Alopecia areata

Alopecia areata: This disease causes hair loss and often occurs in otherwise healthy people.

Alopecia areata: Overview

Alopecia (al-oh-PEE-shah) means hair loss. When a person has a medical condition called alopecia areata (ar-ee-AH-tah), the hair falls out in round patches. The hair can fall out on the scalp and elsewhere on the body.

Alopecia areata can cause different types of hair loss. Each of these types has a different name:

• Alopecia areata (hair loss in patches).
• Alopecia totalis (lose all hair on the scalp).
• Alopecia universalis (lose all hair on the body).

Not everyone loses all of the hair on the scalp or body. This happens to about 5 percent of people.

Hair often grows back but may fall out again. Sometimes the hair loss lasts for many years.

Alopecia is not contagious. It is not due to nerves. What happens is that the immune system attacks the hair follicles (structures that contain the roots of the hair), causing hair loss. This disease most often occurs in otherwise healthy people.

Image used with permission of the American Academy of Dermatology National Library of Dermatologic Teaching Slides.

Alopecia areata: It often begins with a round, smooth, bald patch.

Alopecia areata: Signs and symptoms

If you have alopecia areata, you may have one or more of the following:

• Patchy hair loss: The problem often begins with 1 or more coin-sized, round, smooth, bare patches where hair once was. You may first notice the problem when you see clumps of hair on your pillow or in the shower.
  Hair loss occurs mostly on the scalp. But it can involve eyebrows, eyelashes, beards — any hair-bearing site. Patches vary in size.

• “Exclamation mark” hairs: Often, a few short hairs occur in or at the edges of the bare spots. These hairs get narrower at the bottom, like an exclamation mark.
• Widespread hair loss: With time, some patients go bald. Some lose all their body hair, too. This is not common. Also uncommon is a band of hair loss at the back of the scalp.

Alopecia areata: Nails can have dents, white spots, and roughtness.

• Nail problems: Alopecia areata also can affect your fingernails and toenails. Nails can have tiny pinpoint dents (pitting). They also can have white spots or lines, be rough, lose their shine, or become thin and split. Rarely nails change shape or fall off.
  Sometimes nail changes are the first sign of alopecia areata.

Images used with permission of the American Academy of Dermatology National Library of Dermatologic Teaching Slides.

Alopecia areata: With time, there may be lots of hair loss.

Alopecia areata: Who gets and causes

Who gets alopecia areata?

People can have this type of hair loss at any age. It often begins in childhood. Some patients with alopecia areata have a family member who also has the disease.

What causes alopecia areata?

Alopecia areata is an autoimmune disease. Autoimmune means that the body's immune system attacks the body. When alopecia areata develops, the body attacks its own hair follicles. A person's genetic makeup, combined with other factors, triggers this form of hair loss.
People with alopecia areata may have a higher risk for:

• Another autoimmune disease such as thyroid disease or vitiligo (patches of lighter skin appear)
• Asthma and allergies, mainly atopic dermatitis (more commonly called eczema) and hay fever (nasal allergies)
• Having relatives who have asthma, allergies, or an autoimmune disease such as type 1 diabetes

Alopecia areata: Diagnosis and treatment

How do dermatologists diagnose alopecia areata?

Sometimes a dermatologist can diagnose alopecia areata by looking at the hair loss.

If the patch of hair loss is expanding, the doctor may pull out a few hairs. These hairs will be looked at under a microscope.

Sometimes the dermatologist will perform a skin biopsy to confirm that the disease is alopecia areata. To perform a skin biopsy, the dermatologist removes a small piece of skin so that it can be studied under a microscope.

Blood tests may be necessary if the dermatologist thinks the patient might have another autoimmune disease.

How do dermatologists treat alopecia areata?

There is no cure for alopecia areata. Hair often re-grows on its own. Treatment can help the hair re-grow more quickly. A dermatologist may prescribe one or more of the following to help the hair re-grow more quickly:

• Corticosteroids: This medicine suppresses the immune system. It can be given as shots, with the dermatologist injecting the medicine into the places with hair loss. Sometimes a patient gets a topical (applied to the skin) form of this medicine. It may be a cream, lotion, or ointment. The patient applies the medicine to the bare spots. Less often, patients take corticosteroid pills.
  For adults with alopecia areata, these shots are often the first treatment tried. Patients receive shots every 3 to 6 weeks. Hair growth begins about 4 weeks after the last shot. Sometimes, it takes longer.
  Topical corticosteroids are less effective than shots. This is often the best treatment for children.
  Corticosteroid pills can have serious side effects. Dermatologists do not routinely prescribe them for this reason. Pills may be a treatment choice for patients with many bald spots.
• Minoxidil: A hair re-growth medicine, minoxidil 5%, may help some patients re-grow their hair. Both children and adults can use it. Patients apply it twice a day to the scalp, brows, or beard. New hair may start to grow in about 3 months. Patients most often use this medicine with another treatment.
• Anthralin: This medicine alters the skin’s immune function. The patient applies a tar-like substance to the skin and leaves it on for 20 to 60 minutes. A dermatologist may call this short-contact therapy. After 20 to 60 minutes, the anthralin is washed off to avoid the skin from becoming irritated.
• Diphencyprone (DPCP): This medicine is applied to the bald skin. It causes a small allergic reaction. When the reaction occurs, a patient has redness, swelling, and itching. Dermatologists believe this allergic reaction tricks the immune system, causing it to send white blood cells to the surface of the scalp. This fights the inflammation. It also prevents the hair follicles from going to sleep, and causing the hair loss.
  With DPCP, it can take 3 months for the hair to start re-growing.
• Other treatments: Patients often get more than 1 treatment at a time. A mix of 2 or more treatments often boosts success.

Ask your dermatologist about possible side effects (health problems that can result from the medicines). If you have a bad reaction to a medicine, call your dermatologist right away.

Researchers are working to advance the treatment of alopecia areata. They are exploring other medicines that work on the patient’s immune system. They also are looking at lasers and other light-based therapies.

Outcome

When a person has alopecia areata, the hair will start to re-grow when the body gets the right signals. Sometimes this happens without treatment. Even with treatment, new hair loss can occur. Everything depends on how the immune system reacts.

The following explains what can happen.

• Re-growing hair: It is likely that the hair will grow back even without treatment. It may fall out again, though. Most patients lose their hair more than once before the disease goes away for good. Even people who lose all the hair on their scalp and body can have their hair grow back. When hair loss is widespread (lots of hair loss on the scalp and/or body), there is a greater chance that the hair will not re-grow.
  When hair re-grows, it can be white or fine at first. A person’s own hair color and texture often return later.
• How long it lasts: This varies. For some people, the disease never returns. Others lose and re-grow hair for many years. No one can predict when the hair might re-grow or fall out again. This lack of control makes the disease frustrating.
• Emotional toll: The emotional aspects of living with hair loss can be hard. Our world regards hair as a sign of youth and good health. The good news is that alopecia areata does not affect overall health. It should not stop you from achieving your goals and dreams. You should not let it stop you from doing well in school, sports, and work.
  If your hair loss bothers you a lot, you may wish to join a support group.

Alopecia areata: Tips for managing

Dermatologists offer the following tips to their patients who have alopecia areata:

• Hide hair loss. If you feel embarrassed by hair loss, there are things you can do to hide patchy hair loss:
  • Style your hair to cover the bald spots.
  • Wear a wig, cap, hat, or scarf. These do not interfere with hair re-growth.
  • Some people shave the head.
  • Use makeup to draw missing eyebrows.
• Join a support group. While the above tips can hide the hair loss, people often have trouble dealing with the emotional aspects of hair loss. Because the emotional aspects can be so difficult, you may want to join a support group. You'll find a link to NAAF, which offers support groups, below.

Related resources:

Alopecia World
Offers social networking with links to many groups.

Bald Girls Do Lunch (blog)
Written by a woman who has AA, includes tips, research news, and more.

Children's Alopecia Project
Website includes tips for coping.

National Alopecia Areata Foundation 
Offers message boards, support groups, and pen pal program.

© 2019 American Academy of Dermatology. All rights reserved. Reproduction or republication strictly prohibited without prior written permission. Use of these materials is subject to the legal notice and terms of use located at https://www.aad.org/about/legal