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Epidemiologic Association
Between Atopic Dermatitis and
Alopecia Areata
IEC-NAAF Symposium
February 28, 2019
Aaron Drucker...
Disclosures
• Research and
institutional funding
• Sanofi
• Regeneron
• Consultant
• Sanofi
• RTI Health Solutions
• CADTH...
Objective
• Describe the epidemiologic evidence for associations between atopic
dermatitis and alopecia areata
Global age-standardized Prevalence
GBD Study. https://vizhub.healthdata.org/gbd-compare/
ATOPIC DERMATITIS – 3%
ALOPECIA A...
Global Disability-Adjusted Life Years
Non-Communicable Skin diseases
Other
Decubitus ulcer
Urticaria
Alopecia areata
Itch
...
Atopic dermatitis and immune-related
comorbidities
Atopic march
Atopic dermatitis
(skin barrier
dysfunction and
inflammation)
Food allergy Hayfever Asthma
Atopic Dermatitis Pathogenesis Basics
• Outside-in: Epidermal barrier disruption
• Filaggrin, proteases
• Allows antigens ...
Is atopic dermatitis associated with
autoimmune comorbidities?
Alopecia areata Multiple sclerosis
Ankylosing spondylitis P...
Association of atopic dermatitis with any
autoimmune comorbidity
Odds ratio (Log scale)
OR 2.48
OR 3.46
OR 5.32
Andersen e...
Is atopic dermatitis associated with
autoimmune comorbidities?
Alopecia areata Multiple sclerosis
Ankylosing spondylitis P...
Why?
• Genetic predisposition to inflammatory conditions
• Poorly understood environmental triggers
• Detection (surveilla...
Atopic dermatitis and alopecia areata:
The evidence
Registry study
• Case-control study
• Alopecia areata cases: National Alopecia Areata Registry – self report
• Controls: N...
Population
Alopecia areata
(n=2,055)
Controls
(n=558)
Age, mean (SD) 38.5 (17.8) 40.8 (14.7)
Sex, N (%)
Female 1476 (71.8)...
Association between atopic dermatitis and
alopecia areata
Odds ratio (95% CI)
Atopic dermatitis and alopecia areata 2.61 (...
Atopic Dermatitis and Alopecia Areata
Modified from Mohan and Silverberg. JAMA Dermatol. 2015 May;151(5):522-8.
OR: 2.57, ...
Atopic dermatitis and alopecia areata severity
Mohan and Silverberg. JAMA Dermatol. 2015 May;151(5):522-8.
OR: 1.22, 95% C...
Nurses’ Health Study 2
• Cohort study
• Alopecia areata cases: self-report diagnosis and year of diagnosis
• Atopic dermat...
Population
No atopic dermatitis
(n=78,172)
Atopic dermatitis
(n=9,234)
Age
*
54.5 (4.7) 54.4 (4.6)
Race
White, % 96 95
His...
Association between atopic dermatitis and
alopecia areata
Alopecia cases Non-cases Adjusted OR
No AD 121 78,051
AD 26 9,20...
Population-based data (Denmark)
• Cross-sectional study
• Adults with AD matched with 5 controls (age, sex, time)
• Alopec...
Population
Atopic dermatitis
(n = 8,112)
Controls
(n = 40,560)
Mean age, y (SD) 42.42 (15.16) 42.42 (15.16)
Women, n (%) 4...
Association between Atopic Dermatitis and
Alopecia Areata
AD, n (%) Controls, n (%) Adjusted OR, 95% CI
General population...
Gaps to fill
• Large studies in children
• Inclusion of people with different ethnic backgrounds
• Studies with validated ...
Summary
• Atopic dermatitis is associated with autoimmune comorbidities,
including alopecia areata, in large epidemiologic...
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Epidemiologic association between atopic dermatitis and alopecia areata

Presented at the joint International Eczema Council and National Alopecia Areata Foundation Symposium, "Atopic Dermatitis and Alopecia Areata: Comparison and Contrast”, held during the 2019 Annual American Academy of Dermatology meeting in Washington, DC to explore the similarities and differences between these two common but complex skin diseases and the implications from bench to bedside.

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Epidemiologic association between atopic dermatitis and alopecia areata

  1. 1. Epidemiologic Association Between Atopic Dermatitis and Alopecia Areata IEC-NAAF Symposium February 28, 2019 Aaron Drucker, MD, ScM, FRCPC Assistant Professor, University of Toronto Scientist, Women’s College Research Institute @aaron_drucker
  2. 2. Disclosures • Research and institutional funding • Sanofi • Regeneron • Consultant • Sanofi • RTI Health Solutions • CADTH (Canadian Agency for Drugs and Technology in Health) • Honoraria • Astellas Canada • Prime Inc • Spire Learning • CME Outfitters • Eczema Society of Canada My family has relationships with: AbbVie, Eli Lilly and Company, GlaxoSmithKline, Intarcia Therapeutics, Janssen Pharmaceuticals, Kallyope, Merck & Co., Novartis, Novo Nordisk, Pfizer, Shire , Zafgen
  3. 3. Objective • Describe the epidemiologic evidence for associations between atopic dermatitis and alopecia areata
  4. 4. Global age-standardized Prevalence GBD Study. https://vizhub.healthdata.org/gbd-compare/ ATOPIC DERMATITIS – 3% ALOPECIA AREATA – 0.25%
  5. 5. Global Disability-Adjusted Life Years Non-Communicable Skin diseases Other Decubitus ulcer Urticaria Alopecia areata Itch Acne Psoriasis Dermatitis GBD Study. https://vizhub.healthdata.o rg/gbd-compare/
  6. 6. Atopic dermatitis and immune-related comorbidities
  7. 7. Atopic march Atopic dermatitis (skin barrier dysfunction and inflammation) Food allergy Hayfever Asthma
  8. 8. Atopic Dermatitis Pathogenesis Basics • Outside-in: Epidermal barrier disruption • Filaggrin, proteases • Allows antigens and irritants in • Inside-out: Th2 inflammatory cytokines (IL-4, IL-13, IL-22, IL-25, IL-31)… • Suppress epidermal structure protein synthesis • Induce proteases Malajian D, Guttman-Yassky E. Cytokine. 2015 Jun;73(2):311-8.
  9. 9. Is atopic dermatitis associated with autoimmune comorbidities? Alopecia areata Multiple sclerosis Ankylosing spondylitis Primary biliary cirrhosis Celiac disease Pulmonary fibrosis Chronic glomerulonephritis Rheumatoid arthritis Chronic urticaria Sjögren syndrome Crohn's disease Systemic lupus erythematosus Giant cell arteritis Systemic sclerosis Graves' disease Type 1 diabetes Hashimoto thyroiditis Ulcerative colitis Hemolytic anemia Vitiligo Immune thrombocytopenia purpura Andersen et al. J Am Acad Dermatol. 2017 Feb;76(2):274-280.
  10. 10. Association of atopic dermatitis with any autoimmune comorbidity Odds ratio (Log scale) OR 2.48 OR 3.46 OR 5.32 Andersen et al. J Am Acad Dermatol. 2017 Feb;76(2):274-280.
  11. 11. Is atopic dermatitis associated with autoimmune comorbidities? Alopecia areata Multiple sclerosis Ankylosing spondylitis Primary biliary cirrhosis Celiac disease Pulmonary fibrosis Chronic glomerulonephritis Rheumatoid arthritis Chronic urticaria Sjögren syndrome Crohn's disease Systemic lupus erythematosus Giant cell arteritis Systemic sclerosis Graves' disease Type 1 diabetes Hashimoto thyroiditis Ulcerative colitis Hemolytic anemia Vitiligo Immune thrombocytopenia purpura Andersen et al. J Am Acad Dermatol. 2017 Feb;76(2):274-280.
  12. 12. Why? • Genetic predisposition to inflammatory conditions • Poorly understood environmental triggers • Detection (surveillance) bias
  13. 13. Atopic dermatitis and alopecia areata: The evidence
  14. 14. Registry study • Case-control study • Alopecia areata cases: National Alopecia Areata Registry – self report • Controls: Non-blood relatives • Identified through internet ads, participants friends, invetigators… • Atopic dermatitis: assessed by self-report • Only included if onset PRIOR to Alopecia areata Barahmani et al. J Am Acad Dermatol. 2009 Oct;61(4):581-91.
  15. 15. Population Alopecia areata (n=2,055) Controls (n=558) Age, mean (SD) 38.5 (17.8) 40.8 (14.7) Sex, N (%) Female 1476 (71.8) 361 (64.7) Male 579 (28.2) 197 (35.3) Race, N (%) African American 121 (5.9) 31 (5.5) Hispanic 106 (5.2) 55 (9.9) Caucasian 1828 (88.9) 472 (84.6)
  16. 16. Association between atopic dermatitis and alopecia areata Odds ratio (95% CI) Atopic dermatitis and alopecia areata 2.61 (1.78-3.83) Atopic dermatitis and alopecia totalis/universalis 2.98 (1.95-4.55) Alopecia totalis/universalis vs milder alopecia 1.24 (0.95-1.61)
  17. 17. Atopic Dermatitis and Alopecia Areata Modified from Mohan and Silverberg. JAMA Dermatol. 2015 May;151(5):522-8. OR: 2.57, 95% CI 2.25-2.94
  18. 18. Atopic dermatitis and alopecia areata severity Mohan and Silverberg. JAMA Dermatol. 2015 May;151(5):522-8. OR: 1.22, 95% CI 1.01-1.48
  19. 19. Nurses’ Health Study 2 • Cohort study • Alopecia areata cases: self-report diagnosis and year of diagnosis • Atopic dermatitis cases: self-report diagnosis and year of diagnosis Drucker et al. Allergy. 2017 May;72(5):831-834.
  20. 20. Population No atopic dermatitis (n=78,172) Atopic dermatitis (n=9,234) Age * 54.5 (4.7) 54.4 (4.6) Race White, % 96 95 Hispanic, % 0.1 0.1 Black, % 1 2 Asian, % 1 2 Drucker et al. Allergy. 2017 May;72(5):831-834.
  21. 21. Association between atopic dermatitis and alopecia areata Alopecia cases Non-cases Adjusted OR No AD 121 78,051 AD 26 9,208 1.80 (1.18–2.76)
  22. 22. Population-based data (Denmark) • Cross-sectional study • Adults with AD matched with 5 controls (age, sex, time) • Alopecia areata and atopic dermatitis identified through ICD codes • Secondary analysis: AD patients compared with hyperhidrosis patients Andersen et al. J Am Acad Dermatol. 2017 Feb;76(2):274-280.
  23. 23. Population Atopic dermatitis (n = 8,112) Controls (n = 40,560) Mean age, y (SD) 42.42 (15.16) 42.42 (15.16) Women, n (%) 4982 (61.42) 24,910 (61.42)
  24. 24. Association between Atopic Dermatitis and Alopecia Areata AD, n (%) Controls, n (%) Adjusted OR, 95% CI General population Alopecia areata 77 (0.95) 13 (0.03) 26.31 (14.48-47.80) Hyperhidrosis controls 6.51 (3.34-12.72)
  25. 25. Gaps to fill • Large studies in children • Inclusion of people with different ethnic backgrounds • Studies with validated case definitions • High-quality studies examining the impact of comorbid atopic dermatitis and alopecia areata on: • Severity • Prognosis
  26. 26. Summary • Atopic dermatitis is associated with autoimmune comorbidities, including alopecia areata, in large epidemiologic studies • Some of this association is explained by detection bias • It is unclear whether atopic dermatitis is associated with worse alopecia areata and vice versa
  • SandeepSurse

    Apr. 16, 2019

Presented at the joint International Eczema Council and National Alopecia Areata Foundation Symposium, "Atopic Dermatitis and Alopecia Areata: Comparison and Contrast”, held during the 2019 Annual American Academy of Dermatology meeting in Washington, DC to explore the similarities and differences between these two common but complex skin diseases and the implications from bench to bedside.

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