Management of alopecia areata

Abstract

Alopecia areata is a common chronic inflammatory disease, which is probably mediated by lymphocytes. The predisposition to alopecia areata is polygenic in nature but environmental factors may trigger episodes of the disease. The diagnosis is usually not difficult and this presentation will concentrate mainly on patient management. An explanation of alopecia areata, including discussion of the nature and course of the disease and the available treatments, is an important part of management. Overall, there is a high rate of spontaneous remission but almost all sufferers will experience more than one episode of alopecia and patients presenting to dermatologists tend to be affected more severely. Poor prognostic indicators include onset in childhood, failure of recovery within 1 year and extensive hair loss. The decision to treat alopecia areata actively should not be taken lightly. Treatment can be uncomfortable for the patient, time consuming and potentially toxic. Some patients find it difficult to cope with relapse following or during initially successful treatment and they should be forewarned of this possibility. On the other hand, some patients are appreciative that something has been tried, even if it does not work. A number of treatments can induce hair growth in alopecia areata, but none has been shown to alter the natural history and few have been subjected to randomized controlled trials. Simple topical treatments include topical steroids, minoxidil lotion and dithranol although there is little evidence that the results are superior to placebo. Intra-lesional steroids stimulate hair growth in a high proportion of patients and can be helpful where hair loss is limited in extent or for certain sites such as the eyebrows. Several uncontrolled studies have suggested that pulsed high-dose systemic steroids are effective in some patients and this approach is possibly useful in rapidly progressive alopecia. The most effective treatment in severe alopecia is contact immunotherapy. However, the long-term response rate in this group of patients is low (15–20%), it is available in only a few centres and there are significant safety considerations for patients and carers. Following sympathetic counselling no treatment is an active option for many patients with alopecia areata. Prescription of a wig can make the difference between social isolation and leading a normal life for patients with extensive hair loss. Finally, we have a responsibility to deter patients from indulging in a succession of useless and inevitably expensive ‘cures’.