Dermatology: Practical and Conceptual


Letter  |  Dermatol Pract Concept 2019;9(3):21 241

Dermatology Practical & Conceptual

Introduction

Two 15-year-old female monozygotic twins affected by alo-

pecia areata (AA) and thyroiditis presented to our clinical 

attention. Their family history was negative for thyroiditis. 

AA was localized on their occipital and parietal regions, form-

ing an ophiasis pattern.

Case Presentation

Dermatological examination of the first twin (GC, twin A, 

Figure 1) showed wave-shaped hair-loss patches localized 

predominantly on the right side of the parieto-temporo-

occipital scalp. The disease started at age 4; alopecia was 

widespread to a large part of the scalp. Beginning at age 14, 

twin A was treated with systemic and topical corticosteroids 

and today presents the current clinical features. The second 

twin (GG, twin B, Figure 2), instead, since age 14 presented 

a framework of localized, round, small alopecia localized in 

the temporo-occipital area. During clinical examination, a 

patch of hair loss was evident on the occipital scalp of both 

twins, without other skin lesions or signs of inflammation; 

occasional itch was present.

After our consultation, the twins underwent blood analy-

sis. The results of the laboratory tests were suggestive of 

autoimmune thyroiditis in both patients, as the autoantibody 

values were very high (twin A: thyroglobulin antibodies 28.7 

IU/mL, thyroperoxidase antibodies 617.46 IU/mL; twin B: 

thyroglobulin antibodies 44.51 IU/mL, thyroperoxidase 

antibodies >1,000.00 IU/mL); furthermore, twin A also had 

above-average blood test results: total antioxidant status 494 

IU/mL, hemoglobin 11.6 g/dL, transferrin 398 mg/mL, and 

ferritin 6.67 ng/mL; twin B also had elevated total antioxi-

dant status (407 IU/mL) and vitamin D (10 ng/mL) levels. The 

remaining tests were negative for both patients.

Treatment with oral betamethasone 2 mg/day was started 

for both twins for 1 month when they were 14 years old. It 

was then reduced to 2 mg twice a week in association with 

vasodilatory and antiseptic lotions of the scalp for 2 months. 

This therapy led to a partial remission of dermatological 

manifestations in both patients. An endocrinological con-

sultation was also recommended to better evaluate thyroid 

malfunctioning.

Alopecia Areata in Twins With Autoimmune 
Thyroiditis: Personal Observations

Giusy Schipani1, Stefano Dastoli1, Elisabetta Scali1, Luigi Bennardo1,  
Martina Silvestri1, Steven Paul Nisticò1

1 Dermatology Unit, Department of Health Sciences, Magna Graecia University, Catanzaro, Italy

Key words: autoimmune thyroiditis, alopecia areata, twins

Citation: Schipani G, Dastoli S, Scali E, Bennardo L, Silvestri M, Nisticò SP. Alopecia areata in twins with autoimmune thyroiditis: personal 
observations. Dermatol Pract Concept. 2019;9(3):241-243. DOI: https://doi.org/10.5826/dpc.0903a21

Accepted: January 23, 2019; Published: July 31, 2019

Copyright: ©2019 Schipani et al. This is an open-access article distributed under the terms of the Creative Commons Attribution License, 
which permits unrestricted use, distribution, and reproduction in any medium, provided the original author and source are credited.

Funding: None.

Competing interests: The authors have no conflicts of interest to disclose.

Authorship: All authors have contributed significantly to this publication.

Corresponding author: Luigi Bennardo, MD, Via Serra Tancredi 2 87010 Lattarico (CS), Italy. Email: luigibennardo10@gmail.com



242 Letter  |  Dermatol Pract Concept 2019;9(3):21

lating epithelial cells, fibroblasts, and macrophages. In addi-

tion, a role of Treg lymphocytes has been hypothesized: they 

have an immunosuppressive effect and contribute to prevent 

autoimmune responses. Therefore, defects in Treg cell number 

and/or function may contribute to the development of auto-

immune diseases such as AA [6]. Different immune-cell lines 

including plasmocytic dendritic cells, natural killer (NK) cells, 

and T cells, along with key molecules such as interferon-γ, 
IL-15, MICA, and NKG2D, have been identified as contrib-

uting to the autoimmune process in AA [7]. Genome-wide 

association studies provide evidence for the involvement of 

both innate and acquired immunity in the pathogenesis, and 

mechanistic studies in mouse models of AA have specifically 

implicated an IFN-γ-driven immune response, including IFN-
γ, IFN-γ-induced chemokines, and cytotoxic CD8 T cells as 
the main drivers of disease pathogenesis [8]. Low expression 

of major histocompatibility complex class I and II molecules 

and high expression of macrophage migration inhibitory fac-

tor, an NK cell inhibitor, prevent infiltration of a subset of T 

lymphocytes from the hair follicle of healthy individuals, but 

aggregations of CD56+/NKG2D+ NK cells are found around 

hair follicles from patients with AA [9].

Based on the literature data, which suggest a common 

activation of different immune patterns, and on the data 

obtained by our clinical case, we can say that AA should be 

considered a warning manifestation for other distinct diseases 

such as ones that affect the thyroid. In this unusual case, a 

genetic study to support the relationship between AA and 

autoimmunity may be useful.

References
1. Lortkipanidze N, Zlotogorski A, Ramot Y. Two episodes of simul-

taneous identical alopecia areata in identical twins. Int J Trichol-

ogy. 2016;8(1):47-48.

2. Dogra D, Sood A, Khaitan BK. Alopecia areata in identical twins. 

Indian J Dermatol Venereol Leprol. 1996;62(3):199.

Conclusions

Association between autoimmune disease and AA has been 

widely discussed. Several studies have revealed a high preva-

lence of thyroid disorders in patients with AA. Screening for 

autoimmune thyroiditis and thyroid function should be done 

in all patients with these cutaneous disorders for the early 

identification of this disease.

Recently Lortkipanidze et al [1] described a case of AA 

and alopecia universalis occurring in identical twins in the 

same area of the scalp, forming an ophiasis pattern. Previ-

ously Dogra et al [2] focused their attention on the occurrence 

of AA in the members of the same family, supporting the 

hypothesis that the patients with AA are genetically predis-

posed to develop this kind of disease.

In patients affected by autoimmune thyroid diseases, the 

functions of the different skin cell types may be affected not 

only by variation in thyroid hormone levels but also by the 

presence of thyroid-specific autoantibodies [3]. Thyroid hor-

mones act on epidermal differentiation and their effects are 

particularly important for the function of sebaceous, eccrine, 

and apocrine glands; growth of hair follicles; and synthesis 

of proteo- and glycosaminoglycans by dermal fibroblasts [4]. 

Thyroid hormones were found to induce differentiation and 

apoptosis and inhibit clonal growth of hair follicle epithelial 

stem cells [5]. Moreover, the immunoregulatory genes that 

predispose to autoimmune thyroiditis (FOXP3, CD25, CD40, 

CTLA4, the HLA genes, PTPN22, among other emerging 

immunoregulatory genes) have a critical role in the develop-

ment of an effective immune response including self-toler-

ance, humoral immunity, and cell-mediated immunity. Recent 

data show that the pathogenesis of autoimmune thyroiditis is 

mediated by TH1, TH2, and TH17 subtypes. TH17 lympho-

cytes are mainly characterized by the synthesis of interleukin 

(IL)-17A, IL-17F, IL-21, IL-22, and IL-47, which contribute 

to the release of other proinflammatory mediators by stimu-

Figure 1. AA in twin A. [Copyright: ©2019 Schipani et al.] Figure 2. AA in twin B. [Copyright: ©2019 Schipani et al.]



Letter  |  Dermatol Pract Concept 2019;9(3):21 243

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