— Disease Burden Could Worsen, Impacting Quality of Life, Experts Warn

According to a recent retrospective cohort study, patients diagnosed with alopecia areata (AA) exhibited a greater prevalence of both autoimmune and psychiatric comorbidities at diagnosis. They were also found to be at an increased risk of developing new comorbidities after diagnosis.

At diagnosis, 30.9% of patients with alopecia areata had psychiatric comorbidities compared to 26.8% of control subjects without alopecia areata (P<0.001). Additionally, 16.1% of patients with AA had autoimmune comorbidities, compared to 8.9% of controls (P<0.0001), according to Arash Mostaghimi, MD, and colleagues from Brigham and Women's Hospital in Boston.

After adjusting for variables such as age, sex, and geographic location, the overall incidence of psychiatric comorbidities within the first year was 10.2% for patients with AA versus 6.8% for controls (P<0.001). Similarly, autoimmune or immune-mediated diseases were seen in 6.2% of AA patients compared to 1.5% in controls (P<0.001), according to the findings published in JAMA Dermatology.

In general, patients with alopecia areata had a significantly elevated likelihood of developing psychiatric comorbidities, with an adjusted hazard ratio (HR) of 1.3 (95% CI 1.3-1.4). Their risk for autoimmune comorbidities was even higher at an adjusted HR of 2.7 (95% CI 2.5-2.8).

Mostaghimi and his colleagues emphasized that the onset of these conditions after an alopecia areata diagnosis "could further intensify the disease burden and decrease the quality of life for affected individuals." They suggested that regular monitoring, especially for those at higher risk for comorbidities, might facilitate early and more effective intervention.

The authors explained that both genetic and environmental components contribute to alopecia areata. In particular, they pointed to rising levels of inflammatory cytokines, such as interferon-γ and interleukin-15, which signal through Janus kinase (JAK) pathways, as potential contributors. These inflammatory pathways are also present in other autoimmune disorders like rheumatoid arthritis (RA) and psoriasis.

Previous studies have identified a heightened risk of comorbid conditions in patients with alopecia areata, including systemic lupus erythematosus, metabolic syndrome, and Hashimoto thyroiditis. Meanwhile, psychiatric disorders like anxiety and depression were also more likely in these patients.

In a literature review cited in the study, researchers highlighted "consistent negative effects on mental health" in those with AA, including emotional challenges, impaired social functioning, and heightened stress.

Given that shared signaling pathways exist between alopecia areata and these comorbidities, the authors suggest it's plausible that treatments targeting these pathways could address multiple conditions. They highlighted the recent FDA approval of baricitinib, a JAK inhibitor, for alopecia areata, which is also used to treat rheumatoid arthritis.

There may also be a "significant link between mental health and dermatological conditions," the authors added, suggesting that treating the skin disorder could potentially alleviate psychiatric effects as well.

Cathryn Sibbald, MD, MSc, of the University of Toronto and Hospital for Sick Children, commented that “though the study has some limitations, particularly in terms of dependence on diagnosis codes, it’s an important addition to the literature.”

She noted that “some comorbidities may have existed prior to the alopecia areata diagnosis and were just diagnosed afterward. Nonetheless, the findings highlight how essential thorough reviews and physical exams can be for uncovering related health issues.”

“In my practice, anxiety is the most common psychiatric co-occurrence. Even when patients' alopecia is successfully treated and hair regrows, many describe a constant fear of experiencing a new flare-up,” Sibbald shared. She added that patients often benefit from both therapeutic intervention and medication. Support groups can also play a crucial role in coping.

The study, led by Mostaghimi and colleagues, analyzed data spanning from January 2007 to April 2023 from the Merative MarketScan Research Database, which covers medical and drug claims for over 46 million U.S. patients. A total of 63,384 patients diagnosed with alopecia areata were identified, along with 3,309,107 controls without the condition. After matching, 16,512 individuals were in the AA cohort, while 66,048 represented the control group.

The average age of matched patients was 36.9 years, and women made up 50.6% of the population. The mean Charlson Comorbidity Index score was 0.1 for the AA group and 0.07 for the control group. Individuals with pre-existing immune-mediated inflammatory skin disorders, autoimmune diseases, or psychiatric conditions were excluded from the baseline analysis.

Once matched, patients with alopecia areata saw increased incidences of psychiatric comorbidities such as anxiety (4.0% vs 2.6%), sleep disturbances (2.6% vs 1.7%), and depression (1.9% vs 1.2%; all P<0.001). Autoimmune disorders with notable incidences included atopic dermatitis (2.2% vs 0.3%), vitiligo (1.0% vs 0.1%), and psoriasis (0.9% vs 0.2%; all P<0.001).

The psychiatric comorbidities with the highest risk for AA patients were:

• Adjustment disorder (aHR 1.5, 95% CI 1.3-1.6, P<0.001)
• Panic disorder (aHR 1.4, 95% CI 1.2-1.7, P<0.001)
• Sexual dysfunction (aHR 1.4, 95% CI 1.1-1.8, P=0.003)

Autoimmune and immune-mediated disorders with heightened risk were:

• Systemic lupus erythematosus (aHR 5.7, 95% CI 4.6-7.2, P<0.001)
• Atopic dermatitis (aHR 4.3, 95% CI 3.9-4.8, P<0.001)
• Vitiligo (aHR 3.8, 95% CI 3.2-4.4, P<0.001)

The authors acknowledged that the study may have underestimated the overall disease burden and related risks, due to the inability to account for severity levels in their analysis.

Disclosures

This research was financially supported by AbbVie.

Dr. Mostaghimi reported receiving consulting fees from numerous firms, including AbbVie, Hims & Hers Health, Pfizer, and others. Some study co-authors disclosed involvement with AbbVie, holding stock, or working on associated patents.

Dr. Sibbald disclosed receiving financial compensation from multiple pharmaceutical companies, including AbbVie, Novartis, and Pfizer.

Primary Source

JAMA Dermatology

Source Reference: Mostaghimi A, et al. "Immune-mediated and psychiatric comorbidities among patients newly diagnosed with alopecia areata." JAMA Dermatol 2024; DOI: 10.1001/jamadermatol.2024.2404.