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 Diagnosis & Treatment
Diagnosis
Alopecia areata has to be differentiated from other conditions that cause patchy hair loss such as trichotillomania, tinea capitis (scalp ringworm) and secondary syphilis.
In alopecia areata, the scalp skin appears normal and exclamation mark hairs or black dots representing hairs broken off close to the scalp may be seen. If required, the diagnosis of alopecia areata can be confirmed with a scalp biopsy.
Treatment
Less severe cases of alopecia areata usually recover on their own, but this may take as long as six months and sometimes as long as five years. Unfortunately, it is not possible to accurately predict which patients are going to improve on their own and which are not. Treatment can hasten recovery and is therefore desirable for psychological as well as cosmetic reasons. Below are some of the treatments available:
Intralesional steroids
This involves injecting steroids directly into the bald patches at monthly intervals until re-growth becomes evident, which may take six to 12 weeks. The re-grown hairs may be light or white in colour but will darken as they grow longer.
The injection is no more painful than injections elsewhere and there is no danger of the injection injuring the brain, which is well protected by the skull. Intralesional steroids may not be suitable for children because of the pain.
Topical (applied) steroids
Strong steroids applied to the bald areas twice daily have been reported to produce regrowth in some patients. However, response is slow, taking sometimes up to six months and it is difficult to know whether response is due to treatment or the natural tendency of the condition to improve. Still, topical steroids are convenient, painless and worth a trial, especially in young children who may be fearful of injections.
Oral steroids
Steroids given by mouth are extremely effective, but the problem is that hair often falls out when treatment is discontinued. Therefore, treatment has to be continued until spontaneous remission takes place, which may take six months or ffi9re.
Prolonged trdtment may cause side effects such as weight gain, easy skin bruising, upset stomach, bone thinning and muscle weakness. Therefore, oral steroids are usually only prescribed for severe cases of alopecia areata, alopecia totalis, alopecia universalis and for unresponsive patients who are psychologically very disturbed by their hair loss. Close supervision by the doctor is necessary because of side effects.
Minoxidil
Minoxidil lotion was originally developed for the treatment of male pattern baldness. A few small-scale studies suggest that minoxidil can induce regrowth in 50-80% of patients with alopecia areata, However, these results may not be that impressive when it is remembered that a significant proportion of patients regrow hair spontaneously anyway, Moreover, minoxidil does not work very well in patients with severe alopecia areata, alopecia totalis and alopecia universalis, which are genuinely difficult to treat.
Nonetheless, minoxidil is a new alternative available and may be tried in patients who are not keen on intralesional injections or in those who have not responded to other treatments. Minoxidil is believed to work by directly stimulating the hair follicles or modifying the immune reaction responsible for the hair loss.
Topical irritants
These are applied to the bald areas to irritate and stimulate hibernating hair follicles to produce hair again. Dithranol cream used for treating a skin condition known as psoriasis has been used with some success and regrowth has been reported in a few patients after about two months.
The disadvantage of dithranol is that the cream is somewhat irritating to the skin and causes itching and, occasionally, burning. It may also stain the clothes and skin. A variety of other irritants such as phenol, benzyl benzoate, sodium lauryl sulphate and croton oil have also been used. Irritants have to be applied regularly to maintain the irritation. Treatment is uncomfortable and hence not very popular with patients.
Ultravialet_B light
Ultraviolet_ B from an artificial light source has also been used to induce a mild sunburn on the bald areas. I t is believed that the mild sunburn irritates and stimulates the hair follicles into producing hair again. However, this treatment is inconvenient because the patient has to go to the clinic regularly for treatment.
Topical allergens
Instead of irritation, this method uses allergens (substances that cause an allergic reaction) to stimulate the follicles into producing hair. A number of allergens have been used, for example, DNCB (dinitrochlorbenzene), SADBE (squaric acid dibutylester), diphencyprone, poison ivy resin and primula leaves. f..pplication of anyone of these will induce allergy in most people.
If the same substance (allergen) is applied to the skin again, an allergic reaction will develop at the site of application. Repeated applications maintain the reaction, and about 25_50% of patients with severe alopecia areata have shown re-growth three to six months later.
It is believed that the allergic reaction induces the production of a group of lymphocytes known as suppressor_ T cells which suppress the immune reaction responsible for the hair loss.
Topical allergens definitely work because some patients who have been totally bald for years have re-grown hair. The problem is the reaction canbe very uncomfortable and at times associated with painful swelling of the lymph glands in the neck and fever. DNCB is less popular now because laboratory tests show that it may be cancer-causing.
PUVA
Psoralen plus ultraviolet light-A, normally used for treating psoriasis, has also been used in patients with alopecia areata.This treatment is repeated two to five times a week at the clinic for a total of about 20 treatments, The results have been variable with some doctors reporting benefit and others reporting none.
Like ultraviolet-Blight, this treatment requires the patient to go to the clinic regularly for treatment, Special precautions have to be taken to avoid direct sunlight for several hours after treatment. PUV A has a depleting effect on Langerhan cells (another type of cell that is involved in immune reactions) and this somehow encourages hair growth.
Isoprinosine
This is an immunomodulatory drug (a drug which has effects on the immune system). It has been reported to induce re-growth in patients with alopecia areata who have laboratory evidence of altered immunity. lsoprinosine may cause an increase in uric acid, causing gout; so monitoring of uric acid levels is a necessary precaution during treatment.
Cyclosporin
Cyclosporin is a drug used to prevent the rejection of transplanted organs. It suppresses the immune system and also causes hair growth as a side effect.
Oral cyclosporin has been reported to induce re-growth in some patients with alopecia areata. It may work by suppressing the immune reaction that is causing the hair loss or by directly stimulating hair follicle growth.
Because cyclosporin is toxic when taken by mouth, doctors have tried using topical cyclosporin instead. Unfortunately, only mild re-growth was observed. Like in male pattern baldness, this may be related to the inability of cyclosporin to penetrate the skin and reach the follicles.
Doctors are experimenting with other formulations in an attempt to improve the penetration of cyclosporin into the skin.
Outcome
The outcome of alopecia areata is, unfortunately, very unpredictable. 'As a general guide, 50% of patients will recover their hair within six to 12 months. Unfavourable signs include alopecia areata of greater than one year's duration, extensive alopecia areata, alopecia totalis and alopecia universalis, and a history of atopy (asthma, allergic rhinitis or atopic dermatitis).
Ophiasis, a form of alopecia areata affecting the back of the head and spreading in a band along the scalp margins, also has a poor outlook (Fig. 13). After full recovery, there is a 40-50% chance of a relapse within five years.
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