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    Alopecia Areata (Vitiligo Capitis)

    Allopecia areata[1]

    Alopecia areata is a common nonscarring type of hair loss.

    Alopecia Areata is induced by the following process: auto-immune.

    Presentation

    A characteristic feature is the presence of smooth, slightly erythematous or normal-colored apoplecic patches in hair [8]. The presence of hair tapered near proximal end is pathognomic but this is not always seen. A positive result following a pull test shows active presence of the disease and thus more hair loss should be expected. Additionally, hair loss on other hair bearing areas equally favours the diagnosis. The most common presentation is the appearance of one or more round-oval denuded patches. No epidermal changes are associated with the hair loss.

    Nail involvement is seen in 6.8 to 49.4% of patients and is most common in patients with severe forms of the condition. One of the most common findings is pitting.

    Skin
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  • Workup

    Clinical features are the basis of alopecia areata diagnosis [9].

    Trichoscopy can also help in differential diagnosis. During diagnosis, trichoscopy shows regularly distributed yellow dots known as hyperkeratotic plugs, small exclamation-mark hairs and black dots.

    A biopsy is rarely needed. Histologic findings include peribulbar lymphocytic infiltrate. In some cases of inactive alopecia areata, inflammatory states may not be found. Other helpful findings include pigment incontinence in the hair bulb, follicular stelae as well as a shift in the anagen-to-telogen ratio towards higher telogen.

    Treatment

    Since the condition is benign, treatment is not mandatory [10]. This is also bearing in mind spontaneous remissions and recurrences. Treatments used are believed to stimulate hair growth but there is yet no clear evidence as to whether they affect the natural course of alopecia areata or not. Treatment modalities are often decided on based on the extent of hair loss as well as the age of the patient.

    Topical treatments deployed include the use of corticosteroids, topical immunotherapy, anthralin and minoxidil. Systemic treatments include the use of psoralen plus, prednisone, cyclosporine, tacrolimus, interferon, dapsone and methotrexate.

    Prognosis

    In many cases which start as a small number of patches of hair loss, the hair grows back after a few months to a year [7]. In cases where there is a greater number of patches, hair can either grow back or progress to more severe forms of the condition (Alopecia totalis or universalis).

    The effect of this condition is mostly psychological, being loss of self-image as a result of hair loss. Loss of hair equally means more scalp sun burns following easy exposure to the sun. Loss of nasal hair increases severity of hay fever or other such similar allergic conditions. Since keratin forms both hair and nails, patients may witness aberrant nail formation.

    Hair may grow back and fall out again later. This doesn’t indicate a recurrence of the condition. Rather it may be a natural cycle of growth and shedding. Onset of this condition before puberty predisposes the individual to chronic recurrences of the condition.

    Complications

    Addison's 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.[avensonline.org]
    • It generally happens in families whose members once or are suffering from atopic eczema, asthma, hay fever, early-onset diabetes, Addison’s disease, or pernicious anemia.[drpaulsonline.com]
    • Alopecia areata is also more common in those that suffer from hayfever, eczema, Addison’s disease, pernicious anaemia, rheumatoid arthritis, ulcerative colitis, lichen planus, diabetes mellitus, vitiligo, lupus and thyroid disease .[philipkingsley.co.uk]
    • […] and the increase of relapses in the early spring, which is when there is an increase in viral infections. Research also shows that people who have a family member with other autoimmune diseases , like rheumatoid arthritis, type-1 diabetes, lupus , Addison’s[draxe.com]
    Alopecia
    • Alopecia areata is not contagious.[en.wikipedia.org]
    • , Circumscribed alopecia , Alopecia areata (disorder) , circumscripta; alopecia , pelade , alopecia; areata , alopecia; circumscripta , areata; alopecia Spanish ALOPECIA AREATA , alopecia areata , alopecia circunscripta (trastorno) , alopecia circunscripta[fpnotebook.com]
    • (including Alopecia Totalis (AT) and Alopecia Universalis (AU)) Alopecia Areata (AA) is understood to be an autoimmune condition.[alopeciaonline.org.uk]
    • Alopecia universalis Alopecia universalis is more advanced than alopecia totalis.[naaf.org]
    Alopecia Areata
    Epidermolysis Bullosa
    • “It was 1996 and I’d just transferred here to Columbia,” says Christiano, who had been studying a rare skin disorder called epidermolysis bullosa, or butterfly disease.[pharmaceutical-journal.com]
    Scarring Alopecia
    • Scarring alopecia Scarring alopecia, also known as cicatricial alopecia, is usually caused by complications of another condition.[nhs.uk]
    • Non-scarring alopecia Non-scarring alopecias are more common than scarring alopecias and include male and female pattern hair loss (also known as androgenetic alopecia), alopecia areata, telogen effluvium, and trichotillomania as well as other less common[americanskin.org]
    • Indian J Dermatol Venereol Leprol 2013;79:563-75 Introduction Alopecia areata (AA) is a common form of non-scarring alopecia involving the scalp and/or body, characterized by hair loss without any clinical inflammatory signs.[ijdvl.com]
    • Summary In summary AA is a common non-scarring alopecia which can affect patients of all ages and races.[omicsonline.org]
    • Scarring Alopecia Hair loss which leaves scarring where the hair loss has occurred.[alopeciafree.com]
    Syphilis
    • Differential diagnosis includes tinea capitis , trichotillomania , traction alopecia, lupus , and secondary syphilis .[msdmanuals.com]
    • […] diaper rash and poison ivy Pregnancy Stages See stages of pregnancy and fetal development Scalp, Hair and Nails Conditions such as dandruff, ingrown toenails and premature gray hair Sexually Transmitted Diseases (STDs) STDs such as genital warts (HPV), syphilis[medicinenet.com]
    • If there is doubt about the diagnosis, a scalp biopsy, hair plucking and skin scraping may be performed to rule out tinea or a blood test may be performed to rule out lupus or syphilis.[dermcoll.edu.au]
    • Sometimes diseases such as secondary syphilis, thyroid disease, and systemic lupus erythematosus can lead to non-scarring hair loss also.[americanskin.org]
    Systemic Lupus Erythematosus
    • 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.[avensonline.org]
    • Sometimes diseases such as secondary syphilis, thyroid disease, and systemic lupus erythematosus can lead to non-scarring hair loss also.[americanskin.org]
    • lupus erythematosus (4.3%), rheumatoid arthritis(3.9%), and psoriasis and psoriatic arthritis (2.0%).[emedicine.medscape.com]
    • Systemic lupus erythematosus Hair loss is not uncommon in SLE; however hair loss involving greater than 50% of the scalp area is rarely reported.[omicsonline.org]
    Telogen Effluvium
    • Telogen effluvium Telogen effluvium is a common type of alopecia where there's widespread thinning of the hair, rather than specific bald patches.[nhs.uk]
    • Telogen effluvium Telogen effluvium is a common, transient form of hair loss that can be due to medication, pregnancy, hypothyroidism, or some type of physical or psychological stressor such as surgery or a severe illness.[americanskin.org]
    • It can be hard to diagnose because it looks a lot like other forms of hair loss such as telogen effluvium or male or female pattern hair loss.[naaf.org]
    • The alopecia areata experience varies with age and can be alopecia areata (aa) is probably the third most common form of hair loss dermatologists see, after androgenetic alopecia and telogen effluvium.[youtube.com]
    • Probably, it’s the third most common type of hair loss after Androgenic Alopecia and Telogen Effluvium.[drpaulsonline.com]
    Tinea Capitis
    • Differential diagnosis includes tinea capitis , trichotillomania , traction alopecia, lupus , and secondary syphilis .[msdmanuals.com]
    • In tinea capitis, the scalp skin may be scaly.[omicsonline.org]
    • Your doctor may also perform a scalp biopsy to rule out other conditions that cause hair loss, including fungal infections, such as tinea capitis.[healthline.com]
    Vitiligo
    • Also known as: Alopecia celsi, Alopecia circumscripta, Cazenave's vitiligo, Celsus' vitiligo, Jonston's alopecia, Porrigo decalvans, Vitiligo capitis, Alopecia cicatrisata Alopecia areata is a condition that causes your hair to fall out.[oregon.providence.org]
    • Alopecia areata has been compared by some to vitiligo, an autoimmune skin disease where the body attacks melanin-producing cells, leading to white patches.[medicalnewstoday.com]
    • […] the scalp Alopecia universalis - total loss of body hair Diffuse hair loss - can be seen occasionally The cause is thought to be an autoimmune phenomenon as often; there is a co-existing autoimmune disease e.g. pernicious anaemia, thyroid disorders, vitiligo[gpnotebook.co.uk]
    • Those with alopecia areata are more likely to have family members with other autoimmune or atopic conditions, such as asthma, eczema, hay fever, rheumatoid arthritis, lupus, psoriasis, thyroid disease and vitiligo.[alopeciaonline.org.uk]
    • They should be assessed for atopy, vitiligo , thyroid disease, and other autoimmune conditions.[dermnetnz.org]
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  • Etiology

    Alopecia areata is not contagious [2]. It occurs more frequently in people who have family members affected by the condition which suggests a strong genetic predilection. Strong evidence of genetic association with increased risk for the condition was demonstrated by the identification of at least four susceptibility loci on chromosomes 6, 10, 16 and 18. It is also most likely to occur in people who have relatives with autoimmune conditions.

    Alopecia areata is believed to be a systemic autoimmune disorder where the body attacks its own anagen hair follicles, suppressing or stopping hair growth [3].

    Epidemiology

    On estimate, the global prevalence of alopecia areata is approximately 1 on 1000 people, with the lifetime risk put at approximately 2% [4]. For many patients, the onset of the condition is before age 30. However, men and women are affected equally.

    Sex distribution
    Age distribution

    Pathophysiology

    The pathophysiology for this condition is still open to debate. However, one hypothesis is commonly acccepted in different circles and this is the fact that alopecia areata is a T-cell mediated autoimmune condition with a higher possibility of occurrence in individuals that are genetically compromised for the condition [5]. Over the course of history, there is a lot of evidence to support this hypothesis. 

    Although the process appears to be T-cell mediated, antibodies channeled to hair follicle have been seen more in patients with this condition when compared to the control subjects [6]. With the aid of immunofluorescence, antibodies to anagen-phase hair follicles were seen in as much as 90% of patients with alopecia areata. This is in comparison to less than 37% of control subjects.

    The autoantibody response is heterogenous and targets multiple structures of the anagen-phase hair follicle. The outer root sheath is the structure that is targeted most frequently and this is followed by the inner root sheath, the matrix and finally the hair shaft in that order. Whether these antibodies play a direct role in the pathophysiology is not yet known.

    Prevention

    Since external etiologic factors are poorly documented and a genetic pathway has been established for the development of the disease, there is no clear way of preventing this disease.

    Summary

    Alopecia areata is a recurrent, nonscarring hair loss condition, affecting parts of the body with hair growing abilities [1]. Clinically, alopecia areata can occur in a variety of patterns. It is of a benign nature but this doesn’t stop it from bringing about a great deal of emotional and psychosocial distress in people affected and those around them. 

    Patient Information

    Alopecia areata is a condition that brings about hair loss on not just your scalp but the entire body. It can be as a result of heredity, certain medications consumed or other medical conditions. It is mostly seen in people in their 30s but can happen in people of all age groups.

    The loss of hair takes different shapes and happens in any part of the body.

    Treatment is not compulsory unless when the individual finds the condition to be worrying (more serious cases), in that case, medications or surgery can be used to bring back hair growth in the region affected.

    Self-assessment

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    References

    1. Hoffmann R, Happle R. Topical immunotherapy in alopecia areata. What, how, and why?. Dermatol Clin. Oct 1996;14(4):739-44.
    2. Rokhsar CK, Shupack JL, Vafai JJ, Washenik K. Efficacy of topical sensitizers in the treatment of alopecia areata. J Am Acad Dermatol. Nov 1998;39(5 Pt 1):751-61.
    3. van der Steen P, Traupe H, Happle R, Boezeman J, Sträter R, Hamm H. The genetic risk for alopecia areata in first degree relatives of severely affected patients. An estimate. Acta Derm Venereol. Sep 1992;72(5):373-5.
    4. Huang KP, Mullangi S, Guo Y, Qureshi AA. Autoimmune, Atopic, and Mental Health Comorbid Conditions Associated With Alopecia Areata in the United States. JAMA Dermatol. May 22 2013;1-5. 
    5. Colombe BW, Lou CD, Price VH. The genetic basis of alopecia areata: HLA associations with patchy alopecia areata versus alopecia totalis and alopecia universalis. J Investig Dermatol Symp Proc. Dec 1999;4(3):216-9.
    6. Safavi KH, Muller SA, Suman VJ, et al. Incidence of alopecia areata in Olmsted County, Minnesota, 1975 through 1989. Mayo Clin Proc 1995; 70:628.
    7. Madani S, Shapiro J. Alopecia areata update. J Am Acad Dermatol 2000; 42:549.
    8. Gilhar A, Paus R, Kalish RS. Lymphocytes, neuropeptides, and genes involved in alopecia areata. J Clin Invest 2007; 117:2019.
    9. Messenger AG, Slater DN, Bleehen SS. Alopecia areata: alterations in the hair growth cycle and correlation with the follicular pathology. Br J Dermatol 1986; 114:337.
    10. Whiting DA. Histopathologic features of alopecia areata: a new look. Arch Dermatol 2003; 139:1555.

    • Alopecia areata in children: a clinical profile - A Nanda, AS Al‐Fouzan, F Al‐Hasawi - Pediatric dermatology, 2002 - Wiley Online Library
    • Alopecia areata in aging C3H/HeJ mice - JP Sundberg, WR Cordy, LE King - Journal of investigative , 1994 - nature.com
    • Alopecia areata and auto‐immunity - PS Friedmann - British Journal of Dermatology, 2006 - Wiley Online Library
    • Alopecia areata with features of loose anagen hair - J Nunez, K Grande, S Hsu - Pediatric dermatology, 1999 - Wiley Online Library


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