Alopecia Areata: The Clinical Aspects

1
Alopecia AreataThe Clinical Aspects

• Amy J. McMichael, M.D.
• Associate Professor
• Department of DermatologyWake Forest University
  School of Medicine
• Winston-Salem, NC, USA

2
Alopecia Areata

• Third most common form of hair loss (after AGA
  and telogen effluvium)
• Autoimmune disease of hair follicle
• Patchy or total hair loss from any area on body
• Lifetime risk of 1.7 in general population
• Animal models
• Dundee experimental bald rat and C3H/HeJ mouse
  spontaneous models
• Severe combined immunodeficiency mouse-human
  (SCID-hu) model

3
Presentation of disease

• Usually presents as sudden hair loss in
  well-demarcated, localized area
• Usually round or oval patch
• May be isolated or numerous
• May progress quickly to significant hair loss
• Usually patches are seen in the scalp, but can
  also see involvement of beard area, body,
  eyebrows, and eyelashes, nose hairs

4
Appearance of the patch/patches

• Redness may be present
• Usually no scaling, but there may be red or
  inflamed hair follicles
• Pigmented hairs are often shed while the
  unpigmented or white hairs are spared
• Going gray overnight

5
The most common site of AA

• Scalp most common site
• Study by Muller et al, 1960 showed 95 of
  patients have scalp involvement
• Often the first site affected
• Most treatments are geared towards scalp hair loss

6
Nomenclature and clinical signs

• Types of disease
• Areata, totalis, universalis
• Ophiasis (sisaipho)
• Diffuse
• Signs
• /- Erythema
• Exclamation point hairs
• Positive pull test at active margin
• Hairs usually grow in gray or white
• Nail changes

7
Patchy disease
8
AA may be confused with tinea capitis in children
or vice-versa
Patch of fungus of the scalp with hair loss and
very mild scaling
9
(No Transcript)
10
Patchy Alopecia Areata
11
Patchy disease with hair regrowing
12
Patchy AA in a dark-complexioned person
May be difficult to hide in male patient or in
patient with short hair
13
Diffuse form of alopecia areata in young child
14
AA may mimic male patterned baldness
Purple color from use of anthralin on scalp
15
Ophiasis Pattern
16
Alopecia Totalis
17
Patchy AA in association with Downs Syndrome and
vitiligo
18
Exclamation hairs

• Difficult to photograph
• Often seen at the margins of the active patch of
  hair loss
• A sign of active disease
• Inflammation has affected the growth of a hair
  that was in a mid-anagen (mid-growth) phase
• Pull test may be positive adjacent to the
  exclamation point hairs

19
Exclamation Point Hairs
20
Pull test results

• Pull test is a test for activity of hair loss
• Can be used in other diseases as well
• 30-40 hairs pulled between thumb and forefinger
  from scalp to end of hair
• 0-2 hairs is normal hair loss
• Difficult to perform on extremely long or short
  hair, and extremely curly hair
• Only situation in AA where counting hairs may be
  helpful

21
Regrowth Appearance

• Usually see downy blond or light hair first
• Then you can see thickening and darkening of hair
  shaft as it grows
• Some patients with AA may have persistent color
  change or difference in texture

22
Short regrowing hairs that are dark in color
Pigmented hairs growing in at top of scalp
23
Other sites of loss

• Eyebrows
• Eyelashes
• Beard

24
Common nail changes in AA

• Pitting
• Trachyonychia
• Beaus lines
• Thinning or loss of nails
• White spots and lines or red spots

25
Nail Changes in AA

• Nail involvement may help in diagnosis
• May help to monitor activity of AA (i.e., if you
  have nail changes and then normal nails)
• May not affect all nails
• Should be examined at intervals if seeing a
  dermatologist regularly

26
Nail changes
Pitting and mild trachyonychia
27
Alopecia areata with nail changes
Patient with alopecia totalis and severely
affected nails
Nail involvement was not responsive to
antifungals
28
Treatments for Alopecia Areata

• Current Agents
• Corticosteroids
• Topical
• Intralesional
• Systemic
• PUVA
• Minoxidil
• Topical Sensitizers
• Anthralin
• Imiquimod
• Referral to National Alopecia Areata Foundation

• Investigational agents
• Cytokines
• Antibody
• Gene therapy
• Biologic therapy

Adjunctive agents
29
Topical and Intralesional Corticosteroids

• Topical corticosteroids
• Generally regarded as unhelpful
• Possibly helpful if clobestasol cream under
  occlusion(Tosti et al 2003)
• Intralesional corticosteroids
• Treatment of choice for patchy disease scalp
• 64-97 response rate
• Maximum of 3 ml per visit
• Repeat every 4-6 weeks

30
Systemic corticosteroids

• Usually use prednisone
• 6 week to 3 month course
• Allow no more than 2 courses per year
• 50-60 mg in tapering dose
• Pulse methylprednisolone 250 mg BID for 3 days

Friedli A. et al, 1998
31
Adjunctive Agents

• Minoxidil 5 - shown to work by Price et al.
  Used twice daily. Usually in combination with
  topical steroids under occlusion
• Anthralin Most useful in children and patients
  with less inflammatory disease

32
Topical Sensitizers

• Dinitrochlorobenzene
• Squaric acid dibutyl ester (SADBE)
• Diphenylcyclopropenone (DPCP or DCP)
• Approved for use in alopecia totalis and
  universalis under orphan disease status

33
Future DirectionsBiologic Response Modifiers

• Interrupt Th-1 pathway at level of activation
• Potential role in alopecia areata

34
Summary

• Broad range of presentation seen in AA
• Associated findings may be worse for some
  patients (nails, allergies, conjunctivitis)
• There is no normal or average for AA
• A clear understanding of all the findings is
  helpful for patients and physicians

35
What you present to the world is your hair

• This is my hair with gum in it
• This is my hair when my braids are too tight
• This is my hair with curlers
• This is me with no hair