Alopecia universalis is a condition in which individuals experience total hair loss on the scalp and body. It is a form of alopecia areata. This is an autoimmune disease characterized by patchy hair loss occurring anywhere on the body, but it most commonly affects the scalp. The term "alopecia" refers to hair loss or baldness, and "areata" indicates that the hair loss occurs in small, random areas.
There are various classifications of alopecia areata, primarily based on the extent of hair loss and the areas affected on the body:
- Alopecia Areata Totalis: This classification denotes the complete loss of hair on the scalp.
- Alopecia Areata Universalis: In this form, individuals experience total hair loss on the scalp and across the entire body.
- Diffuse Alopecia Areata: Rather than occurring in distinct patches, hair loss in diffuse alopecia areata is characterized by hair thinning.
- Ophiasis Alopecia Areata: Ophiasis alopecia areata is distinguished by hair loss in a band-like pattern along the lower back sides of the scalp, known as the occipitotemporal scalp.
These different classifications help describe the varying patterns and severity of hair loss experienced by individuals with alopecia areata.1
Symptoms & causes
Alopecia areata is characterized by various symptoms, with the primary and most common symptom being sudden patchy hair loss. The progression of symptoms in alopecia areata can include the following:
- Patchy Hair Loss: The initial symptom is often the sudden appearance of small, round, or oval patches of hair loss on the scalp. These patches can vary in size and number. In some cases, the patches may enlarge and merge over time.
- Extensive Hair Loss: In certain individuals, hair loss can progress rapidly, leading to the loss of all scalp hair without developing distinct patches.
- Additional Symptoms: Many individuals with alopecia areata do not experience pain or other physical symptoms. However, some may report sensations such as tingling, itching, burning, or pain in the affected skin areas. These sensations are typically localized to the areas where hair loss occurs.
The exact cause of alopecia areata remains unclear, but it is known to affect both men and women of all ages. It often begins in childhood, with approximately 50% of cases originating in this phase of life. Alopecia areata has a prevalence of about 1 in 1000 people, regardless of ethnicity.
Several factors are associated with alopecia areata, including:
- Genetic Predisposition: A family history of alopecia areata and other autoimmune conditions is present in 10–25% of patients.
- Autoimmune and Atopic Conditions: Individuals with alopecia areata are more likely to have other autoimmune diseases (such as thyroid disorders or vitiligo) and atopic conditions (such as eczema, asthma, hay fever, and atopic dermatitis).
- Chromosomal Disorders: Alopecia areata is more common in individuals with chromosomal disorders, such as Down syndrome.
- Polygenic Condition: The condition is considered polygenic, meaning that multiple specific genes from both parents must be inherited for a child to go on to develop alopecia areata.
The precise triggers initiating the autoimmune response in which the immune system attacks healthy hair follicles are not fully understood. It remains unclear whether these triggers originate from inside the body, such as infections, or from external factors in the environment. Current research suggests that it may involve a combination of both internal and external factors.2
Diagnosis & tests
Alopecia areata is typically diagnosed through a physical examination conducted by a healthcare provider. During this examination, your provider will inquire about your medical history, including when you first noticed hair loss and whether you have a family history of alopecia areata or autoimmune disorders. They may also inspect your nails, as certain nail changes can be associated with alopecia areata.
In some cases where the diagnosis is not clear from a physical examination, your healthcare provider may perform additional tests, which could include:
- Scalp Examination for Signs of Infection: Your provider may check your scalp for any signs of infection that could be contributing to hair loss.
- Hair Sample Analysis: A sample of your hair may be taken and sent to a laboratory for analysis. This can help confirm the diagnosis.
- Scalp Biopsy: A scalp biopsy may be performed to examine the skin for any underlying skin diseases that could be causing hair loss.
- Blood Tests: Blood tests may be conducted to rule out other medical conditions or autoimmune disorders that can be associated with hair loss.
These additional tests are typically conducted when the diagnosis is not straightforward or when there is uncertainty about the cause of hair loss. The specific tests performed may vary depending on the individual case and the healthcare provider's judgment.1
Management & treatment
Alopecia areata can sometimes resolve on its own without the need for treatment, especially in cases of mild and early hair loss. However, for those seeking treatment, it is important to note that while some treatments can stimulate hair regrowth, none can alter the overall course of the disease. Moreover, it is essential to avoid treatments with serious risks or side effects, as alopecia areata itself does not have any adverse effects on physical health.
Several treatments are available for alopecia areata, and their effectiveness may vary from person to person. Here are some of the common treatments:
- Corticosteroid Creams and Scalp Applications: These are applied directly to the bald patches, usually twice a day for a limited time.
- Local Steroid Injections: This method is highly effective for small patches of hair loss on the scalp and brows. Injections can be repeated every four to six weeks until regrowth is achieved.
- Corticosteroid Tablets: In some cases, large doses of steroid tablets may result in hair regrowth. However, once treatment is discontinued, alopecia often recurs. Long-term use of oral steroids can lead to various side effects, including elevated blood pressure, diabetes, stomach ulcers, cataracts, osteoporosis, and weight gain.
- Dithranol Cream: Typically used to treat psoriasis, this cream may stimulate hair regrowth when applied to bald areas. It is considered safe but can stain the skin and hair with a purple-brown colour.
- Contact Sensitization Treatment: This involves making the patient allergic to a substance (usually diphencyprone) and applying weak strengths of the chemical to the bald patches. It may cause mild inflammation but can have side effects such as itching, blistering, and enlarged neck glands.
- Ultraviolet Light Treatment (PUVA): PUVA involves making the skin sensitive to light by taking a tablet or applying cream and then exposing the bald patches to ultraviolet light two or three times a week for several months. Relapse is common after treatment.
- Minoxidil Lotion: Available over the counter, minoxidil lotion may help some people, although the regrown hair is often fine.
- Immunosuppressant Tablets: These include medications like sulfasalazine, methotrexate, ciclosporin, and azathioprine. They suppress the immune system and are occasionally used for severe alopecia areata that have not responded to other treatments. Their effectiveness is limited, and they can have serious side effects.
- Prostaglandin Analogs: Eye drops like Latanoprost and Bimatoprost may promote hair growth on eyelids, but further studies are needed to confirm their effects on scalp alopecia (a reference would be useful here).
- Tofacitinib, Ruxolitinib, and Baricitinib: These are potentially new immunosuppressive tablets for alopecia areata. Further studies are needed to confirm their effectiveness for the condition.
Individuals with alopecia areata need to consult with a healthcare provider to discuss treatment options and determine the most suitable approach for their specific case.3
Can hair grow back from alopecia?
Alopecia areata is indeed unpredictable, and the course of the condition can vary widely among individuals. Some people experience cycles of hair loss and regrowth, with hair falling out and then growing back, while others may have hair regrow and never experience further hair loss. Each case of alopecia areata is unique, and its progression can be difficult to predict.
The response to therapy also varies from person to person. Depending on the treatment used and its effectiveness, some individuals may start to see new hair growth between four and 12 weeks after initiating treatment. It's important to keep in mind that while treatments can help stimulate hair regrowth in some cases, there is no guarantee of a permanent cure for alopecia areata.
For those living with alopecia areata, it is essential to work closely with a healthcare provider to develop an individualized treatment plan and to monitor the condition's progression over time.1
How can I prevent alopecia areata?
Currently, there is no known way to prevent the onset of alopecia areata. The condition's causes and triggers are not fully understood, making it challenging to prevent its development.
However, as mentioned, there are treatments available that can help reduce the symptoms of alopecia areata and promote hair regrowth in some cases. These treatments should be discussed with a healthcare provider, who can provide guidance on the most appropriate options based on an individual's specific situation.
It's important to note that alopecia areata can be a recurrent condition, meaning it may come and go throughout a person's life. This emphasizes the importance of ongoing monitoring and management, especially if symptoms reoccur or worsen.1
Is alopecia areata hereditary?
Alopecia areata does have a genetic component, and there is a genetic predisposition to the condition. While it can occur in individuals without a family history of the condition, approximately 20% of people with alopecia areata do have a family history of the condition, indicating that it can be passed down through generations.
The genetic predisposition suggests that certain genes may increase an individual's susceptibility to developing alopecia areata. However, the exact genetic factors and mechanisms involved in the development of the condition are still an active area of research, and more studies are needed to fully understand the genetic underpinnings of alopecia areata.3
Living with alopecia areata can present various challenges, but there are strategies and options to help manage the condition. It's essential to work closely with a healthcare provider or dermatologist who can provide guidance on treatment options and help tailor a plan that best suits your individual needs and preferences. Additionally, staying informed about the latest developments in alopecia areata research and treatment options can be beneficial in managing the condition.3
- Cleveland Clinic. Alopecia Areata: Causes, Symptoms & Management [Internet]. Cleveland Clinic. 2023. Available from: https://my.clevelandclinic.org/health/diseases/12423-alopecia-areata
- Alopecia UK. Alopecia Areata [Internet]. Alopecia UK. Available from: https://www.alopecia.org.uk/alopecia-areata
- British Association of Dermatologists. British Association of Dermatologists [Internet]. www.bad.org.uk. 2020. Available from: https://www.bad.org.uk/pils/alopecia-areata/