Alopecia areata (spot baldness) is a condition characterised by full or partial loss of hair, usually from the scalp, but also from other regions of the body.
It is an autoimmune condition that affects 1–2% of the population. Both sexes are affected with equal frequency, and the appearance of alopecia areata is most common in children and adolescents. The autoimmune aetiology of alopecia areata is corroborated by its coexistence with other autoimmune diseases such as vitiligo, Hashimoto’s thyroiditis, Addison’s disease, and autoimmune polyendocrinopathy. It also frequently coexists with atopic dermatitis and Down syndrome.
The classification is as follows:
- Circumscribed alopecia areata. In this case, alopecia areata is usually limited to one single patch, usually on the scalp, with a round or oval shape.
- Localised patchy alopecia areata. More than one patches on the head or body.
- This is a localised type of alopecia areata that occurs in occipital area of the head, stretching from one ear to the other. This form of alopecia areata has a poor prognosis, as it usually leads to total alopecia.
- Alopecia areata In this case, all scalp hair is lost.
- Alopecia areata This form of alopecia areata involves the loss of scalp hair, eyelashes, eyebrows, and facial and body hair.
- Diffuse alopecia areata. This is more common in people who already suffer from androgenetic alopecia.
Total and universal alopecia areata are rare, accounting only for 1–2% of all forms of alopecia areata.
Despite the autoimmune nature of alopecia areata, there are other factors that contribute to its appearance. Such factors are long-term or sudden intense psychological stress or physical stress, such as fever, inflammation, and malignancies. The appearance may be triggered by local injury, viral or bacterial infections, pregnancy, hormonal disorders, chemicals, allergic reactions, and seasonal changes.
Typically, the first symptoms are small bald patches of round or oval shape. The underlying skin in alopecia areata appears normal and non-scarred. The most common sites of alopecia areata are the scalp and beard, but it may occur anywhere on the skin where hair is present. The patches caused by alopecia areata are usually asymptomatic, although they may itch or be slightly painful. The disease may resolve by itself or remain constant as chronic active alopecia areata. The hairs are lost in a short period of time; cases have been reported in which the patient lost all his hair overnight. During the clinical examination, the hairs near the alopecia areata patch appear thin and mimic an ‛exclamation point’, as they become narrower closer to the root. In active alopecia areata, hairs are easily detached under traction, while the regrowth of hair is usually white. The nails may also suffer, displaying small pits or ridging.
Alopecia areata is often accompanied by psychological effects, such as depression and social phobia.
The diagnosis is mainly clinical. A trichogram helps to show the dystrophic anagen and increased telogen hairs. Trichoscopy and biopsy also confirm the diagnosis of alopecia areata, as the latter will show lymphocytic infiltration and degeneration of the hair.
The prognosis is unpredictable. Alopecia areata that appears after puberty usually has a good prognosis, with regrowth in 80% of the cases within 4 to 10 months. Total alopecia areata occurring before puberty, frequent relapses of alopecia areata, ophiasis and coexistence of nail damage are usually associated with poor prognosis.
Alopecia areata – Treatment
Treatment is essential, as it causes intense stress and psychological problems for patients, which aggravate the situation. Treatment of alopecia areata is important, because patients overcome their social phobia and the quality of their lives improves.
In case of small damages, treatment of alopecia areata consists in mere monitoring of the situation, as the problem often is being resolved and the hair grows back.
Alopecia areata that consists of small patches is usually treated with corticosteroids, either topically as cream or in the form of infiltrations with injection. The recommended corticosteroid is triamcinolone acetonide. Treatment of alopecia areata with topical corticosteroids has little effect on the total and universal type, or on extensive forms of hair loss. Systemic use of corticosteroids for the treatment of alopecia areata is avoided, as it only has effect during administration and the problem appears once the treatment is discontinued, while there are also several side effects.
Minoxidil 5% solution is also used in the treatment of alopecia areata, usually in combination with corticosteroids. Local irritants such as tar and anthralin may help in the treatment of alopecia areata.
Topical immunomodulators, such as tacrolimus (protopic), may be used for treatment of alopecia areata that occurs predominantly in small patches on the scalp or face. With this treatment, the patch can be maintained stable for a long time, without expanding or recurrence.
Topical immunotherapy is one of the most important treatments of alopecia areata. It is usually applied to extensive forms of alopecia on the scalp. The agents used are diphencyprone and SADBE (squaric acid dibutylester). This treatment causes local sensitisation with these substances, which are applied progressively in increasing concentration. The allergic dermatitis caused in the region reduces the population of lymphocytes in the lesions, giving the hair a chance to grow back. The side effects of this alopecia areata treatment are irritation and enlargement of the regional lymph nodes, and it should not be used in children under 10 years. Its effectiveness amounts to 50%.
For the treatment of alopecia areata, PUVA light bath therapy has also been used. The effect of PUVA involves local immunosuppression, which allows the hairs to grow back again. The effectiveness of this treatment is 30% in selected cases. The side effects are burns, irritation, allergic reactions, and an increase in the probability of skin cancer. Treatment of alopecia areata with PUVA can not be used for patients who are less than 12 years old. A role in the treatment of alopecia areata is played by excimer laser at 308 nm, which also acts as an immunosuppressant but without the side effects of PUVA.
Anti-TNF biological agents (infliximab, adalimumab, etanercept) have been successfully used to treat alopecia areata, particularly of the total type.
Several studies are being conducted to find gene therapy for alopecia areata, and eight genes have been isolated that are associated with disease. These genes are also related to other conditions, such as rheumatoid arthritis and type 1 diabetes.
Finally, the use of a hair prosthesis (wig) should be taken into consideration, as it covers extensive forms and helps to improve the patient’s psychology, which is an important factor in the treatment of alopecia areata. Nowadays high quality prostheses are available with very good aesthetic performance, that can be worn for as long as needed, until the patient regains his own hair.
Treatment of Alopecia areata with PRP
The latest development in the treatment of alopecia areata is the promising PRP method (Platelet Rich Plasma). PRP therapy has been used for many years in the treatment of wounds, burns and chronic ulcers, significantly speeding up the healing process and distinctly improving the quality of the scar. In recent years, it has been applied with great success in the treatment of hair loss, both in maintenance therapy as well as supplementary in combination with hair transplantation.
For PRP treatment, a small amount of blood is taken from the patient and placed in a centrifuge. The centrifugation isolates the blood plasma, which is rich in platelets. The platelets are then activated by addition of calcium chloride ions; this causes the secretion of a significant amount of growth factors which are able to stimulate the progenitor stem cells located in the hair follicle. They also stimulate the healing power of the body at a topical level, enhancing the multiplication of cells that are essential for the process of healing and the normal function of the skin and its components.
PRP therapy is performed with a 30G microneedle, which makes it virtually painless, and no local anaesthesia is required. The PRP treatment session lasts 30-40 minutes and does not cause skin irritation. Modern PRP therapy protocols prescribe 3-4 sessions at one month intervals, while repeat sessions are recommended every 3-6 months. Clinical response to treatment with PRP varies; it can show the first results immediately, even after the first session, but usually the results become visible after the first 2-3 sessions.
At Advanced Hair Clinics, PRP therapy has been and continues to be applied with great success in many cases of hair loss and alopecia of various aetiologies, mainly in cases of androgenetic or diffuse alopecia in men and women. It has also been implemented with impressive results in many cases, even for universal and generalised forms in which the results of classic conservative therapies are usually poor. With PRP therapy, even cases of universal alopecia areata in young people with a long history of the disease (more than 5 years) who had shown no previous response to other forms of treatment, were treated successfully and have experienced excellent hair regrowth.
FUE Hair Transplantation as Alopecia areata Treatment
Hair transplantation is considered to have no general application in the treatment of alopecia areata, particularly in cases of universal alopecia areata where the donor site of the scalp is insufficient to cover the needs. FUE hair transplantation can, however, be applied in selected cases of localised alopecia areata. Most patients who are selected for this therapy present small, localised, well-defined area, demonstrate stability in the evolution of the damage, and have a fairly long history of alopecia areata (over one year), which excludes the likeliness of spontaneous regrowth of hair in the damaged area with relative certainty.
In this case, follicles are obtained from the donor site at the back of the scalp with the FUE method, and are transferred to the affected area. The growth of the hairs at their new location is gradually completed within 10 to 12 months and the results of the transplantation are excellent. One particular case of hair transplantation with FUE, is transplantation in the eyebrows, which are a common site of the disease, often without other affected areas on the scalp. The results of the transplantation in this case are excellent and very important for the psychology of the patient, as the loss of eyebrows tends to place a high burden on the confidence of patients.
FUE hair transplantation should always be carried out after providing the patient with complete and detailed information about the nature of alopecia areata, and especially the fact that it may recur in the future, in the same or another region and in an unpredictable manner in terms of time, evolution, size or location. Therefore, patients should be aware that the results of FUE hair transplantation are stable and permanent, as in other forms of alopecia, provided that the damage remains stable and does not recur in the future.