Hair
Alopecia Areata
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Alopecia Areata
, Alopecia Totalis, Alopecia Universalis, Exclamation Point Hair
See Also
Alopecia
Definition
Non-scarring autoimmune
Alopecia
Epidemiology
No gender predominance
Most common under age 30 years
Children account for 20% of patients
Prevalence
: 0.2% up to 2% of U.S. population
Types
Patch
y Alopecia Areata
Well circumscribed, flesh colored, oval patches of
Hair Loss
Alopecia Totalis
Hair Loss
over entire scalp
Alopecia Universalis
Hair Loss
over entire body
Signs
Well-demarcated oval patches of
Hair Loss
Exclamation Point Hairs at edges of
Hair Loss
(as visualized under microscope)
Club shaped
Hair Root
Thin proximal
Hair Shaft
Normal caliber distal
Hair Shaft
Non-specific findings
Short
Vellus Hair
s or 2-3 mm broken hairs
Black or yellow dots on scalp
Other associated findings
Nail Pitting
Labs
Options based on presentation
KOH Scraping of patch
Thyroid Stimulating Hormone
(TSH)
Rapid Plasma Reagin
(RPR)
Erythrocyte Sedimentation Rate
(ESR)
Complete Blood Count
(CBC)
Antinuclear Antibody
(ANA)
Rheumatoid Factor
(RF)
Differential Diagnosis
Other non-scarring
Alopecia
Tinea Capitis
Associated Conditions
Atopic Dermatitis
Diabetes Mellitus
Rheumatoid Arthritis
Vitiligo
Thyroid
disease
Pernicious Anemia
Discoid Lupus Erythematosus
Management
Moderate Involvement (<50% of scalp involved)
Intralesional Triamcinolone (
Kenalog
)
Treatment of choice
Dilute
Kenalog
40 mg/ml with saline to 10 mg/ml
Kenalog
40 mg/ml: 0.5 ml
Saline: 2 ml
Inject 0.1 ml into patch at 1 cm intervals
Inject into mid-
Dermis
via 0.5 inch 30 gauge needle
Adverse effects: Atrophy
Avoid injecting too superficially
Avoid injecting >0.1 ml or >10 mg/ml per site (3 ml total per session)
Limit injections to no more often than every 4-6 weeks
Continue until resolution or to a maximum of 6 months
Adjuncts to intralesional injection
Apply
Minoxidil
5% solution twice daily or
Mid-potency
Topical Corticosteroid
(eg.
Kenalog
0.1%)
Apply 1 ml to entire scalp twice daily
Management
Severe Involvement (>50% of scalp involved)
Consider wig or hairpiece
Gene
ral: Combination therapy often used
Contact sensitizers with intralesional
Kenalog
Most effective option
Usually requires referral to dermatology
Minoxidil
5% bid with
Topical Steroid
s or
Anthralin
Topical
Anthralin
Cream (Psoriatec) 0.5 to 1% cream
Course usually limited to 6 months
Apply daily and leave on for 5 minutes to start
Gradually increase time applied up to 60 minutes
Rinse scalp well and then clean with soap
New
Hair Growth
seen within 3 months
Mid-potency
Topical Corticosteroid
(eg.
Kenalog
0.1%)
Apply 1 ml to entire scalp twice daily
Topical
Minoxidil
5%
Use as adjunct to
Anthralin
or
Corticosteroid
Prednisone
(less commonly used)
Start: 40 mg orally daily for 7 days
Taper: Decrease by 5 mg q3 days
Course completed within 6 weeks
Dermatology
Consultation
for contact sensitizer
Dinitrochlorobenzene
Diphenylcyclopropenone
Squaric acid dibutyl ester
Course
Spontaneously resolves in 6-12 months in most cases
Hair
pigmentation may be different in regrowth area
Some cases progress (see prognostic indicators below)
Recurs in 30% of cases (often affects same area)
Prognosis
Indicators of poor prognosis
Course duration longer than one year
Onset of
Alopecia
prior to
Puberty
Family History
of Alopecia Areata
Atopic Patient
s
Down Syndrome
References
Bertolino (2000) Postgrad Med 107(7): 81-90 [PubMed]
Madani (2000) J Am Acad Dermatol 42: 549-66 [PubMed]
Phillips (2017) Am Fam Physician 96(6): 371-8 [PubMed]
Springer (2003) Am Fam Physician 68(1):93-102 [PubMed]
Thiedke (2003) Am Fam Physician 67(5):1007-18 [PubMed]
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