An Overview of Alopecia Areata

Alopecia Areata causing bald patches on a man's chin
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Alopecia areata is a hair loss condition characterized by the rapid onset of hair loss in a sharply defined area. Any hair-bearing surface can be affected, but the most noticeable surface is the scalp. The reason alopecia areata occurs is not completely known, although it's believed to be an autoimmune disorder. In some cases, it is associated with other diseases, but most of the time it is not. Research is ongoing to determine the best treatment for this disease.

Symptoms

The term alopecia areata literally means patchy baldness, which is an accurate description of this condition.

The characteristic patch of alopecia areata is usually round or oval and is completely bald and smooth.

It can develop anywhere on the body but is most obvious when it appears on the scalp, beard area, eyebrows, or eyelashes.

The striking symptoms of alopecia areata include:

  • Patches of baldness on hair-bearing areas
  • The balding skin looks healthy, with no signs of rash or irritation.
  • Hair can fall out very quickly, sometimes within just a few days.
  • Hair may regrow in one area and fall out in another.

"Exclamation-mark" hairs may be seen at the margin of the patch. These are broken, short hairs that taper at the base. Pulling slightly on these hairs causes them to fall out.

Some people may experience a slight burning or tingling in the area of hair loss.

Alopecia areata can occur at any age, however, the vast majority of cases develop before age 30. It's also quite common in children and teenagers. Early-onset alopecia areata, occurring between ages 5 and 10, tends to be most severe.

People who have this condition are, for the most part, otherwise completely healthy. It is not a sign or symptom of a more serious or underlying condition.

Nail Symptoms

For between 10% and 20% of people with the condition, the nails are also affected. Symptoms include:

  • Softer or brittle nails
  • Dents or ridges across the nail
  • Nails that feel rough or "sandpaper-like"
  • Red coloration of the nail bed

Causes

There are several different hypotheses as to what causes alopecia areata. Genetic factors seem to play an important role since there is a higher frequency of a family history of alopecia areata in people who are affected.

Alopecia areata appears to have an autoimmune factor causing the patient to develop antibodies to different hair follicle structures.

Certain chemicals that are a part of the immune system, called cytokines, may play a role in alopecia areata by inhibiting hair follicle growth.

Hair grows a cycle of three phases: anagen phase, catagen phase, and telogen phase. For a simplistic explanation, hair grows during the anagen phase. In the catagen stage, the hair follicle stops growing and in the telogen stage it falls out.

Normally, hairs are going through these stages at random and the growing hairs on the rest of the head outnumber the hairs that fall out. In alopecia areata, something causes all the hairs in a certain area to enter the telogen or catagen stage at the same time. Hair loss occurs because the hair follicles in an area all enter the telogen or late catagen stage of hair growth.

Risk Factors

Alopecia areata is a fairly common condition, with up to 2% of the population experiencing it at some point. There are certain factors make it more likely to develop the condition.

  • Genetic predisposition: As mentioned before, having a close relative (such as a parent or a sibling) who has, or has had, the condition raises the risk of developing it yourself. Approximately 18% of people with alopecia areata have a close relative with the condition.
  • Atopic conditions such as atopic dermatitis (eczema), allergies, and/or asthma
  • Autoimmune diseases such as thyroid conditions, lupus, psoriasis, rheumatoid arthritis, or vitiligo.
  • Being black or Hispanic: One analysis published in 2018 found that alopecia areata was more common in those who are black or Hispanic, at least for women. More research needs to be done to see if that holds true for both sexes.
  • Cold weather: Although cold weather does not cause alopecia areata by any means, it seems to be a triggering factor among those who already have the condition. According to research published in a 2018 issue of the Journal of the American Academy of Dermatology, hair loss flares happened more often during the winter months with periods of regrowth happening during the summer.

Diagnosis

Hair loss can be caused by many different things. In many cases, your physician may be able to diagnose alopecia areata by a physical exam of your hair and nails, along with a detailed medical history.

Blood testing may also be done to look for autoimmune diseases, however, there is no specific test to diagnose alopecia areata.

Other diseases that may be mistaken for alopecia areata include:

  • Telogen effluvium: Generalized hair loss caused by pregnancy, certain drugs, high fever, or stress
  • Androgenic alopecia: Also known as male-pattern baldness
  • Trichotillomania: Manually pulling the hair out caused by a psychological disorder
  • Secondary syphilis: Causing a "moth-eaten" baldness pattern over the entire scalp

Prognosis

The progress of alopecia areata is unpredictable. Some people lose hair in only a small patch. Others may have more extensive involvement.

Alopecia totalis is the loss of 100% of scalp hair. Alopecia universalis is the loss of 100% of body hair. These last two conditions are rare.

In the majority of patients, the hair will regrow completely within one year without any treatment.

Treatment

Alopecia areata can't be cured, however, it can be treated. While there are several different treatments used for alopecia areata, all are used off-label. As of yet, there are no medications approved by the U.S. Food and Drug Administration specifically for treating alopecia areata.

It's important to note that treatment isn't always necessary or advisable. The decision to treat alopecia areata is dependant on many factors, including the age of the person affected, the severity of the hair loss, and where the hair loss is occurring.

The most common course of action is simple observation. If the patch of hair loss is small, it is reasonable to observe it and allow the hair to regrow on its own.

Topical Steroids

Applying a strong topical steroid such as Diprolene (betamethasone) or Temovate (clobetasol) to the patch may stimulate hair regrowth. It may take several months for the hair to grow back using this method.

Topical steroids are the first-line treatment choice for both children and adults.

Steroid Injection

Another common therapeutic option is an injection of a steroid, such as triamcinolone acetonide or Celestone (betamethasone), into the involved scalp skin. This is considered the treatment of choice for adults with alopecia areata of the scalp and eyebrows.

Initial regrowth of hair can be seen in four to eight weeks, with treatments being repeated every four to six weeks. The main side effect of any steroid use is thinning of the skin. These are not used in children younger than 10 years old.

Minoxidil

Minoxidil has been used to promote hair growth and has shown cosmetically acceptable results in 30% of cases. This medication is applied topically to the affected areas, and comes in either a foam or a solution.

Minoxidil does not stop the disease process so stopping applications after hair have started to grow back may cause the hair to fall out again.

Due to relative safety, this is also a good treatment choice for young children.

Topical Contact Sensitizers

This type of treatment is designed to produce a contact dermatitis, or irritation, at the site seemingly stimulating hair growth. The most common irritant used is called anthralin. Some studies suggest using minoxidil and anthralin in combination may be more effective.

Oral Steroids

Oral steroids are not used as first-line treatment but they may be suggested in some cases. They are more likely to be prescribed in severe cases of widespread hair loss (as in the case of alopecia totalis or universalis).

Taking a short course of oral steroids for about six weeks can regrow hair. Because of the risk of side effects, oral steroids should not be taken long term. Also, once oral steroids are stopped the new hair may fall out again.

After oral steroids are stopped most people are switched over to another treatment to continue hair regrowth.

Methotrexate

As with oral steroids, methotrexate is only used in cases where hair loss is severe or widespread. It's not the first treatment choice for alopecia areata.

It can take up to three months for hair regrowth to begin, and up to a year to get considerable hair regrowth. Methotrexate can cause serious side effects.

JAK Inhibitors

JAK inhibitors are not yet used extensively but have shown promise at being very effective at treating alopecia areata. Depending on the study cited, between 50% to 91% of people had significant improvement with many experiencing complete regrowth of hair.

Tofacitinib, ruxolitinib, and baricitinib are among the JAK inhibitors currently being studied for their use in treating alopecia areata.

It's believed that JAK inhibitors reduce the T cell immune response that triggers an "attack" on the hair follicle, while also stimulating hair follicle stem cells and moving the follicle into the anagen (or hair growth) phase.

These medications can help in situations where nothing else has been effective. The downside is that the hair falls out again when the medications are stopped.

The long-term safety of using JAK inhibitors for alopecia areata, or the most appropriate or effective dosage, has not yet been determined.

Research is ongoing, with the current focus on finding an effective topical option. Topical JAK inhibitors would allow a more potent dosage to be delivered directly to needed areas without the systemic side effects that can be caused by oral medications.

Photochemotherapy

Finally, as a measure when "all else fails," PUVA may be used as a treatment. PUVA is also known as photochemotherapy. It involves taking a type of drug called psoralens about 2 hours before measured exposure to long-wave ultraviolet light.

The term PUVA is an acronym for psoralens (P) and ultraviolet-A (UVA).

This treatment is used most commonly in severe cases of psoriasis. The initiation of hair regrowth may take 40 to 80 treatments and complete regrowth in one to two years.

Coping

The sudden and unpredictable nature of this type of hair loss can be difficult to cope with. This condition significantly impacts a person's quality of life, from the embarrassment of trying to hide bald spots to the anxiety that someone will spot the wig or hairpiece.

This is especially true when the condition appears during the formative childhood and teen years. During this time, when young people are figuring out who they are, having an obvious condition such as alopecia is incredibly challenging. Young people may be bullied or made fun of because of the condition.

Both children and adults can experience a loss of self-esteem or social withdrawal due to this condition. Watch for signs of depression or anxiety; they should be reported to a doctor.

Wigs and Hair Pieces

Some people may wish to consider wigs, hairpieces, or hair prostheses. Using these can make you feel more confident. There is a vast array of options available, so there will be a product that is perfect for you or your child's needs.

False lashes are an option for alopecia areata that affects the eyelashes. Tempory lashes can be applied with washable adhesive. You can learn to apply them yourself with a little practice.

Semi-permanent lashes last up to eight weeks. These can be applied by trained hairdressers and estheticians and done at your local salon.

Care must be used when removing false lashes, either temporary or semi-permanent. Never pull on false lashes to remove them so that you don't inadvertently pull out existing lashes or lashes that are trying to regrow.

Finding Support

Connecting with those who have the same, or similar, conditions can be very rewarding. It helps to be able to vent to those who understand what you are going through or to swap coping or treatment tips.

The National Alopecia Areata Foundation can help connect you to local support groups as well as offers phone support by peer mentors.

A Word From Verywell

Alopecia areata is a condition that is challenging to deal with. In many people, the condition resolves spontaneously with complete hair growth. There are treatments available for those whose condition is not improving, or those who don't want to wait for the condition to resolve on its own. With a greater understanding of why alopecia areata develops, and new, effective treatments emerging, the future of alopecia areata treatment is hopeful.

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Article Sources

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