The patient’s unmet needs (PUNs)
A 35-year-old man attends, very distressed by his hair loss. You note a recent diagnosis of alopecia areata, for which a colleague had prescribed a topical steroid cream. The patient isn’t happy with the situation and wants a second opinion. ‘I’ve read that steroids only work if they’re injected into the scalp,’ he says. ‘And I’ve noticed my nails are affected, too, is that a bad sign?’ Examination reveals what looks like patches of alopecia areata affecting the scalp and beard area, with likely nail involvement.
The doctor’s educational needs (DENs)
What is the prognosis of alopecia areata? What might suggest a higher than average likelihood of progression?
The prognosis in patients with one or two patches is excellent, with spontaneous regrowth occurring in 50-80% within 12 months without active treatment. However, one in five patients will progress to total hair loss. Those with more patches, and those who rapidly progress to extensive disease, have a worse prognosis. The severity at the outset is the strongest predictor of long-term outcome.1
Onset pre-puberty, atopy, a family history of alopecia areata, or a personal or family history of autoimmune conditions are all associated with a worse prognosis – as are alopecia areata involving the occipital hair line – in what is termed the ‘ophiasis’ pattern – or involvement of the nails leading to pits.
What differential diagnoses should the GP consider?
The differential diagnosis may include trichotillomania, tinea capitis or scarring conditions that can present with a patch of hair loss such as discoid lupus erythematosus (DLE). A moth-eaten pattern of hair loss can be a feature of secondary syphilis.
In trichotillomania, hair is pulled by the patient and clinically the patch of hair loss is incomplete, with hairs of varying length. Hair from the hair line, where it is more painful to extract, is often spared.
Tinea capitis presents usually with a solitary patch of hair loss and is often associated with scale and crust. Tinea capitis is more likely to be itchy. It is common for other family members or school friends to be infected too.
The hallmark of scarring alopecias is the loss of follicular ostia. The surface of the scalp becomes shiny and sclerotic.
How effective are steroids in alopecia areata, either topically or by injection into the scalp?
Alopecia areata is characterised by inflammation around the hair bulb leading to hairs exiting the growth phase. This can be reversed with steroids – though it is debatable whether there is any lasting change. There may be some benefit with super-potent topical steroids, such as clobetasol propionate, used for up to three months.
However, penetration through the skin to the level of the hair bulb is limited. Intralesional injection of steroid directly at the site of inflammation is more effective.2 Oral steroids can also arrest the condition but are associated with more side-effects.1
What other treatments are available, and how effective are they? Which patients warrant referral, and at what stage?
Numerous other treatments have been trialled in alopecia areata – most have a weak evidence basis for use, low efficacy or a high rate of relapse. These include immunosuppressive therapies and steroid-sparing therapies such as azathioprine, ciclosporin and methotrexate.
Biologic therapies have, to date, been ineffective.
Generating a contact allergy using an artificial sensitiser such as diphencyprone is an effective way of both treating the condition and maintaining the progress in the longer term.1
Referral should be considered when there is diagnostic doubt, when the condition is rapidly progressive or extensive or when it is causing significant psychological stress or impacting on quality of life.
Referral may not lead to hair regrowth, but a single appointment can provide up-to-date knowledge of the condition, explain the pros and cons of treatment, and help address the patient’s wider needs.
What diseases are associated with this condition?
Alopecia areata is associated with other autoimmune conditions such as vitiligo, psoriasis and systemic lupus erythematosus, which may be evident on clinical examination.3 There is also an association with autoimmune thyroid disease. Work from a genome-wide association study has shown a genetic link with rheumatoid arthritis, coeliac disease and inflammatory bowel disease.4
Dr Paul Farrant is a consultant dermatologist and clinical lead for dermatology at Brighton and Sussex University Hospitals Trust. He specialises in the management of hair loss and scalp conditions.
- Messenger A, McKillop J, Farrant P et al. British Association of Dermatologists’ guidelines for the management of alopecia areata. Br J Dermatol 2012;166:916-26
- Kuldeep C, Singhal H, Khare A et al. Randomised comparison of topical betamethasone valerate foam, intralesional triamcinolone acetonide and tacrolimus ointment in management of localized alopecia areata. International Journal of Trichology 2011;3:20-4.
- Chu S, Chen Y, Tseng W et al. Comorbidity profiles among patients with alopecia areata: the importance of onset age, a nationwide population-based study. J Am Acad Dermatol 2011;65:949-56
- Petukhova L, Duvic M, Hordinsky M et al. Genome-wide association study in alopecia areata implicates both innate and adaptive immunity. Nature 2010;466:113-7