Alopecia areata in Adult
See also in: External and Internal Eye,Hair and Scalp,Nail and Distal DigitAlerts and Notices
Synopsis
Alopecia areata is seen equally in both sexes and in patients of all ages and races and ethnicities. There is an increased incidence of alopecia areata in patients with Down syndrome as well as those with autoimmune diseases, most commonly thyroid disease. Patients with alopecia areata are also more likely to have atopy, and its presence is felt to be a poor prognostic indicator.
While medication-induced alopecia areata has been uncommon in the literature, there have been articles published reporting an association with some medications, including the TNF inhibitors adalimumab, etanercept, and infliximab. Other more recently described culprit agents include proton pump inhibitors and immune checkpoint inhibitors (CTLA-4, PD-1) that are used to treat malignancies.
The course of alopecia areata is unpredictable, with wide variation in duration and extent of disease occurring from patient to patient. In most patients, hair will eventually spontaneously regrow, although recurrences are common. The condition is treatable but cannot be cured.
In one retrospective study of 321 patients, temporal area involvement was independently associated with worse prognosis (in addition to extent of hair loss).
A 2022 retrospective population-based study in Taiwan showed an increase in retinal diseases among 9909 patients with alopecia areata. The disease extent and prior steroid treatment were not commented on; further studies are needed to confirm an association.
Codes
ICD10CM:L63.9 – Alopecia areata, unspecified
SNOMEDCT:
68225006 – Alopecia areata
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Diagnostic Pearls
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Differential Diagnosis & Pitfalls
- Trichotillomania, from the twisting and pulling of hair, may mimic alopecia areata. Hairs are broken off at varying lengths.
- Telogen effluvium from nutritional, hormonal, and drug etiologies can lead to large clumps of hair loss in a similar fashion to alopecia areata. The loss is diffuse, not localized.
- Tinea capitis has hair loss accompanied by scale and inflammation.
- Secondary syphilis can result in diffuse patchy alopecia.
- Androgenetic alopecia – male or female pattern
Best Tests
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Management Pearls
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Therapy
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Drug Reaction Data
Below is a list of drugs with literature evidence indicating an adverse association with this diagnosis. The list is continually updated through ongoing research and new medication approvals. Click on Citations to sort by number of citations or click on Medication to sort the medications alphabetically.Subscription Required
References
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Last Reviewed:04/10/2017
Last Updated:01/04/2023
Last Updated:01/04/2023
Patient Information for Alopecia areata in Adult
Overview
Alopecia areata is an autoimmune condition resulting in hair loss. The body's immune system mistakenly targets the hair follicle and stops hair growth. The cause is unknown, but genetic and environmental factors may play a role. Hair loss may be confined to one or two small bald patches (flat, smooth areas larger than a thumbnail), or it may involve most of the scalp. It can also affect the eyebrows, eyelashes, beard, and other body sites, or it may involve the whole body. In most people, hair regrows spontaneously, although recurrences of the condition are also typical.Who’s At Risk
Alopecia areata can occur in any age, race / ethnicity, and sex. The most frequent association is with thyroid disease, but it may also be seen in those with lupus, lichen planus, vitiligo, and Down syndrome.Signs & Symptoms
Hair loss most commonly occurs on the scalp, but it can also target other body sites. Signs and symptoms may include round, patchy areas of nonscarring hair loss, ranging from mild to severe.- Mild: 1-5 scattered areas of hair loss on the scalp and beard
- Moderate: More than 5 scattered areas of hair loss on the scalp and beard
- Severe: loss of all the hair on the scalp and body
Hairs that do grow back may be either temporarily or permanently white. This color change is not seen in other forms of alopecia.
Pits and ridges in the fingernails can also occur.
Self-Care Guidelines
Psychological support may be beneficial.Wigs may be worn to camouflage hair loss.
When to Seek Medical Care
People experiencing areas of patchy hair loss are advised to seek evaluation from a primary care provider or dermatologist.Treatments
The doctor may prescribe topical or oral (systemic) medications as well as injections. Steroid injections may help speed up hair regrowth (including in children) with mild-to-moderate conditions:- A powerful (potent) topical steroid (clobetasol propionate [Clobex, Cormax] gel or solution) can be applied every 12 hours, with or without covering the area (occlusion) overnight. (Note: Clobetasol lotion, shampoo, and spray are not recommended for use in patients younger than age 18 years.)
- Anthralin (Drithocreme) cream 1%, a topical medicine, can activate (stimulate) the immune system to speed up healing. Apply this medication to the affected area and about 1 cm beyond the border for 10-20 minutes, and then wash it off with shampoo (age 12 years and older).
- For more extensive disease, your doctor may expose the affected area to light or apply topical steroids plus minoxidil (Loniten, Minodyl), each used every 12 hours.
- Systemic steroids, such as prednisone, may be prescribed, although they have no long-term benefit and are not recommended for use beyond the short-term.
- Janus kinase (JAK) inhibitors (eg, baricitinib [Olumiant]) are a newer class of prescription medications that may be prescribed in severe cases that are not responding to other treatments (age 12 years and older).
Alopecia areata in Adult
See also in: External and Internal Eye,Hair and Scalp,Nail and Distal Digit