What is alopecia areata?
In alopecia areata, hairs suddenly fall out in one or more round or oval bald patches, usually on the scalp. It can also occur on other hairy areas, such as the beard, eyebrows or eyelashes, and the pubic region or other body hair. Sometimes (almost) all scalp hair falls out, called alopecia totalis; very rarely all body hair is lost, called alopecia universalis. Typical features are small, thin hairs at the edge of a patch that start narrow and end thicker (“exclamation-mark hairs”); newly returning hair that may at first be lighter or white (often temporary); and skin that usually stays calm, without scars or wounds. Alopecia areata is not contagious.
What causes it?
The precise cause is not entirely known, but it is almost certainly an autoimmune reaction, meaning the immune system (temporarily) attacks the hair roots so the hair comes loose. You cannot catch it from someone else and cannot pass it on. In some people stress may play a role as a trigger, but it is usually not the only cause — you do not get alopecia areata “from stress alone”. It sometimes occurs together with other autoimmune diseases, such as vitiligo or certain thyroid problems.
What is the course?
Alopecia areata can vary greatly. In many people one or a few patches develop and the hair later regrows; in others new patches appear over time. The chance that hair returns less easily is greater when, for example, it began at a young age, the hair loss runs mainly along the hairline (a “band” at the back of the head), there are other autoimmune diseases, or the hair loss is extensive. It is unfortunately difficult to predict in advance how it will go.
How is it treated?
The choice of treatment depends on how many patches there are and how large, how long it has existed, your age, whether eyebrows/eyelashes are involved, and how much it bothers you.
- Watchful waiting (for small or few patches) — often the hair regrows on its own, which can take months.
- Topical treatment (for growing or bothersome patches) — corticosteroid cream or ointment, or corticosteroid injections into or just under the skin of the bald patch (usually by the dermatologist).
- Treatment in specialised centres (for large areas or long-lasting baldness) — PUVA light therapy, or contact-sensitisation therapy with diphencyprone (DPCP), done in a limited number of centres.
- Tablets that suppress the immune system (only for severe forms) — such as prednisone or ciclosporin, which can cause clear side effects.
- JAK inhibitors (a newer treatment for severe alopecia areata) — tablets that inhibit certain “signals” in the immune system, reducing the attack on the hair roots. They are for severe disease and prescribed by a dermatologist; examples are baricitinib (adults) and ritlecitinib (adults and young people from 12 years). A first effect is usually seen only after 3 to 6 months, and check-ups (for example blood tests) are needed to watch for side effects such as infections.
What is the effect of treatment?
Many treatments have been tried, but results differ from person to person and there is no treatment that works for everyone. Sometimes the effect is temporary: when a treatment stops, the inflammation around the hair roots can return and the hair can fall out again. The doctor therefore usually discusses each time what your goal is (regrowth, calm, or stopping spread), the chance of effect, and which side effects you find acceptable.
What if treatment does not help enough?
When hair loss is extensive and does not respond well, other options include a wig or hairpiece (often giving quick relief), eyebrow solutions (make-up, microblading) and psychological support if the impact is great. Many people benefit from contact with fellow patients, for example through a patient association.
When to see a doctor
See a doctor if you develop bald patches, if the hair loss spreads or keeps returning, if eyebrows or eyelashes are affected, or if the impact on your wellbeing is significant.