Alopecia areata in solid organ transplant recipients: A retrospective analysis

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A retrospective analysisTo the Editor: Alopecia areata (AA) is a chronic, nonscarring autoimmune alopecia with a polygenic basis.Immunosuppression is central to AA treatment, making its occurrence in solid organ transplant recipients (SOTRs), who receive T-cell-inhibiting regimens, rare. 1 Since 1994, fewer than 20 cases have been reported, most commonly kidney, pancreas, and liver transplants.2 AA may have a greater impact on SOTRs' quality of life due to existing comorbidities.3 This study characterizes its prevalence and clinical features at a large academic center.Following institutional review board approval (IRB# 24-005297), a retrospective analysis of the Mayo Clinic Health System database (October 2005-June 2024) was conducted.SOTRs with a dermatologist-diagnosed AA, with histopathological confirmation in some cases, were included if they had been SOTRs for a year or more.Data on demographics, clinical characteristics, immunosuppressive regimens, AA treatments, and outcomes were collected.Among 28,260 SOTRs, 21 met inclusion criteria, yielding an AA prevalence of 0.074%.The median age was 48 years (range, 4-75), and 13 (61.9%)were female.The average time from transplantation to AA presentation was 5.25 years, ranging from days to years.Fourteen patients presented with focal AA, 5 with diffuse scalp-hair thinning, and 2 with AA universalis.The scalp was the most common site (Table I).Thoracic transplant recipients had a higher rate of diffuse AA (3, 14.2%) compared to abdominal transplants (1, 4.7%).Treatment options and outcomes varied (Supplementary Table I, available via Mendeley at https://data.mendeley. com/datasets/rn3htwbvh6/1).Autoimmune conditions, including type 1 diabetes, vitiligo, Goodpasture syndrome, and IgA glomerulonephritis, were prevalent in this cohort, consistent with prior reports, 2 suggesting a potential autoimmune predisposition.The role of systemic immunosuppression in AA development remains uncertain.Notably, 18 (85%) patients were on tacrolimus, which has been linked to drug-induced alopecia and AA. 4 None of our patients received cyclosporine, although prior studies have suggested a relationship between declining cyclosporine levels and AA. 1 Patients were treated with 2 or 3 immunosuppressants, which theoretically may control AA, but no medication patterns were clearly associated with its development.Unlike previous research, 2 we report on transplant induction therapies, which suppress T-cell activity for extended periods posttransplantation.Lymphodepletion from induction therapy may lead to homeostatic activation of new T cells, potentially causing autoimmunity, as seen with conditions like Graves' disease.4 Another notable finding was the late onset of AA after transplantation in most patients.This may reflect the initial use of high-dose immunosuppressants, which are tapered over time and may have suppressed AA development.Interestingly, the prevalence of AA in our SOTR cohort (0.074%) was lower than in the general US population (0.1% to 0.2%).5 This discrepancy may reflect the ability of immunosuppressive regimens to initially mitigate the autoimmune response associated with AA.The exact pathogenic mechanism of AA in SOTRs remains unclear, likely influenced by the complex immunologic landscape of these patients.Limitations of this study include the small sample size, single-center data, and retrospective design.Additionally, the prevalence of AA may be underestimated due to reliance on database diagnoses and lack of biopsy confirmation in all cases.Further research is needed to better understand AA in SOTRs to improve patient care.

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