Patient education: Alopecia areata (Beyond the Basics)

ALOPECIA AREATA OVERVIEW — Alopecia areata is a skin condition that causes a sudden loss of patches of hair on the scalp and sometimes other parts of the body (picture 1). It is nonscarring, which means that there is no permanent damage to the hair follicle. In most people, new hair eventually grows back in the affected areas, although this process can take months. Approximately 50 percent of people with mild alopecia areata recover within a year; however, most people will experience more than one episode during their lifetime.

Approximately 1 person in 50 will suffer from alopecia areata at some point in their life. It occurs in men and women of all races equally. The condition can develop at any age, although most people develop alopecia areata for the first time before the age of 30.

Alopecia areata is not life-threatening and does not cause physical pain. However, the psychosocial effects of hair loss can be devastating. In addition, patients may experience symptoms related to hair loss, such as increased eye or nasal irritation after loss of eyelash or nasal hair.

More detailed information about alopecia areata can be found separately (see "Alopecia areata: Clinical manifestations and diagnosis" and "Alopecia areata: Management"). Androgenetic alopecia (male-pattern hair loss) is also discussed separately. (See "Patient education: Androgenetic alopecia in men and women (Beyond the Basics)".)

ALOPECIA AREATA CAUSES AND RISK FACTORS — In alopecia areata, the body's immune system mistakenly attacks the hair follicles for reasons that are not clear. Fortunately, the follicles retain their ability to regrow hair, and the hair loss is not permanent in most cases.

Other conditions can occur along with alopecia areata; these may include vitiligo (a disorder that causes patchy whitening of the skin), thyroiditis (inflammation of the thyroid gland), and pernicious anemia (a decrease in the number of red blood cells due to a vitamin B12 deficiency).

Approximately 20 percent of people with alopecia areata have a family member who is also affected. Based on this, experts believe that some people have a genetic predisposition to the disease. A person who has a close relative with alopecia areata has a slightly increased risk of developing it as well. If the relative experienced hair loss before the age of 30, the risk is increased further.

ALOPECIA AREATA SYMPTOMS — People with alopecia areata typically have smooth, round patches of complete hair loss that develop over a period of a few weeks, followed in most cases by regrowth over several months (picture 1). However, alopecia areata may persist for several years and sometimes hair never regrows.

The patches may enlarge and coalesce to form irregular patterns of hair loss. Short hairs, broken off a few millimeters from the scalp, are often found at the edges of expanding patches of hair loss. These are sometimes referred to as "exclamation point hairs."

The scalp is the most common site for hair loss, but any area of the body can be affected. For many people, the disease does not progress beyond patchy hair loss. However, in some cases the hair loss is extensive. A small minority of patients lose all the hair on their head (known as alopecia totalis) or all the hair on their head and body (alopecia universalis).

In addition to hair loss, people with alopecia areata may develop fingernail or toenail abnormalities. The formation of multiple pits in the nail is most common.

ALOPECIA AREATA DIAGNOSIS — The diagnosis of alopecia areata is based upon the appearance of the hair loss. A health care provider will look for the characteristic patterns of hair loss, such as smooth patches with short, broken-off hairs around the borders.

Biopsy (the removal of a sample of tissue for study) is usually not necessary.

Blood tests for thyroid disease or other laboratory studies may be recommended.

PSYCHOSOCIAL IMPACT OF ALOPECIA AREATA — Losing one's hair can be a devastating experience, particularly when the loss develops suddenly and is difficult to hide. Patients who have difficulty with the psychosocial impact of losing their hair should speak to a health care provider about their feelings. Providers can offer support and may recommend that a patient work with a therapist, clinical psychologist, or support group; individual and group therapy can help patients adjust and cope with hair loss, and may also provide tips on cosmetic coverings. In addition, patients can contact organizations such as the National Alopecia Areata Foundation (www.naaf.org) and Alopecia UK (www.alopecia.org.uk) for information on alopecia areata and support resources.

ALOPECIA AREATA TREATMENT — Not all people with alopecia areata require treatment; many patients with limited disease will experience spontaneous hair regrowth.

For patients who use treatments, there are several options. However, alopecia areata cannot be "cured." As noted above, most patients experience future episodes of hair loss.

Corticosteroids — Corticosteroids, commonly called steroids, are anti-inflammatory medications that are used to treat alopecia areata. They can be taken by injection, applied topically (eg, as a cream, lotion, or in a shampoo formulation), or taken by mouth.

Injected corticosteroids — This method of treatment is often recommended for adults with isolated patches of hair loss. The medication is injected directly into the affected area to stimulate hair regrowth. It may take around six to eight weeks to notice new hair growth; injections are repeated every four to six weeks until regrowth is complete. If needed, the affected area can be pretreated with a prescription topical anesthetic cream to reduce the discomfort associated with injections.

Topical corticosteroids — Topical corticosteroids are sometimes prescribed as an alternative to injected corticosteroids for children or adults who cannot tolerate injections. Topical corticosteroids are usually applied to affected areas on a daily basis.

Like injected corticosteroids, this treatment is used for patients with isolated patches of hair loss. Topical corticosteroids may not be as beneficial for people with extensive hair loss.

Oral corticosteroids — Oral corticosteroids are occasionally prescribed for patients who are experiencing rapid, extensive hair loss. Although these drugs may slow hair loss and induce regrowth, long-term treatment is not recommended because of risk for serious side effects. Oral corticosteroids are usually only given for several weeks. Hair loss may recur when patients stop treatment.

Topical minoxidil — Available over-the-counter, topical minoxidil (eg, Rogaine) promotes hair growth by lengthening the growth phase of hair follicles and causing follicles to produce hair.

Minoxidil is approved to treat androgenetic alopecia (male pattern hair loss); it may also be useful in patients with mild alopecia areata. The solution or foam formulation is typically applied twice a day to the area of hair loss and can be used alone or in combination with other therapies. When treatment is successful, new hair growth is seen in about 12 weeks. Minoxidil is not usually effective in patients with severe alopecia areata or total loss of scalp hair.

Anthralin — Anthralin is a treatment that was originally developed for the treatment of another skin condition, psoriasis, but was later found to regrow hair in some people with mild alopecia. It must be used with care because it irritates the skin and eyes and can stain fabrics. Hair regrowth may be seen within three to four months.

Topical immunotherapy — Topical immunotherapy involves applying a substance known to cause an allergic reaction to the area of hair loss. The resulting itching, scaling, and irritation often induce hair growth for reasons that are not completely understood.

Topical immunotherapy is not widely available in the United States. Patients who are interested in trying it should see a dermatologist (clinician specializing in the skin) who is experienced with this treatment.

Immunosuppressive drugs — Drugs that suppress the immune system, such as oral steroids, methotrexate, and cyclosporine, are sometimes used in extensive alopecia areata. They can have significant risks and side effects and are usually only prescribed for patients with severe or rapidly progressing hair loss.

Investigational treatments — New therapies for alopecia areata are emerging. The preliminary results from drugs known as Janus kinase (JAK) inhibitors (tofacitinib and ruxolitinib) look promising, but additional study is necessary to evaluate the efficacy and safety of JAK inhibitors for alopecia areata. Oral JAK inhibitors are expensive, may carry significant risks, and are not yet recommended for routine treatment of alopecia areata. There is ongoing research on topical and oral JAK inhibitors and other therapies, giving hope that better treatments for alopecia areata will become available.

Platelet-rich plasma has also been used to treat alopecia areata, but robust clinical trials to confirm whether this treatment is effective are not available. Other therapies that are being studied for alopecia areata include the use of lipid-lowering medications and changing the gut microbiome.

COSMETIC APPROACHES TO ALOPECIA AREATA — Patients with extensive alopecia areata may opt to purchase a wig or hairpiece. An attractive wig is important for many women and children, although high-quality wigs can be expensive. Wigs can be cut and styled according to an individual's preference and may be attached to the head with double-sided tape or a suction cap.

Men frequently opt to shave their scalp; wigs and hairpieces are generally less acceptable. Temporary tattooing can be helpful for the loss of eyebrows. False eyelashes are an option for patients with hair loss involving the eyelashes.

WHERE TO GET MORE INFORMATION — Your health care provider is the best source of information for questions and concerns related to your medical problem.

This article will be updated as needed on our website (www.uptodate.com/patients). Related topics for patients, as well as selected articles written for health care professionals, are also available. Some of the most relevant are listed below.

Patient level information — UpToDate offers two types of patient education materials.

The Basics — The Basics patient education pieces answer the four or five key questions a patient might have about a given condition. These articles are best for patients who want a general overview and who prefer short, easy-to-read materials.

Patient education: Hair loss (The Basics)

Beyond the Basics — Beyond the Basics patient education pieces are longer, more sophisticated, and more detailed. These articles are best for patients who want in-depth information and are comfortable with some medical jargon.

Professional level information — Professional level articles are designed to keep doctors and other health professionals up-to-date on the latest medical findings. These articles are thorough, long, and complex, and they contain multiple references to the research on which they are based. Professional level articles are best for people who are comfortable with a lot of medical terminology and who want to read the same materials their doctors are reading.

Alopecia areata: Clinical manifestations and diagnosis
Alopecia areata: Management

The following organizations also provide reliable health information.

●National Alopecia Areata Foundation

     (www.naaf.org)

●National Library of Medicine

     (www.nlm.nih.gov/medlineplus/healthtopics.html)

●Alopecia UK

(www.alopecia.org.uk)

●American Academy of Dermatology

     (www.aad.org)

[1-7]