Hair Loss: It's Not Always What You Think

Written on: Sep 17, 2019
By: Shari Hicks-Graham

September is the month designated for Alopecia Areata Awareness, so I thought it would be fitting to use this platform to help contribute to this cause. Alopecia areata (AA) is a common form of hair loss that is caused by inflammation and presents with characteristic circular, smooth patches without hair. We know that the emotional difficulty of having AA is great. Patients with AA have greater rates of depression and anxiety. Sometimes the disease can affect the majority of the scalp and eyebrows, drawing assumptions that the condition is life-threatening, which may leave AA patients feeling isolated and self-conscious. It is frustrating to lose control over a physical feature that is tied so closely with one’s appearance and self-esteem. These feelings are more than what can be unpacked during a visit to the dermatologist, but I try to communicate to my patients that I see their struggles and that I understand. I recommend that people with AA seek professional counseling from licensed therapists on a regular basis to help manage these normal emotions. Additionally, organizations like the National Alopecia Areata Foundation focus on patient and community education and awareness. Visit to learn more. Now, let’s discuss some statistics, what’s going on biologically when AA happens, and how to identify and treat the condition.




Alopecia areata is an equal opportunity disease – the condition may affect children or adults of any gender or ethnicity. In the United States, the cumulative lifetime incidence is 2%. The average age at the time of diagnosis for women was 31.5 years of age, and for men 36.2 in one study.


AA is caused by inflammation that attacks the hair follicle within certain portions of hair-bearing skin. The affected areas may be small or large, and may even involve the entire scalp. These hairless patches may also involve the face and body including eyelashes, eyebrows, arms, legs, underarms, and genital skin. This inflammatory dysregulation is considered autoimmune because the body’s immune system effectively turns against itself and attacks the hair bulb portion of the hair follicle. In recent years, it has become clear that the protected zone (immune privilege) of this portion of the hair follicle is lost in AA. This causes the inflammation to disrupt the hair growth cycle and force premature cell death of the hair epithelium, leading to the resting phase and shedding of the hair.  


The development of AA is often sudden and may not be obvious to the individual who is affected. Many patients have told me that it was brought to their attention by a hairdresser or barber, or they may have noticed it while grooming their own hair. People often feel a sense of irritation or itching prior to the development of a spot. Others recognize that a stressful situation may precede the development of the hair loss. Associated features seen on examination of the body include nail changes like pitting (regularly spaced dotted indentations) of the nail and redness of the underlying nail surface. People with atopic dermatitis, environmental allergies and asthma, and immune-mediated conditions like type-1 diabetes, thyroid disease, vitiligo or psoriasis are also more likely to develop AA. 

There are other hair loss conditions that can look similar to alopecia areata, so it’s important to see your doctor, or even better, a board-certified dermatologist who can help differentiate between other forms of alopecia. Remember that all hair loss is not necessarily managed the same way. Telogen effluvium (generalized hair shedding) can often look like AA, so can early central centrifugal cicatricial alopecia, lupus, secondary syphilis, trichotillomania, or the less common temporal triangular alopecia. Fortunately, the inflammation of AA does not cause scarring of the scalp or affected skin, which means hair regrowth is possible.  A dermatologist would be able to determine this either by examination or with a simple scalp biopsy.


Treatment options for AA include topical and injectable anti-inflammatory steroid medications, topical minoxidil, topical sensitization therapy – using an irritant to “trick” the immune system into stopping the attack at the hair follicle, even systemic medications like prednisone or methotrexate for more resistant cases. Newer medications are on the horizon called the JAK inhibitors. These targeted therapies operate to block signals that turn on inflammation in the affected areas of AA. They are currently not FDA approved for AA, but we are hopeful that they will be in the next 1-2 years. 

Prognosis is extremely variable on a case-by-case basis. Without treatment, hair regrowth may occur at rates up to 60% but, for some, medical treatment may be required to see regrowth. Use of some of the aforementioned therapies have been associated with hair regrowth upwards of 80%. Unfortunately, cases with more extensive areas of involvement are more resistant to treatment. Pediatric cases are also associated with a less favorable prognosis. We are hopeful, however, that with advances in genetic research new targeted therapies will be developed that are more effective, particularly for these resistant pediatric and adult cases.   

Source: J Am Acad Dermatol 2018;78:15-24


It is important to understand the many different forms of alopecia and that they are managed in different ways. Increasing awareness about AA and other types of hair loss is important not just for our own well-being and education but also to hopefully become more sympathetic to what we may see or hear others go through. Chances are high that by your 30s or 40s you have already seen or know someone dealing with AA. The good thing is, despite the high variability of outcomes for the condition, it is fairly easy for a board-certified dermatologist to specifically identify what is happening to your hair and provide some clarity on treatment options. Resolution of AA is certainly possible and we are optimistic that with ongoing research, the future is bright for those suffering with this disease.

Live free & clear,