Alopecia Areata

What is alopecia areata and who is affected?

Alopecia means 'loss of hair' or 'baldness'. There are several different causes and patterns of alopecia. Alopecia areata is one type of hair loss. The exact number of people affected by alopecia areata is not known. Estimates vary between 1 in 1000 to 2 in 100 people being affected at some point in their life. Alopecia areata can occur at any age but most cases first develop in teenagers and children. In about 6 in 10 cases the first patch of hair loss develops before the age of 20 years. Males and females are equally affected.

What are the symptoms of alopecia areata?

The typical pattern is for one or more bald patches to appear on the scalp. These tend to be round in shape, and about the size of a large coin. They develop quite quickly. A relative, friend, or hairdresser may be the first person to notice the bald patch or patches. Apart from the bald patch or patches, the scalp usually looks healthy and there is no scarring. Occasionally, there is some mild redness, mild scaling, mild burning, or a slight itchy feeling on the bald patches.

• Quite often the bald patch or patches re-grow hair within a few months. If hair grows back it may not have its usual colour at first and looks grey or white for a while. The usual colour eventually returns after several months.
• Sometimes one or more bald patches develop a few weeks after the first one. Sometimes the first bald patch is re-growing hair whilst a new bald patch is developing. It can then appear as if small bald patches rotate around different areas of the scalp over time.
• Sometimes several small bald patches develop and merge into a larger bald area.
• Patches of body hair, beard, eyebrows, or eyelashes may be affected in some cases.
• Large bald patches develop in some people. Some people lose all their scalp hair. This is called alopecia totalis.
• In a small number of cases, all scalp hair, body hair, beard, eyebrows, and eyelashes are lost. This is called alopecia universalis.
• The nails are affected in about 1 in 5 cases and can become pitted or ridged.

Some people become self-conscious, anxious or distressed by the appearance of the hair loss.

What causes alopecia areata?

Alopecia areata is thought to be an auto-immune disease. The immune system makes white blood cells (lymphocytes) and antibodies to attack bacteria, viruses, and other 'germs'. If you have an auto-immune disease, your immune system 'mistakes' part or parts of your body as foreign. In people with alopecia areata, many white blood cells gather around the affected hair roots (hair follicles) which are mistaken as 'foreign'. This causes some mild inflammation which leads in some way to hairs becoming 'weak' and falling out to cause the bald patches.

It is not known why it is common for only certain areas of the scalp to be affected. Also, the affected hair follicles are not destroyed. Affected hair follicles are capable of making normal hair again if the immune reaction goes and the situation returns to normal.

It is not known why alopecia areata or other auto-immune diseases occur. It is thought that something triggers the immune system to react against the body's own tissues. Possible triggers include: viruses, infection, medicines, or other environmental factors. There is also an inherited factor which makes some people more prone to auto-immune diseases. About 1 in 4 people with alopecia areata have a close relative who is also affected.

If you have alopecia areata you also have a slightly higher than average chance of developing other auto-immune diseases such as thyroid disorders, pernicious anaemia and vitiligo. (However, it is important to stress that most people with alopecia areata do not develop any of these other conditions.)

Do I need any tests?

Usually not. The diagnosis is usually based on the typical appearance of the bald patches. If there is doubt about the cause of the hair loss, sometimes some blood tests or a skin scrapping from a bald patch may be done to rule out other causes of baldness. A small skin biopsy (small sample) is sometimes taken to look at under the microscope.

What is the outlook (prognosis) for people with alopecia areata?

Alopecia areata is an unpredictable disease. Without treatment, hair re-growth may be complete, partial, or non-existent.

• In some cases there are only one or two small bald patches which grow back within several months.
• In some cases patchy baldness may come and go over many months or years. The size of the bald patch or patches, and how long they last, is quite variable.
• If less than half of your scalp is affected and you have no treatment, you have about an 8 in 10 chance of full hair re-growth within one year.
• With more extensive hair loss, it is less likely that hair will re-grow.

However, even if your hair grows back fully after an episode of alopecia areata, it is common to have one or more recurrences of the condition throughout your life. About 1 in 5 people who develop alopecia areata will progress to alopecia totalis (total scalp baldness) or alopecia universalis (loss of all scalp and body hair.) Progression to these more extensive types of hair loss is more common if:

• The onset occurs in childhood.
• The initial bout of hair loss affects more than half of your scalp.
• You have Down's syndrome.
• You have atopic eczema.
• You have eyelash and/or eyebrow hair loss.
• You have a family history of alopecia areata.
• You have ophiasis (alopecia areata of the scalp margin).
• You have nail changes.
• You have another auto-immune disease.

Treatment can promote hair re-growth in some cases.

What are the treatment options for alopecia areata?

Not treating is a common option

Alopecia areata is a very unpredictable condition. In many cases, bald patches re-grow by themselves without treatment. In particular, if there are just one or two small bald patches then many doctors would advise that you simply leave it alone at first. This is sometimes called 'watchful waiting'.

If the hair loss is not too bad then there is a good chance that hair will re-grow after several months. (Any re-growth usually does not start within three months of hair loss.) A change in hair style may perhaps conceal one or two small bald patches. If the hair loss becomes more extensive, then the decision on whether to treat can be reconsidered. But even with extensive hair loss, there is still a chance that hair will re-grow without treatment.

Note: alopecia areata itself won't damage your general health and so not treating will not lead to any general health problems. When deciding on whether to treat or not, you should take into account the possible side-effects that some of the treatments may have. Also, treatments promote hair to re-grow and do not affect or 'cure' the underlying cause of the condition.

Steroid injections

Injections of steroid into the bald patches of the scalp suppresses the local immune reaction that occurs in alopecia areata. This can then allow the hair follicles to function normally again and for hair to re-grow. This treatment may be an option for one or more small to medium sized bald patches. Steroid injections are thought to be the most effective treatment for patches of alopecia areata that are not too big. However, they do not work in every case.

This treatment is usually only done by a skin specialist and so you will usually need to be referred to hospital for it. Several injections (about 1 cm apart) are usually given at each session of treatment but the number is often limited by pain. Therefore, large bald areas are not suitable for steroid injections. Initial re-growth takes 1-2 months and injections are repeated every 4-6 weeks.

Note: there is no guarantee that any hair re-grown during treatment will persist once the treatment is finished.

Topical ('rub-on') steroid

Steroid cream, gel, etc, may help hair re-growth, but does not work as well as steroid injections. It may be worth a try if you have bald patches that are not suitable for steroid injections, or if you are waiting to see a specialist to have steroid injections. If re-growth occurs it takes 3-6 months. There is no point continuing with this treatment if no re-growth occurs after six months.

Minoxidil solution

This is rubbed into the bald patches and has been shown to promote hair re-growth in some cases. This is the same treatment that is used for the common 'male pattern' baldness. It is not known how it works. The success rate is not high but may be worth a try. In particular, if you have more extensive bald patches that are not suitable for steroid injections, or if you are waiting to see a specialist for steroid injections.

Minoxidil is not available on the NHS. You need a private prescription and have to pay the full cost of the product, which makes it expensive. Also, some people with certain medical conditions may not be able to use it. So, check with your doctor or pharmacist before buying it that it is suitable for you. If it works, it usually takes 2-3 months of treatment for an initial response, and one year for a maximum response. There is no point continuing with this treatment if there is no improvement after one year.

Topical steroid plus minoxidil solution

Some people feel that combining a topical steroid with minoxidil gives a higher chance of hair re-growth than either treatment alone. However, there is little research evidence to prove this.

Topical immunotherapy

It is thought that topical immunotherapy is the most effective option for people with extensive alopecia areata. However, this treatment is only done by some skin specialists and so you will need to be referred to one of these specialists for it.

How topical immunotherapy works is not clear. A substance is put on affected skin to to make the skin react like an allergy. The most commonly used substance is DPCP (diphencyprone). Increasing strengths of this substance are placed on the affected skin once a week over several weeks until the skin looks like it has mild dermatitis (eczema). The skin reaction seems to affect the process involved in causing alopecia areata in some way to allow hair to re-grow. Side-effects from topical immunotherapy can be troublesome. For example, some people develop severe skin reactions. Treating children with topical immunotherapy is controversial.

In one study of people with extensive alopecia areata, topical immunotherapy caused good hair re-growth in 3 in 10 cases after six months which increased to nearly 8 in 10 cases after 32 months of treatment. (It worked less well in people with alopecia totalis or alopecia universalis.) In those where it works, initial re-growth does not occur for 12-24 weeks. Once re-growth occurs, treatment can be stopped but in many cases the hair loss then recurs. Therefore, in many cases, regular maintenance treatment is needed to keep the hair loss from returning.

Dithranol

Dithranol is thought to be less effective than topical immunotherapy, but works in some cases. It is applied each day to the whole scalp if there is extensive hair loss and left for 20-60 minutes before washing it off. One study showed that it helps hair re-growth in about 1 in 4 cases, but takes many weeks of treatment. Side-effects such as itchiness, redness, and scaling are common with dithranol. Dithranol is not widely used for alopecia areata because it is messy to use.

Wigs

Wigs are a common treatment choice in patients with alopecia areata. You can get some wigs on the NHS. However, this needs a referral to hospital as only a skin specialist can sanction the prescription of a wig on the NHS.

Other treatments

Various other treatments may be used or advised. These include the following:

• Ultraviolet light therapy or phototherapy (PUVA) has been used with some limited success. This treatment requires many light therapy sessions in a hospital out-patient department.
• The immunosuppressant medicine called ciclosporin usually works well to cause hair re-growth in extensive alopecia areata. However, its use is limited by potential serious side-effects. Also, hair loss often recurs when the medication is stopped.
• Dermatography (tattooing) can be used to simulate eyebrows that have fallen out.
• Counselling is sometimes helpful for people who find it difficult to cope with hair loss.
• Remember to use sun block or a hat to protect bald patches when out in the sun.

There is not enough evidence to say how effective complementary treatments are in treating alopecia areata. (For example, acupuncture, aromatherapy, etc.)

A final note about treatments

As you can see from the section above, there are various treatment options. It is difficult to say from the outset whether a particular treatment will benefit a particular person. One of the difficulties is that hair grows back without any treatment in many cases. Therefore, it is difficult to research the effect of treatments as hair may re-grow naturally.

Generally, the success rate for the various treatments is probably not high. Also, there is no guarantee that any hair re-grown during treatment will persist once the treatment is finished.

Further help and advice

Alopecia UK (online)

Web: www.alopeciaonline.org.uk
A registered charity that supports people living with alopecia areata by providing information, support and advice. It also works to raise public awareness and understanding of alopecia areata throughout the UK and supports and funds research.

Alopecia Awareness

Web: www.alopecia-awareness.org.uk
Provides a range of help, information and support to anyone associated with hair loss.