To the Editor: Alopecia areata (AA) is a chronic, recurrent, noncicatricial alopecia with an estimated lifetime incidence of 1.7%.1Safavi K.H. Muller S.A. Suman V.J. Moshell A.N. Melton III, L.J. Incidence of alopecia areata in Olmsted County, Minnesota, 1975 through 1989.Mayo Clin Proc. 1995; 70: 628-633https://doi.org/10.4065/70.7.628Abstract Full Text Full Text PDF PubMed Scopus (443) Google Scholar It results from a complex interaction of genetic, immunological, and environmental factors.1Safavi K.H. Muller S.A. Suman V.J. Moshell A.N. Melton III, L.J. Incidence of alopecia areata in Olmsted County, Minnesota, 1975 through 1989.Mayo Clin Proc. 1995; 70: 628-633https://doi.org/10.4065/70.7.628Abstract Full Text Full Text PDF PubMed Scopus (443) Google Scholar The implication of psychological factors, as well as the triggering role of stressful life events (SLEs), remains controversial.2Misery L. Rousset H. Is alopecia areata a psychosomatic disease?. Article in French.Rev Med Interne. 2001; 22: 274-279Crossref PubMed Google Scholar Yet, disease-derived stress may negatively impact its course.3Gupta M.A. Gupta A.K. Watteel G.N. Stress and alopecia areata: A psychodermatologic study.Acta Derm Venereol. 1997; 77: 296-298https://doi.org/10.2340/0001555577296298Crossref PubMed Google Scholar For example, stress, associated with increased activity of the hypothalamic-pituitary-adrenal axis, may inhibit human hair growth and impedes the ability to cope with stressors.4Zhang X. Yu M. Yu W. Weinberg J. Shapiro J. McElwee K.J. Development of alopecia areata is associated with higher central and peripheral hypothalamic-pituitary-adrenal tone in the skin graft induced C3H/HeJ mouse model.J Invest Dermatol. 2009; 129: 1527-1538https://doi.org/10.1038/jid.2008.371Abstract Full Text Full Text PDF PubMed Scopus (63) Google Scholar Furthermore, the lifetime prevalence of psychiatric comorbidities is up to 74%.5Bolduc C. Alopecia areata. In: Emedicine.medscape. 2021. Accessed January 25, 2022. https://emedicine.medscape.com/article/1069931-clinicalGoogle Scholar Therefore, we aimed to investigate the association of recent (previous year) SLEs with the development or recurrence of AA and their impact on patients’ psychosocial outcomes. During a 3-year period, 52 patients with new-onset or recurring AA of any clinical type, severity, or duration, and a convenient sample of 51 well-matched healthy controls were studied. The psychometric evaluation included: Holmes-Rahe Social Readjustment Rating Scale; Hospital Anxiety and Depression Scale (HADS); Brief Illness Perceptions Questionnaire; and Dermatology Life Quality Index (Supplementary Materials and Methods, available via Mendeley at https://data.mendeley.com/datasets/sgdmw8rb67/1). Participants’ clinico-demographic and psychometric profiles are summarized in Table I.Table IClinico-demographic characteristics and psychometric evaluation of study participants∗Mean ± SD or median (25th, 75th percentiles) or N (%) are displayed.Demographic, clinical and psychometric characteristicsAA patients (N = 52)Healthy controls (N = 51)Comparison (P value)Sex (females)33 (63.5)34 (66.7).73†χ2 test.Age (y)42.8 ± 17.644.7 ± 13.3.53‡t test.AA duration (y)4 (1, 10.5)- ≤1 year16 (30.8)- >1 year36 (69.2)-AA subtype Patchy31 (59.6)- Totalis3 (5.8)- Universalis11 (21.2)- Diffuse2 (3.8)- Ophiasis5 (9.6)-AA severity Mild to moderate34 (65.4)- Severe18 (34.6)-Stressful life events (SRRS) Number of events4 (2.5, 7)3 (2, 5).049§Bold indicates P < .05.,‖Mann-Whitney U test. Total impact113.5 (56.5, 199)75 (38, 118).074‖Mann-Whitney U test. Mean impact26.2 (23.6, 32.9)28.2 (21.2, 34.4).93‖Mann-Whitney U test. Maximum impact44 (25, 53)39 (29, 44).16‖Mann-Whitney U test.HADS-A7.45 ± 4.16.55 ± 3.6.24‡t test.HADS-D5.47 ± 3.86.10 ± 3.3.37‡t test.BIPQ36.59 ± 13.8-DLQI3.5 ± 3.5-AA, Alopecia areata; BIPQ, Brief Illness Perceptions Questionnaire; DLQI, Dermatology Life Quality Index; HADS, Hospital Anxiety and Depression Scale; SRRS, Holmes-Rahe Social Readjustment Rating Scale.∗ Mean ± SD or median (25th, 75th percentiles) or N (%) are displayed.† χ2 test.‡ t test.§ Bold indicates P < .05.‖ Mann-Whitney U test. Open table in a new tab AA, Alopecia areata; BIPQ, Brief Illness Perceptions Questionnaire; DLQI, Dermatology Life Quality Index; HADS, Hospital Anxiety and Depression Scale; SRRS, Holmes-Rahe Social Readjustment Rating Scale. Statistical analysis was performed using STATA 14.0. Patients reported significantly more SLEs (P = .049). By univariate logistic regressions, the presence of alopecia was significantly associated with the number of events (odds ratio [OR] = 1.16, P = .028), their total impact (OR = 1.004, P = .042), and, of specific SLEs, personal injury/illness (OR = 3.92, P = .026) and change in sleeping habits (OR = 5.30, P = .003). Changes in sleeping, personal (eg, dress, manners) and eating habits were more common among patients of recent onset (<1 year) (Fig 1). Furthermore, significant associations of number of events (OR = 1.2, P = .025), total impact (OR = 1.005, P = .035), and changes in sleeping (OR = 8.2, P < .001) and personal habits (OR = 3.3, P = .021) were recorded only with alopecia of mild/moderate severity. Patients and controls did not differ significantly in HADS-A and HADS-D scores (Table I). However, all groups by Social Readjustment Rating Scale scores interactions were significant for HADS-A, as well as a group by maximum impact event for HADS-D (Supplementary Table I). Therefore, SLEs were associated with higher HADS (especially HADS-A) scores in patients compared with controls. Patients’ Brief Illness Perceptions Questionnaire and Dermatology Life Quality Index scores were positively associated with the number of events (P = .002 and P < .001, respectively), total impact (P = .001 and P < .001, respectively) and maximum impact event (both P < .001). Emotional trauma, often arising from actual or symbolic loss, occurring some months before alopecia onset, has been identified as a risk factor for AA development,2Misery L. Rousset H. Is alopecia areata a psychosomatic disease?. Article in French.Rev Med Interne. 2001; 22: 274-279Crossref PubMed Google Scholar in line with our findings. In addition, the disease itself may represent a significant stressor for patients, establishing a stress-hair loss vicious cycle. In conclusion, SLEs in the year preceding the onset or the recurrence of AA were more prevalent in patients than in healthy participants. Alterations in sleeping, personal, and eating habits were more strongly associated with disease of recent onset and/or mild/moderate severity. Furthermore, SLEs featured as strong predictors of the psychosocial consequences of AA. Despite our study limitations (small sample size and recall bias), these findings provide evidence for a pathogenetic role of psychological factors and emphasize the importance of a holistic and multidisciplinary approach for AA. None disclosed.