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Indian J Dermatol
Indian J Dermatol
IJD
Indian J Dermatol
Indian Journal of Dermatology
0019-5154
1998-3611
Wolters Kluwer - Medknow India

IJD-69-344
10.4103/ijd.ijd_1060_21
Correspondences
Clinical Profile and Predictors of Relapse in Patients with Alopecia Areata: A Follow-Up Study
Khandelwal Sumit
Lakshminarayanan Subitha 1
Jaisankar Telanseri Jayakar
Ramassamy Sivaranjini
From the Department of Dermatology and STD, Jawaharlal Institute of Postgraduate Medical Education and Research (JIPMER), Puducherry, India E-mail: siva11rsamy@yahoo.com
1 Department of Preventive and Social Medicine, Jawaharlal Institute of Postgraduate Medical Education and Research (JIPMER), Puducherry, India
Jul-Aug 2024
19 8 2024
69 4 344346
12 2021
4 2024
Copyright: © 2024 Indian Journal of Dermatology
2024
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pmcDear Editor,

The course of alopecia areata (AA) is unpredictable. There is evidence for maintenance treatment following response in AA, bearing in mind the high relapse rate in the disease. Very little information if available on the proportion and characteristics of disease relapse in our population, are for individual modalities of treatment.[12] Holistic relapse data in the disease are primarily from retrospective records or clinical evaluation conducted through phone surveys. Therefore, we sought to study the proportion of patients with AA who relapse after achieving remission of alopecia areata (defined as at least 90% hair regrowth), time to relapse among them and the associated disease and treatment variables in an ambi-directional design.

One hundred and twenty-one patients with any past or present history of AA were screened. Of the 121 screened, 100 of them had either experienced remission in the past or had a remission of disease during follow-up. The rest of them whose disease was never remitted were not considered for the study. The mean duration of follow-up was 13.9 ± 5.1 months (min-max, 4-24), calculated from the onset of disease remission to the last follow-up within the study period. Relapse was defined as recurrence of hair loss or extension of old patches after achieving remission. The time to relapse was calculated from the point of remission to the point of relapse.

Seventy-one of the 100 AA patients in remission experienced a relapse of the disease. Studying the factors associated with relapse, childhood-onset disease (≤14 years) and extensive initial scalp surface involvement with AA (≥50%) were significant (P = 0.029), after adjusting for multiple testing using Benjamini and Hochberg procedure (threshold for false discovery rate set at 0.25). However, the evidence of predictivity was insufficient as the 95% confidence interval (C.I) for the odds ratio (O.R) includes the null value of 1 (O.R = 0.13; C.I = 0.01-1.06 and OR = 7.5; C.I = 0.94-59.7, respectively, for the factors). None of the demographic variables, such as gender, age at presentation, and disease factors, such as subtype of initial AA, any history of alopecia totalis/universalis, presence of nail involvement, family history of AA, personal history of other autoimmune diseases, treatment received for the initial episode of AA, could predict relapse on univariate analysis. Logistic regression for predictors namely age at onset of disease and initial scalp severity was performed. The effectiveness of the model was supported by a significant Wald test (χ2 = 16.5, df = 2, P = 0.001) with Hosmer-Lemeshow goodness-of-fit returning a P = 0.95 (P > 0.05). However, none of the variables proved to be predictive of relapse of the disease [Table 1]. It is therefore observed from the study that disease severity at presentation and early-onset of disease may be good predictors of relapse; however, it has to be tested on larger representative samples.

Table 1 Characteristics of alopecia areata among relapsed and non-relapsed participants

Variables	Relapse (n=71)	Non-relapse (n=29)	Univariate	
	
Odds ratio (95% C.I)	P	
Age at disease onset n (%)	≤14 years	15 (21.1)	1 (3.4)	0.13 (0.01-1.06)	0.029	
	>14 years	56 (78.9)	28 (96.5)			
Gender n (%)	Male	48 (67.6)	18 (62.1)	1.2 (0.5−3.1)	0.596	
	Female	23 (32.4)	11 (37.9)			
Family history of AA n (%)		3 (4.2)	-	0.7 (0.6−0.7)	0.261	
Co-morbid associated n (%)	Autoimmune thyroid disease	2 (2.8)	-	1.5 (0.4−4.5)	0.463	
	Vitiligo	3 (4.2)	1 (3.4)			
	Atopy	13 (18.3)	4 (13.7)			
Initial AA type n (%)	Localized patchy (<3)	50 (70.4)	23 (79.3)	0.6 (0.22−1.7)	0.364	
	Multifocal patchy (≥3)	14 (19.7)	5 (17.2)	1.1 (0.3−3.6)	0.774	
	Alopecia totalis/universalis	6 (8.5)	2 (6.9)	1.2 (0.2−6.5)	0.795	
Initial scalp surface area involved n (%)	<50%	56 (78.9)	28 (96.6)	7.5 (0.94−59.7)	0.029	
	≥50%	15 (21.1)	1 (3.4)			
Nail changes n (%)	Any nail involvement (N1 or N2)	10 (14.1))	5 (17.2)	0.78 (0.24−2.5)	0.688	
Treatment modality* n (%)	Topicals alone	40 (56.3)	19 (65.5)	1.41 (1.24−1.60)	0.521	
	Systemic therapy alone or with topicals	27 (38)	7 (24.1)			
	Immunotherapy	3 (4.2)	3 (10.3)			
	Spontaneous remission	1 (1.4)	-			
*Topicals include steroids, anthralin, and minoxidil. Systemic therapy includes steroids such as oral mini pulse, conventional steroids, and methotrexate; immunotherapy was with diphencyprone

The median time to relapse of 70 out of 71 participants (information on time to relapse was not ascertainable in one of them) was 7 months (interquartile range = 3.2-12 months). Using the Kaplan-Meier method, the median survival of the 70 participants with relapse was 12 months. At the end of 6 months, 66% (CI = 62-70%) was the cumulative probability of not having a relapse and at 18 months it was 30% (25-35%). Extensive initial scalp surface involvement by AA was found to have a lower median survival of 5 months as compared to those having a limited scalp involvement, which was 12 months (P = 0.00005) [Figure 1]. These findings suggest that a high proportion of patients have a relapse of AA and it occurs by 1 year in half of them and only one-third are relapse-free by 1.5 years. In addition, the initial disease severity with extensive scalp involvement predicts an early relapse conclusively. These findings are as observed by Lyakhovitsky et al.,[3] who reported that the relapse in AA occurred at any time during the follow-up period of 8.3 years, but declined over time, with most occurring (79%) within 4 years of the initial episode. This concurred with the observations made in the past, where less severe diseases at presentation were more likely to report being free of disease at follow-up.[4] Thus, we could consider maintenance treatment in such a subset of AA to prevent an early relapse.[5]

Figure 1 Survival for relapse in alopecia areata based on the extent of scalp involvement during the initial episode

Limitations of the study include the limited duration of follow-up and the retrospective component with the possibility of recall bias. The inclusion of more patients in systemic therapy could help clarify the actual influence of such therapy on relapse.

Financial support and sponsorship

Nil.

Conflicts of interest

There are no conflicts of interest.
==== Refs
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2 Ucak H Cicek D Demir B Erden I Ozturk S Prognostic factors that affect the response to topical treatment in patchy alopecia areata: The response to topical treatment in patchy alopecia areata J Eur Acad Dermatol Venereol 2014 28 34 40 23181708
3 Lyakhovitsky A Aronovich A Gilboa S Baum S Barzilai A Alopecia areata: A long-term follow-up study of 104 patients J Eur Acad Dermatol Venereol 2019 33 1602 9 30887594
4 Tosti A Bellavista S Iorizzo M Alopecia areata: A long term follow-up study of 191 patients J Am Acad Dermatol 2006 55 438 41 16908349
5 Choe SJ Lee S Lee H Choi J Lee W-S Efficacy of topical diphenylcyclopropenone maintenance treatment for patients with alopecia areata: A retrospective study J Am Acad Dermatol 2018 78 205 7.e1 29241788
