Summary
Dermatological presentations including hair and nail disorders are common in general practice. Primary care practitioners are the first the see these cases. This article focuses and outlines on one of the most common types of hair loss viz., Alopecia Areata (AA) and how to manage it in the community. Differential diagnoses are androgenetic alopecia, teologen effluvium and infective conditions.
Epidemiology and pathophysiology
AA is a chronic inflammatory disorder of the hair follicles with non-scaring hair loss occurring in any hair bearing area including beard and eyebrows in addition to scalp. The life time risk of AA is 1-2 % regardless of age, gender and ethnicity. Prevalence rate peaks in between the second and fourth decades. Presumably AA is due to autoimmunity and genetic predisposition.
Clinical features, types, diagnosis
Table 1 shows morphological classification of AA. A bald patch or thinning hair is noted incidentally by a hairdresser or family member. The patch is a smooth surface (circular,oval) completely devoid of hair or with scattered hair. Nail changes such as pitting, ridging (sand paper nails) can be associated in 10-60% of AA. The diagnosis of AA is clinical and skin tests are rarely indicated.
Table 1. Morphological classification of AA
Management
In fifty percent of cases, the spontaneous remission of AA occurs but relapse may occur. The treatment options are :
- Counseling and psychological support; the disease is extremely depressing for female patients
- Topical treatment includes :
- Intra-lesional corticosteroid injections (ICI) + daily application of potent steroids+ 5%Minoxidil solution or foam , used twice daily as an adjunct onto affected areas. ICI is more useful for patchy loss of hair with triamcinolone acetonide (5-10 md/ml for scalp and 2.5-5 mg/ml for eyebrow and beard) with or without local anesthesia. Injecting several places 1 cm apart into deep dermis (not subcutaneous) using a 25-30 gauge needle with luer-lock syringe type. The process can be repeated every four to six weeks.
- Dithranol (anthralin) ointment or cream 0.5 -1% is another option of topical treatment. Apply to the affected area for a period of 20-30 minutes daily over the first two weeks of therapy.
- Systemic corticosteroids :Oral tapering regime over several weeks and pulse intravenous steroids in high doses can provide temporary regrowth of hair. However, long term side effects outweigh benefits. An IV regimen of 500 mg methylprednisolone daily for three days induced hair regrowth in 88% of patients with recent onset patchy AA and in 21.4% of patients with recent onset alopecia totalis.
- Severe and refractory cases
Immunotherapy (topical diphenylcyclopropenone or squaric acid dibutylester (SADBE) JAK inhibitors (tofacitinib, ruxolitinib) and laser therapy. - Wigs, tattoos, transplant, artificial eyelashes, eye brows.
- Lipid lowering agents (simvastatin, ezetimibe), immunomodulators (methotrexate, sulfasalazine, azathioprine, cyclosporine) and phototherapy.
Prognosis
In eighty percent of patients with single bald patch, spontaneous regrowth occurs within a year. Even in the most severe cases, recovery may occur at some future date. However, poor prognostic features include: extensive involvement (AA totalis, universalis), prolonged history (history more than one year), ophiasis pattern, nail involvement , AA onset before puberty and family history of AA.
References:
- Oakley A,DermNet NZ. Alopecia areata. Hamilton: New Zealand Dermatological Society Inc.; 2003 [Updated December 2015; cited March 2018]. Available from: https://www.dermnetnz.org/topics/alopecia-areata.
- James WD,BergerTG, ElstonDM, editors. Diseases of the skin appendages: diseases of the hair. In: Andrews’ diseases ofthe skin:clinical dermatology. 12thed.Vol 33. Philadelphia: Elsevier; 2016.p. 747-757.
- Zaidi Z, Walton S, Hussain I, Wahid Z. Hair disorders. In: A Manual ofDermatology. 2nded. Vol 24. London: Jaypee Brothers Medical Publishers; 2015. p. 509-542.
- Hordinsky MK.Hair disorders. In: Clinical Dermatology: a LANGE medical book. Vol 19. McGraw-Hill Education; 2013. p. 175-186.
- Perera E, Sinclair R. Alopecia areata. In: Editors Sacchidanand S, Savitha AS, Lakshmi DV- Hair and hair disorders: diagnosis and management. Vol 10. New Delhi: Jaypee Brothers Medical Publishers; 2014. p. 115-124.
- Murrell D, et al. Managing alopecia areata. Australian doctor: how to treat.Sydney. 16th March 2017.
Author: Tim Aung (FRACGP, FRNZCGP, Dip in Skin Cancer Surgery, Advanced Cert in General Dermatology)
