Alopecia areata

What is alopecia areata?

Alopecia is a general term for hair loss. Alopecia areata is a specific, common cause of hair loss that can occur at any age.  It usually causes small, coin-sized, round patches of baldness on the scalp, although hair elsewhere such as the beard, eyebrows and eyelashes, body and limbs can be affected. Occasionally it can involve the whole scalp (alopecia totalis) or even all the body and scalp (alopecia universalis). It is not possible to predict how much hair will be lost. Regrowth of hair in typical alopecia areata is usual over a period of months or, sometimes, years, but cannot be guaranteed. The hair sometimes regrows white at least in the first instance. Further hair loss is not uncommon. In alopecia totalis and alopecia universalis the likelihood of total regrowth is less.

What causes alopecia areata?

Hair is lost because it is rejected by the affected person’s immune system which does not recognise the hair follicles as "self", but regards them as "foreign" (autoimmunity). Why this happens is not fully understood, nor is it known why only localised areas are affected and why the hair regrows again.

Someone with alopecia areata is more likely than a person without it to develop other autoimmune conditions such as thyroid disease, diabetes and vitiligo (white patches on the skin), although the risk of getting these disorders is still low. Your doctor may suggest a blood test looking for antibodies that may predict whether you are likely to develop thyroid problems or pernicious anaemia.

Alopecia areata is not catching nor is it related to diet or vitamin deficiencies. Stress, particularly events such as bereavement, separation and accidents,   occasionally appears to be a trigger for alopecia areata.

Is alopecia areata hereditary?

There is a genetic predisposition to alopecia areata and close family members can be affected. Thyroid problems or diabetes are also more common. 

What are the symptoms?

Occasionally there may be a tingling sensation in the scalp. It can be a very upsetting condition to the sufferer, especially if the bald area cannot be disguised by hairstyle.

What does alopecia areata look like?

Typically, it starts as one or more bald, smooth patches on the scalp, which are not inflamed or scaly. It tends to affect the pigmented hair so there may be some white hairs left within the bald area in older people. Sometimes the hair loss is diffuse rather than well-circumscribed patches. Short, tapered hairs, known as exclamation mark hairs that are characteristic of alopecia areata, may be seen at the edge of the bald patch. Regrowth usually starts at the centre of the bald patch with fine white hair that thickens with time and usually regains its colour. Some people with alopecia areata develop small pits on their nails, similar to the dimples seen on a thimble.

Can it be cured?

No, alopecia areata cannot be cured. If the hair loss is patchy, there is a good chance (about 60-80%) that there will be complete regrowth within 1 year without treatment.  There may, however, be further episodes of hair loss in the future. If there is very extensive hair loss from the start, the chances of it regrowing may not be as good.  In people with Down's syndrome, or those who have severe eczema, the chances of regrowth are not so good either. 

How can alopecia areata be treated?

Many people with mild early alopecia areata may need no treatment, as their hair is likely to come back anyway without it. However some treatments can induce hair growth, though none is able to alter the overall course of the disease. Any treatments that carry serious risks should be avoided, as alopecia areata itself has no direct impact on general health.

Treatments used for alopecia areata include the following:

• Steroid creams and scalp applications: These are applied to the bald patches, usually twice a day, and can help the hair to regrow more quickly.
• Local steroid injections: These can be used on the scalp and brows, and are the most effective approach for small patches of hair loss. Injections may be given via a needle and syringe or with an air jet injector (this may be less uncomfortable). After several weeks, a 0.5 cm diameter tuft of hair will be seen at the injection site. Injections can be repeated every few months. Special care is taken around the eyes, when injecting the brows, as injecting too much may cause glaucoma (raised pressure inside the eyeball). A small dimple may develop at sites of injections, but this usually recovers without treatment after a few months.
• Steroid tablets: Large doses of steroid tablets given long term may cause the hair to grow again, but there are significant risks to general health with this treatment (including raised blood pressure, stomach ulcers, eye lens cataracts and osteoporosis). In view of these dangers, it is currently ‘not possible to support their use until there is better evidence of efficacy’.
• Contact sensitisation treatment: This involves initially applying a strong sensitizer (usually a chemical called diphencyprone) to the skin of a person with alopecia areata to make them allergic to it. Then weaker strengths of the sensitizer are applied to the bald areas every week to produce a mild allergic dermatitis. A worthwhile regrowth will occur in up to 50% of sufferers in about 6 months. The treatment may produce more severe local reactions. Loss of skin colour (depigmentation) may develop, so it is used with caution in those with dark skin.
• Ultraviolet light treatment: Using UVA radiation after taking psoralen tablets, or applying a psoralen cream to the bald areas to sensitise the skin, a treatment called PUVA, may be effective. Treatments are needed twice weekly for a number of months. Relapse of the alopecia is common when the treatment is stopped.
• Minoxidil lotion: This substance, which is applied topically to the bald areas, may help some sufferers although it seldom produces cosmetically useful regrowth in people with extensive hair loss.
• Dithranol: This is an irritant cream that is usually used to treat a skin condition called psoriasis. It can be applied to the bald areas of alopecia areata and may help the hair to regrow. To work, it needs to be used often enough and strong enough, to produce local skin irritation. It is less effective than contact sensitisation, but safer and easier to use. Dithranol will stain blonde or fair hair a purple colour, precluding its use.

What if I need a wig?

Some individuals with alopecia areata will prefer to wear a wig while they wait for recovery.  These can either be bought privately, or obtained through the N.H.S (although a financial contribution is required) on a consultant’s prescription.  Your local hospital orthotic (surgical appliances) department will be able to advise you on the range of hairpieces available on the N.H.S. and can recommend local suppliers who are sensitive to the needs of alopecia areata sufferers.

What can I do?

• You may find that joining a patient support group (see below) and meeting other people with alopecia areata will make it easier for you to adjust to your condition.
  
• Remember that an important function of hair is to protect the scalp from sunlight.  You should cover your bald patches with a sun block or a hat to prevent sunburn and also to reduce the chances of developing long-term sun damage.
  
• If you find that the regrowing hair is slow to recolour, it can be dyed.
  

While every effort has been made to ensure that the information given in this leaflet is accurate, not every treatment will be suitable or effective for every person. Your own doctor will be able to advise you in greater detail.