Alopecia Areata

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Alopecia Areata

• By
• Dr. Ashraf Hamza
• Professor of Dermatology
• Alexandria University

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Alopecia Areata

• Definition
• It is an autoimmune inflammatory disease
  characterized by patchy or total hair loss from
  any hairy area of the body
• Epidemiology
• The third most common cause of hair loss (after
  AGA Telogen Effluvium)
• Life time risk is 1.7 of population

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Is alopecia areata a tissue specific autoimmune
disorder?
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Is alopecia areata an autoimmune disorder?

• The most characteristic histological feature of
  AA is lymphatic infiltration around and within
  the hair follicles.
• Active disease is coincidental with an infiltrate
  of activated CD4 cells around the hair follicles
  
• Immunosuppressive agents such as systemic
  steroids and cyclosporine as well as
  immunotherapy with contact sensitizers exhibit a
  beneficial effect

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Is alopecia areata an autoimmune disorder?

• AA has also been associated with various
  autoimmune disorders such as autoimmune
  thyroiditis and vitiligo
• Patients with AA have an increased frequency of
  autoantibodies to follicular structures
• Alopecia areata has also been reported in
  children with common variable immunodeficiency
  disorders

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Clinical Features
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Clinical Features

• Usually presents as sudden hair loss in a well
  demarcated localized area
• Usually rounded or oval patch
• May be isolated or numerous
• May progress quickly to significant hair loss
• Usually patches are seen on the scalp but can
  also see on bear area, body, eye brows and eye
  lashes

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Appearance of Patch

• Sometimes redness is present
• Usually there is no scaling, but there may be red
  inflamed follicles
• Pigmented hairs are usually shed while white
  hairs are spared
• Going gray overnight

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Appearance of Patch
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Going gray overnight
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Red inflamed follicles
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Red inflamed follicles
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Localizations

• Scalp is the most common site
• Bear area
• Eye brows
• Eye Lashes
• Axilla
• Pubic area

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Clinical Types

• Areata, totalis or universalis
• Ophiasis type
• Reticular type
• Diffuse

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Areata Type
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Totalis Type
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Universalis Type
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Ophiasis Type
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Reticular Type
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Reticular Type
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Clinical Signs

• Erythema
• Exclamation point hair
• Positive pull test at active margin
• Hair usually grow in gray or white
• Nail changes

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Appearance of Patch (Erythema)
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Hair growing in gray
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Exclamation Hairs

• Usually, difficult to photograph
• Usually seen at the margin of active patch of
  hair loss
• It is a sign of active disease
• Indicates that inflammation has affected the
  growth of hair at the mid anagen phase
• Usually pull test is positive adjacent to
  exclamation point hairs

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Exclamation Hairs
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Common nail changes

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

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Nails Pitting
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Trachyonychia
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Beaus lines
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Thinning of nails
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White lines
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Significance of nail changes

• May help in diagnosis
• Help in monitoring disease activity
• May not affect all nails
• Should be examined at intervals

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Pull Test
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Pull Test Results

• Pull test is a test for activity of hair loss
• It can be used in other diseases as well
• 30-40 hairs are pulled between thumb and
  forefinger from scalp to end of hair
• In normal individuals, 0-2 hairs are lost
• It is difficult to perform in too long, too shot
  or curly hair

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Pull Test Results
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Regrowth Appearance

• Usually, downy blond hair first
• Then, you can see thickening and darkening of
  hair shaft as it grows
• In some cases, we get persistent hair colour
  changes or difference in texture

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Downy blond regrowing hair
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Thick dark growing hair
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Persistent hair colour changes
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Treatment of Alopecia Areata
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Treatment of Alopecia Areata
Current Agents
Investigational Agents
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Current Agents

• Corticosteroids
• PUVA
• Minoxidil
• Topical sensitizers
• Anthralin
• Methotrexate
• Zinc therapy

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Investigational Agents

• Cytokines
• Antibody
• Gene Therapy
• Biologic Therapy

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Topical Corticosteroids

• Usually unhelpful
• Only clobestasol under occlusion
• Side Effects
• Folliculitis
• Acneiform eruption
• Telangiectasias
• Epidermal atrophy
• HPA axis suppression

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Folliculitis and Acneiform Eruption
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Intralesional Corticosteroids

• Treatment of choice in patchy type
• Response rate is 64-97
• Should be diluted with saline
• Do not inject more than 3 ml/visit
• Raising continuous intradermal wheal should be
  observed
• Do not repeat before 4 weeks

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Scalp atrophy secondary to injection of undiluted
corticosteroids
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Systemic Corticosteroids

• Usually use prednisone
• Course 6 weeks 3 months
• Do not give more than two courses per year
• Dosage 50-60 mg in tapering dose
• Pulse therapy methylprednisolone 250 mg BID for 3
  days

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Topical Minoxidil

• As an adjuvant to topical anthralin. Data shows
  increased absorption of minoxidil with anthralin
  irritation
• As an adjuvant to topical steroids
• As an adjuvant to systemic steroids and after
  discontinuation of sytemic steroids
• Used as 5 solution but if propylene glycol
  sensitivity occurs, foam is used

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5 Topical Minoxidil Foam

• Vehicle is free from propylene glycol
• More cosmetically acceptable
• It is recommended to apply one cupful of 5
  minoxidil every day
• Fromulated to deliver the same amount of 1 ml
  minoxidil 5 solution
• It has a large safety margin

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Topical Anthralin

• Various preparations available from 0.1 to 1 in
  cream vehicle
• Mechanism of action may be related to inhibition
  to proinflammatory cytokines
• Maintaining low level clinical irritation may be
  critical to response
• Irritation is dose and application time dependent

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Topical Sensitizers

• Dinitrochlorobenzene (DNCB)
• Squaric acid dibutyl ester (SADBE)
• Diphenylcyclopropenone (DPCP)
• Squaric acid

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Methotrexate

• Only published reports in combination with
  systemic steroids
• Useful as steroid sparing agent in extensive
  alopecia
• Dosage 25 mg/week
• Addition of folic acid is recommended
• Duration 3-4 months trial is necessary
• Blood test monitoring monthly

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Biologic Therapy

• Both Etanercept and Alefacept are fusion
  proteins. They are attached to Fc domain of human
  IgG1
• They were used for treatment of extensive
  alopecia areata
• Vellus hair or insignificant growth were noted
• Multicenter trials underway in USA

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Summary

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

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Thank You
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Exclamation point hair