Alopecia areata is a type of hair loss that occurs when your immune system mistakenly attacks hair follicles camera.gif, which is where hair growth begins. The damage to the follicle is usually not permanent. Experts do not know why the immune system attacks the follicles. Alopecia areata is most common in people younger than 20, but children and adults of any age may be affected. Women and men are affected equally.
Alopecia areata, also known as spot baldness, is a condition in which hair is lost from some or all areas of the body.
Alopecia areata is rare before the age of 3 years. There seems to be a significant to inherit the tendency to develop alopecia areata from ancestors.
Alopecia areata is an acquired skin disease that can affect all hair-bearing skin and is characterized by localized areas of non-scarring hair loss. Alopecia areata is occasionally associated with any other external or internal medical problems. Most often these bald areas regrow their hair spontaneously.
Alopecia (al-oh-PEE-shah) means hair loss. When a person has a medical condition called alopecia areata (ar-ee-AH-tah), the hair falls out in round patches. The hair can fall out on the scalp and elsewhere on the body.
Alopecia areata can cause different types of hair loss. Each of these types has a different name:
- Alopecia areata (hair loss in patches).
- Alopecia totalis (lose all hair on the scalp).
- Alopecia universalis (lose all hair on the body).
Not everyone loses all of the hair on the scalp or body. This happens to about 5 percent of people.
Hair often grows back but may fall out again. Sometimes the hair loss lasts for many years.
Alopecia is not contagious. It is not due to nerves. What happens is that the immune system attacks the hair follicles (structures that contain the roots of the hair), causing hair loss. This disease most often occurs in otherwise healthy people.
Signs and symptoms
Alopecia areata most often is asymptomatic, but some patients (14%) experience a burning sensation or pruritus in the affected area. The condition usually is localized when it first appears, as follows:
- Single patch – 80%
- Two patches – 2.5%
- Multiple patches – 7.7%
No correlation exists between the number of patches at onset and subsequent severity.
Alopecia areata can affect any hair-bearing area, and more than one area can be affected at once.
Frequency of involvement at particular sites is as follows:
- Scalp – 66.8-95%
- Beard – 28% of males
- Eyebrows – 3.8%
- Extremities – 1.3%
Associated conditions may include the following:
- Atopic dermatitis
- Thyroid disease
- Collagen-vascular diseases
- Down syndrome
- Psychiatric disorders – Anxiety, personality disorders, depression, and paranoid disorders
- Stressful life events in the 6 months before onset
Alopecia areata can be classified according to its pattern, as follows:
- Reticular – Hair loss is more extensive and the patches coalesce
- Ophiasis – Hair loss is localized to the sides and lower back of the scalp
- Sisaipho (ophiasis spelled backwards) – Hair loss spares the sides and back of the head
- Alopecia totalis – 100% hair loss on the scalp
- Alopecia universalis – Complete loss of hair on all hair-bearing areas
- Nail involvement, predominantly of the fingernails, is found in 6.8-49.4% of patients, most commonly in severe cases. Pitting is the most common; other reported abnormalities have included trachyonychia, Beau lines, onychorrhexis, onychomadesis, koilonychias, leukonychia, and red lunulae
The most prominent symptom of alopecia areata is patchy hair loss. Coin-sized patches of hair begin to fall out, mainly from the scalp. Any site of hair growth may be affected, though, including the beard and eyelashes.
The loss of hair can be sudden, developing in just a few days or over a period of a few weeks. There may be itching or burning in the area before hair loss. The hair follicles are not destroyed and so hair can re-grow if the inflammation of the follicles subsides. People who experience just a few patches of hair loss often have a spontaneous, full recovery without any form of treatment.
About 30 percent of individuals who develop alopecia areata find that their condition either becomes more extensive or becomes a continuous cycle of hair loss and regrowth.
About half of patients recover from alopecia areata within 1 year, but many will experience more than one episode. Around 10 percent of people will go on to develop alopecia totalis or alopecia universalis.
Alopecia areata can also affect the fingernails and toenails, and sometimes these changes are the first sign that the condition is developing.
There are a number of small changes that can occur to nails:
- woman with hair in hairbrush
- Alopecia affects both men and women equally.
- pinpoint dents appear
- white spots and lines appear
- nails become rough
- nails lose their shine
- nails become thin and split
Additional clinical signs include:
Exclamation mark hairs: This occurs when few short hairs that get narrower at their bottom and grow in or around the edges of bald spots.
Cadaver hairs: This is where hairs break before reaching the skin surface.
White hair: This may grow in areas affected by hair loss.
Who gets alopecia areata?
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.
A family history of alopecia areata and/or of other autoimmune conditions is present in 10–25% of patients.
At least 8 susceptibility genes have been detected.
Patients with alopecia areata have higher than expected rates of thyroid disease, vitiligo and atopic eczema.
There is increased prevalence in patients with chromosomal disorders such as Down syndrome.
It’s possibly drug-induced when arising in patients on biologic medicines
What causes alopecia areata?
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.
Alopecia areata is believed to be due to a genetic predisposition and an environmental trigger. This causes an immune attack on hair follicles, in particular the follicles with pigment. In some people, acute stressful episodes, or anxiety attacks, have been implicated as an initiating cause.
Alopecia areata occurs when the body’s immune system mistakes hair follicles as foreign and attacks them. This causes the hairs to fall out. This specific form of autoimmunity is a lifelong tendency that can be inherited from either parent.
It’s what geneticists call a “complex polygenic disease” meaning it arises due to an interaction between multiple genes as opposed to a mutation in a single gene. More than 17 genes have been associated with alopecia areata and scientists expect there are still more genes to be discovered.
While your genes are pretty much fixed from birth, alopecia areata tends to come and go, especially in the early stages.
Doctors, patients and their families have hunted for this elusive trigger hoping its discovery would allow people to avoid relapses. However, no convincing dietary or lifestyle modification has emerged that changes the risk of relapse.
While people regularly blame stress as a trigger, in my experience of treating patients, the condition causes the stress.
The onset or recurrence of hair loss is sometimes triggered by:
- Viral infection
- Hormonal change
- Emotional/physical stressors
What happens in alopecia areata?
Alopecia areata usually begins when clumps of hair fall out, resulting in totally smooth, round hairless patches on the scalp or other areas of the body. In some cases the hair may become thinner without noticeable patches of baldness, or it may grow and break off, leaving short stubs (called “exclamation point” hair). In rare cases, complete loss of scalp hair and body hair occurs. The hair loss often comes and goes-hair will grow back over several months in one area but will fall out in another area.
When alopecia areata results in patches of hair loss, the hair usually grows back in a few months.1 Although the new hair is usually the same color and texture as the rest of the hair, it sometimes is fine and white.
About 10% of people with this condition may never regrow hair.2 You are more likely to have permanent hair loss if you:
- Have a family history of the condition.
- Have the condition at a young age (before puberty) or for longer than 1 year.
- Have another autoimmune disease.
- Are prone to allergies (atopy).
- Have extensive hair loss.
- Have abnormal color, shape, texture, or thickness of the fingernails or toenails.
Because hair is an important part of appearance, hair loss can result in feeling unattractive.
In some people with alopecia areata, the fingernails and toenails become pitted-they look as if a pin had made many tiny dents in them. They may also look like sandpaper.
Alopecia areata cannot be “cured” but it can be treated. Most people who have one episode will have more episodes of hair loss.
- Man with alopecia
- Alopecia areata is a common autoimmune disorder that commonly results in unpredictable hair loss.
- There is currently no cure for alopecia areata, although there are some forms of treatment that can be suggested by doctors to help hair re-grow more quickly.
- The most common form of alopecia areata treatment is the use of corticosteroids, powerful anti-inflammatory drugs that can suppress the immune system. These are mostly commonly administered through local injections, topical ointment application, or orally.
Other medications that can be prescribed that either promote hair growth or affect the immune system include Minoxidil, Anthralin, SADBE, and DPCP. Although some of these may help with the re-growth of hair, they cannot prevent the formation of new bald patches.
The use of photochemotherapy is supported by some studies and presents a potential alternative for patients unable or unwilling to use systemic or invasive therapies.
In addition to its aesthetic aspect, hair affords a degree of protection against the elements. People with alopecia areata who miss the protective qualities of hair may wish to:
Wear sunscreen if exposed to the sun.
Wear wraparound glasses to protect the eyes from the sun and debris which the eyebrows and eyelashes would normally defend against.
Use headwear such as hats, wigs, and scarves to protect the head from the sun or keep it warm.
Use ointment inside the nose to keep membranes moist and to protect against organisms that are normally trapped by nostril hair.
Alopecia areata does not directly make people sick, nor is it contagious. It can, however, be difficult to adapt to emotionally. For many people, alopecia areata is a traumatic disease that warrants treatment addressing the emotional aspect of hair loss, as well as the hair loss itself.
Support groups and counseling are available for people to share their thoughts and feelings, and to discuss common psychological reactions to the condition.
As such, any new developments in the treatment or prevention of either disease may have consequences for the other.
There have been a handful of documented cases where treatment for alopecia areata using diphencyprone (DCP), a contact sensitizer, has led to the development of vitiligo.
Preliminary research in animals has found that quercetin, a naturally occurring bioflavonoid found in fruits and vegetables, can protect against the development of alopecia areata and effectively treat existing hair loss.
Further research is needed, including human clinical trials, before quercetin can be considered a treatment for alopecia areata.
How Is Alopecia Areata Diagnosed?
Your doctor will review your symptoms to determine if you have alopecia areata. They may be able to diagnose alopecia areata simply by looking at the extent of your hair loss and by examining a few hair samples under a microscope.
Your doctor may also perform a scalp biopsy to rule out other conditions that cause hair loss, including fungal infections, such as tinea capitis. During a scalp biopsy, your doctor will remove a small piece of skin on your scalp for analysis.
Blood tests might be done if other autoimmune conditions are suspected. The specific blood test performed depends on the particular disorder your doctor suspects. However, your doctor will likely test for the presence of one or more abnormal antibodies. If these autoantibodies are found in your blood, it usually means that you have an autoimmune disorder.
Other blood tests that can help rule out other conditions include the following:
C-reactive protein and erythrocyte sedimentation rate
- iron levels
- antinuclear antibody test
- thyroid hormones
- free and total testosterone
- follicle stimulating and luteinizing hormone
What is the likely outcome in alopecia areata?
Factors that can indicate a poor prognosis for alopecia areata are large extent hair loss at presentation and a pattern of hair loss shaped like a wave around the circumference of the head called “ophiasis”. The longer the duration of hair loss, the younger the age of onset, a family history of alopecia areata, the presence of other autoimmune diseases and nail involvement suggest a lesser likelihood that the hair will regrow.
The exact prognosis is unpredictable. However, about 50% of affected people will recover within one year. Recurrent episodes of hair loss are likely.
As conventional treatments for alopecia are extremely limited, studies that support natural treatments for alopecia are even thinner on the ground.
There are some people that recommend rubbing onion or garlic juice, cooled green tea, almond oil, rosemary oil, honey, or coconut milk into the scalp. While none of these are likely to cause harm, their effectiveness is also not supported by research.
Some people turn to alternative treatment methods such as acupuncture and aromatherapy, although there is little, if any, evidence to support these treatments.
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