Alopecia Areata: Your Questions Answered

General understanding

What is alopecia areata?

Alopecia areata (AA) is an autoimmune condition where the body attacks the hair follicle leading to patches of hair loss that can progress to total hair loss.

How common is alopecia areata?

AA is very common and affects about 1 in 4000 people per year in the UK. It is estimated there are about 400,000 people with alopecia in the UK.

Is alopecia areata the same as going bald or pattern hair loss?

No. This is a totally different condition.

Is alopecia areata contagious?

No. You can not catch it or give it to anyone else!

Did I do something to cause this?

No. We don’t know what triggers episodes of alopecia or why it occurs in random patches and there is nothing you can do to prevent this, nor did you cause this.

Can alopecia areata affect children?

Yes. It is not uncommon in children and can start when children are very young. It can be difficult to confirm the diagnosis in very young children but is usually more obvious if it occurs age 5+

Does alopecia areata affect men and women differently?

Men and women are fairly equally effected. In men it could also affect beard and moustache areas.

Causes

What causes alopecia areata?

Alopecia areata is caused by your own immune system making a mistake and a population of your white blood cells called T Lymphocytes, attacking the bulb area of the hair follicle.

Is alopecia areata an autoimmune disease?

Yes.

Is alopecia areata hereditary? Does it run in families?

Alopecia is not an inherited condition but the genetic susceptibility to autoimmune conditions, including alopecia areata, can run in families.

Can stress trigger alopecia areata?

Severe stressful incidents can act as a trigger for alopecia.

Can illness or infection trigger alopecia areata?

Viral infections may act as a trigger for alopecia.

Is alopecia areata linked to other autoimmune conditions, like thyroid disease?

There is a link between Alopecia and other autoimmune conditions that can include coeliac disease, inflammatory bowel disease, type 1 diabetes and thyroid disease.

Why does the immune system attack hair follicles in the first place?

Normally the hair follicle is protected from the immune system. It is as if there is a forcefield around the follicle. This is lost, also known as loss of immune privilege. The follicle then exhibits flags to the immune system and danger signals and the white blood cells do what they are supposed to do when they see these flags, which results in the immune attack.

Does the hair follicle get permanently destroyed?

No. The follicle shrinks and goes into hibernation mode to stop it from being destroyed. In this state though it does not grow a hair.

Presentation

What does an alopecia areata patch typically look like?

Alopecia classically presents with smooth round or oval patches of varying size. This can be small like a 10p piece but can spread outwards to palm size or bigger. Patches can join together to form larger areas.

Why does hair loss happen in round or oval patches?

We do not know! It is likely the problem starts in the middle and spreads outwards as the condition progresses involving the neighbouring follicles.

Is the skin underneath the bald patch usually normal?

The skin in alopecia patients is relatively normal in structure. There are a collection of immune cells around the hair bulbs in affected hair follicles and there may be an increase in the number of shrunken or telogen hairs.

What is alopecia totalis?

Alopecia Totalis (AT) is when Alopecia affects the entire scalp leading to 100% scalp hair loss.

What is alopecia universalis?

Alopecia Universalis (AU) is when Alopecia affects other sites as well as the scalp leading to “universal” loss. Eyebrows, eyelashes and body hair are lost in AU.

What is the ophiasis pattern, and is it harder to treat?

Ophiasis refers to a “snake” like pattern around the back of the head and behind the ears affecting an area called the occipital hair line. This is indeed more stubborn to treat.

Can alopecia areata affect eyebrows and eyelashes?

Yes. This can have a particular hard impact on self identity as well as functional problems with dust and debris getting in the eye.

Can it affect body hair, not just the scalp?

Yes.

Why do my nails have pitting or ridges — is that related?

Nail changes with pits and roughness can be a feature of alopecia and is more associated with the severe end of the spectrum.

What are "exclamation mark hairs"?

These are hairs that have broken near the skin surface and taper to a thinner area as it comes out of the skin.

Can alopecia areata come on suddenly, overnight almost?

Yes.

Can it start as one small patch and then spread?

Yes

Course and prognosis

Will my hair grow back on its own?

Single patches or limited disease, particularly if it begins in adulthood, has a high chance of spontaneous regrowth within 6-18 months.

How long does a typical episode last?

Everyone is different and this depends on severity. A single patch can occur and regrow within 6 months or you can have the condition for decades or lifelong.

Can alopecia areata come back after regrowth?

Yes. Relapses over the course of your life and it getting more severe with age are common features of alopecia.

Does having one episode mean I'll get it again in the future?

Not necessarily but the potential will always be there.

Does alopecia areata get worse with each recurrence?

Everyone is different so predicting this is hard and does depend on a number of other clinical features.

Can hair grow back a different colour or texture?

Hair that grows back is often white. A change in texture can sometimes occur. Hairs may be finer initially and then thicken and pigment with time.

Is there any way to predict how my alopecia areata will behave?

There are a number of prognostic tools a dermatologist will use to try and predict the likelihood of response to treatment and chances of relapse.

Diagnosis

How is alopecia areata diagnosed?

Alopecia is usually diagnosed clinically without need for any investigation because of the typical clinical and dermoscopic features.

Do I need blood tests to confirm the diagnosis?

No. Blood tests are not needed to diagnose the condition. They can sometimes be used to look for evidence of other autoimmune conditions or as part of monitoring medications used in the treatment of alopecia.

What is trichoscopy and does it hurt?

Trichoscopy is the use of magnified devices with polarising light sources used to examine the hairs and scalp, also known as dermoscopy. It is painless.

What is a pull test?

A pull test is where a group of hairs are grasped and pulled perpendicular to the scalp surface to see whether they come out and what type they are.

Will I need a scalp biopsy?

No. This is seldom needed and only if there is diagnostic doubt.

How is alopecia areata told apart from other causes of patchy hair loss?

The history, clinical and dermoscopic features of alopecia are usually fairly characteristic to an experienced hair loss expert or dermatologist. Other conditions that cause patchy hair loss will have different trichoscopic features in the majority.

Treatment

Does alopecia areata always need to be treated?

No. It can be observed and this is often preferable in young children or where the chance of spontaneous remission is high.

What treatment is usually tried first?

Topical steroid lotions applied to the patches is the usual first line of therapy.

What do steroid injections into the scalp involve, and do they hurt?

Steroid injections involve multiple injections every 8-10mm being injected into the patch and these are painful but often well tolerated. They can be performed quite quickly, sometimes with vibration devices or cool packs to help patients with the discomfort.

How many steroid injection sessions are typically needed?

This depends on the size of the patch but they are normally spaced every 8-10mm. They need to be repeated every 4-6 weeks.

Are topical steroid creams as effective as injections?

No. Steroid injections are generally much more effective than creams or lotions.

What is topical immunotherapy (e.g. diphencyprone) and how does it work?

Topical immunotherapy is where you deliberately create an allergic reaction to a synthetic chemical. You then use very diluted preparations of that chemical to paint on the areas of alopecia to try and stimulate hair growth.

What are JAK inhibitors, and how do they treat alopecia areata?

JAK inhibitors are the latest class of treatment being used in inflammatory and autoimmune skin conditions, including alopecia areata. They interrupt the signalling that keeps the immune cells attacking the hair, allowing the follicle to recover and regrow hair.

Are JAK inhibitors safe? What monitoring do they require?

All medicines have the potential to cause side effects and we have to be cautious about new classes of medication and longer term side effects that may take years or decades to develop. JAK inhibitors have been used for over 10 years and generally have a very good safety profile.

Does minoxidil help with alopecia areata?

Minoxidil can be used alongside other treatments to help thicken the hair as it regrows and might possibly boost the effect of other medications. It rarely helps on its own.

Is watchful waiting ever an appropriate approach?

Yes. Particularly in children and in those with limited disease.

What treatment options exist for children specifically?

The treatment options for children are broadly similar to adults. A number of the newer licensed treatments will have restrictions with some being licensed from 18 and others from 12 years old.

Can alopecia areata be cured completely?

No. Whilst you can achieve full regrowth with treatment, this is control and not a cure.

If treatment works, will I need to stay on it long-term to keep the hair?

It is highly likely that if you had moderate to severe alopecia, you will need to stay on treatment long term.

Living with alopecia areata

How can I cover or camouflage patches while my hair regrows?

There are make up type products that can be painted on patches so that the pinkiness of the scalp is less obvious. These are matched to your hair colour and are often waterproof.

Are wigs or scalp micropigmentation good options?

Wigs can be a good option to help cover up the loss. Scalp micropigmentation is a more permanent solution of disguising hair loss but can be useful for those with longstanding disease or to mimic stubble or a buzz cut in men.

How can alopecia areata affect emotional wellbeing and self-esteem?

Our hair is very important to our sense of identity, our persona, our image and losing it negatively impacts ones self-esteem. Hair loss is often associated with other disease like cancer.

Are there support groups or patient organisations for alopecia areata?

Yes. There are often really good support groups with Alopecia UK being the main one in the UK.

When should I see a dermatologist about patchy hair loss?

Dermatologists that specialise in hair loss are the best doctors to see as they are trained in diagnosis and will have experience of all the different treatments including the new JAK inhibitors.