Alopecia areata (AA) is probably the third most common form of hair loss dermatologists see, after androgenetic alopecia and telogen effluvium. The lifetime risk for AA is nearly 2%, or two in every 100 people will get AA at some point in their lives. It is not contagious; you can't catch AA from someone who has it.
Researchers believe AA is an autoimmune disease such as rheumatoid arthritis, but in this case the individual's own immune system attacks hair follicles instead of bone joints. Just why or how AA develops is not clear. For whatever reason, the immune system is inappropriately activated and attacks hair follicles. Research using several disease models shows certain types of lymphocytes play a primary role in the hair loss. They seem to attack the hair follicles, mistakenly thinking that somehow they are a threat to the rest of the body.
AA can affect men, women, and children. It often appears as well-defined circular bald patches on the scalp. Many people will get just one or two patches, but for some the hair loss can be extensive. Unfortunately, children who develop AA before puberty are most likely to develop more extensive and persistent hair loss.
Hair loss that spreads to cover the entire scalp is called alopecia totalis. If it spreads over the entire body, affecting scalp, eyebrows, lashes, beard, pubic hair, and everything else, then the condition is called alopecia universalis. If the alopecia is just limited to the beard area in men, it is called alopecia barbae.
The inflammation involved in AA focuses on the roots of hair follicles deep in the skin. As a result there is very little visible at the skin surface. There is no redness and often no pain, although a few people do find their skin itchy or painful to touch in the very early stages of AA development. Usually, though, there is no sensation -- just a patchy shedding of hair.
The hair loss can be quite sudden, developing in a matter of a few days and it may happen anywhere on the scalp. The patch is usually smooth bald skin with nothing obvious to see beyond the absence of hair. Unlike other autoimmune diseases, the target of the inflammatory response in AA, the hair follicles, are not completely destroyed and can re-grow if the inflammation subsides.
People with just one or two patches of AA often have a full and spontaneous recovery within two years whether or not they receive treatment. However, about 30% of individuals find the condition persists and becomes more extensive, or they have repeated cycles of hair loss and re-growth.
Traditionally, AA has been regarded as a stress-induced disease. Unfortunately that view persists today, even among some dermatologists, even though very little scientific evidence supports the view.
AA is much more complicated. Extreme stress might trigger AA in some people, but recent research shows that genes can also be involved. There are probably several genes that can make an individual more susceptible to developing AA. The more of these genes a person has, the more likely they will develop AA.
Some researchers believe there are a wide range of contributing factors that make someone more susceptible to developing AA. Hormones, allergies, viruses, and even toxins might contribute. Probably several factors combined are involved in the activation of AA in any one individual.
Treatments for Alopecia
There are a range of treatments for AA, but none are effective for everyone and some people with AA don't respond to any treatment. Because some of the available treatments have a high risk of side effects, they are often not used for children.
The most common AA treatment involves the use of corticosteroids. Corticosteroid creams applied to the bald patches are popular with the average dermatologist, although this treatment approach is only successful for the very mildest cases. A more potent approach is to inject corticosteroid solutions into the bald patches. This can work well for some people, but close monitoring is required to ensure that side effects, such as skin thinning at the site of injection, do not occur.
In extensive cases, systemic corticosteroids (those taken in pill or other form to affect your body) are used, though not continuously since they can cause significant side effects like bone thinning. But short-term "pulse therapy" often has good results.
More specialized treatment approaches involve the application of contact sensitizing chemicals to the skin. These cause an allergic reaction that can help promote hair growth. That may sound counterintuitive but it seems to work. A variety of experimental approaches are currently in laboratory and clinical trials. One group of drugs being tested are "biologics," which have bits of protein that interfere in a very specific way with the activity of immune cells. Biologics are injected systemically to damp down the immune activity and allow hair to regrow. The results of these trials are awaited with much interest.
Unfortunately, people with more extensive, long-term AA find the treatments currently available do not work well. For these individuals the only practical answer is a wig and lots of emotional support. It can be depressing not to have hair, especially for children, who don't want to be different from their classmates at school, and women. In North America and many other countries of the world, you can access a network of support agencies for people with AA. Details are on the National Alopecia Areata Foundation website (http://www.naaf.org).
Published on March 1, 2010