Alopecia areata
Alopecia areata
What is alopecia areata?
Alopecia is a general term for hair loss. Alopecia areata is a common condition of non-scarring (does not cause scarring to the scalp) hair loss that can occur at any age.
Non-scarring hair loss means that the roots of the hairs have not been permanently lost; therefore, the hair potentially can grow back. It usually causes small, coin-sized, round patches of baldness on the scalp, although hair on other parts of the body, such as the beard, eyebrows, eyelashes, body, can be affected. In some people, larger areas are affected and occasionally it can involve the whole scalp (called alopecia totalis) or the entire body, face, and scalp (called alopecia universalis). Nails can also be seen in some patients. It can affect all genders and occur in both children and adults.
It is not possible to predict how much hair loss alopecia areata will cause. Hair can regrow on its own over a period of months, and rarely, over years. However, this cannot be guaranteed and there is a risk of new patches occurring in the future. The chances of the hair regrowing on its own are better, if less hair is lost at the beginning. If more than half the hair is lost, then the chances of a full recovery are low. The hair sometimes regrows white, at least in the first instance. Most people get further episodes of alopecia areata. In alopecia totalis and alopecia universalis, the likelihood of total regrowth is less without treatment.
A UK based study has demonstrated that alopecia areata patients have higher rates of depression and anxiety than those without alopecia areata which can impact on their daily activities. Therefore, it is important to discuss with your healthcare professional the social or emotional impacts that you might be feeling. They can direct you to the right support – this could mean talking to a therapist, taking medication if needed, or finding support from others who have been through similar experiences.
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What causes alopecia areata?
Hair loss in this condition is caused by inflammation of the hair follicle. Studies have shown that our immune system, the natural defence which normally protects the body from infections and other diseases, mistakenly attacks the hair follicle stopping it from growing hair. The exact cause of why this happens is still not fully understood.
Alopecia areata cannot spread to others and there is no connection to food or diet. There are several theories regarding triggers for alopecia areata including previous infections and stress. However, it is also possible that this link may be coincidental, as it has been impossible to identify such triggers in many people affected by alopecia areata.
Alopecia areata is an autoimmune condition and has been linked to other conditions such as thyroid disease, vitiligo (white patches in the skin) and type 1 diabetes. It has also been linked to atopic conditions such as eczema, hay fever and asthma. If you experience symptoms other than alopecia areata, please consult your doctor. Your doctor may suggest further tests.
Is alopecia areata hereditary?
There is a genetic predisposition to alopecia areata. However, not everyone develops hair loss: we know that only in about 20% of people affected by alopecia areata, there is a family history of the condition. It is thought that multiple genetic factors play a role, and it is unclear what triggers the condition.
What does alopecia areata feel and look like?
Alopecia areata causes sudden hair loss which can affect any parts of the body. There may be itching, burning, or tingling sensation in the affected area before or after the hair loss. If eyelashes are affected, it may cause dry eyes and become sore in dry and windy weather. Some people with alopecia areata develop small pits on their nails or their nails become more brittle and break.
Typically, alopecia areata starts with one or more bald, smooth patches on the scalp. These patches are not inflamed or scaly. It often affects pigmented hair, so there may be some white hair left within the bald area, especially in older people. Sometimes, instead of distinct patches, the hair loss is spread out.
In this condition, short, tapered hairs, called exclamation mark hairs may be seen at the edge of the bald patch. Regrowth usually starts at the centre of the bald patch with fine white hairs that thicken with time and usually regain their natural colour.
Some people with alopecia areata develop small pits on their nails, similar to the dimples seen on a thimble.
How is alopecia areata diagnosed?
This condition is normally diagnosed following assessment by your doctor. Most patients do not require any tests to confirm the diagnosis. In certain cases, if the diagnosis is uncertain a scalp biopsy may be considered.
Can alopecia areata be cured? What is the prognosis of this condition?
Currently, there is no cure for this condition.
Depending on the extent of hair loss there is a good chance that, for 4 out of 5 affected people, complete regrowth will occur within 1 year without treatment. There may, however, be further episodes of hair loss in the future. If there is very extensive hair loss from the start, the chances of it regrowing are not as high. Those with more than half the hair lost at the beginning or with complete hair loss at any stage have only about a 1 in 10 chance of full recovery. The chances of regrowth are lower in the following:
- young children,
- people with family history of alopecia areata or other autoimmune conditions,
- those with hair loss affecting the hairline at the back of the scalp,
- those with nail disease.
What if I need a wig?
Some individuals with alopecia areata may prefer to wear a wig while they wait for recovery. These can either be bought privately or obtained through the NHS on a consultant’s prescription (a financial contribution is usually required in England). Alopecia UK and the British Association of Dermatologists have created a ‘Charter for Best Practice for NHS Wigs Provision’ to help guide patients and health professionals
Your local hospital orthotic (surgical appliances) department will be able to advise you on the range of hairpieces available on the NHS and can recommend local suppliers who are sensitive to the needs of individuals with alopecia areata. Alopecia UK also provides helpful information on choosing and caring for wigs on their website.
How can alopecia areata be treated?
People with mild alopecia areata may not require treatment as their hair may regrow on its own. There is currently no cure for this condition and the aim of treatments is to help with symptoms of hair loss. Some treatments can induce hair growth, though none can alter the overall course of the disease.
The treatments that can be considered depend on the severity of hair loss. This should be discussed with your healthcare professional.
- Wigs/ hair pieces and Camouflage/ cosmetics. Wigs/ hair pieces can be a vital treatment for some patients in helping them regain confidence. The availability and provision of wigs are very variable across the UK. Alopecia UK and the British Association of Dermatologists have tried to address this by creating a Charter for Best Practice for NHS Wig Provision. This charter advocates for all patients with alopecia who require a wig to be offered a minimum of x2 acrylic wigs a year. Hair fibres or cosmetics can help camouflage the areas of hair loss. They can be bought online or over the counter. Microblading for eyebrows can help in cases of severe or permanent eyebrow loss. There are also temporary eyebrow transfers available that can be used daily by men and women.
Topical treatments applied on the skin
Corticosteroid creams
Corticosteroid creams and scalp applications. These are applied to the bald patches on the scalp for around 6 weeks. The course of treatment can be repeated.
Topical JAK inhibitors
Topical JAK inhibitors. Topical JAK inhibitors to treat alopecia areata have been studied through clinical trials and shown that they are not effective in regrowing scalp hair. Reports in the medical literature suggest possible improvement with eyebrow and eyelash regrowth. More studies are needed to review their effect. Topical JAK inhibitors are not available on the NHS.
Dithranol cream
Dithranol cream. This cream, which is usually used to treat a skin condition called psoriasis, causes irritation of the skin, and occasionally this appears to stimulate the hair to regrow when applied to the bald areas of the scalp. Dithranol stains the skin and hair a purple-brown colour, which is particularly prominent in blond and fair-headed people. It is not readily available, as there have been manufacturing issues over the years. It may become available again in the future.
Contact sensitisation treatment
This involves making the patient allergic to a substance (usually a chemical called diphencyprone) and then applying very weak strengths of this chemical to the bald patches, usually once a week to maintain a mild inflammation. Side effects of possible itching, blistering and enlarged glands in the neck can be troublesome. Some people can get widespread eczema. Loss of skin colour (depigmentation) may develop, so it is used with caution in those with dark skin. This treatment is only available in specialised centres.
Prostaglandin analogs
Latanoprost and bimatoprost are types of eyedrops that are used to treat glaucoma (raised pressure in the eyeball). One of the side effects noted in glaucoma patients was increased hair growth of eyelashes with its use. In alopecia areata, it has been found to be useful in promoting eyelash and eyebrow growth when fine hairs are present.
Minoxidil lotion
This is available over the counter. Applied to bald patches or areas of early regrowth with fine hair. There is limited evidence of how effective it can be when used on its own. It can sometimes help boost regrowth when used alongside other treatments. It cannot be applied on eyebrows or eyelashes.
Systemic (tablet or injection) treatments
Local steroid injections
These can be used on the scalp and eyebrows and are the most effective approach for small patches of hair loss. Injections can be repeated and are stopped once regrowth is achieved. A small dimple may develop at the injection sites, but this usually recovers after a few months. Special care is taken around the eyes and eyebrows. This is because excessive injections may cause glaucoma (raised pressure inside the eye) and skin thinning.
Corticosteroid tablets
High doses of steroid tablets may be effective in regrowth of the hair in moderate to severe cases, especially early on in their disease. However, there is a risk of relapse of hair loss once treatment is stopped. Long-term use of steroid tablets is not recommended. This is due to potential side effects including raised blood pressure, diabetes, stomach ulcers, cataracts, and osteoporosis as well as weight gain.
Janus Kinase (JAK) inhibitors
Oral JAK inhibitors are the first class of tablet treatments (taken by mouth) licensed for the treatment of severe alopecia areata. JAK inhibitors are immunomodulatory drugs. This means that they work by blocking a group of proteins in the body called Janus kinases (JAKs). JAK proteins are part of our immune system and play a role in causing inflammation. By blocking JAKs, these medicines dampen down the immune system to help reduce inflammation and the symptoms of alopecia areata.
JAK inhibitors carry a risk of infection as a side effect. Tofacitinib can be used to treat patients for other conditions beyond alopecia areata. When tofacitinib has been used in some of these contexts (for example, to treat people with rheumatoid arthritis), it has been linked with higher rates of heart-related events, cancers, blood clots and serious infections. Although it is very unclear whether people treated with tofacitinib or other JAK inhibitors for AA will also be at elevated risk of these conditions, the regulatory authorities have nevertheless issued a ‘box warning’ for doctors and patients to be cautious when using JAK inhibitors for any condition.
Currently, there are two oral JAK inhibitors that are licensed for alopecia areata:
- Ritlecitinib (JAK3/ TEC inhibitor) is a capsule taken daily by mouth and has been approved for NHS funding in patients aged 12 years and over with severe alopecia areata.
- Baricitinib (JAK 1 & 2 inhibitor) is also a tablet taken daily. It has been licensed for its use in severe alopecia areata. However, it has not been approved for NHS funding for alopecia patients currently due to cost. It is available on private prescriptions. It is currently funded on the NHS for the treatment of other conditions such as: atopic dermatitis, rheumatoid arthritis, COVID and monogenic interferonopathies.
More studies are taking place exploring other tablet-based JAK inhibitors and their potential use in alopecia areata. Therefore, it is likely more treatments may become available in the future.
Immunosuppressant tablets
These tablets include methotrexate, ciclosporin, mycophenolate mofetil and azathioprine. These medications are used in other inflammatory skin conditions such as psoriasis and eczema. These medications are considered in severe alopecia areata when other treatments have failed. They work by suppressing our immune system and therefore several serious side effects have to be considered when starting these medications. The evidence for the use of these medications in the treatment of alopecia areata is limited.
Biological therapies
These are drugs that can mimic or block the way in which immune cells signal to each other, so can decrease inflammation. Dupilumab (interleukin 4 and 13 inhibitor) is currently licensed and funded on the NHS for the treatment of atopic dermatitis from the age of 6 months, and not alopecia areata. There is a suggestion from a clinical trial that dupilumab can potentially help hair regrowth in certain cases, specifically patients who have both atopic dermatitis and alopecia areata. Several other biological agents have been reviewed with limited evidence. There is further research being done on new biological therapies for the treatment of alopecia areata.
Ultraviolet light treatment (PUVA)
This involves taking a tablet or applying a cream that makes the skin sensitive to light. The bald patches are then exposed to ultraviolet light, two or three times a week for a number of months. Recurrence of hair loss is common when the treatment is stopped. There is an increased risk of skin cancer in long-term use.
Other treatments
Complementary & alternative medicine (CAMs)
There is very limited evidence in the medical literature regarding alternative therapies. A study reviewed various types of alternative therapies has suggested that aromatherapy, which uses essentials oils, has been found to help people with alopecia areata, with significant reduction in depression and anxiety symptoms, but no true effect on hair re-growth.
Psychological-based treatments
Small studies have suggested that hypnosis and mindfulness meditation are effective for improving psychological outcomes and quality of life in patients with alopecia areata. However, this does not have an effect to hair regrowth.
What can I do?
- Some men and a few women with extensive alopecia find that shaving off the remainder of the hair provides a good solution.
- Remember that an important function of hair is to protect the scalp from sunlight. You should cover your bald patches with a sun block or a hat to prevent sunburn and also to reduce the chances of developing long-term sun damage.
- The hair also acts as an early warning to prevent scraping the scalp on low doors, cupboards, or trees. Be particularly careful to avoid hurting yourself in these situations.
- You can consult your hairdresser about dyeing regrown hair that is slow to regain its colour.
- People with long hair may use hair extensions to conceal it. Some hairdressers specialise in this. It is important to avoid putting too much tension on the hair during the process. This is because excessive tension could cause hair loss, called traction alopecia.
- Artificial eyelashes, eyebrow pencils and eyebrow tattoos/ microblading may be helpful for people with hair loss around the eye area. People with alopecia areata of the eyebrow also use eyebrow stickers.
Images DermNetNZ.
Animation by Stacy Bias, based on real-life interviews conducted by Goldsmiths anthropologist, Emma Tarlo. For further understanding of the social dimensions of hair, see her book, Entanglement: The Secret Lives of Hair.