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Alopecia areata, also known as spot baldness, is a condition in which hair is lost from some or all areas of the body. It often results in a few bald spots on the scalp, each about the size of a coin. Psychological stress and illness are possible factors in bringing on alopecia areata in individuals at risk, but in most cases there is no obvious trigger. People are generally otherwise healthy. In a few cases, all the hair on the scalp is lost (alopecia totalis), or all body hair is lost (alopecia universalis). Hair loss can be permanent, or temporary.It is distinct from pattern hair loss, which is common among males.
Alopecia areata is believed to be an autoimmune disease resulting from a breach in the immune privilege of the hair follicles.[11][12] Risk factors include a family history of the condition. Among identical twins, if one is affected, the other has about a 50% chance of also being affected. The underlying mechanism involves failure by the body to recognize its own cells, with subsequent immune-mediated destruction of the hair follicle.
No cure for the condition is known. Some treatments, particularly triamcinolone injections and 5% minoxidil topical creams, are effective in speeding hair regrowth. Sunscreen, head coverings to protect from cold and sun, and glasses, if the eyelashes are missing, are also recommended. In more than 50% of cases of sudden-onset localized “patchy” disease, hair regrows within a year. In patients with only one or two patches, this one-year recovery will occur in up to 80%. However, most patients will have more than one episode over the course of a lifetime. In many patients, hair loss and regrowth occurs simultaneously over the course of several years. Among those in whom all body hair is lost, fewer than 10% recover.
About 0.15% of people are affected at any one time, and 2% of people are affected at some point in time. Onset is usually in childhood. Females are affected at higher rates than males.
Signs and symptoms
Typical first symptoms of alopecia areata are small bald patches. The underlying skin is unscarred and looks superficially normal. Although these patches can take many shapes, they are usually round or oval. Alopecia areata most often affects the scalp and beard, but may occur on any part of the body with hair. Different areas of the skin may exhibit hair loss and regrowth at the same time. The disease may also go into remission for a time, or may be permanent. It is common in children.
The area of hair loss may tingle or be mildly painful. The hair tends to fall out over a short period of time, with the loss commonly occurring more on one side of the scalp than the other.
Exclamation point hairs, narrower along the length of the strand closer to the base, producing a characteristic “exclamation point” appearance, are often present.[21] These hairs are very short (3–4 mm), and can be seen surrounding the bald patches.[22]
When healthy hair is pulled out, at most a few should come out, and ripped hair should not be distributed evenly across the tugged portion of the scalp. In cases of alopecia areata, hair tends to pull out more easily along the edge of the patch where the follicles are already being attacked by the body’s immune system than away from the patch where they are still healthy.
Nails may have pitting or trachyonychia.
Causes
Alopecia areata is thought to be a systemic autoimmune disorder in which the body attacks its own anagen hair follicles and suppresses or stops hair growth.[21] For example, T cell lymphocytes cluster around affected follicles, causing inflammation and subsequent hair loss. Hair follicles in a normal state are thought to be kept secure from the immune system, a phenomenon called immune privilege. A breach in this immune privilege state is considered as the cause of alopecia areata. A few cases of babies being born with congenital alopecia areata have been reported. It is recognized as a type 1 inflammatory disease.
Alopecia areata is not contagious. It occurs more frequently in people who have affected family members, suggesting heredity may be a factor. Strong evidence of genetic association with increased risk for alopecia areata was found by studying families with two or more affected members. This study identified at least four regions in the genome that are likely to contain these genes. In addition, alopecia areata shares genetic risk factors with other autoimmune diseases, including rheumatoid arthritis, type 1 diabetes, and celiac disease. It may be the only manifestation of celiac disease.
Endogenous retinoids metabolic defect is a key part of the pathogenesis of the alopecia areata.
In 2010, a genome-wide association study was completed that identified 129 single nucleotide polymorphisms that were associated with alopecia areata. The genes that were identified include those involved in controlling the activation and proliferation of regulatory T cells, cytotoxic T lymphocyte-associated antigen 4, interleukin-2, interleukin-2 receptor A, and Eos (also known as Ikaros family zinc finger 4), as well as the human leukocyte antigen. The study also identified two genes, PRDX5 and STX17, that are expressed in the hair follicle.
A psychodermatological connection is noted with impairment in psychiatric comorbidities including mental well being, self esteem and mental disorders acting as pathogenic triggers for alopecia areata.
Diagnosis
Alopecia areata is usually diagnosed based on clinical features.
Trichoscopy may aid in establishing the diagnosis. In alopecia areata, trichoscopy shows regularly distributed “yellow dots” (hyperkeratotic plugs), small exclamation-mark hairs, and “black dots” (destroyed hairs in the hair follicle opening).[
Oftentimes, however, discrete areas of hair loss surrounded by exclamation mark hairs is sufficient for clinical diagnosis of alopecia areata. Sometimes, reddening of the skin, erythema, may also be present in the balding area.
A biopsy is rarely needed to make the diagnosis or aid in the management of alopecia areata. Histologic findings may include peribulbar lymphocytic infiltration resembling a “swarm of bees”, a shift in the anagen-to-telogen ratio towards telogen, and dilated follicular infundibulae.[7] Other helpful findings can include pigment incontinence in the hair bulb and follicular stelae. Occasionally, in inactive alopecia areata, no inflammatory infiltrates are found
What is alopecia areata?
Alopecia areata produces one or more patches of balding without any obvious change in the texture of the affected skin?????.
Alopecia areata is an acquired skin disease that can affect all hair-bearing skin and is characterized by localized areas of non-scarring alopecia (hair loss).
- Alopecia areata is occasionally associated with other medical problems.
- Most often these bald areas regrow their hair spontaneously.
- Alopecia areata rarely occurs before 3 years of age.
- There seems to be a significant inherited predisposition for the development of alopecia areata.
What causes alopecia areata?
Current evidence suggests that alopecia areata is caused by an abnormality in the immune system that damages hair follicles. This particular abnormality leads to autoimmunity, a misguided immune system that tends to attack its own body. As a result, the immune system attacks particular tissues of the body.
In alopecia areata, for unknown reasons, the body’s own immune system attacks the hair follicles and disrupts normal hair formation. Biopsies of affected skin show immune lymphocytes penetrating the hair bulb of the hair follicles.
Common causes of alopecia areata include:
- Alopecia areata is occasionally associated with other autoimmune conditions such as:
- Thyroid disease
- Vitiligo
- Lupus
- Rheumatoid arthritis
- Ulcerative colitis
- The diagnosis or treatment of these diseases is unlikely to affect the course of alopecia areata.
- Sometimes, alopecia areata occurs within family members, suggesting the role of genes.
Who is affected by alopecia areata?
Alopecia areata tends to occur most often in adults 30 to 60 years of age. However, it can also affect older individuals and, rarely, young children.
Alopecia areata is not contagious. It should also be distinguished from hair shedding that may occur following the discontinuation of hormonal estrogen and progesterone therapies for birth control or the hair shedding associated with the end of pregnancy.
Several treatable conditions could be confused with alopecia areata.
What are the signs and symptoms of alopecia areata?
The most common pattern of alopecia areata is one or more well-defined spots of hair loss on the scalp.
If alopecia occurs in an ophiasis pattern (hair loss involving the temporal and posterior scalp) or if large areas of the scalp are involved for long periods, the prognosis is worse.
- A more generalized form of hair loss is referred to as diffuse alopecia areata where there is widespread dramatic thinning of the scalp hair.
- Occasionally, all of the scalp hair is entirely lost, a condition referred to as alopecia totalis.
- Less frequently, the loss of all of the hairs on the entire body called alopecia universalis occurs.
How do healthcare professionals diagnose alopecia areata?
The characteristic finding of alopecia areata is one or more well-circumscribed areas of otherwise normal, hairless skin in hair-bearing areas.
Occasionally, it may be necessary to biopsy the scalp to confirm the diagnosis. Other findings that may be helpful are the appearance of short hairs that presumably represent fractured hairs, short thin hairs, and gray hair growing in a bald area.
Other causes of hair loss are generally excluded from the consideration by history and clinical evaluation.
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Alopecia AreataSee pictures of hair loss and other scalp related conditionsSee Images
What is the treatment for alopecia areata?
The course of typical alopecia areata is not predictable with a high likelihood of spontaneous remission. The longer the period of hair loss and the larger the area involved, the less likely the hair will regrow spontaneously. Therefore, there are a variety of treatments, but none of these can confidently be predicted to impact the course of this disease.
Treatments for alopecia areata include the following:
- Local steroid injections intracutaneously may be very helpful in restarting the hair growth cycle in treated areas.
- Steroid creams, lotions, and shampoos have been used for many years but are of limited benefit at best.
- Although oral systemic steroids are known to induce hair growth in affected patients, their long-term use is contraindicated because of the likelihood of undesirable side effects.
- The topical sensitizers, diphencyprone or squaric acid dibutylester, have been used in those suffering from recalcitrant alopecia areata or those with more than 50% hair loss. The goal of treatment is to create an allergic contact dermatitis of the scalp. This alteration in the immune response occasionally is accompanied by hair regrowth. The efficacy of topical sensitizers has been demonstrated in both young children and adults, but it probably works less than half the time. Recent success using oral janus kinase inhibitors, including tofacitinib, ruxolitinib, and baricitinib, is efficacious in severe, extensive alopecia areata in adults, but long-term therapy has potential side effects. The durability of response to these medications is variable, and most patients experience a recurrence of hair loss after discontinuation. Perhaps topical therapy with these types of drugs may be available shortly.
- There is no known effective method of prevention, although the elimination of emotional stress is felt to be helpful. No drugs or hair care products have been associated with the onset of alopecia areata.
- Although not precisely a treatment, the cosmetic camouflage of alopecia areata is certainly an important consideration in patient management. The damaging emotional effect of significant hair loss for both women and men can be considerable.
Hair Loss: Alopecia, Thinning Hair in Men and Women
Hair Loss Overview
Hair loss is extremely common, affecting about 50 million men and 30 million women in the U.S. About 50% of men will have some hair loss by the time they turn 50. Hair loss is not life-threatening, though it can have devastating psychological effects, particularly in women.
What Are Causes of Hair Loss?
Hair loss is often caused by genetics, that is, it runs in families. In general, it is not a symptom of disease, however, thyroid disease, anemia, ringworm of the scalp, and anorexia can cause hair loss. In addition, some medications such as cancer chemotherapy may cause temporary hair loss. Hair growth usually returns to normal when the medications are stopped. In some cases, hormones changes after giving birth or during menopause can cause thinning hair.
There are several types of hair loss, often classified by whether the loss is localized, or if it affects large areas, or if the hair loss is patchy or affects the entire scalp. Some of the more common hair loss causes are discussed on the following slides.
Alopecia Areata
Alopecia areata (AA) is a common form of hair loss. It is believed to be an autoimmune condition where circular bald patches appear on the scalp and other hair-bearing areas. The hair loss may occur spontaneously, and the hair may regrow if the inflammation subsides. If the alopecia covers the entire scalp it is called alopecia totalis. If it spreads to the rest of the body including eyebrows, lashes, beard, and pubic hair it is called alopecia universalis. In men, if the alopecia appears only in the area of the beard it is called alopecia barbae.
Alopecia areata is often mistakenly attributed to stress, though there is no evidence that shows this to be the case.
Traction Alopecia
Traction alopecia is caused over time by constant pulling on hair roots. Hairstyles that cause tension on the hair follicles such as tight braids, or “corn rows,” often cause this condition. It may also be caused by chemical straightening or weaving. The sooner this condition is diagnosed the easier it is to treat, and if left untreated over a long period of time, the hair loss may become permanent. Wearing hair in styles that are looser and do not pull on the roots is often the best way to prevent this type of hair loss.
A medical disorder that causes people to pull out their own hair is called trichotillomania. Often a person feels compelled to pull out hairs on their scalp, eyelashes, eyebrows, or other hairs on the body. Cognitive behavioral therapy and medications can help treat the condition.
Tinea Capitis (Fungal Infection)
Tinea capitis, or ringworm of the scalp, is a fungal infection that tends to attack hair shafts and follicles leading to hair loss. It appears as bald spots with black dots where the hair has broken off. It most commonly affects children, but can affect adults as well. Treatment usually includes antifungal compounds.
Telogen effluvium (TE) is a thinning of the hair on the scalp, not necessarily evenly. Hair growth involves several phases. Hair grows for a few years, rests (the telogen phase), sheds, and then regrows. When hair roots prematurely reach the resting phase, this is called telogen effluvium.
Telogen Effluvium (Continued)
Telogen effluvium is often caused by a “shock to the system,” with the hair loss occurring weeks to months after the initial shock. Some causes of TE include:
- high fever
- childbirth
- severe infection
- chronic or severe illness
- severe psychological stress
- major surgery
- over or underactive thyroid
- crash diets
- medications, such as retinoids, beta blockers, calcium channel blockers, antidepressants, and nonsteroidal anti-inflammatories (NSAIDs).
Because the stage following the resting (telogen) phase is regrowth, there is no treatment needed. Hair will usually resume normal growth. It is important to first determine that there is no other underlying medical condition that is causing the hair loss.
Androgenetic alopecia, also sometimes referred to as “male pattern baldness,” accounts for the majority of hair loss in men, but it can also affect women. It is usually caused by a combination of hormones and genetics.
Male-Pattern Baldness
Some men may start to notice thinning hair as early as their 20s, and by age 50, 50% of men see some hair loss. Hair is usually lost in a pattern, starting at the temples, revealing the classic “M” shaped hairline seen as men age.
There are many myths about male-pattern baldness.
- MYTH: Baldness is inherited through the mother’s side of the family. If your maternal grandfather was bald, you will be too.
- FACT: Genes for baldness can come from either parent.
- MYTH: Wearing hats strains hair follicles and causes hair loss.
- FACT: Unless your hat is so tight it cuts off circulation to hair follicles, it will not cause hair loss.
- MYTH: Using a blow dryer causes hair loss.
- FACT: Use of a blow dryer does not cause hair to fall out. However, frequent over-use of a hot dryer can cause hair to become brittle, damaged, and break, which may cause hair to appear thinner.
- MYTH: Washing hair too frequently or using certain styling products can cause hair to fall out.
- FACT: Shampoo and hair care products do not cause hair loss.
- MYTH: Massaging the scalp will help hair regrow by stimulating circulation around the follicles.
- FACT: It may make you feel good, but no studies have shown scalp massage helps regrow hair.
Female-Pattern Baldness
It’s not just men who lose their hair. While men tend to start losing hair on their forehead hairline, women tend to notice hair loss appearing on the top and crown of the scalp. As in men, it may be related to genetics (family history), and it is more commonly seen after menopause. Unlike men, the hair loss does not tend to be total and the front hairline is not usually affected any more than it is in women without hair loss.
There are myths about female-pattern baldness just as there are with male-pattern baldness.
- Long hair does not strain the roots, causing hair to fall out.
- Shampooing, hair coloring, and other chemical processes usually do not cause hair loss.
- Brushing hair too much does not cause hair loss – hair that comes out from brushing or combing was ready to fall out anyway.
- While some hairstyles that pull hair tightly such as braids (“corn rows”) or tight ponytails can cause traction alopecia, a type of hair loss, styling hair in general will not cause hair to fall out.
- Use of hair dryers or curling and flat irons does not cause hair to fall out. The heat from these appliances may damage hair, causing it to become brittle and break, giving the appearance of thinner hair, but they do not cause hair to fall out.
Hair Loss Treatment
First, it is important to determine that hair loss is not caused by an underlying medical condition. If that is the case, the medical condition needs to be addressed.
If there is no medical problem causing the hair loss, treatment options include medications, surgery, grooming techniques, wigs, and hairpieces.
There is no shampoo, conditioner, or other product that will help hair to grow. There are, however, products that can slow down hair loss, including:
- Minoxidil (Rogaine)
- Finasteride (Propecia)
Minoxidil (Rogaine)
Minoxidil (Rogaine) is a topical medication available over-the-counter (OTC), without a prescription. In men, it is used to treat male-pattern baldness. In women it is used to treat thinning hair. It is applied directly to the scalp twice-daily, and there are few side effects. Once treatment with minoxidil is started, it must be continued. Once it’s stopped the hair will start to fall out again.
Finasteride (Propecia) is a prescription medication that is taken orally. It can help grow and thicken hair, but it is mainly used to retain hair that is still on the scalp so it works best for men who have more hair already. A side effect of Propecia is impotence, which goes away when the drug is stopped. This drug is not considered safe for women of childbearing age, though it is probably safe for postmenopausal women.
Laser Treatments for Hair Loss
Low-dose laser therapy is being used under several names as a treatment for genetic baldness. This therapy is also called red light therapy, cold laser, soft laser, biostimulation, and photobiomodulation. Laser therapy may be used instead of, or in addition to, surgical options. Options include:
- Hoods worn inside a salon
- Caps and combs used at home
- Hand-held laser devices
Permanent hair loss can be treated with surgery. There are three common types of hair replacement surgery:
- Hair transplants – also called hair grafting – hair is taken from the back of the head and replaced in the front
- Scalp reduction – bald areas are surgically removed and the hair-bearing areas of the scalp are stitched together
- Scalp expansion – devices are inserted under the scalp to stretch the skin. This may be used before scalp reduction to help make the scalp laxer, or on hair-bearing areas, which can reduce balding.
These procedures are best for men with male-pattern baldness, and some women with female-pattern baldness. It is not recommended for people who do not have sufficient hair in “donor” sites (the parts of their scalp where hair will be taken), and people who tend to form keloid scars.
Grooming Techniques, Wigs, Hairpieces, etc.
When hair loss is mild, styling hair to cover areas of thinning hair can often be effective. Many volumizing shampoos and conditioners can help give volume to hair and make it appear thicker. Consult your hair stylist about the best haircut to help your hair appear thicker.
Other options include wigs or hairpieces for more severe or widespread hair loss. Hair weaves can also be attached to existing hair to fill in thinning areas.
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