follow @PCDSUKCreated: 27th February 2013 | Last Updated: 24th April 2017
Introduction
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Alopecia areata is a chronic inflammatory disease that affects the hair follicle causing patchy non-scarring hair loss on the scalp. Total loss of scalp hair is known as alopecia totalis, and loss of the entire scalp and body hair is known as alopecia universalis. |
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Aetiology
- Alopecia areata is probably an autoimmune disorder
- About 20% of patients have a family history
History
- The onset may be at any age with a peak incidence between the second and fourth decades
- There is no known race or sex preponderance
Clinical findings
- The characteristic initial lesion is a circumscribed, totally bald, smooth patch. The skin within the bald patch is normal or slightly reddened. There is no scarring
- Short broken hairs (exclamation mark hairs) are often seen around the margins of active expanding patches of alopecia
- Yellow dots can be seen around hair follicles
- Other hair-bearing areas of skin such as the beard can be affected. In some patients the eyebrows and eyelashes may be the only affected sites
- Subsequent progress is very varied; the initial patch may regrow within a few months, or further patches may appear after an interval of three to six weeks and then in a cyclical fashion. Sometimes a succession of discrete patches become confluent leading to a diffuse loss of hair
- Occasionally patients go on to lose all / almost all of their scalp hair (alopecia totalis) or their entire scalp and body hair (alopecia universalis)
- Nails are involved in 10% of patients referred for specialist advice, usually in the context of severe hair loss. Nail pitting is the most common finding, but some cases show a roughening of the nail plate or non-specific dystrophic changes
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Other presentations
- Ophiasis is a well-defined pattern of alopecia areata when the hair loss is localised to the sides and lower back of the scalp
- In some cases the initial hair loss is more diffuse over all or part of the scalp
Images
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Figure: 1 Alopecia areata |
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Figure: 2 Same patient as figure 1 |
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Figure: 3 Exclamation mark hairs |
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Figure: 4 Exclamation mark hairs - dermoscopic appearance |
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Figure: 5 Alopecia areata - ophiasis pattern |
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Figure: 6
Alopecia areata with signs of regrowth |
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Figure: 7 Alopecia areata affecting the beard Regrowth apparent (arrow) |
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Figure: 8 Alopecia areata affecting the eyebrow |
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Figure: 9 Alopecia totalis Copied with kind permission from Dermatoweb |
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Figure: 10 Alopecia areata and nail pitting |
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Figure: 11 Alopecia areata and nail dystrophy |
Management
General advice
- Provide a patient information leaflet
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Prognosis
- Even in mild cases the condition will last many months
- Patient more likely to have a full regrowth of hair include those presenting with lesser degrees of hair loss. One study from Japan reported spontaneous remission within one year in 80% of patient with a small number of circumscribed patches of alopecia
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The prognosis is less favourable in the following:
- More severe hair loss at the onset (and such patients are more likely to develop alopecia totalis or universalis, from which full recovery is less than 10%)
- Onset in childhood
- With ophiasis pattern
- Recurrence - most patients will have more than one episode of alopecia areata
- Counselling - some patients are profoundly upset by their alopecia and may require psychological support
Scalp treatment
A number of treatments can induce hair growth in alopecia areata but none have been shown to alter the long-term course of the disease
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Topical steroids
- Very potent topical steroids eg Dermovate ® cream are widely used, and although the evidence for their effectiveness is limited they probably hasten regrowth of hair in some patients with mild to moderate disease
- Regrowth is likely to take several weeks / months, and begins with the growth of fine white hair
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Intralesional steroids
- Can be given by intralesional injections just beneath the dermis or using a Dermajet ®, a needleless device, every 3-4 weeks. One of the most common drugs used is triamcinolone
- This method is best used for patchy hair loss. Larger areas of alopecia are less likely to respond
- The evidence for intralesional treatment is a little stronger than for topical treatment and so should be considered for patients failing to respond to topical steroids
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Contact immunotherapy
- Is the repeated, topical application of contact allergens such as DPCP (2,3-diphenylcyclopropenone)
- Although up to 60% of patients in studies showed response to treatment, the degree of improvement varied widely from 9-87%
- Treatment should be stopped after six months if no response is noted
- Contact immunotherapy is perhaps best reserved for larger / more extensive patches of hair loss, which may have been unsuccessfully treated with intralesional steroids. Patients with extensive hair loss are less likely to respond
- Patients need careful counselling before having this treatment - contact eczema is the most common adverse effect. Uncommon adverse effects include urticaria and vitiligo, and other changes in skin colour especially in patients with darker skin
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Other treatments
- Minoxidil ® has been used for scalp hair loss - the evidence for effectiveness is lacking
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Secondary Care - for rapid / progressive hair loss a number of treatments have been used including systemic steroids, ciclosporin and methotrexate, however, side-effects are a major consideration and in patients with severe hair loss the response rate is probably too low to justify the risks in most such patients
Beard area, eyebrows and eyelashes
- Eyebrows can be treated with intralesional steroid injections
- Loss of eyelashes is very difficult to treat as topical steroids cannot be used at this site
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Patients with alopecia affecting the beard should be advised to try and disguise the hair loss by shaving regularly. The use of potent / super-potent topical steroids could be considered although there is little evidence to support their use and patients need to be warned about the risks of steroid atrophy
Wigs and prosthesis
- Wigs, integrated hair systems, hats and false eyelashes can be used as effective ways to cope with alopecia areata
- Local dermatology departments may be the best contact in terms of obtaining / finding out where to obtain wigs on the NHS. Patients are given a choice of monofilament acrylic wigs or synthetic acrylic wigs. Human hair wigs are normally reserved for patients found on patch tests to be allergic to acrylic wigs
- For individuals with patchy alopecia there is the option to integrate a weft of human hair or use a top piece that is either clipped into surrounding hair or braided in
- The loss of eyebrows can be particularly challenging. Eyebrows can be drawn in using eyebrow pencil ink, or some organisations have developed semipermanent tattoos for eyebrows
Other resources
- Patient support groups - Alopecia UK
- British Association of Dermatologists Guidelines