Diagnostic Considerations

Trichotillomania

Alopecic patches have unusual shapes and sizes and show broken hairs; no inflammation or epidermal change occurs. A scalp biopsy can be helpful if the diagnosis is difficult clinically.

Tinea capitis

The diagnosis is suggested by erythema, scaling, and crusting locally on the scalp.

Scarring alopecia and posttraumatic alopecia

These can be differentiated by the absence of follicular ostia or some degree of atrophy.

Syphilis

Syphilis rarely is seen but should be suspected in patients at high risk or with other signs or symptoms.

Telogen effluvium and androgenetic alopecia

Exclude these when hair loss is diffuse. In androgenetic alopecia, hair loss is patterned and usually is slowly progressive rather than acute. Differentiating telogen effluvium from diffuse alopecia areata is difficult in the absence of an obvious precipitating factor that can result in telogen effluvium. Noting hair loss on other hair-bearing areas can be helpful and favors a diagnosis of alopecia areata.

Differential Diagnoses

Workup

Darwin E, Hirt PA, Fertig R, Doliner B, Delcanto G, Jimenez JJ. Alopecia Areata: Review of Epidemiology, Clinical Features, Pathogenesis, and New Treatment Options. Int J Trichology. 2018 Mar-Apr. 10 (2):51-60. [Medline].
Hoffmann R, Happle R. Topical immunotherapy in alopecia areata. What, how, and why?. Dermatol Clin. 1996 Oct. 14(4):739-44. [Medline].
Rokhsar CK, Shupack JL, Vafai JJ, Washenik K. Efficacy of topical sensitizers in the treatment of alopecia areata. J Am Acad Dermatol. 1998 Nov. 39(5 Pt 1):751-61. [Medline].
Chong JH, Taïeb A, Morice-Picard F, Dutkiewicz AS, Léauté-Labrèze C, Boralevi F. High dose pulsed corticosteroid therapy combined with Methotrexate for Severe Alopecia Areata of Childhood. J Eur Acad Dermatol Venereol. 2017 Apr 20. [Medline].
Browne R, Stewart L, Williams HC. Is methotrexate an effective and safe treatment for maintaining hair regrowth in people with alopecia totalis? A critically appraised topic. Br J Dermatol. 2018 May 19. [Medline].
van der Steen P, Traupe H, Happle R, Boezeman J, Sträter R, Hamm H. The genetic risk for alopecia areata in first degree relatives of severely affected patients. An estimate. Acta Derm Venereol. 1992 Sep. 72(5):373-5. [Medline].
Pullen LC. Alopecia Areata Associated With Autoimmune Comorbidity. Available at http://www.medscape.com/viewarticle/804646. Accessed: May 27, 2013.
Huang KP, Mullangi S, Guo Y, Qureshi AA. Autoimmune, Atopic, and Mental Health Comorbid Conditions Associated With Alopecia Areata in the United States. JAMA Dermatol. 2013 May 22. 1-5. [Medline].
Colombe BW, Lou CD, Price VH. The genetic basis of alopecia areata: HLA associations with patchy alopecia areata versus alopecia totalis and alopecia universalis. J Investig Dermatol Symp Proc. 1999 Dec. 4(3):216-9. [Medline].
Colombe BW, Price VH, Khoury EL, Garovoy MR, Lou CD. HLA class II antigen associations help to define two types of alopecia areata. J Am Acad Dermatol. 1995 Nov. 33(5 Pt 1):757-64. [Medline].
Price VH, Colombe BW. Heritable factors distinguish two types of alopecia areata. Dermatol Clin. 1996 Oct. 14(4):679-89. [Medline].
Jackow C, Puffer N, Hordinsky M, Nelson J, Tarrand J, Duvic M. Alopecia areata and cytomegalovirus infection in twins: genes versus environment?. J Am Acad Dermatol. 1998 Mar. 38(3):418-25. [Medline].
Safavi K. Prevalence of alopecia areata in the First National Health and Nutrition Examination Survey. Arch Dermatol. 1992 May. 128(5):702. [Medline].
Safavi KH, Muller SA, Suman VJ, Moshell AN, Melton LJ 3rd. Incidence of alopecia areata in Olmsted County, Minnesota, 1975 through 1989. Mayo Clin Proc. 1995 Jul. 70(7):628-33. [Medline].
Muller SA, Winkelmann RK. Alopecia areata. An evaluation of 736 patients. Arch Dermatol. 1963 Sep. 88:290-7. [Medline].
Sharma VK, Dawn G, Kumar B. Profile of alopecia areata in Northern India. Int J Dermatol. 1996 Jan. 35(1):22-7. [Medline].
Puavilai S, Puavilai G, Charuwichitratana S, Sakuntabhai A, Sriprachya-Anunt S. Prevalence of thyroid diseases in patients with alopecia areata. Int J Dermatol. 1994 Sep. 33(9):632-3. [Medline].
Werth VP, White WL, Sanchez MR, Franks AG. Incidence of alopecia areata in lupus erythematosus. Arch Dermatol. 1992 Mar. 128(3):368-71. [Medline].
Wang SJ, Shohat T, Vadheim C, Shellow W, Edwards J, Rotter JI. Increased risk for type I (insulin-dependent) diabetes in relatives of patients with alopecia areata (AA). Am J Med Genet. 1994 Jul 1. 51(3):234-9. [Medline].
Perini GI, Veller Fornasa C, Cipriani R, Bettin A, Zecchino F, Peserico A. Life events and alopecia areata. Psychother Psychosom. 1984. 41(1):48-52. [Medline].
Karadag Köse O, Güleç AT. Clinical evaluation of alopecias using a handheld dermatoscope. J Am Acad Dermatol. 2012 Aug. 67(2):206-14. [Medline].
Tosti A, De Padova MP, Minghetti G, Veronesi S. Therapies versus placebo in the treatment of patchy alopecia areata. J Am Acad Dermatol. 1986 Aug. 15(2 Pt 1):209-10. [Medline].
Vestey JP, Savin JA. Natural history of severe alopecia areata. Br J Dermatol. 1987 Oct. 117(4):531. [Medline].
Devi M, Rashid A, Ghafoor R. Intralesional Triamcinolone Acetonide Versus Topical Betamethasone Valearate in the Management of Localized Alopecia Areata. J Coll Physicians Surg Pak. 2015 Dec. 25 (12):860-2. [Medline].
Yee BE, Tong Y, Goldenberg A, Hata T. Efficacy of different concentrations of intralesional triamcinolone acetonide for alopecia areata: A systematic review and meta-analysis. J Am Acad Dermatol. 2020 Apr. 82 (4):1018-1021. [Medline].
Chu TW, AlJasser M, Alharbi A, Abahussein O, McElwee K, Shapiro J. Benefit of different concentrations of intralesional triamcinolone acetonide in alopecia areata: An intrasubject pilot study. J Am Acad Dermatol. 2015 Aug. 73 (2):338-40. [Medline].
Chang KH, Rojhirunsakool S, Goldberg LJ. Treatment of severe alopecia areata with intralesional steroid injections. J Drugs Dermatol. 2009 Oct. 8(10):909-12. [Medline].
Tosti A, Piraccini BM, Pazzaglia M, Vincenzi C. Clobetasol propionate 0.05% under occlusion in the treatment of alopecia totalis/universalis. J Am Acad Dermatol. 2003 Jul. 49(1):96-8. [Medline].
Wiseman MC, Shapiro J, MacDonald N, Lui H. Predictive model for immunotherapy of alopecia areata with diphencyprone. Arch Dermatol. 2001 Aug. 137(8):1063-8. [Medline].
El-Zawahry BM, Bassiouny DA, Khella A, Zaki NS. Five-year experience in the treatment of alopecia areata with DPC. J Eur Acad Dermatol Venereol. 2010 Mar. 24(3):264-9. [Medline].
Tang L, Cao L, Sundberg JP, Lui H, Shapiro J. Restoration of hair growth in mice with an alopecia areata-like disease using topical anthralin. Exp Dermatol. 2004 Jan. 13(1):5-10. [Medline].
Durdu M, Özcan D, Baba M, Seçkin D. Efficacy and safety of diphenylcyclopropenone alone or in combination with anthralin in the treatment of chronic extensive alopecia areata: a retrospective case series. J Am Acad Dermatol. 2015 Apr. 72 (4):640-50. [Medline].
Vila TO, Camacho Martinez FM. Bimatoprost in the treatment of eyelash universalis alopecia areata. Int J Trichology. 2010 Jul. 2 (2):86-8. [Medline].
Coronel-Pérez IM, Rodríguez-Rey EM, Camacho-Martínez FM. Latanoprost in the treatment of eyelash alopecia in alopecia areata universalis. J Eur Acad Dermatol Venereol. 2010 Apr. 24 (4):481-5. [Medline].
Ross EK, Bolduc C, Lui H, Shapiro J. Lack of efficacy of topical latanoprost in the treatment of eyebrow alopecia areata. J Am Acad Dermatol. 2005 Dec. 53 (6):1095-6. [Medline].
Faghihi G, Andalib F, Asilian A. The efficacy of latanoprost in the treatment of alopecia areata of eyelashes and eyebrows. Eur J Dermatol. 2009 Nov-Dec. 19 (6):586-7. [Medline].
Roseborough I, Lee H, Chwalek J, Stamper RL, Price VH. Lack of efficacy of topical latanoprost and bimatoprost ophthalmic solutions in promoting eyelash growth in patients with alopecia areata. J Am Acad Dermatol. 2009 Apr. 60 (4):705-6. [Medline].
Ochoa BE, Sah D, Wang G, Stamper R, Price VH. Instilled bimatoprost ophthalmic solution in patients with eyelash alopecia areata. J Am Acad Dermatol. 2009 Sep. 61 (3):530-2. [Medline].
Taylor CR, Hawk JL. PUVA treatment of alopecia areata partialis, totalis and universalis: audit of 10 years' experience at St John's Institute of Dermatology. Br J Dermatol. 1995 Dec. 133(6):914-8. [Medline].
Sharma VK. Pulsed administration of corticosteroids in the treatment of alopecia areata. Int J Dermatol. 1996 Feb. 35(2):133-6. [Medline].
Acikgoz G, Ozmen I, Cayirli M, Yeniay Y, Kose O. Pulse methylprednisolone therapy for the treatment of extensive alopecia areata. J Dermatolog Treat. 2014 Apr. 25(2):164-6. [Medline].
Friedland R, Tal R, Lapidoth M, Zvulunov A, Ben Amitai D. Pulse corticosteroid therapy for alopecia areata in children: a retrospective study. Dermatology. 2013. 227(1):37-44. [Medline].
Price VH, Willey A, Chen BK. Topical tacrolimus in alopecia areata. J Am Acad Dermatol. 2005 Jan. 52(1):138-9. [Medline].
Joly P. The use of methotrexate alone or in combination with low doses of oral corticosteroids in the treatment of alopecia totalis or universalis. J Am Acad Dermatol. 2006 Oct. 55(4):632-6. [Medline].
Anuset D, Perceau G, Bernard P, Reguiai Z. Efficacy and Safety of Methotrexate Combined with Low- to Moderate-Dose Corticosteroids for Severe Alopecia Areata. Dermatology. 2016. 232 (2):242-8. [Medline].
Phan K, Ramachandran V, Sebaratnam DF. Methotrexate for alopecia areata: A systematic review and meta-analysis. J Am Acad Dermatol. 2019 Jan. 80 (1):120-127.e2. [Medline].
Ross EK, Bolduc C, Lui H, Shapiro J. Lack of efficacy of topical latanoprost in the treatment of eyebrow alopecia areata. J Am Acad Dermatol. 2005 Dec. 53(6):1095-6. [Medline].
Price VH. Treatment of hair loss. N Engl J Med. 1999 Sep 23. 341(13):964-73. [Medline].
Strober BE, Siu K, Alexis AF, Kim G, Washenik K, Sinha A, et al. Etanercept does not effectively treat moderate to severe alopecia areata: an open-label study. J Am Acad Dermatol. 2005 Jun. 52(6):1082-4. [Medline].
Mikhaylov D, Pavel A, Yao C, Kimmel G, Nia J, Hashim P, et al. A randomized placebo-controlled single-center pilot study of the safety and efficacy of apremilast in subjects with moderate-to-severe alopecia areata. Arch Dermatol Res. 2019 Jan. 311 (1):29-36. [Medline].
Ibrahim O, Bayart CB, Hogan S, Piliang M, Bergfeld WF. Treatment of Alopecia Areata With Tofacitinib. JAMA Dermatol. 2017 Mar 29. [Medline].
Liu LY, Craiglow BG, Dai F, King BA. Tofacitinib for the treatment of severe alopecia areata and variants: A study of 90 patients. J Am Acad Dermatol. 2017 Jan. 76 (1):22-28. [Medline].
Craiglow BG, Liu LY, King BA. Tofacitinib for the treatment of alopecia areata and variants in adolescents. J Am Acad Dermatol. 2017 Jan. 76 (1):29-32. [Medline].
Vandiver A, Girardi N, Alhariri J, Garza LA. Two cases of alopecia areata treated with ruxolitinib: a discussion of ideal dosing and laboratory monitoring. Int J Dermatol. 2017 Mar 21. [Medline].
Shreberk-Hassidim R, Ramot Y, Zlotogorski A. Janus kinase inhibitors in dermatology: A systematic review. J Am Acad Dermatol. 2017 Apr. 76 (4):745-753.e19. [Medline].
Damsky W, King BA. JAK inhibitors in dermatology: The promise of a new drug class. J Am Acad Dermatol. 2017 Apr. 76 (4):736-744. [Medline].
Samadi A, Ahmad Nasrollahi S, Hashemi A, Nassiri Kashani M, Firooz A. Janus kinase (JAK) inhibitors for the treatment of skin and hair disorders: a review of literature. J Dermatolog Treat. 2017 Jan 22. 1-11. [Medline].
Ramot Y, Zlotogorski A. Complete Regrowth of Beard Hair with Ruxolitinib in an Alopecia Universalis Patient. Skin Appendage Disord. 2018 Apr. 4 (2):122-124. [Medline].
Iorizzo M, Tosti A. Emerging drugs for alopecia areata: JAK inhibitors. Expert Opin Emerg Drugs. 2018 Mar. 23 (1):77-81. [Medline].
Olsen EA, Kornacki D, Sun K, Hordinsky MK. Ruxolitinib cream for the treatment of patients with alopecia areata: A 2-part, double-blind, randomized, vehicle-controlled phase 2 study. J Am Acad Dermatol. 2020 Feb. 82 (2):412-419. [Medline].
Marks DH, Mesinkovska N, Senna MM. Cause or cure? Review of dupilumab and alopecia areata. J Am Acad Dermatol. 2019 Jun 13. 19:30973-9. [Medline].
Grenier PO, Veillette H. Treatment of alopecia universalis with oral alitretinoin: A case report. JAAD Case Rep. 2017 Mar. 3 (2):140-142. [Medline].
Lattouf C, Jimenez JJ, Tosti A, Miteva M, Wikramanayake TC, Kittles C, et al. Treatment of alopecia areata with simvastatin/ezetimibe. J Am Acad Dermatol. 2015 Feb. 72 (2):359-61. [Medline].
Morillo-Hernandez C, Lee JJ, English JC 3rd. Retrospective outcome analysis of 25 alopecia areata patients treated with simvastatin/ezetimibe. J Am Acad Dermatol. 2019 Sep. 81 (3):854-857. [Medline].
Albalat W, Ebrahim HM. Evaluation of platelet-rich plasma vs intralesional steroid in treatment of alopecia areata. J Cosmet Dermatol. 2019 May 10. [Medline].
Anderi R, Makdissy N, Azar A, Rizk F, Hamade A. Cellular therapy with human autologous adipose-derived adult cells of stromal vascular fraction for alopecia areata. Stem Cell Res Ther. 2018 May 15. 9 (1):141. [Medline].
Abdel Fattah NS, Atef MM, Al-Qaradaghi SM. Evaluation of serum zinc level in patients with newly diagnosed and resistant alopecia areata. Int J Dermatol. 2016 Jan. 55 (1):24-9. [Medline].
Park H, Kim CW, Kim SS, Park CW. The therapeutic effect and the changed serum zinc level after zinc supplementation in alopecia areata patients who had a low serum zinc level. Ann Dermatol. 2009 May. 21 (2):142-6. [Medline].
Lux-Battistelli C. Combination therapy with zinc gluconate and PUVA for alopecia areata totalis: an adjunctive but crucial role of zinc supplementation. Dermatol Ther. 2015 Jul-Aug. 28 (4):235-8. [Medline].
Dastgheib L, Mostafavi-Pour Z, Abdorazagh AA, Khoshdel Z, Sadati MS, Ahrari I, et al. Comparison of zn, cu, and fe content in hair and serum in alopecia areata patients with normal group. Dermatol Res Pract. 2014. 2014:784863. [Medline].
van den Biggelaar FJ, Smolders J, Jansen JF. Complementary and alternative medicine in alopecia areata. Am J Clin Dermatol. 2010. 11(1):11-20. [Medline].
Willemsen R, Haentjens P, Roseeuw D, Vanderlinden J. Hypnosis in refractory alopecia areata significantly improves depression, anxiety, and life quality but not hair regrowth. J Am Acad Dermatol. 2010 Mar. 62(3):517-8. [Medline].

Media Gallery

Alopecia areata affecting the beard.
Alopecia areata affecting the arms.
Patchy alopecia areata.
Ophiasis pattern of alopecia areata.
Sisaipho pattern of alopecia areata.
Alopecia totalis.
Diffuse alopecia areata.
Corticosteroid injection.
Treatment algorithm for alopecia areata.

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Author

Chantal Bolduc, MD, FRCPC Assistant Professor, Department of Dermatology, University of Montreal Faculty of Medicine; Physician, Innovaderm Research, Inc

Chantal Bolduc, MD, FRCPC is a member of the following medical societies: Canadian Dermatology Foundation

Disclosure: Nothing to disclose.

Coauthor(s)

Harvey Lui, MD, FRCPC Professor and Head, Department of Dermatology and Skin Science, Vancouver General Hospital, University of British Columbia; Medical Director, The Skin Centre, Lions Laser Skin Centre and Psoriasis and Phototherapy Clinic, Vancouver General Hospital

Harvey Lui, MD, FRCPC is a member of the following medical societies: Canadian Medical Association, American Society for Photobiology, Photomedicine Society, European Academy of Dermatology and Venereology, National Psoriasis Foundation, Canadian Dermatology Association, College of Physicians and Surgeons of British Columbia, North American Hair Research Society, Canadian Dermatology Foundation, American Academy of Dermatology, American Society for Laser Medicine and Surgery

Disclosure: Received consulting fee from Astellas for review panel membership; Received consulting fee from Amgen/Wyeth for speaking and teaching; Received honoraria from LEO Pharma for speaking and teaching; Received grant/research funds from LEO Pharma for investigator; Received grant/research funds from Galderma for other.

Jerry Shapiro, MD, FAAD, FRCPC Professor, Director, Disorders of the Hair and Scalp, The Ronald O Perelman Department of Dermatology, New York University School of Medicine

Disclosure: Nothing to disclose.

Specialty Editor Board

Richard P Vinson, MD Assistant Clinical Professor, Department of Dermatology, Texas Tech University Health Sciences Center, Paul L Foster School of Medicine; Consulting Staff, Mountain View Dermatology, PA

Richard P Vinson, MD is a member of the following medical societies: American Academy of Dermatology, Texas Medical Association, Association of Military Dermatologists, Texas Dermatological Society

Disclosure: Nothing to disclose.

Lester F Libow, MD Dermatopathologist, South Texas Dermatopathology Laboratory

Lester F Libow, MD is a member of the following medical societies: American Academy of Dermatology, American Society of Dermatopathology, Texas Medical Association

Disclosure: Nothing to disclose.

Chief Editor

Dirk M Elston, MD Professor and Chairman, Department of Dermatology and Dermatologic Surgery, Medical University of South Carolina College of Medicine

Dirk M Elston, MD is a member of the following medical societies: American Academy of Dermatology

Disclosure: Nothing to disclose.

Additional Contributors

Leonard Sperling, MD Chair, Professor, Department of Dermatology, Uniformed Services University of the Health Sciences

Leonard Sperling, MD is a member of the following medical societies: American Academy of Dermatology

Disclosure: Nothing to disclose.