Overview
Alopecia may be localized or generalized, scarring or non-scarring, and can be abrupt or gradual in onset.
Assessment Workflow
View More on Disease Algorithm-
1. History
Review meds, diet restriction, thyroid symptoms.
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2. Exam
Check pull test, facial/body hair, and nails.
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3. Clinical dx
Alopecia areata diagnosis is usually clinical.
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4. Severity
Use SALT or AAS to assess alopecia areata severity.
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5. Psych status
Assess quality of life and psychological status.
Diagnosis
- Alopecia areata is usually a clinical diagnosis.
- Patchy alopecia areata shows circumscribed areas of hair loss.
- Exclamation mark hairs may be seen at the periphery.
- Hair pull test may be positive at the margins.
- SALT is used to assess severity.[1][2]
Differential Diagnosis
| Differential diagnosis | Key Distinguishing Feature |
|---|---|
| Trichotillomania | |
| Tinea capitis | |
| Secondary syphilis | |
| Aplasia cutis | |
| Telogen effluvium |
Diagnostics: Lab Tests and Imaging
| Test / Assessment | Clinical Purpose |
|---|---|
| Trichoscopy | May help visualize findings consistent with alopecia areata.[1] |
| Patch biopsy | May be done in rare difficult cases.[1] |
| TSH level | Routinely performed by many physicians to rule out thyroid abnormality.[1] |
| Medical photography | Recommended for baseline in alopecia areata.[1] |
Pharmacological Management
| Treatment role | Therapy | Key note |
|---|---|---|
| Intralesional | Corticosteroids | First-line for adult patients with <50% limited patchy hair loss.[2] |
| Topical | Corticosteroids | Initial therapy for limited patchy alopecia areata if intralesional is not tolerated.[2] |
| Oral | Corticosteroids | May be considered in moderate to severe or rapidly progressive disease.[2] |
| Systemic immunotherapy | JAK inhibitors | Approved for patients with severe alopecia areata.[2] |
| Topical immunotherapy | DPCP or SADBE | Recommended for chronic extensive alopecia areata, totalis and universalis.[2] |
Non-pharmacological management
- Provide psychosocial support for mild distress.
- Refer moderate to severe distress for psychological intervention.
- Use wigs or scalp prostheses for extensive hair loss.
- Eyebrow pencil may cover eyebrow patches.
- Permanent or semi-permanent eyebrow tattooing may be suggested.[2]
Specialist Referral
Referral Indication: Moderate to severe psychological distress
Suggested Specialist: Specialist for psychological intervention
References
- Lepe K, Syed HA, Zito PM. Alopecia areata. StatPearls [Internet]. Treasure Island (FL): StatPearls Publishing; 2024 Jan.
- Messenger AG. Alopecia areata: Management. UpToDate. Jan 2023.
