What are the aims of this leaflet?
This leaflet has been written to help you understand more about alopecia areata.  It will tell you what alopecia areata is, what causes it, what can be done about it, and where you can get more information about it.

What is alopecia areata?
Alopecia areata is a common cause of hair loss.  It usually causes patchy round areas of baldness to appear on the scalp, although other hair-bearing skin may be affected, including the beard, body, eyebrows and eyelashes.

What causes alopecia areata?
It occurs because the affected person's immune system does not recognise the hair follicles as "self", but regards them as "foreign".  The response produced by the immune system causes the loss of hair.  There is no permanent damage to the affected hair follicle, and once the immune system tolerates the follicle correctly, the hair can regrow.  This type of attack is called an "autoimmune" response.

People of all ages and races can get alopecia areata.  It often starts in childhood. It can run in families.  A person with alopecia areata is more likely than the general population to have or to develop other autoimmune conditions such as thyroid disease, diabetes and vitiligo (this produces white patches on the skin), although the risk of getting these disorders is still low.  Alopecia areata is not catching.

Often we just do not know what triggers an attack of alopecia areata.  For some people stress can play a part, particularly events such as bereavement, separation and accidents.  We know alopecia areata is not due to diet or vitamin deficiencies.  

Is alopecia areata hereditary?

Around 1 in 5 sufferers have a close family member who also has alopecia areata. 

What are the symptoms?
Usually, there are none. Sometimes, you may feel a tingling in your scalp in the affected areas.  Many of those who have alopecia areata are greatly upset by it, particularly if it relapses. 

What does alopecia areata look like?

Hairdressers often spot the condition first as a single patch or small number of patches of hair loss on your scalp.

·      At the edge of the patch of hair loss, you can sometimes see short, tapered hairs called "exclamation mark" hairs.  These hairs are characteristic of alopecia areata. 

·      The affected scalp is usually not scaly or inflamed. 

·      Sometimes you will see fine, pale or even white hairs regrowing in the centre of the patch.  These hairs thicken as time goes by and start to get their colour back (pigmentation). 

·      Sometimes, people with alopecia areata also develop tiny fine pits on the surface of their nails - rather like those seen on a thimble. Otherwise no other parts of the body are affected.

Can it be cured?
No, alopecia areata cannot be cured.  Treatments are available that may help your hair to regrow; but, there is no treatment that will prevent alopecia happening again.

If your hair loss is patchy, there is a good chance (about 60-80%) that you will get complete regrowth within 1 year without treatment.  However, if you have a very large amount of hair loss from the start, the chances of it regrowing may not be as good as this.  In people with Down's syndrome, or those who have severe eczema, the chances of regrowth are not so good either. 

How can alopecia areata be treated?

Many people with mild early alopecia areata may need no treatment, as their hair is likely to come back anyway without it.  However some treatments can induce hair growth, though none is able to alter the overall course of the disease.  Any treatments that carry serious risks should be avoided, as alopecia areata itself has no direct impact on general health.

Treatments used for alopecia areata include the following:

·      Steroid creams and scalp applications. These are applied to the bald patches, usually twice a day, and can help the hair to regrow more quickly.

·      Local steroid injections.  These can be used on the scalp and brows, and are the most effective approach for small patches of hair loss.  Injections may be given via a needle and syringe or with an air jet injector (this may be less uncomfortable). After several weeks, a 0.5 cm diameter tuft of hair will be seen at the injection site.  Injections can be repeated every few months.  Special care is taken around the eyes, when injecting the brows, as injecting too much may cause glaucoma (raised pressure inside the eyeball).  A small dimple may develop at sites of injections, but this usually recovers without treatment after a few months.

·      Steroid tablets.  Large doses of steroid tablets given long term may cause the hair to grow again, but there are significant risks to general health with this treatment (including raised blood pressure, stomach ulcers, eye lens cataracts and osteoporosis).  In view of these dangers, it is currently ‘not possible to support their use until there is better evidence of efficacy’. ¹

·      Contact sensitisation treatment.  This involves initially applying a strong sensitizer (usually a chemical called diphencyprone) to the skin of a person with alopecia areata to make them allergic to it.  Then weaker strengths of the sensitizer are applied to the bald areas every week to produce a mild allergic dermatitis.  A worthwhile regrowth will occur in up to 50% of sufferers in about 6 months.  The treatment may produce more severe local reactions.  Loss of skin colour (depigmentation) may develop, so it is used with caution in those with dark skin. 

·      Ultraviolet light treatment.  Using UVA radiation after taking psoralen tablets, or applying a psoralen cream to the bald areas to sensitise the skin, a treatment called PUVA, may be effective. Treatments are needed twice weekly for a number of months.  Relapse of the alopecia is common when the treatment is stopped. 

·      Minoxidil lotion.  This substance, which is applied topically to the bald areas, may help some sufferers although it seldom produces cosmetically useful regrowth in people with extensive hair loss.

·      Dithranol.  This is an irritant cream that is usually used to treat a skin condition called psoriasis.   It can be applied to the bald areas of alopecia areata and may help the hair to regrow.  To work, it needs to be used often enough, and strong enough, to produce local skin irritation. It is less effective than contact sensitisation, but safer and easier to use.  Dithranol will stain blonde or fair hair a purple colour, precluding its use.

What if I need a wig?
Some sufferers will prefer to wear a wig whilst they wait for recovery from their alopecia.  Wigs and partial hairpieces can be bought privately or obtained through the NHS on a consultant's prescription.  Local dermatology departments can often recommend local suppliers who are sensitive to the needs of alopecia areata sufferers.  An acrylic wig costs between £60 and £200, whilst human hair wigs are around ten times as expensive and need more upkeep.  Current NHS prescription charges (2004 prices) are £50.70 for an acrylic and £195.40 for a human hair wig.  If you get free prescriptions (under 18, over 60 or on income support), you will receive a prescription wig free of charge.  You will only qualify for a human hair wig on prescription if you are allergic to acrylic wigs or you have a skin condition that means you would need a human hair wig.

What can I do?

·      You may find that meeting other sufferers from alopecia areata, or joining a patient support group (below), will make it easier for you to adjust to your condition.

·      Remember that the main function of hair is to protect the top of the scalp from sunlight.  You should cover your bald patches to protect them from the sun, either with a sun block or a hat.  If you expose your bald patches to the sun, they are likely to get sunburnt and you will increase your chances of getting long-term sun damage.

·      If you find that the regrowing hair is slow to recolour, it can be dyed.

Where can I get more information?

Patient Support Groups
National Alopecia Areata Foundation - American web site with useful links and advice about coping with alopecia.    www.naaf.org 

Hairline International - a patient's society
Lyons Court
1668 High Street
Knowle, Nr Solihull
West Midlands
B93 0LY

Information about entitlement to free wigs is given in NHS leaflet HC11.

Reference used to prepare this leaflet:
1.  MacDonald Hull SP, Wood ML, Hutchinson PE, Sladden M, Messenger AG.  Guidelines for the treatment of alopecia areata.  British Journal of Dermatology 2003; 149: 692-699.

(While every effort has been made to ensure that the information given in this leaflet is accurate, not every treatment will be suitable or effective for every person. Your own doctor will be able to advise in greater detail)

BAD PATIENT INFORMATION LEAFLET

PRODUCED AUGUST 2004