There’s no better way of managing the hair loss and other manifestations brought by alopecia areata than going to Dermatology & Skin Health. Our skin experts which include the award-winning Dr. Gary Mendese, MD, FAAD, are guaranteed to help you regain your confidence back through our safe and effective treatments complemented by our knowledge and skills.
What is Alopecia Areata?
Alopecia areata is an autoimmune disorder that manifests as a non-scarring, extensive hair loss because of its impact on the hair follicles, nails, and the retinal pigment epithelium.
It's a form of alopecia that presents as a round, bald patch, differentiating it from other forms of alopecia like androgenetic alopecia or male pattern baldness that manifests as a gradual hair loss from the crown and frontal scalp.
Epidemiology
It occurs in around 2% of the population. No sexual dichotomy exists for this disease in early life, but a shift to women occurs when patients reach > 45 years of age (although this may also mean that women seek medical consultation more than men at this age).
Alopecia areata may occur in all ages, although the mean onset is between 25 to 36 years and those who present it at an early age (5 to 10 years) may present more severe forms like alopecia universalis.
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Types of Alopecia Areata
Types of alopecia areata include the following:
- Patchy alopecia areata - Patchy alopecia areata, as the name suggests, is characterized by patches of hair loss.
- Alopecia totalis - Alopecia totalis is a condition that a severe alopecia areata may progress into, which, from patchy hair loss becomes complete baldness.
- Alopecia universalis - Alopecia universalis is a condition that describes an overall loss of hair, not just of the scalp hair but other body hair as well like the eyebrows, eyelashes, and pubic hair.
- Alopecia incognita - Alopecia incognita is a total hair loss characterized by a positive pull test, yellow dots, and small regrowing hairs. Nails are not involved in this type of alopecia areata.
- Ophiasis - Ophiasis is a type of alopecia areata characterized by a band-like shape of hair loss.
- Sisaipho - Sisaipho is characterized by extensive hair loss but excluding that around the periphery of the scalp.
- Marie Antoinette syndrome - Also called canities subita, Marie Antoinette syndrome is characterized by a sudden graying of hair and preferential loss of pigmented hair.
Concurrent Diseases
A patient presenting with alopecia areata may also present with other diseases, which include the following:
- Depression
- Anxiety
- Hyperthyroidism
- Hypothyroidism
- Goiter Anti Thyroiditis
- Lupus Erythematosus
- Vitiligo
- Psoriasis
- Rheumatoid Arthritis
- Inflammatory Bowel Disease
Other Forms Of Hair Loss
Whereas other forms of widespread hair loss include the following:
- Involutional alopecia - Involutional alopecia is the gradual thinning of hair with age due to more hair staying in the telogen phase (resting phase) of the hair growth cycle.
- Telogen effluvium - Telogen effluvium is a temporary scalp hair loss also due to more hair staying in the telogen phase of the hair growth cycle.
- Trichotillomania - Trichotillomania is a psychological disorder manifested with a person picking their own hair and may even ingest it.
- Scarring alopecia - Scarring alopecia is a permanent hair loss due to skin disorders like lichen planus which can impair the regenerating capacity of the hair. This is different from the temporary hair loss caused by atopic dermatitis, in which excessive scratching causes the hair to fall out.
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What Causes Alopecia?
Alopecia may be caused by an interplay of different factors, namely genetics, and immune response. Other contributing factors that cause alopecia include oxidative stress, vascular and lymphatic system, and environmental triggers.
Genetic Factors
Due to its autoimmune nature, studies on the genetic basis of alopecia areata focused on genes that encode key immune regulators. These genes include the HLA region, a determinant of MHC molecules in humans and is also a major contributor to the alopecia areata phenotype.
Aside from HLA, other genes implicated in the causation of alopecia areata include:
- KLRK1 that encodes for the natural killer (NK) cell receptor D
- ULBP3 that encodes for NKG2DL3 ligand
- RAET1L that encodes the retinoic acid early transcript 1L protein
Immune Response
Alopecia areata is an autoimmune disease, meaning it’s a disorder that occurs when the immune system mistakenly attacks healthy cells because they fail to correctly recognize them. The primary target of this impaired immune response is the hair follicle matrix epithelium.
This is further exacerbated by the fact that hair follicles lose their immune privilege in alopecia areata. The hair follicle, which, in normal conditions has local immune-inhibitory signaling, fails to exhibit this key process, which is then thought to be the major factor in the causation of alopecia areata.
Moreover, autoantigen epitopes are also shown to be involved in the initiation of alopecia areata. As evidence of this, synthetic epitopes from trichohyalin and tyrosinase-related protein-2 are shown to bring higher immune responses in patients with alopecia areata.
Other Contributing Factors
Other contributing factors that are associated with the causation of alopecia areata include the following:
- Oxidative Stress - High levels of biological markers such as malondialdehyde (indicates the peroxidation of fat cells) are seen in patients with alopecia areata as compared to healthier patients. Antibodies against superoxide dismutase (SOD) are also seen in patients with alopecia areata. This suggests a role of oxidative stress and damage to the SOD in the causation of alopecia areata.
- Vasculature and Lymphatic System - Inflammation occurs as a result of an increased blood supply resulting from increased production of new vessels, in both the circulatory and lymphatic systems. This leads to increased temperature in areas affected by alopecia areata.
- Microbiota - Due to the link between inflammatory bowel disease and alopecia areata, research is currently being directed to the effects of the microbiota on alopecia areata and is an interesting therapeutic target for alopecia areata treatment.
- Environmental Triggers - Emotional and physical stress is implicated as an environmental cause of alopecia areata. Other potential triggers associated with this disease entity include vaccinations, flu virus infection, and administration of certain drugs.
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How Is It Diagnosed?
Alopecia areata may be diagnosed by looking at the clinical features presented by the patient. Tests such as dermoscopy and histopathology may also be done to further validate the diagnosis, although it's not needed in most cases.
Clinical Features
Alopecia areata is initially identified via its signs and symptoms, most notably the loss of hair on the scalp, although it can also happen in other body parts as well.
Nails may show pitting and longitudinal striations (trachyonychia) as well, with individuals with nail involvement typically having severe hair loss. Loss of nails may also be observed in rare instances.
Classification of Severity
A scoring system called the Severity of Alopecia Tool (SALT) score and alopecia areata progression index is used to quantify the severity of alopecia areata.
Dermoscopy
Dermoscopy is a diagnostic procedure where the skin is examined using a skin surface microscope. It helps differentiate alopecia areata from other disorders that cause hair loss.
In dermoscopy, observations in alopecia areata include the following:
- yellow dots
- black dots
- broken hairs
- exclamation point hairs
- short vellus hairs
Histopathology
Skin biopsy is another diagnostic modality employed to further ascertain the diagnosis, especially done to differentiate alopecia areata from early-scarring alopecia. Transverse and horizontal sections are the ones reviewed for better histopathological observations.
How Is It Treated?
Treatment for alopecia areata only entails management of symptoms (i.e., help in hair regrowth) and doesn't bring a cure to the disease, as there isn't a discovered cure yet for alopecia areata. As such, management may be done medically where medications may be given, and non-medically where laser treatment and psychological support may be given.
Medical Management
Medical management may be done by administering the following pharmacological agents:
- Local Corticosteroids - Local corticosteroids may be in the form of topical corticosteroids or intralesional steroid administration. They’re effective for mild cases of alopecia areata but aren’t useful for more severe forms like alopecia totalis or alopecia universalis. Topical steroids must also be stopped after 6 months if the patient is unresponsive. Side effects also include folliculitis or the inflammation of the hair follicle.
- Systemic Corticosteroids - Taking oral corticosteroids is shown to help in hair regrowth. While continued use is necessary to yield optimum results, it’s shown that the response from the drug isn’t enough to outweigh the adverse effects of the drug.
- Contact Immunotherapy - Contact immunotherapy entails the sensitization of the patient by applying a potent allergen on the scalp of the patient with alopecia areata, although it may also result in mild contact dermatitis. Common allergens used include diphenylcyclopropenone and squaric acid dibutylester.
- Second-line Therapies - Second-line therapies include minoxidil, anthralin, and PUVA.
- Investigational Treatments - Investigational treatments are currently being reviewed for efficacy and safety, which include tofacitinib (a JAK inhibitor), simvastatin with ezetimibe, hydroxychloroquine, etc.
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Dermatology & Skin Health
At Dermatology & Skin Health, our excellent dermatology services are guaranteed to be safe and effective, performed by the top doctors in their respective fields. Treat your skin problems by contacting us today.
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Non-Medical Management
Non-medical management includes laser therapy, photochemotherapy, and psychological support.
- Laser Therapy - Laser therapy is believed to be a potential alternative to medical treatments for alopecia areata. However, randomized controlled clinical trials are necessary to confirm this since an increase in hair shaft diameter may be the only result of this procedure.
- Photochemotherapy - 60-65% success rate is claimed for all types of PUVA in uncontrolled studies, but these yield inconsistent results, as there are retrospective results that report low response rates or a response akin to a placebo. This procedure may also lead to an unnecessarily high build-up of UV exposure.
- Psychological Support - Coping mechanisms are necessary for patients with alopecia areata, especially those where therapies fail because most of them often suffer from clinically significant depression. Patient support organizations such as the National Alopecia Areata Foundation may also be reached out to help the patients cope with what’s happening to their hair.
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At Dermatology & Skin Health, patient satisfaction is our top priority with the expertise of our healthcare staff combined with revolutionary hair growth procedures. We're here to help you reclaim your self-esteem through effective and safe treatments that can help in hair regrowth. Contact us today at (603) 742-5556 (Dover & Newington), (978) 525-0100 (Peabody), (603) 965-3551 (Londonderry), or (603) 742-5556 (Bedford) or schedule your appointment online to start your hair regrowth journey with us.
We're Actively Treating Alopecia Areata around the Following Service Areas:
*A non-exhaustive list of areas we service
- Nashua, NH
- Fremont, NH
- Hamilton, MA
- Wenham, MA
- Andover, MA
- Boxford, MA
- Middleton, MA
- North Reading, MA
- Reading, MA
- Lynnfield, MA
- Stoneham, MA
- Wakefield, MA
- Saugus, MA
- Lynn, MA
- Essex, MA
- Manchester-by-the-Sea, MA
- Beverly, MA
- Danvers, MA
- Peabody, MA
- Hooksett, NH
- Milford, NH
- Goffstown, NH
- Candia, NH
- Auburn, NH
- Merrimack, NH
- Manchester, NH
- Bedford, NH
- Salem, NH
- Methuen, NH
- Windham, NH
- Pelham, NH
- Litchfield, NH
- Hampstead, NH
- Sandown, NH
- Chester, NH
- Derry, NH
- Londonderry, NH
- York, ME
- New Castle, NH
- Kittery, ME
- Portsmouth, NH
- Greenland, NH
- Rye, NH
- North Hampton, NH
- Exeter, NH
- Stratham, NH
- Newfields, NH
- Newmarket, NH
- Durham, NH
- Newington, NH
- Eliot, ME
- Barrington, NH
- Madbury, NH
- North Berwick, NH
- South Berwick, NH
- Rochester, NH
- Somersworth, NH
- Dover, NH
