Alopecia Areata

By: Dr. Mark Becker

Alopecia areata is an autoimmune disease, in which the body’s own immune system mistakenly attacks the hair follicles, the tiny structures in the skin from which hairs grow. This can lead to hair loss on the scalp and elsewhere.

Alopecia Areata ChildAlopecia Areata Hair Loss Adult

In most cases of alopecia areata, 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.

However, in some people, the hair loss is more extensive. Although uncommon, the disease can cause complete hair loss on the head (alopecia totalis) or the head, face, and body (alopecia universalis).

Alopecia areata is not a life-threatening disease and those with it are generally healthy. But the disease has unexpected impact on a person’s appearance and can be a tremendous source of stress.

What causes alopecia areata?

In alopecia areata, cells of the body’s immune system attack the rapidly growing cells in the hair follicles that make the hair. The affected follicles shrink and drastically slow down hair production. Fortunately, the stem cells that continually supply the follicle with new cells do not seem to be targeted. So the follicle always has the potential to regrow hair.

Scientists do not know exactly why the immune system targets the hair follicles this way. But they suspect that genetics may predispose some people to the disease. In these people, some type of trigger, perhaps a virus or something in the environment, brings on the attack against the hair follicles.

Who is most likely to get alopecia areata?

Alopecia areata affects an estimated four million Americans of both genders and of all ages and ethnic backgrounds. It often begins in childhood.

1 in 5 people with the disease has a family member who has it as well. Those with a close family member with alopecia areata are at slightly greater risk of hair loss themselves. If the family member developed a patch of hair loss before age 30, the risk to other family members is greater.

Keep in mind that most children with alopecia areata do not have a parent with the disease, and the vast majority of parents with alopecia areata do not pass it along to their children.

Will the hair ever grow back?

There is a good chance your hair will regrow, but it may also fall out again. No one can predict when it might regrow or fall out. 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. Others continue to lose and regrow hair for many years. A few lose all the hair on their head; some lose all the hair on their head, face, and body. Even in those who lose all their hair, the possibility for full regrowth remains.

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.

What can I expect next?

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. You may continue to lose hair, or your hair loss may stop. The hair you have lost may or may not grow back, and you may or may not continue to develop new bare patches.

How is it alopecia areata treated?

While there is neither a cure for alopecia areata nor drugs approved for its treatment, some people find that medications approved for other purposes can help hair grow back, at least temporarily. The following are some treatments for alopecia areata.

Keep in mind that while these treatments may promote hair growth, none of them prevent new patches or actually cure the underlying disease. Consult with your doctor about the best option for you.


Corticosteroids are powerful anti-inflammatory drugs similar to a hormone called cortisol produced in the body. Because these drugs suppress the immune system if given orally, they are often used in the treatment of various autoimmune diseases, including alopecia areata. Corticosteroids may be given three ways for alopecia areata:

Corticosteroid injections

Injections of corticosteroids directly into hairless patches on the scalp, brow, and beard areas increase hair growth in most people. Injections deliver small amounts of cortisone to affected areas, preventing the more serious side effects encountered with long-term oral use. After 1 or 2 months, new hair growth may become visible, and the injections usually have to be repeated monthly. The main side effects of injections are transient pain, mild swelling, and occasional changes in pigmentation, as well as small indentations in the skin that go away when injections are stopped. Injections usually must be repeated monthly. Because injections can be painful, they may not be the preferred treatment for children, nor for large areas.

Topical corticosteroids

Topical corticosteroids (ointments or creams rubbed directly onto the affected skin) are less traumatic than injections and are therefore sometimes preferred for children. However, topical corticosteroids alone are less effective than injections; they work best when combined with other topical treatments, such as minoxidil or anthralin.

Oral corticosteroids

Corticosteroids taken by mouth, such as prednisone, are a standard treatment for many autoimmune diseases and may be used in more extensive alopecia areata. But because of the risk of side effects, such as hypertension and cataracts, oral corticosteroids are used only occasionally for alopecia areata and for shorter periods of time.

Rogaine® (minoxidil)

Topical minoxidil solution promotes hair growth when the hair follicle is small and not growing to its full potential. Minoxidil is FDA-approved for treating male and female pattern hair loss. It may also be useful in promoting hair growth in alopecia areata. The solution, applied twice daily, has been shown to promote hair growth in both adults and children, and may be used on the scalp, brow, and beard areas. With regular and proper use of the solution, new hair growth appears in about 12 weeks.

Anthralin (Psoriatec®)

Anthralin, a synthetic, tar-like substance that alters immune function in the affected skin, is an approved treatment for psoriasis. Anthralin is also commonly used to treat alopecia areata. Anthralin is applied for 20 to 60 minutes (“short contact therapy”) to avoid skin irritation, which is not needed for the drug to work. When it works, new hair growth is usually evident in 8 to 12 weeks. Anthralin is often used in combination with other treatments, such as corticosteroid injections or minoxidil, for improved results.


A sulfa drug, sulfasalazine has been used to treat different autoimmune disorders, including psoriasis. It acts on the immune system and has been used in patients with severe alopecia areata.

Topical sensitizers

Topical sensitizers are medications that, when applied to the scalp, provoke an allergic reaction that leads to itching, scaling, and eventually hair growth. If the medication works, new hair growth is usually established in 3 to 12 months. Two topical sensitizers are used in alopecia areata: squaric acid dibutyl ester (SADBE) and diphenylcyclopropenone (DPCP). Their safety and consistency of formula are currently under review.

PUVA Phototherapy

With PUVA, a treatment used most commonly for psoriasis, a person is given a light-sensitive drug called a psoralen either orally or topically and then exposed to an ultraviolet (UV) light source. In clinical trials, approximately 55 percent of people achieve cosmetically acceptable hair growth using PUVA. However, the relapse rate is high, and patients must go to a treatment center where the equipment is available at least two to three times per week. Furthermore, the treatment increases the risk of developing skin cancer.

Alternative therapies

When drug treatments fail to bring sufficient hair regrowth, some people turn to alternative therapies. Alternatives purported to help alopecia areata include acupuncture, aromatherapy, evening primrose oil, zinc, vitamin supplements, and Chinese herbs. Because many alternative therapies are not backed by clinical trials, they may or may not be effective for regrowing hair. In fact, some may actually make hair loss worse. Furthermore, just because these therapies are natural does not mean that they are safe. As with any therapy, talk to your doctor before you try them.

In addition to treatments to help hair grow, there are measures that can be taken to minimize the physical dangers or discomforts of lost hair.

  • Sunscreens are important for the scalp, face, and all exposed areas.
  • Eyeglasses (or sunglasses) protect the eyes from excessive sun, and from dust and debris, when eyebrows or eyelashes are missing.
  • Wigs, caps, or scarves protect the scalp from the sun and keep the head warm.
  • Antibiotic ointment applied inside the nostrils helps to protect against organisms invading the nose when nostril hair is missing.

How can I cope with the effects of the disease?

Living with hair loss can be hard, especially in a culture that views hair as a sign of youth and good health. Even so, most people with alopecia areata are well-adjusted, contented people living full lives.

The key to coping is valuing yourself for who you are, not for how much hair you have or don’t have. Many people learning to cope with alopecia areata find it helpful to talk with other people who are dealing with the same problems. More than four million people nationwide have this disease at some point in their lives, so you are not alone. If you would like to be in touch with others with the disease, the National Alopecia Areata Foundation (NAAF) can help through its penpal program, message boards, annual conference, and support groups that meet in various locations nationwide.

Another way to cope with the disease is to minimize its effects on your appearance. If you have total hair loss, a wig or hairpiece can look natural and stylish. For small patches of hair loss, a hair-colored powder, cream, or crayon applied to the scalp can make hair loss less obvious by eliminating the contrast between the hair and the scalp. Skillfully applied eyebrow pencil can mask missing eyebrows.

Children with alopecia areata may prefer to wear bandanas or caps. There are many styles available to suit a child’s interest and mood-some even have ponytails attached.

For women, attractive scarves can hide patchy hair loss; jewelry and clothing can distract attention from patchy hair; and proper makeup can camouflage the effects of lost facial hair. If you would like to learn more about camouflaging the cosmetic aspects of alopecia areata, ask your doctor or members of your local support group to recommend a cosmetologist who specializes in working with people whose appearance is affected by medical conditions.

Learn more from The National Alopecia Areata Foundation

Reference: National Institutes of Health

Images courtesy of Gerald Goldberg, M.D.