10.5826/dpc.1401a68
Introduction: Alopecia areata (AA) has diverse disease characteristics and multiple factors may interfere with the prognosis of the disease.
Objectives: In this study, the factors affecting the AA recurrence were evaluated.
Methods: A total of a hundred patients diagnosed with AA between June 2022 and March 2023 were included in this retrospective, cross-sectional study. The patients were divided into two groups according to the presence of outbreaks. Both groups were compared in terms of age, gender, disease duration, number of outbreaks, family history of AA, previous medical treatment history for AA, clinical type, disease severity, presence of accompanying nail findings, and trichoscopic and laboratory characteristics.
Results: Among 100 patients, male dominance was found (N = 69). Most of the patients had patchy disease (90/100), mild disease severity (88/100), and a solitary outbreak (65/100). Male gender, longer disease duration, family history, presence of S2 severity of alopecia tool score, trachyonychia, short vellus hairs in trichoscopic examination, hypothyroidism, and folic acid deficiency were factors for AA outbreaks. Male gender and the presence of a family member with AA in the family were defined as the independent prognostic factors for disease recurrence.
Conclusions: While demographic, laboratory, and clinical findings are factors for AA outbreaks in the follow-up, male gender and family history should be considered independent predictors.
text/xml
2160-9381
3615
en
Didem Kazan
https://creativecommons.org/licenses/by-nc/4.0
Dermatology Practical & Conceptual
trichoscopy
Evaluating the Effect of the Demographic, Trichoscopic and Laboratory Characteristics on The Recurrence of Alopecia Areata 
Text.Serial.Journal
https://dpcj.org/index.php/dpc
Original Article
2024-01-31
2023-07-05
2024-01-31
2024-02-21
e2024068
Dermatol Pract Concept
Introduction: Alopecia areata (AA) has diverse disease characteristics and multiple factors may interfere with the prognosis of the disease.
Objectives: In this study, the factors affecting the AA recurrence were evaluated.
Methods: A total of a hundred patients diagnosed with AA between June 2022 and March 2023 were included in this retrospective, cross-sectional study. The patients were divided into two groups according to the presence of outbreaks. Both groups were compared in terms of age, gender, disease duration, number of outbreaks, family history of AA, previous medical treatment history for AA, clinical type, disease severity, presence of accompanying nail findings, and trichoscopic and laboratory characteristics.
Results: Among 100 patients, male dominance was found (N = 69). Most of the patients had patchy disease (90/100), mild disease severity (88/100), and a solitary outbreak (65/100). Male gender, longer disease duration, family history, presence of S2 severity of alopecia tool score, trachyonychia, short vellus hairs in trichoscopic examination, hypothyroidism, and folic acid deficiency were factors for AA outbreaks. Male gender and the presence of a family member with AA in the family were defined as the independent prognostic factors for disease recurrence.
Conclusions: While demographic, laboratory, and clinical findings are factors for AA outbreaks in the follow-up, male gender and family history should be considered independent predictors.
Didem Kazan
2024/01/31
10.5826/dpc.1401a68
e2024068
Kutahya Health Sciences University Evliya Celebi Education and Research Hospital, Kutahya, Turkey
2160-9381
trichoscopy
en
e2024068
Goksin S. Retrospective evaluation of clinical profile and comorbidities in patients with alopecia areata. North Clin Istanb. 2022;9(5):451-458. DOI: 10.14744/nci.2022.78790. PMID: 36447582. PMCID: PMC9677058.
Evaluating the Effect of the Demographic, Trichoscopic and Laboratory Characteristics on The Recurrence of Alopecia Areata 
https://dpcj.org/index.php/dpc/article/download/3615/2414
            Evaluating the Effect of the Demographic,
           Trichoscopic and Laboratory Characteristics
               on The Recurrence of Alopecia Areata
                                                          Didem Kazan1


1 Kutahya Health Sciences University Evliya Celebi Education and Research Hospital, Kutahya, Turkey



Key words: alopecia areata, recurrence, dermoscopy, trichoscopy
Citation: Kazan D. Evaluating the Effect of the Demographic, Trichoscopic and Laboratory Characteristics on The Recurrence of Alopecia
Areata. Dermatol Pract Concept. 2024;14(1):e2024068. DOI: https://doi.org/10.5826/dpc.1401a68
Accepted: September 20, 2023; Published: January 2024
Copyright: ©2024 Kazan. This is an open-access article distributed under the terms of the Creative Commons Attribution-NonCommercial
License (BY-NC-4.0), https://creativecommons.org/licenses/by-nc/4.0/, which permits unrestricted noncommercial use, distribution, and
reproduction in any medium, provided the original authors and source are credited.
Funding: This work was supported by the Research Council of Shiraz University of Medical Sciences under Grant 22355.
Competing Interests: None.
Corresponding Author: Didem Kazan, Kutahya Health Sciences University Evliya Celebi Education And Research Hospital, Kutahya,
Turkey. Business tel: +90 2742236053 E-mail: didem.senses_343@hotmail.com




  ABSTRACT             Introduction: Alopecia areata (AA) has diverse disease characteristics and multiple factors may inter-
                       fere with the prognosis of the disease.
                       Objectives: In this study, the factors affecting the AA recurrence were evaluated.
                       Methods: A total of a hundred patients diagnosed with AA between June 2022 and March 2023
                       were included in this retrospective, cross-sectional study. The patients were divided into two groups
                       according to the presence of outbreaks. Both groups were compared in terms of age, gender, disease
                       duration, number of outbreaks, family history of AA, previous medical treatment history for AA,
                       clinical type, disease severity, presence of accompanying nail findings, and trichoscopic and laboratory
                       characteristics.
                       Results: Among 100 patients, male dominance was found (N = 69). Most of the patients had patchy
                       disease (90/100), mild disease severity (88/100), and a solitary outbreak (65/100). Male gender, longer
                       disease duration, family history, presence of S2 severity of alopecia tool score, trachyonychia, short
                       vellus hairs in trichoscopic examination, hypothyroidism, and folic acid deficiency were factors for AA
                       outbreaks. Male gender and the presence of a family member with AA in the family were defined as
                       the independent prognostic factors for disease recurrence.
                       Conclusions: While demographic, laboratory, and clinical findings are factors for AA outbreaks in the
                       follow-up, male gender and family history should be considered independent predictors.




Original Article | Dermatol Pract Concept. 2024;14(1):e2024068                                                                       1
Introduction                                                        together with their families, and the pediatric patient volun-
                                                                    teer form was obtained.
Alopecia areata (AA) is an autoimmune, organ-specific hair             All patients age, gender, disease duration, number of out-
disease that develops as a result of damage to hair follicles       breaks, family history of AA, clinical type, disease severity,
by sensitive T lymphocytes and progresses with non-scarring         presence of accompanying nail findings, and trichoscopic and
hair loss. Although the pathophysiology of the disease is not       laboratory characteristics were obtained from the hospital
fully understood, genetic factors that predispose to autoim-        registry system and recorded in the case report files. Tricho-
mune diseases and environmental factors such as infection           scopic examination was performed with Plusmed. Disease se-
and/or emotional stress are blamed. It mostly affects individ-      verity was evaluated by the severity of alopecia tool (SALT)
uals younger than 30. Non-scarring oval patches in 1-3 cm           classification based on affected hair loss area of scalp and
diameter on the scalp are the most common clinical form.            scored as S0 (0%), S1 (<25%), S2 (25–49%), S3 (50–74%),
In addition, there are other clinical forms such as ophiasis        S4 (75–99%) and S5 (100%) [7]. The patients were divided
in which hair loss is observed on the temporal and occipital        into two groups according to the number of outbreaks non-­
areas of the scalp, and the central area of the scalp is pro-       recurrent disease and recurrent disease. The patients with the
tected, ophiasis inversus with the hair loss on the central area    first outbreak were included in the group of non-recurrent dis-
of the scalp, reticular type, and diffuse types, such as totalis    ease. The patients with 2 and more outbreaks were included in
(total scalp hair loss) and universalis (total body and scalp       the group of recurrent disease. In terms of age, gender, disease
hair loss) [1].                                                     duration, number of outbreaks, family history of AA, clinical
    Although the clinical examination is often sufficient in        type, disease severity, presence of accompanying nail findings,
the diagnosis of the disease, trichoscopic findings could also      and trichoscopic and laboratory characteristics, the statistical
help clinicians. These trichoscopic findings are yellow dots,       relationship between the two groups was investigated.
black dots, short vellus hairs, broken hairs, exclamation
mark hairs, and pigtail hairs [2].                                  Statical Analysis
    There are many studies regarding clinical findings and          Statistical analysis was done with IBM SPSS v20.0 (IBM
trichoscopic and laboratory features of AA, however, the            Corp.). Numerical variables were given as mean ± standard
results are controversial. There is also no comprehensive           deviation or median (25th-75th percentile). Categorical vari-
evaluation examining the demographic, trichoscopic, and             ables were given as frequency (percentage). Relationship be-
laboratory characteristics of patients with AA from our             tween categorical variables were evaluated using chi-square
region. Also, to date disease, recurrence is associated with        analysis. Binary logistic regression was performed for uni-
stressful life events, the presence of a family member with         variate and multivariate analysis and P value less than 0.05
AA, COVID-19 infection, and vaccination [3-6]. However,             was considered as statistically significant.
more comprehensive studies are needed on this subject [6].             Comparing the family history rates between the
                                                                    non-recurrent and recurrent alopecia areata groups, we cal-
Objectives                                                          culated the effect size of W=2.02 using SPSS. A post-hoc test
                                                                    was conducted using G*power version 3.1 for power analy-
Therefore, in this study, the demographic, trichoscopic, and        sis. With a significance criterion of α= 0.05 and 35 patients in
laboratory characteristics of patients with AA in our region        each group. The power of the study was calculated as 0.98.
were examined. Also, the relationship between disease char-
acteristics and the recurrence of AA was analyzed.
                                                                    Results
Methods                                                             A total of a hundred patients, 31 (31%) female and 69 (69%)
                                                                    male patients who applied to dermatology clinic due to AA
Study Design                                                        were included in the study. The prevalence of the disease
This study is a descriptive, retrospective, and a cross-sectional   was calculated as 1.5% (100/6600). In terms of outbreaks,
study. It was carried out in a tertiary dermatology center          the patients were divided into two groups. Sixty-five (65%)
after the ethics committees approval (Approval number:              patients who had one outbreak were grouped as Group 1
2023/06-17). A hundred patients who were admitted to the            (non-recurrent disease). Other 23 (23%) patients who had
dermatology outpatient clinic between June 2022 and March           two outbreaks, and 12 (12%) patients who had three out-
2023 and diagnosed with AA were included in the study.              breaks were grouped together as Group 2 (recurrent disease).
The patients older than 18 gave an informed patient con-               Patients’ demographic and clinical features were sum-
sent form. The patients under the age of 18 were informed           marized in Table 1. The rate of male gender, long ­disease




2                                                                       Original Article | Dermatol Pract Concept. 2024;14(1):e2024068
                                     Table 1. Patients demografic and clinic features.
                                                                  Non-Recurrent Disease         Recurrent Disease
                  Demographic features                                  (N = 65)                    (N = 35)        P value
 Gender
 -Female                                                                 25 (38.5%)                 6 (17.1%)       0.028a
 -Male                                                                   40 (61.5%)                29 (82.9%)
 Age (mean+SD, year)                                                     26.2 + 14.8               31.2 + 11.8      0.096
 Disease duration (mean+SD, month)                                       1.71 + 0.92               2.34 + 1.01      0.002a
 Number of outbreaks
 1                                                                       65a (100%)                 0b (0%)
                                                                                                                    0.001a
 2                                                                         0a (0%)                23 b (65.7%)
 3                                                                        0 a (0%)                12 b (34.3%)
 The presence of family member with AA
 Absent                                                                  61 (93.8%)                18 (51.4%)       0.001a
 Present                                                                  4 (6.2%)                 17 (48.6%)
 Additional dermatological disease
 Absent                                                                   52 (80%)                 30 (85.7%)
 Androgenetic alopesia                                                    4 (6.2%)                  2 (5.7%)
 Seborrheic dermatitis                                                    5 (7.7%)                   0 (0%)         0.370
 Acne vulgaris                                                            1 (1.5%)                  2 (5.7%)
 Telogen effluvium                                                        2 (3.1%)                   0 (0%)
 Vitiligo                                                                 1 (1.5%)                  1 (2.9%)
 Previous medical treatment history
 Topical steroid                                                          13 (20%)                  5 (14.3%)
 Topical steroids + topical minoxidil                                    37 (56.9%)                23 (65.7%)       0.842
 Intralesional steroid                                                    8 (12.3%)                 4 (11.4%)
 Intramuscular steroid                                                    7 (10.8%)                 3 (8.6%)
 Additional systemic disease
 Absent                                                                  60a (92.3%)               27b (77.1%)
                                                                                                                    0.043a
 Autoimmune hypothyroidism                                                2a (3.1%)                 6b (17.1%)
 Type-1 diabetes mellitus                                                 3a (4.6%)                  2a (5.7%)
 Clinical features
 Clinical type
 Patchy type                                                             64a (98.5%)               26b (74.3%)
 Reticular type                                                            0a (0%)                  5b (14.3%)      0.001a
 Ofiasis type                                                              0a (0%)                   3b (8.6%)
 Alopecia totalis                                                         1a (1.5%)                  1a (2.9%)
 Disease severity (SALT score)
 S1                                                                      62a (95.4%)               18b (51.4%)
 S2                                                                       2a (3.1%)                6b (17.1%)
                                                                                                                    0.001a
 S3                                                                        0a (0%)                 8b (22.9%)
 S4                                                                        0a (0%)                  2a (5.7%)
 S5                                                                       1a (1.5%)                 1a (2.9%)
 Hair pull test
 Positive                                                                34 (52.3%)                17 (48.6%)       0.721
 Negative                                                                31 (47.7%)                18 (51.4%)
 Accompying nail finding
 Absent                                                                   52a (80%)                18b (51.4%)
 Pitting                                                                  9a (13.8%)                6a (17.1%)      0.015a
 Trachyonychia                                                             2a (3.1%)               11b (31.4%)
 Beau lines                                                                2a (3.1%)                 0a (0%)

AA = Alopecia Areata; SALT = severity of alopecia tool; SD = standard deviation.
a
 p<0.05, Chi-square test for categorical, Independent samples t-test for numerical variables.




Original Article | Dermatol Pract Concept. 2024;14(1):e2024068                                                                3
duration, presence of a family member with AA, accompa-            atopy, vitiligo, and thyroid disease had a statistically signif-
nying autoimmune hypothyroidism, ophiasis, and reticulary          icant relationship with disease severity [11]. Agre et al also
clinical type, presence of S2 and S3 SALT score, and accom-        reported that having a first-degree relative with AA was a
panying nail finding (pitting and trachionychia) were higher       risk factor for recurrence [12]. In this study, there is a sta-
in Group-2 than Group-1 (P = 0.028, P = 0.002, P = 0.001,          tistically significant relationship between the male gender,
P = 0.043, P = 0.001, P = 0.001, and P = 0.015, respectively).     long disease duration, the presence of a family member with
There was no significant relationship between groups in            AA, and accompanying autoimmune hypothyroidism and
terms of previous medical treatment (P = 0.842). The pa-           disease outbreak. Male gender, accompanying autoimmune
tients trichoscopic and laboratory findings were compiled in
Table 2. Short vellus hairs, hypothyroidism, and folic acid             Table 2. Patients dermoscopic and laboratory
deficiency rates were higher in Group 2 than in Group 1                                    features.
(P = 0.031, P = 0.001, and P = 0.037, respectively).                                         Non-
    Univariate and multivariate analysis results were shown             Dermoscopic        Recurrent       Recurrent        P value
in Table 3. According to these results, the female gender was             features          Disease         Disease
associated with a lower outbreak rate. However, long disease           Exclamation
                                                                       mark hairs
duration, the presence of a family member with AA, the pres-                                                                0.463
                                                                       Absent              23 (35.4%) 15 (42.9%)
ence of S2 SALT score, accompanying trachyonychia, the
                                                                       Present             42 (64.6%) 20 (57.1%)
presence of short vellus hairs in trichoscopic examination,
                                                                       Black dots
hypothyroidism, and folic acid deficiency were associated              Absent              31 (47.7%) 17 (48.6%)            0.933
with higher outbreak rate. In multivariate analysis, female            Present             34 (52.3%) 18 (51.4%)
gender was found to be an independent prognostic factor                Short vellus
in a lower outbreak rate, whereas the presence of a family             hairs
                                                                                                                            0.031a
member with AA was found to be an independent prognostic               Absent               48(73.8%) 17 (48.6%)
factor in a higher outbreak rate.                                      Present             17 (26.2%) 18 (51.4%)
                                                                       Split hairs
                                                                       Absent              32 (49.2%) 19 (54.3%)            0.630
Conclusions                                                            Present             33 (50.8%) 16 (45.7%)
                                                                       Yellow dots
In this study, the characteristics of patients with AA who at-
                                                                       Absent               33(50.8%) 19 (54.3%)            0.737
tended the dermatology clinic were analyzed and the factors            Present             32 (49.2%) 16 (45.7%)
affecting disease recurrence were defined. The most import-            Pigtail hairs
ant finding of the demographic features of the patients was            Absent              47 (72.3%) 23 (65.7%)            0.493
male dominance. Most of the patients had patchy disease                Present             18 (27.7%) 12 (34.3%)
(90/100), mild disease severity (88/100), and a solitary out-          Laboratory findings
break (65/100). Female gender was found to be an indepen-              Iron deficiency
dent prognostic factor in a lower outbreak rate, whereas the           Absent              38 (58.5%) 27 (77.1%)            0.062
presence of a family member with AA was found to be an                 Present             27 (41.5%)  8 (22.9%)
independent prognostic factor in a higher outbreak rate.               Vitamin B12
    In contrast to recent studies, male dominance (69%) was            deficiency
                                                                                                                            0.051
                                                                       Absent              49 (75.4%) 32 (91.4%)
detected in the study [8,9]. This result may be related to the
                                                                       Present             16 (24.6%)   3 (8.6%)
fact that men notice hair loss earlier than women due to
                                                                       25-OH vitamin
shorter hair. In addition, regular visits to the hairdresser may
                                                                       D deficiency
lead to routine scalp control and earlier awareness of hair                                                                 0.209
                                                                       Absent              55 (84.6%) 26 (74.3%)
loss than women. Furthermore, the fact that women in our               Present             10 (15.4%)  9 (25.7%)
region often cover their hair may also cause them to realize           Hypothyroiditis
hair loss later than men.                                              Absent              64 (98.5%) 27 (77.1%)            0.001 a
    Several studies investigated the effect of demographic,            Present               1 (1.5%)  8 (22.9%)
clinic, and trichoscopic features on the severity of AA. Ka-           Folic acid
vak et al reported that ophiasis type, onset in childhood,             deficiency
                                                                                                                            0.037 a
                                                                       Absent              62 (95.4%) 29 (82.9%)
and presence of a family member with AA showed a posi-
                                                                       Present               3 (4.6%)   6(17.1%)
tive correlation with disease severity [10]. Also, Bhardwaj
et al reported that female gender, early onset, accompanying       a
                                                                   p<0.05, Chi-square test for categorical variables




4                                                                         Original Article | Dermatol Pract Concept. 2024;14(1):e2024068
                          Table 3. The independent prognostic factors of disease recurrence
                                                                 Univarite Analysis                         Multivariate Analysis
                                                      OR               C.I.            P value         OR           C.I.      P value
 Female gender                                       0.33          0.120-0.910          0.032        0.14       0.026-0.719    0.019
 Disease duration                                    2.43          1.442-4.110          0.001
 The presence of a family member with AA             14.40         4.297-48.272         0.001        16.3      2.792-95.189    0.002
 SALT score
 S1                                                  Ref               Ref
 S2                                                  10.3          1.918-55.674         0.007
 S3                                                   5.6              0.0-              0.99
 S4                                                   5.6              0.0-              0.99
 S5                                                   3.4          0.205-57.847          0.39
 Accompanying trachyonychia                          2.22          1.290-3.808          0.004
 Accompaying autoimmune hypothyroiditis              18.96        2.260-159.086         0.007
 Short vellus hairs                                  2.99          1.261-7.089          0.013
 Folic acid deficiency                               4.28          0.999-18.308          0.05

AA = Alopecia Areata; C.I. = Confidence Interval; OR = Odds Ratio; SALT = severity of alopecia tool.



hypothyroidism, and the presence of a family member with                      Due to its chronic autoimmune nature, low ferritin,
AA can be considered as demographic findings indicating the            ­vitamin B12, and vitamin D levels could accompany AA.
genetic basis of the disease. Therefore, patients with these           Numerous studies showed that patients with AA have
                                                                       ­
demographic characteristics may have more frequent out-                ­vitamin and mineral deficiencies [18-20]. In this study, fo-
breaks. Long disease duration, on the other hand, may cause            lic acid deficiency had a statistically significant relationship
frequent outbreaks by causing high inflammation levels and             with disease recurrence. This result may suggest that vitamin
the presence of excess memory T cells in the tissue [13].              deficiencies that are effective in hair follicle growth may also
    The SALT score evaluation provides clinicians with                 trigger disease recurrence.
great benefits in the evaluation of the treatment response of                 Trichoscopy is a noninvasive diagnostic tool and helps
patients with AA. To date, it has been evaluated in recent             clinicians in the diagnosis of alopecia areata. However, the
studies to show the efficacy of many drugs in the treatment            relationship between AA disease severity and dermoscopy
of AA and also to determine the prognosis of the disease               findings is controversial. Abhijet et al reported that yellow
[14-16]. However, no other study previously reported the               dots are the most common trichoscopic finding in AA [21].
relationship between the SALT score of the patients and dis-           They also declared a statistically significant correlation be-
ease recurrence. In this study, the rate of S1 was higher in           tween yellow dots and disease severity, and an inversely pro-
non-recurrent disease group, on the other way both S2 and              portional between short vellus hairs and disease severity. In
S3 were higher in recurrent disease group. This result should          this study, the presence of short vellus hairs had a significant
direct us that patients with S2 and S3 are more prone to fre-          relationship with outbreaks. This relationship may be asso-
quent outbreaks due to intense inflammation and memory T               ciated with more vellus hairs due to hair regrowth in those
cell in the tissue [9].                                                patients after outbreaks.
    The prevalence of accompanying nail findings in AA has                    The most important limitation of this study is its ret-
been reported at rates between 7% and 66%. The most fre-               rospective design and having unequal number of patients
quently described nail findings are trachyonychia and pitting          in each group. The strengths of the study were that it in-
of the nails. Other possible deviations are leukonychia, ony-          vestigated the factors affecting disease recurrence with a
cholysis, and onychomadesis. Patients with high SALT scores            high number of patients and showed the effect of clinical,
are more likely to manifest nail alterations [1,17]. In this           trichoscopic, and laboratory features on disease recurrence.
study, pitting and trachyonychia were the most common nail             Future studies with a higher number of patients, investigat-
findings, and beau lines were also detected in 2 patients. Ac-         ing the genetic background in more detail, will increase our
companying nail finding was related with disease recurrence            knowledge.
in our study. High systemic inflammation in patients with                     In Conclusion, demographic and clinical findings, vita-
AA could be a reason to have nail involvement and frequent             min and mineral deficiencies, and trichoscopic findings are
disease recurrence.                                                    essential clues for clinicians in the follow-up of patients




Original Article | Dermatol Pract Concept. 2024;14(1):e2024068                                                                         5
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6                                                                                 Original Article | Dermatol Pract Concept. 2024;14(1):e2024068
