The pattern and profile of alopecia areata in Singapore – a study of 219 Asians

International Journal of Dermatology

2002,

41

, 748–753 © 2002

The International Society of Dermatology

748

Abstract

Background

Alopecia areata is believed to be an autoimmune condition with a worldwide

occurrence. It usually presents as patchy, nonscarring hair loss. There is a paucity of clinical

data in Asians.

Objective

To study the epidemiology, clinical aspects, associations, and treatment of alopecia

areata in an Asian population over a 1-year period.

Methods

Records of all newly diagnosed alopecia areata cases seen from May 1998 to April

1999 at the National Skin Center were collated with regard to the epidemiology, pattern of

alopecia, and associations according to the investigational guidelines published by Oslen

et al.

The treatment and psychologic impact of alopecia areata were also assessed.

Results

Two hundred and nineteen new case referrals of alopecia areata were seen from May

1998 to April 1999. The incidence of alopecia areata was 3.8%. There were 173 Chinese (79%),

35 Indians (16%), and 11 Malays (5.0%). The male to female ratio was 1 : 1.3. The median age

at presentation was 25.2 years. The majority of patients (85.5%) had their first episode of

alopecia areata before the age of 40 years. Of the patients with onset of alopecia areata before

the age of 40 years, 36.5% presented with extensive alopecia, compared with 5.5% above the

age of 40 years (

P

< 0.05). Nail changes, consisting of pitting, trachyonychia, and longitudinal

ridging, were reported in 23 patients (10.5%).

A significant percentage of patients had an associated personal and family history of atopy

(60.7%). There was no significant association between a personal history of atopy and the

extent of alopecia areata. The frequencies reported for the following associated diseases were:

thyroid disease, 2.3%; vitiligo, 4.1%; diabetes mellitus, 3.2%; Down’s syndrome, 1.4%; and

rheumatic arthritis, 0.9%. A family history of alopecia areata was reported in 4.6%.

Intralesional triamcinolone acetonide was the first-line treatment for limited alopecia areata,

while squaric acid dibutyl ester was used for extensive involvement. The majority of patients

with limited alopecia areata (82.1%) had more than 50% improvement with intralesional

triamcinolone acetonide after 3 months. The majority of patients who received squaric acid

dibutyl ester (87.5%) achieved more than 50% regrowth at the end of 6 months. Poor

prognostic factors for alopecia areata were extensive involvement, early age of onset, and

Down’s syndrome.

Thirteen out of 132 respondents (9.8%) recalled stressful events preceding hair loss. Patients

with extensive alopecia areata experienced more psychologic adverse effects than those with

limited alopecia areata (

P

< 0.05). Males with extensive alopecia areata experienced more

severe psychologic ill-effects, such as depression and feelings of inability to improve hair loss.

Conclusions

Our findings are similar to those reported in the Western literature where

alopecia areata is predominantly a disease of the young. A holistic approach is important

in the management of alopecia areata as the disease can have a severe psychologic impact

on an individual’s well-being.

Blackwell Science LtdOxford, UKIJDInternational Journal of Dermatology0011-9059Blackwell Science, 20012001000000

Report

Alopecia areata in SingaporeTan et al.

The pattern and profile of alopecia areata in Singapore – a study of 219 Asians

Eileen Tan,

MD

, Yong-Kwang Tay,

MD

, Chee-Leok Goh,

MD

, and Yoke Chin Giam,

MD

From the National Skin Center, Singapore

Correspondence

Eileen Tan,

MD

National Skin Center 1 Mandalay Road Singapore 308205 E-mail:

[email protected]

IJD_1357.fm Page 748 Wednesday, November 6, 2002 9:58 PM

© 2002

The International Society of Dermatology International Journal of Dermatology

2002,

41

, 748–753

749

Tan

et al. Alopecia areata in Singapore

Report

Introduction

Alopecia areata (AA) usually presents as a sudden onset ofpatchy, nonscarring alopecia. In severe cases, hair loss may bediffuse or total. There are limited clinical studies on AA inAsian patients. The aim of this study was to review the profileand pattern of AA in a mixed ethnic Asian population.

Materials and methods

Records of all newly diagnosed AA cases seen at the National

Skin Center, a tertiary referral skin center, from May 1998 to April

1999 were reviewed with regard to the demography, duration,

extent, and pattern of AA. We adopted the AA investigational

assessment guidelines collated by Olsen

et al

.

1

The extent of hair

loss was classified as < 50% (S1–S2) involvement, 50–99%

(S3–S4) involvement, alopecia totalis, and alopecia universalis

at the time of presentation.

The personal and family history (first-degree relatives) were

assessed for the following: alopecia, atopy, thyroid disease, vitiligo,

diabetes mellitus, lupus erythematosus, pernicious anemia,

rheumatoid arthritis, inflammatory bowel disease, celiac disease,

psoriasis, Down’s syndrome, and immunodeficiency.

A simple questionnaire to assess the psychologic impact of the

disease on the patient’s life was also carried out (Table 1). For

patients who were no longer on regular follow-up, telephone

interviews were conducted for incomplete data. Fisher’s exact

probability test was used for statistical evaluation. A significance

level of

P

< 0.05 was used.

Results

Incidence and demographic data (Table 2)

There were a total of 219 new referrals of AA seen from May1998 to April 1999. The total number of new dermatologic

cases seen over this period was 5764. The incidence of AA was3.8%. Of a total of 219 cases, 173 were Chinese (79%), 35Indians (16%), and 11 Malays (5.0%) (racial distribution ratioof 14 : 3.1 : 1). This was comparable to the racial compositionof the general dermatologic patients seen at the NationalSkin Center: Chinese : Indian : Malay = 14 : 2 : 1. There were 97males and 122 females, with a male to female ratio of 1 : 1.3.

At the time of presentation, AA occurred in 68 patients(31.1%) in the age range 1–20 years, 105 patients (47.9%) inthe age range 21–40 years, 42 patients (19.2%) in the age range41–60 years, and four patients (1.8%) in the age range 61–80 years (Table 2). The median age of the patients at the timeof presentation was 25.2 years (age range, 2–80 years). Femaleshad a lower mean age of onset (24.2 years) than males (26.7years). One hundred and eighty-eight patients (85.8%) experi-enced their first episode of AA within the first four decades oflife, of which 40.2% occurred before the age of 20 years. Themajority of patients (80.2%) sought medical treatment withinthe first 6 months. AA was present for a mean duration of6.4 months (range, 2 weeks to 2 years) before presentation.

Clinical characteristics and pattern of AA

All patients presented with alopecia on the scalp with or with-out the involvement of other body sites. We classified theextent of hair loss according to the guidelines published byOlsen

et al

.

1

At the time of first presentation, 127 patients(58%) had patchy alopecia with less than 50% involvement(S1–S2), 71 patients (32.4%) had patchy alopecia with 50–99% involvement (S3–S4), 17 patients (7.8%) had alopeciatotalis, and four patients (1.8%) had alopecia universalis (Fig. 1).

Of the patients with onset of alopecia before the age of40 years, 36.5% presented with extensive alopecia (S3 andabove), compared to 5.5% after the age of 40 years. Thisdifference was statistically significant. Alopecia totalis anduniversalis occurred in 16 patients below the age of 30 years.

Question Score

1 Compares own hair with that of others2 Annoyed by jokes about hair loss3 Worried about baldness4 Little understanding from others5 Feels less attractive6 Discomfort in front of others7 Feels ashamed8 Talks frequently about hair loss9 Goes out less10 Considered a wig11 Less able to make social contact12 Feels incapable of improving hair loss13 Has suffered severe depression or has had previous suicidal intentTOTAL SCORE (13)

Patients score 1 point if the answer is yes, 0 if the answer is no. Maximum score of 13 points.(Adopted and modified from Cash et al.19)

Table 1 Questionnaire to assess the psychologic impact of alopecia areata in our study cohort



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The proportions of males and females presenting with limitedAA (less than 50% involvement) were 28.3% and 29.7%,respectively, vs. 16.0% and 26.0%, respectively, withextensive AA. There were more females with extensive AAcompared to males. In terms of racial distribution, 43.4%Chinese, 10.5% Indians, and 5% Malays presented withlimited AA, compared to 35.6% Chinese, 5.5% Indians, andno Malays with extensive alopecia.

In 19 patients (8.7%), more than one body site was con-comitantly affected. This included findings of sparse eye-brows, beard, axillary, and pubic hair. Nail changes werereported in 23 patients (10.5%). The nail changes includedpitting (11.4%), trachyonychia (8.2%), and longitudinalridging (2.3%). Most patients presented with single ormultiple patches of alopecia, such as oval, round, lancet, orreticular shapes. Of the 219 patients, an ophiasis patternwas observed in six (2.7%) (age range, 6–27 years).

Associated diseases

One hundred and thirty-three (60.7%) patients and familymembers of 117 patients (53.4%) were reported to have an

atopic history (namely atopic dermatitis, asthma, and allergicrhinitis). Atopy was present in 61 patients (27.8%) with lim-ited alopecia, compared with 72 patients (32.9%) with severealopecia. The difference was not statistically significant. Fivepatients (2.3%) and family members of 10 patients (4.6%)had thyroid disease; nine patients (4.1%) and family membersof six patients (2.7%) had vitiligo, and interestingly all wereIndians. Seven patients (3.2%) and family members of 15patients (6.8%) had diabetes mellitus; three Chinese malepatients (1.4%) had Down’s syndrome. The onset of AA inDown’s syndrome patients occurred before the age of15 years and all presented with extensive AA. Two patients(0.9%) and family members of five patients (2.3%) had rheu-matoid arthritis. Family members of 10 patients (4.6%) werereported to have a past history of AA. There was no relationbetween the frequency of occurrence of family members withAA and the severity of the disease.

Treatment of AA

Treatment options for AA patients included topical orintralesional corticosteroids, oral corticosteroids, and

Table 2 Extent of hair loss in relation to age at time of presentation

Age at presentation (years) Sex/nationality

Extent of hair loss

S1–S2 (< 50%) S3–S4 (50–99%) Alopecia totalis Alopecia universalis

1–20 Male 15 (6.8%) 11 (5.0%) 1 (0.5%) 1 (0.5%)Female 21 (9.6%) 10 (4.6%) 7 (3.2%) 2 (0.9%)Chinese 27 (12.3%) 21 (9.6%) 7 (3.2%) 3 (3.2%)Malay 4 (1.8%) 0 0 0Indian 5 (2.3%) 0 1 (0.5%) 0

21–40 Male 27 (12.3%) 16 (7.3%) 2 (0.9%) 0Female 30 (13.7%) 24 (10.9%) 5 (2.3%) 1 (0.5%)Chinese 39 (17.8%) 34 (15.5%) 7 (3.2%) 1 (0.5%)Malay 5 (2.3%) 2 (0.9%) 0 0Indian 13 (5.9%) 4 (1.8%) 0 0

41–60 Male 17 (7.8%) 4 (1.8%) 0 0Female 13 (5.9%) 6 (2.7%) 2 (0.9%) 0Chinese 25 (11.4%) 3 (1.4%) 2 (0.9%) 0Malay 0 0 0 0Indian 5 (2.3%) 7 (3.2%) 0 0

61–80 Male 3 (1.4%) 0 0 0Female 1 (0.5%) 0 0 0Chinese 4 (1.8%) 0 0 0Male 0 0 0 0Indian 0 0 0 0

Figure 1 Number of patients vs. the extent of alopecia areata


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immunotherapy (squaric acid dibutyl ester, SADBE). Theevaluation of the treatment of AA is difficult as the conditionis dynamic and may undergo spontaneous resolution.

For limited lesions, intralesional triamcinolone acetonide(10 mg/mL) or topical corticosteroid (0.1% betamethasonescalp lotion or Synalar 0.025% scalp gel) remains the primarymode of therapy; 82.1% of patients with limited AA showedmore than 50% improvement with intralesional triamcinoloneacetonide after 12 weeks. Three patients were switched toimmunotherapy after 4 months because of poor response tointralesional steroids.

Immunotherapy is the recommended first-line treatmentfor extensive AA. SADBE was the topical immunotherapyagent used in our center. The patient was first sensitized with2% SADBE in acetone applied to a 2-cm patch of alopecia onthe scalp. Two weeks after sensitization, patients were startedon weekly treatment with SADBE at a concentration whichproduced minimal erythema on patch testing. Further dose

adjustment was titrated according to the clinical response.Of the 72 patients who received SADBE, 63 patients (87.5%)achieved more than 50% regrowth at the end of 6 months.The youngest patient treated was aged 6 years (Fig. 2). Thenine poor respondents of immunotherapy had either alopeciatotalis or universalis. Three of the nine poor respondents hadassociated Down’s syndrome. All were young, with the firstonset of AA occurring between 4 and 14 years of age, with adisease duration of at least 8 months.

Ten patients (with 50–99% involvement) received intra-lesional steroids because they refused immunotherapy. Theyhad a variable response of between 25% and 50% at the endof 6 months. Ten patients were started on oral prednisoloneand all reported improvement (between 50% and 75%) at theend of 6 months. The starting dose of prednisolone variedbetween 20 and 30 mg/day and the duration of therapyranged from 3 to 5 months.

Psychosomatic evaluation

There are few reports on the psychologic impact of AA on apatient’s life.

2–4

We attempted to explore the extent of thepatients’ perception and self-worth in relation to their hairproblem. A simple questionnaire was designed to assess thepsychologic impact on the patients and to correlate this withthe severity of the disease (Table 1). This was conductedvia telephone interviews. An inquiry into stressful events6 months preceding hair loss and the history of psychiatricdisorders was made.

Only 13 of the 132 respondents (9.8%) recalled undergo-ing stressful events preceding hair loss, and none had a pasthistory of psychiatric disorders. Stressful events mentionedwere examination stress, job change, and traumatic eventssuch as the loss of loved ones. Interestingly, other triggerscited by patients included the possibility of sexually transmit-ted disease (

n

= 30) and food (

n

= 42).Of the 219 patients, 132 responded to the questionnaire to

assess the psychologic impact of the disease on their life. Ofthose who responded, 53% were females and 47% weremales. The majority of the respondents had limited AA (69%).Of the patients with extensive AA, 82% of the respondentshad a score of > 7 out of 13, compared to 11% with limitedAA. This difference was statistically significant (

P

< 0.05). Atotal of 81.2% of males with AA (< 40 years) had a score of> 7 out of 13 compared to 50.1% of females within the sameage group (

P

< 0.05). Males with extensive AA experiencedmore severe adverse psychologic effects, including depressionand feelings of inability to improve hair loss.

Discussion

The clinical behavior of AA is unpredictable and the patho-genesis is not completely clear.

5

There have been few clinicalepidemiologic studies on AA worldwide.

6–9

It accounts for

Figure 2 A 6-year-old boy with Down’s syndrome and extensive alopecia areata



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et al.

about 2% of new dermatology outpatient attendances in theWest

7,8

and 0.7% in one report from India.

6

Our local inci-dence of 3.8% is higher than these earlier reports.

AA affects the young with an equal sex ratio.

5,9

In ourstudy, there was a slight female preponderance (1.3 : 1).Although the prevalence of Chinese patients appears to pre-dominate in our study, compared to other races, the ratio isconsistent with the racial distribution locally. The age of onsetof AA ranges from less than 1 year to the late seventies.

6,9

Ouryoungest patient was 2 years of age and the oldest was afemale aged 80 years. The age of onset of AA is consistentwith that of previous reports,

6,7,10

where 85.8% experiencedtheir first episode of AA in the first four decades of life. Juve-nile AA is thought to be more severe and has a less favorableprognosis.

10

In accordance with earlier studies,

5,6,9,10

alopeciatotalis and universalis, which constituted 8.7% of all AAcases, affected young individuals. The finding that femalespresent with an earlier onset of disease compared to males issimilar to that reported by Sharma

et al

.

6

In contrast, how-ever, we observed a higher proportion of females compared tomales (22.4% vs. 14.2%) presenting with extensive AA,although this was not statistically significant.

Various nail changes have been associated with AA. Theseinclude pitting, Beau’s lines, trachyonychia, onychorrhexis,etc.

5

Sharma

et al

.

6

reported nail changes in 20% of theirstudy population which occurred more frequently in thosewith severe AA. In our study, the frequency of onychodystrophywas 10.5%; this may not reflect the true frequency as the nailchanges are usually asymptomatic.

Various disease associations with AA were examined in ourstudy. The relationship between atopy and AA is well estab-lished. We found a significant proportion of individuals witha personal and family history of atopy. The frequency of asso-ciated atopy of 60.7% was higher than that of earlier studieswhich reported frequencies between 10 and 50%.

6,9,11–14

Astudy conducted in The Netherlands reported a positivesignificant correlation between atopy and the severity of AA.

10

In our study, however, there was no significant correlationbetween a personal history of atopy and the extent of AA(27.8% vs. 32.9%), which was similar to the results of a studyof AA in Indian children.

12

A strong family history of AA(frequency of 20–40%) was reported in the Western popu-lation.

8,9,11

A family history of AA was seen in 4.6% of ourpatients. This low frequency was also noted in an Indian popu-lation (1.7%).

6,12

We postulate that this difference may be dueto the different genetic background of Asians and Caucasians.

There have been a few reports of an association betweenAA and autoimmune diseases. The main associations are withthyroid disease and vitiligo. In our study, the frequency ofmost associated autoimmune diseases was relatively low com-pared with that in other reports. Some reports have shown anincidence of 8–28% of AA patients with thyroid disease.

8,9

Our finding of associated thyroid disease in 2.3% of patients

is similar to that from India and The Netherlands.

6,10

Thefrequencies of associated vitiligo were: 1.8% reported by anIndian group;

6

3% by Snellow

et al

.;

11

4% by Muller andWinkelmann;

9

and 16% by Cunliffe

et al

.

8

The frequency ofassociated vitiligo was 4.1% in our study. It was interestingthat all our patients with vitiligo and AA were Indians. Thefrequencies of individuals with associated diabetes mellitusand rheumatoid arthritis were only 3.2% and 0.9%, respec-tively. Diabetes mellitus is said to occur more frequently inrelatives of patients with AA, rather than in AA patients them-selves.

6,11

This observation is reflected in our study.Two authors have reported an increased frequency of AA

in patients with Down’s syndrome.

15,16

In our study, therewere three male AA patients with Down’s syndrome and allhad extensive AA with a disease onset below the age of15 years. We agree with Carter and Jegasothy

15

that immuno-logic abnormalities in Down’s syndrome may contribute tothe development of AA. This subgroup has an earlier diseaseonset, more extensive involvement, and responds poorly totreatment. Poor prognostic indicators of AA include:

5

thepresence of atopy, other autoimmune diseases, family historyof AA, young age at onset, nail dystrophy, extensive hair loss,and ophiasis.

8,9

Although it is difficult to comment on prog-nostic indicators as our follow-up period was short, we foundthat a young age at onset, extensive hair loss, and Down’s syn-drome were related to a poor prognosis.

The treatment options in AA are varied. Initial therapeuticsuccess often does not prevent future relapses. The majority oflimited AA cases have a good prognosis: 82.1% of ourpatients with limited AA showed more than 50% improve-ment after 12 weeks of intralesional corticosteroid. TopicalSADBE is a potent contact sensitizer currently used as a top-ical immunotherapy agent. Two prognostic factors reportedto influence the treatment outcome to topical SADBE includethe extent and duration of AA.

16,17

In our cohort, the poorrespondents to immunotherapy were young (aged between 4and 20 years) and presented with extensive disease.

A simple questionnaire was carried out to assess thepatients’ perception of possible triggers of and psychologicimpact of AA. Only 13 patients (six females and seven maleswith limited AA) recalled stressful life events that precededtheir episodes of hair loss. Emotional triggers were not corre-lated with any particular type of AA. The question of whetherpsychologic factors play an important role in the pathogenesisof AA is a controversial issue. Some studies suggest a positivecorrelation,

5,10

while others do not.

2,6

In our experience, emo-tional stress does not seem to play a significant role in thepathogenesis of AA.

AA can have a profound psychologic impact on a patient’slife.

4,18

From our questionnaire, we found that patients withlimited AA appeared to be less distressed by their disease com-pared with those with severe AA. This finding is expected asa greater severity of disease will have a greater adverse effect


© 2002


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on the quality of life. Interestingly, younger males appeared tobe more distressed by the disease. This may be related cultur-ally to the fact that Asian males perceive themselves as thestronger sex and are ashamed to express their concerns andseek help as readily as their female counterparts. From thebrief questionnaire, it is clear that AA can be psychologicallydevastating, affecting an individual’s psychologic well-beingand quality of life. Hence, dermatologists must offer bothmedical treatment and understanding of their patients’ con-cerns in order to provide effective management.

Conclusions

The profile of AA in a mixed ethnic Asian population revealssome interesting features. Similar to that reported in the West-ern literature, AA is predominantly a disease of the young,and poor prognostic factors include early onset of disease,extensive AA, and Down’s syndrome. A large percentage ofour patients had associated atopy, although there was no sig-nificant association between atopy and the extent of AA. Thepsychologic impact of AA should not be dismissed lightly byphysicians, especially in males and those with extensive AA.

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The pattern and profile of alopecia areata in Singapore – a study of 219 Asians

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