Baldness (Alopecia)

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Overview

Alopecia areata is a common type of hair loss that affects approximately 2% of the population, or more than 4 million people in the United States. It affects both men and women, predominately children and young adults, but it can also develop in older adults. It usually starts out as smooth, small, round or oval patches of baldness that rapidly form on one side of the head.

The edges of the patches are usually studded with "exclamation point hairs." Erythema (inflammatory redness of the skin) may be present early on. For most people, the hair regrows within a year without treatment. The longer the time before hair regrows, the less likely it will regrow without treatment. Sometimes, the hair loss is permanent.

Causes

Alopecia areata is an autoimmune disease (i.e., the immune system attacks the hair follicles). The follicles become very small, hair production slows, and there is a lack of visible hair for months or years. Yet, the follicles usually resume normal hair growth within a year.

Attacks of alopecia areata are often associated with other autoimmune conditions such as lupus and allergies. In about 20% of cases, the patient is related to someone who has or has had the disease.

Signs and Symptoms

Alopecia areata usually appears as one or two bald patches on one side of the head, but also causes thinning all over the scalp. In the areas of baldness, the hairs are very short, broken, and narrow. They look like exclamation points and are sometimes called "exclamation point hairs." They can usually be seen with a hand lens.

Alopecia areata has a variable course. In some cases, the bald patches regrow within a few months or a year. Sometimes, extensive patchiness develops. Extensive alopecia has a poor prognosis. There is about a 25% recurrence rate. All the hair from the scalp (alopecia totalis) or all the hair over the entire body (alopecia universalis) may be lost. Individuals may have patchy or even more diffuse hair loss on the scalp and/or body.

Fingernails or toenails can be affected. The nails are stippled with rows of what look like tiny pin pricks. Rarely, the nails may be entirely distorted.

Diagnosis

The hair is sometimes biopsied to confirm the diagnosis. A biopsy involves taking a sample of hair and looking at it under a microscope to determine if there are lymphocytes (immune system cells)inside the hair follicles.

Treatment

There is no cure for alopecia areata. A combination of treatments is often the best approach. Treatment usually depends upon how severe the hair loss is and whether it involves only one or two patches or is more extensive. Many advertised treatments have no proven benefit.

Systemic

Monthly steroid (cortisone) injections are the most common treatment for milder cases and small bald patches. A very small needle is used to inject cortisone into and around the bald areas. The patient may feel a mild tingling sensation during the injection.

New hair growth is usually visible within a few weeks. Injections can initiate new hair growth in bald patches, but don't prevent other patches from developing. Sometimes the injections cause small, temporary depressions in the scalp called dells.

Cortisone pills are sometimes prescribed in patients with more complete hair loss. Patients should be aware that cortisone could cause serious side effects when used for a long period of time. The hair that regrows usually falls out when this treatment stops.

Topical

The synthetic corticosteroid clobestrol (ointment or cream) and the corticosteroid fluocinonide (cream) are applied to the scalp. They have been used to treat alopecia for years.

Topical minoxidil is applied twice a day to the bald patches, sometimes followed 30 minutes later with an application of cortisone cream. Minoxidil is not effective on severe cases of alopecia. Minoxidil is intended for treatment of hereditary balding only.

Anthralin cream or ointment, a synthetic substance similar to coal tar, has some benefit in treating mild cases of alopecia areata. It is applied to the bare patches once a day and then washed off 30 to 60 minutes later. New hair growth is visible within 8 to 12 weeks. Prolonged treatment with anthralin can cause skin irritation and a temporary brownish discoloration. Some dermatologists prescribe daily anthralin treatment only after monthly steroid injections have proven ineffective.

Topical immunotherapy (cyclosporine) causes an allergic reaction that resembles poison oak or ivy. Hair grows back after about 6 months of treatment. This treatment works for about 40% of patients. Because it itches, it can be unpleasant in hot weather, especially if the patient wears a wig.

A combination of medicines such as minoxidil, irritants (anthralin, topical coal tar), and topical immunotherapy (cyclosporine) is effective in some cases.

Other

Although not a treatment per se, some people with extensive or total hair loss that does not respond to treatment choose to wear wigs.

Aromatherapy with essential oils has proven effective in some patients. In particular, cedarwood, lavender, thyme, and rosemary oils have been used with success.

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