Alopecia areata (AA)
Alopecia areata is considered an autoimmune disease, in which the immune system, which is designed to protect the body from foreign invaders such as viruses and bacteria, mistakenly attacks the hair follicles, the structures from which hairs grow. This can lead to hair loss on the scalp and elsewhere (it can affect any hair bearing area). It is one of the most common hair loss disorders after pattern hair loss and effluviums.
In most cases, hair falls out in small, round patches about the size of a quarter. In many cases, the disease does not extend beyond a few bare patches. In some people, hair loss is more extensive. Although uncommon, the disease can progress to cause total loss of hair on the scalp (referred to as alopecia areatatotalis) or complete loss of hair on the scalp, face, and body (alopecia areatauniversalis).
The lifetime incidence of AA is approximately 2% worldwide. Both formal population studies found no sex predominance. First onset is most common in the third and fourth decades of life but may occur at any age. An earlier age of first onset corresponds with an increased lifetime risk of extensive disease.Alopecia areata often occurs in people whose family members have other autoimmune diseases, such as type 1 diabetes, rheumatoid arthritis, thyroid disease, systemic lupus erythematosus, pernicious anemia, or Addison’s disease. People who have alopecia areata do not usually have other autoimmune diseases, but they do have a higher occurrence of thyroid disease, atopic eczema, nasal allergies, and asthma.
Alopecia areata is not a life-threatening disease. It does not cause any physical pain, and people with the condition are generally healthy otherwise. But for most people, a disease that unpredictably affects their appearance the way alopecia areata does is a serious matter.
The effects of alopecia areata are primarily socially and emotionally disturbing. In alopecia universalis, however, loss of eyelashes and eyebrows and hair in the nose and ears can make the person more vulnerable to dust, germs, and foreign particles entering the eyes, nose, and ears.
Diagnosis of alopecia areata:
Sometimes a hair transplant surgeon can diagnose alopecia areata by looking at the patchy nature of hair loss preceded by sudden onset.If the patch of hair loss is expanding, the doctor may pull out a few hairs. These hairs will be looked at under a microscope.
Trichoscopy has some specific findings associated with alopecia areata –Exclamation mark hairs, Black Dots, Broken hairs represent severity as well as activity and yellow dots are observed in every stage of AA. Short vellous hairs represent hair re-growth, and hence they negatively correlate disease activity. And finally, honey comb pattern and white dots are observed in alopecia totalis of longer duration.
The course of the disease varies from person to person. Some people lose just a few patches of hair, then the hair regrows, and the condition never recurs. Other people continue to lose and regrow hair for many years. A few lose all the hair on the scalp; some lose all the hair on the scalp, face, and body. Even in those who lose all their hair, the possibility for full regrowth remains. The course of alopecia areata is highly unpredictable, and the uncertainty of what will happen next is probably the most difficult and frustrating aspect of the disease.
In some, the initial hair regrowth is white, with a gradual return of the original hair color. In most, the regrown hair is ultimately the same color and texture as the original hair.
Treatment of alopecia areata:
There are a range of treatments for AA, but none are effective for everyone and some people with AA don’t respond to any treatment. Because some of the available treatments have a high risk of side effects, they are often not used for children.
The most common AA treatment involves the use of corticosteroids. Corticosteroid creams applied to the bald patches are popular. A more potent approach is to inject corticosteroid solutions into the bald patches. This can work well for some people, but close monitoring is required to ensure that side effects, such as skin thinning at the site of injection, do not occur.In extensive cases, systemic corticosteroids (those taken in pill or other form to affect your body) are used, though not continuously since they can cause significant side effects like bone thinning. But short-term “pulse therapy” often has good results.
More specialized treatment approaches involve the application of contact sensitizing chemicals to the skin. These cause an allergic reaction that can help promote hair growth. That may sound counterintuitive but it seems to work. A variety of experimental approaches are currently in laboratory and clinical trials. One group of drugs being tested are “biologics,” which have bits of protein that interfere in a very specific way with the activity of immune cells. Biologics are injected systemically to damp down the immune activity and allow hair to regrow. The results of these trials are awaited with much interest.
Scarring alopecia (Cicatricial alopecia)
Scarring alopecia, also calledCicatricial alopecia, refers to a group of rare disorders that destroy hair follicles. The follicles are replaced with scar tissue, causing permanent hair loss. However, scarring may be due to other reasons like injury to the scalp caused by physical trauma or burns, bacterial infections such as folliculitis, fungal infections, and viral infections such as shingles (herpes zoster) etc.
Cicatricial alopecia has two forms. In the primary form, the hair follicle is the target of the destructive process. In the secondary form, the hair follicle is an innocent bystander, destroyed by another cause. This can be a severe burn, an infection, radiation, or a tumor.
The cause of cicatricial alopecia is not well understood. What is known is that redness, heat, pain, or swelling occurs at the upper part of the hair follicle. That is the place where stem cells and sebaceous (oil) glands are located. Stem cells are cells that can develop into different kinds of cells. If the stem cells and oil glands are destroyed, the hair follicle cannot regrow, and hair is permanently lost.
Cicatricial alopecia is not contagious. It occurs worldwide in otherwise healthy men and women. It affects all ages, but is not common in children.
This condition usually affects only one family member. One exception is central centrifugal alopecia. It most commonly affects women of African ancestry, and may occur in more than one family member.
Types of Cicatricial Alopecias:
- Those involving mostly lymphocytes:
- Lichen planopilaris (LPP)
- Frontal fibrosing alopecia
- Central centrifugal alopecia
- Pseudopelade of Brocq
- Those involving mostly neutrophils:
- Folliculitis decalvans
- Tufted folliculitis
- Those involving both (called mixed inflammatory infiltrate):
- Dissecting cellulitis
- Folliculitis keloidalis
Symptoms of scarring alopecia
In some cases, hair loss happens quickly, and there is severe itching, pain, and burning. In other cases, hair loss is gradual, and there are no other symptoms.
Diagnosis of scarring alopecia:
A clinical evaluation of the scalp, noting symptoms such as itching, burning or tenderness; signs of inflammation including redness, scaling, and pustules; and overall extent and pattern of hair loss.
Trichoscopy helps in diagnosis of cicatricial alopecia. Trichoscopy reveals typical features seen in scarring alopecias – loss of follicles, Blue gray dots or large yellow dots,Peripilar erythema, crusting and scaling, perifollicular whitish halo, follicular keratotic plugs and telangiectasias.
Final confirmation is possible by scalp biopsy.
The hair loss is permanent in scarring alopecia and it is important to start aggressive treatment at the earliest.
The treatment is essentially medical and involves topical and oral medications. The specific treatment used varies, depending largely on whether lymphocytes, neutrophils, or both are predominantly responsible for the hair follicle destruction.
The lymphocytic form of scarring hair loss usually is managed by use of anti-inflammatory medications. Common medicines used topically are corticosteroids, immunomodulators like Tacrolimus. Also antibiotics and antimalarials have been shown to be useful. Sometimes injecting corticosteroids directly into the bald patches may be required or helpful. Recently,a class of diabetes medications called thiazolidinediones has been shown to be useful.
The scarring alopecia due to neutrophilic infiltrate is treated with antibiotics, anti-inflammatory medications, and retinoids (isotretenoin). More experimentally, drugs like methotrexate, tacrolimus, cyclosporin, and even thalidomide have been used to treat some forms.
Although hair cannot grow back after a follicle has been destroyed, it may be possible to stimulate follicles in the affected area before permanent damage occurs. Applying Minoxidil (medicine that promotes hair growth) may stimulate viable follicles.
Treatment is usually long term. It usually continues till there is remission of symptoms and no new patches are seen or the existing patches have stabilized. The disease is also known to have periods of remission followed by sudden exacerbation even after many years. Even when the disease is in remission some hair loss may continue.
Is there a role for hair transplantation in treatment of scarring alopecia?
Can surgical hair restoration be helpful in people suffering from scarring hair loss?
Once a scarring alopecia has reached the burnt-out stage (of complete remission where there are no new patches or existing patches have remained the same size for a few years) and there has been no more hair loss for a few years, bald areas can be either surgically removed (alopecia reduction) if they are not too big or the bald patches can be transplanted with hair follicles taken from unaffected areas. In alopecia reduction, the affected bald patch of the scalp is removed, and the part of the scalp next to it is pulled together and sutured to cover the gap. In hair transplantation surgery, follicles from the back of the head are surgically removed and transplanted into bare areas of the scalp.
When a hair transplant is performed in patients of scarring alopecia a few points should always be kept in mind
- The disease should not be active
- Always better to perform a small test patch of hair transplant to assess if the follicles would indeed grow in the affected scarred area. It is ideal to wait for six months before an assessment can be made.
- While implanting the follicular unit grafts the spacing between the grafts is a little more than that when hair transplant is performed in non-scarred skin.
- Multiple stages may be needed to achieve optimal density
- There is always a possibility of disease reactivation which may lead to new areas of scarring hair loss or loss of implanted hair follicles.
Traction hair loss
Traction alopecia results from tension applied persistently to hair, such as in the case of certain hairstyles including one or more of the following…
- Very tight ponytails or pigtails
- Tight braids or cornrows
- Extension (single) braids
- Hair weaves or wigs attached with glue, clips or tape
- Certain hair clips, slides or barrettes that hold the hair tightly and are worn in the same position every day
- Headbands – even fabric ones – worn day after day
- Tight hairpieces
- Tight headgear like cycling helmets that are worn frequently or for long stretches of time and tend to rub or pull repeatedly on the same area of hair
- Repeated use of hair rollers
- Repeated pulling of the hair with the hands (this is an emotional condition called trichotillomania)
This kind of hair loss is seen among Sikh males as a result of stress on the hair from wearing a turban.
The constant tension in the affected area either pulls out the hairs’ roots completely, or causes the follicles to become inflamed. As time goes by, the damage to the follicles causes them to become atrophied (wasted away)… and if you don’t put a stop to the cause of the problem, they will reach the point where they no longer produce hair at all.Affected areas correspond to areas under the greatest amounts of pressure, and usually hair loss occurs at scalp margins.
Traction alopecia is common in people who wear hair piece/wigs/weaves. Wigs are generally applied through braiding, weaving, fusion, netting or bonding – and the sad fact is that any or all of these methods can lead to traction alopecia if used extensively, over long periods of time.The same goes for hair extensions, which can also cause hair loss problems in the lower half of the scalp.
Sikhism is a religion followed primarily by inhabitants of Punjab, a state in India.As part of their religious practice, males as well as females are forbidden to cut their hair. Males more specifically are required to wear a turban on their head. The turban is a long scarf which is wrapped tightly in a particular way around the long hair and placed atop the head. Before wrapping the cloth around the hair, the hair is tied into a tight knot resting on the frontal region of the scalp. Most Sikhs will wear this style for a full 24 hours or longer, after which the turban will be removed and the hair combed. The frontal scalp region is where the alopecia will usually occur given that it experiences the bulk of the trauma. Traction alopecia can also arise in the submandibular area because the majority of the followers of Sikhism will also practice a similar method of knotting their beard. Beard hair, like scalp hair, is grown long and never cut. The hair is put into a ponytail, twisted, and tightly tied into a knot under the chin. In time, alopecia over the mandible can be seen.
Treatment of traction hair loss
To prevent permanent alopecia, patients are advised to switch to more relaxed hairstyles as soon as possible to relieve the stress on their hair. Pharmacological treatments include minoxidil, which has been beneficial for some patients, as well as antibiotics and corticosteroids in the event of folliculitis or inflammation, respectively. Surgical intervention remains an option for patients with advanced hair loss.
Treatment of traction alopecia in Sikh patients can be a difficult process. Religious laws forbid the cutting of hair and require the wearing of the turban. Therefore cutting the hair is not an option. Patients can be advised to allow their hair to be tied loosely and free of a turban for as long as possible during the day. At night they should refrain from wearing the turban and tie their hair in a loose ponytail without the knot. When wearing the turban, the hair should be tied loosely at the scalp to decrease the tension. Patients can be treated with topical steroids, however, unless the tension is relieved, these treatments will prove ineffective. Patients should also be advised that traction alopecia may lead to permanent alopecia, which is progressive if the traction is not removed.
When cutting of the hair is permitted, hair restoration using hair transplantation is possible.