 Alopecia areata is a recurrent nonscarring type of hair loss that can

affect any hair-bearing area.

 Clinically, alopecia areata can manifest many different patterns.

 Although medically benign, alopecia areata can cause tremendous

emotional and psychosocial distress in affected patients and their

families.
 Pathophysiology

 The exact pathophysiology of alopecia areata remains unknown.

 The most widely accepted hypothesis is that alopecia areata is a T-

cell–mediated autoimmune condition that is most likely to occur in

genetically predisposed individuals.

 Classifications of alopecia areata
Localized alopecia areata

Episodes of localized (< 50% involvement) patchy alopecia areata usually

are self-limited; spontaneous regrowth occurs in most patients within a few

months, with or without treatment.

Extensive alopecia areata

Extensive (>50% involvement) forms of alopecia areata are less common.

Alopecia totalis or alopecia universalis are reported to occur at some point

in 7% of patients.The proportion of patients with alopecia totalis appears to

decrease with every decade of life.

Manifestations
• The presence of smooth, slightly erythematous (peach color) or normal-

colored alopecic patches is characteristic.

• The most common presentation is the appearance of one or many round-

to-oval denuded patches. (Patchy hair loss)

• No epidermal changes are associated with the hair loss.

• Exclamation mark” hairs: few short hairs occur in or at the edges of the

bare spots. These hairs get narrower at the bottom, like an exclamation

mark.
 The natural history of alopecia areata is unpredictable.

 Extreme variations in duration and extent of the disease occur from

patient to patient.

 The condition usually is localized when it first appears.

 No correlation exists between the number of patches at onset and

subsequent severity.

 More than one area can be affected at once.

 Alopecia is not contagious

Alopecia areata most often is asymptomatic, but some patients (14%)

experience a burning sensation or pruritus in the affected area.

The condition usually is localized when it first appears, as follows:

•Single patch - 80%

•Two patches - 12.5%

•Multiple patches - 7.5%

Alopecia areata can affect any hair-bearing area, and more than one

area can be affected at once.

Frequency of involvement at particular sites is as follows:

• Scalp - 66.8-95%

• Beard - 28% of males

• Eyebrows - 3.8%

• Extremities - 1.3%
Associated conditions may include the following:

• Atopic dermatitis

• Vitiligo

• Thyroid disease

• Down syndrome

• Psychiatric disorders: Anxiety, personality disorders and depression

• Stressful life events in the 6 months before onset

Alopecia areata can be classified according to its pattern, as follows:

• Reticular - Hair loss is more extensive and the patches coalesce

• Ophiasis - Hair loss is localized to the sides and lower back of the

scalp

• Sisaipho (ophiasis spelled backwards) - Hair loss spares the sides and

back of the head

• Alopecia totalis - 100% hair loss on the scalp

• Alopecia universalis - Complete loss of hair on all hair-bearing areas

Nail problems:

• Alopecia areata also can affect your fingernails and toenails. Nails can

have tiny pinpoint dents (pitting).

• They also can have white spots or lines, be rough, lose their shine, or

become thin and split.

• Rarely nails change shape or fall off.

• Sometimes nail changes are the first sign of alopecia areata.

 Risk factors

 No known risk factors exist for alopecia areata, except a

positive family history.

 Diagnosis usually can be made on clinical

grounds; a scalp biopsy seldom is needed,

 There is no cure for alopecia areata.

 Hair often re-grows on its own.

 Treatment can help the hair re-grow more quickly.

 Patient Education
• Patient education is a key factor in alopecia areata.
• Inform patients of the chronic relapsing nature of alopecia areata.
• Reassure patients that the condition is benign and does not threaten
their general health.
• Most patients try to find an explanation about why this is happening
to them.
• Reassure these patients that they have done nothing wrong and that it
is not their fault.
• Inform patients that expectations regarding therapy should be
realistic.
 Intralesional steroids

• They are used widely in the treatment of alopecia areata.

• Intralesional steroids are the first-line treatment in localized conditions and

are usually superior to topical corticosteroids.

• Triamcinolone acetonide is used most commonly

• Adverse effects mostly include pain during injection and minimal transient

atrophy.

• The presence of atrophy should prompt a reduction in the triamcinolone

acetonide concentration and avoidance of the atrophic site.

• Injections are administered every 4-6 weeks.

 Topical steroids

• They are useful especially in children who cannot tolerate injections.

• Ex: Fluocinolone acetonide, Betamethasone dipropionate and Clobetasol

propionate

• Treatment must be continued for a minimum of 3 months before regrowth

can be expected, and maintenance therapy often is necessary.

• The most common adverse effect is local folliculitis, which appears after a

few weeks of treatment, and local atrophy also have been reported.
 Systemic steroids

• Oral prednisone usually is reserved for patients with rapidly

progressive alopecia areata.

• The relapse rate is high, and the potential for multiple severe adverse

effects when used long term limits its usefulness.

• Systemic prednisone is not an agent of choice for alopecia areata

because of the adverse effects associated with both short- and long-

term treatment
 Immunotherapy
• Topical immunotherapy is defined as the induction of an allergic contact
dermatitis by topical application of potent contact allergens.
• Commonly used agents include squaric acid dibutylester (SADBE) and
diphencyprone (DPCP).
• No serious adverse effects have been reported.
• The most common side effect, which is desired, is a mild contact dermatitis
(redness, scaling, itching).
• The mechanism of action of topical immunotherapy is unknown. Antigenic
competition has been hypothesized. That is, the introduction of a second
antigen can initiate a new infiltrate containing T-suppressor cells and
suppressor macrophages that may modify the preexisting infiltrate and allow
regrowth.
 Immunomodulators

 Cyclosporine causes hypertrichosis in patients treated for conditions

unrelated to hair loss.

 Anthralin

• Anthralin is a synthetic derivative of a tree bark extract.

• Its mechanism of action in alopecia areata is unknown. Most likely, it has

immunosuppressive actions.

• Both short-contact and overnight treatments have been used.

• High concentration (1-3%) is used for short-contact treatments.

• Lower concentrations (0.1-0.4%) are used for overnight treatments.

• Applications in excessive amounts may stain clothing.

 Vasodilators

• Vasodilators relax arteriolar smooth muscle, causing vasodilation; hair

growth effects are secondary to vasodilation.

• Minoxidil stimulates hair growth in general and is effective in many

types of hair loss.

• The exact mechanism of action remains unclear, but it does not appear

to have either hormonal or immunosuppressant effects.

• The 5% solution appears to be more effective.

 Psoralen plus UV-A

• Both systemic and topical PUVA therapies have been used.