Alopecia areata

Alopecia areata is the sudden loss of hair on any part of the body. In most cases, alopecia areata is almost always caused by psychological factors and usually involves the spontaneous regrowth of hair.

Demographic notes

Alopecia areata occurs in 0.1-0.2% of the population, irrespective of location, gender or ethnicity. In 20% of cases, alopecia areata presents in childhood, and peaks between the second and fourth decades of life.

Clinical presentation

Alopecia areata usually begins as a well-demarcated circular or oval patch of hair loss that is asymptomatic and causes no particular changes in the skin. In 90% of cases, it appears as a single bald patch on the scalp, but more bald spots may appear. Alopecia areata can be patchy or generalized. The latter means that 100% of the hair at the affected area has fallen out and is known as total alopecia areata. In cases where the condition affects 100% of the hair on the body, as well as that of the scalp, it is referred to as universal alopecia areata. 5% of total alopecia areata cases transition to the universal form of the condition. In rare cases, the ophiasis form of the condition appears where the hair loss occurs bands, rather than circles. The hair at the periphery of the alopecia patch looks similar to an exclamation point – it thins towards the root and the bulb appears as a dot. This hair will detach immediately following even the slightest bit of traction.

The typical alopecia areata patch appears as an area of hairlessness with sharp boundaries and a round or oval shape.

Alopecia areata may be patchy, meaning there is not complete hair loss. The hair that is still present usually appears white.

Hair loss may occur in a linear pattern instead of a round or oval patch pattern (ophiasis).

Alopecia areata also frequently appears in the beard area as a coin-shaped patch.

In some cases, alopecia areata will occur simultaneously on the scalp and beard area. A single alopecia areata patch could also appear in areas of the body with hair, without any sign of the condition anywhere else.

Other areas frequently affected by the condition are the eyelashes and the eyebrows.

Alopecia and the nails

In total or universal forms of alopecia areata, damage to the nail plates in the fingers and toes is common. It is believed that the nail matrix is also affected by alopecia but to a lesser extreme. The nail plate may appear as if it has been treated with sandpaper, in a phenomenon called trachyonychia. While rare, it can cause such extreme harm that it can lead to nail loss.

Diagnosing alopecia areata

The clinical observation of symptoms and an analysis of the patient’s history are usually sufficient for a diagnosis of alopecia areata to be made. Sometimes, a tricho-dermoscopic examination is performed whereby the alopecic patch is examined with a dermatoscope to detect the typical characteristics of the condition: broken hair, black and/or yellow spots, exclamation point hair and “vellus” hairs. Such data can rule out other forms of alopecia such as trichotillomania, or areas of alopecia in diseases such as in lichen, erythematodes or syphilis, etc.

Causes of alopecia areata

The causes of alopecia areata are still largely unknown. However, many consider genetic predisposition to be possible, as it is common for several members of the same family to suffer, or to have suffered, from alopecia areata. In many cases, patients have endured a psychological trauma or a period of particular stress prior to the appearance of the patch of alopecia. Alopecia areata may appear following distressing events such as a bereavement in the family, after an accident, or after the loss of a job. In children, the most common events preceding alopecia areata are parental quarrels or separation, the birth of a sibling or conflicts within the school environment.

What to do if alopecia areata appears

If a patch of alopecia appears, the most important thing to do is not to panic about further hair loss, otherwise this added stress will mean that from one patch others will follow. A physician or dermatologist should reassure the patient about spontaneous hair regrowth, highlighting that this will take several months and advising against any local or systemic treatment. There are no medications with proven activity on hair regrowth for this type of hair loss. Considering the psychosomatic nature of alopecia areata, creams or lotions should not be recommended because, with each application, the patient could be reminded of the condition which may cause a negative emotional reaction. Usually, once a patient with alopecia areata has been reassured of a good outcome, they almost “forget” about the problem, which often results in the alopecic patch closing spontaneously and within a shorter timeframe. It is important that a physician or dermatologist explores the psychological aspect behind alopecia areata in order to determine whether the trigger was a one-off, or if emotional distress could be lingering which may cause the alopecia to worsen. In such cases, pharmacological, psychological, and other aids must be used to both overcome the emotional hurdle and to encourage hair growth.

When alopecia areata doesn’t resolve itself

In around 20% of cases, alopecia areata does not resolve spontaneously. Such cases are usually linked to total or universal alopecia areata, but the prognosis is equally as negative among individuals who developed alopecia at a young age and/or those for whom there is an unclear psychological cause. There are likely to be moments of sparse, thin, unpigmented hair growth that may give the illusion of resumed growth, however these will quickly relapse. It is important to assess the psychological impact that hair loss is causing the patient. Some individuals accept this change in appearance with ease and do not seek treatment, while others will be distressed with what has happened and will want their hair back as soon as possible. It is important to remember that there is no specific cure to regrow hair in cases of alopecia areata. While there are methods that have been shown to stimulate hair regrowth, they do not guarantee stabilization of the result.

Proposed treatments

Cortisone is the most prescribed drug to treat alopecia areata, despite the fact that it is the most useless and potentially most harmful option. The rationale for cortisone use lies in the fact that some lymphocytes are found around the hair bulbs of the hair that falls out. This has led to the idea that alopecia areata is an autoimmune disease that should, therefore, be treated with cortisone. It is true that the administration of cortisone, whether through an injection into the scalp or through ointments, will usually result in hair growth. However, either through continued use of cortisone or its sudden discontinuation, any hair that has regrown will quickly fall out. Furthermore, as cortisone is absorbed into the skin, it causes damage to both the scalp and patient as a whole. Minoxidil is the second most prescribed pharmaceutical, but again it is useless. A potent vasodilator, minoxidil has been shown to stimulate hair regrowth in early and juvenile forms of androgenetic alopecia. However, when applied to the scalp of people with alopecia areata, it either has no effect whatsoever, or has the same effect as a placebo. Any regrown hair will eventually fall out. Another method to stimulate hair regrowth is local immunotherapy, where allergenic substances such as stearic acid dibutyl ester or Diphenylcyclopropenone (DPCP) are used. A high concentration of treatment is applied to the skin and, once the skin has been sensitized (the patient has become allergic to the solution), a lower concentration of the same substance is applied to the alopecic area some days later. The aim is to create an eczema-like reaction that will stimulate hair regrowth. However, this method is often prone to relapse, with any regrown hair quickly falling out again. In addition, the continuous exposure to allergens may cause swelling of the lymph nodes in the neck, and general feelings of fatigue and malaise.

Treatment with natural products: aromatherapy and coal tar dye

According to many studies, aromatherapy has been used to treat alopecia areata. Patients should rub their scalp with the aromatherapy mixture (below) for two minutes, before covering their head with a warm towel for one hour. The composition of the aromatherapy mixture is as follows: 2 drops of thymus vulgaris, 3 drops of lavandula angustifolia essential oil, 3 drops of rosmarinus officinalis, 2 drops of cedrus atlantica, solubilized in 3ml of jojoba oil, plus 20ml of grape seed oil. It is important to note that this treatment has produced mixed results, and the role in curing alopecia areata has not been defined.

Coal tar dye

When applied to the skin, coal tar has indisputable anti-inflammatory and stimulative properties, and can be used to treat psoriasis and atopic dermatitis. Coal tar can also enhance ultraviolet rays, which are credited as positively helping alopecia areata. To treat alopecia areata, massage the formula (below) well onto the alopecic patch once or twice per week. The formula for coal tar dye is as follows:

Other treatments

Many different treatments such as UV therapy, photochemotherapy, laser treatment and photodynamic therapy have also been used in an attempt to treat alopecia areata without noticeable results. According to some studies, needling with 0.5mm needles on alopecic patches every 15 days has also given positive results, but the data is recent and awaits confirmation. Finally, in the wake of the autoimmune therapy for aesthetic areata, there has been no shortage of studies where oral immunosuppressants such as methotrexate and cyclosporine are used as treatment, however these have given negative results on a par with cortisone. In conclusion, the proposed treatments for cases of alopecia areata that do not clear up spontaneously are generally disappointing for both the dermatologist and, more importantly, the patient. This, however, should not deter the dermatologist from attempting a treatment, if only to give hope to the patient and to stem the anguish generated by their hair loss.

Treatments of the future

Researchers at the Columbia University Medical Center have identified a receptor expressed by sufferers of alopecia areata that binds hair follicles and lymphocytes, which would cause hair loss. This binding is said to be at the root of hair loss. A monoclonal drug capable of acting as a JAK receptor inhibitor would lead to the resolution of alopecia in the majority of cases. DermaClub trusts that the data from the Columbia studies will be confirmed and that the drug will soon be available in Italy.