Symptoms
Alopecia areata manifests as single or multiple, clearly defined, smooth, oval to round hairless areas. The skin is healthy and not inflamed. Hair loss most commonly occurs on the hair of the head, but all other body hair, such as the eyelashes, eyebrows, underarm hair, beard, and pubic hair, may be affected, and changes in nail structure may occur. At the edge of the bald patches, so-called exclamation mark hairs appear, which become thicker towards the outside. The clinical picture is variable and differs from person to person. The course is dynamic, unpredictable and sometimes chronically recurrent. In the course of the disease, there may be spontaneous improvement, stabilization or worsening. When hair grows back, it is often depigmented first, that is, white (see under Complications).
Causes
The causes are not fully understood. Alopecia areata is considered an inflammatory, tissue-specific autoimmune disease. Histologically, infiltrates of immune cells such as T lymphocytes are found in the hair follicle area.
Complications
The disease is benign and primarily a cosmetic problem. The loss of hair and the unpredictability of the disease can be a major psychological burden for patients, especially adolescents, who are often affected. In addition to the hair, the nails can also be affected. Small dimples, grooves or roughenings form on the nail plate. The lunulae may be reddened in spots, rarely there is complete nail loss. The hair loss may spread to several areas. Occasionally, the entire head hair (alopecia totalis) or the entire head and body hair is lost (alopecia universalis). The following are considered to be prognostically unfavorable: an onset at a young age, a family history of alopecia areata, a large extension, an infestation of the nails and autoimmune diseases. If the hair loss occurs in areas at the back of the head and on the sides, it is called ophiasis. Rarely, in an acute episode: swelling of the lymph nodes behind the ears.
Risk factors
- Age: In the majority of patients, the disease begins under 20 years of age.
- Genetic predisposition
- Down syndrome
- Autoimmune diseases, atopy
Differential diagnosis
The diagnosis can usually be made on the basis of the clinical picture alone. A detailed history and biopsy may be necessary to rule out other causes:
- Androgenetic alopecia
- Diffuse hair loss
- Trichotillomania
- Fungal infection (tinea capitis)
- Alopecia syphilitica (syphilis)
- Discoid lupus erythematosus, lichen planopilaris, Brocq’s pseudopelade.
Non-drug treatment
No treatment: it is a cosmetic problem that does not necessarily require therapy. In mild alopecia areata, spontaneous improvement often occurs within a year, even in large-scale hair loss is possible, but less common. In case of small extension, the area on the head can be hidden under the remaining hair. Shaving is also possible, especially in the beard area, wearing a head covering or wig. Psychotherapy: Accompanying psychotherapy may be indicated in cases of alopecia areata associated with a psychosocial conflict situation or adjustment disorders with depressive, anxious mood or social behavioral impairment. However, the value of psychotropic drugs, such as antidepressants, in the treatment of alopecia areata is currently controversial. Self-help groups: Affected individuals can benefit from sharing experiences within self-help groups when dealing with their condition.
Drug treatment
To date, there are no medications that lead to a permanent cure of the disease. Glucocorticoids are mainly used, which can lead to improvement over the course of a few weeks to months. Relapses are frequent. The disease should be treated by a physician. In self-medication, alternative medicines could be tried at most. Glucocorticoids:
- Topical glucocorticoids: Betamethasone, dexamethasone, halcinonide, or clobetasol, among others, have been studied in clinical trials.
- Glucocorticoids such as triamcinolone are also injected locally into individual affected sites.
- Systemic glucocorticoids are effective. However, the numerous adverse effects associated with prolonged therapy pose a problem, especially since the effect is not permanent. They are considered primarily as pulse therapy in an acute, extended disease flare.
Topical immunotherapy with contact allergens:
- Topical immunotherapy uses a contact allergen to temporarily induce allergic contact dermatitis on the scalp. Diphenylcyclopropenone (DCP) and squaric acid dibutyl ester (SADBE) are among the agents used for this purpose. Side effects include severe eczema reactions and undesirable vitiligo-like pigmentation disorders, especially in dark-skinned individuals. The mechanism of action is not precisely known. The success rate is about 30 percent.
Other controversial options:
- Minoxidil is said to stimulate hair growth and is an alternative in self-medication. Its effectiveness is disputed in professional circles, except in combination with a glucocorticoid. It is approved in many countries only for the treatment of androgenetic alopecia.
- Dithranol (anthralin) is a drug used to treat psoriasis and is an irritant therapy in the treatment of alopecia areata because of its irritant potential. Dithranol is controversial among experts.
- Systemic immunosuppressants such as ciclosporin or methotrexate appear to be partially effective, but the health risks associated with their use are too great to justify their use in the longer term.
- Photochemotherapy (PUVA) is costly and also controversial.
Alternative medicine:
- Alternative medicine procedures, such as Traditional Chinese Medicine (TCM) and aromatherapy can be tried. The actual effectiveness of such means can not be reliably assessed in individual cases due to the high spontaneous healing rate.
Worth knowing
White or gray hair can be spared from alopecia areata. In the case of rapid and extensive hair loss, such a “graying overnight” is possible. This phenomenon is also called “Marie Antoinette syndrome” or “Thomas More syndrome”. Both historical figures are said to have turned gray overnight before their execution.
