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Therapeutics in Dermatology
A reference textbook in dermatology

Alopecia

14 October 2019, by SANCHEZ M.

1 - ACKNOWLEDGEMENTS

Chapter written with the help of the EADV, the Fondation René Touraine and the Therapeutics in Dermatology

2 - OVERVIEW

Alopecia is a general term for “hair loss”. It is a common clinical complaint that is a manifestation of a wide variety of disorders.

Alopecia areata is a common cause of non-scarring (does not cause permanent damage to the hair follicle) alopecia that causes a sudden loss of round patches of hair on the scalp and sometimes on other parts of the body. It is not possible to predict how much hair will be lost and, in most cases, new hair eventually grows back in the affected areas.

Although alopecia areata is not life-threatening and does not cause physical pain, the psychosocial effects of hair loss can be devastating.

3 - SYMPTOMS AND CLINICAL MANIFESTATIONS

People with alopecia areata typically have smooth, round patches of complete hair loss that develop over a period of a few weeks. Short hairs, broken off a few millimeters from the scalp, known as exclamation mark hairs are characteristic of alopecia areata and may be seen at the edge of the bald patch. Regrowth may occur over several months and usually starts at the center of the bald patch, with fine white hair that thickens with time and usually regains its color.

The scalp is the most common site of hair loss, but any area of the body can be affected. Although in most cases the disease does not progress beyond patchy hair loss, in some cases the hair loss is extensive. A small minority of patients lose all the hair on their head (alopecia totalis) or all the hair on their head and body (alopecia universalis). In addition to hair loss, fingernail and/or toenail abnormalities may be present, frequently with the appearance of multiple nail pits.

4 - CAUSES

In alopecia areata, the body’s immune system inaccurately attacks hair follicles, due to unknown reasons. Fortunately, the follicles maintain their capacity to regrow, and the hair loss is not permanent in most cases. Why this might happen is not fully understood, nor is it known why only localized areas are affected and why the hair usually regrows again.

A patient with alopecia areata is slightly more likely to develop other autoimmune conditions, these may include: vitiligo (white patches on the skin), thyroiditis (inflammation of the thyroid gland), pernicious anemia (a decrease in red blood cells due to a vitamin B12 deficiency), diabetes and lupus. Although the risk of getting these disorders is very low, if you have other symptoms then discuss these with your doctor.

Approximately 20 percent of people with alopecia areata have a family member with the same disease. As such, specialists believe that a genetic predisposition may exist.

5 - DIAGNOSIS

The diagnosis of alopecia areata is based upon the clinical appearance of the hair loss by a health care provider. A skin biopsy (the removal of a sample of tissue for study) is usually not necessary. 

However, blood tests for thyroid disease or other laboratory studies may be recommended.

6 - TREATMENT

Mild early alopecia areata may require no treatment, since hair is likely to regrow by itself. It is worth noting that treatments that carry serious risks should be avoided, as alopecia areata itself has no adverse effect on physical health.

7 - TIPS FOR MANAGING

In general terms, the following treatment modalities are available, and should be always discussed with the physician and adapted to the extent and severity of alopecia areata:

  • Local steroid injections. This treatment is often recommended for adults with isolated patches of hair loss. The injections are repeated every four to six weeks into the affected area to stimulate hair regrowth and until regrowth is complete. It may take around six to eight weeks to notice new hair growth.
  • Steroid creams and scalp applications. Sometimes prescribed as an alternative to injected corticosteroids for children or adults who cannot tolerate injections. They are applied to the bald patches, usually twice a day, for a limited time.
  • Steroid tablets. Although large doses of steroid tablets may result in regrowth of the hair, in some types of alopecia when the treatment stops it often recurs. These tablets may also have side effects including raised blood pressure, diabetes, stomach ulcers, cataracts and osteoporosis as well as weight gain.
  • Minoxidil lotion. Available over-the-counter, topical minoxidil promotes hair growth by lengthening the growth phase of hair follicles and causing follicles to produce hair. The solution or foam formulation is typically applied twice a day to the area of hair loss and can be used alone or in combination with other therapies. Minoxidil is not effective in patients with severe alopecia areata or total loss of scalp hair.
  • Topical immunotherapy - contact sensitisation treatment. This treatment is only available in specialized centers and involves making the patient allergic to a substance (usually a chemical called diphencyprone) to initiate a mild inflammation. It is probably the most effective treatment for patients with extensive and/or recurrent scalp involvement.
  • Photochemotherapy - ultraviolet light treatment (PUVA). A light-sensitive drug (either applied to the skin or taken by mouth) is given to the patient and then exposed to an ultraviolet light source. Although studies have shown conflicting results, a trial of photochemotherapy may be reasonable in people with extensive alopecia areata, when topical immunotherapy is not available.
  • Immunosuppressant tablets. These include sulfasalazine, methotrexate, ciclosporin, and azathioprine. They suppress the immune system, and are occasionally used to treat severe some severe forms of alopecia areata, always under strict supervision by a physician.
  • Investigational treatments. New therapies for alopecia areata are emerging. The preliminary results from drugs known as Janus kinase (JAK) inhibitors (tofacitinib and ruxolitinib) look promising, but additional study is necessary to evaluate efficacy and safety.
  • Platelet-rich plasma has been used to treat alopecia areata, but no robust clinical trials to confirm whether this treatment is effective have been published. Other therapies such as the use of lipid-lowering medications and altering the gut microbiome are being studied for alopecia areata.

8 - OTHER STRATEGIES THAT CAN BE USED

  • Some individuals with alopecia will prefer to wear a wig while they wait for recovery. Wigs can be cut and styled according to an individual’s preference and may be attached to the head with double-sided tape or a suction cap.
  • Some men and a few women with extensive alopecia find that shaving off the remainder of the hair provides a good and decent solution.
  • Artificial eyelashes, eyebrow pencils and eyebrow tattooing can be helpful for some people with problems involving these areas.

9 - WHAT CAN I DO?

Understandably, hair loss is an upsetting and disturbing condition, particularly in young women. 

  • Counselling is sometimes helpful for people who find it difficult to cope with hair loss and psychological support may be required.
  • Joining a patient support group and meeting other people with alopecia areata might make it easier for to adjust to this condition.
  • Currently, there is not enough evidence to say how effective complementary treatments are in treating alopecia areata (for example, acupuncture, aromatherapy, etc).

10 - THINGS YOU SHOULD BE AWARE

  • An important function of hair is to protect the scalp from sunlight and trauma.
    • Bald patches should be covered with a sun block or a hat to prevent sunburn, thereby reducing the chances of developing long-term sun damage.
    • Be particularly careful to avoid hurting yourself in situations where the hair usually prevents scraping the scalp, such as knocking into doors, cupboards or even trees.

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