What is alopecia areata?
Alopecia (al-oh-PEE-shah) areata (ar-ee-AH-tah) is a recurrent nonscarring type of hair loss that occurs when your immune system mistakenly attacks hair follicles, which is where hair growth begins. It can affect any hair-bearing area, may manifest in many different patterns, and more than one area can be affected at once. Frequency of involvement at particular sites is as follows:
- Scalp – 66.8%-95%
- Beard – 28% of males
- Eyebrows – 3.8%
- Extremities – 1.3%
Although it is a benign condition and most patients are asymptomatic, it can cause emotional and psychosocial distress. Self-consciousness concerning personal appearance can become important. Openly addressing these issues through support groups is important in helping them cope with the condition. The damage to the follicle is usually not permanent. Experts do not know why the immune system attacks the follicles. Alopecia areata (AA) is most common in people younger than 20, but children and adults of any age may be affected. Peak incidence appears to occur from age 15-29 years. As many as 44% of people with alopecia areata have onset at younger than 20 years. Onset in patients older than 40 years is seen in less than 30% of patients with alopecia areata. Data concerning the sex ratio for alopecia areata vary slightly in the literature. In one study including 736 patients, a male-to-female ratio of 1:1 was reported. In another study on a smaller number of patients, a slight female preponderance was seen. This disorder most often occurs in otherwise healthy people.
Alopecia areata most often is asymptomatic, but some patients (roughly 14%) experience a burning sensation or pruritus in the affected area. The condition usually is localized when it first appears. No correlation exists between the number of patches at onset and subsequent severity.
Associated conditions may include the following:
- Atopic dermatitis
- Thyroid disease
- Collagen-vascular diseases
- Down syndrome
- Psychiatric disorders – Anxiety, personality disorders, depression, and paranoid disorders
- Stressful life events in the 6 months before onset
Alopecia areata can cause different types of hair loss. Each of these types has a different name:
- Alopecia areata (hair loss in patches).
- Alopecia Areata Incognita (thinning of all the hair on the scalp or “overnight” graying of the hair).
- Alopecia totalis (lose all hair on the scalp).
- Alopecia universalis (lose all hair on the body).
Alopecia areata can be classified according to its pattern, as follows:
- Reticular – Hair loss is more extensive and the patches coalesce
- Ophiasis – Hair loss is localized to the sides and lower back of the scalp
- Sisaipho (ophiasis spelled backwards) – Hair loss spares the sides and back of the head
- Alopecia totalis – 100% hair loss on the scalp
- Alopecia universalis – Complete loss of hair on all hair-bearing areas
In some people with alopecia areata, the fingernails and toenails become pitted — they look as if a pin had made many tiny dents in them. They may also look like sandpaper. Nail involvement is found in 6.8-49.4% of patients, most commonly in severe cases. Pitting is the most common; other reported abnormalities have included trachyonychia, Beau lines, onychorrhexis, onychomadesis, koilonychias, leukonychia, and red lunulae
What happens in alopecia areata?
Alopecia areata usually begins when clumps of hair fall out, resulting in totally smooth, round hairless patches on the scalp. In some cases the hair may become thinner without noticeable patches of baldness, or it may grow and break off, leaving short stubs (called “exclamation point” hair). In rare cases, complete loss of scalp hair and body hair occurs. The hair loss often comes and goes — hair will grow back over several months in one area but will fall out in another area.
When alopecia areata results in patches of hair loss, the hair usually grows back in a few months. Although the new hair is usually the same color and texture as the rest of the hair, it sometimes is fine and white.
About 10% of people with this condition may never regrow hair. You are more likely to have permanent hair loss if you:
- Have a family history of the condition.
- Have the condition at a young age (before puberty) or for longer than 1 year.
- Have another autoimmune disease.
- Are prone to allergies (atopy).
- Have extensive hair loss.
- Have abnormal color, shape, texture, or thickness of the fingernails or toenails.
Because hair is an important part of appearance, hair loss can result in feeling unattractive.
Alopecia areata cannot be “cured” but it can be treated. Most people who have one episode will have more episodes of hair loss.
How is alopecia areata diagnosed?
Alopecia areata is diagnosed through a medical history and physical examination. Your doctor will ask you questions about your hair loss, look at the pattern of your hair loss, and examine your scalp. And he or she may tug gently on a few hairs or pull some out.
If the reason for your hair loss is not clear, your doctor may do tests to check for a disease that could be causing your hair loss. Tests include:
- Hair analysis. Your doctor will take a sample of your hair and examine it under a microscope. A scalp sample is also sometimes taken.
- Blood tests, including testing for a specific condition, such as an overactive or underactive thyroid gland (hyperthyroidism or hypothyroidism).
How is it treated?
Because hair usually grows back within a year, you may decide not to treat alopecia areata.
If you choose not to treat the condition and wait for your hair to grow back, you may wish to:
- Wear hairpieces. Hairpieces are made from human or synthetic hair that is implanted into a nylon netting. Hairpieces may be attached to the scalp with glue, metal clips, or tape. But hair weaving, which involves sewing or braiding pieces of longer hair into existing hair, is not recommended because it may cause permanent hair loss.
- Use certain hair care products and styling techniques. Hair care products or perms may make hair appear thicker. Dyes may be used to color the scalp. But continual use of perms or dyes may result in more hair loss.
The most common treatment for patchy hair loss is many injections of corticosteroids into the scalp every 4 to 6 weeks.
Children and some adults may be treated with topical corticosteroids that are applied to the affected skin. Minoxidil (Rogaine) may be used along with topical corticosteroids.
Contact immunotherapy triggers an allergic reaction on the scalp that may help hair to grow. A medicine is “painted” on the scalp once a week. This irritates the skin and makes it red and scaly. Hair growth may appear within 3 months of beginning treatment. Side effects of contact immunotherapy include a severe rash (contact dermatitis) and swollen lymph nodes, especially in the neck.
Psoralen with ultraviolet A light (PUVA) therapy may also be used to treat alopecia areata. PUVA usually is reserved for people who have large areas of skin affected by the disorder or who cannot use other treatments. For PUVA, a medicine called a psoralen is used to make the skin more sensitive to ultraviolet A (UVA) light. Then the skin is exposed to UVA light.
How will alopecia areata affect your life?
Alopecia areata does not affect you as another condition might: it is not painful, it does not make you feel sick, and it does not result in serious health problems. You cannot spread it to other people, and it should not interfere with school, work, or recreation.
But if hair loss is making you feel unattractive, it is important to talk to someone about it. A counselor can help, as can talking to other people with the same condition.
- Muller SA, Winkelmann RK. Alopecia areata. An evaluation of 736 patients. Arch Dermatol. 1963 Sep. 88:290-7. [Medline].