Alopecia areata is an autoimmune disease in which immune cells attack hair follicles, causing round patches of sudden hair loss without scarring. The follicles stay alive, so hair often regrows, although the disease can come back or spread to the whole scalp or body.
Key symptoms
- One or more smooth, round bald patches that appear over days to weeks
- Usually no pain; sometimes mild tingling or itch before the hair falls
- Loss of eyebrows, eyelashes or beard hair
- Nail changes such as small pits
What you find on exam
- Smooth, nonscarring patches with normal-looking skin and visible follicle openings
- Short broken exclamation point hairs at the edges
- Positive gentle hair pull test at the margin when the disease is active
- Look at the nails for pitting and check other hair-bearing areas
Tests
- Usually a clinical diagnosis; dermoscopy shows yellow dots and exclamation point hairs
- Thyroid tests if symptoms suggest thyroid disease, since autoimmune diseases cluster
- KOH prep or fungal culture if scaling suggests tinea capitis
- Scalp biopsy only if the diagnosis is unclear
Treatment basics
- Limited patches: intralesional triamcinolone injections every 4 to 6 weeks
- Potent topical corticosteroids, especially in children
- Topical minoxidil as an add-on to help regrowth
- Severe or extensive disease: oral JAK inhibitors such as baricitinib
- Emotional support and counseling; wigs or hairpieces if wanted
Red flags
- Scarring, redness, scale or pus, which point to another cause
- Rapid spread to loss of all scalp or body hair
- Marked distress, anxiety or low mood
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Sources: NCCPA PANCE Content Blueprint; NBOME COMLEX-USA clinical presentations; AAMC Core Entrustable Professional Activities (Core EPAs). Written by Making Synapses. Making Synapses is not affiliated with these organizations.