Updated: 12/17/2021

Alopecia Areata

Review Topic
  • Snapshot
    • A 23-year-old man with a past medical history of vitiligo comes to the dermatologist for multiple, round patches of painless bald spots on his scalp and eyebrows. He denies pulling any hair out intentionally. There is notably no scarring, erythema, or inflammation. Nail exam reveals pitting of the nail plate. He has an extensive family history of autoimmune diseases.
  • Introduction
    • Chronic, autoimmune non-scarring hair loss disorder
      • as opposed to scarring cicatricial alopecic disorders such as discoid lupus or lichen planopilaris that lead to destruction of hair follicle
    • Variants
      • alopecia totalis
        • complete hair loss on scalp
      • alopecia universalis
        • complete hair loss on scalp and body (including eyelashes, eyebrows, extremities)
    • Associated conditions
      • other autoimmune diseases, especially thyroid and atopic disorders
  • Epidemiology
    • Rare (1.7% lifetime risk of developing disease)
    • Affects males and females equally
    • Affects children and adults equally
  • Presentation
    • Symptoms
      • smooth, discrete, circular patches of hair loss that are typically without pain or itchiness
      • can spontaneously regrow hair or spontaneously progress to alopecia totalis/universalis
      • no erythema, inflammation, or scarring
      • new hairs often fine and white in color
      • nail abnormalities are common, including pitting of nail plate (up to 30% of patients)
  • Evaluation
    • Clinical evaluation of hair loss sites
      • exclamation point hairs” at margins of patches
        • short, broken hairs that narrow at the base
        • extracted easily
        • low sensitivity
    • Punch biopsy
      • peribulbar lymphocytic inflammatory infiltrates surrounding follicles
    • Laboratory studies normal
  • Differential Diagnosis
    • Tinea capitis
    • Trichotillomania (nervous hair pulling)
    • Androgenetic alopecia
    • Cicatricial alopecia
    • Telogen effluvium
    • Traction alopecia
      • secondary to hair tension that is prolonged or repetitive
  • Treatment
    • In many cases, hair may regrow spontaneously
    • Limited therapies available; all with limited efficacy
      • steroids
        • intralesional (Kenalog aka triamcinolone acetonide) injections
        • topical steroids
        • systemic steroids
      • topical immunotherapies, irritants (retinoids, anthralin)
    • Currently under investigation: targeted oral immunotherapies
      • Janus kinase inhibitors tofacitinib, ruxolitinib
  • Prognosis, Prevention, and Complications
    • Variable, unpredictable pattern of regrowth, patchy hair loss, and progression to alopecia totalis or universalis
    • Complications
      • if eyelashes are lost, can result in dry eyes or corneal abrasions
    • Quality of life often impacted
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