Dr Li-Chuen Wong
Paedeatric Dermatologist
Westmead Childrens Hospital
Alopecia areata is uncommon, with 1% of the population suffering from this condition by 50 years of age. It occurs at all ages, though the first attack usually happens in childhood. In 10-20% of patients, there will be another family member also affected.
The typical clinical picture is of a sudden onset of one or more round or oval well- circumscribed patches of hair loss. The scalp is most often affected but other areas of body hair, including the eyebrows, eyelashes, and beard area may also be involved. Re-growing hairs may be white (depigmented). They may remain white or may repigment with time.
Ophiasis (derived from the Greek word for serpent), refers to the pattern of alopecia most commonly seen in children. It begins as a bald patch on the back of the scalp (occiput), extending to the right and left, and up to the ears. Alopecia totalis is the term used when the entire scalp is bald, whilst alopecia universalis refers to complete loss of all scalp and body hair.
The nails can also be affected, with the commonest findings being either grid-like stippling or pitting of the nails. Usually the more severe the hair loss, the worse the nail changes will be.
Diagnosis is made clinically and biopsy is usually not required.
The cause of alopecia areata is unfortunately unknown. However, it is an auto-immune disease and rarely is associated with other auto-immune disorders, such as thyroid disease, pernicious anaemia and vitiligo. Children are highly unlikely to have another auto-immune disease, and routine testing is not warranted if the child is otherwise well on clinical examination.
Unfortunately, it is very difficult to predict the long term prognosis. If the disease is only limited to a few patches of hair loss, then the outcome is generally good, with complete regrowth within one year in 95% of children. However, up to 10% of patients may develop a severe chronic form of the condition. Indicators of a poorer outcome are the presence of other autoimmune diseases, a family history of alopecia areata, young age at onset, extensive hair loss, an ophiasis pattern, nail abnormalities and a background history of asthma, eczema or hayfever.
All treatments presently available help only with hair regrowth of the treated area, and none cure the condition. Not all treated areas respond to therapy. Treatment does not prevent further spread of the disease, nor prevent new areas of involvement developing.
Steroid (cortisone) creams are unhelpful, though steroid injections into the patches of hair loss (in children, with laughing gas sedation) can be very helpful in stimulating hair re-growth.
Oral steroids are generally not recommended except for a few select patients with severe and rapid hair loss. There are many associated side effects and a high relapse rate on reduction of the medication.
Topical minoxidil (Rogaine) solution applied twice daily can be helpful in 20-45% of cases. However, this treatment is usually successful only in the milder cases, and side effects can occur.
Topical immunotherapy (diphencyprone;DCP) is based on the principle of activating the immune system, stimulating re-growth of the hair. The treated areas will become itchy, red and irritated. This treatment is in general not practical for children.
When scalp hair loss is extensive, continuing treatment may be futile, and a good quality wig is then essential.
Finally, it is crucial that alopecia areata sufferers and their families receive adequate emotional support. The amount of stress and suffering that this condition can cause must never be underestimated.
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