Alopecia areata

Last Updated: 2021-10-15

Author(s): -

  • Celsus 30-60 A.D Chr.
  • Sauvages 1706

Pélade, Area Celsi.

Circular, often reversible, acute, 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)
  • Frequency peak: 15-30 years.
  • Alopecia areata localisata
  • Subform: Alopecia areata of the type of Ophiasis
  • Alopecia areata unguium (associated with atopic dermatitis)
  • Alopecia areata diffusa
  • Subform: Marie-Antoinette and Thomas More syndrome
  • Alopecia areata totalis
  • Alopecia areata universalis (maligna)
  • Genetic
    • Family history in approx. 25%
    • Association with the gene locus TRAF1/C5
    • Association with HLA markers: DR-4, DR-5, DR-6, DR-7, DR-11, DQ3, DQB-1
    • Atopy
    • Trisomy 21: Occurs in about 10% of people with trisomy 21
  • Autoimmunological influences
    • Autoimmune diseases
      • Autoimmune thyroid: 20% have elevated thyroid antibodies
      • Addison's disease
      • Vitiligo
      • Diabetes mellitus type I
  • Congenital 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)
  • On the capillitium, eyebrows, beard hair, axillary or genital almost foudroyant, centrifugally spreading, circular, hairless areas. The follicles remain visible. Carcass hairs (comedon-like "points noirs")
  • In a few cases the eyelashes can also fall out
  • Plucking test: if the AA is active, hairs from the border area can be plucked painlessly
  • Initially, grey and white hairs are spared. If a suddenly appearing Alopecia areata totalis occurs, only the white/grey hairs can survive. It comes to a "greying over night".
  • In an acute flare, there may be locoregional lymph node swelling
  • Special form: Ophiasis
    • Alopezia areata, which are localised on the hairy edges
  • Severe degrees of alopecia areata
    • Grade 1: < 30% of the capillitium
    • Grade 2: > 30% of the capillitium
    • Grade 3: Alopecia areata totalis
    • Grade 4: Alopecia areata universalis
  • Dermatoscopic: comma hairs, exclamation mark hairs
  • Alopecia areata and nails
    • In 10-50% of patients with alopecia areata
    • Koilonychia, trachyonychia, beau lines, onychorrhexis, onychomadesis and onycholysis
  • Medical history
  • Clinical features: Plucking test
  • Trichogram from the border area
  • Exclusion of an autoimmune thyroid disease.
    • fT3,fT4, TSH, thyroid gland antibodies (Anti-TPO-Ak = thyroperoxidase antibody, TAK or Tg-Ak = thyroglobulin antibody, TRAK =TSH receptor antibody.
  • Biopsy (in case of diagnostic uncertainty)

Thyroid disease?

Bee swarm lymphocytic, perifollicular, sometimes intrabulbar, arranged infiltrate with follicular infiltration (anagen phase). Late stage follicle reduction. Inverse anagen/telogen ratio.

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


Treatment of 1st choice by Lebwohl

Level of evidence

Intralesional steroids


Topical immunotherapy



Treatment of 2nd choice by Lebwohl 


Topical glucocorticoids




Retinoic acid


Topical Minoxidil







Treatment of 3rd choice by Lebwohl 


Systemic glucocorticoids




Minoxidil (per os)












Pulsed infrared diode laser


Excimer laser


Bexarotene (topical)


Azelaic acid (topical) 


Combination (Simvastatin/Ezetimibe)


Onion juice


Combination (Onion gel and topical Betamethasone)



  • Mometasone fluorate solution
  • Clobetasol foam / emulsion
  • Triamcinolone 10/40 mg Injection suspension


Diphenylcyclopropenone (DCP)

  • DCP causes a 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: Sensitization with 2.0% (to create a contact sensitization), then start 2 weeks later with the lowest dosage once a week. Increase the dose every week until a slight eczema develops.


  • Tacrolimus ointment (off-label-use) 0.03/0.1% 2x daily 2 weeks

  • Pimecrolimus cream (off-label-use) 1% 2x daily for 2 weeks
  • Minoxidil Topical solution 2/5

  • Imiquimod 3 times a week for 12 weeks.

Radiation therapy

  • UVA Therapy

Systemic therapy

  • Prednisolone p.o. 20-60 mg daily over 1-2 months gradually taper off
  • Dapson p.o. 1.5mg/kg bw daily, if necessary increase every 2 weeks by 25-50mg, up to max. 300mg daily.
  • No compounds are currently approved in Switzerland.
  • Before administration: exclusion of a glucose-6-phosphate dehydrogenase deficiency
  • Met-Hb: should be controlled 2 weeks and 6 weeks after the start of therapy.
  • Ciclosporin p.o. 3-5 mg/kg bw daily

  • Methotrexate s.c. 15 mg once a week

  • Folic acid p.o. 5 mg 1-0-0 the following day to reduce side effects.

  • Zinc p.o. 50 mg 2x daily

  • Biotin (vitamin B7) 1x daily for 2 months

  • Experimental: JAK inhibitors (Ruxolitinib/Tofacitinib)

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