Patients with psoriasis and alopecia areata (AA) should also be screened for underlying metabolic abnormalities, according to results of a recent case report.
Rim S. Ishak, MD, from the department of dermatology at the Cleveland Clinic, reported on two women who were both diagnosed with severe psoriasis and several comorbid conditions, including androgen excess, metabolic syndrome, thyroiditis and AA. Both women eventually progressed to treatment-resistant alopecia universalis, according to the paper published Journal of Investigative Dermatology Symposium Proceedings.
Each of the female patients (aged 18 and 29 years) had strong family histories of autoimmunity and both suffered from thyroid abnormalities, which may have contributed to their hair loss, the researchers wrote.
The 18-year-old patient had a history of psoriasis on her scalp and body, in addition to psoriatic arthritis diagnosed at age of 5 years, and patchy alopecia since the age of 15 years. Her past medical history was remarkable for hypothyroidism, polycystic ovarian syndrome, obesity (BMI: 33.9 kgm-2) and elevated lipid levels.
Following treatment with intralesional triamcinolone acetonide (5mg/mL-1, 4 mL per session), the patient initially had full regrowth. About 1 year later, she developed new patches of AA likely related to severe anxiety. During this time, the patient’s psoriasis and psoriatic arthritis were under excellent control.
The 29-year-old patient had a six-year history of pustular psoriasis and psoriatic arthritis that was treated with methotrexate, etanercept (Enbrel, Amgen) and efalizumab (Raptiva, Genentech).
Her medical history was remarkable for obesity (BMI: 30.4 kgm-2), Hashimoto’s thyroiditis, polymorphic eruption of pregnancy and atopic dermatitis. She had diffuse thinning of her scalp hair, with background patchy alopecia, thinning of lateral eyebrows, and diffuse alopecia of her arms and legs. Her fingernails were pitted, and her big toenails were onycholytic, according to the case report.
Her alopecia was treated with diphenylcyclopropenone, biotin and iron, but she failed all treatments after several months and soon stopped all therapies.
“It is interesting that in these patients, their AA flared as their psoriasis control improved after initiating therapy with biological agents, which previous studies have suggested is linked to poorer prognosis,” Ishak and colleagues wrote. “There is compelling evidence that patients with psoriasis and psoriatic arthritis have a higher risk to develop other autoimmune disorders, particularly AA, with two large population studies demonstrating an odds ratio of 2.4.”
“The immunological interplay between psoriasis and AA must be considered when selecting therapeutic regimens for these complex patients, in order to avoid worsening one of their inflammatory conditions while treating the other,” the researchers concluded.