Hair loss - Alopecia Areata - Alopcia Universalis - Alopecia Totalis - What are the causes and Treatments?

Alopecia orhair loss is the medical term for loss of hair from the head or body, sometimes amounting to baldness. In contrast to cosmetic depilation of body hair, alopecia is involuntary and usually unwelcome. Whereas for men baldness is relatively common, for women it may represent a devastating loss of one of the feminine attributes - beauty. In some orthodox communities, notably in Judaism and Islam, women cover their heads as a sign of modesty and also to withhold their attractiveness from men not in their family.

Alopecia may be caused by a psychological compulsion to pull out one's own hair (trichotillomania) or the unforeseen physical consequences of voluntary hairstyling routines including tight ponytails or braids, or burns to the scalp from caustic solutions or hot hair irons.

Alopecia areata is a disorder in which there is loss of hair causing patches of baldness but with no scarring of the affected area. It can affect the entire scalp (alopecia totalis) or cause loss of all body hair (alopecia universalis). Alopecia with scarring is cicatricial alopecia.

Picture of alopecia totalis.

Picture of alopecia totalis in a woman

Alopecia is a relatively common condition affecting 0.15% of the population.

In some cases, alopecia is an indication of an underlying medical concern, such as iron deficiency.^{0301,

0701}Gynaecologists frequently see patients with alopecia in relation to hyperandrogenism - androgenic alopiecia and also in association with heavy periods where there may be resulting anaemia and iron deficiency.

In many cases it can be a self-limiting condition, but hair loss can often have a severe social and emotional impact.

A review of seventeen trials⁰⁸⁰¹ included from 6 to 85 participants and they assessed a range of interventions that included topical and oral corticosteroids, topical ciclosporin, photodynamic therapy and topical minoxidil. Overall, none of these interventions showed significant treatment benefit in terms of hair growth when compared with placebo. There have been no randomised controlled trials on the use of diphencyprone, dinitrochlorobenzene, intralesional corticosteroids or dithranol although they are commonly used for the treatment of alopecia areata. Similarly although topical steroids and minoxidil are widely prescribed and appear to be safe, there is no convincing evidence that they are beneficial in the long-term. There is a desperate need for large well conducted studies that evaluate long-term effects of therapies on quality of life. Considering the possibility of spontaneous remission especially for those in the early stages of the disease, the options of not being treated therapeutically or, depending on individual preference wearing a wig may be alternative ways of dealing with this condition.

Alopecia - Hair loss

Picture of a woman with alopecia who chooses a wig.

What is alopecia areata?

Alopecia areata is a hair-loss condition which usually affects the scalp. It can, however, sometimes affect other areas of the body. Hair loss tends to be fairly rapid and often involves one side of the head more than the other.

Alopecia areata affects both males and females.

Alopecia - Hair loss

Picture of a young woman with alopecia areata.

What causes alopecia areata?

Alopecia areata is caused by autoimmunity. In alopecia areata, the body's own immune system attacks the hair follicles and disrupts normal hair formation. Biopsies of affected skin show immune cells inside of the hair follicles. The cause is unknown. Alopecia areata is sometimes associated with other autoimmune conditions such as allergic disorders, thyroid disease, lupus, rheumatoid arthritis, and ulcerative colitis. Sometimes, alopecia areata occurs within family members, suggesting a role of genetic predisposition.

What are the different patterns of alopecia areata?

The most common pattern is one or more spots of hair loss on the scalp. There is also a form of more generalized thinning of hair referred to as diffuse alopecia areata throughout the scalp. Sometimes, all of the scalp hair is lost - alopecia totalis. Infrequently, the loss of all of the hairs on the entire body - alopecia universalis.

Alopecia universalis is when complete hair loss on the body occurs, similar to how hair loss associated with chemotherapy.

Who is affected by alopecia areata?

Alopecia areata tends to occur most often in children, teenagers, and young adults.

Alopecia areata in not contagious. It should not be confused with the hair shedding that may occur following the discontinuation of hormonal oestrogen and progesterone therapies for birth control or the hair shedding associated with the end of pregnancy.

How is alopecia areata diagnosed?

The characteristic finding of alopecia areata is the exclamation point hair. These unusual hairs can be found in areas of hair loss. They are visible with a hand lens as short, broken off hairs that are narrower closer to the scalp and appearing like an exclamation point. A biopsy of the scalp may be necessary for diagnosis.

How is alopecia areata treated?

In approximately 50% of patients, the hair will grow again within a year without any treatment. The longer the period of time of hair loss, the less likelihood of recovery. A variety of treatments can be tried. Steroid injections, creams, and shampoos including clobetasol or fluocinonide for the scalp have been used for a number of years. Other medications include minoxidil, irritants - topical coal tar, and topical immunotherapy - cyclosporine, each of which are sometimes used in different combinations.

There is no known effective method of prevention, although the elimination of emotional stress is felt to be helpful. No drugs or hair-care products have been associated with the onset of alopecia areata. Much research remains to be completed on this complex condition. Interestingly, there is some evidence that aromatherapy may be helpful.⁹⁸⁰¹

^{What is androgenic alopecia?}

Androgenic alopecia, also known as male pattern baldness, androgenetic alopecia oralopecia androgenetica, is a common form of hair loss in both men and women. Hair is lost in a well-defined pattern, beginning above both temples. Over time, the hairline recedes to form a characteristic "M" shape. Hair also thins at the crown of the head and often progressing to partial or complete baldness.

In women, the hair becomes thinner all over the head, and the hairline does not recede. Androgenic alopecia in women rarely leads to total baldness.

A variety of genetic and environmental factors are likely play a role in causing androgenic alopecia. Although researchers are studying risk factors that may contribute to this condition, most of these factors remain unknown. Researchers have determined that this form of hair loss is related to hormones called androgens, particularly an androgen called dihydrotestosterone (DHT). Androgens also have other important functions in both males and females, such as regulating hair growth and sex drive.

Hair loss genetics

Research indicates that susceptibility to premature male pattern baldness is largely X-linked. Other genes, that arenâ€™t sex linked, are also involved.

Hormone levels correlated with androgenetic alopecia

5-alpha-reductase is the enzyme responsible for converting free testosterone into DHT. Levels of 5alpha-reductase are one factor in determining levels of DHT in the scalp and drugs which interfere with 5alpha-reductase, including finasteride, have been approved by the FDA as treatments for hair loss.

Sex hormone binding globulin (SHBG), which is responsible for binding testosterone and preventing its bioavailability and conversion to DHT, is typically lower in individuals with high DHT. SHBG is downregulated by insulin.

High insulin levels seem the likely link between metabolic syndrome and baldness. Low levels of SHBG in men and non-pregnant women are also correlated with glucose intolerance and diabetes risk, though this correlation disappears during pregnancy.

Hair loss and lifestyle

Allthough genetic factors seem to play the main role in the development and progression of androgenic alopecia, lifestyle also plays a role.

Daily, vigorous aerobic exercise has been shown to reduce baseline insulin levels as well as baseline total and free testosterone, significantly lowering baseline DHT.

Treatments

There are treatments which can reduce or halt hair loss, and in early stages or in rare cases, reverse it entirely. Treatments include:

Diet ⁰³⁰²and Lifestyle improvement Hormone related treatments including Finasteride

Reviews suggest that anti-hormonal therapy (e.g. cyproterone acetate, spironolactone) is helpful in treating female pattern alopecia in some women who have normal hormone levels. The use of hormonal therapies is most extensively studied in post-menopausal women. Several studies have suggested that cyproterone acetate with or without ethinyl estradiol and spironolactone can ameliorate female androgenetic alopecia in women with normal hormone levels, but larger controlled studies need to be done.
- Flutamide was found to be more effective than spironolactone or cyproterone in one study. Testosterone conversion inhibitors have been tried in post-menopausual women with normal hormone levels to treat alopecia.
- No study has shown that 1 mg of finasteride effectively treats female androgenetic alopecia but doses of 2.5 and 5 mg finasteride have helped some women in a few open studies.

Hair transplantation.
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What is cicatricial alopecia or scarring alopecia?

Cicatricial alopecia includesa diverse group of rare disorders that destroy the hair follicle, replace it with scar tissue, and cause permanent hair loss. In some cases, hair loss is insidious, without symptoms, and is unnoticed for long periods. In others, hair loss is accompanied by severe itching, burning and pain and is rapid. The inflammation that destroys the follicle is below the skin surface and there is usually no "scar" seen on the scalp. Affected areas of the scalp may show little signs of inflammation, or have redness, scaling, increased or decreased pigmentation or pustules. Cicatricial alopecia occurs in otherwise healthy men and women of all ages and is seen worldwide.

What are there different kinds of cicatricial alopecia?

Cicatricial alopecias are classified as primary or secondary. In primary cicatricial alopecias the hair follicle is the target of the destructive inflammatory process. In secondary cicatricial alopecias, destruction of the hair follicle is incidental to a non-follicle-directed process or external injury, including severe infections, burns, radiation, or rarely tumours.

What are the causes of cicatricial alopecia?

All cicatricial alopecias involve inflammation directed at the hair follicle, usually the upper part of the follicle where the stem cells and sebaceous gland (oil gland) are located. If the stem cells are destroyed, there is then no possibility for regeneration of the hair follicle and permanent hair loss results.

Cicatricial alopecias are not contagious.

Who is affected by cicatricial alopecias?

Cicatricial alopecias affect both men and women, most commonly young adults although all ages may be affected.

The majority of patients with cicatricial alopecia have no family history of a similar condition.

Are cicatricial alopecias associated with other illnesses?

In general, cicatricial alopecias are not associated with other illnesses.

How are cicatricial alopecias diagnosed?

Symptoms of itching, burning, pain or tenderness usually signal ongoing activity. Signs of scalp inflammation include redness, scaling, and pustules. However, in some cases there are few symptoms or signs and only the scalp biopsy demonstrates the active inflammation. The overall extent and pattern of hair loss is noted and sometimes photographed for future comparison.

A scalp biopsy is enecessary for the diagnosis of cicatricial alopecia . Findings of the scalp biopsy, including the type of inflammation present, location and amount of inflammation, and other changes in the scalp, are necessary to diagnose the type of cicatricial alopecia, to determine the degree of activity, and to select appropriate treatment.

It is helpful to be evaluated by a dermatologist with a special interest or expertise in scalp and hair disorders, and who is familiar with current diagnostic methods and therapies.

How are cicatricial alopecias treated?

Primary cicatricial alopecias are classified by the predominant type of inflammatory cells that attack the hair follicles: i.e., lymphocytes, neutrophils, or mixed inflammatory cells.

Treatment of the lymphocytic group involves use of anti-inflammatory medications. The aim of treatment is to reduce or eliminate the inflammatory cells that are attacking and destroying the hair follicle. Oral medications include hydroxychloroquine, doxycycline, cyclosporine, or corticosteroids. Topical medications may include corticosteroids and topical tacrolimus. Triamcinolone acetonide (a corticosteroid) may be injected into inflamed, symptomatic areas of the scalp.

Treatment of the neutrophilic group of cicatricial alopecias is directed towards eliminating the predominant microbes that are invariably involved in the inflammatory process. Oral antibiotics are the mainstay of therapy, and topical antibiotics may be used to supplement.

Treatment of the mixed group of cicatricial alopecias (folliculitis keloidalis and erosive pustular dermatosis) may include antimicrobials, isotretinoin (especially for folliculitis keloidalis), and anti-inflammatory medications.

The course of cicatricial alopecia is usually prolonged. Treatment is continued until the symptoms and signs of scalp inflammationsettle, and progression of the condition has been halted. Treatment may then be stopped. Unfortunately, the cicatricial alopecias often re-activate even after a quiet period of years, and treatment must be started again.

If the disease has been inactive for many years and the area of hair loss is small, then surgical removal of the scarred scalp and/or hair transplants may be considered for cosmetic benefit.

Will my hair grow back?

Hair will not grow back once a follicle is destroyed. However, it may be possible to treat the inflammation in and around surrounding follicles before they are destroyed and for this reason it is important to begin treatment as early as possible to halt the inflammatory process. Minoxidil solution (2% or 5%) applied twice daily to the scalp may be helpful to stimulate any small, remaining, unscarred follicles.

What signs and symptoms should I look out for?

It is important to continue to watch for symptoms and signs of active disease during and after treatment to ensure that the disease is responding adequately and has not re-activated after treatment has been discontinued. Response to therapy may be indicated by the resolution of scalp symptoms such as itching, burning, pain or tenderness, by improvement in the signs of scalp inflammation such as decreased redness, scaling or pustules, and by halting the progression of hair loss.

How should I take care for my hair?

Hair care products and shampoos can generally be used with any Frequency desired, as long as the products are gentle and non-irritating to the scalp. Hair pieces, wigs, hats, scarves may be used freely.

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