Alopecia Areata

Aka: Alopecia Areata, Alopecia Totalis, Alopecia Universalis, Exclamation Point Hair

1. Definition
   1. Non-scarring autoimmune Alopecia
2. Epidemiology
   1. No gender predominance
   2. Most common under age 30
   3. Prevalence: 0.1 - 0.2% of U.S. population
3. Types
   1. Alopecia Areata: Patches of Hair Loss
   2. Alopecia Totalis: Hair Loss over entire scalp
   3. Alopecia Universalis: Hair Loss over entire body
4. Signs
   1. Well-demarcated oval patches of Hair Loss
   2. Exclamation Point Hairs at edges of Hair Loss (2-3 mm broken hairs)
      1. Club shaped Hair Root
      2. Thin proximal Hair Shaft
      3. Normal caliber distal Hair Shaft
5. Labs (Consider)
   1. KOH Scraping of patch
   2. Thyroid Stimulating Hormone (TSH)
   3. Rapid Plasma Reagin (RPR)
   4. Erythrocyte Sedimentation Rate (ESR)
   5. Complete Blood Count (CBC)
   6. Antinuclear Antibody (ANA)
   7. Rheumatoid Factor (RF)
6. Differential Diagnosis
   1. Other non-scarring Alopecia
   2. Tinea Capitis
7. Associated Conditions
   1. Atopic Dermatitis
   2. Diabetes Mellitus
   3. Rheumatoid Arthritis
   4. Vitiligo
   5. Thyroid disease
   6. Pernicious Anemia
   7. Discoid Lupus Erythematosus
8. Management: Moderate Involvement (<50% of scalp involved)
   1. Intralesional Kenalog
      1. Treatment of choice
      2. Dilute kenalog 40 mg/ml with saline to 10 mg/ml
         1. Kenalog 40 mg/ml: 0.5 ml
         2. Saline: 2 ml
      3. Inject 0.1 ml into patch at 1 cm intervals
      4. Inject into mid-Dermis via 0.5 inch needle
      5. Adverse effects: Atrophy
         1. Avoid injecting too superficially
         2. Avoid injecting >0.1 ml or >10 mg/ml per site
         3. Limit injections to no more often than q4-6 weeks
         4. Discontinue if no improvement at 6 months
   2. Adjuncts to intralesional injection
      1. Apply Minoxidil 5% solution twice daily or
      2. Mid-potency Topical Corticosteroid (eg. Kenalog 0.1%)
         1. Apply 1 ml to entire scalp twice daily
9. Management: Severe Involvement (>50% of scalp involved)
   1. General: Combination therapy often used
      1. Contact sensitizers with intralesional kenalog
         1. Most effective option
         2. Usually requires referral to dermatology
      2. Minoxidil 5% bid with Topical Steroids or Anthralin
   2. Topical Anthralin Cream (Psoriatec) 0.5 to 1% cream
      1. Course usually limited to 6 months
      2. Apply daily and leave on for 5 minutes to start
         1. Gradually increase time applied up to 60 minutes
      3. Rinse scalp well and then clean with soap
      4. New Hair Growth seen within 3 months
   3. Mid-potency Topical Corticosteroid (eg. Kenalog 0.1%)
      1. Apply 1 ml to entire scalp twice daily
   4. Topical Minoxidil 5%
      1. Use as adjunct to Anthralin or Corticosteroid
   5. Prednisone (less commonly used)
      1. Start: 40 mg PO qd for 7 days
      2. Taper: Decrease by 5 mg q3 days
      3. Course completed within 6 weeks
   6. Dermatology consultation for contact sensitizer
      1. Dinitrochlorobenzene
      2. Diphenylcyclopropenone
      3. Squaric acid dibutyl ester
10. Course
    1. Spontaneously resolves in 6-12 months in most cases
       1. Hair pigmentation may be different in regrowth area
       2. Some cases progress (see prognostic indicators below)
    2. Recurs in 30% of cases (often affects same area)
11. Prognosis: Indicators of poor prognosis
    1. Course duration longer than one year
    2. Onset of Alopecia prior to Puberty
    3. Family History of Alopecia Areata
    4. Atopic Patients
    5. Down Syndrome
12. References
    1. Bertolino (2000) Postgrad Med 107(7): 81-90
    2. Madani (2000) J Am Acad Dermatol 42: 549-66
    3. Springer (2003) Am Fam Physician 68(1):93-102
    4. Thiedke (2003) Am Fam Physician 67(5):1007-18