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ORIGINAL ARTICLE
Year : 2019  |  Volume : 20  |  Issue : 1  |  Page : 32-35

Evaluation of vitamin D in pediatric alopecia areata: A case–control study of thirty patients in a tertiary care hospital


Department of Dermatology, Raja Rajeswari Medical College and Hospital, Kambipura, Mysore Road, Bangalore, India

Date of Web Publication14-Dec-2018

Correspondence Address:
Dr. Yadalla Hari Kishan Kumar
70, Padma Nivasa, Skin Care Clinic, 3rd Cross MG Extension, HV Halli, Raja Rajeswari Nagar, Bengaluru - 560 098, Karnataka
India
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Source of Support: None, Conflict of Interest: None


DOI: 10.4103/ijpd.IJPD_83_18

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  Abstract 


Background: Alopecia areata is a common form of autoimmune, non-scarring alopecia and about one-third of cases affect people aged below 18 years. Alopecia in pediatric age group can cause psychological stress to parents and patients. Vitamin D plays a role in immune regulation and maintenance of hair cycle. Aims and Objectives: To evaluate serum vitamin D levels in pediatric alopecia areata cases. Methods: A comparative case-control study with 30 cases of pediatric alopecia areata and 30 age and sex matched healthy controls was conducted between Feb 2015 to July 2015. All subjects underwent complete evaluation and laboratory investigations including serum vitamin D was done. Results: Mean serum vitamin D level of pediatric alopecia areata cases (17.21±6.57 ng/ml) was significantly lower when compared to controls (25.03±13.84 ng/ml) (P < 0.05). Distribution of vitamin D deficiency was significantly higher in cases (73%) when compared to controls (46%) (P < 0.05). There was a significant inverse correlation between SALT scores of cases and their serum vitamin D levels (P < 0.05). Conclusions: There was decreased vitamin D levels observed in cases suggesting a possible role of vitamin D in alopecia areata and treating the deficiency may prevent the chronicity of the disease in children.

Keywords: Alopecia areata, pediatric alopecia areata, Vitamin D


How to cite this article:
Siddappa H, Kumar YH, Neladimmanahally V. Evaluation of vitamin D in pediatric alopecia areata: A case–control study of thirty patients in a tertiary care hospital. Indian J Paediatr Dermatol 2019;20:32-5

How to cite this URL:
Siddappa H, Kumar YH, Neladimmanahally V. Evaluation of vitamin D in pediatric alopecia areata: A case–control study of thirty patients in a tertiary care hospital. Indian J Paediatr Dermatol [serial online] 2019 [cited 2019 Jul 19];20:32-5. Available from: http://www.ijpd.in/text.asp?2019/20/1/32/247561




  Introduction Top


Alopecia areata is an autoimmune disease characterized by nonscarring alopecia and can affect any hair-bearing area of the body. It is caused by T-cell infiltrates (CD4+ and CD8+) and cytokine production around anagen-stage hair follicles.[1] The estimated lifetime risk of developing alopecia areata is 1.7%.[2]

Pediatric alopecia areata is common. In India, up to one-third of newly diagnosed alopecia areata cases are in patients aged <18 years. It has been postulated that patients presenting with alopecia areata below 10 years of age are most likely to develop atopic dermatitis or systemic lupus erythematosus (SLE). Patients presenting with alopecia areata in the second decade have a high risk of developing psoriasis or rheumatoid arthritis.[3]

The understanding of pediatric alopecia areata is important due to its chronic course in the pediatric age group. They are more prone to multiple relapses and progression to alopecia universalis or totalis.

Vitamin D is a modulator of immune functions including activities of T-lymphocytes and B-lymphocytes.[4] Vitamin D deficiency was established as a risk factor for the occurrence of various autoimmune diseases such as SLE, psoriasis, vitiligo, rheumatoid arthritis, multiple sclerosis, and inflammatory bowel disease.[5],[6]

It has been demonstrated that Vitamin D receptors are strongly expressed in the key structures of hair follicles and are necessary for the maintenance of the normal hair cycle.[7] There are few studies demonstrating serum Vitamin D deficiency in alopecia areata patients. However, there is no study involving the pediatric age group. Hence, the aim of the study is to evaluate serum Vitamin D levels in pediatric alopecia areata cases.


  Materials and Methods Top


The study is a comparative case–control study involving thirty cases of pediatric alopecia areata and thirty healthy controls, conducted from February 2015 to July 2015. The cases and controls were recruited from the Outpatient Department of Dermatology, Venereology and Leprology at Rajarajeswari Medical College and Hospital, Rural Bengaluru district of southern India. Ethical clearance for the study was taken from the Institutional Ethics Committee.

All cases and controls were enrolled during the months of February to July, which are the seasons of spring and summer in India. The amount of sun radiations reaching the surface is almost the same in these months.

Patients with alopecia areata of both sexes and <18/20 years of age were included in the study. Patients with other causes for alopecia (such as tinea capitis, androgenetic alopecia, trichotillomania, scarring alopecia, and traction alopecia), dermatological conditions (such as psoriasis and vitiligo), autoimmune or systemic diseases (such as diabetes mellitus, anemia, hypo/hyperthyroidism, SLE, rheumatoid arthritis, and scleroderma), and on medications such as steroids, immunosuppressants, calcium, and Vitamin D in the past 4 weeks and on phototherapy for the past 1 month were excluded from the study.

Detailed history was taken, and a thorough systemic and cutaneous examination was done to all cases. Diagnosis of alopecia areata was made through the clinical findings. In doubtful cases, histopathological examination (perifollicular lymphocytic infiltration)[3] and trichoscopy (exclamation mark hairs, coudability, yellow dots, black dots, and short vellus hairs) were performed. Clinical assessment of alopecia areata of scalp lesions was performed by determining the site of involvement and calculating the Severity of Alopecia Tool (SALT) score.

Clinical photographs of cutaneous lesions were taken with patient's consent for the assessment of severity of lesions. The healthy control group consisted of thirty age- and sex-matched individuals without any history of alopecia areata or other autoimmune/systemic diseases. Serum Vitamin D was measured through chemiluminescence immunoassay method and graded as follows: deficiency <20 ng/ml, insufficiency 20–29.99 ng/ml, and normal >30 ng/ml.

Statistical analysis

The statistical software, namely, Statistical Package for the Social Sciences (SPSS) version 17.00 (SPSS Inc., Chicago, IL), was used for the analysis of the data, and Microsoft Word and Excel have been used to generate graphs, tables, etc., Student's t-test (two-tailed, independent) has been used to find the significance of study parameters on continuous scale between two groups (intergroup analysis) on metric parameters. Chi-square/Fisher's exact test has been used to find the significance of study parameters on categorical scale between two or more groups. Correlation has been performed using Spearman's correlation. P < 0.05 is considered to be statistically significant and P < 0.001 as highly significant.


  Results Top


A total of 30 cases and 30 controls satisfying the inclusion and exclusion criteria were included in the study. The cases ranged from 5 to 18 years. The mean age of the cases was 11.13 ± 4.17 years, and controls were 11.47 ± 4.42 years. There were 18 males and 12 females among cases and 16 males and 14 females among controls. The male: female ratio was 1.5:1 among cases and 1.14:1 among controls.

Most commonly involved site was scalp. Twenty-five cases had exclusively scalp lesions, four cases had lesions in both scalp and eyebrows, and one case had exclusively eyebrow lesion [Table 1].
Table 1: Demographic and clinical data of cases and controls

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The mean serum Vitamin D level of cases was significantly lower than that of controls (17.21 ± 6.57 ng/ml vs. 25.03 ± 13.84 ng/ml; P < 0.05). The number of cases with Vitamin D deficiency was significantly more among cases than in controls (73% vs. 46%; P < 0.05) [Table 2] and [Figure 1].
Table 2: Comparison of serum Vitamin D between new and old cases

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Figure 1: Distribution of serum Vitamin D deficiency between cases and controls

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When the serum Vitamin D levels of cases with scalp lesions were compared with their SALT scores, there was a significant inverse correlation between the two (r = −0.379; P < 0.05) [Figure 2].
Figure 2: Correlation between serum Vitamin D and Severity of Alopecia Tool score

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  Discussion Top


Alopecia areata is a common form of autoimmune, nonscarring alopecia involving the scalp and/or body, characterized by hair loss without any clinical inflammatory signs.[3] It is an organ-specific autoimmune disease caused by T-cell infiltrates (CD4+ and CD8+) and cytokine production around anagen-stage hair follicles.[1]

Pediatric alopecia areata is important to understand due to its chronicity and bad prognosis in severe cases. They can be associated with atopy, nail changes, and positive family history. Although pediatric alopecia areata patients commonly present with mild localized disease affecting <50% of the scalp, it is important to evaluate the impact of the disease on the child's physical, emotional well-being and parent's anxiety and expectations.[8] It is also important to assess the various treatment options in the pediatric age group as many treatment options safe in adults may not be viable in pediatric age.

Vitamin D is known as a prohormone primarily synthesized in epidermal keratinocytes under the influence of ultraviolet radiation or acquired from diet.[9],[10] After synthesis, Vitamin D is hydroxylated to 25-hydroxyvitamin D (25[OH]D) in the liver. 25(OH)D is then converted to 1,25-dihydroxyvitamin D3 (1,25[OH] 2D3) in the kidney by the enzyme 1-alpha-hydroxylase.[11] Although 1,25(OH) 2D3 is the biologically active form of Vitamin D, 25(OH)D is considered as the primary indicator of Vitamin D status, as the half-life of 1,25(OH) 2D3 is <4 h.[9],[10]

It is postulated that the development of hair follicle depends on the Vitamin D receptor expression which correlates with increased differentiation of the follicle keratinocytes.[12] Recent study demonstrated that the decreased expression of Vitamin D receptor in alopecia areata lesions is related to decreased expression of the Wnt signaling pathway, which inhibits proliferation and differentiation of hair follicles and epidermal cells.[13] Studies by Aksu Cerman et al.,[4] Yilmaz et al.,[12] Mahamid et al.,[14] Attawa et al.,[15] El-Mongy et al.,[16] and Bhat et al.[17] found decreased serum Vitamin D levels in alopecia areata. However, all these studies included adult population. No study to date provides an analysis involving the pediatric age group. Hence, this study was undertaken to find the association between serum Vitamin D levels and alopecia areata in the pediatric age group.

In our study, the mean serum Vitamin D level of the cases was 17.21 ± 6.57 ng/ml. This was significantly less than the controls, 25.03 ± 13.84 ng/ml, and it was statistically significant (P < 0.05). Even Yilmaz et al.,[12] Aksu Cerman et al.,[4] Mahamid et al.,[14] Attawa et al.,[15] El-Mongy et al.,[16] and Bhat et al.[17] found similar significant lower levels of serum Vitamin D in cases when compared to controls.

An analysis of the distribution of serum Vitamin D deficiency among cases and controls showed a significantly increased percentage of Vitamin D deficiency among cases than in controls (73% vs. 46%; P < 0.05). Similarly, Mahamid et al.,[14] Aksu Cerman et al.,[4] and Yilmaz et al.[12] found that the percentage of Vitamin D deficiency was significantly more among cases when compared to controls.

There was a statistically significant inverse correlation between the SALT score and serum Vitamin D levels (P < 0.05). Similarly, Aksu Cerman et al.[4] and Bhat et al.[17] in their study found a significant inverse correlation between SALT scores and serum Vitamin D levels. Whereas Yilmaz et al.[12] and El-Mongy et al.[16] did not find any significant correlation with duration or severity of alopecia areata, possibly suggesting Vitamin D plays a role in the incidence of the disease but not in its subsequent course.

To our knowledge, this is the first comparative case–control study among the pediatric population to evaluate the role of serum Vitamin D in alopecia areata. We found that there was a significant difference in serum Vitamin D levels in pediatric alopecia areata cases when compared to a healthy control group. There was also a significant inverse correlation between serum Vitamin D levels and SALT scores.

This association of serum Vitamin D levels with respect to pediatric alopecia areata and its severity may suggest a role of serum Vitamin D deficiency in the pathogenesis of alopecia areata and could act as a useful marker for disease severity.

Further studies are required to evaluate the role of supplementing Vitamin D in the treatment of pediatric alopecia areata to prevent its progression into severe or chronic cases.

Financial support and sponsorship

Nil.

Conflicts of interest

There are no conflicts of interest.



 
  References Top

1.
McElwee KJ, Tobin DJ, Bystryn JC, King LE Jr., Sundberg JP. Alopecia areata: An autoimmune disease? Exp Dermatol 1999;8:371-9.  Back to cited text no. 1
    
2.
Safavi KH, Muller SA, Suman VJ, Moshell AN, Melton LJ 3rd. Incidence of alopecia areata in Olmsted county, Minnesota, 1975 through 1989. Mayo Clin Proc 1995;70:628-33.  Back to cited text no. 2
    
3.
Seetharam KA. Alopecia areata: An update. Indian J Dermatol Venereol Leprol 2013;79:563-75.  Back to cited text no. 3
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4.
Aksu Cerman A, Sarikaya Solak S, Kivanc Altunay I. Vitamin D deficiency in alopecia areata. Br J Dermatol 2014;170:1299-304.  Back to cited text no. 4
    
5.
Hewison M. An update on Vitamin D and human immunity. Clin Endocrinol (Oxf) 2012;76:315-25.  Back to cited text no. 5
    
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Ersoy-Evans S. Commentary: Vitamin D and autoimmunity: Is there an association? J Am Acad Dermatol 2010;62:942-4.  Back to cited text no. 6
    
7.
Bikle DD. Vitamin D metabolism and function in the skin. Mol Cell Endocrinol 2011;347:80-9.  Back to cited text no. 7
    
8.
Nanda A, Al-Fouzan AS, Al-Hasawi F. Alopecia areata in children: A clinical profile. Pediatr Dermatol 2002;19:482-5.  Back to cited text no. 8
    
9.
Saleh HM, Abdel Fattah NS, Hamza HT. Evaluation of serum 25-hydroxy Vitamin D levels in vitiligo patients with and without autoimmune diseases. Photodermatol Photoimmunol Photomed 2013;29:34-40.  Back to cited text no. 9
    
10.
Holick MF. Sunlight and Vitamin D for bone health and prevention of autoimmune diseases, cancers, and cardiovascular disease. Am J Clin Nutr 2004;80:1678S-88S.  Back to cited text no. 10
    
11.
Baeke F, van Etten E, Gysemans C, Overbergh L, Mathieu C. Vitamin D signaling in immune-mediated disorders: Evolving insights and therapeutic opportunities. Mol Aspects Med 2008;29:376-87.  Back to cited text no. 11
    
12.
Yilmaz N, Serarslan G, Gokce C. Vitamin D concentrations are decreased in patients with alopecia areata. Vitam Trace Elem 2012;1:105-9.  Back to cited text no. 12
    
13.
Lim YY, Kim SY, Kim HM, Li KS, Kim MN, Park KC, et al. Potential relationship between the canonical Wnt signalling pathway and expression of the Vitamin D receptor in alopecia. Clin Exp Dermatol 2014;39:368-75.  Back to cited text no. 13
    
14.
Mahamid M, Abu-Elhija O, Samamra M, Mahamid A, Nseir W. Association between Vitamin D levels and alopecia areata. Isr Med Assoc J 2014;16:367-70.  Back to cited text no. 14
    
15.
Attawa EM, Kandil AH, Elbalaat W, Samy AM. Assessment of Vitamin D level in patients of alopecia areata. J Clin Invest Dermatol 2016;4:1-4.  Back to cited text no. 15
    
16.
El-Mongy NN, El-Nabarawy E, Hassaan SA, Younis ER, Shaker O. Serum 25-hydroxy Vitamin D3 level in Egyptian patients with alopecia areata. J Egypt Dermatol Soc 2013;10:37-41.  Back to cited text no. 16
    
17.
Bhat YJ, Latif I, Malik R, Hassan I, Sheikh G, Lone KS, et al. Vitamin D level in alopecia areata. Indian J Dermatol 2017;62:407-10.  Back to cited text no. 17
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