of osteopontin in Th1-mediated inflammation, we have postulated that OPN may be involved in AA pathogenesis. The aim of our study was to investigate plasma OPN level in alopecia areata before and after DPCP treatment. Our results showed that OPN plasma levels in patients with alopecia areata were higher than in healthy controls, but patients achieving complete recovery after DPCP treatment did not show a statistically significant reduction of OPN plasma levels.

Alopecia areata--Part I: Background

Alopecia areata is a trichosis characterized by loss of hair, with the abrupt onset of round or oval, nonscarring, flat, single or multiple areas of alopecia lesions, which can coalesce. Several hypotheses have been raised to explain its etiology, with autoimmunity being accepted until today, along with genetic factors.

Hair disorders associated with autoimmune connective tissue diseases

Hair disorders are frequently observed in various systemic diseases, including autoimmune connective tissue diseases (CTDs), with predilection of lupus erythematosus (LE), followed by dermatomyositis (DM) and scleroderma. Hair disorders in CTDs may manifest as various clinical patterns, such as telogen hair loss, diffuse thinning or fragility of hair, and scarring alopecia. Less common hair disorders include anagen effluvium, alopecia areata, and trichomegaly. Some drugs used to treat CTDs may cause hair loss in a drug-related manner or hyperthrichosis. In the assessment of common hair loss patterns, such as telogen effluvium, the possible association with CTDs must be borne in mind and should not be overlooked. Alopecia appears to be a significant sign in the course of LE and especially systemic LE. In DM, the involvement of the scalp is common, and is often characterized by a diffuse, violaceous, scaly, non-scarring and symptomatic hair loss. Linear scleroderma en coup de sabre is an uncommon localized form of morphea with involvement of the paramedian forehead and frontal scalp, where it is associated with cicatricial alopecia. The most important variant of scarring alopecia in the context of CTDs is that associated with discoid lupus erythematosus (DLE). In the diagnostic work-up of DLE-related cicatrical alopecia, histopathological and immunopathological studies are useful, and a relevant role has been attributed to dermatoscopy (trichoscopy) over the last years. Hair loss has been reported in several other CTDs, including mixed and undifferentiated CTDs, and primary Sjögren's syndrome, although it is likely to be underestimated in such diseases.

Cutaneous manifestations associated with thyroid disease

AIM

To present the clinical and laboratory features of patients with dermatologic disorders associated with thyroid diseases, diagnostic criteria, type of administered treatment and its effectiveness.

MATERIAL AND METHODS

This study is a retrospective study based on the medical records of patients with thyroid diseases admitted to the Dermato venereology Clinic of the Iasi "Sf. Spiridon" University Emergency Hospital between January 1, 2012-December 31, 2013. Data on clinical manifestations, methods of investigation, therapeutic approach, and associated dermatologic and systemic diseases were reviewed.

RESULTS

A total of 38 patients were enrolled in this study of which 36 females and two males. An high incidence of cases with autoimmune thyroiditis (63%), followed by polynodular goiter (26.3%) and hypothyroidism (10.7%) was found during the study. The identified dermatologic disorders associated with thyroid diseases were in order of frequency alopecia areata (22%), followed by lichen planus (18%).

CONCLUSIONS

This study demonstrates that there is a significant association between certain dermatologic disorders and thyroid diseases, requiring periodic thyroid function tests.

Association between vitamin D levels and alopecia areata

BACKGROUND

Alopecia areata (AA) is an autoimmune disease, based on the response to local and/or systemic corticosteroid treatment. The role of vitamin D in the pathogenesis of immune/autoimmune mediated diseases has been widely studied.

OBJECTIVES

To investigate a possible association between serum 25-hydroxyvitamin D levels and alopecia areata.

METHODS

The study included 23 patients diagnosed with AA followed at our outpatient clinic during the period March 2010 to May 2011, as well as a control group matched for age and gender. All subjects underwent a complete work-up and medical examination, anthropometric measurements and laboratory tests. Laboratory tests included complete blood count, C-reactive protein (CRP), and vitamin D levels.

RESULTS

Mean CRP values were significantly higher in the AA group than the control group (1.1 +/- 0.7 mg/dl vs. 0.4 +/- 0.8 mg/ dl, P < 0.05). Vitamin D levels were significantly decreased in the AA group (11.32 +/- 10.18 ng/ml vs. 21.55 +/- 13.62 ng/ml in the control group, P < 0.05). Multivariate analysis showed that CRP (odds ratio 3.1, 95% confidence interval 2.6-4.2, P = 0.04) and serum vitamin D levels < 30 ng/ml (OR 2.3, 95% CI 2.2-3.1, P = 0.02) were associated with AA.

CONCLUSIONS

We found a significant correlation between AA and vitamin D deficiency. Vitamin D deficiency can be a significant risk factor for AA occurrence.

Alopecia Areata: news on diagnosis, pathogenesis and treatment

This review focuses on recent changes in the clinical, pathogenetic and therapeutic developments with regards to Alopecia Areata. Some new clinical forms and some phenomena have been described for the first time in recent years. Several phenomena previously observed such as the Renbok, the Koebner and the possibility that an exclamation mark hair can resume its physiological growth have been confirmed. The pathogenetic role of cytotoxic cells is increasingly evident, as well as the deficit of cells and the factors regulating the autoimmune response. The concept of immune privilege of the hair follicle has had further confirmation and have been identified some of the molecular mechanisms such as the expression of the receptors for killer lymphocytes on the trichokeratinocytes of the Outer Root Sheat. There is a renewed interest on the possible role of mast cell as a key element in the acute and chronic phases of the disease. New therapies are focused on the inhibition of the killer cells directed against antigens not yet fully specified of the hair follicle and on the restoration of the immune privilege of this structure. Alopecia Areata is a disease with high emotional impact, able to reduce the quality of life of patients and their family entourage. It is often frustrating for those affected and for the therapists due to its evolution quite unpredictable and the mixed response to the few validated therapies. Investment in research originate almost exclusively from voluntary associations of patients, which need to be known and supported.

Hair loss in autoimmune systemic diseases

Hair loss is commonly seen in autoimmune diseases. In pemphigus, although scalp involvement is common, hair loss is rarely reported. In classical bullous pemphigoid, alopecia is not reported while it is described in the Brusting-Perry variant of bullous pemphigoid and in epidermolysis bullosa acquisita. In these two diseases alopecia is cicatricial. In connective tissue diseases, in lupus erythematosus (LE) hair loss is frequent; in particular in LE there are two types of alopecia: non scarring and scarring alopecia. The non scarring form is a finding of acute systemic LE and the scarring form develops when a typical discoid lesion is located on the scalp. In dermatomyositis alopecia is usually non scarring and generalized. In scleroderma, alopecia is associated with en coupe de sabre morphea.

What causes alopecia areata?

The pathobiology of alopecia areata (AA), one of the most frequent autoimmune diseases and a major unsolved clinical problem, has intrigued dermatologists, hair biologists and immunologists for decades. Simultaneously, both affected patients and the physicians who take care of them are increasingly frustrated that there is still no fully satisfactory treatment. Much of this frustration results from the fact that the pathobiology of AA remains unclear, and no single AA pathogenesis concept can claim to be universally accepted. In fact, some investigators still harbour doubts whether this even is an autoimmune disease, and the relative importance of CD8(+) T cells, CD4(+) T cells and NKGD2(+) NK or NKT cells and the exact role of genetic factors in AA pathogenesis remain bones of contention. Also, is AA one disease, a spectrum of distinct disease entities or only a response pattern of normal hair follicles to immunologically mediated damage? During the past decade, substantial progress has been made in basic AA-related research, in the development of new models for translationally relevant AA research and in the identification of new therapeutic agents and targets for future AA management. This calls for a re-evaluation and public debate of currently prevalent AA pathobiology concepts. The present Controversies feature takes on this challenge, hoping to attract more skin biologists, immunologists and professional autoimmunity experts to this biologically fascinating and clinically important model disease.

Alopecia areata: more than skin deep

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.

Koebner phenomenon in alopecia areata: rapid appearance after trichogram. Implications for the pathogenesis and therapy

Anecdotical experiences indicate that Koebner phenomenon (KP) can also be observed in alopecia areata (AA). The present short report gives an account of what has been observed in some patients with remitting-relapsing AA in multiple patches, in whom the phenomenon was accidentally caused by perilesional Trichogram. The almost immediate appearance of relapses of the disease (1-7 days) and their evolution can be useful to understand the physiopathology of AA and and emphasize the compelling need for a rapid and appropriate diagnosis and treatment in the acute phase of AA, even with the active participation of the patient adequately trained. The method of trichogram should be reserved for cases in which non-invasive methods such as the Pull Test or Trichoscopy are not sufficient to verify the activity of the disease.

Endogenous retinoids in the pathogenesis of alopecia areata

Alopecia areata (AA) is an autoimmune disease that attacks anagen hair follicles. Gene array in graft-induced C3H/HeJ mice revealed that genes involved in retinoic acid (RA) synthesis were increased, whereas RA degradation genes were decreased in AA compared with sham controls. This was confirmed by immunohistochemistry in biopsies from patients with AA and both mouse and rat AA models. RA levels were also increased in C3H/HeJ mice with AA. C3H/HeJ mice were fed a purified diet containing one of the four levels of dietary vitamin A or an unpurified diet 2 weeks before grafting and disease progression followed. High vitamin A accelerated AA, whereas mice that were not fed vitamin A had more severe disease by the end of the study. More hair follicles were in anagen in mice fed high vitamin A. Both the number and localization of granzyme B-positive cells were altered by vitamin A. IFNγ was also the lowest and IL13 highest in mice fed high vitamin A. Other cytokines were reduced and chemokines increased as the disease progressed, but no additional effects of vitamin A were seen. Combined, these results suggest that vitamin A regulates both the hair cycle and immune response to alter the progression of AA.

Letter: Alopecia areata during ustekinumab administration: Co-existence or an adverse reaction?

Alopecia areata (AA) is a tissue-specific, T-cell-mediated autoimmune disease characterized by non-scarring hair loss. Ustekinumab is a human immunoglobulin monoclonal antibody that binds with the p40-subunit of interleukin-12 (IL-12) and IL-23 and has been licensed for the treatment of moderate to severe plaque psoriasis. The exact pathogenesis of AA remains unclear. However, increased Th1 serum cytokine levels have been associated with this condition. Thus, IL-12 inhibitors (ustekinumab) would be expected to treat or at least to prevent hair loss. We report two cases of acute AA occurring while on ustekinumab administration.

Progressive pigmented purpuric dermatitis and alopecia areata as unusual skin manifestations in recognizing hereditary hemochromatosis

Hereditary hemochromatosis (HHC) is a common genetic disorder of iron overload, caused by mutations in the HFE gene. If untreated, abnormal accumulation of iron may lead to organ damage and premature death. Significant changes in the symptomatology of HHC have been observed in recent years, and its full clinical expression is rarely seen. The disorder presents a large phenotypic heterogeneity. We report a case of newly identified HHC in a 56-year-old man presenting as pigmented purpuric dermatitis and alopecia areata affecting the beard, accompanied with elevated liver enzymes and elevated serum ferritin level on screening chemistry panels. Histopathologic examination of skin biopsy revealed changes consistent with the diagnosis of progressive pigmented purpuric dermatitis. The diagnosis of HHC was confirmed by genetic testing, with compound heterozygosity for the C282Y/H63D mutation. He had no signs of cardiomyopathy, gonadal insufficiency, arthropathy, or glucose intolerance. The diagnosis of HHC in our patient was based on clinical findings, laboratory findings, histopathologic examination of skin biopsy and genetic tests. Early diagnosis and therapeutic phlebotomy are very important in the prevention of all known complications of HHC, and are the major determinants of survival. Pigmented purpuric dermatitis and alopecia areata may be unusual early clinical skin presentations of HHC. The relation between inheritance of one or more hemochromatosis genes and susceptibility for progressive pigmented purpuric dermatitis or alopecia areata needs further investigation.

Cure of alopecia areata after eradication of Helicobacter pylori: a new association?

Alopecia areata is a disease of the hair follicles, with strong evidence supporting autoimmune etiology. Alopecia areata is frequently associated with immune-mediated diseases with skin manifestations such as psoriasis and lichen planus, or without skin manifestations such as autoimmune thyroiditis and idiopathic thrombocytopenic purpura. Helicobacter pylori (H. pylori) infection is present in around 50% of the world's population and has been associated with a variety of immune-mediated extra-digestive disorders including autoimmune thyroiditis, idiopathic thrombocytopenic purpura, and psoriasis. A case of a 43-year old man with an 8-mo history of alopecia areata of the scalp and beard is presented. The patient was being treated by a dermatologist and had psychiatric support, without any improvement. He had a history of dyspepsia and the urea breath test confirmed H. pylori infection. The patient went into remission from alopecia areata after H. pylori eradication. If such an association is confirmed by epidemiological studies designed for this purpose, new therapeutic options could be available for these patients, especially in areas where infection with H. pylori is highly prevalent.