Psoriasis: DMARDs, Biologics Linked to Less Alopecia Areata

Medscape

14-05-2025

SAN DIEGO — Disease-modifying antirheumatic drugs (DMARDs) and biologics were linked to as much as a 74.5% reduction in the risk for alopecia areata (AA) in patients with psoriasis, a new retrospective cohort study reported.
'With higher numbers and more data, this could definitely be clinically applicable in patients we know are at higher risk of AA,' said study Co-Author Bethany Rohr, MD, associate professor of dermatology, Case Western Reserve University School of Medicine, Cleveland, in an interview prior to the presentation of her findings at the annual meeting of the Society for Investigative Dermatology. 'We could choose a medication for their psoriasis to give them some protective benefit,' she added.
Patients with psoriasis have an increased risk for AA. A 2022 systematic review and meta-analysis estimated that the pooled prevalence rate of AA in patients with psoriasis was 0.5% (95% CI, 0.3-0.7%). The pooled risk for AA in patients with psoriasis was estimated at 2.71 (95% CI, 2.29-3.21). Both AA and psoriasis are autoimmune disorders.
Some DMARDs and biologics are used to treat AA off-label, while others have not been evaluated as treatments for the disease, Rohr said. She noted that methotrexate can actually cause alopecia but not AA, and in fact, has been studied as a treatment for AA.
'We wanted to investigate if our drug choice for these patients who require systemic therapies could have some protective benefit,' Rohr said.
Via the TriNetX international electronic record database, she and her coauthors tracked 48,724 patients with psoriasis who were on DMARDs (average age, 52.6 years ± 16.3; 56.6% women; 70.4% White individuals; 21.9% with overweight/obesity) vs a propensity-matched cohort who were not taking systemic medications. The patients were followed for 5 years following the start of therapy.
The tracked DMARDs were methotrexate, cyclosporine, and apremilast. The primary outcome was AA within 5 years of medication initiation.
Researchers also tracked 66,837 patients with psoriasis who were on biologics (average age, 52.9 years ± 16.9; 54.8% women; 71.5% White individuals; 21.5% with overweight/obesity) vs a propensity-matched cohort who were not taking systemic medications.
The biologics were tumor necrosis factor inhibitors (adalimumab, etanercept, infliximab, certolizumab pegol, and golimumab), interleukin (IL)-17 inhibitors (brodalumab, ixekizumab, secukinumab, and bimekizumab), and IL-12/23 and IL-23 inhibitors (ustekinumab, guselkumab, risankizumab, and tildrakizumab).
They found that 19 patients in the DMARD group developed AA vs 37 in the nonsystemic treatment group (risk ratio [RR], 0.514; 95% CI, 0.295-0.893; P = .019). In the biologics group, 13 developed AA vs 51 in the nonsystemic treatment group (RR, 0.255; 95% CI, 0.139-0.469; P < .001).
No statistically significant difference was seen between the DMARD and biologic groups ( P = .322).
Other studies have reported similar links between psoriasis and AA.
Study lead author Nada Hentati, a medical student at Case Western Reserve, told Medscape Medical News that the researchers had to group many medications together because the sample size was small. 'We lost some of the granularity regarding which medications might be independently protective,' she said.
In addition, she said, 'the number of cases was pretty low. Part of that is because we constrained our data to make sure that all the cases we were seeing were within 5 years of starting the drugs.'
The reduction in risk 'has the potential to be significant,' Rohr noted in the interview. 'However, it's important to remember this is a pilot study,' she added, and the data has limitations.
'Ideally,' she said, 'it would be nice to have a really large prospective study following individual drugs and patients with similar body surface area and severity of psoriasis to better understand the significance of our data.'
Asked to comment on the study findings, Deshan Sebaratnam, MBBS, MMed, associate professor of dermatology at the University of New South Wales, Sydney, Australia, told Medscape Medical News many DMARDs are used to treat AA, and 'there have been small-volume case reports where patients with alopecia areata have improved on biologics.'
It's feasible that dampening the immune system may make patients less likely to develop AA, added Sebaratnam, who was not involved with the study. However, for psoriasis, he noted, 'I don't think this is really going to change management. You wouldn't immunosuppress someone to decrease the likelihood of developing AA.'