Screening of celiac disease in children with alopecia areata.

Sir,

Celiac disease (CD) is a life-long gluten sensitive intestinal enteropathy with multifactorial etiology. The disease provides an exciting model where both genetic and environmental factors play an important role.[1] In the first CD prevalence study in our country, the prevalence of CD was found as 1:115.[2] Because CD is often atypical and silent on clinical grounds, many cases remain undiagnosed and CD may become apparent at any age.

Alopecia areata (AA) is one of the most common forms of hair loss in childhood. It affects approximately 1-2% of the population and commonly has an onset during childhood or adolescence. AA is characterized by sudden onset patchy hair loss on the scalp. The etiology of AA is as yet unclear, but it is presumed to be a result of an autoimmune reaction. AA tends to cluster in the same individuals with other autoimmune disorders, such as Addison's disease, autoimmune thyroiditis, atrophic gastritis, systemic lupus erythematosus, rheumatoid arthritis, myasthenia gravis, and vitiligo.[34] An association between AA and CD has recently been reported.[45] Our aim in this study was to screen for CD in children with AA.

We investigated CD in 12 children with AA. Of subjects, eight (66.7%) were girls and four (33.3%) were boys. Mean age was 8.88 ± 4.2 years (range: 3-17 years) in this study. Total serum immunoglobulin A (IgA) was measured in all children with AA. None of the patients had IgA deficiency. Patients were tested for anti-tissue transglutaminase IgA. Parents of the children who had positive test result were informed about CD, and a small intestinal biopsy was proposed. A pathologist blinded to the serology results examined all biopsy specimens according to the modified Marsh's criteria.

Of 12 children with alopecia, five (41.7%) had positive anti-tissue transglutaminase IgA. Of these children, four (80%) were girls and one (20%) was boy. Of all children with AA, four had vitiligo, two had Down syndrome, and two had autoimmune thyroiditis. None of children with AA had chronic diarrhea, abdominal pain, iron deficiency anemia, and megaloblastic anemia. Four children with AA had short stature.

Biopsy of small intestinal mucosa was performed in all children with positive anti-tissue transglutaminase IgA. All of them had enteropathy of Type III-c according to Marsh's criteria. Of all children with AA and CD, four (80%) had vitiligo and one had Down syndrome. We administered gluten-free diet children with AA and CD. Administration of a gluten-free diet to these patients resulted in complete hair growth.

AA is an autoimmune disease. Although autoantibodies are postulated to play an integral role in the disease process, current research implicates a cell-mediated autoimmune mechanism as the underlying pathogenic etiology.[3] In this study, we found the prevalence of CD in children with AA as 41.7%. We detected the prevalence of CD in the 1,263 health children as 0.87% in the same city.[2] These findings indicate that prevalence of silent CD is very high among children with AA. AA might be the only clinical manifestation of CD. We suggest that children with AA should be screened for CD.