Alopecia Areata

Alopecia areata is an autoimmune disease that causes your immune system to attack your hair follicles, leading to patchy hair loss on the scalp, face, or body—affecting nearly 7 million people in the United States.

What is alopecia areata?
Types and classifications
Who gets alopecia areata?
What causes this condition?
Symptoms and signs
How doctors diagnose alopecia areata
Treatment options
Will hair regrow?
Living with alopecia areata
Self-care and daily management

What is alopecia areata?

Alopecia areata is a common skin disease where your body’s immune system mistakenly attacks your hair follicles, causing hair loss. The word “alopecia” means hair loss or baldness, and “areata” means that it occurs in small, random areas^[1]. This is an autoimmune disease, which means your body’s defense system mistakes healthy parts of your body as dangerous invaders and begins attacking them^[2].

Most people with alopecia areata lose hair in circular, coin-sized patches on the scalp, but in more severe cases, they may lose all of their hair^[2]. The condition can affect the scalp, face, and sometimes other body areas, like under the arms or on the legs^[2]. When your immune system attacks your hair follicles, your hair begins to fall out, often in clumps the size and shape of a quarter^[1].

Types and classifications

There are several different types of alopecia areata, classified based on the amount of hair lost and where it occurs on the body^[1]:

Alopecia areata totalis: Complete loss of all hair on the scalp
Alopecia areata universalis: Complete loss of all hair on the scalp and all body hair
Diffuse alopecia areata: Hair is thinning rather than falling out in patches
Ophiasis alopecia areata: Loss of a band of hair on the bottom back sides of the scalp^[1]

These terms describe the same diagnosis but indicate different patterns and severity of hair loss^[11].

Who gets alopecia areata?

Anyone can develop alopecia areata, regardless of age, gender, or racial and ethnic background^[2]. About 2% of people across the world will experience alopecia areata at some point in their lifetime. This means nearly 7 million people in the United States and 160 million worldwide have, have had, or will have alopecia areata^[2].

Your chances of developing alopecia areata are greater if you are a child, have a family history of the condition, or if you or your family members have other autoimmune disorders, including diabetes, lupus, or thyroid disease^[1]. Research suggests that women are more likely to develop alopecia areata than men^[2]. Several studies found the odds of developing the disease were higher among Asian, Black, and Hispanic individuals than among whites^[2].

Although alopecia areata can begin at any age, most people develop the disease early in life. More than 80% show signs of the disease before age 40, and 40% experience symptoms by age 20^[2]. The hair loss often first appears during childhood, but how and when this happens is different for everyone^[2].

What causes this condition?

Alopecia areata is a polygenic disease, meaning it is related to multiple genetic factors. Your genetic makeup may trigger your body’s autoimmune reaction, or your genes combined with a virus or another environmental factor may cause the condition^[1]. Scientists know it is an autoimmune disease, but they aren’t sure why the immune system attacks the healthy hair follicles of people with certain gene variations in the first place^[2].

About 20% of people with alopecia areata have at least one family member who also has the disease^[2]. However, not everyone with the genes develops the condition. For example, identical twins share all the same genes, but if one twin has alopecia areata, there is only a 55% chance that the other twin will have it^[2].

Your immune system attacks your hair follicles because it thinks they’re foreign invaders—bacteria, viruses, parasites, or fungi—that cause infection, illness, and disease^[1]. This condition targets the anagen hair follicles (the growing phase of hair) and leads to hair loss without permanent damage to the follicles^[3].

Symptoms and signs

The classic presentation of alopecia areata involves isolated, smooth, sudden, and patchy hair loss on the scalp or any area with hair growth^[3]. The patches are usually small and round—about the size of a quarter—but the shape and amount of hair you lose may be bigger or smaller^[1].

Common symptoms include^[1]:

Patches of hair loss, including on the scalp, facial hair, eyebrows, eyelashes, and body hair
Nail pitting (small dents or pits in the nails that may make them feel coarse or gritty, like sandpaper)

Your patches won’t typically have any other symptoms, but in rare cases, they may itch, change color (red, purple, brown, or gray), develop visible openings in your hair follicles, have black dots (hair shafts visible in the follicles), grow short hairs that are thicker on the top and narrow toward your scalp (called exclamation point hairs), or grow white hairs^[1].

Alopecia areata usually presents as localized patches of hair loss on the scalp, which develop over a few weeks^[3]. Most people lose hair in circular, coin-sized patches on the scalp, but in more severe cases, they may lose all of their hair^[2].

How doctors diagnose alopecia areata

Typically, a diagnosis of alopecia areata can be made based on the pattern and history of hair loss^[11]. Doctors can usually recognize the condition by well-defined patches of hair loss with exclamation mark hairs at the edges of the patches^[10].

In some cases, your doctor may need to perform a biopsy to confirm the diagnosis. When doctors do a biopsy, they look for immune cells around the base of the hair follicle^[11]. The underlying skin where hair has been lost is unscarred and looks superficially normal^[4].

Treatment options

While there is no cure for alopecia areata, there are treatments that may help your hair regrow^[8]. Treatment is not mandatory because the condition is benign, and spontaneous remissions and recurrences are common^[12]. The kind of treatment your doctor recommends depends on the type or form of your hair loss, the severity of hair loss (how much hair you have lost), your age, what you have tried already, and if you also have an allergic condition^[8].

Effective treatments for alopecia areata block the immune system attack on the hair follicles so hair can regrow^[8]. However, there is no good evidence that any treatment will guarantee the hair will regrow^[13].

Common treatments for mild or limited disease

For limited areas of alopecia, some people decide not to have any treatment. Instead, they use different products, such as scarves and hairpieces, or camouflage techniques like hairstyles to hide the affected areas^[8]. If you do want treatment, commonly available options include^[8]:

Intralesional corticosteroids: The most common treatment for adults with patchy alopecia areata. A very fine needle injects medication into the areas of missing hair on the scalp or face. If the injections are successful, you may see new hair growth within six to eight weeks^[8].
Topical corticosteroids: Steroid cream, ointment, or solution applied to the skin where hair loss has occurred. These are often a common first choice for children or for adults who can’t have injections^[8].
Minoxidil: Available as oral tablets or topical solutions and foams. Although some studies have shown that low doses of oral minoxidil have helped hair regrow, it is most often used in combination with other treatments^[8]. Topical minoxidil and triamcinolone injections are effective in speeding hair regrowth^[4].
Topical calcineurin inhibitors: Another type of medicine put on the skin^[13].

Advanced treatments

Since June 2022, the Federal Drug Administration (FDA) has approved three medications for severe disease^[8]. These are Janus kinase (JAK) inhibitors, a breakthrough class of medicines for treating alopecia areata:

Baricitinib (Olumiant®): Approved in June 2022 for the treatment of severe alopecia areata in adults^[11].
Ritlecitinib (LITFULO®): Approved in June 2023 for people with severe alopecia areata ages 12 years and older^[11].
Deuruxolitinib (Leqselvig®): Approved in July 2024^[11].

More advanced or refractory cases might require oral immunosuppressants, topical diphenylcyclopropenone, or topical anthralin^[10]. There is little evidence that use of oral medicines will produce lasting hair regrowth, and the side effects of these medicines usually outweigh any potential benefit^[13].

Other care recommendations

Sunscreen, head coverings to protect from cold and sun, and glasses (if the eyelashes are missing) are also recommended^[4]. If your eyes get irritated due to missing eyelashes, make sure to have eye drops available to soothe any discomfort^[15].

Will hair regrow?

Although many people experience spontaneous hair regrowth within one year, alopecia areata is a chronic condition characterized by recurring episodes of hair loss^[3]. In more than 50% of cases of sudden-onset localized patchy disease, hair regrows within a year. In patients with only one or two patches, this one-year recovery will occur in up to 80%^[4].

However, many people will have more than one episode over the course of a lifetime. In many patients, hair loss and regrowth occur simultaneously over the course of several years^[4]. For limited areas of alopecia, the affected hairs shed and new hair may regrow, with 95% of the time the hair will regrow without treatment^[13].

Several factors affect hair regrowth^[13]:

Age: The younger a person is when hair loss starts, the less likely it is to grow back
Amount of hair involved: If there are many areas of hair loss, it is not likely to grow back
Amount of time: The longer the hair loss continues, the less likely it is to grow back

People with alopecia totalis or alopecia universalis usually have a poorer prognosis, and treatment failure is seen in most patients with any therapy. Among those in whom all body hair is lost, fewer than 10% recover^[4].

Living with alopecia areata

Living with alopecia areata can be challenging. Hair loss and regrowth are unpredictable and can be cyclical (comes and goes)^[14]. Alopecia areata doesn’t typically affect your physical health or cause pain. However, it can affect you psychologically and emotionally. You may experience stress, anxiety, and depression^[1].

People with alopecia areata and their loved ones experience various feelings and frustrations^[14]. Common emotions include:

Loneliness, withdrawal, and isolation
Loss and grief
Sadness, which can lead to depression
Confusion and denial
Stress and anger
Hopelessness and embarrassment
Fear and guilt or self-blame^[14]

Research shows that over 70% of adults with alopecia areata experience depression or anxiety, and about 60% go on drugs to help these symptoms^[16]. It’s very normal to have these feelings. Your hair is often linked to your personal identity. If you lose your hair, you may feel like you’ve lost part of yourself^[16].

When to seek professional help

If you are overwhelmed or have trouble coping with everyday life, it may be time to seek professional help from a therapist, counselor, social worker, or psychologist. They can help you understand your feelings and teach you ways to cope^[14].

Consider reaching out to a professional if you experience any of these issues^[14]:

Difficulty completing routine tasks
Missing work or school
Isolating yourself from friends and family
Emotions that seem out of control (anger, crying, helplessness)
Feelings of wanting to hurt yourself
Difficulties in your intimate or family relationships
Using unhealthy behaviors to cope, such as abusing alcohol

Warning signs of depression include a persistent sad mood, loss of interest in regular activities, fatigue and lack of energy, trouble with concentration, problems with sleeping, suicidal thoughts, and changes in appetite. If these last for more than two weeks, let your doctor know^[16].

Finding support

Finding the right support for any chronic disease is important. Support can come in different ways, from group meetings (online or in person) to one-on-one conversations. The choice depends on your comfort level and what is available^[14]. An excellent way to meet others with alopecia areata and get support is by joining a support group or attending awareness events^[14].

Many people with alopecia areata reach a point of acceptance, and many turn their experience into something positive^[14].

Self-care and daily management

Managing your alopecia areata and practicing self-care is important. Seemingly minor things that you do day after day can make a major difference^[15].

Hair care routine

Your hair care routine can make a difference when it comes to the extent of hair loss from alopecia areata. Suggestions include^[15]:

Brush gently: Use a soft-bristled brush or wide-toothed comb to minimize tugging that can pull out hair
Keep shampooing: Don’t stop washing your hair because you’re worried about hair loss. That can lead to dandruff and other issues that can sometimes worsen alopecia areata
Keep the heat down: If you use a hair dryer, keep it on medium heat or lower to avoid overstressing your hair. Hot rollers or hot irons can damage hair and cause breakage

Sun protection

Hair strands form a protective layer that shields your scalp from the sun’s harmful ultraviolet rays. Bald patches left by an alopecia areata flare-up expose your skin to these damaging rays. You can protect yourself by applying sunscreen to exposed areas (choose sunscreen with at least 30 SPF) and wearing a hat with a wide brim^[15].

Guard against the cold

Hair provides warmth and insulation for your head. If alopecia areata leaves a few bare patches on your head, you’re going to lose a bit of heat from those spots. When the temperature starts to drop, you’re going to feel colder sooner. You may find that you need to wear a hat earlier in the season. Sleeping caps may also come in handy when you go to bed given cooler temperatures at night^[15].

Managing other hair loss

Alopecia areata can also affect hair anywhere on your body^[15]:

Eyebrow loss: Eyebrows help keep sweat, water, or debris from trickling into your eyes. If you lose your eyebrows, wearing a hat, headband, or bandana can help absorb sweat and water
Eyelash loss: Eyelashes guard your eyes by blocking dirt, grit, and dusty debris. Wearing glasses or sunglasses can help fill the void if you lose your eyelashes
Nose hair: Loss of nose hair can affect filtering of air

Celebrating overall health

It’s important to celebrate your overall health. Most people who have alopecia areata are healthy^[16]. The condition doesn’t shorten your life or make it difficult to walk or talk. If you have small patches, you can use hair-colored powder, cream, or crayon to camouflage them. If they are larger, you can try a wig, hairpiece, scarf, or hat^[16].

Stress management

Some people with alopecia areata report that they notice a new cycle of hair loss after they go through a period of stress. It’s important to try to learn to manage your stress with techniques such as yoga or meditation. Exercise is also a good way to relieve tension^[16].