Alopecia areata

Introduction

Although the mechanism is not fully understood alopecia areata is an autoimmune condition which is thought to be mediated by T-cell release of pro-inflammatory cytokines and chemokines that reject the hair. In around half of cases it commences in childhood, with 80% of cases occurring before the age of 40. Common triggers include trauma, hormonal change, viral infection and physical or emotional stress.¹

Many patients do not notice any symptoms of alopecia areata however some patients experience trichodynia which is a burning discomfort to the affected area. Signs of alopecia include loss of hair from anywhere there is hair and has three stages: loss of hair, expansion of balding area and hair regrowth.¹

Commonly exclamation mark hair can be seen in area of hair loss. This is where the hair is tapered or broken with a club-shaped root. It is important to review eyebrows, eyelashes, and pubic hair to exclude more severe types of hair loss. Nails can also be affected with pitting and ridging.¹

One third of patients with alopecia areata will have ongoing hair loss. Just under a half of patients will regrow their hair in 6 months and a further third will re-grow their hair in 12 months.¹
A number of treatments can induce hair regrowth in alopecia areata but do not change the course of the underlying disease.

Pre-referral management

First line treatment

• Potent topical corticosteroids such as betamethasone dipropionate 0.05% (cream and/or ointment) are typically used.2, 4 Generally, 2 to 4 months is required until regrowth occurs.
  • Betamethasone dipropionate 0.05% lotion can also be prescribed; however, it is not listed on the Pharmaceutical Benefits Scheme (PBS).
• Mometasone furoate 0.1% lotion is easier to apply through hair and can be used as a PBS listed alternative and is also less potent than betamethasone dipropionate 0.05%.4

Other considerations

• Consider counselling if significant psychosocial impact.

Other treatments

• For other topical treatments such as immunotherapy and dithranol (also known as anthralin)3 Dermatologist review is recommended.

When to refer

For children up to 16 years of age; and have any of the following criteria, refer to Dermatology:

• Failure to respond to conventional therapy
• Associated significant psychosocial impact. 

Essential information to include in your referral

• Duration and severity of alopecia areata.
• Types of treatment used in the past and current treatments.

How to refer

• Routine non-urgent referrals from a GP or a Consultant are made via the Central Referral Service
• Routine non-urgent referrals from a nurse practitioner, non-medical referrers or private hospitals are made via the PCH Referral Office
• Urgent referrals (less than seven days) are made via the PCH Referral Office. Please call PCH Switch on 6456 2222 to discuss with the Dermatology registrar. 

References

1. Teillac D. Alopecia areata in children. Ann Pediatr (Paris) [Internet]. 1988 [cited 2022 Feb 23];35(5):327–30. Available from: DermNet NZ-Alopecia areata in children
2.  UpToDate [Internet]. Uptodate.com [cited 2022 Feb 23]. Available from: Alopecia areata: Management - UpToDate (health.wa.gov.au)
3. MIMS Online [Internet]. [cited 2022 Feb 2022]. Available from: MIMS | MIMS | Full Product Information (health.wa.gov.au)
4. Aung T, Aung ST. Selection of an effective topical corticosteroid. Aust J Gen Pract [Internet]. 2021 [cited 2022 Feb 23];50(9):651-5. Available from: RACGP - Selection of an effective topical corticosteroid 

Useful resources

1. Alopecia - Health Direct
2. American Academy of Dermatology Association-Hair loss types: alopecia areata diagnosis and treatment
3. Alopecia areata in children - DermnetNZ

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