Hair loss, skin conditions, and weight fluctuations can be distressing experiences. When these issues occur together, it's essential to understand the potential underlying causes and how they might be interconnected. This article explores the causes of acute alopecia (hair loss), eczema (specifically atopic dermatitis), and rapid weight loss, providing a comprehensive overview of their relationships and management strategies.
What is Alopecia Areata?
Alopecia areata is an autoimmune condition characterized by patchy hair loss on the scalp, face, and other areas of the body. Affecting approximately 2% of the population, it can manifest at any age, although it commonly begins in early adulthood. The term "alopecia" refers to hair loss or baldness, while "areata" indicates that it occurs in small, random areas.
Classifications of alopecia areata include:
- Alopecia areata totalis: Complete loss of hair on the scalp.
- Alopecia areata universalis: Complete loss of hair on the scalp and body.
- Diffuse alopecia areata: Hair thinning rather than patchy hair loss.
- Ophiasis alopecia areata: Hair loss in a band on the bottom back sides of the scalp.
While hair loss is the primary symptom, alopecia areata often coexists with other health conditions, making it crucial for clinicians to recognize and manage these comorbidities.
Common Comorbidities in Patients with Alopecia Areata
Managing comorbidities in alopecia areata patients is essential for building trust and improving treatment outcomes. These additional health issues can influence the course of alopecia areata and affect treatment effectiveness.
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Alopecia areata is frequently linked to several autoimmune conditions:
Thyroid Dysfunction
Thyroid dysfunction, particularly hypothyroidism, is strongly associated with alopecia areata. Patients with alopecia areata are 3.2 times more likely to develop thyroid issues than the general population. Symptoms include fatigue, weight gain, cold sensitivity, dry skin, and constipation. Yearly thyroid function tests, such as TSH, free T3, and free T4, are essential for monitoring patients. Proper management with medications like levothyroxine may improve both thyroid health and alopecia areata outcomes.
Atopic Disorders
Atopic disorders like eczema, asthma, and allergic rhinitis also frequently occur with alopecia areata. Eczema is 2 to 3 times more common in these patients. Treating atopic symptoms with antihistamines, corticosteroids, JAK inhibition, or biologics can reduce both the severity of the atopic disease and the progression of alopecia areata. Research breakthroughs are giving patients with atopic dermatitis/eczema more ways to treat this condition.
Vitiligo and Psoriasis
Vitiligo, another autoimmune condition, causes depigmented patches of skin or hair and may appear before or during alopecia areata. Psoriasis, with its distinctive red plaques and nail changes, often overlaps with alopecia areata. Some treatments, such as JAK inhibition and biologics, can benefit both conditions.
Metabolic and Endocrine Comorbidities with Alopecia Areata
Alopecia areata has strong ties to metabolic and endocrine conditions, particularly diabetes and obesity, both of which can influence alopecia areata progression and treatment.
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Diabetes
Alopecia areata is linked to both Type 1 and Type 2 diabetes. Type 1 has an autoimmune connection, with patients showing a higher prevalence of alopecia areata. Symptoms include increased thirst, frequent urination, and unexplained weight loss. In Type 2 diabetes, shared inflammatory pathways may contribute to this type of hair loss. Management includes regular glucose monitoring, insulin for Type 1, and lifestyle changes, oral or novel GLP-1 medications for Type 2. Collaboration between dermatology and endocrinology improves care.
Obesity and Metabolic Syndrome
Obesity and metabolic syndrome can worsen autoimmune conditions like alopecia areata through chronic inflammation and immune dysfunction. Recognizing signs like abdominal obesity and hypertension is important. Treatment focuses on lifestyle changes and GLP-1 therapy-as well as medications for hypertension, dyslipidemia, or glucose control. Addressing these issues may improve both overall health and alopecia areata management.
Less Common Comorbidities of Alopecia Areata
Though less common, rheumatologic disorders like lupus and rheumatoid arthritis are associated with alopecia areata. Patients may present with joint pain, fatigue, and skin findings. Collaborating with rheumatology for treatment, including DMARDs, JAK inhibition, and biologics, can be helpful. Celiac disease, triggered by gluten, may also be linked to alopecia areata. Gastrointestinal symptoms, malabsorption, and a strict gluten-free diet are central to its management. Chronic inflammation in alopecia areata may increase cardiovascular risk. Lifestyle changes and regular assessments help manage cardiovascular health in alopecia areata patients.
The Connection Between Weight Loss and Hair Loss
Hair loss during weight loss is commonly caused by nutrient deficiencies as well as other effects sudden and rapid weight loss can have on your body. Sudden weight loss and restrictive diets have been linked to acute telogen effluvium (TE), one of the most common causes of widespread hair loss on the scalp. Typically, TE occurs around 3 months after a triggering event like rapid weight loss and lasts about 6 months. Weight loss and nutrient deficiencies associated with restrictive diets are also linked to other types of hair loss, including chronic TE, which lasts longer than 6 months, and androgenic alopecia, also known as male or female pattern baldness.
Crash Dieting
The link between crash dieting and hair loss has been documented in research. Your hair needs adequate calories and nutrients to grow properly. When your body doesn’t receive what it needs, side effects like hair loss can occur. Many studies have linked hair loss to rapid weight loss, calorie restriction, nutrient deficiencies, and psychological stress - all commonly in people who are following crash diets. Poorly planned diets, such as crash diets, can lead to deficiencies in essential fatty acids, zinc, protein, and overall calories, all of which can lead to hair loss.
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Very Low Protein Diets
Amino acids, the building blocks of protein, are essential for hair growth. That’s because amino acids are necessary for the production of keratin, the main structural protein of hair. Protein malnutrition - when your body doesn’t get enough protein - can result in hair loss. Thus, if you’re following a low calorie weight loss diet that doesn’t contain enough protein, you may experience hair loss as a result. When your protein needs aren’t met, your body prioritizes important protein-dependent functions like tissue repair, digestion, pH and water balance regulation, and hormone production. Because hair growth isn’t essential to keep you alive, hair loss may occur.
Weight Loss Surgeries
Weight loss surgery is associated with rapid weight loss and commonly causes deficiencies in protein, vitamins, and/or minerals, which in turn can spark hair loss. For example, a 2018 study that included 50 people who underwent sleeve gastrectomy, a surgical procedure that removes a large portion of the stomach, observed hair loss in 56% of the participants. Hair loss was more common in women. Notably, the participants with hair loss had much lower levels of zinc and vitamin B12 both before and after surgery.
In addition to reducing stomach capacity, some types of weight loss surgery allow food to bypass part of the intestines, leading to malabsorption of nutrients and increasing the risk for deficiencies.
Restrictive Diets
Just like crash diets, restrictive diets that cut out entire food groups can cause hair loss as a result of nutrient deficiency or stress. Deficiencies in iron, zinc, protein, selenium, and essential fatty acids have all been linked to hair loss. Very low calorie diets have been shown to cause hair loss as well. Major stress, which sometimes comes along with restrictive dieting, has also been linked to hair loss.
Toxic Agents and Alopecia
Exposure to toxins is one of many etiological mechanisms that may cause alopecia, particularly in acute-onset alopecia associated with generalized symptoms, such as nausea, vomiting, diarrhea, fatigue, as well as skin and nail changes. There are a number of compounds identified that cause alopecia when taken at toxic levels, either accidentally or intentionally.
Heavy Metals
Heavy metals, such as thallium and mercury, have long been implicated in alopecia. Thallium, whose salt form is tasteless, odorless, colorless, and dissolves completely in liquids, reportedly causes hair loss by binding to the sulphydryl group of hair keratins, thus disrupting formation of the hair shaft. Thallium poisoning specifically results in anagen effluvium, defined as active hair loss >100 hairs/day over a period of 2-4 weeks, often presenting as diffuse alopecia 2-3 weeks after toxic thallium exposure. Mercury, like thallium, binds to the sulphydryl group of keratins in hair and can result in anagen effluvium. At toxic levels, mercury causes free-radical damage, resulting in symptoms such as fatigue, depression, insomnia, irritability, memory loss, recurrent infections, tremors, and hair loss.
Other Toxic Agents
Other reported causes of alopecia include colchicine, arsenic, selenium, botulinum toxin, Podostroma cornu-damae, and the synthetic opioid MT-45. Boric acid toxicity causes anagen effluvium and eyelash loss. Vitamin A at toxic levels reportedly causes scalp alopecia as well as loss of eyelashes and eyebrows.
Comprehensive Screening and Management of Alopecia Areata
Taking a whole-person, team-based approach to managing alopecia areata and its comorbidities is key. Clinicians should screen for autoimmune, metabolic, and psychological conditions with regular thyroid tests, glucose monitoring, and mental health assessments. Coordinated care with specialists, such as endocrinology, dermatology, and mental health professionals, ensures comprehensive treatment. Educating patients helps them recognize symptoms and advocate for their health. By fostering collaboration and standardized screenings, clinicians can begin to address both the physical and emotional needs of alopecia areata patients.
Alopecia Areata Treatment Considerations Based on Comorbidities
Care plans must consider other health conditions. Autoimmune thyroid disorders require monitoring when using immunosuppressants, while diabetic or hypertensive patients need caution with oral corticosteroids due to their effects on blood sugar and pressure. For mental health concerns, treatments like high-dose corticosteroids should be used carefully to avoid worsening mood disorders.
As of September 2024, alopecia areata has seen notable advancements in treatment, with new FDA-approved options that provide hope for patients with severe hair loss. Topical treatments, like corticosteroids and minoxidil, remain common first-line options, but are not at all targeted. The most significant advancement is JAK inhibitors. As of 2024, 3 FDA-approved JAK inhibitors-baricitinib (Olumiant), ritlecitinib (Litfulo), and deuruxolitinib (Leqselvi)-are transforming severe alopecia areata management by blocking inflammatory pathways that trigger hair loss. These medications provide new avenues for patients, with research focusing on long-term safety and combination therapies.
Preventing Hair Loss During Weight Loss
To prevent hair loss, avoid crash and restrictive diets, fuel your body properly, and supplement before and after weight loss surgery. Work with a qualified healthcare provider to identify the cause of hair loss and to find a plan to facilitate hair regrowth.
Instead of a fad diet, choose a balanced diet that provides your body with the nutrients it needs to function optimally. Saying no to restrictive diets that promise rapid weight loss is essential for protecting your physical and mental health and reducing the risk of side effects like hair loss.
If undergoing weight loss surgery, ensure that your levels of nutrients like zinc, iron, and vitamin B12 are optimal before the procedure, and supplement with nutrients recommended by your doctor or dietitian afterward. This can help prevent surgery-related hair loss.
Facilitating Hair Regrowth
If you’re experiencing hair loss, it’s critical that you identify the cause before you try to treat it. Remember, hair loss can have many causes, not just rapid weight loss or nutrient deficiencies. If the hair loss is caused by a deficiency in one or more nutrients like zinc or iron, correcting the deficiency or deficiencies may stop the loss and lead to hair regrowth.
If a restrictive or crash diet that’s not giving your body enough calories or nutrients is to blame, it’s essential to stop the diet immediately and begin fueling your body correctly with a balanced diet rich in nutrient-dense foods.