How Managing Comorbidities Can Transform Alopecia Areata Treatment Outcomes

Single patch of alopecia areata | Image credit: DermNet

Alopecia areata is an autoimmune condition that leads to patchy hair loss on the scalp, face, and other parts of the body. Affecting about 2% of the population, alopecia areata can develop at any age, though it most commonly begins in early adulthood. While hair loss is the primary symptom, alopecia areata often coexists with other health conditions, making it important for clinicians to recognize and manage these.

Managing comorbidities in alopecia areata patients builds trust and improves treatment outcomes. These additional health issues can influence the course of alopecia areata and affect treatment effectiveness. A well-rounded approach to care addresses both hair loss and associated autoimmune, inflammatory, or psychological conditions, improving overall quality of life.¹

Common Comorbidities in Patients with Alopecia Areata

Alopecia areata is often linked to several autoimmune conditions, including thyroid disorders, atopic diseases, vitiligo, and psoriasis. Understanding these connections helps provide better patient care.

Thyroid dysfunction, especially hypothyroidism, is strongly linked to alopecia areata. Patients with alopecia areata are 3.2 times more likely to develop thyroid issues than the general population. Symptoms include fatigue, weight gain, cold sensitivity, dry skin, and constipation. Yearly thyroid function tests, such as TSH, free T3, and free T4, are key in monitoring patients. Proper management with medications such as levothyroxine may improve both thyroid health and alopecia areata outcomes.²

Atopic disorders like eczema, asthma, and allergic rhinitis also frequently occur with alopecia areata. Eczema is 2 to 3 times more common in these patients. Treating atopic symptoms with antihistamines, corticosteroids, JAK inhibition, or biologics can reduce both the severity of the atopic disease and the progression of alopecia areata.¹

Vitiligo, another autoimmune condition, causes depigmented patches of skin or hair and may appear before or during alopecia areata. Psoriasis, with its distinctive red plaques and nail changes, often overlaps with alopecia areata. Some treatments, such as JAK inhibition and biologics, can benefit both conditions.¹

Metabolic and Endocrine Comorbidities with Alopecia Areata

Alopecia areata has strong ties to metabolic and endocrine conditions, particularly diabetes and obesity, both of which can influence alopecia areata progression and treatment.

Alopecia areata is linked to both Type 1 and Type 2 diabetes. Type 1 has an autoimmune connection, with patients showing a higher prevalence of alopecia areata. Symptoms include increased thirst, frequent urination, and unexplained weight loss. In Type 2 diabetes, shared inflammatory pathways may contribute to this type of hair loss. Management includes regular glucose monitoring, insulin for Type 1, and lifestyle changes, oral or novel GLP-1 medications for Type 2. Collaboration between dermatology and endocrinology improves care.³

Obesity and metabolic syndrome can worsen autoimmune conditions like alopecia areata through chronic inflammation and immune dysfunction. Recognizing signs like abdominal obesity and hypertension is important. Treatment focuses on lifestyle changes and GLP-1 therapy—as well as medications for hypertension, dyslipidemia, or glucose control. Addressing these issues may improve both overall health and alopecia areata management.³

Recognizing and Managing Less Common Comorbidities of Alopecia Areata

Though less common, rheumatologic disorders like lupus and rheumatoid arthritis are associated with alopecia areata. Patients may present with joint pain, fatigue, and skin findings. Collaborating with rheumatology for treatment, including DMARDs, JAK inhibition, and biologics, can be helpful.⁴ 

Celiac disease, triggered by gluten, may also be linked to alopecia areata. Gastrointestinal symptoms, malabsorption, and a strict gluten-free diet are central to its management.⁵

Chronic inflammation in alopecia areata may increase cardiovascular risk. Lifestyle changes and regular assessments help manage cardiovascular health in alopecia areata patients.

Comprehensive Screening and Management of Alopecia Areata in Clinical Practice

Taking a whole-person, team-based approach to managing alopecia areata and its comorbidities is the key. Clinicians should screen for autoimmune, metabolic, and psychological conditions with regular thyroid tests, glucose monitoring, and mental health assessments. Coordinated care with specialists, such as endocrinology, dermatology, and mental health professionals, ensures comprehensive treatment. Educating patients helps them recognize symptoms and advocate for their health. By fostering collaboration and standardized screenings, clinicians can begin to address both the physical and emotional needs of alopecia areata patients.⁶

Alopecia Areata Treatment Considerations Based on Comorbidities

While this article focuses on common comorbidities and not specific treatment, care plans must consider other health conditions. Autoimmune thyroid disorders require monitoring when using immunosuppressants, while diabetic or hypertensive patients need caution with oral corticosteroids due to their effects on blood sugar and pressure. For mental health concerns, treatments like high-dose corticosteroids should be used carefully to avoid worsening mood disorders.

As of September 2024, alopecia areata has seen notable advancements in treatment, with new FDA-approved options that provide hope for patients with severe hair loss. Topical treatments, like corticosteroids and minoxidil, remain common first-line options, but are not at all targeted.

The most significant advancement is JAK inhibitors. As of 2024, 3 FDA-approved JAK inhibitors—baricitinib (Olumiant), ritlecitinib (Litfulo), and deuruxolitinib (Leqselvi)—are transforming severe alopecia areata management by blocking inflammatory pathways that trigger hair loss. These medications provide new avenues for patients, with research focusing on long-term safety and combination therapies.

Conclusion

Recognizing and managing comorbidities in alopecia areata patients improves outcomes and supports well-rounded care. A multidisciplinary approach involving dermatology, endocrinology, and mental health professionals ensures that all aspects of a patient’s health are addressed. Clinicians and patients should take an active role in screening for comorbidities, improving both physical and emotional well-being. Ongoing research continues to uncover the complexities of alopecia areata and its associated conditions, emphasizing the need for comprehensive, whole-person care.

References

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2. Yang J, Zhu Z, Zhang C, Guo Y, Wang G, Fu M. Association between non-scarring alopecia and hypothyroidism: a bidirectional two-sample Mendelian randomization study. Front Endocrinol (Lausanne). 2024 Mar 18;15:1356832. doi: 10.3389/fendo.2024.1356832.
3. Kwiat VR, Reis G, Valera IC, Parvatiyar K, Parvatiyar MS. Autoimmunity as a sequela to obesity and systemic inflammation. Front Physiol. 2022 Nov 21;13:887702. doi: 10.3389/fphys.2022.887702.
4. Choi EW, Kim HJ, Jung YC, Go HS, Seong JK. Effects of high fat diet-induced obesity on pathophysiology, immune cells, and therapeutic efficacy in systemic lupus erythematosus. Sci Rep 12, 18532 (2022). https://doi.org/10.1038/s41598-022-21381-3
5. Medina G, Vera-Lastra O, Peralta-Amaro AL, et al. Metabolic syndrome, autoimmunity and rheumatic diseases. Pharmacol Res. 2018 Jul;133:277-288. doi: 10.1016/j.phrs.2018.01.009. Epub 2018 Jan 31.
6. Wyrwich KW, Kitchen H, Knight S, et al. The Alopecia Areata Investigator Global Assessment scale: a measure for evaluating clinically meaningful success in clinical trials. Br J Dermatol. 2020;183(4):702-709. doi:10.1111/bjd.18883