Clinical manifestations and diagnosis of alopecia areata
- Andrew G Messenger, MD, FRCP
Andrew G Messenger, MD, FRCP
- Professor of Dermatology
- University of Sheffield
- Section Editors
- Robert P Dellavalle, MD, PhD, MSPH
Robert P Dellavalle, MD, PhD, MSPH
- Section Editor — General Dermatology
- Professor of Dermatology and Public Health
- University of Colorado School of Medicine
- Colorado School of Public Health
- Chief, Dermatology Service
- US Department of Veterans Affairs
- Eastern Colorado Health Care System
- Maria Hordinsky, MD
Maria Hordinsky, MD
- Section Editor — Hair and Scalp Disease
- Chair and Professor - Department of Dermatology
- University of Minnesota Medical School
Alopecia areata is a chronic immune-mediated disorder that targets anagen hair follicles and causes nonscarring hair loss. The condition most commonly presents with discrete patches of alopecia on the scalp. Other hair-bearing areas may also be affected. In severe cases, patients may experience loss of all scalp or body hair.
The clinical manifestations and diagnosis of alopecia areata will be discussed here. The therapeutic management of alopecia areata and information on other types of nonscarring hair loss are reviewed separately. (See "Management of alopecia areata" and "Evaluation and diagnosis of hair loss", section on 'Nonscarring alopecia'.)
The estimated prevalence of alopecia areata is approximately 1 in 1000 people, with a lifetime risk of approximately 2 percent [1,2]. For most patients the onset is before age 30; however, the disorder may occur at any age . Men and women are equally affected.
T-cell mediated peribulbar inflammation leading to disruption of the normal hair cycle has been implicated in the pathogenesis of alopecia areata . Unlike cicatricial alopecias (eg, lichen planopilaris or discoid lupus), the inflammatory process in alopecia areata does not lead to scarring and destruction of the hair follicle. (See 'Cicatricial alopecia' below.)
Disruption of the hair cycle — Hair follicles in normal skin cycle through periods of active hair growth (anagen), follicular involution (catagen), and follicular rest (telogen) (figure 1). In alopecia areata, peribulbar inflammation is associated with dystrophic changes in anagen follicles and stimulates premature transition of anagen follicles to the nonproliferative catagen and telogen phases [3-5]. (See "Evaluation and diagnosis of hair loss", section on 'Hair cycle'.)
- 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.
- Madani S, Shapiro J. Alopecia areata update. J Am Acad Dermatol 2000; 42:549.
- Gilhar A, Paus R, Kalish RS. Lymphocytes, neuropeptides, and genes involved in alopecia areata. J Clin Invest 2007; 117:2019.
- 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.
- Whiting DA. Histopathologic features of alopecia areata: a new look. Arch Dermatol 2003; 139:1555.
- Alkhalifah A, Alsantali A, Wang E, et al. Alopecia areata update: part I. Clinical picture, histopathology, and pathogenesis. J Am Acad Dermatol 2010; 62:177.
- Petukhova L, Duvic M, Hordinsky M, et al. Genome-wide association study in alopecia areata implicates both innate and adaptive immunity. Nature 2010; 466:113.
- Xing L, Dai Z, Jabbari A, et al. Alopecia areata is driven by cytotoxic T lymphocytes and is reversed by JAK inhibition. Nat Med 2014; 20:1043.
- Craiglow BG, King BA. Killing two birds with one stone: oral tofacitinib reverses alopecia universalis in a patient with plaque psoriasis. J Invest Dermatol 2014; 134:2988.
- Liu LY, Craiglow BG, Dai F, King BA. Tofacitinib for the treatment of severe alopecia areata and variants: A study of 90 patients. J Am Acad Dermatol 2017; 76:22.
- Martinez-Mir A, Zlotogorski A, Gordon D, et al. Genomewide scan for linkage reveals evidence of several susceptibility loci for alopecia areata. Am J Hum Genet 2007; 80:316.
- Sundberg JP, Silva KA, Li R, et al. Adult-onset Alopecia areata is a complex polygenic trait in the C3H/HeJ mouse model. J Invest Dermatol 2004; 123:294.
- Duvic M, Nelson A, de Andrade M. The genetics of alopecia areata. Clin Dermatol 2001; 19:135.
- McDonagh AJ, Tazi-Ahnini R. Epidemiology and genetics of alopecia areata. Clin Exp Dermatol 2002; 27:405.
- Barahmani N, de Andrade M, Slusser JP, et al. Human leukocyte antigen class II alleles are associated with risk of alopecia areata. J Invest Dermatol 2008; 128:240.
- Megiorni F, Pizzuti A, Mora B, et al. Genetic association of HLA-DQB1 and HLA-DRB1 polymorphisms with alopecia areata in the Italian population. Br J Dermatol 2011; 165:823.
- Tobin DJ, Orentreich N, Fenton DA, Bystryn JC. Antibodies to hair follicles in alopecia areata. J Invest Dermatol 1994; 102:721.
- McDonagh AJ, Messenger AG. The pathogenesis of alopecia areata. Dermatol Clin 1996; 14:661.
- Blaumeiser B, van der Goot I, Fimmers R, et al. Familial aggregation of alopecia areata. J Am Acad Dermatol 2006; 54:627.
- Jackow C, Puffer N, Hordinsky M, et al. Alopecia areata and cytomegalovirus infection in twins: genes versus environment? J Am Acad Dermatol 1998; 38:418.
- Rodriguez TA, Fernandes KE, Dresser KL, et al. Concordance rate of alopecia areata in identical twins supports both genetic and environmental factors. J Am Acad Dermatol 2010; 62:525.
- Willemsen R, Vanderlinden J, Roseeuw D, Haentjens P. Increased history of childhood and lifetime traumatic events among adults with alopecia areata. J Am Acad Dermatol 2009; 60:388.
- Aksu Cerman A, Sarikaya Solak S, Kivanc Altunay I. Vitamin D deficiency in alopecia areata. Br J Dermatol 2014; 170:1299.
- Chartier MB, Hoss DM, Grant-Kels JM. Approach to the adult female patient with diffuse nonscarring alopecia. J Am Acad Dermatol 2002; 47:809.
- Lew BL, Shin MK, Sim WY. Acute diffuse and total alopecia: A new subtype of alopecia areata with a favorable prognosis. J Am Acad Dermatol 2009; 60:85.
- Saceda-Corralo D, Grimalt R, Fernández-Crehuet P, et al. Beard alopecia areata: a multicentre review of 55 patients. J Eur Acad Dermatol Venereol 2017; 31:187.
- Gilhar A, Etzioni A, Paus R. Alopecia areata. N Engl J Med 2012; 366:1515.
- Muñoz MA, Camacho FM. Sisaipho: a new form of presentation of alopecia areata. Arch Dermatol 1996; 132:1255.
- Kasumagic-Halilovic E, Prohic A. Nail changes in alopecia areata: frequency and clinical presentation. J Eur Acad Dermatol Venereol 2009; 23:240.
- Barahmani N, Schabath MB, Duvic M, National Alopecia Areata Registry. History of atopy or autoimmunity increases risk of alopecia areata. J Am Acad Dermatol 2009; 61:581.
- Wang SJ, Shohat T, Vadheim C, et al. Increased risk for type I (insulin-dependent) diabetes in relatives of patients with alopecia areata (AA). Am J Med Genet 1994; 51:234.
- Du Vivier A, Munro DD. Alopecia areata, autoimmunity, and Down's syndrome. Br Med J 1975; 1:191.
- Daneshpazhooh M, Nazemi TM, Bigdeloo L, Yoosefi M. Mucocutaneous findings in 100 children with Down syndrome. Pediatr Dermatol 2007; 24:317.
- Schepis C, Barone C, Siragusa M, et al. An updated survey on skin conditions in Down syndrome. Dermatology 2002; 205:234.
- Collins SM, Dominguez M, Ilmarinen T, et al. Dermatological manifestations of autoimmune polyendocrinopathy-candidiasis-ectodermal dystrophy syndrome. Br J Dermatol 2006; 154:1088.
- Ruiz-Doblado S, Carrizosa A, García-Hernández MJ. Alopecia areata: psychiatric comorbidity and adjustment to illness. Int J Dermatol 2003; 42:434.
- Ghanizadeh A. Comorbidity of psychiatric disorders in children and adolescents with alopecia areata in a child and adolescent psychiatry clinical sample. Int J Dermatol 2008; 47:1118.
- Koo JY, Shellow WV, Hallman CP, Edwards JE. Alopecia areata and increased prevalence of psychiatric disorders. Int J Dermatol 1994; 33:849.
- Shapiro J, Madani S. Alopecia areata: diagnosis and management. Int J Dermatol 1999; 38 Suppl 1:19.
- MacDonald Hull SP, Wood ML, Hutchinson PE, et al. Guidelines for the management of alopecia areata. Br J Dermatol 2003; 149:692.
- Tosti A, Bellavista S, Iorizzo M. Alopecia areata: a long term follow-up study of 191 patients. J Am Acad Dermatol 2006; 55:438.
- Tobin DJ. Morphological analysis of hair follicles in alopecia areata. Microsc Res Tech 1997; 38:443.
- Ross EK, Vincenzi C, Tosti A. Videodermoscopy in the evaluation of hair and scalp disorders. J Am Acad Dermatol 2006; 55:799.
- Inui S, Nakajima T, Nakagawa K, Itami S. Clinical significance of dermoscopy in alopecia areata: analysis of 300 cases. Int J Dermatol 2008; 47:688.
- Tosti A, Whiting D, Iorizzo M, et al. The role of scalp dermoscopy in the diagnosis of alopecia areata incognita. J Am Acad Dermatol 2008; 59:64.
- Miteva M, Tosti A. Hair and scalp dermatoscopy. J Am Acad Dermatol 2012; 67:1040.
- Abraham LS, Torres FN, Azulay-Abulafia L. Dermoscopic clues to distinguish trichotillomania from patchy alopecia areata. An Bras Dermatol 2010; 85:723.
- Disruption of the hair cycle
- Genetic background
- CLINICAL FEATURES
- Nail abnormalities
- Associated diseases
- Course of disease
- Laboratory studies
- DIFFERENTIAL DIAGNOSIS
- Tinea capitis
- Nervous hair pulling (trichotillomania)
- Cicatricial alopecia
- Androgenetic alopecia
- Secondary syphilis
- Telogen effluvium
- Triangular alopecia
- INFORMATION FOR PATIENTS
- SUMMARY AND RECOMMENDATIONS