Hair Loss
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Alopecia areata is considered an autoimmune disease, in which
the immune system, which is designed to protect the body from foreign invaders
such as viruses and bacteria, mistakenly attacks the hair follicles, the
tiny cup-shaped structures from which hairs grow. This can lead to hair
loss on the scalp and elsewhere.
In most cases, hair falls out in small, round patches about
the size of a quarter. In many cases, the disease does not extend beyond
a few bare patches. In some people, hair loss is more extensive. Although
uncommon, the disease can progress to cause total loss of hair on the head
(referred to as alopecia areata totalis) or complete loss of hair on the
head, face, and body (alopecia areata universalis).
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In alopecia areata, immune system cells called white blood
cells attack the rapidly growing cells in the hair follicles that make
the hair. The affected hair follicles become small and drastically slow
down hair production. Fortunately, the stem cells that continually supply
the follicle with new cells do not seem to be targeted. So the follicle
always has the potential to regrow hair.
Scientists do not know exactly why the hair follicles undergo
these changes, but they suspect that a combination of genes may predispose
some people to the disease. In those who are genetically predisposed, some
type of trigger--perhaps a virus or something in the person's environment--brings
on the attack against the hair follicles.
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Alopecia areata affects an estimated four million Americans
of both sexes and of all ages and ethnic backgrounds. It often begins in
childhood.
If you have a close family member with the disease, your risk
of developing it is slightly increased. If your family member lost his
or her first patch of hair before age 30, the risk to other family members
is greater. Overall, one in five people with the disease have a family
member who has it as well.
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Alopecia areata is not a life-threatening disease. It does
not cause any physical pain, and people with the condition are generally
healthy otherwise. But for most people, a disease that unpredictably affects
their appearance the way alopecia areata does is a serious matter.
The effects of alopecia areata are primarily socially and emotionally
disturbing. In alopecia universalis, however, loss of eyelashes and eyebrows
and hair in the nose and ears can make the person more vulnerable to dust,
germs, and foreign particles entering the eyes, nose, and ears.
Alopecia areata often occurs in people whose family members
have other autoimmune diseases, such as diabetes, rheumatoid arthritis,
thyroid disease, systemic lupus erythematosus, pernicious anemia, or Addison's
disease. People who have alopecia areata do not usually have other autoimmune
diseases, but they do have a higher occurrence of thyroid disease, atopic
eczema, nasal allergies, and asthma.
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It is possible, but not likely, for alopecia areata to be inherited.
Most children with alopecia areata do not have a parent with the disease,
and the vast majority of parents with alopecia areata do not pass it along
to their children.
Alopecia areata is not like some genetic diseases in which
a child has a 50-50 chance of developing the disease if one parent has
it. Scientists believe that there may be a number of genes that predispose
certain people to the disease. It is highly unlikely that a child would
inherit all of the genes needed to predispose him or her to the disease.
Even with the right (or wrong) combination of genes, alopecia
areata is not a certainty. In identical twins, who share all of the same
genes, the concordance rate is only 55 percent. In other words, if one
twin has the disease, there is only a 55 percent chance that the other
twin will have it as well. This shows that other factors besides genetics
are required to trigger the disease.
To learn more about the genes and other factors involved in
alopecia areata risk, the National Institute of Arthritis and Musculoskeletal
and Skin Diseases (NIAMS) is funding an alopecia areata registry. The registry
is an organized network of five centers throughout the United States that
will identify and register patients with the disease and collect data and
blood samples (which contain genes). Data, including genetic information,
will be made available to researchers studying the genetic basis and other
aspects of disease and disease risk.
There is every chance that your hair will regrow, but it may
also fall out again. No one can predict when it might regrow or fall out.
The course of the disease varies from person to person. Some people lose
just a few patches of hair, then the hair regrows, and the condition never
recurs. Other people continue to lose and regrow hair for many years. A
few lose all the hair on their head; some lose all the hair on their head,
face, and body. Even in those who lose all their hair, the possibility
for full regrowth remains.
In some, the initial hair regrowth is white, with a gradual
return of the original hair color. In most, the regrown hair is ultimately
the same color and texture as the original hair.
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The course of alopecia areata is highly unpredictable, and
the uncertainty of what will happen next is probably the most difficult
and frustrating aspect of the disease. You may continue to lose hair, or
your hair loss may stop. The hair you have lost may or may not grow back,
and you may or may not continue to develop new bare patches.
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While there is neither a cure for alopecia areata nor drugs
approved for its treatment, some people find that medications approved
for other purposes can help hair grow back, at least temporarily. The following
are some treatments for alopecia areata. Keep in mind that while these
treatments may promote hair growth, none of them prevent new patches or
actually cure the underlying disease. Consult your health care professional
about the best option for you.
- Corticosteroids--Corticosteroids are powerful anti-inflammatory
drugs similar to a hormone called cortisol produced in the body. Because
these drugs suppress the immune system if given orally, they are often
used in the treatment of various autoimmune diseases, including alopecia
areata. Corticosteroids may be administered in three ways for alopecia
areata:
- Local injections--Injections of steroids
directly into hairless patches on the scalp and sometimes
the brow and beard areas are effective in increasing hair
growth in most people. It usually takes about 4 weeks for
new hair growth to become visible. Injections deliver small
amounts of cortisone to affected areas, avoiding the more
serious side effects encountered with long-term oral use.
The main side effects of injections are transient pain, mild
swelling, and sometimes changes in pigmentation, as well
as small indentations in the skin that go away when injections
are stopped. Because injections can be painful, they may
not be the preferred treatment for children. After 1 or 2
months, new hair growth usually becomes visible, and the
injections usually have to be repeated monthly. The cortisone
removes the confused immune cells and allows the hair to
grow. Large areas cannot be treated, however, because the
discomfort and the amount of medicine become too great and
can result in side effects similar to those of the oral regimen.
- Oral corticosteroids--Corticosteroids
taken by mouth are a mainstay of treatment for many autoimmune
diseases and may be used in more extensive alopecia areata.
But because of the risk of side effects of oral corticosteroids,
such as hypertension and cataracts, they are used only occasionally
for alopecia areata and for shorter periods of time.
- Topical ointments--Ointments or creams
containing steroids rubbed directly onto the affected area
are less traumatic than injections and, therefore, are sometimes
preferred for children. However, corticosteroid ointments
and creams alone are less effective than injections; they
work best when combined with other topical treatments, such
as minoxidil or anthralin.
- Minoxidil (5%) (Rogaine*)--Topical minoxidil solution
promotes hair growth in several conditions in which the hair follicle
is small and not growing to its full potential. Minoxidil is FDA-approved
for treating male and female pattern hair loss. It may also be useful
in promoting hair growth in alopecia areata. The solution, applied twice
daily, has been shown to promote hair growth in both adults and children,
and may be used on the scalp, brow, and beard areas. With regular and
proper use of the solution, new hair growth appears in about 12 weeks.
*Brand names included in this booklet are provided
as examples only, and their inclusion does not mean that these
products are endorsed by the National Institutes of Health or
any other Government agency. Also, if a particular brand name
is not mentioned, this does not mean or imply that the product
is unsatisfactory.
- Anthralin (Psoriatec)--Anthralin, a synthetic tar-like
substance that alters immune function in the affected skin, is an approved
treatment for psoriasis. Anthralin is also commonly used to treat alopecia
areata. Anthralin is applied for 20 to 60 minutes ("short contact therapy")
to avoid skin irritation, which is not needed for the drug to work. When
it works, new hair growth is usually evident in 8 to 12 weeks. Anthralin
is often used in combination with other treatments, such as corticosteroid
injections or minoxidil, for improved results.
- Sulfasalazine--A sulfa drug, sulfasalazine has been
used as a treatment for different autoimmune disorders, including psoriasis.
It acts on the immune system and has been used to some effect in patients
with severe alopecia areata.
- Topical sensitizers--Topical sensitizers are medications
that, when applied to the scalp, provoke an allergic reaction that leads
to itching, scaling, and eventually hair growth. If the medication works,
new hair growth is usually established in 3 to 12 months. Two topical
sensitizers are used in alopecia areata: squaric acid dibutyl ester (SADBE)
and diphenylcyclopropenone (DPCP). Their safety and consistency of formula
are currently under review.
- Oral cyclosporine--Originally developed to keep people's
immune systems from rejecting transplanted organs, oral cyclosporine
is sometimes used to suppress the immune system response in psoriasis
and other immune-mediated skin conditions. But suppressing the immune
system can also cause problems, including an increased risk of serious
infection and possibly skin cancer. Although oral cyclosporine may regrow
hair in alopecia areata, it does not turn the disease off. Most doctors
feel the dangers of the drug outweigh its benefits for alopecia areata.
- Photochemotherapy--In photochemotherapy, a treatment
used most commonly for psoriasis, a person is given a light-sensitive
drug called a psoralen either orally or topically and then exposed to
an ultraviolet light source. This combined treatment is called PUVA.
In clinical trials, approximately 55 percent of people achieve cosmetically
acceptable hair growth using photochemotherapy. However, the relapse
rate is high, and patients must go to a treatment center where the equipment
is available at least two to three times per week. Furthermore, the treatment
carries the risk of developing skin cancer.
- Alternative therapies--When drug treatments fail to
bring sufficient hair regrowth, some people turn to alternative therapies.
Alternatives purported to help alopecia areata include acupuncture, aroma
therapy, evening primrose oil, zinc and vitamin supplements, and Chinese
herbs. Because many alternative therapies are not backed by clinical
trials, they may or may not be effective for regrowing hair. In fact,
some may actually make hair loss worse. Furthermore, just because these
therapies are natural does not mean that they are safe. As with any therapy,
it is best to discuss these treatments with your doctor before you try
them.
In addition to treatments to help hair grow, there are measures
that can be taken to minimize the physical dangers or discomforts of lost
hair.
- Sunscreens are important for the scalp, face, and all exposed areas.
- Eyeglasses (or sunglasses) protect the eyes from excessive sun, and
from dust and debris, when eyebrows or eyelashes are missing.
- Wigs, caps, or scarves protect the scalp from the sun and keep the
head warm.
- Antibiotic ointment applied inside the nostrils helps to protect against
organisms invading the nose when nostril hair is missing.
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This is a common question, particularly for children, teens,
and young adults who are beginning to form lifelong goals and who may live
with the effects of alopecia areata for many years. The comforting news
is that alopecia areata is not a painful disease and does not make people
feel sick physically. It is not contagious, and people who have the disease
are generally healthy otherwise. It does not reduce life expectancy and
it should not interfere with the ability to achieve such life goals as
going to school, working, marrying, raising a family, playing sports, and
exercising.
The emotional aspects of living with hair loss, however, can
be challenging. Many people cope by learning as much as they can about
the disease; speaking with others who are facing the same problem; and,
if necessary, seeking counseling to help build a positive self-image. To
address quality-of-life issues for alopecia areata and all other skin diseases,
the NIAMS sponsored a scientific meeting in September 2002 on the burden
of skin diseases.
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Living with hair loss can be hard, especially in a culture
that views hair as a sign of youth and good health. Even so, most people
with alopecia areata are well-adjusted, contented people living full lives.
The key to coping is valuing yourself for who you are, not
for how much hair you have or don't have. Many people learning to cope
with alopecia areata find it helpful to talk with other people who are
dealing with the same problems. More than four million people nationwide
have this disease at some point in their lives, so you are not alone. If
you would like to be in touch with others with the disease, the National
Alopecia Areata Foundation (NAAF) can help through its pen pal program,
message boards, annual conference, and support groups that meet in various
locations nationwide.
Another way to cope with the disease is to minimize its effects
on your appearance. If you have total hair loss, a wig or hairpiece can
look natural and stylish. For small patches of hair loss, a hair-colored
powder, cream, or crayon applied to the scalp can make hair loss less obvious
by eliminating the contrast between the hair and the scalp. Skillfully
applied eyebrow pencil can mask missing eyebrows.
Children with alopecia areata may prefer to wear bandanas or
caps. There are many styles available to suit a child's interest and mood-some
even have ponytails attached.
For women, attractive scarves can hide patchy hair loss; jewelry
and clothing can distract attention from patchy hair; and proper makeup
can camouflage the effects of lost facial hair. If you would like to learn
more about camouflaging the cosmetic aspects of alopecia areata, ask your
doctor or members of your local support group to recommend a cosmetologist
who specializes in working with people whose appearance is affected by
medical conditions.
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While a cure is not imminent, researchers are making headway
toward a better understanding of the disease. This increased understanding
will likely lead the way to better treatments for alopecia areata and eventually
a way to prevent or even cure it.
Alopecia research ranges from the most basic studies of the
mechanisms of hair growth and hair loss in mice to testing medications
and ways to apply medications to help regrow hair in people. Both the National
Institutes of Health and the National Alopecia Areata Foundation support
research into the disease and its treatment. Here are some areas of research
that hold promise.
- Developing an animal model--This is a critical first
step toward understanding the disease, and much progress has been made.
By developing a mouse with a disease similar to human alopecia areata,
researchers hope to learn more about the mechanism of the disease and
eventually develop immune system treatments for the disease in people.
- Mapping genes--Scientists are studying the possible
genetic causes and mechanism of the disease both in families that have
one or more persons with the disease and in the general population. An
understanding of the genetics of the disorder will aid in disease prevention,
early intervention, and development of specific therapies.
- Studying hair follicle development--By studying how
hair follicles form in mouse embryos, researchers hope to gain a better
understanding of hair cycle biology that may lead to treatments for the
underlying disease process.
- Targeting the immune system--Several new agents found
to be effective in treating psoriasis may prove to be effective in alopecia
areata. These drugs work by blocking certain chemical messengers that
play a role in the immune response, or by interfering with the activity
of white blood cells (called T-cells) that are involved in the immune
system's attack on hair follicles. New therapies for treating other autoimmune
diseases like rheumatoid arthritis and lupus may also benefit patients
with alopecia areata.
- Finding better ways to administer drugs--One limitation
of current topical therapies is getting the drug to the source of the
problem. Scientists are looking for a substance that penetrates the fat
under the skin to deliver medication directly to hair follicles. In laboratory
animals, topically applied synthetic sacs called liposomes seem to fill
the bill. Studies are still needed to show whether liposomes do the same
for people.
- Understanding cytokines--Chemical messengers called
cytokines play a role in regulating the body's immune response, whether
it is the normal response to a foreign invader such a virus or an abnormal
response to a part of the body. Researchers believe that by giving certain
inflammation-suppressing cytokines, they may be able to slow down or
stop the body's abnormal response to the hair follicles. Because giving
the cytokines systemically may cause adverse effects, they believe a
topical medication using liposomes to get the agents to the root of the
hair inside the follicle may be preferable.
- Understanding stem cell biology--Epithelial stem cells
are immature cells that are responsible for regenerating and maintaining
a variety of tissues, including the skin and the hair follicles. Stem
cells in the follicle appear to be spared from injury in alopecia areata,
which may explain why the potential for regrowth is always there in people
with the disease. By studying the biology of these cells, and their immediate
offspring, which seem to be targeted by the immune system, scientists
hope to gain a better understanding of factors that trigger the disease.
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National Institute
of Arthritis and Musculoskeletal and Skin Diseases (NIAMS)
National Center for
Complementary and Alternative Medicine Clearinghouse
American Academy of Dermatology
National Alopecia Areata Foundation
American Hair Loss Council
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Acupuncture--a traditional Chinese system
of healing in which symptoms are relieved by inserting needles beneath
the skin at selected points and then stimulating the points by rotating
the needles or exposing them to heat or electrical current.
Addison's disease--a condition that occurs
when the adrenal glands (a pair of glands situated on top of the kidneys)
fail to secrete enough corticosteroid hormones. Without treatment, the
disease can be fatal.
Alopecia areata--an autoimmune, often reversible
disease in which loss of hair occurs in sharply defined areas usually involving
the scalp or beard, but at times every hair on the body.
Alopecia areata totalis--a form of alopecia
areata characterized by the total loss of hair from the scalp and face.
Alopecia areata universalis--a form of alopecia
areata in which all hair on the scalp, face, and body is lost.
Aroma therapy--the therapeutic use of essential
oils (highly concentrated aromatic extracts distilled from a variety of
aromatic plant materials including grasses, leaves, flowers, needles and
twigs, fruit peels, wood, and roots) to promote the health of body, mind,
and spirit.
Autoimmune disease--a disease that results
when the immune system mistakenly attacks the body's own tissues. Rheumatoid
arthritis and systemic lupus erythematosus are autoimmune diseases ("auto" means
self).
Chemotherapy--the use of strong drugs to suppress
the immune system. Though originally associated with cancer treatment,
chemotherapy is used for many different diseases involving the immune system.
Corticosteroids--potent anti-inflammatory
hormones that are made naturally in the body or synthetically (man-made)
for use as drugs. They are also called glucocorticoids. The most commonly
prescribed drug of this type is prednisone.
Cyclosporine--a strong drug that suppresses
the immune system. Originally developed to keep the body's immune system
from rejecting transplanted organs, cyclosporine is being used increasingly
in autoimmune diseases, including (in rare cases) alopecia areata.
Diabetes--a disease in which the body does
not produce or properly use insulin, a hormone that is necessary to convert
sugar, starches, and other food into energy.
Evening primrose oil--the oil of a weedy plant
containing the essential fatty acid gamma linolenic acid (GLA), which is
converted into anti-inflammatory agents by the body. Evening primrose oil
is available as a nutritional supplement and touted as a pain and inflammation
reliever.
Hair bulb--a bulbous collection of actively
growing cells at the base of the follicle that constantly produces a strand
of hair.
Hair follicle--a small cup-shaped structure
in the skin from which hair grows. The cup is lined with cells and connective
tissue.
Immune system--a complex network of specialized
cells and organs that work together to defend the body against attacks
by "foreign" invaders such as bacteria and viruses. In some rheumatic conditions,
it appears that the immune system does not function properly and may even
work against the body.
Liposome--a synthetic microscopic globule
made of fatty layers encapsulating drugs or other substances. Liposomes
are often used to deliver substances to the body's cells and tissues.
Pernicious anemia--a potentially dangerous
form of anemia, usually caused by an autoimmune process, which results
in a deficiency of vitamin B-12.
Rheumatoid arthritis--an autoimmune disease
that targets primarily the membrane lining the joints, leading to pain,
stiffness, swelling, and joint deformity.
Systemic lupus erythematosus--a chronic autoimmune
disease of the connective tissue that can attack and damage the skin, joints,
blood vessels, and internal organs.
Topical sensitizers--medications that, when
applied to the scalp, provoke an allergic reaction that leads to itching,
scaling, and often hair growth. They include squaric acid dibutyl ester
and diphenylcyclopropenone.
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