There is a well-defined area of hair loss, no scaling, no scarring, no breakage of hair at different length.

  • Trichotillomania
  • Tineacapitis (non – inflammatory)
  • Syphilis
  • Androgenetic Alopecia
  • Pseudopelade of Brocq
  • Telogen Effluvium
  • Traumatic Alopecia
  • Alopecia Mucinosa
  • Cong Triangular Alopecia
  • Metastatic malignancies
  • Alopecia areata is sometimes known as “ area celsi” in tribute to Cornelius Celsus.
  • Alopecia areata” was first used by Sauvages in his “Nosologica Medica”, published in 1760 in Lyons, France.
  • Also known as Pelade
  • Area circumscripta
  • Porrigo decalvans
  • Ophiasis of Greek
  • Common, chronic inflammatory disease causing unpredictable nonscarring form of hair loss
  • 2nd to 4th decade
  • M = F
  • Genetic + Environmental + Autoimmune
  • “Immune privilege” becomes defective
  • Interferon -> Keratinocyte stimulation -> IL-15 , 2, 5, 7, 21
  • JAK-STAT pathway involved in (Animal model)
  1. Associated with other autoimmune diseases
    • Addison’s disease
    • Hashimoto’s thyroiditis
    • Pernicious anemia
    • Others
  2. Presence of Autoantibodies
    • Anti-thyroid Ab
    • Anti-smooth muscle Ab
    • Antinuclear Ab
    • Against hair follicle
    • Against gastric parietal cell
    • Against adrenal tissue
    • Against ovary
  3. T-cell infiltration around anagen hair follicle
  4. Depletion of CD4 & CD8 in animal model
  5. Response to steroids
  1. Anagen hair follicle
  2. Anterior chamber of Eye
  3. Testis
  • These areas don’t express MHC class I Ag
  • So, not attracted by CD8 cells
  • Normal – 1:1 to 2:1
  • AA – 3-4 : 1
  • CD8 – decreased
  • Family history  + in 10-20% cases
  • MC in age < 30 years
  • Down’s syndrome patients
  • Monozygotic wins – 55%
  • Dizygotic twins – 0%
  • HLA associated
    • DR4
    • DR11
    • DQ3
    • DRB1*1104
  • HLA DR11 & DRB1*1104 – A.totalis & A. universalis
  • Chromosome 21 a/w
    • Down syndrome
    • Autoimmune polyglandular syndrome
  • Atopy -> a/w early onset & severe disease

Non-scarring

  • Diffuse
    • AGA
    • Telogen effluvium
    • Postpartum alopecia
    • Neonatal alopecia
    • Anagen Effluvium
    • Drug induced
    • Hair shaft disorders
    • Occasional AA
  • Focal
    • AA
    • Fungal, bacterial or viral infection
    • Trichotillomania
    • Traction alopecia
    • Tick bite alopecia

Scarring

    • Lymohocyte associated
        • LPP
        • Central centrifugal cicatricial alopecia
        • Graham Little Piccardi Lassueur syndrome
        • Pseudopelade of Brocq
        • DLE
    • Neutrophil associated
    • Perifollicutis capitis abscedens suffodiens
    • Folliculitis decalvans
    • Mixed typE
      • Acne keloidalis nuchae
      • Acne necrotica
      • Pustular Dermatoses of scalp
  • Hippocrates called alopecia, “Fox’s disease
  • Alopecia areata was first described by Cornelius Celsus in 30 AD.
  • Cornelius Celsus actually described two types of alopecia, alopecia totalis, and alopecia Ophiasis, which gives a “snake” like pattern. Celsus actually thought that alopecia Ophiasis only occurred in children
  • The prevalence of alopecia areata is 0.1 to 0.2%, with a calculated lifetime risk of 2%
  • Family history positive in 10 % AA patients
  • Dundee experimental bald rat (DEBR)
  • C3H/ HeJ mouse
  • Common type (81%)
    • Patchy pattern with short duration
  • Atopic type(10%)
    • Ophiasis and reticular, 50% may go into totalis
  • Prehypertensive type (4%)
    • reticular
  • Autoimmune type/ endocrine type (5%)
    • Alopecia totalis
  • No, as the percentage of patients with prehypertensive group is very few, they should be classified as adult and childhood AA
  • And further subdivided into- classical, atopic and autoimmune in both groups
  • Generalized: universalis
  • Totalis: Restricted to scalp
  • Patchy
    • Ophiasis
    • Sisaphio
    • Reticulate
    • Diffuse
    • Subtotal
    • totalis
  • Asymptomatic
  • Patches of hairloss on scalp or beard or anywhere on body usually noticed by a relative or the barber
  • Overnight greying of hair
  • Brittle nails with pitting
  • Hair pull test- positive (take 20 hair and more than 10 % hair get pulled out)
  • Exclamation mark hair
  • Cadaver hair-broken hair seen over scalp as comedones (black dots)
  • Follicular ostia- ostia are well preserved in alopecia areata, in contrast to the findings in scarring alopecia
  • Depigmented hair
  • Frayed rope appearance of free ends
  • Coudability test- try to push hair towards scalp and it bends
  • Dystrophic hair
  • Anagen hair suffers defective keratinization & thinning and later turns into telogen, which causes narrowing of the shaft

  • As this hair grows out it appears broad distally and thin proximally, appearing like an exclamatory mark

  • This is seen in most severe form of injury

  • If least form of injury, the anagen bulb does not go into telogen but only changes to dystrophic anagen hair
  • In moderate form of injury, we notice only a telogen bulb on hair mount
  • Scotch plaid nail pitting
  • Trachyonychia (sandpaper like roughness because of excessive longitudinal ridging)
  • Red or mottled lacunae
  • Nail thinning and ridging
  • Longitudinally arranged punctate leukonychia
  • Dystrophy, onycholysis
  • Few reports of cataracts have been reported
  • AA: Regular pitting, superficial pitting, scotch plaid pattern
  • Psoriasis: Irregular pitting, deep pitting
  • Yellow dot- Sebum collection in ostia
  • Black dots- broken hair
  • Severity of alopecia tool score (SALT SCORE)
  • Down’s syndrome
  • Hashimoto’s thyroiditis
  • Addisons disease
  • Pernicious anemia
  • Vitiligo
  • LP
  • Morphea
  • Lichen sclerosis et atrophicus
  • Pemphigus foliaceus
  • SLE
  • Sjogren Syndrome
  • Ulcerative colitis
  • Myasthenia gravis
  • Autoimmune hemolytic anemia
  • Diabetes mellitus
  • Autoimmune testicular and ovarian disease
  • Chronic mucocutaneous candidiasis with endocrinopathy
  • Early age of onset

  • Extensive scalp involvement

  • Loss of eyebrows and eyelashes

  • Alopecia totalis

  • Alopecia universalis

  • Recurrent episode

  • Pattern-ophiasis, sisaphio, reticular

  • Nail changes

  • Associated systemic disorders

  • Associated genetic disorders-Down’s

  • Patchy regrowth of terminal hairs

  • Family history

  • Fungal culture
  • Skin biopsy
  • Serology for lupus erythematosus
  • Serology for syphilis
  • CBC for anemia
  • Thyroid Function Tests
  • Swarm of bees appearance

  • Decrease in total number of follicles

  • Increase in number of vellus hair

  • Spontaneous remission occurs in up to 80% of patients with limited patchy hair loss of short duration (< 1 year).
  • Such patients may be managed by reassurance alone, with advice that regrowth cannot be expected within 3 months of the development of any individual patch.
  • The prognosis in longstanding extensive alopecia is poor and a wig may be an option.

TOPICAL :

  • Immunosuppresants – ILS
  • Immunomodulators – tacrolimus
  • Contact sensitizers – SADBE, DPCP, DNCB
  • VEGF stimulators – minoxidil 5-10%
  • Phototherapy – PUVA
  • Cryotherapy – liquid nitrogen
  • LASER theraphy – Excimer 208, P. diode Laser 904nm

SYSTEMIC :

  • Immunosuppresants – Cyclosporine
  • Immunomudulators – Alefacept, Isoprinosin
  • Photoshemotherapy – Whole body PUVA
  • Misc. – Sulfasalazine, IVIg

OTHERS :

  • Psychotherapy – Hypnotherapy, systemic desensitization
  • Supportive – tattooing, hair pieces, wigs
  • PRP, IL candida antigen
  • Contact immunotherapy was introduced by Rosenberg and Drake in 1976.
  • The contact allergens used include:
    • 1-chloro,2,4,dinitrobenzene (DNCB); [Banned because mutagenic]
    • squaric acid dibutylester (SADBE)
    • 2, 3-diphenylcyclopropenone (DPCP)
  • Initially patient senstitzed w ith higher concentration of allergen applied on forearm.
  • Later patient challenged with very low concentration of allergens on the alopecic areas to maintain a brisk erythema over the lesion.
About Author

Dr. Howthul Alam

MD DVL Postgraduate Madras Medical College

Leave a Reply