Alopecia Areata

Autoimmune reaction to Hair Follicles
Prematurely transitions Anagen phase (growth) hairs to Catagen or Telogen phase (with more rapid loss)
Often associated with Thyroid disease

Patchy Alopecia Areata
1. Well circumscribed, flesh colored, smooth, discrete oval patches of Hair Loss
Ophiasis
1. Band-like Hair Loss around temporal and occipital scalp
Alopecia Totalis
1. Hair Loss over entire scalp
Alopecia Universalis
1. Hair Loss over entire body

Characteristics
1. Well-demarcated oval or round patches of Hair Loss
2. Patches of Hair Loss may coalesce into larger areas of Hair Loss
Distribution
1. Hair Loss on scalp is most common (but may occur in any body region)
Timing
1. Hair Loss develops over the course of weeks
Exclamation Point Hairs at edges of Hair Loss (as visualized under microscope)
1. Club shaped Hair Root
2. Thin proximal Hair Shaft
3. Normal caliber distal Hair Shaft
Non-specific findings
1. Short Vellus Hairs or 2-3 mm broken hairs
2. Black or yellow dots on scalp
3. Positive Hair Pull Test
Associated nail findings
1. Nail Pitting (most common)
2. Other nail findings
  1. Trachyonychia
  2. Beau Lines
  3. Onychorrhexis
  4. Onychomadesis
  5. Nail thickness changes (thinning or thickening)
  6. Leukonychia (transverse or punctate)
  7. Koilonychia
  8. Lunula red marks

Intralesional Triamcinolone (Kenalog)
1. Treatment of choice
2. Dilute Kenalog 40 mg/ml with saline to 10 mg/ml
  1. Kenalog 40 mg/ml: 0.5 ml
  2. Saline: 2 ml
3. Inject 0.1 ml into patch at 1 cm intervals
4. Inject into mid-Dermis via 0.5 inch 30 gauge needle
5. Adverse effects: Atrophy
  1. Avoid injecting too superficially
  2. Avoid injecting >0.1 ml or >10 mg/ml per site (3 ml total per session)
  3. Limit injections to no more often than every 4-6 weeks
  4. Continue until resolution or to a maximum of 6 months
Adjuncts to intralesional injection
1. Apply Topical Minoxidil 5% solution twice daily or
2. Apply mid-potency Topical Corticosteroid (eg. Kenalog 0.1%)
  1. Apply 1 ml to entire scalp twice daily
  2. Consider in children with Alopecia Areata

Consider wig or hairpiece
General: Combination therapy often used
1. Contact sensitizers with intralesional Kenalog
  1. Most effective option
  2. Usually requires referral to dermatology
2. Minoxidil 5% bid with Topical Steroids or Anthralin
Topical Anthralin Cream (Psoriatec) 0.5 to 1% cream
1. Course usually limited to 6 months
2. Apply daily and leave on for 5 minutes to start
  1. Gradually increase time applied up to 60 minutes
3. Rinse scalp well and then clean with soap
4. New Hair Growth seen within 3 months
Mid-potency Topical Corticosteroid (eg. Kenalog 0.1%)
1. Apply 1 ml to entire scalp twice daily
Topical Minoxidil 5%
1. Use as adjunct to Anthralin or Corticosteroid
Prednisone (less commonly used)
1. Start: 40 mg orally daily for 7 days
2. Taper: Decrease by 5 mg q3 days
3. Course completed within 6 weeks
Dermatology Consultation
1. Contact sensitizer
  1. Dinitrochlorobenzene
  2. Diphenylcyclopropenone
  3. Squaric acid dibutyl ester
2. Disease Modifying Antirheumatic Drug
  1. Methotrexate
  2. Immunosuppressants (e.g. Azathioprine)

Spontaneously resolves in 6-12 months in most limited presentations (<50% scalp involved)
1. Hair pigmentation may be different in regrowth area
2. Some cases progress (see prognostic indicators below)
Recurs in 30% of cases (often affects same area)