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ALOPECIA AREATA: WHAT IS IT?

Skin and Psoriasis Foundation &
Alopecia Areata Support Association ( http://home.vicnet.net.au/~aasa/).

Alopecia means hair loss.

Alopecia areata is a particular disease affecting hair growth in the scalp and elsewhere. This loss is the cause of great concern to those affected, since the hair is the most important part of our "body image".

WHO GETS ALOPECIA AREATA?: The condition can commence in children, and is most common in teenagers and young adults. It can occur for the first time in old age. Most studies show that males and females are equally affected.

IS IT INFECTIOUS?: No. There is no way that a person with alopecia can transmit the problem to anyone else, and it is not "caught" by using someone else's comb or towel.

IS ALOPECIA AREATA INHERITED?: This condition usually affects one member of a family. As will be discussed later, some related conditions can appear in other family members, and occurrence of alopecia in relatives would be possible but unlikely.

IS IT COMMON?: No figures are available to answer this question - but 1-2% of new patients seen by dermatologists have alopecia areata. It is perhaps best to say it is not "uncommon".

HOW DOES IT START?: Usually a bare scalp patch is noticed by the patient - or by hairdressers or relatives. It is unusual for the lost hair to be seen on the comb or on washing the hair.

WHAT AREAS ARE AFFECTED?: The scalp is the usual area, but the beard in men, and eyelashes or eyebrows, may be affected alone or together with scalp hair loss. In the uncommon severe forms, body hair may be lost as well. The only other structures affected are the nails - and people with severe alopecia areata may show dull and rigid finger nails.

WHAT DOES IT LOOK LIKE?: The patches are smooth, with few remaining hairs in the centre. Round the edge of the patch stub-like hairs can usually be seen (often called "exclamation mark" hairs as they are they are thicker at the tip than at scalp level).

CAN THE LOSS BE DIFFUSE?: Less commonly, some hair may be lost over wide areas, causing general thinning of the hair. This can cause the hair to "turn white overnight" by selectively affecting dark hairs and leaving grey hairs.

WHAT CONDITIONS CAN LOOK SIMILAR?: In children, tinea (ringworm) can produce hairless patches, but usually the hairs are broken and not lost, and the area is inflamed. The condition which most closely resembles alopecia areata occurs with the habit of "hair pulling" when this is confined to one area and is severe. Scalp diseases with scarring or diffuse hair loss due to other causes are significantly different from alopecia areata.

HOW IS IT DIAGNOSED?: The diagnosis is made from the story of loss and seeing the typical patch of bare skin. It is very rare for tests to be needed to make a diagnosis.

WHAT TESTS CAN BE PERFORMED?: Hair can be plucked and examined under a microscope, and if tinea is suspected, hairs may be taken for culture. For very careful study, a small biopsy may be performed for microscopical examination of the scalp skin. In most cases, tests are performed only if there is a need to access general health: blood tests do not show any abnormality in alopecia areata.

WHAT CAUSES ALOPECIA AREATA?: The mechanism is known- inflammation develops round hair roots, and the hair roots become inactive and shrink in size. However the cause of this inflammation is not understood.
It is safe to say that no simple explanation such as deficiency of vitamins or other food, methods of hair care or external injury can be given. The cause is not any fungal, bacterial or viral infection, and it cannot be transmitted to any other person. It is likely that eventually the condition will be found to be "auto-immune", with another body tissue attacking the hair roots.

DO NERVES CAUSE ALOPECIA?: A severe shock can definitely set off an attack, but there is much less certainty that ordinary stresses of life affect the condition. Of course, the person often becomes more tense and nervous through worrying about the problem itself.

WHAT CONDITIONS CAN ACCOMPANY ALOPECIA?: In children, alopecia areata may occur more often, or more severely if the child has eczema. In adults it is known that the patient or the relatives are slightly more likely to show other auto-immune conditions than is the general population. These include colour loss (vitiligo) and thyroid disorders.

DOES ALOPECIA AREATA AFFECT GENERAL HEALTH?: No. All aspects of general health are unaffected - apart from the rare associations with other diseases. It usually occurs in healthy young people.

WHAT HAPPENS AFTER ALOPECIA DEVELOPS?: It is thought that the majority of cases settle down and regrow after one or more patches have been present for some months.
However, sometimes the condition persists, and new patches can appear while old patches regrow. Sometimes the affected area extends as a ring around the regrowing area.
In the worst cases the condition progresses (gradually or quickly) until large areas of hair have been lost. These cases naturally bring most distress to the people affected.
When the condition first appears, it is not possible to predict whether it will be mild and recover soon or become severe.

IS IT KNOWN WHY SOME CASES BECOME SEVERE?: Apart from the uncommon type which is accompanied by eczema in children, no information is available about this. Everyone hopes that early treatment will stop the progress of the condition but if the alopecia is destined to be severe, this course may still be followed despite treatment.

TREATMENT

Many treatments have been used over the years and in different countries, and it is certain that new and improved treatments will be discovered. The success of D.N.C.B. treatment (to be discussed below) in some people, has awakened new research interest in alopecia areata and new study techniques are being employed.

The paragraphs that follow give some general information, but obviously full detail cannot be given here.

FOOD AND VITAMINS: There is no evidence that any deficiency exists, or that changing diets will be helpful.

ZINC TREATMENT: There have been medical articles from Central Europe stating that prolonged treatment with zinc sulphate is helpful. There is no zinc deficiency discoverable in the body, and short term treatment with zinc is not helpful.

HAIR CARE: There is no special shampoo to use or avoid and hair styles will be chosen by each person to cover the patch. Scalp tonics and hair conditioners do not help.

IRRITANT CHEMICALS : FREEZING : ULTRAVIOLET LIGHT: These methods have been used and in early mild cases may have some influence. The most recent chemical described in this group is "dithranol" which probably acts by irritating the scalp and not by specific effect.

CORTISONE CREAMS AND LOTIONS: These agent s are commonly used, sometimes with a plastic film applied over the scalp to assist penetration of the cortisone. This treatment is quite safe.

INJECTION OF CORTISONE INTO PATCHES: This is standard treatment, especially for early cases which affected small areas. It seems to give the best quick results - speeding recovery in mild cases, but is less effective in more severe cases. The total amount of cortisone used is not high and does not produce any adverse affects.

CORTISONE TABLETS: There is no doubt that taking cortisone tablets can produce regrowth in many people. However, the regrowth may only last as long as the cortisone tablets are continued - and long term cortisone treatment can affect many aspects of general health. Therefore, most doctors advise against cortisone tablet treatment except in severe and progressive alopecia in adults

D.N.C.B. TREATMENT: D.N.C.B. is a chemical (dinitrochioro benzene), which rapidly produces skin sensitivity. In some people with severe alopecia, continued application of D.N.C.B (enough to produce a continuing rash) can result in regrowth of hair.
This method is not advised for less severe cases, and it does not always work - but it does suit a number of people.

P.U.V.A TREATMENT: The success of using photosensitizing "psoralens" with ultraviolet light in the A range (P.U.V.A) in other skin conditions has suggested it could be used in alopecia areata. There have been some encouraging reports, but long term studies have yet to show what success this treatment will have, and who should be treated by this method.

TREATMENT OF NERVOUS PROBLEMS: This is an important part of treatment when people with alopecia are under great stress, or are upset by the problem. Doctors differ in their opinion about using sedatives or mild tranquillisers for alopecia sufferers who are not obviously affected by stress and problems.

REGAINE (TOPICAL MINOXIDIL): Minoxidil was first used in tablet form for the treatment of high blood pressure. Hair growth was observed as a side effect in patients taking the preparation for this condition. Tests were then carried out to see if monoxidil could be applied to the scalp, as a topical (liquid) preparation. Clinical trials involving thousands of men established the efficiency of Regaine® (topical minoxidil) in treating alopecia androgenetica (male pattern baldness) for a percentage of men. Regain® is currently indicated for the treatment of male pattern baldness. Those most likely to respond include men who are balding on the crown rather than temples, and who have been balding for less than ten years.

In addition, there have been reports of Regain®'s effectiveness for alopecia areata. Regaine® takes 4- 6 months to be effective and it is available by prescription in Australia at a cost of approximately $70 per month (Some of this is reimbursed by private health care funds.)

WIGS: for children and adults with severe alopecia, wearing a wig may become the best "treatment". Wigs do not stop hair from regrowing and do not make the problem worse.

In 1981 the government introduced a scheme for wigs to be obtained free of charge for people with severe alopecia and details may be obtained by your doctor. It is to be hoped that this valuable service will continue to be available for future years and under full medical funding arrangements.