Alopecia areata is a disorder characterized by loss of hair. Sometimes, this means simply a few bare patches on the scalp. In other cases, hair loss is more extensive. Although the exact cause is not known, this is thought to be an autoimmune disorder in which the immune system, the body’s own defense system, mistakenly attacks the hair follicles, the tiny structures from which hairs grow. Unpredictable hair loss is the only noticeable symptom of this disorder. Regrowth of hair may or may not occur. Hair loss is usually confined to the head and face, although the entire body may be involved.
Kerion celsi is a deep dermatophytic infection of the scalp. The diagnosis is based on the characteristic clinical picture and is verified by examination for the fungus. Treatment consists of griseofulvin in a dosage of 10 mg/kg/day. The present article is a retrospective investigation of 18 patients with kerion celsi who had been treated in the Department of Dermatology in Marselisborg Hospital during the period 1978-1989. Sixteen out of the 18 patients were children. Twelve of the children were boys.
A questionnaire investigation revealed that only five out of 18 patients had normal hair growth. We found a connection between the degree of severity of the alopecia and the age of the patient and the extent of the primary affection, respectively, so that low patient age and large primary affection result in a poorer prognosis. On the other hand, we have not found any connection between the latent period from the first appearance of symptoms and relevant treatment and the alopecia. Nor is there any evidence that treatment with systemic steroid is of significance for the prognosis.
Alopecia areata, also known as spot baldness, is a condition in which hair is lost from some or all areas of the body.
Synonyms of Alopecia Areata
- Alopecia Celsi
- Alopecia Cicatrisata
- Alopecia Circumscripta
- Cazenave’s Vitiligo
- Celsus’ Vitiligo
- Jonston’s Alopecia
- Porrigo Decalvans
- Vitiligo Capitis
Subdivisions of Alopecia Areata
- Alopecia Seminuniversalis
- Alopecia Totalis
- Alopecia Universalis
What causes alopecia areata?
Alopecia areata is an autoimmune disease. This means it’s caused by the body’s immune system attacking its own tissues. The immune system attacks the hair follicles. It causes hair to stop growing, and then break off and fall out.
You may be more likely to have alopecia areata if you have another type of autoimmune disease, such as:
- Thyroid disease
- Eczema (atopic dermatitis)
The exact cause of alopecia areata is not known. An autoimmune mechanism is suspected in this disorder. Autoimmune disorders are caused when the body’s natural defenses against “foreign” or invading organisms (e.g., antibodies) begin to attack healthy tissue for unknown reasons. Some cases may be linked to abnormal reactions by blood cells (serum antibodies) to a thyroid protein (thyroglobulin), stomach (parietal) cells, or adrenal cells.
In 20 percent of cases, a familial pattern has been proposed, suggesting that some individuals may have a genetic predisposition to alopecia areata. A genetic predisposition means that a person may carry a gene for a disease but it may not be expressed unless something in the environment triggers the disease. It is not known whether this trigger comes from outside the body, such as a virus, or is internal. People who develop alopecia areata for the first time after age 30 are less likely to have other family members who also have the disorder.
The gene responsible for alopecia universalis (total absence of hair on the body) is located on the short arm of chromosome 8 (8p12).
Chromosomes are found in the nucleus of all body cells. They carry the genetic characteristics of each individual. Pairs of human chromosomes are numbered from 1 through 22, with an unequal 23rd pair of X and Y chromosomes for males and two X chromosomes for females.
Each chromosome has a short arm designated as “p” and a long arm identified by the letter “q”. Chromosomes are further subdivided into bands that are numbered. For example, chromosome 8p12 refers to band 12 on the short arm of chromosome 8.
The AA occurs in 0.1-0.2% of the population and is reported in any latitude and ethnicity.
It affects males and females equally.
In 20% of cases the AA occurs in childhood and has a peak between the second and fourth decade of life.
The AA is presented as a well-defined patch of hair / hair loss, asymptomatic, without particular changes in the skin.
In 90% of cases the AA presents itself as a single spot on the hairline.
In other cases, the patches of the hairline appear from the beginning multiple or become after the appearance of the first patch.
At the hairline the AA can be patchy or generalized ie with 100% of fallen hair. In this case it takes the name of Alopecia Areata Totale (AAT)
The AA can also affect 100% of body hair as well as hair and in this case takes the name of Alopecia Areata Universale (AAU).
In 5% of the cases of AAT we are witnessing the transition to AAU.
In rare cases the AA is presented in a band and not in a circular form and in this case takes the name of Ofiasi.
The hair on the outskirts of the patch detach easily with a modal traction and appear to “Point Exclamation” that is, thinner towards the redice and then the bulb is highlighted as a dot.
The typical spot of AA appears as an area of lack of hair with sharp, round or oval shaped edges.
The AA can appear as a spot where the hair loss is not total but some are still present and usually appear white.
Hair loss can occur with a linear pattern instead of a round or oval pattern (ofiasis).
AA frequently appears in the beard area and also in this area with a round or coin-like appearance.
In some cases, AA occurs at the same time as the hairline and beard area
The single patch of AA can also appear in hairy areas without other patches in the hairline or in the beard area
An area of frequent involvement of the AA concerns the eyelashes and eyebrows
When the AA is in Total or Universal form it is frequent to observe damage to the nail plate of several fingers and toes.
It is believed that even the nail matrix undergoes the same damage that causes hair loss but in a more limited way. The lamina of the nail appears as if it had been treated with abrasive paper and this phenomenon is called Trachionichia.
Only in a few cases the nail damage is so intense that it leads to the loss of the nail.
Signs & Symptoms
Alopecia areata often begins suddenly with oval or round bald patches appearing most commonly on the scalp. Other areas of hairy skin may also be involved. Gradually, the affected skin becomes smooth. New patches may spread by joining existing bald patches. These larger bald areas can appear while hair is regrowing in older hairless patches. Loss of hair can be permanent in some cases. Hair follicles may deteriorate, but oil producing glands in the skin (sebaceous glands) usually change very little. The skin does not become hard or atrophied. In a very few cases, all body hair may be lost. Cases beginning during childhood tend to be more severe than cases with an onset during adulthood.
The physical manifestations of this disorder may not be as difficult to handle for some individuals as the emotional ones. Most people with alopecia areata are generally healthy otherwise, and the disorder itself is not a sign of a serious or life-threatening disease.
Alopecia areata affects males and females in equal numbers. It may appear at any age, but most typically begins during childhood. There are approximately 2.5 million individuals in the United States affected by alopecia areata.
Loss of hair (alopecia) can occur from a wide variety of causes. Symptoms of the following disorders can be similar to those of alopecia areata. Comparisons may be useful for a differential diagnosis:
Trichotillomania, also known as hair pulling, is a neurotic habit that usually appears in children. It may remain undiagnosed for a long time. The hairs may be broken off or pulled out. Stubby regrowth may replace damaged hair or bald areas. This mental illness may be hard to distinguish from alopecia areata without careful observation of the affected child’s habits. Hair can be similarly damaged by permanent wave solutions, softeners or hot combs. (For more information on this disorder, choose “trichotillomania” as your search term in the Rare Disease Database.)
Hypotrichiasis (hypotrichosis, alopecia congenitalis, alopecia adnata, congenital alopecia, congenital baldness) is a condition characterized by the absence of hair at birth. This disorder is usually inherited as a dominant trait, but can also be due to a recessive gene. It often occurs in association with other surface skin layer (ectodermal) defects.
Alopecia medicamentosa is characterized by widespread hair loss, most commonly of the scalp, caused by a reaction to various types of drugs in sensitive or allergic individuals. It may also be a result of chemotherapy used in treating various disorders (e.g., cancer).
Alopecia mucinosa, also known as follicular mucinosis, occurs in children and young adults. Hard, reddish, well defined plaques underlie the areas of hair loss. A fine scaling may develop on the face, scalp, trunk, arms or legs. A loss of sensation may occur as the plaques develop. The exact cause of this form of hair loss in not known, although a skin inflammation is suspected. Symptoms often spontaneously resolve after a few months in many cases.
Alopecia neurotica is characterized by hair loss caused by injury to the nerves in the area where balding occurs.
Postpartum alopecia is characterized by temporary loss of hair at the termination of a pregnancy. The cause is not known.
Premature alopecia is characterized by male pattern baldness occurring at an abnormally early age.
Alopecia presenilis is characterized by ordinary or common baldness occurring in early or middle life without any apparent disease of the scalp. This condition is very common in males, but rare in females.
Alopecia symptomatica is characterized by hair loss associated with other illnesses or conditions, most commonly following prolonged illnesses marked by high fever.
Alopecia toxica, also known as toxic alopecia, is characterized by hair loss thought to be caused only by fever.
Alopecia triangularis congenitalis is a congenital defect consisting of a triangular patch of baldness on the front of the scalp.
Treatment of alopecia areata is directed at producing regrowth of hair. Although there is no cure for alopecia areata at the present time, the hair may sometimes return by itself. In some cases, it may also fall out again after returning. The course of this disorder varies among individuals, and is difficult to predict.
For mild, patchy alopecia areata, in which less than 50% of the scalp hair is gone, cortisone may be injected locally into areas of bare skin. These injections are done with tiny needles, and repeated once a month. Topical solutions, creams and ointments may also help.
For more extensive alopecia areata, cortisone pills are sometimes given. However, these pills may have undesirable side effects that should be discussed with a physician beforehand.
Treatment tends to be less effective for more extensive alopecia areata than in cases of mild, patchy alopecia areata.
For cosmetic reasons, wigs and hairpieces may be necessary, especially for affected women and children.
Diagnosis of AA
For the diagnosis of AA, clinical observation of the manifestation is usually sufficient and the patient’s history is to be heard.
Sometimes trichodermoscopic examination may be useful. In practice we examine the alopecica area with the dermoscope to detect the characteristics of AA which are: broken hair, blackheads, exclamation hair, “vellus” hairs, yellow dots.
These data can exclude other forms of alopecia such as Trichotillomania or areas of alopecia in diseases such as Lichen, Eritematode, Siflide etc.
What to do in case of appearance of the AA
If a patch of alopecia appears, the most important thing to do is not to panic about hair loss, otherwise others will derive from a patch. The doctor or dermatologist must then reassure the patient about the spontaneous regrowth of hair and inform that it will take several months before this happens and discourage any local or systemic care.
In fact there are no drugs with proven activity on hair re-growth in this type of fall.
Considering the psychosomatic nature of AA it is good not to prescribe treatments on the patches of alopecia, such as creams or lotions, because these would remind, to each application, the problem to the patient, with negative fallout of the psychic type.
If the patient with AA, once reassured about the successful outcome, “forgets” the problem, it is easier for the alopecia patch to spontaneously close in a short time.
What the Doctor / Dermatologist must investigate is the psychic aspect of the AA event in the sense that if the triggering event has been entirely occasional and will not be repeated there are no problems, on the contrary if the element of psychic suffering is still in place there is to expect an enlargement of alopecia.
In this case, pharmacological, psychological and other aid must be used to help overcome the stress phase or to lessen the negative consequences on hair growth.
When the AA does not resolve spontaneously
In some cases, quantifiable at around 20%, AA does not resolve spontaneously.
Usually these are the most striking cases such as Alopecia Areata Totale (AAT) or the Universal Alatecia (AAU). Even the onset at a young age or the lack of known psychic motivations that justify the AA are negative prognostic factors.
In these cases, after the loss of all hair (AAT) or even hair (AAU), there are moments of re-growth of thin, non-pigmented hair / hair that give the illusion of a resumption of growth but which then fall back.
In these cases it is important to evaluate the psychological impact that the hair / hair fall event causes in the subject.
In fact, some subjects easily overcome the moment of change of appearance and do not seek treatment at all costs while others are terrified of what happened and ask to get their hair / hair as soon as possible.
As mentioned, there is no specific treatment to regrow hair / hair in Alopecia Areata.
However, there are drugs / methods that have been shown to stimulate hair / hair re-growth in the case of AA, even if they do not guarantee stabilization of the result.
When the AA does not solve spontaneously what to do
As in all the pathologies where there is no specific treatment, dozens of measures, some sensible, others useless, others harmful, are considered treatments.
The AA is no exception.
Cortisone is the most prescribed drug in the case of AA, even if it is the most useless or harmful.
The reason for the use of cortisone in AA consists in the fact that some lymphocytes are found around the hair bulbs of the hair that fall and this makes us think that AA is an autoimmune disease and therefore should be treated with cortisone.
In fact, by administering cortisone, both by direct injection into the scalp and by application of ointment, in most cases, hair regrowth is obtained. However, it is a common experience that by continuing this treatment or by suspending it, the hair that has grown back due to cortisone stimulation all fall back. In addition, cortisone creates damage both to the scalp and, by absorption, to the subject subjected to this treatment.
Minoxidil is the second most prescribed drug but also in this case it is a useless drug.
Minoxidil is a potent vasodilator which, when applied to the scalp, has been shown to stimulate hair regrowth in early and juvenile Androgenetic Alopecia. Applied in the forms of AA has no effect or rather has the same effect as a placebo and eventually even the regrown hair fall back.
Another method to stimulate hair regrowth and Local Immunotherapy.
In this case allergenic substances such as Di Butil Ester of Squearic Acid and Difenyl Cycle Propenone are used. In practice, the subject is sensitized by applying substances of high concentration to the skin and, once the sensitization is obtained, the same substances with low concentration are applied to the alopecia area. It creates a reaction to type eczema and this stimulates the regrowth of hair. Even the regrowth of her hair stimulated with this practice is often destined to fall back and in addition the continuous stimulation with the allergens causes swollen lymph nodes in the neck, tiredness and malaise.
Treatments with natural products: Aromatherapy and Coal Tar Tincture
According to studies published in the literature for the AA Aromatherapy was used. In this treatment patients should rub the scalp with the aromatherapy mixture for 2 minutes and then cover the head with a warm towel for one hour.
The composition of the aromatherapy mixture is as follows:
2 drops of Thymus vulgaris, 3 drops of essential oil of Lavandula Angustifolia, 3 drops of Rosmarinus Officinalis, 2 drops of Cedrus Atlantica, solubilized in 3 ml of jojoba oil, plus 20 ml of grapeseed oil. This treatment has given mixed results and the role in the AA has not been defined.
Coal Tar tincture
The Coal Tar applied on the skin has undoubted anti-inflammatory and stimulating actions, it is used in fact for the treatment of Psoriasis and Atopic Dermatitis also the Coal Tar is an enhancer of the Ultraviolet rays also accredited for positive action on the AA.
Various physical methods such as UV-ray therapy, photochemotherapy, LASER, and photodynamic therapy without appreciable results have also been used in the AA.
Even the Needling with 0.5 mm needles, applied on the alopecia patches every 15 days, according to some authors, has given positive results but the data is recent and is waiting to be confirmed.
Finally, there are studies where, on the wave of the AA autoimmune theory, oral immunosuppressants such as Metotrexate and Cyclosporine have been used, which have produced negative results like cortisone.
In conclusion, the treatments proposed for the AA that does not resolve spontaneously are very disappointing both for the dermatologist and, above all, for the patient.
This should not make the dermatologist desist from a therapeutic attempt useful if nothing else to give hope to the patient and to temper the anxiety generated by the hair loss event.
Treatments of the future
Researchers at Colunbia University Medical Center have identified a receptor expressed by those suffering from AA that allows the link between hair follicles and lymphocytes. This link would be at the root of the hair / hair loss.
A monoclonal drug capable of acting as an inhibitor of JAK receptors would lead to resolution of the AA in most cases.
DermaClub is confident that the data from Columbia’s studies will be confirmed and that the drug will soon be available in Italy.
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