What is Alopecia?

According to a 2021 study of the epidemiology of alopecia areata in the UK, approximately 1 in every 4,000 people will develop alopecia areata each year. In a city the size of Sheffield, this would equate to approximately 150 people every year. The study also showed that, at the end of 2018, 1 in every 170 people in the study’s population had active alopecia areata or had had it in the past.

With such prevalence of the condition, it is important that we understand more about what alopecia is, what the signs and symptoms are, the causes of it and possible treatments.

What is alopecia?

Many people have heard of alopecia, but they might not be too familiar with the different kinds of alopecia. Alopecia is the loss of hair from the scalp or any other part of the body. Some types of alopecia are temporary and the hair may grow back, whereas others are permanent.

Alopecia usually refers to hair loss from the scalp that is sudden. It can start patchy before affecting the whole of the scalp as well as eyebrows, facial hair and body hair. The patchy loss of hair is unpredictable. Some patches may regrow; others may not. The patches that regrow may also then fall out again.

There are different types of alopecia:

• Alopecia Areata is characterised by the sudden loss of hair in localised patches on the scalp, beard, eyebrows and eyelashes.
• Alopecia Totalis is characterised by the complete loss of scalp hair.
• Alopecia Universalis is characterised by the complete loss of hair from the scalp and the rest of the body.
• Androgenic Alopecia is pattern hair loss, which is different in males and females. For men, the hair falls out in well-defined typical baldness patterns. For women, the hair normally thins out over the whole head.
• Central Centrifugal Cicatricial Alopecia is commonly called scarring alopecia. This is a type of alopecia that results in hair follicles being replaced by scar tissue and therefore causes permanent hair loss. Central centrifugal cicatricial alopecia starts in the centre of the scalp and spreads outwards over time.
• Chemotherapy-induced Alopecia (Anagen Effluvium) is a reversible type of alopecia that is caused by the drugs used to treat cancer. For those suffering from the disease, it is often one of the most distressing side effects.
• Frontal Fibrosing Alopecia (scarring alopecia) is another type of scarring alopecia that affects the front of the scalp and sometimes the eyebrows.
• Lichen Planopilaris (scarring alopecia) is a type of primary scarring alopecia that destroys hair follicles and causes permanent hair loss. It appears in patches, more commonly on the side, back, lower and front of the scalp.
• Telogen Effluvium causes more hair than is typical to move into the resting (telogen) phase of the hair cycle and shed. This means that sufferers will notice more hair falling out than usual. This type of hair loss is usually temporary and is caused by a psychological or physical trigger. As a result, it often resolves itself later.
• Traction Alopecia is a type of alopecia that is caused by a repeated pulling action of the hair. This happens in cases where people wear the same tight hairstyles all the time or can be caused by extensions and relaxers.
• Trichotillomania, whilst not a type of alopecia per se, it still affects sufferers similarly to those suffering from other types of alopecia. With trichotillomania, sufferers pull out their own hair compulsively. It is a psychological condition but the repeated pulling out of hair leads to hair loss. Sufferers tend to pull hair from the eyebrows, eyelashes and scalp.

What is alopecia areata?

Alopecia areata is the patchy loss of hair on the scalp. It first appears with a single smooth patch of the scalp, usually no bigger than a coin, before more patches are noticed. It can start on other parts of the body too such as the eyebrows, beard, eyelashes, and pubic hair.

Alopecia areata affects both women and men irrespective of age. In around half of cases, it begins in childhood. Ethnicity also does not appear to play a role in its prevalence.

Alopecia areata is an auto-immune condition. This means that the body’s immune system works against itself and attacks otherwise healthy cells. According to Alopecia UK, in alopecia areata, T cells known as NKG2D+ T cells collect around hair follicles and attack them, stopping the follicles from producing more hair.

Alopecia areata can develop into other more widespread forms of alopecia. The patchy nature of alopecia areata can turn into alopecia totalis, where all the hair from the whole scalp falls out, or alopecia universalis, where all the hair across the whole body falls out. For many people, however, alopecia areata continues and does not develop into other forms of alopecia. This is often called “chronic alopecia areata” or “persistent patchy alopecia areata”.

What is androgenic alopecia?

Androgenic alopecia is more commonly known as ‘male pattern hair loss’ or ‘female pattern hair loss’. This type of alopecia is different to alopecia areata in that it is quite common, especially for males. It affects around 50% of men over 50 and 50% of women over the age of 65.

For males, the hair loss pattern often begins with thinning at the crown and front of the head, often seen in an ‘M’ pattern. For women, there is often thinning generally all over with increased thinning at the crown.

The causes of this condition are not fully understood but are considered to be both genetic and hormonal, particularly related to a hormone called dihydrotestosterone (DHT). This leads to a shorter cycle of hair growth.

Androgenic alopecia is a permanent condition and cannot be reversed. There are treatment options which can delay further development of the condition, but hairs that have been lost permanently will not regrow.

What are the signs and symptoms of alopecia?

For most people, the first sign of alopecia is a suddenly appearing patch of hair loss on the scalp. Other patches may develop and, eventually, patches can join up to make larger ones. However, for some people, alopecia develops suddenly and all hair on the scalp can fall out simultaneously with no smaller patches appearing first.

In the case of androgenic alopecia, men begin to experience typical male-pattern baldness. This can happen as young as in their 20s but is often more apparent in the late 30s upwards. For many men, the hairline starts to recede at the forehead. For women with androgenic alopecia, the signs are thinning hair in older women who have gone through menopause.

For most people, hair loss is the only symptom. There are mostly no other ‘warning signs’. However, occasionally, some people experience burning, itching, tingling or pain in the skin as well as headaches. Other people also often notice that their nails are affected, with between 10-15% of people having ridges or splits in their nails.

What causes alopecia?

Alopecia areata is an auto-immune condition. As mentioned above, a type of immune T cell in the body attacks hair follicles, meaning they no longer produce hair. However, researchers do not really know why the immune system in alopecia sufferers suddenly decides to attack healthy hair follicles. It is thought that there must be some form of ‘trigger’ for the condition, be it an infection within the body, environmental factors, or perhaps a combination.

Having said that, some people have a clear genetic disposition to develop alopecia areata. It can run in families but not necessarily with direct links. A person with alopecia could find that their grandparent or aunt has the condition, but their parents do not.

Identical twins have been known to develop alopecia areata, which clearly shows that there is some genetic link to the condition. These cases have also shown similar hair loss patterns. Research into these cases has included genome-wide association studies (GWAS). This research has investigated what gene sequences are present in those with the condition. So far, they have identified 15 different sequences of genes that may influence alopecia areata. The studies show that the more of these sequences of genetic information a person has, the more likely they are to develop alopecia areata at some point in their life.

Researchers mostly agree that a trigger is needed for alopecia to begin. The environmental factors are thought to play a bigger role in determining whether someone develops alopecia, even if they have the gene sequences mentioned. For some people, a single trigger may be enough to induce alopecia whereas others may need to encounter several triggers in their environment for it to result in the condition.

For some sufferers of alopecia, stress has proven a very clear link to the onset of their condition. Some people can pinpoint a moment in their life such as a stressful event that happened a few weeks or months before they first noticed hair loss. For others, a period of chronic stress over months or years can seem to be their ‘trigger’.

Cortisol, commonly known as the ‘stress hormone’, can have a huge impact on the immune system. It prepares us for ‘fight or flight’ but too much of it is definitely not a good thing for our bodies. It is not understood how it affects the onset of alopecia, but there is a clear link between the two. However, despite this, some people may not be able to identify a clear trigger and stress may not have played a part in the onset of their alopecia.

What are the risk factors of alopecia?

Alopecia areata happens to many people for many (often unclear) reasons. It does not really discriminate by age or ethnicity, so pinpointing risk factors can be tricky. That said, there is a genetic predisposition to developing alopecia and some lifestyle factors are thought to potentially be a trigger for the disease.

Some potential risk factors include:

• A family history of alopecia or baldness, either close relatives or within the extended family.
• Having other autoimmune conditions such as diabetes Type 1 or lupus.
• Some medications.
• Pregnancy in women.
• Poor diet and nutrition.

The statistics also show that alopecia areata is more common in people who have chromosomal disorders including Down syndrome.

As mentioned, stress is a significant precursor to the onset of alopecia in some people. However, it’s not really clear how stress causes alopecia directly.

Because alopecia is an auto-immune condition, people who have alopecia areata are also more likely to develop other auto-immune conditions such as vitiligo or thyroid disease. They are also more like to have other atopic medical conditions such as hay fever, asthma, atopic dermatitis and eczema.

The risk factors for androgenic alopecia are different. A family history of baldness, advancing age, prostate cancer in males, and polycystic ovary syndrome in women are all risk factors for this kind of alopecia. This is because it is driven by hormonal factors. For women, exposure to UV radiation, smoking and stress have been associated with female pattern hair loss development.

Can alopecia be prevented?

Given that alopecia is impossible to predict, it’s also impossible to say that it has been prevented! However, there are certain things that everyone can do to lead a healthy lifestyle which may contribute towards preventing many illnesses and conditions including alopecia:

• Having a healthy diet. Including a wide variety of fruits and vegetables in your diet helps to prevent the onset of many medical conditions. Some research has shown that a diet high in herbs and raw vegetables can help delay androgenic alopecia in men.
• Eating more protein. Research has identified a link between losing hair and a lack of certain amino acids that we get from protein, specifically keratin.
• Taking vitamins and other supplements. Vitamin D and iron are both important for having fuller, healthier hair. However, some research does imply that too much vitamin A may contribute to losing hair.
• Styling hair gently and avoiding tight hairstyles such as ponytails.
• Reducing stress and practising techniques to manage stress.

How is alopecia diagnosed?

Alopecia is diagnosed by a doctor. Doctors perform blood tests to see if there are any underlying conditions that may be contributing to hair loss such as iron or vitamin D deficiencies.

Sometimes, tests are carried out on samples of the hair and scalp to identify the condition. This may include a ‘pull test’ where the doctor gently pulls a selection of hairs to see how many come out. This is used to determine at what stage of the shedding process the hair is at.

A scalp biopsy is also sometimes performed where the doctor will scrape samples from the skin as well as taking a few hairs. They will then examine the samples under a microscope. Light microscopy might also be used to see if the hairs have any possible disorder on the hair shaft.

How is alopecia treated?

Whether or not alopecia can be treated will depend on its cause. If the hair loss is caused by an underlying condition or medication, a doctor may advise someone to stop taking their medication for a period of time if it is safe to do so.

For alopecia areata, there are some possible treatment options including clinical drug trials:

Topical corticosteroids

These are in the form of ointments, creams and lotions that are applied to the surface of the skin or scalp. These products work to calm inflammation in the skin. However, usually, a strong topical corticosteroid is needed for alopecia areata. They are painless to apply which is why they are often prescribed for children. However, they are not always well absorbed through the scalp and their effectiveness is not always that good. Also, long-term use results in thinning of the skin which makes it appear redder.

Intralesional corticosteroids

These are steroid treatments that are injected under the skin of affected areas. These have proven to be more effective than creams, inducing hair growth in some cases within four to six weeks. However, the injection can cause a small dent in the area, and it can also be painful if the area needing treatment is large. As a result, injections are usually only a line of treatment if the area is small, or the alopecia is in localised patches.

Systemic corticosteroids

This is a form of steroid medication that is taken as a pill such as prednisolone. This can be used to kick-start the immune system which causes hair to regrow. However, long-term use can cause unpleasant side effects and is best avoided. Typical short-term side effects include an increased risk of infection, heartburn, weight gain and mood disturbance. Long-term side effects can include high blood pressure, bone thinning and diabetes. Additionally, once the treatment has stopped, there is a very high risk that hair loss will return.

Immunosuppressants

Ciclosporin and methotrexate are both immunosuppressant oral medications. Both are commonly used to treat inflammatory skin conditions such as eczema and psoriasis. Ciclosporin is in tablet form and is taken once a day whereas methotrexate is taken weekly and can be taken for longer than ciclosporin. Both of these drugs require blood test monitoring because they affect organs such as the kidneys (ciclosporin) and liver and blood cells (methotrexate). With methotrexate, people of childbearing age should prevent pregnancy whilst taking it and for six months after as it can have severe effects.

Contact immunotherapy

This type of treatment works by causing a local allergic reaction on the skin that stimulates the hair follicles to regrow by essentially distracting them from their attack on hair follicles.

Initially, a small amount of the treatment is applied in a high concentration to a certain area. This is called ‘sensitisation’ and it essentially makes the person allergic to it.

Next, a few weeks later, a weaker version is applied to the scalp for around 24 hours before being washed off. This causes a low-level allergic reaction, causing the scalp to feel red, itchy and flaky.

Research has shown that it causes a worthwhile response in around half of all patients with alopecia areata. However, it takes around a year to gain the full effect and is not so successful with alopecia totalis or alopecia universalis.

For androgenic alopecia. There are some possible treatment options which include:

• Minoxidil (Rogaine) – This is available over the counter as a foam or liquid that is applied once or twice each day. Hair regrowth can take up to six months to appear.
• Finasteride (Propecia) – This medication is available on private prescription from hair loss clinics or after having a private medical consultation. It works by reducing the hormone DHT (dihydrotestosterone). This is the hormone that is responsible for causing pattern baldness. It can even reverse the condition. It is taken as a tablet.
• Hair transplant surgery – Hair transplants are only available privately in the UK and, according to the NHS, can cost between £1,000 and £30,000 depending on how severe the hair loss is. However, the Wimpole Clinic has produced a detailed UK Clinic Cost Analysis Report and its findings showed that the lowest cost hair transplant in the UK was £1,995 and the most expensive was £15,000. They reported an average cost of £4,820 for the procedure.