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Defining Different Types of Hair Loss

Alopecia areata is also called AA; alopecia areata is an autoimmune disease that causes hair loss (see the sidebar “What’s an autoimmune disease?”).

AA is sometimes called spot baldness because it causes round spots of hair loss. The disease, which is relatively common, tends to run in families and affects about 1 to 2 percent of the population in the United States. In about 2 percent of patients, the disease changes into a more diffuse form of hair loss, covering wider areas of the scalp. Alopecia areata occurs when a person’s white blood cells attack and destroy the body’s hair follicles.

After hair follicles are attacked, they stop producing hair, causing the distinctive localized bald patches that are the mark of alopecia areata. The hair loss usually occurs over a short period of time. Severe alopecia areata can take two forms:

Alopecia totalis: All hair on the scalp is lost.

Alopecia universalis: All hair on the scalp is lost, along with hair on the eyebrows, eyelashes, and all other parts of the body. Less severe alopecia areata can take these forms:

Alopecia areata monolocularis: Baldness occurs in only one place on the scalp.

Alopecia areata barbae: Hair loss occurs in patches in a man’s beard.

AA can occur at any age, with most patients diagnosed between the ages of 15 and 29 and nearly half being under age 20. An equal number of men and women develop AA, and the disease occurs equally in every race.

Diagnosing the disorder

Alopecia areata doesn’t follow a predictable path. Some patients feel burning or itching in the area of balding, but others don’t. Eighty percent of patients have only one bald spot. The bald patches can be round or oval in shape, and expose smooth, bald skin.

The disease normally affects only the scalp, but other body hair also can be affected and aid in diagnosing the condition. Interestingly, if you have fingernail abnormalities such as small pits on the nail plate, you may also have alopecia areata. Atopic dermatitis (an allergic skin condition) and vitiligo, a disease that causes white patches on the skin, are also more common in people with AA.

An important diagnostic clue to alopecia areata is the presence of “exclamation point hairs” on the perimeter of the bald patch. These hairs form as the body attacks the lower portion of the hair follicle, and the damage produces a finely tapered end. As the hair continues to grow, it looks like a tiny spear stuck in the scalp. Eventually this hair will be lost, but its presence is a sign of alopecia areata in its active stage.

Your doctor may gently pull hair along the edge of a bald patch to determine whether you have alopecia areata. Healthy hair doesn’t come out when pulled gently, but hair afflicted with alopecia areata is easily removed.

Exploring treatment options

If you’re diagnosed with alopecia areata, the good news is that in 90 percent of cases, hair grows back on its own and no treatment is needed. The chances of regrowth are best when the condition is localized to just a few places on the scalp and the patient is over age 40. In younger patients, unfortunately, the condition tends to be more severe. If the disease progresses to alopecia totalis or alopecia universalis, no surefire treatment is available.

Options for treatment include:

Steroids: One of the main functions of steroids is to reduce inflammation, but in patients with AA, steroids are used to stop the body’s immune cells from destroying hair follicles. Your doctor may inject steroids directly into your bald patches or may prescribe a topical steroid cream that you can apply to the bald patches at home.

When the disease is too extensive to treat with multiple injections or topical creams, oral steroids are an option. Usually, you only take them for a short period of time because of the many side effects of long-term use, including osteoporosis, very fragile skin, and diabetes.

Minoxidil: This medicine works because hair growth is a side effect of the drug that may directly affect bald spots. You apply it directly to the bald patches. Minoxidil is commonly used to treat pattern baldness, but for unknown reasons it also sometimes helps patients with AA.

Cyclosporine: This potent immunosuppressant specifically inhibits T cells, the immune system cells that attack hair follicles in AA. Cyclosporine is most often given orally. It’s more commonly used to treat other conditions such as psoriasis, and many physicians are hesitant to use it medicine to treat AA because it can cause kidney damage, high blood pressure, and suppress your body’s immune system.

DNCB: This chemical (full name dinitrochioro benzene) rapidly produces skin sensitivity. In some people with severe alopecia areata, continued application of DNCB (enough to produce a continuing rash caused by the activation of white blood cells to boost the local immune function). This caused hair regrowth in some individuals. It doesn’t always work, however. You should take DNCB only under the strict supervision of a doctor who’s experienced with this treatment.