Review Question - QID 102989

This patient is suffering from alopecia areata. Although typically a benign condition, alopecia areata has an unpredictable course that typically involves response to treatment, spontaneous hair regrowth, and recurrence of hair loss.

Alopecia areata commonly presents as the rapid development of bald spots on the scalp. Physical exam may reveal a smooth, hairless area on the scalp that is surrounded by 'exclamation point' hairs, which are hairs that have an enlarged club-shaped root and a narrowed proximal shaft. Alopecia totalis is the total loss of all scalp hair, whereas alopecia universalis is the loss of all hair on both the scalp and entire body. The first presentation of this disease most often occurs in children or young adults, with a presumed polygenic inheritance pattern.

Mounsey et al. review the presentation, disease course, and management of alopecia areata. Treatment of alopecia areata may induce hair growth, but it does not change the course of the disease, as hair loss typically recurs. Topical and oral steroids, topical minoxidil, topical cyclosporine, and photo-therapy are a few of the numerous potential treatment options. None of these therapies showed a long-term benefit for patients. Overall, approximately 30-50% of patients with alopecia areata will recover within one year; however, greater severity of disease is associated with a worse prognosis, with less than 10% of alopecia totalis and universalis patients recovering.

Islam et al. discuss autoimmune pathogenetic hypothesis in alopecia areata. Hair follicles are thought to be immune-privileged sites; however, individuals with alopecia areata have been shown to exhibit infiltration of CD4+ and CD8+ T cells as well as TH1-related cytokines. Viral infections, trauma, and genetics have also been implicated in playing a role in the etiology of this condition. In addition, recent investigations have proposed disruption of the JAK biochemical pathway as a potential treatment option.

Figure A is an image of a patient with alopecia areata. Illustration A shows 'exclamation point' hairs; note the enlarged root, thin proximal shaft, and normal width distal shaft. Illustration B is an initial treatment algorithm for the management of alopecia areata.

Incorrect Answers:
Answer 1: Numerous treatment options (steroids, minoxidil, immunotherapy) are effective at stimulating hair growth; however, these agents typically do not alter natural course of the disease.
Answer 3: Topical immunotherapy is typically reserved and most effective for patients with greater than 50% hair loss of the scalp. Intralesional corticosteroids is the first-line treatment strategy for less severe forms of the disease.
Answer 4: Pharmacologic treatment of alopecia areata may induce hair growth but is not effective at altering the disease course. Recurrence of hair loss is common.
Answer 5: Overall, approximately 35-50% of alopecia areata patients will recover spontaneously within one year from their initial presentation. This number is even higher for patients, such as in this question, who have relatively limited involvement.