Alopecia areata is a condition where patches of hair loss develop, usually on the head. In some cases, total baldness develops. Usually the hair regrows after several months. In some cases, the hair loss is permanent. Treatments to promote hair regrowth work in some cases, but often the hair regrows of its own accord.
What is alopecia areata and who is affected?
Alopecia means loss of hair or baldness. There are a few different ways it can affect people, but the most common is small patches of hair loss, like circles, appearing on the scalp: this is called alopecia areata. There are other types, like alopecia totalis, where all the hair on the head is lost; there is also something called alopecia universalis, where all the hair on the body (including the eyebrows, groin area and under the arms) disappears. But these are rare.
In the UK, alopecia areata is estimated to affect about 15 in 10,000 people. Most family doctors will have seen at least one case, and you probably know of a friend or family member who has had it.
Alopecia areata can occur at any age but about half of cases come on in childhood and 80% of cases come on before the age of 40 years. Men and women are equally affected. The condition tends to be milder if it comes on at an older age.
A relative, friend or hairdresser may be the first person to notice the bald patch or patches. Apart from the patch, the scalp usually looks healthy and there is no scarring. Occasionally, there is some mild redness, mild scaling, mild burning or a slightly itchy feeling on the bald patches, but usually the person doesn't feel anything.
What does alopecia areata look like?
The typical pattern is for one or more bald patches to appear on the scalp. These tend to be round in shape and about the size of a large coin. They develop quite quickly. Often the person with it hasn't noticed it at all, particularly if they have long hair which is covering the bald patch.
This photo shows a typical patch of alopecia areata on the back of a young man's head:
By Abbassyma at English Wikipedia via Wikimedia Commons
This photo shows a patch of hair loss on a woman's head:
By Carolyn P Speranza [CC BY 2.0 (https://creativecommons.org/licenses/by/2.0)] via Wikimedia Commons
When a bald patch first develops, it is difficult to predict what will happen. The following are the main ways it may progress:
- Quite often the bald patch or patches regrow hair within a few months. If hair grows back, it may not have its usual colour at first and look grey or white for a while. The usual colour eventually returns after several months.
- Sometimes one or more bald patches develop a few weeks after the first one. Sometimes the first bald patch is regrowing hair whilst a new bald patch is developing. It can then appear as if small bald patches rotate around different areas of the scalp over time.
- Sometimes several small bald patches develop and merge into a larger bald area.
- Patches of body hair, beard, eyebrows or eyelashes may be affected in some cases, but this is unusual.
- Large bald patches develop in some people. Some people lose all their scalp hair. This is called alopecia totalis. This is very rare though.
- In a small number of cases, all scalp hair, body hair, beard, eyebrows and eyelashes are lost. This is called alopecia universalis. Again, this is very rare.
- The nails are affected in about 1 in 10 cases and can become pitted or ridged.
Below shows a beard hair loss patch: this is quite common and usually grows back by itself.
By XxRoxettexX (Own work) via Wikimedia Commons
Understandably most people with alopecia areata become self-conscious, anxious or distressed by the appearance of the hair loss. It can help a lot though to remain calm and stay positive because the hair regrows by itself in almost all cases.
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What causes alopecia areata?
Alopecia areata is called an 'autoimmune disease'. This is one of those annoying conditions where the body's immune system, which usually fights off germs, accidentally attacks itself.
So tiny cells in the immune system, called T cells, gather around the base of a hair follicle and try to kill it. This causes the hair to fall out. But at some point the immune attack must come to an end and the hair grows back.
Alopecia areata can be triggered by a recent illness, like a viral infection, or by taking certain medications for other medical conditions. Some people can link the onset of their alopecia to a stressful life event, but many can't. Sometimes it seems to run in families and it has been known to come on in twins at the same time. More often than not, no cause is found at all.
If you have alopecia areata you also have a slightly higher-than-average chance of developing other autoimmune diseases such as thyroid disorders, pernicious anaemia and vitiligo. Your doctor may wish to check for these if there are any signs of them along with the hair loss.
Do I need any tests?
Usually not. The diagnosis is usually based on the typical appearance of the bald patches. If there is doubt about the cause of the hair loss, sometimes some blood tests or a skin scraping from a bald patch may be done to rule out other causes. A small sample of skin (skin biopsy) is sometimes taken to look at under the microscope.
Occasionally you may need some tests to check for other autoimmune diseases. For example, if you have certain other symptoms, you might need to have blood tests to check your blood count and thyroid function. Usually blood tests come back entirely normal with alopecia areata.
What is the outlook for people with alopecia areata?
- Thankfully, mild cases of alopecia areata often get better without treatment within a few months to a year.
- In some cases, patchy baldness may come and go over many months or years. The size of the bald patch or patches and how long they last are quite variable.
- If less than half of the scalp is affected and no treatment is started, there is about an 80% chance of full hair regrowth within one year.
- With more extensive hair loss, it is less likely that hair will regrow.
However, even if your hair grows back fully after an episode of alopecia areata, it is common to have one or more recurrences of the condition throughout your life. A few people who develop alopecia areata will progress to total scalp baldness (alopecia totalis). Even fewer people will lose all scalp and body hair (alopecia universalis). Progression to these more extensive types of hair loss is more common if:
- The bald patches start in childhood.
- The initial bout of hair loss affects more than half of your scalp.
- You have atopic eczema.
- You have eyelash and/or eyebrow hair loss.
- You have a family history of alopecia areata.
- You have hair loss around the scalp margin.
- You have nail changes.
- You have another autoimmune disease.
Treatment can promote hair regrowth in some cases.
What are the treatment options for alopecia areata?
Understandably, hair loss is upsetting - particularly in young women. So there are plenty of private clinics out there who will promise 'instant hair regrowth'. Be careful: a lot of treatments for alopecia are unproven, often don't work and can quickly become very expensive. Before trying a private treatment, it might be worth getting an impartial opinion from a doctor in a state-funded system like the NHS.
Not treating is a common option
In many cases, bald patches regrow by themselves without treatment. In particular, if there are just one or two small bald patches then many doctors would advise that you simply leave it alone at first.
If the hair loss is not too bad then there is a good chance that your hair will regrow after several months. Be patient: hair regrowth often doesn't happen for a few months.
A change in hairstyle may perhaps conceal one or two small bald patches. If the hair loss becomes more extensive then the decision on whether to treat can be reconsidered. But even with extensive hair loss, there is still a chance that hair will regrow without treatment.
Note: alopecia areata itself won't damage your general health and so not treating will not lead to any general health problems. When considering any treatment choices, you should take into account the possible side-effects that some of the treatments may have. Also, treatments promote hair to regrow and do not affect or cure the underlying cause of the condition.
Injections of steroid into the bald patches of the scalp can in theory suppress the local immune reaction that occurs in alopecia areata. This can then allow the hair follicles to function normally again for hair to regrow. This treatment may be an option for one or more small- to medium-sized bald patches. Steroid injections are thought to be the most effective treatment for patches of alopecia areata that are not too big. However, they do not work in every case.
This treatment is usually only done by a skin specialist and referral to hospital will usually be needed. Several injections (about 1 cm apart) are usually given at each session of treatment but the number is often limited by pain. Therefore, large bald areas are not suitable for steroid injections. It takes 1-2 months for the hair to start to regrow. Injections are repeated every 4-6 weeks.
Note: there is no guarantee that any hair regrown during treatment will persist once the treatment is finished.
Rub-on (topical) steroid creams or gels may help hair regrowth but do not work as well as steroid injections. It may be worth a try if you have bald patches that are not suitable for steroid injections, or if you are waiting to see a specialist to have steroid injections. If regrowth occurs, it takes 3-6 months. There is no point continuing with this treatment if you do not develop any regrowth after 3-6 months.
Topical minoxidil solution
This is rubbed into the bald patches and has been shown to promote hair regrowth in some cases. This is the same treatment that is used for the common male pattern baldness. It is not known how it works. The success rate is not high but may be worth a try - in particular, if you have more extensive bald patches that are not suitable for steroid injections.
Minoxidil is not available on the NHS. You need a private prescription and have to pay the full cost of the product, which makes it expensive. Also, some people with certain medical conditions may not be able to use it. It would normally only be recommended by a specialist. This is because minoxidil is not licensed for alopecia areata. It is licensed for other types of alopecia, such as male pattern baldness. If it works, it usually takes 2-3 months of treatment for an initial response and one year for a maximum response. There is no point continuing with this treatment if there is no improvement after one year.
It is thought that topical immunotherapy is the most effective option for people with extensive alopecia areata. This is a very specialised treatment that is only available in some hospitals. A substance is put on affected skin to make the skin react like an allergy. A commonly used substance is diphencyprone (DPCP). Increasing strengths of this substance are placed on the affected skin once a week over several weeks until the skin looks like it has mild dermatitis (eczema). The skin reaction seems to affect the process involved in causing alopecia areata in some way to allow hair to regrow. Side-effects can be troublesome. For example, some people develop severe skin reactions. Treating children with topical immunotherapy is controversial.
Once regrowth occurs, treatment can be stopped but, in many cases, the hair loss then recurs. Therefore, regular maintenance treatment is often needed to keep the hair loss from returning.
These photos show immunotherapy being used by a specialised hospital. Note they have put the treatment only on half of the woman's head, to show that it is working rather than just the hair regrowing by itself. Once the doctors have shown it works, they've put it on both sides of her head. Full hair regrowth had taken place after a year of treatment.
Image source: Open-i (Harries MJ et al) - see Further reading below
Wigs are a common treatment choice in patients with alopecia areata. You can get some wigs on the NHS in the UK. However, this needs a referral to hospital as only a skin specialist can sanction the prescription of a wig on the NHS.
Various other treatments may be used or advised. These include the following:
- A plant substance called psoralen combined with ultraviolet A (PUVA) light therapy or phototherapy has been used with some limited success. This treatment requires many light therapy sessions in a hospital outpatient department.
- Tattooing (dermatography) can be used to create the look of eyebrows that have fallen out.
- Counselling is sometimes helpful for people who find it difficult to cope with hair loss.
- Complementary therapies. There is not enough evidence to say how effective complementary treatments are in treating alopecia areata (for example, acupuncture, aromatherapy, etc).
Always remember to use sunblock or a hat to protect bald patches when out in the sun.
A final note about treatments
As you can see from the section above, there are various treatment options. It is difficult to say from the outset whether a particular treatment will benefit a particular person. One of the difficulties is that hair grows back without any treatment in many cases. Therefore, it is difficult to research the effect of treatments, as hair may regrow naturally.
Generally, the success rate for the various treatments is not that high Also, there is no guarantee that any hair regrown during treatment will persist once the treatment is finished. But generally hair regrows by itself, so try to stay calm and think positive.
Further reading and references
Guidelines for the management of alopecia areata; British Association of Dermatologists (2012)
Alopecia areata; NICE CKS, March 2018 (UK access only)
Darwin E, Hirt PA, Fertig R, et al; Alopecia Areata: Review of Epidemiology, Clinical Features, Pathogenesis, and New Treatment Options. Int J Trichology. 2018 Mar-Apr10(2):51-60. doi: 10.4103/ijt.ijt_99_17.
Hordinsky MK; Alopecia Areata: The Clinical Situation. J Investig Dermatol Symp Proc. 2018 Jan19(1):S9-S11. doi: 10.1016/j.jisp.2017.10.015.