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 Table of Contents  
ORIGINAL ARTICLE
Year : 2021  |  Volume : 34  |  Issue : 2  |  Page : 498-502

Troponin I in alopecia areata and female pattern hair loss


1 Department of Dermatology, Andrology and STIs, Faculty of Medicine, Menoufia University, Menoufia, Egypt
2 Department of Medical Biochemistry and Molecular Biology, Faculty of Medicine, Menoufia University, Menoufia, Egypt
3 Department of Dermatology, Al Shorouk general Hospital, Cairo, Egypt

Date of Submission29-Dec-2019
Date of Decision24-Feb-2020
Date of Acceptance27-Feb-2020
Date of Web Publication30-Jun-2021

Correspondence Address:
Amira S Iraqi
MBBCH, Department of Dermatology, Al Shorouk General Hospital, Cairo
Egypt
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Source of Support: None, Conflict of Interest: None


DOI: 10.4103/mmj.mmj_394_19

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  Abstract 


Objective
To evaluate troponin I level in patients with alopecia areata and those with female pattern hair loss in comparison with controls.
Background
Alopecia areata is an autoimmune disease with a variable, typically relapsing or remitting course. Its incidence rate is 2%. Alopecia areata is associated with numerous comorbid diseases including hypothyroidism, celiac disease, type 1 diabetes, hyperlipidemia, and atherosclerosis. All these comorbidities are risk factors for cardiovascular disease. Female pattern hair loss is a nonscarring progressive thinning of hair. Its incidence rate is 12%. It is often associated with dyslipidemia, obesity, insulin resistance, and hypertension as comorbidities. Cardiovascular diseases are of particular importance as they often directly affect the patients' mortality.
Patients and methods
This case–control study was carried out on 29 female patients with alopecia areata, 30 cases with female pattern hair loss, and 23 age-matched and sex-matched healthy controls. All participants were subjected to a full history taking, general examination, and local examination with assessment of alopecia areata by Severity of Alopecia Tool score and assessment of female pattern hair loss by Ludwig classification. Troponin I level was done for all cases and controls.
Results
Our results showed that patients with alopecia areata had significantly higher mean levels of cardiac troponin I than female pattern hair loss group and control group.
Conclusion
High troponin I levels in patients with alopecia areata reinforces the association between alopecia areata and cardiovascular diseases compared with female pattern hair loss and normal population.

Keywords: alopecia areata, cardiovascular diseases, female pattern hair loss, troponin I


How to cite this article:
Shoeib MA, Bakry OA, Soliman SE, Iraqi AS. Troponin I in alopecia areata and female pattern hair loss. Menoufia Med J 2021;34:498-502

How to cite this URL:
Shoeib MA, Bakry OA, Soliman SE, Iraqi AS. Troponin I in alopecia areata and female pattern hair loss. Menoufia Med J [serial online] 2021 [cited 2024 Mar 28];34:498-502. Available from: http://www.mmj.eg.net/text.asp?2021/34/2/498/319730




  Introduction Top


Alopecia areata is an autoimmune disease with a variable, typically relapsing or remitting course that can be persistent especially when hair loss is extensive [1]. The prevalence of alopecia areata is ~2% [2]. In Egypt, the prevalence of alopecia areata is ~1% of population and is ~0.6% among children in Al Sharqia Governorate [3].

The pathogenesis of alopecia areata is still unclear. The upregulation of immune mechanisms and disruption of the immune privilege of the hair follicle are believed to be the main causative pathogenic mechanisms [4].

Female pattern hair loss is a nonscarring progressive thinning of hair that results from follicular miniaturization. There are reported incidences of 12% in females around 30 years old and around 40% in the female population around 60 years old [5].

The mechanism through which this follicular transformation occurs in female pattern hair loss is not completely understood. An increased sensitivity of the hair follicle to normal androgen levels can explain the onset of the disease in patients without hyperandrogenism [6].

Several disorders were identified as alopecia areata comorbidities like type 1 diabetes, hyperlipidemia, and atherosclerosis. All these comorbidities are risk factors for cardiovascular disease [7]. There are previous studies that have suggested an association between female pattern hair loss and cardiovascular risk [8],[9]. This is owing to the association of female pattern hair loss with dyslipidemia, obesity, insulin resistance, hypertension, and metabolic syndrome [6],[10].

Cardiac troponins are components of the cardiac myocytes contractile apparatus. The plasma level of cardiac troponin I is greatly increased following myocardial infarction owing to cardiac cell death, making it an important marker of cardiac myocyte injury [11]. It has been shown that cardiac troponin I level is elevated in patients with autoimmune disease even without the presence of heart failure; indicating subclinical myocardial injury [12].

Recently, a relationship between alopecia areata and increased risk of cardiovascular diseases particularly in patients with severe hair loss has been observed. These patients are more likely to develop major cardiac events.

So we aimed in this work to estimate the serum level of cardiac troponin I in patients with alopecia areata and those with female pattern hair loss to detect the possible association between both diseases and increased risk of cardiovascular disease in comparison with controls.


  Patients and methods Top


The study was approved from the ethical committee of Faculty of Medicine, Menoufia University, and the patients gave an informed consent. This case–control study included 82 patients who were attending the Menoufia Skin and Andrology Outpatient Clinic during the period from October 2018 to March 2019.

They were classified into three groups: group 1 included 29 female patients with alopecia areata, group 2 included 30 patients with female pattern hair loss, and group 3 (control group) included 23 age-matched and sex-matched healthy participants.

All study participants were subjected to the following after taking written consent: complete history tacking, general examination, and local examination with assessment of alopecia areata by Severity of Alopecia Tool (SALT) score and assessment of female pattern hair loss by Ludwig classification. Troponin I level was done for all cases and controls.

Patients who had any other dermatological diseases; systemic disease, for example, liver, kidney, or heart diseases; or patients receiving drugs for alopecia areata or female pattern hair loss less than 1 month before enrolling to the study were excluded. Moreover, all cases and controls with any risk factor for cardiac diseases were excluded from the study like type 1 diabetes, hyperlipidemia, hypertension, and atherosclerosis. All cases and control with BMI above 30 were excluded. All study participants had no family history of cardiac diseases. The Perceived Stress Scale questionnaire to measure the degree of stress was applied on all study participants to exclude any individual who suffered from stress life events.

The results were statistically analyzed by SPSS, version 23 (SPSS Inc., Armonk, New York, USA). Statistics were calculated in terms of number, percentage, mean, SD, median, range, analysis of variance, Mann–Whitney test, and P value.


  Results Top


This study included 29 female patients with alopecia areata, 30 cases with female pattern hair loss, and 23 age-matched and sex-matched healthy controls. The age of patients with alopecia areata ranged from 18 to 55 years, with mean ± SD age of 33.31 ± 8.79 years. Female pattern hair loss age ranged from 15 to 55 years, with mean ± SD age of 31.10 ± 8.83 years. Control group age ranged from 19 to 48 years, with mean ± SD age of 30.65 ± 6.74 years [Table 1].
Table 1: Comparison between cases and controls regarding age

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Duration of alopecia areata disease ranged from 8 to 48 months, with mean ± SD of 7.40 ± 9.66 months. Percent of hair loss in affected area ranged from 5 to 100%, with mean ± SD 26.72 ± 26.80%. Percent of scalp hair loss ranged from 1 to 100%, with mean ± SD 10.90 ± 19.66%.The most affected scalp areas were parietal area in nine (31%) patients, vertex area in nine (31%) patients, occipital area in seven (24.1%) patients, combined occipital and vertex areas in two (6.9%) patients, combined occipital and parietal areas in one (3.4%) patient and all scalp areas were affected in one (3.4%) patient. Regarding pattern, patchy was the most common in 24 (82.8%) patients then ophiasis in four (13.8%) patients, and finally, totalis was present in one (3.4%) patient. According to SALT score, 25 (86.2%) patients were S1, three (10.3%) patients were S2, and only one (3.4%) patient was S5. Regarding severity, it was mild in 24 (82.8%) patients, moderate in one (3.4%) patient, severe in one (3.4%) patient, and ophiasis in three (10.2%) patients. Prognosis was good in 23 (79.3%) patients. Recurrence occurred in five (17.2%) patients. Body hair loss (B1) was present in one (3.4%) patient. There was a positive family history in 15 (51.7%) patients [Table 2].
Table 2: Clinical data of patients with alopecia areata

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In female pattern hair loss, age of disease onset ranged from 15 to 35 years, with mean ± SD 22.03 ± 4.97 years. Duration of the disease ranged from 1 to 20 years, with mean ± SD 8.50 ± 6.27 years. Grade I was presented in 12 (40%) cases, grade II was presented in more than half of the studied cases, that is, 17 (56.7%) cases, and grade III was presented only in one (3.3%) case. Regarding family history of similar condition was positive in 27 (90%) cases [Table 3].
Table 3: Clinical data of patients with female pattern hair loss

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There was a highly significant difference between alopecia areata and control groups regarding cardiac troponin I (P = 0.003) [Table 4]. Patients with alopecia areata had significantly higher mean levels of cardiac troponin I levels than female pattern hair loss group (P = 0.001) [Table 5].
Table 4: Comparison between alopecia areata and control according to troponin I level

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Table 5: Comparison between female pattern hair loss and alopecia areata regarding troponin I level

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  Discussion Top


Alopecia areata is a common, nonscarring skin disease caused by T-cell-mediated autoimmune reactions against anagen-stage hair follicles, which presents by patches of hair loss on the scalp and face, and in severe forms can present by alopecia totalis (total loss of hair of the scalp) and alopecia universalis (complete loss of hair of the scalp and body) [13]. Alopecia areata is a relatively frequent disease with a prevalence of 1–2% worldwide [2].

In spite of the fact that skin is the primary target organ affected by alopecia areata, associated comorbidities are common. Several disorders were identified as alopecia areata comorbidities like type 1 diabetes, hyperlipidemia, and atherosclerosis. All these comorbidities are risk factors for cardiovascular disease [7].

Female pattern hair loss is characterized by a reduction in hair density over the crown and frontal scalp with retention of the frontal hairline [14]. It is the most common form of alopecia, affecting up to 50% of women in the course of their life [15].

Cardiac troponin I is presented in cardiac muscle tissue. The level of cardiac troponin may directly reflect various pathophysiological processes including cardiac myocyte necrosis and apoptosis. Assessment of circulating troponin concentrations is suitable to predict first and subsequent adverse events [16].

The aim of this study was to estimate serum level of cardiac troponin I in alopecia areata and female pattern hair loss to detect the possible association between both diseases and increased risk of cardiovascular disease.

This study revealed that patients with alopecia areata had significantly higher mean levels of cardiac troponin I than female pattern hair loss group and control group.

Elevated cardiac troponin I in alopecia areata without cardiac symptoms may give evidence of associated subclinical myocardial injury, a postulation that needs to be confirmed in future studies.

Alopecia areata is associated with a strong T-helper 1-mediated cytokine response based on increased lesional expression of interferon-gamma and interleukin-1 and 2, which are intensely expressed on alopecia areata follicular epithelium and act as a potent inhibitor of hair follicle growth in affected area of alopecia areata [17].

Inflammatory cytokines may modulate myocardial functions by a variety of mechanisms including stimulation of hypertrophy of cardiac myocytes, induction of apoptosis, and stimulation of genes involved in myocardial remodeling that lead to improper cellular repair, tissue damage, and dysfunction [18].

Therefore, the association between alopecia areata and cardiovascular risk can be explained by shared the same inflammatory pathway between both diseases.

In addition, oxidative stress plays a role in alopecia areata. Cardiovascular pathology associated with oxidative stress is observed in several cardiac diseases [19]. Oxidative stress and inflammation are closely interrelated; oxidative stress can cause inflammation, which in turn can induce oxidative stress. Both oxidative stress and inflammation cause injury to cells and necrosis [20].

Stress-induced cardiac dysfunction is frequently seen as a complication of acute stress states. The pathophysiology mechanisms include catecholamine excess both locally in the myocardium and in the circulation. Stress-induced cardiomyopathy diagnosed by ECG abnormalities elevated cardiac biomarkers, substernal chest pain, and dyspnea [21].

The results of the current study demonstrated significant correlation between cardiac troponin I and percent of hair loss and SALT score. This may give evidence that severe types of alopecia areata are associated with severe myocardial affection.

This study revealed that there was a significant correlation between alopecia areata and family history of alopecia areata. This was explained by genetic susceptibility in patients with alopecia areata to develop the disease and had commonly more sever types [22].

This study revealed that there was no significant difference in female pattern hair loss and control group regarding cardiac troponin I levels, as female pattern hair loss did not cause cardiac myocytes remodeling or apoptosis.

The results of the current study demonstrated a significant correlation between female pattern hair loss and similar family condition, because genetic predisposition increases susceptibility of developing female pattern hair loss at an earlier age. Family history does not affect course of hair loss which is only influenced by the duration of the condition [23].


  Conclusion Top


Increased cardiac troponin I levels in patients with alopecia areata reinforces the association between alopecia areata and cardiovascular diseases. When diagnosing a patient with alopecia areata, clinicians need to consider the possibility of associated comorbidities. Educational and psychological support in addition to medical therapy for alopecia areata could improve their long-term physical outcomes.

Financial support and sponsorship

Nil.

Conflicts of interest

There are no conflicts of interest.



 
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    Tables

  [Table 1], [Table 2], [Table 3], [Table 4], [Table 5]


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