Alopecia Areata: A Comprehensive Guide

Quick Summary: Understanding Alopecia Areata

What is Alopecia Areata? An autoimmune condition where the immune system mistakenly attacks hair follicles, causing hair loss in random, patchy spots. It can affect anyone, regardless of age, gender, or ethnicity, and is often linked with other autoimmune disorders like thyroid diseases and vitiligo.

Causes and Influences: Genetics play a role, with about 20% of patients having a family history. Environmental factors such as stress and lifestyle choices also significantly impact the onset and progression of the condition.

Symptoms and Forms: The condition manifests as patchy hair loss on the scalp, beard, or even the entire body in various types—ranging from small patches (Alopecia Areata) to complete hair loss on the scalp (Alopecia Totalis) or body (Alopecia Universalis). Nail changes like pitting and ridging may also occur.

Treatment and Management: Options range from topical treatments like corticosteroids and new medications such as Ritlecitinib to lifestyle adjustments aimed at reducing stress and improving diet. While there’s no cure, these treatments help manage symptoms and encourage hair regrowth.

Key Takeaway: Engaging with the alopecia community and utilising available support resources like counselling and sun protection are crucial. Early diagnosis and proactive management are essential for improving outcomes, making it important to seek professional advice if symptoms appear.

What is Alopecia Areata?

Alopecia areata is a condition that causes hair loss in small, random patches. The term “alopecia” means hair loss, and “areata” means patchy. This condition is autoimmune, meaning the body’s immune system mistakenly attacks hair follicles, thinking they are harmful. Normally, our immune system protects us from harmful substances, but in autoimmune conditions, it turns against our own cells.

Understanding that alopecia areata is an autoimmune condition helps in grasping why it happens and how it might be treated. 

Who Can Be Affected by Alopecia Areata?

Alopecia areata can affect anyone, regardless of age, gender, or ethnicity. It has a genetic component, meaning it can run in families, but it can also occur without any family history. Even if no one else in your family has it, you can still develop alopecia areata.¹

Statistics show it’s a common condition, affecting about 1 in 1,000 people, with a lifetime risk of 2%. A study in the UK by Harries et al. found a 0.58% prevalence of alopecia areata, noting 6,765 new cases from 2009 to 2018. The most commonly affected age group was 25-29 years. Although alopecia areata can strike at any age, it’s more frequently observed before the age of 40, especially in one’s 20s and 30s. When it occurs in childhood or early age, it tends to be more severe and chronic.²

It’s also worth noting that the study observed higher incidence rates of alopecia areata in urban areas and places with social deprivation, potentially linked to increased stress, depression, anxiety, and environmental factors like air pollution, though solid evidence is still lacking.

People at risk of developing alopecia areata may have other existing autoimmune conditions such as³:

• Thyroid Disorders: Conditions like Hashimoto’s thyroiditis or Graves’ disease due to an underactive or overactive thyroid.
• Vitiligo: A condition that causes loss of skin pigment.
• Rheumatoid Arthritis: An autoimmune disorder affecting the joints.
• Type 1 Diabetes: An autoimmune condition that affects insulin production.
• Lupus: A systemic autoimmune disease that can affect the skin, joints, and organs.
• Psoriasis: An autoimmune condition characterised by red, scaly skin patches.

Currently Known Causes of Alopecia Areata

• Autoimmune Nature
  • Alopecia areata (AA) is thought to occur when hair follicles are mistakenly attacked by the immune system, causing them to shift from the growth phase (anagen) to the resting phase (telogen), leading to hair follicle miniaturisation and hair loss – It does not scar, and it’s usually not a permanent hair loss but rather episodes of loss and regrowth. 
  • This condition is considered autoimmune because the immune system, which usually protects the body from harmful invaders, identifies the hair follicles as foreign objects. Normally, hair follicles are “immune privileged,”⁴ meaning they are protected from immune system attacks. 
  • Here’s one common theorised explanation for this: Keratinocytes, which are crucial cells in the outer layer of the skin and also influence the microenvironment of hair follicles, usually function without triggering an immune response. However, in AA, these keratinocytes might display abnormal characteristics or behaviours. This abnormal behaviour causes immune cells, particularly T-cells, to mistakenly attack the keratinocytes in the hair follicles, leading to hair loss.
  • As mentioned before, having an autoimmune condition like vitiligo, lupus, and thyroid disorders are known to be risk factors for the development of AA as well. 
• Genetic Factors
  • About 20% of people with alopecia areata have a family history of the condition. This suggests that genes can play a role in developing AA, although it’s not the only factor involved.⁵ 
• Environmental Triggers (Lifestyle)
  • Stress is believed to be related to the onset and progression of AA⁴. Lifestyle factors such as smoking, alcohol consumption, diet, and sleep disturbances are also thought to play a role. However, there is no solid evidence yet to conclusively support these claims. Nonetheless, we always encourage a healthy lifestyle here at The Treatment Rooms, as there is evidence that these habits have an impact on overall scalp and hair health.

Signs and Symptoms of Alopecia Areata

Signs and symptoms may appear quickly, sometimes without you even noticing. Here are the common signs and symptoms to look out for if you suspect you may have alopecia areata^1,5:

• Hair Loss Patterns – First would be the development of the bald patch – it usually happens at the scalp or beard, and to a lesser extent the eyebrows and eyelashes, but it can occur in any area of the skin that has hair. Some may even notice only pigmented hair falling off, while the grey hair stays. There are different types of AA: 
  • Patchy Alopecia Areata – It may usually be patchy, with the circular or oval bald patches being the size of a large coin. 
  • Alopecia Barbae: patchy hair loss on beard.
  • Alopecia Ophiasis: This is a bit more extensive than patches. The hair loss occurs in a band or strip around the sides and back of the head, often around the temporal area (sides of the forehead) and the lower part of the scalp.
  • Other less common types of AA include:
    • Alopecia Totalis – Loss of all scalp hair.
    • Alopecia Universalis – Loss of all body hair.

• Nail Changes
  • In about 10-15% of the people affected with AA, changes to the nails like pitting, ridges or white spots, and nails may become thinner and more prone to breaking. These symptoms are usually associated with more severe cases of AA and are not always present. 
• Some people might experience mild itchiness, scaling, redness, tingling, or a burning sensation. However, most people don’t feel anything, and the affected scalp area usually looks normal and healthy.

Alopecia areata progresses and presents differently in each person. For example, the amount of hair loss, the speed at which it begins, and the rate of hair regrowth can all vary greatly from one individual to another.

Hair Regrowth with Alopecia Areata

Understanding how hair regrows with alopecia areata can help you better manage the condition. Here’s a closer look^6,7:

• An approximate regrowth timeline: After an episode of alopecia areata, hair typically starts to grow back within 6 to 12 months. However, it’s important to know that hair loss might happen again, which is called a relapse. Relapses can occur as often as once a year or within 5 years, but some people may not have another episode at all (and some may experience hair loss more often).
• There may be variabilities: The pattern of hair loss and regrowth varies widely from person to person. 4 out of 5 affected people may experience full regrowth, while others may see only partial, or no regrowth. Hair regrowth in AA can be more challenging in younger children, those with a family history of autoimmune diseases, people with nail issues, and if hair loss occurs at the back of the scalp.⁸ 
• Managing expectations: Because there is no fixed pattern for AA, it’s difficult to predict exactly how each case will unfold. If hair regrowth is slow or not happening as hoped, treatments might help, though there’s currently no permanent cure for the condition.

Preparing for these fluctuations and recognising the uniqueness of each case can help you manage this condition more effectively.

Diagnosing Alopecia Areata

We understand how challenging it can be to navigate alopecia areata and find the right help. It’s important to address your concerns, even if they seem minor or primarily cosmetic. So, what can you expect when you visit your GP or dermatologist about alopecia areata?

1. Review of Medical History: The doctor will ask about your overall health, hair loss history, family medical background, and any recent stress or illness. This helps them understand potential underlying causes and factors.
2. Physical Exam: Expect the doctor to examine your scalp and any other affected areas of hair loss. They’ll look for specific patterns of hair loss and check for signs of skin changes or other symptoms.
3. Possible Tests: To rule out other conditions, the doctor might suggest some tests. These could include blood tests to check for autoimmune issues or a scalp biopsy, where a small sample of skin is taken for closer examination.
4. Discussion and Plan: Based on the findings, the doctor will explain their diagnosis and discuss treatment options. They’ll help you understand what might be causing your hair loss and how best to manage it.

Understanding this process helps you have a smoother visit and feel more informed about your diagnosis and treatment options.

Treatment and Management for Alopecia Areata

While there is no known cure for alopecia areata yet, several treatments are available that aim to manage symptoms and encourage hair regrowth. These treatments primarily focus on suppressing the autoimmune reactions responsible for the symptoms. We’ll explore below a range of treatment options, from lifestyle adjustments to prescription medications and even potential surgical interventions, to help manage AA effectively.

Lifestyle Adjustments

While the exact relationship between stress and alopecia areata (AA) isn’t fully established, emotional stress and psychological factors have been observed to correlate with the condition. Research indicates that about 23% of patients report experiencing significant emotional stress prior to an AA episode.⁹ Furthermore, mental stress can impact physical health, including potential effects on hair follicles through stress-related biochemical signalling in the body. 

Understanding this complex link requires further research, but the evidence suggests a possible connection between lifestyle habits and AA. Addressing stress and making healthy lifestyle choices may help manage or mitigate the condition.

Given that AA involves autoimmune-related inflammation, reducing inflammation is also crucial. Avoiding inflammatory foods and drinks, smoking, excessive alcohol consumption, poor sleep habits, and factors contributing to obesity can be beneficial. These adjustments not only support overall health but may also help manage symptoms of AA.¹⁰

So in a nutshell: 

• Manage Stress: Try and address emotional stress and psychological factors as they may influence hair loss in AA. Reducing stress through techniques like meditation, yoga, or therapy may indirectly benefit hair regrowth.
• Eat a well-balanced healthy diet: Avoiding inflammatory foods and drinks can help reduce autoimmune-related inflammation. At the same time, eating anti-inflammatory foods can support immune health and potentially reduce symptoms.
• Avoid Smoking and Excessive Alcohol: Both can worsen inflammation and negatively impact overall health, so it would be beneficial to try and reduce it. 
• Improve Sleep Habits: Good sleep is crucial for reducing stress and inflammation.
• Maintain Healthy Weight: Avoiding obesity-related health issues which can exacerbate inflammation, and opting for regular exercise can benefit both hair health and overall well-being.

Medical Treatments

As mentioned earlier, Although symptoms of alopecia areata are usually minimal and not painful, and hair often regrows on its own, doctors can suggest treatments to lessen symptoms and encourage hair regrowth if you’re experiencing difficulties with the condition.^7,11,12 

• Topical Treatments:
  • Steroid Creams: These can be applied to the affected areas to help reduce inflammation and encourage hair growth.
  • Minoxidil (Rogaine): Commonly used for pattern baldness, it’s also applied to the scalp to stimulate hair regrowth in alopecia areata.
• Steroid Injections:
  • Corticosteroid Injections: Injected directly into the bald patches to suppress the immune response and stimulate hair growth.
• Oral Treatments:
  • Corticosteroids: Sometimes prescribed for short-term use to rapidly reduce inflammation.
  • Update on New Treatments: Ritlecitinib, a once-a-day pill that reduces enzymes causing inflammation, has recently been recommended by NICE UK for severe cases in individuals aged 12 and over.¹³

Specialised Therapies

• Topical/Contact Immunotherapy: This involves applying a special chemical (e.g. DCPC or Dithranol) to the scalp to trigger a controlled allergic reaction. The idea is to distract your immune system from attacking your hair follicles by focusing it on the allergic reaction instead. This process can help prevent further hair loss and may encourage new growth. The chemical is applied weekly and works over time to help hair gradually start growing back.

Other Supportive Options

• Wigs and Hairpieces: For extensive hair loss, wigs and hairpieces can mimic natural hair, helping those with significant hair loss regain confidence and maintain a desired appearance. 
• Counselling: Emotional support through counselling or support groups can help manage the stress and psychological impact of hair loss. It would also help with confidence and overall well-being. 
• Sun Protection: It’s also important to protect exposed scalp areas with high-SPF sunscreen or hats to prevent sunburn and reduce the risk of skin damage.

It is very important to note that treatments vary in effectiveness and may have side effects. We highly encourage discussing all options with a GP or dermatologist to tailor the approach based on your specific condition and health profile.

If you would like a more detailed overview on the available treatment for alopecia areata, you may find this FAQ page by Alopecia UK helpful. 

Hair Transplant and Alopecia Areata

Considering a hair transplant for alopecia areata? It’s important to know that this usually isn’t our go-to recommendation due to the unpredictable nature of the condition. Alopecia areata often allows hair to regrow with alternative treatments, without needing a transplant. But, we understand that every case is unique.

In specific situations—like when you’ve had stable, unchanged patches of hair loss for several years despite other treatments—a transplant might be considered. Remember, a successful transplant needs a stable donor area, which can be tricky to predict with alopecia areata and its unpredictable nature that varies from person to person. For those with complete hair loss, like Alopecia Totalis or Universalis, a transplant isn’t possible without donor hair available, unless you have an identical twin.

If you’re still wondering if hair transplant could be an option for you, let’s talk it through. Our team of experts is here to provide honest advice, help you understand your options, and set realistic expectations. At The Treatment Rooms, we are committed to supporting you every step of the way, ensuring you make the best decision for your hair health.

Impact of Alopecia Areata on Daily Life

We understand that alopecia areata can challenge your self-image and affect how you interact socially. It’s common to feel self-conscious about your appearance, which can influence relationships and everyday social engagements. Remember, it’s okay to seek support from friends, family, or professional counsellors who understand the emotional challenges of hair loss.

Work and School 

When navigating professional and educational environments, it might feel daunting to face peers or colleagues when experiencing visible hair loss. Developing strategies to maintain your confidence, such as using styling alternatives like wigs or scarves, can help you slowly but surely meet the situation with a bit more confidence. At the same time, speaking to a counsellor or joining a support group can help develop additional coping mechanisms. 

Connecting with others who have alopecia areata can also be incredibly beneficial. Alopecia UK is a good place to start your search. Communities as such offer valuable insights, shared experiences, and a network of support tailored to those navigating this condition.

Here are some additional resources and information leaflets we feel people experiencing alopecia areata might benefit from: 

• Patient Information Leaflet by British Association of Dermatology
• Patient Health Advice for alopecia areata by Patient.info
• Guidance on Hair Loss by NHS

If Not Alopecia Areata, What Else Could It Be? 

Understanding what might be causing your hair loss is crucial. Here are some conditions to consider if your symptoms don’t align perfectly with alopecia areata 

If you’re experiencing patchy hair loss

• Tinea Capitis: A fungal infection of the scalp that often appears in circular, patchy areas.
• Trichotillomania: A psychological condition where a person pulls out their own hair, creating irregular bald spots.
• Traction Alopecia: Hair loss from hairstyles that pull tightly on the roots, like braids or ponytails.
• Scarring Alopecia: Permanent hair loss caused by inflammatory conditions that destroy hair follicles.
• Secondary Syphilis: An infection that can cause patchy hair loss as one of its symptoms.

If you’re experiencing a more diffuse hair loss

• Telogen Effluvium: Generalised hair shedding due to stress, illness, or hormonal changes.
• Anagen Effluvium: Hair loss associated with chemotherapy or other medications that can disrupt the normal hair growth cycle.
• Androgenetic Alopecia: A gradual pattern of hair loss common in men and women.

Conclusion

To wrap up and summarise, alopecia areata is an autoimmune disease where the immune system mistakenly targets hair follicles—normally protected as ‘immune privileged’ areas—and attacks them, causing temporary patchy hair loss.

While we can’t pinpoint the exact cause of this condition, it’s clear that both emotional and physical health play crucial roles in its development. The condition is linked to how our body’s biochemical signals influence inflammation, particularly around the hair follicles.

Thankfully, there are numerous treatment options available. These range from lifestyle adjustments that promote overall well-being to prescribed medical treatments specifically designed to reduce symptoms and encourage hair regrowth. It’s important for those experiencing alopecia areata to know that they are not alone. There is a community of people with shared experiences, and support is readily available. If alopecia areata is significantly affecting your life, like self-esteem and social interactions, we encourage you to seek help and explore the treatment options that can aid in managing this condition.

References

1. NIAMS. Alopecia Areata [Internet]. National Institute of Arthritis and Musculoskeletal and Skin Diseases. 2019. Available from: https://www.niams.nih.gov/health-topics/alopecia-areata
2. Harries M, Macbeth AE, Holmes S, Chiu WS, Gallardo WR, Nijher M, et al. The Epidemiology of Alopecia areata: a Population‐based Cohort Study in UK Primary Care. British Journal of Dermatology [Internet]. 2021 Oct 21;186(2):257–65. Available from: https://www.ncbi.nlm.nih.gov/pmc/articles/PMC9298423/
3. Thomas EA, Kadyan RS. ALOPECIA AREATA AND AUTOIMMUNITY: A CLINICAL STUDY. Indian Journal of Dermatology [Internet]. 2008;53(2):70–4. Available from: https://www.ncbi.nlm.nih.gov/pmc/articles/PMC2763714
4. Azzawi S, Penzi LR, Senna MM. Immune Privilege Collapse and Alopecia Development: Is Stress a Factor. Skin Appendage Disorders [Internet]. 2017 Dec 20;4(4):236–44. Available from: https://www.ncbi.nlm.nih.gov/pmc/articles/PMC6219219/
5. CKS NICE. Alopecia Areata Background Information [Internet]. NICE. NICE; 2023. Available from: https://cks.nice.org.uk/topics/alopecia-areata/background-information/causes/
6. Ludmann P. Alopecia areata: Overview [Internet]. www.aad.org. AAD; 2023. Available from: https://www.aad.org/public/diseases/hair-loss/types/alopecia
7. Harvard Health Publishing. Alopecia Areata – Harvard Health [Internet]. Harvard Health. Harvard Health; 2019. Available from: https://www.health.harvard.edu/a_to_z/alopecia-areata-a-to-z
8. BAD. Alopecia Areata Patient Information Leaflet [Internet]. British Association of Dermatologists; 2024 Apr [cited 2024 Jul 31]. Available from: https://cdn.bad.org.uk/uploads/2021/11/15134411/Alopecia-areata-PIL-April-2024-1.pdf
9. Brajac I, Tkalčić M, Dragojević DM, Gruber F. Roles of Stress, Stress Perception and Trait-Anxiety in the Onset and Course of Alopecia Areata. The Journal of Dermatology [Internet]. 2003 Dec;30(12):871–8. Available from: https://pubmed.ncbi.nlm.nih.gov/14739513/
10. Minokawa Y, Sawada Y, Nakamura M. Lifestyle Factors Involved in the Pathogenesis of Alopecia Areata. International Journal of Molecular Sciences [Internet]. 2022 Jan 18;23(3):1038. Available from: https://www.ncbi.nlm.nih.gov/pmc/articles/PMC8835065/
11. Vincent P. Alopecia Areata [Internet]. Tiddy C, editor. patient.info. 2023 [cited 2024 Jul 31]. Available from: https://patient.info/skin-conditions/alopecia-areata#alopecia-areata-treatment
12. Alopecia UK. Treatments for Alopecia Areata [Internet]. Alopecia UK. Available from: https://www.alopecia.org.uk/Pages/FAQs/Category/treatments-for-alopecia-areata
13. NICE. Recommendations | Ritlecitinib for treating severe alopecia areata in people 12 years and over | Guidance | NICE [Internet]. www.nice.org.uk. 2024 [cited 2024 Jul 31]. Available from: https://www.nice.org.uk/guidance/ta958/chapter/1-Recommendations
14. Alopecia areata summary diagram illustrated using biorender.com