Randy Jacobs, M.D. Patient Education

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Alopecia Areata






Alopecia areata (al-oh-PEE-shah air-ee-AH-tah) is a common condition that results in the loss of hair on the scalp and elsewhere. It usually starts with one or more small, round, smooth patches. It occurs in males and females of all ages, but young persons are affected most often. Normally, in total, hair follicles on the scalp are producing 35 meters of hair each day. In alopecia areata, the affected hair follicles slow down production drastically, become very small, and grow no hair visible above the surface for months or years. While in this hibernation-like state, the hair follicles remain alive below the surface and are ready to resume normal hair production whenever they receive the appropriate signal. Some people develop only a few bare patches and regrow them within a year even without treatment. The scalp is the most commonly affected area, but the beard in men, or any hair-baring site, can be affected alone or together with the scalp. In some, the condition spreads until all the hair on the scalp is lost alopecia totalis. In others, all the hair on the entire body is lost alopecia universalis. No matter how widespread the hair loss, the hair follicles remain alive below the skin surface, and the possibility of hair regrowth remains.


Alopecia areata is a highly unpredictable, autoimmune skin disease resulting in the loss of hair on the scalp and elsewhere on the body. This common but very challenging and capricious disease affects approximately 1.7 percent of the population overall, including more than 4 million people in the United States alone. Due to the fact that much of the public is still not familiar with alopecia areata, the disease can have a profound impact on one's life and functional status, both at work and at school.


In alopecia areata, the affected hair follicles are mistakenly attacked by a person's own immune system (white blood cells), resulting in the arrest of the hair growth stage. Alopecia areata usually starts with one or more small, round, smooth bald patches on the scalp and can progress to total scalp hair loss (alopecia totalis) or complete body hair loss (alopecia universalis).


Alopecia areata occurs in males and females of all ages and races; however, onset most often begins in childhood and can be psychologically devastating. Although not life-threatening, alopecia areata is most certainly life-altering, and its sudden onset, recurrent episodes, and unpredictable course have a profound psychological impact on the lives of those disrupted by this disease.

What is the signal that triggers the condition to start or stop?


It's not clearly known, but evidence is mounting that an immunological signal is involved. Modern immunological research is showing alopecia areata is probably an autoimmune disorder, one in which the body forms antibodies against some part of the hair follicle (a type of "self-allergy"). In those with alopecia areata, other antibodies directed against other normal parts of the body are also sometimes present, even though there is no disease or disability associated with these other antibodies.


Is alopecia areata hereditary?

Hereditary sometimes plays a role. In one out of five persons with alopecia areata, someone else in the family has also had it. Alopecia areata often occurs in families whose members have had asthma, hay fever, atopic eczema, or other autoimmune conditions such as thyroid disease, vitiligo, early-onset diabetes, rheumatoid arthritis, lupus erythematosus, pernicious anemia, or Addison's disease.


What other parts of the body are affected?

In some, the nails may develop stippling that looks as if a pin had made tiny dents in rows across the nail. In a few, the nail changes are extensive. However, other than the hair and occasionally the nails, no other part of the body is affected.


How will it affect my daily life?

In a physical sense, alopecia areata is not disabling at all. Persons with alopecia areata are usually in excellent physical health. In an emotional sense, it can be challenging, especially for those with extensive hair loss. One of the main purposes of the National Alopecia Areata Foundation is to reach out to individuals and families with alopecia areata and help them live full, productive lives. There are thousands of successful, well-adjusted, contented people living with this condition. The emotional pain of alopecia areata can be overcome with one's own inner resources, sound medical facts, and the support of others. Sometimes professional counseling from a psychiatrist, psychologist, or social worker is needed to develop one's self-confidence and good self-image.


Does the hair ever grow back?

Yes, the hair can definitely grow back, and in some cases it may or may not fall out again in time.


Is alopecia areata due to nerves?

No, alopecia areata is not a nervous disorder, and those who have it have not caused it and have no control over its course.


Should plans for school, sports, friends, career, dating, and marriage change?

No, not at all. Patients with alopecia areata can live normal, productive lives.



What treatments are available?

There are several treatments available; the choice depends mainly on age and the extent of hair loss. Alopecia areata occurs in two forms: a mild, patchy form where less than 50% of scalp hair is lost, and an extensive form where greater than 50% of scalp hair or all the scalp hair is lost. These two forms of alopecia areata behave quite differently, and the choice of treatment depends on which form is present. Current treatments do not turn alopecia areata off; they prod the sluggish follicle to produce normal hair again, and they all need to be continued until the condition turns itself off, it take months or years.


For mild, patchy alopecia areata:

Cortisone injections: For mild, patchy alopecia areata, the most common treatment in this country is the injection of cortisone into the bare patches. The injections are usually given by Dr. Jacobs or his nurse, who uses a tiny needles to give multiple injections into the skin in and around the bare patches. The injections are repeated once a week to once a month. Both the needle prick and the slight tingling are usually well tolerated by most people, and there is no discomfort after leaving the doctor's office. New hair growth is usually visible four weeks later. Treatment however, does not prevent new patches from developing. There are few side effects from local cortisone injections. Occasionally, temporary depressions in the skin result from the local injections, but these "dells" usually fill in by themselves.


Anthralin cream or ointment. Another treatment for mild, patchy alopecia areata is the application of anthralin cream or ointment. Anthralin is a synthetic, tar-like substance that has been used widely for psoriasis. Anthralin is applied as a cream or ointment to the bare patches once daily and washed off after a short time, usually 30 to 60 minutes. New hair growth is often seen in eight to twelve weeks. Anthralin can be irritating to the skin and cause temporary, brownish discoloration of the treated skin. By using short treatment times, skin irritation and skin staining are reduced without decreasing effectiveness. Care must be taken not to get anthralin in the eyes, and hands must be washed after applying.


Topical minoxidil. Topical minoxidil is the newer treatment for alopecia areata. It is discussed later.


For extensive alopecia areata, or alopecia totalis/alopecia universalis:

Wigs. For extensive alopecia areata, or alopecia totalis/alopecia universalis, treatment is more difficult. There is no simple, sure solution, and for this reason an attractive wig is often the best alternative. There are many ways to make a wig completely natural, and every wig has to be cut, thinned, and styled, often several times, until it is just right. To keep a wig from falling off, even during active sports, special double-sided sticky tape can be purchased in beauty supply outlets and fastened to the inside of the wig. There are also suction caps to which any wig can be attached, or there are entire suction cap units available.


Cortisone pills. Cortisone pills are sometimes given for extensive scalp hair loss or when the condition is rapidly spreading. Cortisone taken internally is much more powerful than local injections of cortisone into the skin. It's necessary to discuss possible side effects of cortisone pills with Dr. Jacobs. Ask your pharmacist for a list of side effects. Healthy, young adults often tolerate cortisone pills well and with few side effects. In general, however, cortisone pills are used in relatively few patients with alopecia areata because they often must be given for prolonged periods, and the regrown hair may fall out when the cortisone pills are stopped.


Allergic contact dermatitis. Another method of treating extensive alopecia areata, or alopecia totalis/universalis, is to produce an allergic rash or allergic contact dermatitis. Chemicals such as dinitrochlorobenzene (DNCB) or squaric acid dibutyl ester are applied to the scalp to produce and allergic rash which resembles poison oak or poison ivy. Approximately half the patients treated with allergic contact dermatitis will regrow the scalp hair. Those who do successfully regrow the hair still need to continue the treatment to maintain the hair regrowth, at least until the condition turns itself off. An itchy rash may be uncomfortable in very hot weather, especially under a wig. One must also be careful not to produce an itchy, allergic rash on other parts of the body. Treatment with DNCB or squaric acid dibutyl ester is not available everywhere.


PUVA. Extensive alopecia areata is sometimes treated with PUVA which combines the use of a light-sensitizing medication (psoralen) and long wave ultraviolet light (UVA). In a modest number of patients, hair regrowth is stimulated with this method. Treatments are given two or five times a week for many months at a medical center or dermatologist's office. Because of this frequent travel to a treatment center, PUVA therapy is time consuming. There is also some concern about the long-term safety of intensive ultraviolet light irradiation of the skin and skin cancer. As with DNCB, PUVA therapy is available only at certain medical centers. Dr. Jacobs can refer you for this treatment.


Topical Minoxidil. Minoxidil is a drug used to treat severe high blood pressure. One of the side effects of the oral form of the medication is a tendency to stimulate hair growth in various parts of the body. Studies have shown topical application of minoxidil in those with extensive and patchy alopecia areata will also grow hair. Twice daily applications are needed, and, after a year of treatment, many will grow sufficient hair to cover the scalp. The eyebrows and beard may also respond to such treatment. Unfortunately topical minoxidil is not effective in most individuals with 100% scalp hair loss. Minoxidil solution (Rogaine) is safe and easy to use. If you have any other questions, please ask Dr. Jacobs at your next visit.


For a support group:

National Alopecia Areata Foundation (NAAF)


PO Box 150760

San Rafael, CA




Fax 415.472.5343