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The Connection Between Alopecia Areata and Atopic Dermatitis

At the inaugural San Diego Dermatology Symposium, Natasha Mesinkovska, MD, covered a number of nonscarring alopecia topics, including the potential connection between alopecia areata and atopic dermatitis.1 Dr Mesinkovska is a dermatologist/dermatopathologist and vice chair of clinical research at the University of California, Irvine. She also serves as the chief scientific officer of National Alopecia Areata Foundation.

“Something that caught my eye from Dermatology World Weekly says, ‘Ask every patient you see if they are having an issue with their hair,’” said Dr Mesinkovska, only to then describe how many dermatologists fear addressing hair-related issues in their practice. “But hopefully I can make you feel a little bit better about these patients,” she continued.

Her presentation focused on three key areas: alopecia areata, scalp allergies, and tips from her clinic. “But one of the most interesting things that has really come out is the connection between areata and atopic dermatitis,” she said.

Historically, she noted, alopecia areata is considered a type 1 inflammatory disease, whereas atopic dermatitis is a type 2 inflammatory disease. However, alopecia areata is known to have many atopic comorbidities, including rhinitis, asthma, and atopic eczema. She noted that the literature has shown higher odds ratios for alopecia areata and atopic comorbidities. In addition, mast cells and eosinophils are found even in infiltrates around the hair bulbs as well as lymphocytes.

Dr Mesinkovska also pointed out that alopecia areata commonly follows a seasonal exacerbation pattern, with the autumn months seeing more cases vs the spring for children and adults. Interestingly, she pointed to studies by Putterman and Castelo-Soccio2 and Kim et al3 that demonstrated a seasonal severity fluctuations in atopic dermatitis.

“So this brings in a potential role for antihistamines for alopecia areata control,” explained Dr Mesinkovska. She stated that she regularly uses antihistamines in her patients who are cyclic shedders or who have seasonal allergies, even as prophylaxis. She identified 11 manuscripts on antihistamine use in alopecia areata, noting that the most published is fexofenadine in several case reports. Also included in the literature are ebastine, cimetidine, and hydroxyzine.

Another treatment with some clinical optimism is dupilumab. Citing 10 published cases, Dr Mesinkovska noted that 50% of the literature showing improvement in alopecia areata with 50% demonstrating new onset alopecia. She clarified that the new onset alopecia tends to be somewhat different on histology with more atrophic sebaceous glands.

Dr Mesinkovska recommended starting the patient with alopecia and eczema on dupilumab and seeing their results after a 3-month period.

References
1. Mesinkovska N. Non-scarring alopecia. Presented at:  San Diego Dermatology Symposium; September 11-13, 2020; virtual.

2. Putterman E, Castelo-Soccio L. Seasonal patterns in alopecia areata, totalis, and universalis. J Am Acad Dermatol. 2018;79(5):974-975. doi:10.1016/j.jaad.2018.06.029

3. Kim M, Kim YM, Lee JY, et al. Seasonal variation and monthly patterns of skin symptoms in Korean children with atopic eczema/dermatitis syndrome. Allergy Asthma Proc. 2017;38(4):294-299. doi:10.2500/aap.2017.38.4055

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