Alopecia Areata – What you need to know

Welcome to the Hair Loss Show. Dr. Russell Knudson and Dr. Vikram Jayaprakash discuss issues relating to hair loss and the medical and surgical treatment of hair loss in both men and women.

Hi everyone and welcome back to the Hair Loss Show. My name is Dr. Vikram Jayaprakash.

And I’m Dr. Russell Knudson.

Well, welcome. Thanks again for watching and subscribing to the channel. It’s good to be back with you, Russell. In today’s episode, we’re going to talk about alopecia areata. We’ve spent a lot of time talking about androgenetic alopecia, and there are lots of different forms of alopecia, but specifically today—yeah, all right—so the first thing I want to explain is that alopecia is a generic term for hair loss.

So, androgenetic alopecia means there’s some androgens, which are male hormones, involved in that hair loss. Alopecia areata is a very different beast. But we see a lot of it come into the practice, and I want to talk a little bit about it today.

So, areata—areata is patchy hair loss. Now, the interesting thing about it is that the hair has shed out, but the follicles still exist in the skin. They’ve just switched off. This is what we call an autoimmune condition, which means that your immune system looks at the protein of your hair follicles and says, “Hey, that’s a foreign protein.” So, it mobilizes the immune system to surround the hair bulb and switch it off.

In theory—and in practice—it can regrow perfectly normal, healthy hairs. So, if you have a single patch as an adult that looks like a 50-cent piece or a berry size—it can be quite small—80% of those will regrow within six months with no treatment. So, sometimes it’s just a matter of watch and wait.

Multiple patches become a little bit more of a problem. That’s still areata. But then there are specific patterns—for example, a ring around the neck—which is more resistant to treatment. The more severe version is where the entire scalp hair disappears. That’s called totalis, meaning total loss of hair on the scalp. And then the worst one is alopecia universalis, and that means body hair as well. So, you lose everything—eyebrows, everything.

That’s right. So, that’s the worst one. But it’s very common to have areata in the population—it’s about 1% of the population. It does have a bit of a familial ring to it. So, it does travel in some families, not in others. And it’s bizarre as to where the patch is going to be, because there seems no rhyme nor reason to it—it just can be anywhere on the scalp. Multiple patches can appear in different locations.

Unfortunately, once you’ve had one patch of areata, there’s a significant chance that you’ll get it again sometime later in life. It’s rarely a one-hit. And if you get it as a child, it’s usually more severe than if you get it as an adult.

The traditional means of treating it are: no treatment, if it’s a single patch for example. Or you can use steroids, either topically or injected. Steroids would be common to do that. We can use minoxidil topically to the patch to try and stimulate those hairs to come back, and that can work.

Basically, the less severe forms can respond pretty well. But the severe forms—up until recently—have not responded well to anything, and that’s been a real challenge.
I mean, sometimes what I see regularly is that, especially if it’s in the minor form, it’s almost found by accident.

Yes, a hairdresser finds it.

Yes, because it’s a small patch tucked away back here, and the hairdresser goes, “Oh my God, you’re going bald.” Then they come in going, “Actually, no.” You can—the characteristic of it is normal skin, and basically, there are these tiny, sharp, broken hairs around the margin often as well. That’s the way we can tell.

There’s no pain, or itching, or scarring.

No symptoms. Right. But again, if you get it, it can be managed if it’s in the less severe forms. But the more severe forms are challenging, and we will talk about that on another episode.

No one likes to lose hair, especially in this sort of manner, because it looks—it’s patchy, it looks unnatural. It can be very emotionally fraught. So, we spend a lot of time reassuring people, especially if it looks like a minor form—don’t worry, all things being normal, the hair should return.

Sometimes people are really keen to try and get ahead of this and transplant into the area.

Yeah, okay. Well, here’s the problem there: if you transplant into an area where the immune system is active, then the transplanted hairs won’t grow. So, it’s rare. There are a couple of cases historically where they’ve had a stable alopecia patch for maybe 20 years, and they’ve transplanted into it, and the hairs have started to grow—but that’s a rare event.

The thing to remember is that the patch has got normal hair follicles there—they’re just switched off. So, adding hairs into that environment doesn’t necessarily improve the outcome at all, because you’re just going to damage the existing hairs that are switched off at the moment.

So no, we will not operate ordinarily into alopecia patches. But we try to be supportive and try to do these therapies, like topical or injectable steroids. The thing is, a hair that falls out today is not going to regrow for at least three months.

One of the fascinating things about areata is that when the hair starts to grow back, it often starts back as depigmented hairs—bit like this—as they grow back, and then they repigment as they go along. So, it’s a very interesting condition, but I can understand it’s very traumatic to patients when they come in with it.

But mostly, if it’s just a single patch or a couple of small patches, it’s quite manageable.
Yeah, so I think this also again highlights the bit that we talk about constantly on most of the videos, which is the importance of getting the diagnosis right and being assessed by someone who knows what they’re looking at.

You want to make sure that you catch this relatively early and start treatment if it’s appropriate—but not, you know, not transplant it.

Yeah, not transplant it. Certainly, something like finasteride won’t do a thing for treating alopecia areata.

So it’s about making sure that the diagnosis is done properly, and that you’re assessed in a proper and timely manner.

That’s right. Because not all hair loss is the same. There are multiple causes. We need to know exactly what we’re treating, because the different diagnoses have different treatment parameters.

Good. All right, so that’s alopecia areata. We’re going to come back in another episode, and we’re going to talk about other treatment options—brand-new treatment options.
Yes! So, we’ll see you in the next episode. Thanks for watching, and keep subscribing.
Take care. Bye.