Alopecia Areata:The Clinical Aspects: Alopecia Areata: The Clinical Aspects Amy J. McMichael, M.D. Associate Professor Department of Dermatology Wake Forest University School of Medicine Winston-Salem, NC, USA


Alopecia Areata: Alopecia Areata Third most common form of hair loss (after AGA and telogen effluvium) Autoimmune disease of hair follicle Patchy or total hair loss from any area on body Lifetime risk of 1.7% in general population Animal models: Dundee experimental bald rat and C3H/HeJ mouse –spontaneous models Severe combined immunodeficiency mouse-human (SCID-hu) model


Presentation of disease: Presentation of disease Usually presents as sudden hair loss in well-demarcated, localized area Usually round or oval patch May be isolated or numerous May progress quickly to significant hair loss Usually patches are seen in the scalp, but can also see involvement of beard area, body, eyebrows, and eyelashes, nose hairs


Appearance of the patch/patches: Appearance of the patch/patches Redness may be present Usually no scaling, but there may be red or inflamed hair follicles Pigmented hairs are often shed while the unpigmented or white hairs are spared “Going gray overnight”


The most common site of AA: The most common site of AA Scalp most common site Study by Muller et al, 1960 showed 95% of patients have scalp involvement Often the first site affected Most treatments are geared towards scalp hair loss


Nomenclature and clinical signs: Nomenclature and clinical signs Types of disease Areata, totalis, universalis Ophiasis (sisaipho) Diffuse Signs +/- Erythema Exclamation point hairs Positive pull test at active margin Hairs usually grow in gray or white Nail changes


Patchy disease: Patchy disease


AA may be confused with tinea capitis in children or vice-versa: AA may be confused with tinea capitis in children or vice-versa Patch of fungus of the scalp with hair loss and very mild scaling


Patchy Alopecia Areata: Patchy Alopecia Areata


Patchy disease with hair regrowing : Patchy disease with hair regrowing


Patchy AA in a dark-complexioned person: Patchy AA in a dark-complexioned person May be difficult to hide in male patient or in patient with short hair


Diffuse form of alopecia areata in young child: Diffuse form of alopecia areata in young child


AA may mimic male patterned baldness: AA may mimic male patterned baldness Purple color from use of anthralin on scalp


Ophiasis Pattern: Ophiasis Pattern


Alopecia Totalis: Alopecia Totalis


Patchy AA in association with Downs Syndrome and vitiligo : Patchy AA in association with Downs Syndrome and vitiligo


Exclamation hairs: Exclamation hairs Difficult to photograph Often seen at the margins of the active patch of hair loss A sign of active disease Inflammation has affected the growth of a hair that was in a mid-anagen (mid-growth) phase Pull test may be positive adjacent to the exclamation point hairs


Exclamation Point Hairs: Exclamation Point Hairs


Pull test results: Pull test results Pull test is a test for activity of hair loss Can be used in other diseases as well 30-40 hairs pulled between thumb and forefinger from scalp to end of hair 0-2 hairs is normal hair loss Difficult to perform on extremely long or short hair, and extremely curly hair Only situation in AA where counting hairs may be helpful


Regrowth Appearance: Regrowth Appearance Usually see downy blond or light hair first Then you can see thickening and darkening of hair shaft as it grows Some patients with AA may have persistent color change or difference in texture


Short regrowing hairs that are dark in color: Short regrowing hairs that are dark in color Pigmented hairs growing in at top of scalp


Other sites of loss: Other sites of loss Eyebrows Eyelashes Beard


Common nail changes in AA: Common nail changes in AA Pitting Trachyonychia Beau’s lines Thinning or loss of nails White spots and lines or red spots


Nail Changes in AA: Nail Changes in AA Nail involvement may help in diagnosis May help to monitor activity of AA (i.e., if you have nail changes and then normal nails) May not affect all nails Should be examined at intervals if seeing a dermatologist regularly


Nail changes: Nail changes Pitting and mild trachyonychia


Alopecia areata with nail changes: Alopecia areata with nail changes Patient with alopecia totalis and severely affected nails Nail involvement was not responsive to antifungals


Treatments for Alopecia Areata: Treatments for Alopecia Areata Current Agents Corticosteroids Topical Intralesional Systemic PUVA Minoxidil* Topical Sensitizers Anthralin* Imiquimod* Referral to National Alopecia Areata Foundation Investigational agents Cytokines Antibody Gene therapy Biologic therapy * Adjunctive agents


Topical and Intralesional Corticosteroids: Topical and Intralesional Corticosteroids Topical corticosteroids Generally regarded as unhelpful Possibly helpful if clobestasol cream under occlusion—(Tosti et al 2003) Intralesional corticosteroids Treatment of choice for patchy disease <50% of scalp 64-97% response rate Maximum of 3 ml per visit Repeat every 4-6 weeks


Systemic corticosteroids: Systemic corticosteroids Usually use prednisone 6 week to 3 month course Allow no more than 2 courses per year 50-60 mg in tapering dose Pulse methylprednisolone 250 mg BID for 3 days* *Friedli A. et al, 1998


Adjunctive Agents: Adjunctive Agents Minoxidil 5% - shown to work by Price et al. Used twice daily. Usually in combination with topical steroids under occlusion Anthralin: Most useful in children and patients with less inflammatory disease


Topical Sensitizers: Topical Sensitizers Dinitrochlorobenzene Squaric acid dibutyl ester (SADBE) Diphenylcyclopropenone (DPCP or DCP) Approved for use in alopecia totalis and universalis under orphan disease status


Future Directions:Biologic Response Modifiers: Future Directions:Biologic Response Modifiers Interrupt Th-1 pathway at level of activation Potential role in alopecia areata


Summary: Summary Broad range of presentation seen in AA Associated findings may be worse for some patients (nails, allergies, conjunctivitis) There is no “normal or average” for AA A clear understanding of all the findings is helpful for patients and physicians


What you present to the world is your hair: What you present to the world is your hair “This is my hair with gum in it” “This is my hair when my braids are too tight” “This is my hair with curlers…” “This is me with no hair”