Alopecia Areata

Alopecia (ah-low-pee-sha) is simply the medical term for hair loss. Alopecia Areata (AA) is a very particular and common type of hair loss that usually causes circular patches of complete hair loss leaving clear patches of skin in the scalp.

It is an autoimmune condition, in which the body’s immune system malfunctions and attacks the body’s own hair follicles. In most cases, the follicles remain intact and often complete recovery of their growth occurs, although this is not always the case.

In about 1 in 20 people hair loss can progress and involve the whole scalp, which is described as alopecia totalis. Sometimes nails may also be affected, with tiny pits or thinning. Occasionally Alopecia Areata may cause more general thinning of the hair without individual patches.

A dermatologist should be able to diagnose AA. Although there is currently no cure, hair will often regrow spontaneously and treatments may help the hair regrow more quickly.

Treatments include:

• Steroids
  These can be given as a lotion, but probably work more effectively when injected about every 6 weeks into the part of the skin where the hair follicles are located. Regrowth may occur within a month, but can take longer. Occasionally steroid tablets may be used, but these are not a long-term option because of side effects.

• Minoxidil
  Normally a treatment for male or female pattern hair loss, minoxidil 5% (Regaine) may help hair regrow in alopecia areata. It can be applied twice a day and may take 3 months to start working.

• Diphencyprone
  This is a medicine which is used to deliberately cause an allergic reaction on the bald patches of skin, producing red and slightly itchy areas resembling eczema. This alters the immune response in the skin and often causing new hair growth to occur. Hair regrowth may take 3 months.

• Jak inhibitors
  Although they are not yet available outside clinical trials, these exciting and completely new treatments for alopecia areata have been identified in the last 2 years. Jak inhibitors interfere with a communication pathway inside immune cells that are known to be involved in alopecia areata. So far two oral medicines (tofacitinib and ruxulitinib) have been tested in small clinical trials. Substantial hair regrowth occurred although this was better in patients without complete hair loss. Larger studies are now underway. It is also possible that these medicines might be used in future to treat male and female-pattern hair loss.

The outlook for alopecia areata is usually good. In patchy AA, hair growth often recovers, perhaps initially with white hair or thinner hair than before, although other new areas may appear.

Four out of 5 people with limited patches recover completely within 1 year without any treatment. Often recovery may occur with the condition coming back at some stage in the future. People with more than half of the scalp involved have a 1 in 10 chance of full recovery.

Those with involvement of the hairline at the back, sides or front of the scalp are less likely to fully regrow. In general, children with AA show less hair recovery than adults.

Scarring Alopecias

Scarring alopecias occur when the hair-bearing scalp skin is replaced by permanent scar tissue. In this case hair loss cannot recover, because the follicles have been lost. The absolute key is to treat these conditions as early as possible by obtaining an accurate diagnosis and starting medication to control the cause.

There are many causes of scarring alopecia. The commonest are:

• Frontal Fibrosing Alopecia or FFA
  This causes permanent receding of the frontal hairline in women after the menopause. Unlike Female-Pattern Hair Loss, FFA causes slight reddening and inflammation of the hair follicles and hair loss that cannot be reversed. After diagnosis by a dermatologist, treatments may include topical steroids, and oral medications, for example hydroxychloroquine, and hormones that inhibit the effect of testosterone on the hair follicles (5-α reductase inhibitors or flutaminde/ dutasteride).
• Lichen Planopilaris
  A condition that causes hair follicle inflammation which is related to a common skin condition called lichen planus. In the scalp it can cause hair follicle reddening, inflammation and destruction leading to general and potentially permanent thinning of the hair. Treatment with topical steroids and tablets such as hydroxychloroquine is often effective.
• Centrifugal Cicatricial Alopecia (CCA)
  The commonest cause of hair loss in black women, however it can occur in all races and hair types. It is thought to be caused by hair care practices including hot combing, and use of chemical relaxers, braiding and tight extensions, however other factors such as bacterial or fungal infections may also play a role. In CCA, hair loss occurs centrally, producing a shiny scalp with loss of follicular openings, which slowly extends outwards. Discontinuation or minimisation of the damaging hair practices is key.