Alopecia Areata -Patchy Hair Loss

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Alopecia Aerata

Alopecia areata is usually patchy, non scarring hair loss than can occur equally between men and women in 1.75% of the population.

It is the most common hair loss complaint in children.

60% of people have their first episode by the age of 20.

There is a family history of alopecia areata in up to 40% of cases.

Autoimmunity is thought to be major pathogenic process

Possible causes include stress, infection, vaccinations, hormonal factors and genetics (it is genetically associated to Rheumatoid Arthritis and Crohns)

Associated diseases
:There is a strong association with thyroid and vitiligo but it is also associated to pernicious anemia, Diabetes mellitus, Systemic Lupus Erythematosus, myasthenia gravis, polymyalgia rheumatic, ulcerative colitis, celiac disease, lichen planus and polyglandular syndrome type1.

How it presents:
Hair loss is usually abrupt with marked hair shedding and affects colored hair preferentially.

It is most often a roundish smooth patch involving the scalp or any hair bearing area on the body. The patch of skin has a pinkish red or peach colour.

Hair loss in Alopecia Areata can also be diffuse.

There are intact and fractured hairs giving the appearance of exclamation hairs (the distal end is broader than the proximal end). There can also be yellow and black dots on close examination. The openings (ostia) of the hair follicles are preserved in alopecia areata (they are not preserved in scarring alopecia).

Hair loss is most often without symptoms but there can be itching, burning, pain or tingling before the hair loss appears.

Nail changes can occur before, during or after Alopecia Areata in some or all nails. There can be irregular pitting or in rows, longitudinal striations giving a sandpaper appearance, grooves (Beau’s lines), splitting of the nail, detachment and loss of the nail thinning or thickening of the nail, the nail can become concave (koilonychia), white marks and the lunula can become red( whitish are at the origin of nail).

Alopecia Totalis is complete loss of hair on the scalp, Alopecia Universalis is loss of all body hair.

Regrowth often starts with white hairs that then regain their color. It can range from complete to minimal.
People with atopy (asthma, allergic rhinitis eczema), those who have other auto-immune diseases, a family history of alopecia areata onset at a young age, nail dystrophy and extensive involvement especially at the occiput (ophiasis pattern) have less chances of complete recovery.

The majority of patient will have complete regrowth within a year.
Patients usually have several episodes during their lifetime but there is no way to predict this.

Diagnosis
The diagnosis is usually evident by the history and examination. The pull test is positive. In some cases, a 4mm biopsy at the margin of the lesion is performed.

Blood tests and cultures
TSH and thyroid antibodies to rule out thyroid disease including autoimmune (Hashimoto’s thyroiditis)
In some cases, levels of ferritin, vitamin D, B12, selenium, zinc and copper are requested.
Fungal cultures to rule out fungal infection (usually redness and scales are present). In the case of microsporum canis a woods lamp will fluoresce the scalp.

Treatment Plan (adults <50% involvement of the scalp) – UCSF-UBC treatment protocol for alopecia areata

In some cases, no intervention can be considered as a significant amount of patient will see their hair grow back within 1 year.

Intralesional corticosteroids-
This is first line therapy for patients with <50% involvement in a patchy well delimited pattern. Triamcinolone acetonide 5-10mg/cc is the most widely used preparation for the scalp. A weaker concentration of 2.5mg/cc can be used for the beard and the eyebrows. 0.1 cc per injection site 1 cm apart. These injections are administered every 4-6 weeks. Side effects include atrophy of the skin.

There is improvement in 65% of patients.

Initial regrowth can take 8 weeks, if there is no response after 3-4 months we add a combination of topical minoxidil 5% solution and clobetasol propionate 0.05% cream. If there is no response after 6 months, injection of Intralesional corticosteroids are stopped.

Combination Minoxidil 5% solution and Super Potent Topical corticosteroid cream
Minoxidil 5% solution twice a day followed by Clobetasol propionate 0.05% cream twice a day 30 minutes apart.
Minoxidil can be applied to the scalp, eyebrows and beard. Initial hair growth is seen after 12 weeks and maximum at 12 months. It must be continued till resolution of the alopecia areata episode.

Side effects
of minoxidil include irritation, allergic contact dermatitis and facial hair growth.
Side effects of topical corticosteroids include atrophy, folliculitis (especially with ointment form) and telangiectasia (small visible vessels at the surface of the skin

Other treatment options

Anthralin

Contact sensitizers
DPCP DNCB SADBE

Phototherapy
PUVA, 308nm Excimer laser

Further information and support:
The National Alopecia Areata Foundation (NAAF)
www.naaf.org

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REFERENCE

This text is a summary of the chapter “Alopecia aerata: pathogenesis, clinical features, diagnosis, and management from : Shapiro,J and Otberg,N. Hair loss and Restoration. Second ed. Boca Raton: Taylor & Francis Group; 2015. P85-145.

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Video: Update on Alopecia Areata Treatment

Dr Donovan gives a very good overview of available treatments for Alopecia Aerata. Alopecia Aereata is a disorder of hair manifested by well circumscribed areas of hair loss.

Dr Donovan décrit les modalités de traitements pour l’Alopecie Aereata. L’Alopecia Aereata est une maladie des cheveux et du poils caracterisée par une perte bien circonscrite de poils