Alopecia Areata

Diagnosis of alopecia areata is by inspection. Alopecia areata typically manifests as discrete circular patches of hair loss characterized by short broken hairs at the margins that resemble exclamation points. Nails are sometimes pitted, display longitudinal ridging, or display trachyonychia, a roughness of the nail also seen in lichen planus Lichen Planus Lichen planus is a recurrent, pruritic, inflammatory eruption characterized by small, discrete, polygonal, flat-topped, violaceous papules that may coalesce into rough scaly plaques, often accompanied... read more . Red lunula may also be seen.

Differential diagnosis includes tinea capitis Tinea Capitis (Scalp Ringworm) Tinea capitis is a dermatophyte infection of the scalp. Diagnosis is by clinical appearance and by examination of plucked hairs or hairs and scale on potassium hydroxide wet mount. Treatment... read more , trichotillomania Trichotillomania Trichotillomania is characterized by recurrent pulling out of one's hair resulting in hair loss. Patients with trichotillomania repeatedly pull or pluck out their hair for noncosmetic reasons... read more , traction alopecia, lupus Systemic Lupus Erythematosus (SLE) Systemic lupus erythematosus is a chronic, multisystem, inflammatory disorder of autoimmune etiology, occurring predominantly in young women. Common manifestations may include arthralgias and... read more , and secondary syphilis Secondary syphilis Syphilis is caused by the spirochete Treponema pallidum and is characterized by 3 sequential symptomatic stages separated by periods of asymptomatic latent infection. Common manifestations... read more . If findings are equivocal, further testing can be pursued with potassium hydroxide preparation, fungal culture, screening for syphilis, or biopsy. Patients with clinical findings suggesting associated autoimmune diseases (particularly thyroid disease) are tested for those diseases.

Biopsy is occasionally necessary.

Alopecia areata may spontaneously regress, become chronic, or spread diffusely. Risk factors for chronicity include extensive involvement, onset before adolescence, atopy, and involvement of the peripheral temporal and occipital scalp (ophiasis).

If therapy is considered, intralesional corticosteroid injection is the treatment of choice in adults. Triamcinolone acetonide suspension (typically in doses of 0.1 to 3 mL of 2.5 to 5 mg/mL concentration every 4 to 8 weeks) can be injected intradermally if the lesions are small. Potent topical corticosteroids (eg, clobetasol propionate 0.05% foam, gel, or ointment 2 times a day for about 4 weeks) can be used; however, they often do not penetrate to the depth of the hair bulb where the inflammatory process is located. Oral corticosteroids are effective, but hair loss often recurs after cessation of therapy and adverse effects limit use.

Topical anthralin cream (0.5 to 1% applied for 10 to 20 minutes daily then washed off; contact time titrated as tolerated up to 1 hour/day) may be used to stimulate a mild irritant reaction. Minoxidil 5% solution may be helpful as an adjuvant to corticosteroid or anthralin treatment.

Induction of allergic contact dermatitis using diphenylcyclopropenone or squaric acid dibutylester (topical immunotherapy) leads to hair growth due to unknown mechanisms, but this treatment is best reserved for patients with diffuse involvement who have not responded to other therapies.

Oral methotrexate has been successfully used for the treatment of alopecia totalis and alopecia universalis in both adult and pediatric populations. Doses range from 15 to 25 mg weekly. Methotrexate can also be used in combination with oral corticosteroids. Its use is typically reserved for refractory alopecia areata in patients who fail standard therapy (1 Treatment reference Alopecia areata is typically sudden patchy nonscarring hair loss in people with no obvious skin or systemic disorder. Diagnosis is typically by inspection, although sometimes a skin biopsy is... read more ).

Systemic and topical PUVA have been used with limited success in patients who fail conventional therapy. However, this is a less favored treatment option because of high relapse rates, lack of randomized controlled trials, and increased risk of cancer with PUVA.

Baricitinib is a Janus kinase (JAK) inhibitor that is beneficial in treating alopecia areata.

Hairpieces and camouflage techniques can be used to mask the effects of hair loss.