Alopecia Areata

A characteristic of this condition is the patchy hair thinning, leading to partial or total hair loss from the scalp and/or other parts of the body in more severe cases.
As far as the pathogenesis of alopecia areata is concerned, various causes have been suggested, among which the most important are the following:

  • Genetic factors
  • Psychological factors
  • Immunological factors
  • Endocrinological factors
  • Other factors
  • Heterogeneity

In most cases alopecia is confined in one or more areas of the scalp. However, in more severe cases total hair loss may occur on the scalp only (“alopecia totalis”) or on the whole body (“alopecia universalis”). More specifically, the clinical picture of alopecia areata may qualify under one of the following types:

  1. Simple
  2. Extensive
  3. Ophiasiform
  4. Alopecia Totalis
  5. Alopecia Universalis
  6. Diffuse

It is a non-cicatricial alopecia and in most cases it resolves spontaneously after a few months. However, there are some cases that alopecia areata does not resolve spontaneously but it actually gets worst and treatment is necessary for its management. It is also important to make a differential diagnosis from other skin conditions, such as tinea capitis, trichotillomania, syphilitic alopecia as well as post-inflammatory and cicatricial alopecias.

Management strategies of alopecia areata

There are many different available treatment options for alopecia areata, including topical medications and systemic treatments. Topical treatments include corticosteroids, irritants, and minoxidil. Systemic treatments include the administration of corticosteroids per os, PUVA treatment, as well as the administration of zinc sulfate.

Topical treatments

Topical application of corticosteroids is effective for treatment of patchy alopecia according to some research studies, especially when potent steroids are used. However, their effectiveness has not been established for more severe cases of alopecia areata, i.e. in alopecia totalis or alopecia universalis. Furthermore, despite the fact that they are fairly inexpensive there is a main side effect, the development of transient folliculitis.
Another topical treatment for alopecia areata is the use of irritants, including anthralin (dithranol) and retinoic acid. Despite the fact that they are inexpensive and safe to use, evidence for their efficacy is limited. More specifically, for patients with dark hair, anthralin has the advantage of camouflaging a pale area of scalp by staining it brown. Application needs to be frequent and at a fairly high concentration, as it needs to induce significant irritation to be effective. Retinoic acid is more practical for use in patients with fair hair.
Topical minoxidil is also a safe treatment option for alopecia areata. However, most studies have failed to demonstrate a response of cosmetic value in most patients.
Among other options of topical treatment contact sensitizers like diphencyprone (DNCB) are included. In particular, topical immunotherapy concerns the induction of contact allergy on the scalp. Diphencyprone is effective and safe and it is used quite often. In any case it is important to start treatment with the lowest effective dos to achieve mild erythema and pruritus (itching).
Finally, topical tacrolimus has been established as an effective method for the treatment of alopecia areata.

Systemic treatments

Systemic corticosteroids administered per os are effective in some cases if high doses are used. However, they should be administered at high doses, and according to some research studies the use of certain intermittent administration regimens may be also effective. Furthermore, some cases alopecia totalis, alopecia universalis and ophiasiform alopecia areata do not respond well and high relapse rates make this toxic treatment hard to justify. This is also the case for systemic cyclosporine, which has to be administered at high doses. Nevertheless, since the response is not maintained on cessation of therapy, and again it is difficult to justify its use.
Finally, apart from topical and systemic treatment regimens, some patients prefer to use a wig so that to hide areas of hair thinning on their scalp, while many patients select the method of tattooing (dermatography) of the eyebrows so that to achieve a more socially acceptable image.

Proper diagnosis and selection of the appropriate treatment regimen

In any case patients should be aware of the fact that treatment may be long-term, as well as that the effectiveness of each treatment method may differ depending on the severity and the duration of alopecia areata. Moreover, since there is a chance of relapse, patients should be prepared so that to avoid disappointment. Counselling on the natural progress of alopecia can really help. Sometimes it may be necessary to provide psychological counselling to patients, since our appearance is characterised by our hair. The first step for every patient is to make the right diagnosis by an experienced dermatologist and determine the best treatment regimen for the management of alopecia areata.