Alopecia areata: why it appears and how it is treated

What exactly is alopecia areata?

Alopecia areata is an autoimmune inflammatory disease that can affect the follicles of the scalp and other areas of the body.

Our immune system is designed to defend us.

But in autoimmune diseases, it mistakenly recognises certain of the body's own structures as targets.

In alopecia areata, this immune response is directed against the hair follicle and disrupts the normal hair growth cycle.

The result can be rapid hair loss in certain areas. (aad.org)

How can we recognise it?

The classic presentation is quite characteristic: one or more round or oval bald patches.

In many cases, the skin in the affected area appears seemingly normal.

We do not necessarily see scarring.

At the edges, certain characteristic signs may be found when examining the hair and performing trichoscopy.

But alopecia areata does not always present in exactly the same way.

It can affect the scalp, beard, eyebrows, eyelashes, and other areas of the body.

Nail changes may also be present in some patients.

Is it the same as androgenetic alopecia?

No. They are two completely different conditions.

In androgenetic alopecia, certain follicles undergo progressive miniaturization and the hair becomes increasingly fine. The progression usually occurs slowly.

In alopecia areata, on the other hand, the immune system abruptly disrupts follicle activity and we can observe areas that lose hair over a relatively short period.

That is why we cannot simply speak of types of alopecia as if they all shared the same mechanism.

Nor can we treat them in the same way.

Why does it appear?

This is one of the first questions patients ask: 'Why did this happen to me?'

There is a genetic and immunological predisposition, but in general we cannot identify a single concrete cause.

We know that certain people have a greater susceptibility and that the condition can be associated with other autoimmune diseases.

But this does not mean that every person with alopecia areata has another autoimmune disease.

Nor does it mean that we can point to a single event and say: 'This is what triggered it.'

Is stress the cause?

Here we must be especially careful.

Many patients recall a stressful situation before the patch appears and automatically draw a connection.

Stress can interact with numerous immunological processes and has been studied as a possible triggering or modulating factor in predisposed individuals.

But simply saying: 'Alopecia areata appears because of stress' is an oversimplification.

Alopecia areata is a multifactorial autoimmune disease, not simply a psychological consequence of stress. (pubmed.ncbi.nlm.nih.gov)

Can it affect women?

Yes.

Alopecia areata in women can appear at any age, just as it can in men.

In a woman with hair loss, it is important to distinguish it from other common causes, such as female androgenetic alopecia or telogen effluvium.

The distribution of the loss, clinical examination, and trichoscopy help differentiate them.

Can the hair grow back?

Yes. And this is one of the important aspects of this condition.

Since the follicle is not usually permanently destroyed, regrowth is possible.

In limited forms, especially when there are only a few patches, spontaneous regrowth can even occur without treatment.

However, the course of the disease is unpredictable.

The hair may grow back and then a new patch may appear afterwards.

Some patients experience a single episode in their lifetime. Others experience relapses. And a smaller group develops more extensive forms.

That is why we must not simply promise: 'It will grow back and it will never happen again.'

What is total alopecia?

When the loss affects practically all of the hair on the scalp, we speak of alopecia totalis.

It is a more extensive form of alopecia areata.

And what is universal alopecia?

When the process spreads and causes an almost complete loss of scalp hair and body hair, we speak of alopecia universalis or universal alopecia.

It can affect the scalp, eyebrows, eyelashes, beard, and body hair.

The expression alopecia areata universalis is also used in patient searches to refer to these generalized forms.

These extensive forms have different behavior and therapeutic needs compared to a small isolated patch.

How is it diagnosed?

In many cases, the clinical appearance is very telling.

But a dermatological examination makes it possible to confirm that we are truly dealing with alopecia areata and to rule out other causes.

Trichoscopy is especially useful. It allows us to observe characteristics of the follicle and the hair that help with diagnosis and with assessing disease activity.

In selected cases, we can carry out additional tests if the clinical history raises suspicion of associated conditions.

And when the diagnosis remains uncertain, a biopsy may exceptionally be necessary.

Alopecia areata treatment: what can we do?

When we look into alopecia areata treatment, it is important to understand that there is no single strategy that works for everyone.

Treatment depends fundamentally on: the patient's age, the extent of the disease, the areas affected, the duration of the condition, its activity, and previous treatments.

A small, recent patch and universal alopecia require completely different approaches.

Corticosteroids

In localized forms, corticosteroids are one of the classic treatments.

In adults with few patches, intralesional corticosteroid injections administered directly into the affected areas may be used.

Topical treatments also exist, particularly in certain circumstances and age groups.

The goal is to reduce the inflammatory activity that is interfering with the follicle. (aad.org)

Is minoxidil used?

It can be used as a complementary treatment in certain patients to promote hair growth, but we must understand the difference: minoxidil does not by itself correct the autoimmune mechanism responsible for alopecia areata.

That is why we must not confuse the treatment of androgenetic alopecia with that of alopecia areata.

What happens when alopecia is extensive?

Here, treatment has changed considerably in recent years.

Understanding the immunological pathways involved in alopecia areata has made it possible to develop treatments targeted specifically against certain inflammatory signals.

Among these are JAK inhibitors.

JAK inhibitors are currently approved for certain patients with severe alopecia areata, although the exact indications depend on the medication, the patient's age, and each country's regulations. These treatments require medical assessment and ongoing follow-up due to their potential side effects. (ema.europa.eu)

This represents a significant shift compared to what we could offer patients with extensive disease just a few years ago.

Do I need vitamins?

Not necessarily.

Alopecia areata is an autoimmune disease.

Taking supplements indiscriminately does not eliminate the immune mechanism responsible for the condition.

If a proven nutritional deficiency exists, we must of course correct it.

But having alopecia areata does not automatically mean having a vitamin deficiency.

Should I change my shampoo?

A shampoo can care for the scalp.

But a conventional shampoo cannot on its own stop the autoimmune response responsible for the disease.

This is another example of why correctly diagnosing hair loss is far more important than immediately starting an 'anti-hair loss' product.

Can it come back?

Yes.

Even after a full recovery, new patches may appear in the future.

We cannot perfectly predict the individual course of the disease.

Some clinical factors are associated with potentially more persistent or extensive forms, but none of them allows us to know with certainty what will happen in any specific person.

That is why follow-up is also part of managing the disease.

When should we seek medical advice?

When a hairless area appears suddenly — especially if we notice one or more clearly defined patches — it is worthwhile having a dermatological assessment.

We should also seek advice when the loss progresses rapidly, affects the eyebrows or eyelashes, nail changes appear, or there is any doubt about the diagnosis.

And there is a simple reason: the sooner we know what type of alopecia we have, the sooner we can decide whether we should treat it and how to do so.

What I want you to remember

If tomorrow you discover a round bald patch, it does not automatically mean that the follicle is dead.

In alopecia areata, it is generally still there.

The problem is that an immune response is temporarily interfering with its functioning.

And this leaves us with a very important idea: alopecia areata does not necessarily mean permanent hair loss.

But we should not treat every patch in the same way either.

First we confirm the diagnosis. We assess extent and activity. And then we decide whether to simply observe or whether treatment is needed.

Because, once again, when we talk about hair loss, the correct treatment begins with giving the problem the correct name.