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Alopecia areata (AA) is a complex autoimmune condition that causes nonscarring hair loss. It typically presents with sharply demarcated round patches of hair loss and may present at any age. In this article, we review the epidemiology, clinical features, pathogenesis, and new treatment options of AA, with a focus on the immunologic mechanism underlying the treatment. While traditional treatment options such as corticosteroids are moderately effective, a better understanding of the disease pathogenesis may lead to the development of new treatments that are more directed and effective against AA. Sources were gathered from PubMed, Embase, and the Cochrane database using the keywords: alopecia, alopecia areata, hair loss, trichoscopy, treatments, pathogenesis, and epidemiology.

Alopecia areata/AA is an autoimmune cause of nonscarring hair loss. The pathogenesis of AA involves many immune axes, including Th1/Th2 pathways. Delgocitinib is a pan-Janus kinase/JAK inhibitor that broadly blocks pro-inflammatory cytokines and has been effective in other inflammatory skin conditions. Recent human studies/reports have shown that use of some systemic JAK inhibitors led to hair regrowth, suggesting this medication class as a potential therapy for AA. However, topical treatment is desirable due to potential systemic side effects. To assess the efficacy and safety of topical delgocitinib in AA, we conducted a double-blind, randomized, vehicle-controlled clinical trial in 31 moderate-to-severe AA patients that were randomized 2:1 to receive delgocitinib ointment 30 mg/g ( n  = 20) or ointment vehicle ( n  = 11) for 12 weeks. The primary endpoint was change in severity of Alopecia Tool/SALT score from baseline to week 12. The secondary endpoint included safety profile by reported adverse events. Twenty-three subjects completed the trial, with eight discontinuing mostly due to voluntary withdrawal. Ten patients receiving delgocitinib ointment and three patients receiving vehicle showed SALT score improvements after 12 weeks, but the mean percent SALT improvement at week 12 compared to baseline between the two arms was not significant ( p  = 0.92). Our study suggests that delgocitinib ointment is not effective in moderate-to-severe AA, likely due to its inability to penetrate sufficiently deeply into the dermis of the scalp, but larger studies are necessary to assess whether a different formulation of topical JAK inhibitors may be suitable to treat mild or more localized forms of AA.

Alopecia areata (AA) is primarily associated with a Type 1 (Th1) inflammatory response, but emerging evidence also suggests a potential contribution of Type 2 (Th2) immunity. However, the relationship between IgE levels and pathogenesis of AA, as well as its clinical features, remains unclear, with limited and conflicting evidence in current research. This study aims to compare the total serum IgE levels between AA patients without atopic diseases and healthy controls, and to examine the correlation of IgE levels with gender, age, disease severity, disease duration, and affection of eyebrows, eyelashes, and nails. AA patients without other hair loss diseases and conditions, or systemic treatment known to affect serum IgE were included. Medical records of 436 patients and 181 normal controls were retrospectively analyzed between May 2018 and November 2024. Among AA patients, clinical features and total serum IgE levels were analyzed. The elevated total serum IgE rate was observed in 31.0% of AA patients, which was significantly higher than that in control groups (P < 0.001). Among AA patients, total serum IgE levels differed significantly by gender (P = 0.002), age (P < 0.001), and disease severity (P = 0.040). Patients with alopecia universalis or totalis (AU/AT) had higher total serum IgE levels compared to those with localized AA (P = 0.049). No significant correlation was found between total serum IgE levels and disease duration. Our research reveal that total serum IgE levels are elevated in AA patients compared to control group. Male patients, children, and individuals with moderate-severe AA patients showed significantly higher IgE levels. These results suggest the involvement of IgE and Th2 cytokines in AA pathogenesis.

Dupilumab is an interleukin (IL)-4 receptor alpha antagonist that showed significant improvement of atopic dermatitis (AD). Many reports have shown significant resolution of alopecia areata, alopecia universalis, and alopecia totalis after dupilumab treatment for AD. We present one of the few reported cases that showed improvement of underlying alopecia universalis treated with dupilumab.

Rituximab, an anti-CD20 monoclonal antibody, is being used more frequently to treat refractory autoimmune disorders such as myasthenia gravis. While it is usually well tolerated, rare cases of paradoxical immune-mediated skin reactions have been rarely reported. However, the concurrent development of vitiligo and alopecia universalis following rituximab therapy has not been previously described. We report a rare case of simultaneous vitiligo and alopecia universalis developing during long-term treatment with rituximab in a patient with myasthenia gravis and discuss the clinical course and treatment response. This case report describes a 30-year-old woman with myasthenia gravis who developed vitiligo followed by alopecia universalis during a long term of Rituximab therapy. Cutaneous findings included well-demarcated depigmented patches on the trunks and bilateral arms and diffuse non-scarring alopecia affecting the scalp, eyebrows, eyelashes, and body hair, consistent with 100% score of Severity of Alopecia tool (SALT) indicating Alopecia universalis. Rituximab was discontinued due to a possible drug-reaction. Treatment with oral Baricitinib was initiated to target both vitiligo and alopecia universalis. Within three months, there was significant scalp hair regrowth and re-pigmentation of vitiligo patches with minimal adverse effects. This case highlights a unique temporal association of rituximab therapy and the simultaneous onset of vitiligo and alopecia universalis. Although the relationship between the drug and the onset of the skin diseases cannot be established, it is important to be aware of the possibility of immune-related skin adverse effects during rituximab therapy. Early intervention and the use of Janus kinase inhibitors, such as baricitinib, may lead to good clinical outcomes.

Alopecia areata (AA) is an autoimmune disease characterized by nonscarring hair loss. As a clinically heterogeneous disease, various classification systems have evolved for defining its severity. In this high-level review of the literature, we discuss the traditional classification systems for AA severity and their strengths and weaknesses. Most recent classifications have focused on the extent of scalp hair loss as a defining feature, but additional clinical aspects of the disease, including location, pattern, and duration of hair loss as well as impact on the patient’s quality of life, are also relevant. These various components have typically been used unidimensionally to classify patients. We propose a multidimensional framework to define AA severity that incorporates multiple patient- and illness-related domains. Using such a framework, dermatologists may better assess the severity of the disease for the individual patient beyond the extent of hair loss.

In response to the COVID-19 pandemic several vaccines were produced, including novel mRNA and viral vector-based vaccines. Though COVID-19 had its own associated dermatological sequelae, the vaccines were associated with a new set of cutaneous side effects, including hypersensitivity reactions, vasculitis, and autoimmune-mediated reactions. Notably, alopecia areata (AA) was reported in several patients closely following a COVID-19 vaccine, especially in those with a personal or family history of AA. A PubMed and Google Scholar search was conducted in July 2024 which resulted in 26 case reports/case series, 1 prospective study, and 3 cross-sectional retrospective chart reviews. Based on our holistic literature review, there is no evidence to support an increased association between COVID-19 vaccination and AA. Despite recent literature highlighting the incidence of de novo and recurrent AA after COVID-19 vaccines, several large retrospective analyses have shown that the overall incidence of AA in vaccinated individuals does not differ from that of historical controls. The potential for de novo AA after COVID-19 vaccine is low and the benefit of being vaccinated far outweighed the risks, especially within the first few years of COVID-19 vaccine rollout. While the decision to get vaccinated is a personal choice, the threat of developing AA secondary to vaccination should not be a deterrent.

Alopecia universalis (AU), an advanced form of alopecia areata (AA), is a condition characterized by the complete loss of hair over the entire skin surface. Recent progress has significantly enhanced our understanding of the pathogenesis of AU. In particular, interferon-γ (IFN-γ) and interleukin (IL)-15 seem to play a pivotal role in the pathogenesis of the disease. Nonetheless, a variety of medications has been used to treat the disease with frequently inconsistent results. Given the broad modulation of the immune system and inhibition of key molecules, including IFN-γ and IL-15, oral janus kinase (JAK) inhibitors represent a treatment option for moderate to severe cases of AA, as demonstrated in case reports supporting their efficacy and tolerability. We present the case of a patient suffering from psoriatic arthritis and AU who experienced a sudden improvement in peripheral arthritis and AU while receiving JAK1 selective treatment with upadacitinib. So far, there are very limited case reports of successful upadacitinib treatment for patients with AA, mostly in patients also suffering from atopic dermatitis. Thus, we provide evidence for the efficacy of upadacitinib in managing AU in adults, as well as in the context of inflammatory arthritis such as psoriatic arthritis.

Alopecia areata (AA) is an autoimmune hair loss disorder, with Janus kinase inhibitors (JAKis) emerging as an effective treatment. However, concerns about malignancy risk remain due to boxed warnings primarily based on studies in rheumatoid arthritis. This retrospective cohort study evaluated the association between JAKis and malignancy risk in AA using the TriNetX Global Collaborative Network. Patients with severe AA were categorized by treatment history, including JAKis, traditional immunosuppressants, and no systemic treatment. Propensity score-matched Cox proportional hazards models assessed the risks of squamous cell carcinoma (SCC)/basal cell carcinoma (BCC), internal malignancies, and hematologic malignancies. Among matched cohorts of 920 patients treated with traditional immunosuppressants and 920 treated with JAKis (mean follow-up: 1,302 and 1,229 days, respectively), SCC/BCC risk was not significantly different (HR = 0.324 [0.065, 1.609]). However, internal malignancy (HR = 4.906 [2.168, 11.101]) and hematologic malignancy (HR = 8.713 [1.104, 68.796]) risks were significantly higher with traditional immunosuppressants. No significant difference in malignancy risk was observed between 446 JAKi-treated and 446 untreated patients. These findings align with previous meta-analyses in autoimmune diseases, which have not linked JAKis to an increased malignancy risk. While this study found no evidence that JAKis elevate malignancy risk, the role of JAK-STAT signaling in cancer remains complex. Given AA’s unclear baseline malignancy risk and this study’s retrospective nature and limited follow-up, longer-term studies are needed to better understand the long-term safety of JAKis in AA and refine risk assessment and screening strategies.

Alopecia areata (AA) is an autoimmune disease of the hair follicles. It is characterized by a well-defined non-scarring alopecic patch or patches that may extend to the entire scalp or lead to total body hair loss. Due to its unpredictable clinical course, AA causes substantial psychological harm. Despite the high prevalence of this disease and extensive research, its exact pathomechanism is unclear, and current treatments have a high relapse rate that has deemed AA incurable. Over the past few decades, researchers have investigated multiple potential factors that may help alleviate its pathogenesis and provide effective treatment. Given its complex immunopathogenesis, AA is considered an autoimmune disease with multiple factors. This review gathers current evidence that emphasizes molecular mechanisms, possible causative etiologies, and targeted immunotherapies for AA. Understanding its underlying mechanisms may shed light on new strategies to effectively manage AA in the future.