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Characterization of thyroid disorders in alopecia areata patients: A cross-sectional evaluation
*Corresponding author: Nikhila R. Nair, Department of Dermatology and Venereology, Government Medical College, Thiruvananthapuram, Kerala, India. nikhilanithish374@gmail.com
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Received: ,
Accepted: ,
How to cite this article: Nair NR, Mathew R, Varghese SA, George AE. Characterization of thyroid disorders in alopecia areata patients: A cross-sectional evaluation. J Skin Sex Transm Dis. doi: 10.25259/JSSTD_46_2025
Abstract
Objectives:
Alopecia areata is an inflammatory disease that leads to non-scarring hair loss. Several studies have identified an association between alopecia areata and other autoimmune diseases; however, there is no consensus on this among Indian studies. If a high prevalence of thyroid dysfunction exists among patients with alopecia areata, routine screening for thyroid abnormalities may be warranted for early detection. This study aimed to investigate thyroid dysfunction in patients presenting with alopecia areata and to explore its association with the clinical profile of alopecia areata.
Materials and Methods:
This was a hospital-based study with a cross-sectional, comparative design. Thirty-two patients with a clinical diagnosis of alopecia areata were included as cases, and 32 individuals who were caregivers without alopecia areata served as the comparison group. Free T4, thyroid-stimulating hormone, and anti-thyroid peroxidase (TPO) antibody levels were measured for all participants. The Chi-square test was utilized to analyze qualitative variables, while the Student’s t-test and Mann–Whitney U-test were applied for quantitative variables. A P < 0.05 was considered statistically significant.
Results:
The predominant age group in the study population was 21–30 years, with a male-to-female ratio of 1:1.13. The most common presentation appeared to be patchy alopecia areata, with the scalp being the most frequent area affected. Thyroid dysfunction was more frequently identified through investigation than through the presence of symptoms. Symptoms of thyroid dysfunction were present in 18.75% of cases. However, hypothyroidism was observed in 25% of the cases compared to only 6.25% in the comparison group, a difference that was statistically significant. In addition, autoimmune thyroid dysfunction was identified in 18.75% of cases and in none of the comparison groups, which was also statistically significant with a P = 0.01. No statistically significant association was found between the epidemiology, clinical profile, or severity of alopecia areata and thyroid status.
Limitations:
The relatively small sample size of the study may restrict the applicability of its findings to a larger population. As the study was conducted in a hospital-based setting, the results may not fully represent the broader community or other geographic regions.
Conclusion:
This study highlights that thyroid dysfunction was frequently detected in patients with alopecia areata, even when clinical symptoms of thyroid dysfunction were absent. This underscores the significance of routine thyroid screening in all patients with alopecia areata, irrespective of the presence of thyroid-related symptoms, facilitating early detection and management. While coexisting autoimmune diseases are often considered poor prognostic factors in alopecia areata, this may not always hold true, as most patients with thyroid dysfunction in this study had mild alopecia areata.
Keywords
Alopecia areata
Autoimmune thyroid disease
Cross-sectional study
Thyroid dysfunction
Thyroid peroxidase
INTRODUCTION
Alopecia areata is a chronic inflammatory hair disorder causing non-scarring hair loss. It ranks as the second most common type of non-scarring alopecia, with androgenetic alopecia being the most prevalent.[1] The exact etiology of alopecia areata remains unidentified. Among the numerous factors proposed to explain its underlying pathogenesis, immunological, environmental, psychological, and genetic factors stand out as the most compelling. However, the relative significance of each is not fully understood.
There have been many reports linking alopecia areata with other autoimmune diseases, including Graves’ disease, Hashimoto’s thyroiditis, vitiligo, diabetes mellitus, and atopic diseases.[2] Thyroid dysfunction can be effectively diagnosed through patient history, clinical examination, thyroid function tests, and thyroid autoantibody testing. Although studies from different parts of the world have shown an association between thyroid dysfunction and alopecia areata, there is a lack of agreement on this matter among Indian studies.[3-5]
The presence of other autoimmune diseases is considered a poor prognostic factor in alopecia areata.[6] Hence, thyroid function and thyroid autoantibody testing could play a crucial role in assessing the prognosis of affected individuals. If there is a high prevalence of thyroid dysfunction in patients with alopecia areata, routine screening for thyroid abnormalities should be implemented to enable early detection and intervention.
Moreover, alopecia areata not only causes cosmetic disfigurement but also leads to psychological disturbances such as lack of self-esteem and feelings of vulnerability of self. Hence, it is very important to find the underlying disorders associated that could help in the treatment of alopecia areata as well as the underlying disease.
This study was aimed at finding the association between thyroid dysfunction and the clinical profile of alopecia areata.
MATERIALS AND METHODS
This was a hospital-based study with a cross-sectional comparative design conducted in a tertiary care center for a period of 1 year. Approval was obtained from the Institutional Ethics Committee (HEC No. 02/26/2021/MCT) before initiating the research. All participants were given an information sheet that explained the details of the study.
Inclusion criteria
Patients clinically diagnosed with alopecia areata who had not received any prior treatment were included as cases, while consenting individuals who were caregivers without any history of alopecia areata formed the comparison group.
Exclusion criteria
Pregnant women and those in the postpartum period (up to 6 months post-delivery) were excluded from the study.
Sample size calculation
The sample size was determined using the following formula:
N = (Z1-α/2 + Z1-β) 2 (σ12 + σ22)/(µ1–µ2)2,
where N is the sample size, Z1-α/2 value with α = 0.05 is 1.96, Z1-β value with β = 95% is 1.645, σ1 = Standard deviation (SD) of thyroid dysfunction in Group 1, σ2 = SD of thyroid dysfunction in Group 2, µ1=Mean value of thyroid dysfunction in Group 1, µ2= Mean value of thyroid dysfunction in Group 2.
Based on the reference study by Bakry et al.,[7] σ1 = 0.36, σ2 = 0.1, µ1 = 1.40, µ2 = 1.14
Using the formula, the calculated sample size was 32. Therefore, 32 patients with a clinical diagnosis of alopecia areata were included as cases, and 32 people without alopecia areata were included as the comparison group.
Study procedure
A structured questionnaire was employed to document the history and examination findings of alopecia areata and thyroid dysfunction. Alopecia areata diagnosis was made clinically based on the presence of circular patches of hair loss without scarring and small “exclamation mark” hairs at the periphery in the initial stages of the disease. Clinical profile of alopecia areata included age of disease onset, duration, family history, site, number and morphology of lesions, as well as associated nail changes.
The severity of alopecia areata was classified using the grading scale proposed by Kavak et al.[8] as follows:
Mild – three or less alopecia patches with a widest diameter of 3 cm or less, or the disease limited to the eyelashes and eyebrows.
Moderate – more than three patches or a patch >3 cm at the widest diameter, without alopecia totalis or alopecia universalis
Severe – alopecia totalis or alopecia universalis.[8]
After obtaining informed consent, a 10 mL sample of venous blood was collected in a plain tube and sent for determination of free T4, thyroid-stimulating hormone (TSH), and anti-TPO antibody using an enhanced chemiluminescence immunoassay. Patients were categorized as hypothyroid, euthyroid, or hyperthyroid based on the test results.
Diagnosis of thyroid dysfunction was done using the following criteria:
Overt hypothyroidism – TSH >5.2 microIU/mL, F.T4 <0.6 ng/dL
Overt hyperthyroidism – TSH <0.34 mIU/mL, F.T4 >1.1 ng/dL
Subclinical hypothyroidism – TSH >5.2 mIU/mL with normal F.T4.
Subclinical hyperthyroidism – TSH <0.34 mIU/mL with normal F.T4.
Normal TSH: 0.34–5.2 microIU/mL
Normal F.T4 level: 0.6–1.1 ng/dL
Normal anti-TPO value: <9 IU/mL
Elevated anti-TPO antibody level indicated autoimmune thyroiditis.
Statistical analysis
All collected data were entered into an Excel sheet and analyzed using IBM Statistical Package for the Social Sciences software. Categorical variables were expressed as frequency (percentage) and quantitative variables as mean ± SD. Statistical significance for qualitative variables was assessed using the Chi-square test, whereas the Student’s t-test and Mann–Whitney U-test were employed for quantitative variables. A P-value below 0.05 was regarded as indicative of statistical significance.
RESULTS
The study included 32 patients diagnosed with alopecia areata, along with 32 individuals in the comparison group. Participants’ ages ranged from 7 to 68 years. The most frequent age group was 21–30 years, accounting for 11 patients (34.4%). The mean age ± SD in the alopecia areata group was 29.63 ± 14.66, compared to 31.66 ± 13.07 in the comparison group [Figure 1]. There was a slight female preponderance in both groups, with 17 (53.1%) patients being females and 15 (46.9%) patients being males.
- Age distribution of patients with alopecia areata and comparison group.
Half (50%) of the patients (16 patients) in the study had a disease duration of more than 3 months, followed by 5 (15.6%) patients who had the disease for about 1 month [Figure 2]. The primary complaint among all patients was hair loss in different areas of the body, with no additional symptoms in the affected regions. Six cases (18.75%) reported experiencing stress before the onset of alopecia areata. There were no comorbidities in 13 (40.6%) cases. The most common associated disease was atopy, which was present in 6 (18.75%) cases, followed by diabetes in 4 (12.5%), hypertension, and coronary artery disease, each in 2 (6.25%) patients. Other comorbidities included dyslipidemia, seizures, adjustment disorder, vision abnormality, pedal edema, and talipes equinovarus. A positive family history of alopecia areata was observed in two cases, accounting for 6.3% of the total.
- Duration of alopecia areata.
On examination, 13 (40.6%) patients had more than three patches of hair loss, 11 (34.4%) had 2–3 patches, and 8 (25%) patients had a single patch of hair loss. The most common pattern was the classical patchy alopecia areata, found in 22 (68.75%) cases. This was followed by ophiasis in 8 (25%), alopecia universalis in 3 (9.4%), and alopecia totalis in 2 (6.25%) cases [Figure 3]. None of the cases exhibited reticulate or Sisaipho patterns. Hair loss on the scalp was present in 29 cases (90.6%). Most patients had involvement of multiple areas of the scalp. The most common site involved was occiput in 23 patients (71.87%). Areas beyond the scalp were involved in 14 cases, accounting for 43.75% of cases. The most common site excluding the scalp with alopecia was the beard, involved in 10 (31.25%) cases. Whole body hair was lost (alopecia universalis) in 3 (9.4%) patients. Area-wise distribution of hair loss is summarized in Figure 3. Exclamation mark hairs were observed in 16 (50%) cases. Based on severity grading, 14 (43.8%) patients had mild alopecia areata, followed by 13 (40.6%) patients who had moderate alopecia and 5 (15.6%) cases with severe alopecia areata. Nail involvement was absent in 15 (46.9%) cases, while 3 (9.4%) patients showed involvement in all 20 nails. The most common nail finding was pitting found in 14 cases (43.75%), followed by onycholysis, onychodystrophy, and leukonychia.
- Area-wise distribution of hair loss in alopecia areata.
Patients were assessed for symptoms of thyroid dysfunction, including both hypothyroidism and hyperthyroidism, in both the alopecia areata and comparison groups. The most commonly reported symptoms in patients with alopecia areata were fatigue, increased sensitivity to cold, weight gain, and dry, coarse skin, each reported in 6 (18.75%) cases. This was followed by anorexia and constipation in 4 (12.5%) patients and depression in 1 (3.1%) of the cases. In the comparison group, fatigue and dry skin were reported by 3 (9.4%) participants, while increased sensitivity to cold was reported by 2 (6.25%) and weight gain and constipation by 1 (3.12%) participant each.
Eight cases (25%) and 2 participants in the comparison group (6.25%) had overt hypothyroidism which was statistically significant (χ2 = 4.267, df = 1, P = 0.039). The remaining participants in both groups were euthyroid. Autoimmune thyroid dysfunction, indicated by elevated anti-TPO levels, was found in 6 out of 32 cases (18.75%) and none among the comparison group (0%). All six cases of autoimmune thyroid dysfunction were found to be hypothyroid, with the difference being statistically significant (χ2 = 6.621, df = 1, P = 0.01). The mean anti-TPO levels were 16.8 ± 29.31 in the alopecia areata group and 4.7 ± 1.3 in the comparison group. The Mann–Whitney U-test revealed no statistically significant difference in the value of anti-TPO levels between alopecia areata patients and caregivers (U = 462.500, Z = −0.665, P = 0.5).
While correlating the clinical profile of alopecia areata with thyroid dysfunction, no statistically significant relationship was found between thyroid dysfunction and the age or gender of patients with alopecia areata. Similarly, there was no statistically significant association between thyroid dysfunction and the duration or clinical profile of alopecia areata.
DISCUSSION
This study included 32 alopecia areata patients as cases and 32 caregivers without alopecia areata as a comparison group. Participants’ ages ranged from 7 to 68 years, with the 21-30 age group being the most common (mean age: 29.63 ± 14.66 years). This aligns with the findings from Bakry et al. (mean age: 26.38 ± 10.85 years).[7] While most of the previous studies reported equal male-to-female distribution, this study observed a slight female predominance of 17 cases (53.1%), yielding a female-to-male ratio of 1.13:1. Family history was positive in 2 (6.3%) of the cases which point toward the genetic etiology of alopecia areata.
The most common associated disease found in the majority of studies was atopy,[3,4] so was it in this study also, where 6 (18.75%) patients had atopy. Sixteen (50%) cases reported they had a disease duration of more than 3 months. Stress before the onset of the disease was reported by 6 (18.75%) cases, including both emotional stress in 4 (12.5%) and physical stress in 2 (6.25%) cases. This was notably higher when compared with the observation by Sharma et al., where 5.8% of the patients reported emotional stress.[3]
The predominant pattern in previous studies was patchy alopecia areata. This study also had similar findings, with patchy form seen in 22 (68.75%) cases followed by ophiasis in 8 (25%), alopecia universalis in 3 (9.4%), and alopecia totalis in 2 (6.25%) cases. The most common site for hair loss was the scalp, with the occiput being the most frequently affected region, followed by vertex and temporal regions. Compared with other studies, scalp involvement was much higher in this study, accounting for 29 (90.6%) cases.[3] Non-scalp involvement was observed in 14 (43.75%) cases, which was much higher when compared to the observation by Tan et al., where other body sites were involved only in 8.7%.[9] The most common non-scalp site involved was beard, involved in 10 (31.2%) cases, followed by eyebrows in 6 (18.75%) and eyelashes and mustache in 4 (12.5%) each.
In this study, the severity of alopecia areata was determined by the grading system proposed by Kavak et al.[8] According to this, 14 (43.8%) patients had mild alopecia areata, 13 (40.6%) had moderate, and 5 (15.6%) patients had severe disease. These values contrast with Bakry et al., where 60% of cases had mild alopecia, and 20% had moderate and severe alopecia each.[7]
Nail involvement in alopecia areata varied from 10% to 66% in various studies. In this study, nail involvement was observed in 17 (53.1%) cases, which was markedly higher than Thomas and Kadyan’s findings, where nail involvement was reported in 16.8% of cases.[4] Nail pitting was the most prevalent nail finding, observed in 14 (43.75%) cases. Other nail findings in the study were onycholysis, onychodystrophy, and leukonychia.
The association of alopecia areata with other autoimmune diseases is well established, which suggests an underlying autoimmune etiology. However, the precise mechanisms that drive this association remain incompletely understood. Numerous studies have explored the link between alopecia areata and thyroid disease, but reported prevalence rates vary widely. According to Puavilai et al., the prevalence of thyroid involvement in alopecia areata was very low (7.2%), and there was no statistically significant difference between cases and controls.[10] In the study by Sharma et al. from Chandigarh, the prevalence was as low as 1%[3], and Seyrafi et al. reported 8.9% of the cases to be having thyroid dysfunction.[2] However, Thomas and Kadyan observed the prevalence to be 18.3%[4], and in the study by Bakry et al., it was 16%.[7] These variations in findings highlight the need for further research for a better understanding of the relationship between alopecia areata and thyroid disease.
Our study reveals a significant association between alopecia areata and thyroid dysfunction, with 8 (25%) of the alopecia areata patients showing thyroid dysfunction while only 2 (6.25%) among the comparison group were having thyroid dysfunction. This finding was statistically significant, with a P = 0.039. Importantly, all affected patients had overt hypothyroidism, yet only 6 (18.75%) patients exhibited symptoms of thyroid dysfunction. These findings underscore the critical need for routine thyroid screening in all patients with alopecia areata, regardless of the presence of symptoms, to enable early detection and management of thyroid disorders.
To explore the autoimmune basis of thyroid dysfunction in alopecia areata, anti-TPO levels were assessed. Elevated anti-TPO levels were detected in six cases (18.75%), and none in the comparison group, a statistically significant finding (P = 0.01). This highlights the potential role of anti-TPO testing in identifying autoimmune thyroid dysfunction in patients with alopecia areata. The mean anti-TPO levels in cases were 16.8 ± 29.31, compared to 4.7 ± 1.3 in the comparison group. However, the difference in mean anti-TPO levels between the two groups did not reach statistical significance.
Interestingly, our study found no statistically significant relationship between thyroid dysfunction and factors such as age, gender, disease duration, or clinical profile of alopecia areata. This further emphasizes that thyroid dysfunction in alopecia areata may occur independently of these variables.
Ultimately, the findings of this study highlight the definite association between alopecia areata and thyroid dysfunction, often presenting asymptomatically. This evidence strongly supports the recommendation for routine thyroid evaluation in all patients with alopecia areata, as early detection and management can improve patient outcomes and provide insights into the autoimmune mechanisms underlying the condition.
Limitations of the study
The relatively small sample size of the study may restrict the generalizability of the findings to a broader population. As the study was conducted in a hospital-based setting, the results may not fully represent the broader community or other geographic regions. Furthermore, the absence of follow-up data means that the progression of thyroid dysfunction in alopecia areata patients could not be assessed.
CONCLUSION
This study provides compelling evidence of a strong association between thyroid dysfunction and alopecia areata.
Although this study did not find a significant relationship between thyroid status and the severity or clinical profile of alopecia areata, the statistically significant elevation in anti-TPO levels in alopecia areata cases underscores the potential autoimmune underpinnings of the condition.
Ethical approval:
The research/study was approved by the Institutional Review Board at Government Medical College, Thiruvananthapuram, number 02/26/2021/MCT, dated January 23, 2021.
Declaration of patient consent:
The authors certify that they have obtained all appropriate patient consent.
Conflicts of interest:
There are no conflicts of interest.
Use of artificial intelligence (AI)-assisted technology for manuscript preparation:
The authors confirm that there was no use of artificial intelligence (AI)-assisted technology for assisting in the writing or editing of the manuscript and no images were manipulated using AI.
Financial support and sponsorship: Nil.
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