What is Alopecia Areata?
Alopecia areata is a long-term condition caused by an overactive immune system that mistakenly attacks the body’s own cells. This condition affects hair follicles (the parts of your skin that grow hair), sometimes your nails and, in rare cases, the layer of cells at the back of your eye (retinal pigment epithelium).
This mistaken immune response specifically targets hair follicles in their active growth stage, leading to hair loss. However, the good news is that this hair loss doesn’t permanently damage the follicles.
Alopecia areata typically shows up as patches of hair loss on the scalp over a period of a few weeks. It’s characterized by sudden hair loss in specific areas—these patches of hair loss are smooth and don’t lead to scarring. Even though the hair can grow back on its own within a year, this disease tends to come and go. This means that despite hair regrowth, there might be future times when the hair begins to fall out again.
Because this can be a distressing experience, emotional support is often needed alongside medical treatment. There are various treatment options available—these include corticosteroids (anti-inflammatory medicines), immunotherapy (therapy that uses the immune system to help fight the disease), Janus kinase (JAK) inhibitors (medications that block certain enzymes to stop the immune system from attacking the hair follicles), and topical solutions (medicines applied directly to the skin). These treatments can help manage and limit the hair loss.
What Causes Alopecia Areata?
The process of hair growth consists of three stages – the anagen, catagen, and telogen phases. The anagen phase is when hair actively grows, while the catagen phase is when the top end of the hair hardens, which is a process known as keratinization. Afterwards, the old hair falls out and the top end of that hair dies off, a process known as apoptosis. The telogen phase is the rest period between when the old hair falls out and the growth of new hair begins.
During the active growth phase, or anagen, there are six stages of hair growth. Stage VI represents a fully grown hair follicle. For people who have a condition called alopecia areata, which causes hair to fall out, their hair follicles get stuck in stage III or IV. This causes the hair to prematurely revert to the catagen or telogen phase resulting in sudden hair loss and a lack of new hair growth.
Risk Factors and Frequency for Alopecia Areata
Alopecia areata, a form of hair loss, can occur in roughly 2% of people at some point in their lives. It’s estimated that about 1 in 1,000 people will have alopecia areata. It affects both males and females with no particular preference; however, it is seen more frequently in Asian, Black, and Hispanic individuals. Children and adults can experience alopecia areata, and the chances increase as one gets older. On average, men start noticing signs around the age of 32, while women tend to start around the age of 36.
This hair loss condition is often associated with other skin and overall health issues like vitiligo, lupus erythematosus, psoriasis, atopic dermatitis, thyroid disease, and allergic rhinitis.
- It is most common in the general population with a 2% risk.
- Approximately 1 in 1000 people will have alopecia areata.
- It affects all races but is more common in Asian, Black, and Hispanic people.
- Both children and adults can get it, but the risk increases with age.
- On average, men start to show signs at age 32, while women start at age 36.
- It may be linked to conditions like vitiligo, lupus, psoriasis, atopic dermatitis, thyroid disease, and allergic rhinitis.
It’s also important to note that people with Down syndrome and polyglandular autoimmune syndrome type 1 are more likely to develop alopecia areata. These groups have an increased risk compared to the general population.
Signs and Symptoms of Alopecia Areata
Alopecia areata is a condition that causes patches of hair loss. These bald patches normally appear on the scalp and are noticeable within a few weeks. However, it can also lead to hair loss in other areas such as the beard, eyebrows, eyelashes, and even body hair on the arms and legs. When the disease is active, so-called ‘exclamation-mark’ hairs are commonly seen at the margins of the bald patches. These are hairs that are narrow at the root end and wider at the other.
In rare cases, the condition can advance to complete hair loss on the scalp or throughout the body, known as alopecia totalis and alopecia universalis respectively.
There are also various specific patterns in which hair loss can occur:
- Ophiasis pattern: Hair loss specifically in the back of the head.
- Sisaipho pattern (or ophiasis inversus): Hair loss on the front, sides, and top of the scalp while the back of the head is unaffected.
- Diffuse pattern: Quick, widespread hair loss followed by regrowth within a few months.
Interestingly, alopecia areata sometimes affects the nails. About 10% to 15% of people with alopecia areata get changes in their nails, such as tiny dents (pitting), roughness (trachyonychia), brittle nails (onychorrhexis), red spots on the lunulae, nail separation (onycholysis), and complete loss of nails (onychomadesis). Additionally, people with alopecia areata often initially notice rapid greying as white hair tends not to fall out as much. Further, alopecia areata has been associated with a higher risk of eye conditions such as retinal detachment and vein occlusion.
Testing for Alopecia Areata
Alopecia areata, a condition that causes hair loss, is typically diagnosed by relying on the patient’s medical history and a physical examination. The sudden appearance of bald patches on the skin, occasionally accompanied by slight redness, should make your doctor suspect this condition. A tool called a dermoscope can help confirm the diagnosis by allowing your doctor to look at your skin more closely.
Signs of early hair regrowth include broken hairs, yellow dots, black dots, exclamation point hairs (these are hairs that narrow towards the root), and short, fine hairs. If there are no hair follicles visible, this could indicate a type of hair loss that causes scarring (cicatricial alopecia). Your doctor may perform a ‘hair pull test’ to confirm active hair loss – this is when some hairs are gently pulled out to see how many come loose. It may also be useful to look at the nails for any changes that might support the diagnosis.
If the diagnosis still isn’t clear, a small sample of skin may be taken from the edge of a bald patch for analysis. Though Alopecia areata can be linked with other diseases where the immune system attacks the body’s own tissues (autoimmune diseases), routine screening for these is not normally recommended unless your medical history suggests it could be necessary.
Treatment Options for Alopecia Areata
For about half of those suffering from alopecia areata (a condition where hair falls out in patches), hair naturally regrows within one year without any medical treatment. Some choose not to get treatment, but for those who do, the first options often include injections of corticosteroids into the scalp (intralesional) or applying corticosteroid creams or lotions (topical).
Let’s dive deeper into treatment options:
1. Intralesional Corticosteroids: A drug called Triamcinolone acetonide is injected directly into the scalp every 4-6 weeks, promoting hair regrowth in about 60%-67% of patients. Eyebrows and beards can also be treated, with new hair usually appearing in 6-8 weeks. These injections are continued until full hair regrowth occurs. The amount of drug used doesn’t affect the rate of regrowth, but higher concentrations can cause skin thinning. Occasionally, another corticosteroid, called Betamethasone, may be used, but more research is needed to determine its effectiveness. Despite being typically safe, corticosteroid injections can occasionally cause side effects like skin thinning, pain, blood vessel enlargement (telangiectasia), and color changes. Very rarely, they can affect the body’s natural steroid production or cause Cushing syndrome.
2. Topical Corticosteroids: Betamethasone dipropionate is a potent corticosteroid cream, lotion, or ointment used for alopecia areata. It’s great for children and patients who can’t tolerate injections. Applied daily to the affected area, the treatment is stopped if there’s no improvement within 3 months. If progress is noticed, the dosage is slowly decreased. Although generally safe, applying betamethasone under dressings or bandages can increase the risk of side effects.
3. Immunotherapy & JAK Inhibitors: For those with extensive hair loss (over 50% of the scalp), other treatments like topical immunotherapy or JAK inhibitors may be preferable. Between the two, choice depends on factors like patient preference and availability. JAK inhibitors are easy to use but can cause whole-body side effects, while topical immunotherapy can be cumbersome to apply and may cause skin discomfort and side effects. Immunotherapy involves weekly application of potent allergens (substances that cause an allergic reaction) to stimulate hair regrowth. Contact immunotherapy seems to work well, with around 75% of patients with patchy alopecia showing hair regrowth. However, without maintenance treatment, hair loss might reoccur in about 49% of patients. JAK inhibitors work by suppressing specific immune cells, and must be taken continuously to maintain benefits. They carry a risk of serious side effects including severe infections and cancer.
4. Other Treatments: Some patients may benefit from other treatments including topical or oral minoxidil, methotrexate, azathioprine, cyclosporine, platelet-rich plasma, topical anthralin, laser treatment or ultraviolet light therapy. In cases of rapid and widespread hair loss, oral glucocorticoids may be beneficial but have limited usage due to side effects. For eyelash alopecia, there are no effective topical treatments, but systemic therapy, false eyelashes, and even tattooed eyebrows might be helpful. In any case, dealing with alopecia areata can be stressful and consulting a mental health professional can be beneficial.
What else can Alopecia Areata be?
There are several medical conditions that could be confused with alopecia areata, a condition that causes hair loss. These include:
- Androgenetic alopecia (a type of hair loss that runs in families)
- Traction alopecia (hair loss from hairstyles that pull at the hair)
- Trichotillomania (a mental disorder that involves the urge to pull out one’s hair)
- Tinea capitis (a fungal infection of the scalp)
- Secondary syphilis (a sexually transmitted infection that can cause hair loss)
- Aplasia cutis (a skin condition where a person is born without certain areas of skin)
- Temporal triangular alopecia (a condition which causes hair loss in a triangular area on the scalp)
What to expect with Alopecia Areata
People with a condition called alopecia areata, which causes patchy hair loss, have a chance to see their hair grow back. In fact, between 34% and 50% of individuals with this condition see their hair return naturally within a year. However, most people will experience reoccurring hair loss, and fewer than 10% will see a full recovery.
About 10% of individuals with alopecia areata may eventually develop more severe forms of hair loss known as alopecia totalis or alopecia universalis.
The chance of hair regrowth can depend on several factors. These include how severe the hair loss is and the age when alopecia first starts. Alopecia is more likely to persist if it starts in childhood, if the hair loss is in a band shape around the sides and back of the head (this is called ‘ophiasis’), or if there’s a family history of alopecia areata.
Other factors that could indicate a poor chance of recovery include if the condition has lasted for more than a year, if there are changes in the texture and shape of the nails (known as ‘nail dystrophy’), if an individual has an allergic condition (known as ‘atopy’), or if someone has another disease where the immune system attacks the body (an ‘autoimmune disease’).
Possible Complications When Diagnosed with Alopecia Areata
Alopecia areata is a condition that can cause several potential complications, including:
- Mental health issues like depression and anxiety
- Permanent loss of hair
- Chances of experiencing the condition again
- Changes to the nails
- Risk of sunburn and skin damage
- Unpredictable changes in the pattern, texture, and speed of hair growing back
Apart from these, people with alopecia areata may also face a higher risk of developing skin and other health conditions such as:
- Thyroid disease
- Vitiligo (a condition that causes loss of skin color in patches)
- Psoriasis
- Lupus erythematosus (an autoimmune disease)
- Atopic dermatitis (a type of inflammation of the skin)
Possible side effects of alopecia medications may include:
- Thinning and puckering of the skin
- Loss of skin colour
- Infections
- Skin cancer
- Inflammation of the skin
- Blood clotting
Moreover, there’s a three times higher risk of developing eye-related issues like:
- Retinal detachment (when the retina pulls away from its normal position)
- Obstruction of the blood vessels in the retina
- Damage to the retina.
Preventing Alopecia Areata
Alopecia areata is a medical condition where the immune system, our body’s natural defense, mistakenly attacks hair follicles (the part of the skin that makes hair), causing sudden and patchy hair loss. This can happen anywhere on the body. The silver lining is that this doesn’t permanently damage the hair follicles. In fact, nearly half of people with this condition see their hair grow back within a year.
While alopecia areata isn’t life-threatening, it can have a big emotional impact, considering the significance of hair in person’s overall appearance. It can be helpful to talk to a mental health professional or join a support group. The National Alopecia Areata Foundation’s website also has plenty of resources.
Right now, there’s no permanent cure for alopecia areata, and many who have it will experience periods of hair loss throughout their lives. Not everyone with the condition decides to pursue treatment, but there are several options available if they do.
Changing the way you look can help manage your hair loss:
- High-quality wigs and hairpieces offer natural-looking options that can give you a confidence boost.
- False eyelashes can highlight your eyes if you’ve lost eyelashes.
- Tattoos can serve as a permanent solution for eyebrow hair loss.
Below are also some medications that aid controlling alopecia areata:
- Topical or injected corticosteroids can reduce inflammation at the source, promoting hair regrowth.
- Topical immunotherapy, which helps to stimulate the immune system to grow hair back.
- An application known as anthralin can also help hair return in affected spots.
- Minoxidil, either oral or topical, sometimes helps hair to regrow.
- Oral JAK inhibitors, a newer medication, can be used for severe cases of alopecia areata.
Alopecia areata is often linked with other skin and systemic diseases, so it’s crucial to know the symptoms of conditions like thyroid disease, systemic lupus erythematosus (an autoimmune disease causing inflammation), psoriasis (a skin disease), and atopic dermatitis (eczema) and report any that you notice. Healthcare professionals also stay vigilant when treating patients with Down syndrome and polyglandular autoimmune syndrome type 1 as these individuals are at higher risk of alopecia areata and should be monitored for signs of patchy hair loss.