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)

Atopy?
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

A

Topical immunotherapy

B

   

Treatment of 2nd choice by Lebwohl 

 

Topical glucocorticoids

B

Anthralin/Dithranol

B

Retinoic acid

B

Topical Minoxidil

B

Bimatoprost/Latanoprost

B

PUVA

B

   

Treatment of 3rd choice by Lebwohl 

 

Systemic glucocorticoids

B

Ciclosporin

C

Minoxidil (per os)

B

Sulfasalazine

B

Methotrexate

C

Azathioprine

C

Inosiplex

B

Cryotherapy

B

Pulsed infrared diode laser

C

Excimer laser

C

Bexarotene (topical)

C

Azelaic acid (topical) 

C

Combination (Simvastatin/Ezetimibe)

E

Onion juice

B

Combination (Onion gel and topical Betamethasone)

B

Dermocorticoids

  • 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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