Alopecia Areata

Aka: Alopecia Areata, Alopecia Totalis, Alopecia Universalis, Exclamation Point Hair

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II. Definitions

  1. Alopecia Areata
    1. Non-scarring autoimmune Alopecia

III. Epidemiology

  1. No gender predominance
  2. Most common under age 30 years
    1. Children account for 20% of patients
  3. Prevalence: 0.2% up to 2% of U.S. population

IV. Pathophysiology

  1. Autoimmune reaction to Hair Follicles
  2. Prematurely transitions Anagen phase (growth) hairs to Catagen or Telogen phase (with more rapid loss)
  3. Often associated with Thyroid disease

V. Types

  1. Patchy Alopecia Areata
    1. Well circumscribed, flesh colored, smooth, discrete oval patches of Hair Loss
  2. Ophiasis
    1. Band-like Hair Loss around temporal and occipital scalp
  3. Alopecia Totalis
    1. Hair Loss over entire scalp
  4. Alopecia Universalis
    1. Hair Loss over entire body

VI. Signs

  1. Characteristics
    1. Well-demarcated oval or round patches of Hair Loss
    2. Patches of Hair Loss may coalesce into larger areas of Hair Loss
  2. Distribution
    1. Hair Loss on scalp is most common (but may occur in any body region)
  3. Timing
    1. Hair Loss develops over the course of weeks
  4. Exclamation Point Hairs at edges of Hair Loss (as visualized under microscope)
    1. Club shaped Hair Root
    2. Thin proximal Hair Shaft
    3. Normal caliber distal Hair Shaft
  5. Non-specific findings
    1. Short Vellus Hairs or 2-3 mm broken hairs
    2. Black or yellow dots on scalp
    3. Positive Hair Pull Test
  6. Associated nail findings
    1. Nail Pitting (most common)
    2. Other nail findings
      1. Trachyonychia
      2. Beau Lines
      3. Onychorrhexis
      4. Onychomadesis
      5. Nail thickness changes (thinning or thickening)
      6. Leukonychia (transverse or punctate)
      7. Koilonychia
      8. Lunula red marks

VII. Labs: Options Based on Presentation

  1. KOH Scraping of patch
  2. Thyroid Stimulating Hormone (TSH)
  3. Rapid Plasma Reagin (RPR)
  4. Erythrocyte Sedimentation Rate (ESR)
  5. Complete Blood Count (CBC)
  6. Antinuclear Antibody (ANA)
  7. Rheumatoid Factor (RF)

VIII. Differential Diagnosis

  1. Other non-scarring Alopecia
  2. Tinea Capitis

IX. Associated Conditions

  1. Atopic Dermatitis
  2. Diabetes Mellitus
  3. Rheumatoid Arthritis
  4. Vitiligo
  5. Thyroid disease
  6. Pernicious Anemia
  7. Discoid Lupus Erythematosus

X. Management: Moderate Involvement (<50% of scalp involved)

  1. Intralesional Triamcinolone (Kenalog)
    1. Treatment of choice
    2. Dilute Kenalog 40 mg/ml with saline to 10 mg/ml
      1. Kenalog 40 mg/ml: 0.5 ml
      2. Saline: 2 ml
    3. Inject 0.1 ml into patch at 1 cm intervals
    4. Inject into mid-Dermis via 0.5 inch 30 gauge needle
    5. Adverse effects: Atrophy
      1. Avoid injecting too superficially
      2. Avoid injecting >0.1 ml or >10 mg/ml per site (3 ml total per session)
      3. Limit injections to no more often than every 4-6 weeks
      4. Continue until resolution or to a maximum of 6 months
  2. Adjuncts to intralesional injection
    1. Apply Topical Minoxidil 5% solution twice daily or
    2. Apply mid-potency Topical Corticosteroid (eg. Kenalog 0.1%)
      1. Apply 1 ml to entire scalp twice daily
      2. Consider in children with Alopecia Areata

XI. Management: Severe Involvement (>50% of scalp involved)

  1. Consider wig or hairpiece
  2. General: Combination therapy often used
    1. Contact sensitizers with intralesional Kenalog
      1. Most effective option
      2. Usually requires referral to dermatology
    2. Minoxidil 5% bid with Topical Steroids or Anthralin
  3. Topical Anthralin Cream (Psoriatec) 0.5 to 1% cream
    1. Course usually limited to 6 months
    2. Apply daily and leave on for 5 minutes to start
      1. Gradually increase time applied up to 60 minutes
    3. Rinse scalp well and then clean with soap
    4. New Hair Growth seen within 3 months
  4. Mid-potency Topical Corticosteroid (eg. Kenalog 0.1%)
    1. Apply 1 ml to entire scalp twice daily
  5. Topical Minoxidil 5%
    1. Use as adjunct to Anthralin or Corticosteroid
  6. Prednisone (less commonly used)
    1. Start: 40 mg orally daily for 7 days
    2. Taper: Decrease by 5 mg q3 days
    3. Course completed within 6 weeks
  7. Dermatology Consultation
    1. Contact sensitizer
      1. Dinitrochlorobenzene
      2. Diphenylcyclopropenone
      3. Squaric acid dibutyl ester
    2. Disease Modifying Antirheumatic Drug
      1. Methotrexate
      2. Immunosuppressants (e.g. Azathioprine)

XII. Course

  1. Spontaneously resolves in 6-12 months in most limited presentations (<50% scalp involved)
    1. Hair pigmentation may be different in regrowth area
    2. Some cases progress (see prognostic indicators below)
  2. Recurs in 30% of cases (often affects same area)

XIII. Prognosis: Indicators of poor prognosis

  1. Course duration longer than one year
  2. Onset of Alopecia prior to Puberty
  3. Family History of Alopecia Areata
  4. Atopic Patients
  5. Down Syndrome

XIV. References

  1. Bertolino (2000) Postgrad Med 107(7): 81-90 [PubMed]
  2. Darwin (2018) J Trichology (2):51-60 [PubMed]
  3. Longfellow (2022) Am Fam Physician 105(3): 317-8 [PubMed]
  4. Madani (2000) J Am Acad Dermatol 42: 549-66 [PubMed]
  5. Phillips (2017) Am Fam Physician 96(6): 371-8 [PubMed]
  6. Springer (2003) Am Fam Physician 68(1):93-102 [PubMed]
  7. Thiedke (2003) Am Fam Physician 67(5):1007-18 [PubMed]

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