Presented by: Christine Shaver, MD and Herbert Allen, MD.
Drexel University College of Medicine
May 16, 2016
Alopecia areata is a complex genetic, T-cell–mediated autoimmune condition that is most likely to occur in genetically predisposed individuals. The infiltrate consists mostly of T-helper cells and, to a lesser extent, T-suppressor cells. While the process appears to be largely T-cell-mediated, antibodies directed to hair follicle structures also have been found with increased frequency in alopecia areata patients compared with control subjects. The condition is estimated to affect approximately 6-7 million people in the United States without a known age, race, or ethnic predilection.
Alopecia totalis is a variant of alopecia areata resulting in complete loss of scalp hair, whereas alopecia universalis is a complete loss of hair on the scalp and body. Approximately 7% of alopecia areata patients will develop alopecia totalis or alopecia universalis in their lifetime. The mean progression to alopecia totalis from date of onset of alopecia is 4 months.
While most patients with alopecia areata are asymptomatic, some patients report a mild burning sensation or pruritus in the affected areas. The scalp is the most often involved site and is classified further according to the pattern observed. A reticular pattern is defined by extensive hair loss with numerous coalescing patches. Ophiasis pattern consists of hair loss localized to the sides and lower occipital scalp, while sisaipho pattern is alopecia that spares these areas and is mainly located on the vertex and frontal scalp. Fingernail involvement can also be seen, and the most common abnormality observed is nail pitting, although other findings include trachyonychia, Beau’s lines, onychorrhexis, onychomadesis, koilonychias, leukonychia, and red lunulae.
Alopecia areata and totalis have also been associated with other diseases including atopic dermatitis, vitiligo, thyroid disease, collagen-vascular disease, Down syndrome and type 1 diabetes. Among patients with alopecia areata and alopecia totalis, there is an increased prevalence of anxiety, personality disorders, depression, and paranoid disorders ranging from 17-22% of patients. The lifetime prevalence of psychiatric disorders is estimated to be 74% in patients with alopecia areata. No association has been made between the severity of the psychiatric disorder and that of alopecia areata or its variants.
Diagnosis of alopecia areata is often made clinically; however, biopsy can help with confirmation if the diagnosis is uncertain. Histopathology classically reveals the presence of a peribulbar lymphocytic infiltrate surrounding the anagen hair follicles.
Current treatment options are numerous, though none seem to provide universal effectiveness, sustained remission, or cure. For localized disease, options for treatment include topical and intralesional steroids, anthralin, topical immunotherapy, and minoxidil among others. For more extensive disease, systemic agents are often employed such as PUVA, prednisone, cyclosporine, dapsone, methotrexate, and newer biologic agents, such as TNF-alpha and JAK inhibitors.
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Great case