Moderate to Severe Alopecia Areata Linked to Higher Risk of Atopic Dermatitis Diagnosis

Patients with moderate to severe alopecia areata (AA) face a significantly elevated risk of developing atopic dermatitis (AD) compared with those with milder disease, according to new findings published in the Journal of Investigative Dermatology.¹

Researchers found that patients with moderate to severe AA had a 78% higher risk of receiving an AD diagnosis compared with patients with mild AA (adjusted HR, 1.8; 95% CI, 1.1-2.8; P = .0124). The retrospective cohort study, which drew on data from over 11,000 patients in the Merative MarketScan Research Databases, offers real-world evidence on how AA disease severity impacts the burden of comorbid AD and has implications for treatment planning.

“This study adds to previous reports by not only highlighting prevalence, incidence, and risk of AD by AA severity but also providing evidence on comorbid AD severity,” the authors wrote.

The overall 5-year baseline prevalence of AD among patients with AA was 3.2% compared with 12.1% when assessed across the full database period. Patients with moderate to severe and very severe AA were more likely to have comorbid AD during the preindex period than those with mild disease (4.9% and 3.3% vs 2.7%, respectively).

Among adolescent patients aged 12 to 17 years with AA, the 5-year prevalence of AD reached 7.6%, and those with moderate to severe or very severe AA were more than twice as likely to have AD compared with peers with mild disease (14.3% and 12.8% vs 6.3%, respectively). Adolescents with very severe AA had an AD incidence of 43.1 per 1000 person-years compared with 5.9 per 1000 person-years in those with mild disease.

Patients seen by dermatologists had notably higher rates of comorbid AD across all AA severity levels compared with those diagnosed by nondermatologist providers.

From a mechanistic standpoint, the authors acknowledged that the precise biological drivers of the AA-AD relationship remain incompletely understood. AA is predominantly a T helper 1–mediated condition, while AD is more heterogeneous, with T helper 2 inflammation playing a central role. However, emerging data suggest patients with AA exhibit elevated markers of T helper 2 activity and higher immunoglobulin E levels even without overt atopy, hinting at shared immunological underpinnings that warrant further study.²

With several Janus kinase (JAK) inhibitors now approved by the FDA for both AA and AD independently, these and other data raise the possibility that systemic therapies could simultaneously address both conditions in patients with comorbid disease, potentially streamlining treatment regimens and improving adherence, the authors explained.¹

“Such approaches could also reduce patient burden by simplifying treatment regimens, thereby improving adherence and optimizing overall disease management,” the authors wrote. “Furthermore, the elevated risk of AD development underscores the importance of incorporating routine monitoring for atopic changes into the standard care for patients with AA.”

The authors noted that the study is limited by its reliance on claims data, which carries inherent risks of misclassification, and that disease severity was determined using treatment as a proxy rather than direct clinical assessment. Generalizability is also restricted given that the population was limited to commercially insured patients.

Still, the findings support proactive monitoring of atopic comorbidities—particularly AD—as a routine component of care for patients with AA, especially those with more severe or extensive disease.

“This cohort study found that patients with moderate to severe and very severe AA have higher prevalence and incidence of comorbid AD than patients with mild AA,” the authors concluded. “Similarly, patients with more severe AA seemed to have an increased risk of being diagnosed with AD, which can exacerbate the overall disease burden and diminish the QOL [quality of life] for those affected. Routine monitoring of patients with AA, particularly those at risk of being diagnosed with comorbid AD, may enable earlier and more effective interventions.”

References

1. Bunick CG, Armstrong AW, Grada A, et al. The epidemiology of atopic dermatitis among adults and adolescents with alopecia areata in the United States. J Invest Dermatol. 2026;146(2):365-373.e3. doi:10.1016/j.jid.2025.06.1578

2. Renert-Yuval Y, Pavel AB, Del Duca E, et al. Scalp biomarkers during dupilumab treatment support Th2 pathway pathogenicity in alopecia areata. Allergy. 2023;78(4):1047-1059. doi:10.1111/all.15561