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What is alopecia areata?
Alopecia areata is a sudden and in most cases temporary loss of hair on the scalp and sometimes on other parts of the body, usually in round to oval patches. This condition is not that rare since about 1 in 50 people will develop alopecia areata at some point in their life. It occurs in males and females of all races and ages. Most people develop alopecia areata before the age of 30.
It usually does not cause permanent damage to the hair roots, and it resolves without any treatment in most patients. This can take months, and new hair may be lighter or even white. About half of people with limited alopecia areata recover within a year; however, most people may have more than one episode during their lifetime.
What are the causes and risk factors for alopecia areata?
Unfortunately the exact cause is still unknown, but for some unknown reasons the immune system mistakenly attacks the hair follicles. In most cases the damage is not permanent, and hair usually regrows sometimes even without any treatment.
Since alopecia areata is a form of autoimmune disorder (autoimmune means that immune system attacks its own body) some other autoimmune conditions can occur along with alopecia areata. These include vitiligo (an autoimmune disorder where immune system attacks cells that produce skin color that results in white patches on the skin), thyroiditis (an autoimmune inflammation of the thyroid gland), and pernicious anemia (an autoimmune disorder where immune system attacks cells in stomach which are necessary for absorption of vitamin B12 from the gut, and therefore causes low vitamin B12 levels. Since vitamin B12 is necessary to maintain normal numbers of red blood cells, their number becomes low (i.e. the person becomes anemic).
Genes also play role in alopecia areata, since about 1 in 5 relatives have also had alopecia areata at some point in their life.
We also search for any source of infection in our patients with alopecia areata such as decayed teeth or chronic sinusitis, since these have also been shown to trigger the hair loss in alopecia areata.
Stress also plays a role in triggering alopecia areata, which we have noticed in some of our patients.
How do I find out if I have alopecia areata?
You probably have alopecia areata, if you develop oval to round patches of hair loss that appeared suddenly, or over a period of a few weeks, followed in most cases by regrowth over several months. The hairless patches may have pinkish to salmon colored appearance, probably from autoimmune inflammation. The new hair may be lighter of even white, but this should also improve over the time. However, alopecia areata may persist for several years, and, unfortunately, in some cases hair never regrows.
Most people will only have patchy involvement of the scalp; however, any hair bearing area of the body can be involved, usually eyebrows and beard area. Minority of the patients will lose hair over the entire scalp (known as alopecia totalis), or all the hair on their head and body (known as alopecia universalis). Some people will also develop fine pitting of the fingernails.
What should I do if I think that I have alopecia areata?
You should see your health care provider to confirm the diagnosis, plus your health care provider may need to do some tests to rule out possibility of other autoimmune disorders. In addition some treatments have been shown to improve the alopecia.
How will my health care provider determine that I have alopecia areata?
Usually good physical exam with touching the skin and looking at it with special instrument called dermatoscope will be enough. Dermatoscope is a handheld instrument that looks similar to battery lamp, but with special system of polarized lenses and LED light that enables your healthcare provider to take deeper look into the skin. With this instrument it is much easier to visualize so-called exclamation point hairs, which are hairs with tapered ends towards the scalp.
However, even the most experienced health care provider sometimes may not be sure whether your hair loss is due to alopecia areata. In that case the best would be that you have a test called a skin biopsy, which is a cutting a small sample of the changing skin off to be looked under microscope. The best type of biopsy for hair loss is so-called punch biopsy, which is performed under local anesthesia and takes about 5-10 minutes to perform.
We also search for any source of infection in our patients with alopecia areata, such as decayed teeth or chronic sinusitis, as well as for any sources of stress in our patients’ lives, since these have also been shown to trigger the hair loss in alopecia areata. If needed, blood tests for thyroid disease or pernicious anemia are also done.
What is the treatment for alopecia areata?
Since patients may recover without any treatment, the true efficacy of any regimen is questionable (i.e. you are never sure if the hair has regrown spontaneously, or if it has happened due to the treatment). Listed below are current treatments available for alopecia areata.
- Corticosteroids. These medications have immunosuppressive effects (i.e. they tame your own immune system). We usually use clobetasol solution or foam applied on the skin twice daily, but almost always in combination with minoxidil foam twice daily, and/or intralesional triamcinolone acetonide injections (see below). This medication drives away immune cells from hair follicles protecting them from injury by your own immune system. However, these medications applied on the skin surface cannot go deep into the skin, so we frequently also do so-called intralesional injections of triamcinolone acetonide (trade name Kenalog) directly into the affected areas and areas around it to reduce immune reaction against your hair follicles, which in turn stimulate hair regrowth. We usually repeat injections every four to eight weeks until regrowth is noticeable in the form of stubby new hair that may be initially lighter or white. Since these injections are painful, we usually pretreat for 1-2 hours with a topical anesthetic cream such as Emla or LMX4 cream. The cream is wiped off immediately before injection.
- Minoxidil foam or liquid (brand name Rogaine). This medication is available over-the-counter, and costs about $10 per month. It promotes hair growth by lengthening the growth phase of hair follicles causing more follicles to produce hair. We usually use it in combination with topical clobetasol twice daily, but at least 2 hours apart from one medication to another. We prefer foam over the liquid since it is less greasy. New hair growth is usually seen in 3 months.
- Anthralin cream (brand names: Dritho-Scalp, Zithranol etc.). We rarely use it to treat alopecia areata, since almost all patients experience itching, redness and scaling of the treated skin. About 1 in 4 patients develop cosmetically noticeable hair regrowth, but that can take up to 4-6 months. Most common approach is to use it as a short contact therapy (i.e. the cream (0.5-1.0%) is left on skin for 30-60 minutes daily, then washed off).
- Topical immunotherapy using diphenylcyclopropenone and dinitrochlorobenzene— these medications cause an allergic reaction (itching, redness and scaling) on the applied area of hair loss. For unclear reasons this dermatitis can trigger hair regrowth in some patients. The problem with these medications is that they are very unpleasant to use, and that they are hard to obtain, at least in the United States.
- Psychological support. Many patients take sudden hair loss very hard which is very understandable. We recommend to our patients to contact the National Alopecia Areata Foundation (https://www.naaf.org) where you can find useful information and tips on how to cover the hairless areas, as well as contact information on local support groups. However, sometimes that is not enough, and in that case we refer the patient to a psychologist.
- Cosmetic support. Wigs and hairpieces (usually an option for females) and shaving head (usually an option for males). Cosmetic tattooing is another option, especially for eyebrows. Artificial eyelashes are an option for people with loss of eyelashes.