Imagine waking up to find clumps of hair on your pillow or noticing sudden bald patches on your scalp. For millions living with alopecia areata, this is a harsh reality. Though unpredictable and emotionally challenging, breakthroughs in treatment options offer hope for hair regrowth and restoring confidence. Let’s explore them.

What is Alopecia areata?

Alopecia areata is a disease in which the immune system attacks and destroys hair follicles, a part of skin from which hair grows, resulting in hair loss. Although hair may be lost from any region of the skin, alopecia areata tends to affect the head and face first. The usual pattern is one or more small, round, bare patches on the scalp, although there can also be more considerable hair loss. Patients with the disease are usually otherwise healthy, with no other symptoms.¹

Alopecia areata can affect all individuals of any sex or ethnicity; it typically starts during one's teens, twenties, or thirties. The condition is usually more extensive in cases when the process starts in children under 10 years of age. Although family history sometimes intervenes, most conditions arise without genetic influences. It is an autoimmune genetic disease concerning abnormal immune function, which is common in individuals suffering from other autoimmune diseases such as psoriasis and thyroid disease. However, most cases of alopecia areata are not associated with an obvious cause of stress or sickness.¹

Understanding Alopecia areata

Symptoms

Alopecia areata usually manifests as circular patches of hair loss on the scalp, face, eyebrows, eyelashes, or body. It is often also associated with small amounts of nail loss. Though it is usually asymptomatic (involving no other symptoms), affected patches may rarely itch, show color changes (red, purple, brown, or gray), or may show other bizarre signs such as prominent follicular openings, black dots (cadaver hairs), exclamation-point hairs, or even white hairs. These changes in hair texture and color may indicate the course of the condition, though these vary greatly among individuals in their severity and aspect.²

Causes

Alopecia areata is an autoimmune disease where the immune system mistakenly thinks that hair follicles are harmful invaders, like bacteria or viruses, and subsequently attack them. This causes large clumps of hair to fall out, usually about the size of a quarter. In general, the more common forms only involve small patches, but it may be so advanced as to cause total baldness. Thus, the elicitation of this autoimmune response may require a strong genetic predisposition, and sometimes an external stimulus, likely a virus. It is for this reason that the course of alopecia areata is so unpredictable- due to the interplay between genetic predisposition and environmental triggers.²

Diagnosis

Medical professionals typically diagnose alopecia areata when doing a physical examination, taking a medical history of the individual concerning the actual timescale of hair loss, and enquiring about the patient’s family history of autoimmune diseases. They may also check one's nails for related symptoms. The testing can be done for infection of the scalp, laboratory analysis of a hair sample, biopsy of the scalp to rule out various skin diseases, and blood tests to rule out other underlying conditions that may be causing the hair loss. These tests confirm the diagnosis and help indicate proper treatment.²

Conventional medical treatments

Topical treatments

• Corticosteroids: Treatment for autoimmune diseases usually involves anti-inflammatory medication. Corticosteroids can be injected into your scalp or other affected areas, taken orally as a pill, or applied topically- rubbed into your skin-as an ointment, cream, or foam. Your body might be slow to respond to corticosteroids. Increased appetite, weight gain, mood changes, and blurred vision are some common side effects²
• Minoxidil (Rogaine®): Minoxidil is a topical drug; it treats both male and female pattern baldness. It usually takes around 12 weeks of treatment before your hair actually starts to regrow. Some side effects include headache, scalp irritation, and unusual hair growth²

Advanced and emerging treatments

• Phototherapy: Phototherapy uses ultraviolet light from special lamps. Your healthcare provider may use a drug called psoralen combined with ultraviolet A (PUVA) or ultraviolet B (PUVB). The ultraviolet light waves in phototherapy may help alleviate certain skin and nail disorders, including alopecia areata²
• Platelet-Rich Plasma (PRP) Therapy: A physician removes blood from the body, processes it, and administers it into your scalp to trigger hair growth. Common side effects include scalp pain and irritation, dizziness, nausea, and vomiting.² Several studies document that PRP is effective for hair loss treatment. Although commonly used, the exact mechanism of action of PRP is not fully understood³
• Janus Kinase (JAK) Inhibitors: Six JAK inhibitors have been reported to be successful in the treatment of AA, including tofacitinib, ruxolitinib, baricitinib, CTP-543, PF-06651600, and PF-06700841. All of these drugs are oral agents. Oral drugs with comfortable dosing regimens have demonstrated efficacy and safety in large studies, as therapy for other dermatological diseases such as rheumatoid arthritis and psoriatic arthritis. Side effects that have been identified so far include nausea, headaches, increased infection risk including herpes/cold sore reactivation, anaemia, increased cholesterol, and possibly increased risk of blood clotting⁴
• Excimer laser and excimer light: Excimer laser and excimer light represent two of the more recent additions to the phototherapeutic armamentarium available for many skin and hair disorders. A few clinical studies have reported on the efficacy of excimer laser and excimer light in alopecia areata. The treatment is usually well tolerated, with erythema (redness of the skin) reported as the only adverse effect⁴

Oral medications

• Systemic corticosteroids: Systemic steroids can completely halt the advance of alopecia areata, but bad outcomes, adverse side effects of the drug, and high recurrence rates limit their long-term use. Oral minipulse therapy with high-dose corticosteroids given for 2 successive days every week has demonstrated hair growth of 71.43% in 4 months and is, thus, a more promising alternative for some patients⁴
• Immunosuppressants: Most often, immunotherapy is reserved for severe, treatment-resistant cases. Azathioprine given at 2.5 mg/kg/day demonstrates approximately 50% hair regrowth, although similar paediatric responses have been observed at 1 mg/kg/day. In severe cases, Cyclosporine is effective at a dose of 4-6 mg/kg/day for 5.77 months demonstrating a 66% response rate. Sulfasalazine inhibits T-cell proliferation, NK-cell activity, and inflammatory cytokines, which induces hair regrowth. Treatment is usually started at a dosage of 500 mg twice daily and then titrated to 1g three times daily⁴

Considerations in choosing treatment

For patients who need treatment for alopecia areata, the first priority is hair regrowth without experiencing further loss, and to be able to cope with other accompanying problems, such as the safety of the treatment. The risk of side effects that may be associated with a given treatment both locally and otherwise is important to the patient, especially in cases where they have pre-existing conditions. Apart from cost, the time needed for the actual treatment, its invasiveness, and its effects on daily living are all factors that would come into play in the decision-making process. In many cases, the need for quick results is bound with the search for minimal intervention and at the same time, the need for long-term safety. After all, what you need is treatment that is effective for your health conditions and in your current concerns or activities, with the least possible adverse effects and risks.⁵

Conclusion

There are several types of treatment available for alopecia areata; however, treatment always takes a multi-disciplinary approach, such as with medical therapies involving corticosteroids and immunosuppressants apart from JAK inhibitors. Other alternative therapies may involve PRP and light therapy in order to ensure optimum results. The patient’s emotional and mental wellbeing can be addressed with the help of solutions during the treatment period (since responses to therapeutic approaches may vary considerably among people). As there is no one-size-fits-all in handling alopecia areata, it usually requires trying many types of treatment until the optimal one is identified. Although not all treatments can be guaranteed to work with any particular person, ongoing research and new treatments, such as the JAK inhibitors, promise consistent and effective results in the near future.