Definitions for the levels of evidence (1++, 1+, 1-, 2++, 2+, 2-, 3, 4) and strength of recommendations (A-D) are presented at the end of the "Major Recommendations" field.
The diagnosis of alopecia areata is usually straightforward although the following may cause diagnostic difficulties:
- Trichotillomania: This condition probably causes most confusion and it is possible that it coexists with alopecia areata in some cases. The incomplete nature of the hair loss in trichotillomania and the fact that the broken hairs are firmly anchored in the scalp (i.e., they remain in the growing phase, anagen, unlike exclamation mark hairs) are distinguishing features.
- Tinea capitis: The scalp is inflamed in tinea capitis and there is often scaling but the signs may be subtle.
- Early scarring alopecia
- Telogen effluvium
- Anagen effluvium (drug-induced) may mimic diffuse alopecia areata
- Systemic lupus erythematosus
- Secondary syphilis
Dermoscopy can aid the diagnosis of alopecia areata. Regular round yellow dots are commonly seen in areas of hair loss and can indicate active disease progression. Dermoscopy also highlights common features seen in this condition such as dystrophic hairs with fractured tips (exclamation mark hairs) and hairs fractured before emergence from the scalp (cadaverized hairs). These findings are not present in triangular alopecia, trichotillomania or localized scarring conditions, which are sometimes considered within the differential of alopecia areata. Occasionally, alopecia areata presents as diffuse hair loss which can be difficult to diagnose. The clinical course often reveals the true diagnosis but a biopsy may be necessary in some cases.
Investigations are unnecessary in most cases of alopecia areata. When the diagnosis is in doubt appropriate tests may include fungal culture, skin biopsy, serology for lupus erythematosus, or serology for syphilis. The increased frequency of autoimmune disease in patients with alopecia areata is probably insufficient to justify routine screening.
One small case series suggested that iron deficiency is more common in women with alopecia areata than the population at large but this was not confirmed in two subsequent studies, and routine testing for iron status is not recommended. There are no published studies demonstrating a treatment response to iron replacement therapy.
An overriding consideration in the management of alopecia areata is that, although the disease may have a serious psychological effect, it has no direct impact on general health that justifies the use of hazardous treatments, particularly of unproven efficacy. In addition, many patients, although by no means all, experience spontaneous regrowth of hair. However, the psychological effects of alopecia may impact on general health and depends on the individual's coping strategy when dealing with an altered body image, which can result in higher levels of anxiety and a greater risk of depression leading to social, work-related and personal problems.
An explanation of alopecia areata, including discussion of the nature and course of the disease and the available treatments, is essential. Some patients are profoundly upset by their alopecia and may require psychological support. Many find it difficult to disclose their alopecia to family members and friends and struggle to find the answers to their medical and many practical questions. Contact with other patient experts and patient support groups can help individuals cope with the changing aspects of alopecia and provide support to find a new level of self-acceptance of their altered body image.
Alopecia areata in children can be particularly difficult. If a parent feels there is a significant change in a child's needs (withdrawn, low self-esteem, failing to achieve at school, change in behaviour), referral to a paediatric clinical psychologist, educational psychologist or social worker may be needed.
It is important to consider both the positive and negative aspects of active treatment in this chronic condition. Some patients do respond well to treatment. However, treatment can be uncomfortable for the patient, time-consuming and can be associated with undesirable side-effects. It may also alter the patient's attitude to their hair loss. Some patients find it difficult to cope with relapse following or during initially successful treatment and they should be forewarned of this possibility. These considerations are particularly important in children where the social disruption and focusing of the child's attention on their hair loss, which may result from active treatment, have to be carefully weighed against the potential benefits. On the other hand, some patients are appreciative that something has been tried, even if it does not work.
An individual's reaction to alopecia will vary depending on their own perceptions of body image, self-esteem, coping strategies, personality traits and their social support network. Commonly, people may feel self-conscious, conspicuous, angry, rejected, embarrassed or different and they may behave in a shy, cautious, aggressive, retreating, evasive or defensive (SCARED) manner. It is important to mention self- acceptance particularly in those with long-standing, extensive and persistent alopecia areata.
Summary of Treatment Recommendations
Alopecia areata is difficult to treat and few treatments have been assessed in randomized controlled trials. The tendency to spontaneous remission and the lack of adverse effects on general health are important considerations in management, and not treating is the best option in many cases. On the other hand, alopecia areata may cause considerable psychological and social disability and in some cases, particularly those seen in secondary care, it may be a chronic and persistent disease causing extensive or universal hair loss. In those cases where treatment is appropriate there is reasonable evidence to support the following:
Limited Patchy Hair Loss
- Potent topical steroid (Strength of Recommendation C)
- Intralesional corticosteroid (Strength of Recommendation C)
Treatment with potent topical corticosteroids probably advances regrowth of hair in some patients with mild to moderate disease but there are no data on long-term outcomes. Intralesional corticosteroids stimulate hair regrowth at the site of injection. The effect is temporary, lasting a few months, and it is unknown whether the long-term outcome is influenced.
Extensive Patchy Hair Loss
- Contact immunotherapy (Strength of Recommendation C)
- Wig/hairpiece (Strength of Recommendation D)
- Contact immunotherapy (Strength of Recommendation C).
- Wig (Strength of Recommendation D)
Contact immunotherapy is the best-documented treatment in severe alopecia areata but it is not widely available, involves multiple visits to hospital over several months and stimulates cosmetically worthwhile hair regrowth in <50% of patients. It is the only treatment likely to be effective in AT/AU, although the response rate is low. It may cause troublesome temporary local inflammation but serious side-effects are rare.
Dithranol (anthralin) and minoxidil lotion are widely prescribed by dermatologists for limited patchy alopecia areata, and are safe, but there is no convincing evidence that they are effective.
Continuous or pulsed systemic corticosteroids and psoralen plus ultraviolet A (PUVA) have also been used to treat alopecia areata. However, in view of the potentially serious side-effects and inadequate evidence of efficacy, none can be recommended at this time.
Children may be treated in a similar fashion to adults. However, intralesional steroids are often poorly tolerated and many clinicians are reluctant to use aggressive treatments such as contact immunotherapy in children.
Levels of Evidence
|Level of Evidence
||Type of Evidence
||High-quality meta-analyses, systematic reviews of randomized controlled trials (RCTs), or RCTs with a very low risk of bias
||Well-conducted meta-analyses, systematic reviews of RCTs, or RCTs with a low risk of bias
||Meta-analyses, systematic reviews of RCTs, or RCTs with a high risk of bias*
||High-quality systematic reviews of case–control or cohort studies
High-quality case–control or cohort studies with a very low risk of confounding, bias or chance and a high probability that the relationship is causal
||Well-conducted case–control or cohort studies with a low risk of confounding, bias or chance and a moderate probability that the relationship is causal
||Case–control or cohort studies with a high risk of confounding, bias or chance and a significant risk that the relationship is not causal*
||Nonanalytical studies (for example, case reports, case series)
||Expert opinion, formal consensus
*Studies with a level of evidence '-' should not be used as a basis for making a recommendation.
Strength of Recommendation
- At least one meta-analysis, systematic review, or randomized controlled trial (RCT) rated as 1++, and directly applicable to the target population or
- A systematic review of RCTs or a body of evidence consisting principally of studies rated as 1+, directly applicable to the target population, and demonstrating overall consistency of results or
- Evidence drawn from a National Institute for Health and Clinical Excellence (NICE) technology appraisal
- A body of evidence including studies rated as 2++, directly applicable to the target population, and demonstrating overall consistency of results, or
- Extrapolated evidence from studies rated as 1++ or 1+
- A body of evidence including studies rated as 2+, directly applicable to the target population and demonstrating overall consistency of results, or
- Extrapolated evidence from studies rated as 2++
- Evidence level 3 or 4, or
- Extrapolated evidence from studies rated as 2+ or
- Formal consensus
- A good practice point is a recommendation for best practice based on the experience of the guideline development group