What is alopecia areata? Causes, course and treatment approaches

What is alopecia areata, and how do you notice it?

Alopecia areata, sometimes called spot baldness, is a condition in which the hair falls out in certain areas within a short time. It is often noticed as one or more round or oval bald patches on the scalp. The skin in these patches is usually smooth; marked redness or flaking is not expected.

The condition can affect not only the scalp but also the beard, eyebrows, eyelashes and body hair. It can occur at any age and in both sexes; it often first appears in childhood, adolescence or young adulthood. It is not contagious.

At the edge of a bald patch, there may be short, broken hairs that get thinner toward the skin; these are called exclamation mark hairs. Some people also have tiny pits in their nails. A fungal infection of the scalp, an urge to pull out one’s own hair (trichotillomania) and types of hair loss that leave permanent scars can look similar. The diagnosis is made by a dermatologist, who uses trichoscopy (examining the scalp with a magnifying device) or a biopsy (examining a small piece of skin) when needed. We do not diagnose online.

What causes alopecia areata?

Alopecia areata is considered an autoimmune disease; this means the immune system mistakes the body’s own tissue for something foreign and turns against it. In this case, the target is the hair roots (follicles) in the growth phase.

Under normal conditions, a follicle in the growth phase is relatively protected from attack by the immune system; this is called immune privilege. In alopecia areata, this protection is thought to break down. T lymphocytes (a type of white blood cell) gather around the lower part of the follicle and cause inflammation there. Hair production is disrupted, the follicle enters the transition and resting phases earlier than usual, and the hair breaks or falls out. We describe these phases in our article on the hair growth cycle.

The inflammation is concentrated in the lower part of the follicle, while the upper part, where the stem cells are found, is usually spared. That is why, in alopecia areata, the follicle is often not replaced by scar tissue and can produce hair again once the inflammation settles down. Hair that grows back may be fine and white or light-colored at first; it usually regains its original color over time.

Why the immune system turns against the follicle is not fully known. Genetic predisposition is thought to play an important role, and the condition is more common in people with a family history of alopecia areata. It can occur together with other autoimmune diseases, such as autoimmune thyroid disease and vitiligo (a condition that causes loss of skin color), as well as with allergic conditions such as atopic eczema, asthma and hay fever. That is why a dermatologist may order blood tests to check for conditions that may accompany it. Stress or a recent illness is often mentioned as a trigger; however, this link has not been clearly proven.

What are the types of alopecia areata?

The types of alopecia areata are named according to the extent and shape of the affected area; in the same person, the condition can move from one type to another over time.

The total and universal types are much less common than the patchy type; in most people, the condition stays limited to patches. We cover telogen effluvium, which can be confused with the diffuse type, in a separate article.

How does alopecia areata progress?

The course of alopecia areata varies greatly from person to person and cannot be predicted. In people with a few small patches, it is common for the hair to grow back within months, even without treatment. In the same person, one patch may fill in while a new one appears somewhere else. After the hair has fully grown back, the condition may stay quiet for years or become active again.

Some features are associated with a tendency for the condition to last longer and be more persistent:

• Onset in childhood
• A large affected area, especially in the total and universal types
• Hair loss in the ophiasis pattern
• Involvement of the nails
• Hair loss that has been going on for a long time
• An allergic tendency or another autoimmune disease alongside it

These features only point to a tendency; on their own, they do not tell you how a particular person’s condition will progress. The change in appearance and the uncertainty can be emotionally difficult. If you feel this way, do not hesitate to talk to your doctor about it.

What treatment approaches are used for alopecia areata?

Treatment for alopecia areata is planned by a dermatologist. Which approach is chosen depends on the extent of the affected area, how long the condition has been present, the person’s age and any other health problems. The following information is general; these medications and procedures are only used after your doctor’s assessment and under their supervision. Do not start any of them on your own.

• Monitoring: With a few small patches, monitoring for a while without treatment is also one of the options.
• Corticosteroids: For limited patches, these anti-inflammatory medications are often injected into the patch with a fine needle; they can also be used as a cream or lotion. Side effects such as thinning of the skin where they are applied can occur. When the condition is spreading quickly, the doctor may consider short-term use by mouth or through a vein, taking their side effects into account.
• Contact immunotherapy: This aims to redirect the immune response by causing a controlled, mild allergic reaction on the scalp. It is usually used for alopecia areata that covers a large area or has lasted a long time, in specialist dermatology units; skin reactions can be stronger than intended.
• JAK inhibitors: These are prescription medications taken by mouth that block a signaling pathway (the Janus kinase pathway) involved in communication between immune cells. In recent years, they have been approved in some countries for the treatment of severe alopecia areata; approval in one country does not mean that the medication is also licensed for the same purpose in Turkey. Because of possible side effects, such as a higher risk of infections, they require regular follow-up by a doctor and blood tests; when the medication is stopped, the hair may fall out again.

These treatments aim to suppress the activity of the condition and help the hair grow back; the response varies from person to person. At present, no treatment is known that gets rid of alopecia areata completely or prevents it from coming back.

Some people choose camouflage options such as wigs, hats or eyebrow makeup, alongside or instead of treatment; this is a personal choice and does not affect the course of the condition.

What is still unknown about alopecia areata?

• Whose hair will grow back on its own? There is no test that can tell in advance when a person’s hair will grow back or whether the condition will become active again.
• What are the long-term effects of the new medications? JAK inhibitors are relatively new in the treatment of this condition; their effects and safety when used for many years are still being researched.
• Do supporting procedures have a role? The evidence on the role of vitamin supplements or supporting procedures such as PRP (platelet-rich plasma prepared from a person’s own blood) in alopecia areata is limited; they are no substitute for treatment by a dermatologist.

Can you have a hair transplant if you have alopecia areata?

A hair transplant is not suitable while the condition is active, that is, while hair is still falling out or new patches are appearing. Even when the condition seems quiet, a transplant is often not the right option. The main reasons are:

• Transplanted hair can also be affected. Grafts (the natural groups of hairs taken for transplanting) are usually taken from the donor area at the back and sides of the head. The fact that this hair stays resistant to male pattern hair loss even after it is moved is called donor dominance; however, this resistance applies only to the effect of hormones and offers no protection against alopecia areata. The donor area itself can also be affected by the condition.
• The hair follicles are often still there. Because the hair can grow back on its own or with treatment, a transplant may turn out to be unnecessary and waste some of the limited donor supply.

The condition can become active again even after staying quiet for years. That is why, even if your condition has been quiet for a long time, we only discuss a transplant after your dermatologist has assessed you. The same principle applies to gaps in the beard and eyebrows; we also touch on this on our beard transplant page. We list the other situations in which a transplant may not be suitable in our article on who should not have a hair transplant.

When you come to us with hair loss, during the examination we look together at whether the hair loss is patchy or widespread, the hairs at the edges of any bald patches, your eyebrows, eyelashes, beard and nails, whether you have had similar episodes before and whether anyone in your family has alopecia areata.

If we suspect alopecia areata, we put the transplant plan on hold and refer you to a dermatologist for diagnosis and treatment. If you have genetic hair loss as well as alopecia areata, we assess together, taking the dermatologist’s opinion into account, whether a transplant is suitable and when it should be done. Whether you are suitable for a hair transplant is determined during the examination, and results vary from person to person.