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. 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 80 percent of people with mild alopecia areata recover within a year; however, most people will experience more than one episode during their lifetime.

About one 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 during childhood.

Alopecia areata is not life threatening, and does not cause physical pain. However, the cosmetic effects of hair loss can be devastating.

More detailed information about alopecia areata can be found separately. (See "Clinical manifestations and diagnosis of alopecia areata" and "Management of alopecia areata".) Androgenetic alopecia (male-pattern hair loss) is also discussed separately. (See "Patient information: Hair loss in men and women (androgenetic alopecia)".)

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 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). (See "Vitiligo".)

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 [1]. 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. However, alopecia areata may persist for several years and sometimes hair never regrows.

The patches may enlarge and form bizarre patterns (picture 1). 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).

ALOPECIA AREATA DIAGNOSIS

The diagnosis of alopecia areata is based upon the appearance of the hair loss. A healthcare 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 pernicious anemia may be recommended.

PSYCHOSOCIAL IMPACT OF ALOPECIA AREATA

Losing one's hair can be a devastating experience, particularly because it develops suddenly and the loss is difficult to hide. Women and children frequently struggle with depression or low self-esteem as a result of their hair loss.

Patients who have difficulty with the psychosocial impact of losing their hair should speak to a healthcare 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 the United States, patients can contact the National Alopecia Areata Foundation (www.alopeciaareata.org), a national support group that publishes a newsletter and provides names of local support groups.

ALOPECIA AREATA TREATMENT

Not all people with alopecia areata require treatment; up to 80 percent of 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.

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

Injected glucocorticoids — 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 (picture 2). New growth is usually seen within four weeks; injections are repeated every four to six weeks until regrowth is complete.

Because injections can be painful, the affected area may be pretreated with a topical anesthetic cream. The cream should be applied generously and covered with a tightly fitting shower cap or plastic wrap for 1.5 to 2 hours before treatment. The cream is removed immediately before injection.

Topical glucocorticoids — Although topical glucocorticoids (ointments, lotions, cream, or foam) are often used, there is limited evidence to support their effectiveness. They may work best when used in combination with other topical treatments, such as minoxidil (see below), or injected glucocorticoids [2].

Topical minoxidil — Available over-the-counter, topical minoxidil (eg, Rogaine®) promotes hair growth by lengthening the growth phase of hair follicles and causing more follicles to produce hair [3].

Minoxidil is approved to treat androgenetic alopecia (male pattern hair loss); it may also be useful in patients with mild alopecia areata. The solution 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 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.

Given that treatment with anthralin is uncomfortable and of limited benefit, we generally do not recommend it.

Topical immunotherapy — Topical immunotherapy is probably the most effective treatment for patients with extensive or recurrent scalp involvement. This technique 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 (physician specializing in the skin) who is experienced with this treatment.

Photochemotherapy — In photochemotherapy, the person is given a light-sensitive drug (either applied to the skin or taken by mouth) and then exposed to an ultraviolet light source. Studies have shown conflicting results. However, a trial of photochemotherapy may be reasonable in people with extensive alopecia areata if topical immunotherapy is not available. Treatment is usually continued for four to six months.

Some of the light-sensitive medication can remain in the skin for several weeks, causing the person to be sensitive to sunlight and even strong indoor lighting. Thus, it is important to avoid direct sunlight for several weeks after treatment. (See "Patient information: Sunburn prevention".)

COSMETIC APPROACHES TO ALOPECIA AREATA

Female patients with extensive alopecia areata usually 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.

WHERE TO GET MORE INFORMATION

Your healthcare provider is the best source of information for questions and concerns related to your medical problem.

This article will be updated as needed every four months on our web site (www.uptodate.com/patients).

Related topics for patients, as well as selected articles written for healthcare professionals, are also available. Some of the most relevant are listed below.

Patient level information

Patient information: Hair loss in men and women (androgenetic alopecia)
Patient information: Sunburn prevention

Professional level information

Clinical manifestations and diagnosis of alopecia areata
Management of alopecia areata
Vitiligo

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)

• American Hair Loss Council

      (www.ahlc.org)

• American Academy of Dermatology

      (www.aad.org)

UpToDate wishes to acknowledge Kelly Crowley for her contributions to this topic.

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