Table of contents
Alopecia areata
What's new
Updated 2024 BAD guidelines for the management of alopecia areata.
Background
Overview
Definition
Alopecia areata is an autoimmune disease characterized by non-scarring hair loss, where the immune system attacks the hair follicles, leading to hair loss.
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Pathophysiology
The pathophysiology of alopecia areata involves the collapse of the immune privilege of the hair follicle and subsequent autoimmune attack. This is mediated by various immune cells and cytokines, including regulatory T cells, cytotoxic T lymphocyte-associated antigen 4, IL-2/IL-21, and IFN-γ.
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Epidemiology
The prevalence of alopecia areata worldwide is estimated at 212.77 per 100,000 population.
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Risk factors
Risk factors for alopecia areata include a personal or familial history of autoimmune or atopic diseases, as well as recent exposure to stressful events. Genetic predisposition, particularly involving genes that regulate immune responses and hair follicle functionality, is also implicated in the pathogenesis of the disease.
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Disease course
Clinically, alopecia areata presents as patchy, non-scarring hair loss, generally affecting the scalp, but can also affect other parts of the body. Other clinical variants include alopecia totalis, alopecia universalis, ophiasis, sisaipho, and Canitis subita. Nail changes, such as pitting and trachyonychia, can also be present in some patients.
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Prognosis and risk of recurrence
The prognosis of alopecia areata is unpredictable and varies widely among individuals. While spontaneous regrowth of hair is common, the disease can also progress to more extensive hair loss.
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Guidelines
Key sources
The following summarized guidelines for the evaluation and management of alopecia areata are prepared by our editorial team based on guidelines from the American Academy of Family Physicians (AAFP 2024), the British Association of Dermatologists (BAD 2024), and the British Photodermatology Group (BPG/BAD 2019).
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Diagnostic investigations
Initial assessment: as per BAD 2024 guidelines, elicit a comprehensive history in patients with alopecia areata, including site and type of alopecia areata, disease extent, disease stability, age of onset, speed of progression, triggering factors, QoL, psychological and psychosocial impact, maximum severity experienced, and personal and family history of other autoimmune diseases.
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Medical management
Topical therapy, corticosteroids: as per BAD 2024 guidelines, offer a potent or very potent topical corticosteroid once daily for 3-6 months as first-line therapy in patients with alopecia areata with scalp hair loss.
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Topical therapy (minoxidil)
Topical therapy (anthralin)
Topical therapy (prostaglandin analogs)
Topical therapy (agents with no evidence for benefit)
Contact immunotherapy
Systemic therapy (corticosteroids)
Systemic therapy (minoxidil)
Systemic therapy (immunosuppressive agents)
Systemic therapy (JAK inhibitors)
Systemic therapy (agents with no evidence for benefit)
Nonpharmacologic interventions
Use of wigs: as per BAD 2024 guidelines, offer wigs, including toppers, in patients with alopecia areata whose QoL is likely to benefit from their use. Offer a minimum of two synthetic wigs or one human hair wig per year due to the product lifespan.
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Psychosocial support
Alternative and complementary therapies
Therapeutic procedures
Intralesional corticosteroids: as per AAFP 2024 guidelines, consider offering intralesional corticosteroids for the treatment of alopecia areata.
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Light and laser therapy
PUVA therapy
Therapies with no evidence for benefit