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Author: Honorary Associate Profesor Amanda Oakley, Dermatologist, Hamilton, New Zealand, 1997. Updated December 2015.
The term alopecia means hair loss. In alopecia areata, one or more round bald patches appear suddenly, most often on the scalp. Alopecia areata is also called autoimmune alopecia, which can also cause diffuse alopecia.
Alopecia areata can affect males and females at any age. It starts in childhood in about 50%, and before the age of 40 years in 80%. Lifetime risk is 1–2% and is independent of ethnicity.
Alopecia areata is classified as an autoimmune disorder. It is histologically characterised by T cells around the hair follicles. These CD8(+)NK group 2D-positive (NKG2D(+)) T cells release pro-inflammatory cytokines and chemokines that reject the hair. The exact mechanism is not yet understood.
The onset or recurrence of hair loss is sometimes triggered by:
Several clinical patterns of alopecia areata are described. More severe disease is associated with young age, concurrent atopic eczema, and chromosomal abnormalities.
Most patients have no symptoms, and a bald patch or thinning hair is noted incidentally, often discovered by a hairdresser. Other patients describe a burning, prickly discomfort in the affected areas—this is known as trichodynia.
Patches of alopecia areata can affect any hair-bearing area, most often the scalp, eyebrows, eyelashes and beard.
Patchy alopecia areata has three stages.
The bald areas may have a smooth surface, completely devoid of hair or with scattered 'exclamation mark' hairs.
Exclamation mark hairs
Alopecia areata nails
Alopecia may be temporary or persistent. More severe and persistent disease increases the chance that alopecia areata will cause psychosocial consequences of their disease, such as depression and anxiety.
Alopecia areata is diagnosed clinically. Although usually straightforward, additional tests are sometimes needed to confirm the diagnosis.
There is not yet any reliable cure for alopecia areata and other forms of autoimmune hair loss. Because spontaneous regrowth is common in alopecia areata, especially in the early stages of the disease, and research has often been of poor quality, the effectiveness of reported treatments is mostly unknown. Systemic therapy is reserved for patients with:
Several topical treatments used for alopecia areata are reported to result in temporary improvement in some people. Their role and efficacy are unknown. The hair may fall out when they are stopped. These include:
Injections of triamcinolone acetonide 2.5–10 mg/ml into patchy scalp, beard or eyebrow alopecia areata may speed up regrowth of hair. Its effect is temporary. If bald patches reappear, they can be reinjected.
Oral and pulse intravenous steroids in high dose can lead to temporary regrowth of hair. Most physicians agree that long-term systemic steroid treatment is not justified because of potential and actual adverse effects.
The sensitisers diphenylcyclopropenone (diphencyprone) and dinitrochlorobenzene provoke contact allergic dermatitis in treated areas. These sensitisers can be reapplied once weekly to bald areas on the scalp. The resultant dermatitis is irritating and may be unsightly. It is often accompanied by a swollen lymph gland.
A combination of the lipid-lowering medications simvastatin and ezetimibe (which have immunomodulating effects) has been reported to be effective.
A single case is reported of substantial hair growth in a patient with longstanding alopecia totalis following the use of dupilumab for her concomitant severe atopic eczema.
Several patients with severe alopecia areata have had improvement when treated with oral tofacitinib or oral ruxolitinib, which are Janus kinase (JAK) inhibitors. It is thought they may act by blocking interleukin (IL)-15 signalling and gamma interferon (IFNγ). Watch out for the results of clinical trials of these biologic medicines.
Some people with alopecia areata seek and benefit from professional counselling to come to terms with the disorder and regain self-confidence.
A hairpiece is often the best solution to disguise the presence of hair loss. These cover the whole scalp or only a portion of the scalp, using human or synthetic fibres tied or woven to a fabric base.
Styling products include gels, mousses and sprays to keep hair in place and add volume. They are reapplied after washing or styling the hair.
Artificial eyelashes come as singlets, demilashes and complete sets. They can be trimmed if necessary. The lashes can irritate the eye and eyelids. They are stuck on with methacrylate glue, which can also irritate and sometimes causes contact allergic dermatitis.
Eyeliner tattooing is permanent and should be undertaken by a professional cosmetic tattooist. The colour eventually fades and may move slightly from the original site. It is extremely difficult to remove the pigment, should the result turn out to be unsatisfactory.
Artificial eyebrows are manufactured from synthetic or natural human hair on a net that is glued in place.
An eyebrow pencil can be obtained in a variety of colours made from inorganic pigments.
Tattooing can also be undertaken to disguise the loss of eyebrows but tends to look rather unnatural because of the shine of hairless skin.
We do not yet know how to prevent the onset of alopecia areata.
In many patients with a single bald patch, spontaneous regrowth occurs within a year. Even in the most severe cases of alopecia totalis and alopecia universalis, recovery may occur at some future date. Research has shown:
Poor prognostic factors include:
New monoclonal antibody biologic agents targeting cytokine pathways offer promise for future treatment of alopecia areata.
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