Alopecia

What It It, Causes, Signs, and Treatment

Author: Ashley Mauldin MSN, APRN, FNP-BC

Editors: Antonella Melani, MD, Lisa Miklush, PhD, RN, CNS

Illustrator: Jillian Dunbar


What is alopecia?

Alopecia (also known as alopecia areata) is a chronic, immune-mediated skin disease characterized by sudden loss of hair on the scalp, beard, and sometimes eyebrows, eyelashes, and body hair. It can also be described as bald spots or bald patches. This patchy hair loss is very unpredictable, as the hair growth can return to normal at any time, and then suddenly fall out again. The affected areas show no signs of inflammation or other reasons for the hair falling out. 

The patches of hair loss can be as small as the size of a coin, or entirely involve the affected area. The most common presentation of alopecia areata are localized bald spots, most often on the scalp or beard. If there is complete loss of all the hair on the scalp, it is called alopecia totalis. If both the hair on the scalp and body hair are involved, it is called alopecia universalis.

What are the main causes of alopecia?

Alopecia is a type of autoimmune disorder in which the immune system attacks the hair follicles, causing the hair to decrease in size, slow down growing, or stop growing altogether. The triggers involve a combination of multiple environmental and genetic factors. Alopecia can often be associated with other autoimmune disorders, such as thyroid disease, systemic lupus erythematosus, psoriasis, rheumatoid arthritis, and other inflammatory diseases.

Is alopecia genetic?

Alopecia can have genetic predisposition and tends to cluster in families. However, the inheritance pattern is unclear, as it involves a combination of multiple environmental and genetic factors.

Is alopecia contagious?

Alopecia is not contagious. Individuals who develop alopecia areata typically have both a family history and some type of environmental trigger, such as emotional or physical stress.

What are the early signs of alopecia?

Common signs and symptoms of alopecia areata include a single small round patch, or multiple patches of hair loss. Alopecia areata usually starts out in a small localized area, but it can progress to alopecia totalis and alopecia universalis. 

The typical finding of active alopecia is the “exclamation mark” hair at the edge of the bald patches, which can be seen by the naked eye as short hairs with a narrower base at the skin, and thicker end. These hairs are more fragile and likely to fall out.

Additionally, some individuals with alopecia experience nail abnormalities like pitting of the nail plate. Nail abnormalities can occur before or during hair loss, or even after the hair has started to grow back. 

What is the best treatment for alopecia?

Individuals with small patches of hair loss may benefit from anti-inflammatory treatment, using a topical steroid in the form of shampoo, lotion, or foam. Topical steroid treatment should be used for at least three months to see results, and stopped at six months if there is no new hair growth. Potential side effects include folliculitis, rash, and skin thinning. Topical steroid treatment is not indicated for alopecia totalis and alopecia universalis.

Another treatment option for patchy hair loss is intralesional steroid application in the form of an injection directly into the top layer of skin. Multiple injections are typically needed, and this can lead to the skin atrophy on the injection site. Intralesional steroid injections are not recommended for individuals with rapidly progressing alopecia areata, or those with alopecia totalis or alopecia universalis. 

Another topical treatment is anthralin (Dritho-Scalp), which is available as a cream, ointment, or lotion. Anthralin has anti-inflammatory properties, and typically takes about eight weeks for any new hair growth to appear. Potential side effects of anthralin are skin discoloration and irritation, thus making it an undesirable choice for long-term treatment. 

Alopecia can also be treated with oral medications, such as minoxidil (Rogaine). Minoxidil acts as a vasodilator, which enhances blood flow to the scalp. With minoxidil, it may take months to see hair growth, so it is typically used in combination with a topical steroid. Common side effects seen with minoxidil can include skin inflammation, headaches, and hair overgrowth. 

For alopecia totalis and alopecia universalis, the potential treatments involve long-term use of a corticosteroid and contact immunotherapy. Systemic corticosteroid treatment with oral prednisolone should be continued for up to 6 months to maintain the hair growth. Due to the side effects of long-term oral corticosteroid use, it is reserved for those individuals with very extensive alopecia. A weekly treatment with a topical immunotherapy allergen, such diphenylcyclopropenone, has been shown to be effective in some cases. In order to see adequate hair growth, treatment should be continued for at least six months. 

In addition, many people seek psychological support and cosmetic items, such as wigs or hair weaves.

Can alopecia be cured?

There is no cure for alopecia areata. Due to its unpredictability, alopecia can be very difficult to treat. Some individuals can achieve some hair growth with treatment, while others have no success. Many experience spontaneous remissions, followed by exacerbations. The failure rate of all current treatment options is high, and at this time, there are no specific treatments approved for alopecia by the US Food and Drug Administration (FDA). There are currently clinical trials being conducted with laser treatments and photochemotherapy in the hopes of finding a treatment that has few side effects and a better response rate for hair regrowth.

What are the most important facts to know about alopecia?

Alopecia is a chronic, immune-mediated skin disease that causes a sudden loss of hair. The scalp, beard, eyelashes, eyebrows, and body can all be affected. 

To develop alopecia, an individual must have both a family history, and some type of environmental trigger. The most common presentation involves bald patches on the scalp or beard. The hair loss is very unpredictable, with periods of sudden hair loss, followed by spontaneous hair growth. The hairs affected by alopecia will have a characteristic “exclamation point” shape, making them more likely to fall out.

There is no cure for alopecia, and the available treatments are mostly ineffective or have a very low response rate. The goal of most treatments is either to block the immune response or stimulate hair growth. Even with treatment, the hair may fall out again when the treatment is stopped.

Related links

Clinical reasoning: Alopecia
Alopecia areata
Hair, skin, and nails

Resources for research and reference

Harries, M. J., Sun, J., Paus, R., & King, L. E., Jr (2010). Management of alopecia areata. BMJ (Clinical research ed.), 341:c3671. DOI: 10.1136/bmj.c3671

Piazza, G. (2018). Minoxidil may improve blood vessel structure. National Institutes of Health. Retrieved August 12, 2020, from https://www.nih.gov/news-events/nih-research-matters/minoxidil-may-improve-blood-vessel-structure

Pratt, C. H., King, L. E., Jr, Messenger, A. G., Christiano, A. M., & Sundberg, J. P. (2017). Alopecia areata. Nature Reviews Disease Primers, 3:17011. DOI: 10.1038/nrdp.2017.11

Singh, G. & Lavanya, M. (2010). Topical immunotherapy in alopecia areata. International Journal of Trichology, 2(1):36–39. DOI: 10.4103/0974-7753.66911

Suchonwanit, P., Thammarucha, S., & Leerunyakul, K. (2019). Minoxidil and its use in hair disorders: a review. Drug Design, Development and Therapy, 13:2777–2786. DOI: 10.2147/DDDT.S214907

Treatments for Alopecia Areata. (n.d.). National Alopecia Areata Foundation. Retrieved August 6, 2020, from https://www.naaf.org/alopecia-areata/alopecia-areata-treatments

What you need to know about alopecia areata. (n.d.). National Alopecia Areata Foundation. Retrieved August 4, 2020, from https://www.naaf.org/alopecia-areata