Spot Baldness
Alopecia areata (AA), commonly known as “spot baldness” or “alopecia areata,” is a prevalent non-scarring hair loss condition. Currently, it is generally believed to be associated with factors such as autoimmune responses, genetics, emotional stress, and endocrine imbalances.
Clinically, it is characterized by the sudden appearance of well-defined, patchy hair loss areas. These areas exhibit no scarring or inflammation.
What is the prevalence of alopecia areata ?
Based on incidence rates, the prevalence of alopecia areata in the general population is approximately 0.1% to 0.2%, with around 7% to 10% of cases classified as moderate to severe alopecia areata.
Alopecia areata can occur at any age, with a higher incidence in young and middle-aged adults. About 1.7% of the population will experience alopecia areata at some point in their lifetime.
What are the types of alopecia areata?
Alopecia areata can be categorized based on the extent of hair involvement into focal patchy alopecia (AAP), totalis alopecia (AT), and universalis alopecia (AU).
1. **Focal Patchy Alopecia (AAP):** Occurs in specific areas with well-defined patchy hair loss.
2. **Totalis Alopecia (AT):** Involves complete hair loss across the entire scalp.
3. **Universalis Alopecia (AU):** Involves complete hair loss not only on the scalp but also on the entire body.
Neurological and psychological factors, endocrine imbalances, and other factors are believed to be related to alopecia areata. Approximately 25% of cases have an unclear etiology, but it is currently understood that factors such as autoimmune responses, genetics (including a family history), and neurological and psychological factors play significant roles.
What are the causes of alopecia areata?
Immune Factors:
The breakdown of immune tolerance in hair follicles is a key factor in the development of alopecia areata. It often coexists with autoimmune-related disorders such as hyperthyroidism, vitiligo, and Sjögren’s syndrome.
Genetics:
There is a hereditary basis for the occurrence of alopecia areata. Monozygotic twins with a sibling suffering from alopecia areata have a high probability (up to 55%) of also developing the condition. Around 10% to 20% of parents who have experienced alopecia areata will have at least one child affected by it.
What are the triggering factors of alopecia areata?
Environmental Factors and Susceptibility:
There is a certain relationship between environmental factors and the susceptibility, severity, course, response to treatment, and prognosis of alopecia areata.
Neurological and Psychological Factors:
Alopecia areata can be triggered by psychological stressors such as tension, anxiety, depression, insomnia, and nervous exhaustion.
Infections:
Alopecia areata can occur following diseases like shingles, fungal infections, influenza, and syphilis. This might be related to a lowered immune response due to infections.
Allergies:
Alopecia areata patients have a higher likelihood of concurrent atopic dermatitis compared to the general population. Some patients with alopecia areata exhibit elevated total IgE levels and specific IgE levels to dust.
Characteristics of Hair Loss Areas:
Sudden onset, circular or oval shape, varying sizes and numbers, clear borders, smooth skin at the hair loss site, absence of inflammation, scales, or scarring.
Staging of the Condition:
Progressive Stage:
Hair along the edges of the affected area becomes loose and easily plucked. When observed under a microscope, the pulled-out hair displays a characteristic exclamation mark pattern, with the hair shaft near the scalp appearing shrunken and tapering from thick to thin.
Static Stage:
Hair along the edges of the hair loss area is no longer loose, and after about 3 to 4 months, the condition enters a recovery phase.
Recovery Stage:
New hair starts to grow, initially as fine and light-colored vellus hairs, gradually becoming thicker and darker until a full recovery is achieved.
Special Manifestations:
Totalis Pattern: Complete loss of hair on the scalp.
Universalis Pattern: Complete loss of hair on the scalp, eyebrows, eyelashes, underarm hair, pubic hair, etc.
Ophiasis Pattern: Band-like hair loss along the scalp’s temporal and occipital edges.
Nail Changes: Nails (fingers and toes) may become uneven, rough, or detached; this is common in children.
Alopecia areata patients typically don’t experience discomfort aside from hair loss. However, when there are numerous hair loss patches or the affected area is extensive, impacting daily life, medical treatment is necessary.
Certain cases of alopecia areata have a low likelihood of self-recovery, such as ophiasis pattern or cases in young individuals. In such situations, prompt medical intervention is crucial.
Indications for Medical Consultation:
1. Sudden occurrence of one or multiple well-defined hair loss patches affecting appearance and causing severe psychological stress.
2. Expanding hair loss patches.
3. Widespread hair loss, including loss of scalp, eyebrow, eyelash, and other body hair.
4. Hair loss in children, especially if accompanied by changes in nails like unevenness or roughness.
5. Patchy hair loss associated with other conditions like diabetes, vitiligo, thyroid disorders, or mental health conditions such as depression.
If any of these conditions are present, seeking medical attention is advised.
Diagnostic Process:
After seeking medical attention, the doctor may ask the following questions:
- When did the hair loss start, and how has it progressed?
- Does anyone in your family have a history of hair loss?
- Have you experienced hair loss before?
- Do you have a history of conditions such as vitiligo, diabetes, thyroid disorders, or depression?
- Have you undergone any treatment, and what were the results?
The doctor will observe the affected areas, conduct a hair pull test if necessary, perform dermatoscopy, and consider further tests like tissue pathology examination to confirm the diagnosis.
Which medical department should you visit for alopecia areata?
Dermatology
What are the relevant examinations for alopecia areata?
1. **Hair Pull Test:**
The patient refrains from washing their hair for 5 days. Then, using the thumb and index finger, a bundle of hair (approximately fifty to sixty strands) is gently pulled, and a light force is applied along the direction of hair growth towards the tips. The number of pulled-out hairs is counted. If more than 6 hairs are pulled, it’s considered positive, indicating active hair loss. Less than 6 hairs being pulled is considered negative.
2. **Microscopic Examination:**
Hair pulled from the edge of the hair loss area reveals tapered hair shafts under the microscope, resembling exclamation mark shapes, with the lower portion of the hair shaft being shrunken and the upper part thicker.
3. **Dermoscopy:**
Dermoscopy of the hair loss area can reveal features like yellow dots, black dots, broken hairs, exclamation mark hairs, dystrophic (unhealthy) hairs, and short vellus-like hairs.
These examinations help in the diagnosis and assessment of alopecia areata’s progression stage and characteristics. Always consult with a medical professional for accurate evaluation and interpretation of test results.
What diseases should alopecia areata be distinguished from?
1. **Pseudopelade of Brocq:**
Also known as “false alopecia areata,” this condition is characterized by hair loss with scalp atrophy. The edges are irregular, and follicular openings disappear. The hair at the edge of the bald area doesn’t pull out easily (negative pull test). It progresses slowly and is often secondary to inflammatory skin conditions like lupus erythematosus, lichen planus, and flat lichen. It results in permanent hair loss.
2. **Tinea Capitis (Ringworm):**
Caused by fungal infection. It’s more common in children. Hair loss isn’t complete, and hair is easily broken. Residual hair roots remain, and scales or crusts may be present, often with detectable fungal elements in broken hair.
3. **Trichotillomania:**
Common in children and driven by psychological and behavioral abnormalities. The hair loss area’s appearance is irregular and bizarre, with varying lengths of broken hair, often jagged and uneven. Hair at the edge of the area doesn’t pull out easily in the pull test.
4. **Folliculitis Decalvans (Tufted Folliculitis):**
Caused by bacterial infection. Localized infection of the hair follicles leads to scarring and hair loss. It’s characterized by follicular pustules and tufted hair follicles. Recurrent outbreaks can occur.
Proper diagnosis requires a skilled medical professional, and clinical context and testing are important for differentiation.
The goal of treating alopecia areata is to stop disease progression, alleviate hair loss symptoms, and promote hair regrowth. Treatment often involves using topical or systemic medications and may also include physical therapies like phototherapy.
**General Treatment Measures for Alopecia Areata:**
1. Actively treat underlying conditions like diabetes, thyroid disorders, nervousness, and infections to remove triggering factors.
2. Avoid stress, ensure adequate sleep, maintain a balanced diet, and establish a regular daily routine to alleviate psychological burden.
3. Hairstyle changes, wearing suitable wigs or hairpieces, can help manage the appearance and boost self-esteem.
**Medication Treatments for Alopecia Areata:**
Due to significant individual variability, there’s no universally “best,” “fastest,” or “most effective” medication. Beyond over-the-counter options, the choice of medication should be guided by a doctor and tailored to the individual’s condition.
**Topical Medications:**
* **Topical Corticosteroid Injections:**
Also known as “localized blocked therapy.” Long-acting corticosteroids are injected into the affected scalp area to suppress inflammation and immune responses around the hair follicles. Adverse effects might include local pain, skin atrophy, and depigmentation.
Remember that treatment outcomes can vary widely, and a personalized approach under medical supervision is crucial.
**Topical Medications for Alopecia Areata:**
**Potent Topical Corticosteroids:**
These have anti-inflammatory and immune-suppressive effects and are widely used to treat pediatric alopecia areata or adult alopecia areata with less than 50% hair loss. Coupled with “occlusive therapy” (applying plastic wrap over the scalp after applying corticosteroid cream), it enhances drug absorption in the local scalp area, boosting effectiveness. Folliculitis is a common adverse reaction.
**Topical Minoxidil:**
It works by dilating local blood vessels, promoting hair transition from the resting phase to the growth phase, and accelerating hair regrowth. Commonly available in 2% and 5% concentrations, the 5% concentration yields better results but also carries a relatively higher risk of adverse effects. Contact dermatitis and increased hair growth are the main adverse reactions.
**Topical Sensitizers:**
Application of sensitizers outside the alopecia areata lesion induces artificial allergic contact dermatitis, promoting local hair regrowth. Diphencyprone (DPCP) is the most commonly used sensitizing agent for alopecia areata treatment. Adverse reactions include itching, dermatitis, vesicles, and lymph node enlargement at the application site.
**Topical Diphenylcyclopropenone (DPCP):**
A stimulant with anti-inflammatory and immune-suppressive effects, mainly used for adults with chronic or severe alopecia areata and children with severe forms. Commonly used concentrations range from 0.5% to 1%. Adverse reactions include folliculitis, contact dermatitis, and local lymph node enlargement.
These topical treatments offer various mechanisms to promote hair regrowth in cases of alopecia areata. It’s important to consult a healthcare professional before starting any treatment to determine the most suitable approach based on individual circumstances.
**Systemic Medications for Alopecia Areata:**
**Corticosteroids:**
Oral or injectable corticosteroid therapy is suitable for rapidly progressing cases of alopecia areata with extensive hair loss, such as advanced-stage alopecia areata, totalis, and universalis. While effectively controlling hair loss and promoting regrowth, monitoring for steroid-related adverse effects is crucial. These can include weight gain, increased blood pressure, osteoporosis, gastrointestinal ulcers, and acneiform dermatitis.
**Immunosuppressants:**
Immunosuppressive agents like cyclosporine and methotrexate have anti-inflammatory and immunosuppressive effects and can be used to treat alopecia areata. However, due to relatively significant adverse effects, they are considered when the condition is severe, other treatments are ineffective, or in cases with specific contraindications.
**Other Approaches:**
- **Herbal Extracts:**
Compound glycyrrhizinic acid has anti-inflammatory and immunomodulatory effects and has shown relatively clear efficacy and safety in alopecia areata treatment. Adverse reactions mainly include increased blood pressure, dizziness, and edema. Extracts of white peony root also possess similar properties, with the primary adverse reaction being diarrhea.
- **Antihistamines and Mast Cell Stabilizers:**
For cases where traditional treatment approaches are ineffective or in individuals with a predisposition to allergies, combining oral antihistamines (such as cetirizine) and mast cell stabilizers (such as montelukast) can promote hair growth.
Systemic medications offer a range of options for treating alopecia areata, and their selection depends on factors like disease severity, patient tolerance, and response to other treatments. A healthcare professional’s guidance is essential to determine the most suitable approach for each individual.
**Surgical Treatments for Alopecia Areata:**
It’s worth noting that surgical treatments are generally not the primary approach for managing alopecia areata. However, in cases of severe and resistant alopecia areata or for those who have not responded well to other treatments, some surgical options may be considered:
1. **Hair Transplantation:** Hair transplantation involves taking hair follicles from areas with normal hair growth (donor sites) and transplanting them into the areas affected by alopecia areata. This technique can be effective in cases of localized hair loss. However, its success depends on factors such as the availability of donor hair and the patient’s specific condition.
2. **Microblading or Micropigmentation:** These are techniques commonly used for eyebrows and other areas of the face. Pigments are applied to the skin to mimic the appearance of hair follicles, providing a more natural look to the affected areas.
**Traditional Chinese Medicine (TCM) Approaches for Alopecia Areata:**
TCM treatment for alopecia areata usually involves a combination of methods, including herbal medicine, acupuncture, and dietary adjustments. Practitioners will focus on identifying the underlying imbalances in the body and use tailored treatments based on TCM principles. These treatments aim to promote overall health, balance Qi (energy flow), and support the body’s self-healing mechanisms.
**Other Treatment Approaches:**
- **Phototherapy:** Phototherapy techniques such as ultraviolet (UV) light exposure, photodynamic therapy, excimer lasers, low-level lasers, and fractional CO2 lasers have shown some therapeutic effects for alopecia areata.
- **Platelet-Rich Plasma (PRP) Injection:** Local injections of PRP, a concentration of platelets from the patient’s own blood, can stimulate hair follicles and promote hair growth.
- **Microneedling and Acupuncture:** Techniques involving local needling, like microneedling or acupuncture, may have a positive impact on hair growth in alopecia areata cases.
These additional treatment options can serve as adjuncts to conventional therapies, especially for more resistant cases of alopecia areata. It’s important to work with a qualified healthcare provider to determine the most appropriate treatment plan based on individual circumstances.
New Advancements？
In recent years, there have been new advancements in the treatment of alopecia areata, particularly for patients who do not respond to conventional treatment methods.
**JAK Inhibitor Treatment:** JAK inhibitors are a class of drugs that target Janus kinases (JAKs) and regulate immune responses and inflammatory processes. Representative examples include Tofacitinib, Ruxolitinib, and Baricitinib. These medications interfere with the signaling pathways of the immune response, improving the immune environment of hair follicles and promoting hair regrowth.
Recent clinical studies have shown that oral JAK inhibitor treatment has significant effects on moderate to severe alopecia areata patients. Approximately half of the patients experience almost complete hair regrowth after treatment. This approach is relatively safe, with the main adverse effects being minor upper respiratory tract infections.
It is important to note that JAK inhibitors are still under research and clinical application, and their long-term safety and effectiveness require further study and monitoring.
The new treatment advancements offer hope for alopecia areata patients who do not respond well to traditional therapies. These advancements also underscore the importance of personalized treatment, as the choice of treatment should be based on the individual patient’s circumstances.
The course of alopecia areata can last for several months to several years, during which most of the hair can regrow, but relapses can also occur.
Alopecia areata can resolve naturally, with complete recovery observed in about 40% to 70% of patients with localized patchy hair loss. The larger the affected area, the lower the probability of complete hair regrowth, and the more likely it is to become chronic. However, acute and extensive cases of totalis and universalis alopecia are exceptions, as they progress rapidly but have a high likelihood of spontaneous recovery.
Elderly individuals with alopecia areata tend to have milder cases and respond better to treatment. Severe forms such as alopecia areata incognito, totalis, universalis, as well as cases associated with nail involvement, childhood onset, atopic constitution, and concurrent autoimmune diseases, are relatively challenging to treat and have a higher recurrence rate.
For alopecia areata patients, managing daily life involves several considerations:
1. **Maintain a Regular Routine:** Keeping a consistent daily schedule, including balanced work and rest, is important. Adequate sleep and managing stress are beneficial for overall well-being.
2. **Healthy Diet:** While there are no specific dietary restrictions, focusing on a well-rounded and nutritious diet is essential. A diet rich in vitamins, minerals, and proteins can contribute to hair health.
3. **Stress Management:** Stress is often linked to the onset or exacerbation of alopecia areata. Practicing stress-reduction techniques such as meditation, yoga, and relaxation exercises can be helpful.
4. **Hair Care:** Be gentle with your hair and avoid excessive styling or treatments that could further stress the hair follicles. Using mild shampoos and avoiding harsh chemicals can also be beneficial.
5. **Avoid Harsh Hair Practices:** Avoid tight hairstyles that could put strain on the hair shafts. Gentle brushing and avoiding excessive heat styling can help prevent further hair damage.
6. **Sun Protection:** If the affected area is exposed to sunlight, consider using sunblock or protective clothing to prevent sunburn on the scalp.
7. **Psychological Support:** Living with alopecia areata can have emotional effects. Seeking support from friends, family, or support groups can help cope with the psychological impact.
8. **Regular Check-ups:** It’s important to keep up with regular medical check-ups to monitor the condition’s progression and response to treatment.
Remember, while these lifestyle management strategies can contribute to overall well-being, it’s crucial to work closely with a healthcare professional to develop a comprehensive treatment plan tailored to individual needs.
Preventing alopecia areata:
The specific causes of alopecia areata are not yet fully understood, but you can take steps to potentially reduce the risk of its occurrence.
1. **Emotional Management:** Maintain a positive and optimistic mindset, avoiding excessive stress, anxiety, and depression. Emotional well-being might be linked to the onset of alopecia areata.
2. **Regular Exercise:** Engage in appropriate physical activities to enhance your overall resistance and immune system.
Please note that while these measures might contribute to reducing the risk, there is no guaranteed method for preventing alopecia areata as its underlying causes remain unclear.
