A cross-sectional analysis from the Nurses’ Health Study (NHS) and Nurses’ Health Study II (NHSII) showing increased odds of alopecia areata based on self-reported diagnosis and race, in black and Hispanic women.

1. Prevalence of alopecia areata
differs by race in two large cohorts
Jordan M. Thompson, BS, MSIV, Min Kyung Park, PhD,
Tricia Li, MS, Abrar A. Qureshi, MD, MPH, and
Eunyoung Cho, ScD

2. Epidemiology of AA
• Focus on: medical and psychiatric comorbidities
– E.g. thyroid disease, depression/anxiety
• National Alopecia Areata Registry; phenomenal
resource
• Few large population based studies

3. Epidemiology of AA
• 2 population based studies1,2; Olmstead
County, Minnesota
• Rochester Epidemiology Project
• Cumulative lifetime incidence of 1.7-
2.1%
• Racial homogeneity of region
precludes comparisons of relative
incidence/prevalence by race
1Mirzoyev SA, Schrum AG, Davis MD, Torgerson RR. Lifetime incidence risk of alopecia areata estimated at 2.1% by Rochester
Epidemiology Project, 1990-2009. J Invest Dermatol. 2014 Apr;134(4):1141-2.
2Safavi 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 Jul;70(7):628-33.

4. Our question
• Does the risk of AA differ by self-
reported race?

5. Methods
• Nurses’ Health Study
– Est. 1976; goal: long-term consequences of oral
contraceptives
– 121,700 female nurses (30-55 y/o) answered baseline
questionnaire re: lifestyle factors and medical history
– 11 most populous states with Nursing Boards that agreed to
release address data
• California, Connecticut, Florida, Maryland, Massachusetts,
Michigan, New Jersey, New York, Ohio, Pennsylvania, and Texas
– Follow-up questionnaires every 2 years since
– Response rate >90% in most 2 year cycles

6. Methods
• Nurses’ Health Study II
– Est. 1989; 116,430 female nurses (25-42 y/o, compared to
30-55 y/o in NHS) answered baseline questionnaire re:
lifestyle factors and medical history
– 11 most populous states with nursing Boards that agreed to
release address data
• California, Connecticut, Indiana, Iowa, Kentucky, Massachusetts,
Michigan, Missouri, New York, North Carolina, Ohio, Pennsylvania,
South Carolina, and Texas
– Follow-up questionnaires every 2 years since
– Response rate 85-90% in most 2 year cycles

7. Methods
NHS 2012
NHS II 2011NHS II 1985 and 2005
NHS 1992 and 2004
Race Alopecia areata history

8. Methods
• Logistic regression analysis to determine odds ratios
(OR) for diagnosis of alopecia areata comparing
black- to white-identifying respondents
– Age-adjusted model
– Multivariate model adjusting for:
• age, smoking status, alcohol intake, body mass index, physical activity, UV-B flux at
residence, post-menopausal hormone use, and history of immune-mediated disease
(e.g. psoriasis, systemic lupus), cardiovascular disease, hypertension, high
cholesterol, or diabetes

9. Results
Cohort Race Total Participants # of AA
Cases
% Lifetime
Prevalence
Age-adjusted Odds Ratios
(95%CI)
Multivariate-adjusted
Odds Ratios (95%CI)
NHS White 55562 358 0.64 1 (referent) 1 (referent)
Black 702 9 1.28 2.01 (1.04-3.92) 2.16 (1.10-4.23)
NHS2 White 90408 712 0.79 1 (referent) 1 (referent)
Black 1476 61 4.13 5.29 (4.05-6.91) 5.17 (3.54-7.55)
Table 1. Alopecia areata percent prevalence and odds ratios by race in cross-sectional analyses of
the Nurses Health Study (NHS) and Nurses Health Study 2 (NHS2)

10. Past evidence?
• National Ambulatory
Medical Care Survey
• ICD-9 codes to
identify AA visits

11. Discussion
• Explanation 1: There is a true disparity in burden of
disease between black- and white- identifying women
– 1. Some aspect of AA pathophysiology that predisposes
black women?
• Autoimmune predisposition? E.g. Lupus is 3x as common in black
women
• Genetic predisposition

12. Discussion
• Explanation 2: Black female respondents might
endorse history of AA, but in fact had a different type
of hair loss, itself more prevalent in black women
Traction alopecia Central centrifugal cicatricial
alopecia (CCCA)

13. Conclusions
• Nurses’ Health Study Cohorts; 1165 total AA cases
– Rich lifestyle factor data over decades: e.g. diet, exercise, medication
use
• Present study: Self-reported, Dr. Dx’d AA is more common
in black women in NHS I and II
– Disparity may be true
– or is explained by greater prevalence of other hair loss conditions
(CCCA, traction alopecia)
• Findings draw attention to diagnostic challenge in hair loss
• Important consideration for epidemiologic studies of AA

14. Future Directions
• Two ways to validate these self-reported
AA dx
– Medical record review
– Secondary screening questionnaire
• Collaboration with Dr. Arash Mostaghimi and Dr. Kathy Huang
(Harvard)
• Pilot testing ongoing

15. Thank you!
• Nurses’ Health Study I/II participants
• Mentors:
– Abrar Qureshi, MD, MPH
– Eunyoung Cho, ScD
• Colleagues: Min Kyung Park, PhD, Tricia Li, MS