Updated: 1/23/2017

Alopecia Areata

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Topic
Snapshot
  • A 35-year old woman with a past medical history of atopic dermatitis comes to the dermatologist for multiple, round patches of balding on her scalp. She has had more and more of these bald spots for about 2 months. She cannot recall any instigating events and denies pulling out her hair intentionally. Physical exam reveals no inflammation or erythema in the affected areas. A punch biopsy reveals lymphocytic infiltration. She has a family history of rheumatoid arthritis and Grave’s disease. 
Introduction
  • Chronic, autoimmune non-scarring hair loss disorder
    • as opposed to scarring cicatricial alopecic disorders such as discoid lupus or lichen planopilaris that lead to destruction of hair follicle
  • Epidemiology:
    • rare (1.7% lifetime risk of developing disease)
    • affects males and females equally
    • affects children and adults equally
  • Associated conditions:
    • other autoimmune diseases, especially thyroid and atopic disorders 
Presentation
  • Symptoms:
    • smooth, discrete, circular patches of hair loss that are typically without pain or itchiness
    • can spontaneously regrow hair or spontaneously progress to alopecia totalis/universalis
    • no erythema, inflammation, or scarring
    • nail abnormalities are common, including pitting of nail plate
Evaluation
  • Clinical evaluation of hair loss sites
    • “exclamation point hairs” at margins of patches
      • short, broken hairs that narrow at the base
      • extracted easily
      • low sensitivity
  • Punch biopsy
    • peribulbar lymphocytic inflammatory infiltrates surrounding follicles
  • Laboratory studies normal
Differential Diagnosis
  • Tinea capitis
  • Trichotillomania (nervous hair pulling)
  • Androgenetic alopecia
  • Cicatricial alopecia
  • Telogen effluvium
  • Traction alopecia
    • secondary to hair tension that is prolonged or repetitive
Treatment
  • Watchful waiting for mild cases, as hair may regrow spontaneously
  • Limited therapies available; all with limited efficacy
    • intralesional corticosteroids (triamcinolone)
    • topical steroids
    • pulsed prednisone
    • topical immunotherapy
  • Currently under investigation: targeted immunotherapies
    • janus kinase inhibitors tofacitinib, ruxolitinib 
Prognosis, Prevention, and Complications
  • Variable, unpredictable pattern of regrowth, patchy hair loss, and progression to alopecia totalis or universalis 
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Questions (2)

(M1.MK.15.48) A 22-year-old female presents to a dermatologist concerned about the formation of several bald spots on her scalp that have developed over the last 6 weeks. She denies any past medical history; however, she reports a family history of a similar hair loss pattern in her maternal uncle. Physical examination reveals the patient's scalp as shown in Figure A. The patient asks her physician about the prognosis of this disease. Which of the following statements is true about this patient's presenting condition? Tested Concept

QID: 102989
FIGURES:
1

Treatment strategies are ineffective at inducing hair regrowth

3%

(3/93)

2

Hair loss often recurs after successful treatment or spontaneous resolution

54%

(50/93)

3

Topical immunotherapy is the first-line treatment option and is effective for all patients with the disease

8%

(7/93)

4

Treatment with minoxidil is likely to be curative, with permanent resolution of hair loss

13%

(12/93)

5

Spontaneous resolution rarely occurs

18%

(17/93)

M 4 D

Select Answer to see Preferred Response

(M1.MK.15.46) A 19-year-old male presents to a dermatologist with a concern of patchy hair loss resulting in several areas of baldness on his scalp (Figure A). These bald spots have manifested over the last 2 months. There is no notable scaling, inflammation, or scarring associated with these patches. Which of the following conditions is associated with this patient's presentation? Tested Concept

QID: 102987
FIGURES:
1

Non-insulin dependent diabetes

8%

(13/157)

2

Migraine headaches

3%

(4/157)

3

Scoliosis

6%

(10/157)

4

Gonococcal arthritis

6%

(9/157)

5

Autoimmune thyroiditis

76%

(119/157)

M 4 D

Select Answer to see Preferred Response

Evidence (2)
Topic COMMENTS (2)
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