Alopecia Areata
In medical terms, alopecia means hair loss. In alopecia areata, hair falls out suddenly, leaving round hairless patches.
What causes alopecia areata?
Alopecia areata is an autoimmune disease. In autoimmune diseases, for an unknown reason, the immune system sees the body's own cells as foreign and starts to fight them. In this case, cells called lymphocytes around the hair roots release chemicals called cytokines, and this causes the hair to fall out.
Is alopecia areata hereditary (genetic)?
There is a genetic predisposition to the disease, and close family members may be affected. Thyroid problems or diabetes are also quite common.
Is alopecia areata contagious?
Alopecia areata is not contagious. It never spreads from person to person, nor from one area of a person's body to another. Although alopecia areata may look different from ordinary hair loss or resemble hair loss due to a fungal infection, alopecia areata is definitely not contagious.
What are the symptoms of alopecia areata?
An early sign of alopecia areata can sometimes be a tingling sensation on the scalp.
What does alopecia areata look like?
The disease typically begins as one or more bald areas on the scalp in the form of smooth patches, with no inflammation or scaling. Pigmented hairs tend to be affected, so in older people a few white hairs may remain within the bald area. Sometimes the patches are well defined; more rarely the hair loss may be widespread. Short, tapering hairs are known as the characteristic "exclamation mark" hairs of alopecia areata and can be seen at the edge of the bald patch. Regrowth usually begins with fine white hair in the middle of the bald area; over time the hair thickens, darkens and regains its colour. Some patients may develop small pits in their nails.
Does alopecia areata get better?
If the hair loss is patchy, the course is more favourable, and the hair may grow back completely within 1 year without treatment (about 60–80%). However, attacks of hair loss may recur in the future. If there is very extensive hair loss at the outset, recovery is not as good. The course of the disease is also less favourable in patients with Down's syndrome or severe eczema.
Treatment approaches in alopecia areata
A- CURRENT TREATMENTS AND INNOVATIONS;
1- Corticosteroids;
a) Intralesional
b) Topical
c) Systemic
2- Minoxidil
3- Anthralin (Dithranol)
4- Immunomodulators;
a) Dinitrochlorobenzene (DNCB)
b) Squaric acid dibutyl ester (SADBE)
c) Diphenylcyclopropenone (DPCP)
5- Photochemotherapy (PUVA)
a ) Local
b) Systemic
c) Combination treatments
6- Other treatments;
a) Ciclosporin
b) Sulfasalazine
c) Interferon
d) Tacrolimus
e) Nickel and isoprinosine
f) Dapsone
g) Imiquimod
h) Thalidomide
i) Aromatherapy
j) Cryotherapy
k) Acupuncture
l) Thymectomy
m) Selective serotonin reuptake inhibitors (SSRIs)
7- Non-pharmacological methods (cosmetic approaches)
a) Dermography (scalp micropigmentation)
b) Local hair accessories (hairpieces)
8- Psychiatric treatment approaches
9- Patient education
B- NEW RESEARCH ON HAIR GROWTH;
1) Hair follicle culture systems
2) Scalp implantation
C- GENE THERAPY STUDIES
How is alopecia areata treated?
Patients with mild, early-stage disease do not need treatment; their hair grows back without anything being done. Although they cannot change the course of the disease, some treatments can increase hair growth. Since the disease itself does not harm physical health, treatments that carry serious risks should be avoided.
Treatments used for alopecia areata include:
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Steroid creams and scalp applications: These are applied to the bald areas, usually twice a day, for a limited period.
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Local steroid injections: These are given in the scalp and eyebrows and are the most effective treatment approach for hair loss in small patches. The injections can be repeated every few months. A small depression may develop at the edge of the injected area, but this usually recovers after a few months. Care should be taken around the eyes; when the eyebrows are injected, glaucoma (increased pressure within the eyeball) may develop as the number of injections increases.
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Steroid tablets: High doses of steroid tablets can make the hair grow back, but the alopecia often returns when treatment is stopped. When oral steroids are taken beyond a certain period, they can cause serious side effects including weight gain, raised blood pressure, diabetes, stomach ulcers, cataracts and osteoporosis.
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Dithranol cream: This cream, used to treat another skin disease called psoriasis, irritates the skin and sometimes stimulates hair growth when applied to bald areas. The cream is safe to use, but it stains the skin and hair purple-brown, especially in blond and fair-skinned people.
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Contact sensitiser treatment: This involves deliberately making the patient allergic to a chemical (usually a chemical called diphencyprone), and then applying a very low concentration of this chemical to the bald area; application once a week is usually enough to maintain mild inflammation. Itching, blistering and enlarged lymph nodes in the neck are possible troublesome side effects. Lightening of the skin colour (depigmentation) may occur, so dark-skinned people are warned before this substance is used. This treatment is only given in specialist centres.
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Ultraviolet light treatment: Here the skin is made sensitive to light with a tablet taken or a cream applied, and the bald areas are then exposed to ultraviolet light two or three times a week for several months. The alopecia is likely to return when treatment stops. There may also be a long-term risk of skin cancer with this treatment.
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Minoxidil lotion: Application to the bald areas is cosmetically beneficial for hair growth and may help some patients.
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Antidepressant treatment: The disease can cause psychosomatic problems, or psychosomatic problems can predispose to the disease. Antidepressant treatment may therefore be helpful.
Hair Shaft Abnormalities
Abnormalities and hair loss due to hair shaft defects become apparent at birth or in the first months after birth. They can be diagnosed by microscopic examination of the hair. Hair shaft defects cause hair loss by making the hair break. They may be congenital and occur on their own, or occur together with other systemic diseases. Hair shaft defects can also be acquired, i.e. develop later in life. They are often confined to the hair only. Hair shaft abnormalities are divided into 2 groups.
- Hair shaft abnormalities that cause hair loss through breakage
- Trichorrhexis Nodosa Congenita;
This is the most commonly observed hair shaft defect. One or two nodal, knot-like structures are seen on the hair shaft, and the hair breaks at these points. On microscopic examination it looks as if two brushes have been pushed into each other. Clinically the hair is short and breaks easily. White dots visible even to the naked eye on the hair indicate the nodules. In these patients the hair is initially of normal thickness and length; after 1 year the hair breaks and snaps quickly. It rarely occurs on its own, and it is important because it is often associated with another disease, such as Netherton syndrome, Tay syndrome, Bazex-Dupré-Christol syndrome, Menkes disease, biotin and zinc deficiency, and argininosuccinic aciduria.
- Monilethrix
It is most often seen in the occipital area, but sometimes causes alopecia over the whole scalp. At birth there is vellus hair on the scalp, but within a short time this is replaced by dry, broken, fragile hair. Alopecic areas 0.5–2.5 cm in diameter appear, containing small bumps corresponding to the hair follicles. Apart from the scalp, it can also affect the eyebrows, eyelashes and body hair. Microscopically, the hair shows intermittent elliptical nodal swellings with narrowings in between. These narrowings have no medulla, and the hair breaks at these narrow points. Clinically the hair is dull and fragile. Papules resembling keratosis pilaris are seen in the affected area. Because it does not affect vellus hair, the hair is normal at birth and the condition shows itself later as terminal hair appears on the scalp.
- Pseudomonilethrix
Microscopically the appearance is similar to monilethrix, but the nodules and the narrowings between them are more irregular.
- Pili torti
The hair shaft is twisted 180 degrees around its own long axis. As a result there is considerable breakage and loss of hair. It can occur in Menkes disease (a congenital disorder of copper metabolism), with pili torti and neurological signs. It can occur on its own without any other disease, or together with other problems such as zinc deficiency and ectodermal dysplasias. The congenital form is seen in females, especially blondes.
- Trichorrhexis invaginata – bamboo hair;
There are many swelling-like knots along the hair, and the hair breaks at these points. Clinically the hair is dry, coarse, brittle and short, and breaks immediately with friction. It may improve with age. On microscopic examination, segments like those on a bamboo stem are seen, and the hair breaks at these points, causing hair loss. It may occur together with Netherton disease. (Netherton disease is inherited, is seen most often in females, and features ichthyosis, trichorrhexis invaginata and atopy.)
- Trichodystrophia
This results from a reduction in the cysteine and sulphur that make up the keratin of the hair. Because of the lack of sulphur that binds the keratin together, the hair is short and brittle. The hair shaft appears banded, like a tiger's skin. The hair is short and breaks quickly. The eyebrows and eyelashes may be affected. These people also have learning disability, delayed physical development, nail and tooth development disorders, cataracts, premature ageing and light sensitivity.
- Pili bifurcati
The hair shaft splits into 2 along its long axis. Each part contains its own cuticle.
2. Hair shaft abnormalities that do not cause breakage, i.e. hair loss;
- Diffuse partial woolly hair
Clinically, 2 groups of hair of different lengths are seen.
- Pili annulati
There are light and dark bands along the hair shaft. This hair abnormality is seen more often in people with bright blond hair. The cortex is most often affected. It can rarely appear in the armpits and groin.
- Woolly hair
Literally, this means wool-like hair. Clinically the hair looks curly, like Afro-textured hair, and cannot be combed.
Apart from the genetic and familial forms, in the naevoid form there is woolly hair in only one patch of the scalp.
Acquired hair shaft abnormalities;
- Weathering-related hair shaft abnormalities;
This hair breaks easily, and trichorrhexis nodosa and trichoptilosis develop. The hair is dry, dull and difficult to comb. It arises from repeated exposure of the hair to environmental conditions during the day. Environmental factors include UV light, salt or chlorinated water, wind and air pollution, hair dyes, hair lighteners, hairdryers, hair straighteners, curling tongs, harsh and frequent combing and brushing, frequent use of hair styling products, blow-drying and styling tools, etc.
- Trichoptilosis
This is splitting of 2–3 cm along the long axis of the hair shaft, more often at the tip (split ends).
- Acquired progressive kinking of the hair
There is often curly, short hair in the area around the ears, often seen together with androgenetic alopecia (AGA).
What causes trichotillomania?
There is no definitively known cause of this disease. Research continues into its causes, the changes that take place in the brain during the illness, how it differs from other conditions and the factors that make it worse. The scientific fact established so far is that the disease is a neurobiological process and that genetic, i.e. hereditary, factors also play a role in its development. Just like alcoholism, pathological gambling, depression and many other psychiatric illnesses, trichotillomania arises from a combination of genetic, emotional and environmental factors. However, it should not be forgotten that hair pulling can be a symptom that appears in a variety of different conditions. Just as a high temperature can have different causes such as pneumonia, urinary tract infection or sunstroke, hair pulling can also be seen in the course of different psychiatric illnesses.
Where does the name trichotillomania come from?
The hair-pulling disorder was given this name in 1889 by the French dermatologist François Hallopeau. In Greek, "tricho" means hair, "tillo" means pulling, and "mania" means madness or excessive craving.
Who gets trichotillomania?
The disease can be seen in people of every age, ethnic group, sex, nationality and socio-economic level. In childhood it occurs almost equally often in girls and boys, whereas in adulthood 80–90% of cases are women. Its prevalence in the population is 1–3%. In other words, in Türkiye there are about 1–1.5 million cases of trichotillomania, some receiving treatment and some not, some aware of their condition and some not, some severe and some mild.
When does trichotillomania start?
The disease can begin at any age, but it often starts in late childhood and adolescence, around the age of 11–13. The fact that it more often begins in this period suggests that certain hormonal changes may play a part in its onset. However, there are rare cases in which the disease is seen in old age or in babies under 1 year old. The disease is often seen during a stressful period of life, following a significant life event, but it can also start out of the blue while everything in the person's life is going on as usual.
Can trichotillomania go away on its own?
It is not possible to predict exactly how the disease will progress in an individual. In people who never receive treatment, trichotillomania usually lasts for many years, but over time there are periods when it worsens and eases, and even periods of months or years in between when it almost completely disappears and then flares up again. This chronic course can last a lifetime. However, in many cases that begin in infancy or early childhood, hair pulling may continue for a short time and then disappear on its own.
Is hair pulling painful?
When we ask our patients whether hair pulling is painful, we get very different answers. Many say that pulling out hair from different parts of the body is, rather than painful, a relieving act. They describe the urge to pull and the relief that comes from pulling out the hair once the urge becomes irresistible. Some patients liken it to having a very itchy spot and the relief felt when it is scratched. Others say they feel pain but still cannot resist. A person may pull out hundreds, sometimes thousands, of hairs a day, and the repeated pulling movement can cause pain in the hands, wrists and elbows. Painful swellings may appear due to inflammation of the hair roots. Yet even these bad consequences often do not help the person stop pulling.
Is hair pulling (trichotillomania) deliberate self-harm?
No. The person is not happy with the condition, wants to be free of it and suffers from the harm it causes. They know it damages their appearance and their life, and they try to stop but fail – much like people who bite their nails want to stop but cannot. Every time someone who has not experienced the condition says "you could stop if you wanted to, just don't pull", the distress of not being understood makes it even worse.
Is trichotillomania a form of obsessive-compulsive disorder?
The names of diseases, i.e. labels, exist to make communication between doctors and other health professionals easier. For this reason, various disease classifications have been created so that the same diagnosis is made and similar treatments are applied for the same disease all over the world. In these classifications, trichotillomania and obsessive-compulsive disorder are listed as different groups of disorders. Rather than an obsession, trichotillomania is classified in a group known as "impulse control disorders". However, with its repetitive pattern of behaviour and the irresistible urge to do it, trichotillomania also resembles obsessive-compulsive disorder. The fact that the person sometimes pulls hair automatically, without noticing, resembles a tic disorder. When treatment is sought, however, the doctor and psychologist will approach each case according to the patient's own characteristics rather than the label of the disease.
Is swallowing hair part of the disorder too?
Putting the roots of pulled-out hair or other body hair in the mouth, sucking them or swallowing the hair whole is quite common behaviour. Swallowing may involve only the root of the hair or the whole hair. If whole hairs are swallowed, over time the hair accumulating in the intestines can form a ball and block the bowel. This condition, called a trichobezoar, can be serious enough to require emergency surgery. If the necessary intervention is not carried out, this rare condition can be fatal. The risk of a fatal outcome increases when the person, out of embarrassment about their condition, does not seek medical help.
Pseudopelade
This is a disease that leads to irreversible hair loss. If the disease progresses, the hairs around the patches can easily be pulled out. There is no effective treatment. In the late stages of the disease, to improve the cosmetic appearance, hair can be transplanted surgically from an unaffected area of the scalp to the affected area. However, good results may not always be achieved.
Poliosis
This is the appearance of white hair in a group of neighbouring hairs, due to a reduction in or absence of the cells that give hair its colour. It can be seen in certain diseases (such as alopecia areata and vitiligo).
Hirsutism
Hirsutism is the growth in women of excessive amounts of dark, male-pattern hair in places where it should not be (moustache area, chin, chest, abdomen). It can be seen in about 8% of women of reproductive age. Excessive hair growth is usually due to overproduction of male hormones such as testosterone. In some patients, blood hormone levels may be normal. The signs are usually obvious and the diagnosis can easily be made with simple tests. Treatment of excessive hair growth is usually directed at the underlying cause. Shaving is not recommended for excessive hair growth, but waxing can be used. Among cosmetic treatments the best is laser hair removal, but it is costly. The hormones that increase hair growth (testosterone) come in women from either the ovaries or the adrenal glands. If hair growth develops and progresses rapidly, its cause should be investigated.
Excessive hair growth – causes of hyperandrogenism
Excessive hair growth – signs and diagnosis of hirsutism
In most women with increased hair growth there is sometimes no hormonal increase – this is called idiopathic hirsutism – or it is due to polycystic ovary syndrome. Excess prolactin, an overactive adrenal gland and certain medicines can also cause hair growth. Sometimes tumours of the ovaries and adrenal glands can also cause excessive hair growth.