A new study sheds new light on psychiatric and autoimmune diseases and alopecia areata.
Newly diagnosed patients with alopecia areata have a “significantly higher risk” of developing psychiatric and autoimmune diseases, a large study has revealed.
Leading Australian AA expert Professor Rod Sinclair says the findings, published in JAMA Dermatology, are important and challenge the popular theory that conditions like stress, anxiety and depression and even autoimmune diseases cause hair loss.
They also support the routine monitoring of patients with AA, especially those at risk of developing comorbidities to ensure earlier and more effective intervention.
“It’s a really good paper,” he told Rheumatology Republic.
“One of the great strengths of it is the huge data set – they’ve got 3.3 million controls and they’ve got 63,000 patients and they were looking at new onset diseases.
“So in other words, what it shows is that alopecia areata is not more likely to affect people who have anxiety or depression or bipolar disorder or things like that. It’s actually that a lot of these disorders follow the alopecia – it’s almost a cause or a contributor.”
The retrospective cohort study of 3.3 million patients found that those newly diagnosed with alopecia areata had a significantly higher risk of developing a new-onset psychiatric or other autoimmune disease than patients without alopecia areata.
“This study builds on prior evaluations that demonstrated that patients with AA often have comorbid autoimmune, immune-mediated, and psychiatric disorders,” the authors wrote.
“Prior research has shown that, compared with healthy controls, patients with AA had a significantly higher likelihood of having several comorbidities, including systemic lupus erythematosus, metabolic syndrome and Hashimoto thyroiditis, as well as an increased likelihood of comorbid anxiety and depression.”
Professor Sinclair, who is also the editor of our sister publication Dermatology Republic, said the study also highlighted the other autoimmune conditions that were linked to AA, including an increased risk of psoriasis, vitiligo, lupus, rheumatoid arthritis and inflammatory bowel disease.
He said it was also concerning to see the high rates of psychiatric disease diagnosed in the 12 months after an AA diagnosis.
The research found that within the first 12 months after AA diagnosis, the overall incidence for any psychiatric disease was 10.2% for patients with AA and 6.8% for the control group.
Psychiatric diseases with the highest incidence for patients with AA compared with the control group were anxiety (4.0% vs 2.6%), sleep disturbance (2.6% vs 1.7%) and depression (1.9% vs 1.2%). Other psychiatric disorders with raised risk included schizophrenia, personality disorder, adjustment disorder, panic disorder and sexual dysfunction.
“It directs what sort of things to look for, absolutely, in terms of the anxiety, sleep disturbance and depression and other psychiatric red flags,” said Professor Sinclair.
Overall incidence for any autoimmune or immune-mediated disease within the first 12 months after AA diagnosis was 6.2% for patients with AA and 1.5% for the control group. Autoimmune and immune-mediated disorders with the highest incidence for patients with AA vs the control group were atopic dermatitis (2.2% vs 0.3%), vitiligo (1.0% vs 0.1%) and psoriasis (0.9% vs 0.2%) (P < .001). Other autoimmune conditions with raised risk included systemic lupus erythematosus, celiac disease, Sjogren disease, inflammatory bowel disease and rheumatoid arthritis.
Professor Sinclair said that while the study did not provide overwhelming evidence to support routine screening in all the patients for psychiatric and autoimmune diseases, it should raise awareness of being alert to the early signs and symptoms.
“It’s important to recognise them so they can actually be addressed and treated,” he said.
“The earlier the diagnosis the better – for example the thing about rheumatoid arthritis is you want to make a diagnosis early before they start to get joint damage. With lupus, you want to make the diagnosis early before they get kidney damage and so, so there’s a whole range of those, those conditions where there’s a an imperative to diagnose early.”
Professor Sinclair said it was also significant to educate patients as well, to ensure they could understand the risks of developing other conditions.
“I think it actually validates a lot of people who feel guilty about feeling bad about their hair. A lot of people think, ‘it’s just hair loss, I shouldn’t feel this bad’,” he said.
“But what we know is that in the first year the rate of anxiety, sleep disturbance and depression are going to be significantly increased compared to the population, probably about 10 to 15% of people are going to feel one or more of these symptoms – that could help a lot of people.”
The authors said longer-term studies were needed to determine the most effective treatment that can maximise patient health and minimise patient cost.
“Future studies should assess whether, for patients with AA who have psychological or autoimmune comorbidities, the use of a single therapy can treat both indications more cost-effectively than multiple therapies,” they wrote.
“Likewise, further research is needed to understand whether earlier and/or more aggressive treatment of AA may limit the development of comorbidities.”
