Alopecia areata

Last Updated: 2022-01-21

Author(s): Anzengruber, Navarini

  • Celsus 30-60 AD
  • Sauvages 1706

Pélade, Area Celsi.

Circular, often reversible, acute-onset, non-scarring hair loss.

  • Lifetime incidence: approx. 1.7%
  • Prevalence: approx. 0.1-0.2% per year
  • Men = women (in some studies, women have a higher incidence)
  • Peak in incidence: 15-30 y.
  • Genetics
    • Familial clustering in about 25%
    • Association with the TRAF1/C5 gene locus
    • Association with HLA markers: DR-4, DR-5, DR-6, DR-7, DR-11, DQ3, DQB-1
    • Atopy
    • Trisome 21: Occurs in about 10% of all people with trisomy 21
  • Autoimmunological influences
    • Autoimmune diseases
      • Autoimmune thyroid: 20% have elevated thyroid antibodies
      • Morbus Addison
      • Vitiligo
      • Diabetes mellitus type I
  • Annatal immunodeficiency syndromes
    • APECED (Autoimmune Polyendocrinopathy-Candidiasis-Ectodermal Dystrophy)
    • CVID (Common Variable Immunodeficiency Syndrome)
    • IPEX (immunodysregulation polyendocrinopathy enteropathy X-linked syndrome)
    • DiGeorge syndrome
  • Psychological factors (depression or anxiety)
  • At the capillitium, eyebrows, whiskers, axillary or genital almost foudroyant, centrifugally spreading, circular, hairless areas. The follicles remain visible. Cadaver hairs (comedone-like "points noirs")
  • In a few cases, the eyelashes may also come out
  • Pulling test: if AA is active, hairs from the marginal area can be painlessly plucked out
  • Initially, grey and white hairs are spared. If sudden alopecia areata totalis occurs, only the white/grey hairs can survive. This results in "greying overnight"
  • In the acute episode, locoregional lymph node swelling may occur
  • Special form: ophiasis
    • Alopezia areata, which are localised at the hairy edges
  • Severe degrees of alopecia areata
    • Grade 1: < 30% of capillitium
    • Grade 2: > 30% of the capillitium
    • Grade 3: Alopezia areata totalis
    • Grade 4: Alopezia areata universalis
  • Dermatoscopically: comma hairs, exclamation mark hairs
  • Alopecia areata and nails
    • In 10-50% of patients with alopecia areata
    • Coilonychia, trachyonychia, beau lines, onychorrhexis, onychomadesis and onycholysis
  • Anamnesis
  • Dermoscopy: exclude scarring, look for yellow dots, look for cadaver hairs
  • Clinic: pluck test, nail involvement
  • Biopsy 4mm (instead of obsolete trichogram)
  • Ruling out autoimmune thyroid disease
    • TSH, tfT3,fT4, thyroid antibodies (anti-TPO-Ak = thyroperoxidase antibodies, TAK or Tg-Ak = thyroglobulin antibodies, TRAK =TSH receptor antibodies).
  • Atopia?
  • Thyroid disease?

Swarm-like lymphocytic, perifollicular, sometimes intrabulbar, arranged infiltrate with follicular infiltration (anagen phase). Follicle reduction in the late stage. Inverse anagen/telogen ratio.

  • Remission:
    • After 6 months: in 30%
    • After 12 months: in 50%
    • After 5 years: 75%

Dermocorticoids

  • Mometasone fuorate solution once daily
  • Clobetasol foam / emulsion once daily
  • Triamcinolone Kenacort A10/A40 mg injection suspension every 4 weeks with Dermojet, dilute 1:1, educate regarding atrophy risk

Diphenylcyclopropenone (DCP)

  • DCP causes contact allergy and thus locally activates the immune system.
  • Concentration 0.00001; 0.0001; 0.001; 0.01; 0.05; 0.1; 0.5; 1.0; 2.0%
    • Procedure: Sensitisation with 2.0% (to produce contact sensitisation) on an area of 5 x 5 cm under light protection, skin cleansing only after 3 days. No scratching, risk of eczema spreading.
    • Increase weekly if no eczema reaction: 0.002, 0.005, 0.01 etc. up to max. 2 %
    • Target: "Therapeutic eczema": mild erythema, pityriasiform scaling, intermitt. Pruritus (over 24 - 48 hrs)
    • Maintenance therapy: Half-sided (A.a. totalis) at the capillitium 1 x/week in determined concentration
    • Proof of efficacy: Half-sided application (min. 6 months) until hair growth (HW) (vellus- resp. in the course terminal hair) --> then bilateral application further.
    • In case of bilateral HW: Therapy stop (whs. spontaneous remission)
    • In case of total remission: wait for therapy stop and spontaneous progression, if necessary extend application interval to 2 - 4 weeks
  • Contraindicated in age < 10 years, pregnancy/breastfeeding

Systemic therapy

  • Tofacitinib 2 x 5mg daily, prior cost consultation
  • Methylprednisolone 500mg i.v. daily for 3 days as an inpatient, 3 cycles at monthly intervals
  • Prednisolone p.o. 20-60 mg daily for 1-2 months, slow tapering

 

 

 

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