Q: WHAT IS ALOPECIA AREATA?
Alopecia Areata (AA) is an autoimmune condition affecting hair follicles, causing hair loss. It is a common cause of hair loss that can occur at any age and does not result in permanent scalp scarring. It usually causes small, coin-sized, round patches of baldness throughout the scalp. It can, however, affect other areas of the body which grow hair, such as the beard, eyebrows, eyelashes, body and limbs can be affected.
AA can spread to larger areas in some people and occasionally involve the whole scalp (alopecia totalis) or even the entire body and scalp (alopecia universalis).
The National Alopecia Areata Foundation states that 147 million people worldwide are affected by this condition.
One study estimates Alopecia Areata affects nearly 2% of the general population at some point during their lifetime.
Q: WHO GETS ALOPECIA AREATA? HOW DOES IT AFFECT WOMEN/ MEN? WHO IS AT MOST RISK?
AA can affect people of all sexes and all ages. Research in one study suggests that 24% of people who have AA have a family history of the condition. It also suggests that children under 18 with a family history of AA are more likely to have a longer duration of the condition than an adult aged over 18.
The peak onset of the condition is in the age bracket 20s to 30s, and onsets are before the 40s in most patients.
Conditions such as Down syndrome, polyglandular autoimmune syndrome type 1, vitiligo or thyroid disease may increase the risk of AA.
Q: WHAT CAUSES ALOPECIA AREATA?
The exact cause of Alopecia Areata is unknown, but it is thought that follicles growing hair are affected by inflammation.
It is thought that the immune system, the body’s natural defence mechanism from infections and other diseases, attacks the base of the hair follicle, the ‘factory’ that grows the hair.
Hair follicles in their growing phase display what is known as immune privilege. This means that they are undetectable by the immune system. However, before the onset of AA the follicles appear to lose their immune privilege, making them susceptible to attack from T Cells (immune cells).
Why this might happen is not fully understood, nor is it known why only localised areas are affected and why the hair usually regrows again.
AA is not contagious and chronic stress, or intense infections can occasionally appear to be a linked trigger for this condition, but there are many cases of AA without the background of stress or infection also.
Q: WHAT ARE THE PRESENTING SYMPTOMS?
Typically, an onset of AA starts as one or more circular shaped areas of hair loss where the skin within these areas is smooth to touch, often described ‘like feeling baby skin’. The areas of hair loss on the scalp are not inflamed or scaly.
Occasionally the hair loss is diffused (patchier and more spread out) rather than well-defined patches. Short, slightly spiky hairs, known as exclamation mark hairs, are characteristic of alopecia areata, and these may be seen or felt at the edge of the AA patch.
There may be a tingling, crawling or itching sensation within the scalp prior to and during an onset of AA. This is known as Trichodynia.
Q: HOW DOES IT AFFECT YOUR HEALTH?
Hair loss in alopecia areata has minimal effects that create physical health issues.
However, the psychological impact can be significant, and working with a psychological healthcare specialist should be considered in chronic cases.
Q: HOW IS IT DIAGNOSED?
Alopecia areata is a particularly distinctive condition typically diagnosed on clinical features.
However, if there is any uncertainty or a differential diagnosis is required, an additional clinic test may aid in diagnosis.
Q: WHAT IS THE PROGNOSIS?
It is not possible to predict how alopecia areata will spread. Regrowth of hair in typical alopecia areata is usual over a period of months or sometimes years but cannot be guaranteed. The less hair is lost at the beginning, then the chances of the hair regrowing are improved.
With only a few small patches, most people get full regrowth within a year. The prognosis of a full recovery is not good if more than 50% of the hair is lost.
People will likely experience further onsets of alopecia areata if they have had one onset. The younger the age of the individual at onset, the greater the chance of repetitive episodes. In alopecia totalis and alopecia universalis, the likelihood of total regrowth has a poorer prognosis.
Response to treatment is highly variable, and hair loss may recur when therapy is stopped.
Poor prognostic factors include:
- Younger age at onset
- Extensive disease
- Hair loss of greater than one-year duration
- Nail dystrophy
- Ophiasis pattern
- Family history of alopecia areata
- Presence of atopy or other autoimmune diseases.
Q: WHAT TYPES OF TREATMENT IS AVAILABLE?
People with mild early alopecia areata may need no treatment, as their hair will likely come back anyway without treatment within a 12-month.
Some treatments can induce hair growth, but none can alter the disease’s course. Any treatments with serious risks should be avoided, as alopecia areata has no adverse effect on physical health.
The available treatments include:
- Steroid creams and Minoxidil scalp applications. These are applied to the bald patches, usually twice a day, for a limited time. Genetic testing can be used to assess the most effective blend of topical solutions.
- Local steroid injections.
- Steroid tablets.
- Dithranol cream.
- Contact sensitisation treatment. This treatment is only available in specialised centres.
- Ultraviolet light treatment (PUVA).
- Immunosuppressant tablets. These tablets include sulfasalazine, methotrexate, ciclosporin, and azathioprine.
- Prostaglandin analogs. This includes Latanoprost, and genetic testing can be used to see if this would be a suitable treatment.
- Tofacitinib, ruxolitinib and baricitinib are being tested a potentially new immunosuppressive tablets for alopecia areata.