Alopecia areata

Alopecia areata is a chronic inflammatory disease of the hair follicles. Hair falls out in round patches on the scalp, in the beard, on the eyebrows or eyelashes, and sometimes disappears from the whole scalp or the entire body. It is not contagious and does not scar: the follicles survive, so the hair is able to grow back.

Its course is unpredictable. A patch may fill in on its own, and a new one may appear later. Alopecia areata can start at any age, but it often begins in childhood and adolescence, and in children it is the most common hair disease.

At the Trichology Institute it is one of our main research areas. Professor Inessa Serbina studies its immune mechanisms, severity assessment, associated diseases and treatment in children, and Professor Yuliya Ovcharenko wrote her doctoral thesis on alopecia areata. We treat adults and children in Kharkiv, at 17 Danylevskoho Street.

When to see a trichologist

Come in after the first patch, even a small one. A round bald spot is not always alopecia areata: fungal scalp infections, the habit of pulling out hair (trichotillomania) and scarring alopecias can look similar. These conditions are treated in completely different ways, so an accurate diagnosis comes first.

Reasons to book a visit:

one or more hairless patches have appeared on the scalp, in the beard, on the eyebrows or eyelashes;
the patches are growing or merging, and hair at their edge comes out easily;
hair is thinning evenly over the whole scalp for no clear reason;
small pits or roughness have appeared on the nails;
a bald patch has appeared on a child;
after a period when all was well, the patches have come back.

Do not treat yourself or wait for more patches to appear: the right treatment depends on the stage and the area involved. The cost of a trichologist consultation with digital trichoscopy is listed in the consultations price list.

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What causes alopecia areata

Science does not yet have a complete answer. Today alopecia areata is regarded as an autoimmune disease with a genetic predisposition. A healthy hair follicle is protected by what is called immune privilege: the immune system leaves it alone. Genetic factors and external triggers can break this protection, and T lymphocytes then attack follicles in the active growth phase.

An affected follicle stops growing too early, and the hair thins, breaks and falls out. Yet the follicle's stem cells, unlike in scarring alopecias, usually stay intact. That is why hair loss in alopecia areata is, in principle, reversible. The process is not confined to the skin: the whole immune system takes part in it.

Triggers vary. In a study of 110 adult patients by Professor Serbina, about a third linked the onset to stress, others named childbirth or menopause, infections or vaccination, and more than a quarter could not link it to anything. In children the disease often starts at times of strain: starting school, the years before puberty, quarrels or losses in the family.

The mechanisms are described in detail in the publications "Pathogenesis of alopecia areata: immune mechanisms" and "Immunomorphological features of alopecia areata formation".

What alopecia areata looks like

The typical picture is a round or oval bald patch with clear borders. The skin inside it is smooth, with no scaling or scarring. At the start some people feel mild itching, burning or a crawling sensation where the hair later falls out. Short broken hairs are visible at the edge of an active patch, and in a band up to a centimetre wide the hair pulls out easily.

Forms

patchy: one or several separate patches;
multifocal, when patches merge;
ophiasis: a band of hair loss along the hairline at the back of the head and above the ears;
diffuse: even thinning without clear patches, easily mistaken for other types of hair loss;
totalis: no hair on the whole scalp;
universalis: no hair on the scalp, face or body.

Stages

In the active stage patches grow or new ones appear. In the chronic stage there are no complaints, hair in the patch does not grow, and the skin is a normal colour and slightly thinned.

The disease can affect the nails, causing small pits or roughness on the nail plates; see the publication "Onychodystrophies: differential diagnostic markers". Sometimes an acute episode looks like sudden greying: mostly pigmented hairs fall out while grey ones stay (see "The mysteries of grey hair").

Diagnosis at the Trichology Institute

The diagnosis is usually clear from the clinical picture, but the doctor confirms it with instruments and determines the stage. The doctor examines the hair on the scalp and body, the eyebrows, eyelashes and nails, performs a hair pull test at the edge of the patches and asks about the course, earlier treatment and other illnesses.

Digital trichoscopy on FotoFinder equipment. Yellow and black dots, exclamation-mark hairs and broken hairs indicate an active process; pigmented hairs growing back upright indicate recovery. Trichoscopy helps tell alopecia areata apart from trichotillomania and other types of hair loss.
Severity assessment with the international SBN system: the share of scalp hair lost (from S0 to S5), and involvement of the body and nails. These data guide the choice of treatment and allow objective comparison at follow-up visits.
Tests. Alopecia areata often comes with other conditions, so the doctor may order laboratory tests, for example of thyroid function, iron or vitamin D levels.
Scalp skin biopsy with histology, when the picture is atypical and other diseases need to be ruled out.

Complex cases are reviewed with clinical, trichoscopic and pathomorphological analysis, and when needed at an international consilium. Severity scales are covered in "Assessing the severity of alopecia areata", trichoscopic signs in "Trichoscopic differential diagnostic algorithms for non-scarring alopecias".

How we treat alopecia areata

No method anywhere in the world guarantees that the disease will never return. The plan is therefore individual and takes into account the form and severity, the stage, age, duration of the disease and other conditions. The aim is to stop inflammation in the patches, restore hair growth and keep the result.

Depending on the situation, the doctor may consider:

topical corticosteroids;
intralesional corticosteroid injections, performed in the clinical trichology department;
systemic therapy when the disease progresses fast or covers a large area;
topical immunotherapy for severe chronic forms;
hair growth stimulants as an addition to the main treatment;
management of associated conditions together with other specialists.

The doctor chooses the method, the medicine and the length of the course after the examination, weighing benefits and risks. We follow research on newer drug groups, including JAK inhibitors, but whether they suit a particular patient is for the doctor alone to decide.

Alopecia areata tends to relapse, so follow-up continues after the hair grows back: we compare trichoscopy findings at control visits and adjust the plan in time. Injection methods are reviewed in the publication "Injection options in the therapy of hair pathology".

Patches can be concealed during treatment: trichopigmentation with a shaved-hair effect is compatible with treatment, and for extensive forms hair replacement systems help. Hair transplantation is contraindicated if you have had alopecia areata. The list of procedures and current prices is in the clinical trichology price list.

Create a treatment plan

Children, associated diseases and outlook

Alopecia areata in children

In young children with a mild form the hair often grows back on its own, so watchful waiting can be a reasonable approach. When the process is extensive or progressing, the doctor discusses treatment options with the parents and weighs the risks: there is less research in children than in adults, and some methods are used with restraint at a young age. The approach is described in "Modern approaches to treating alopecia areata in children".

A study by Institute doctors showed that in children with alopecia areata social life and school life suffer most, and parents rate the child's well-being higher than the child does ("Study of quality of life in children with alopecia areata"). So we talk to the child, not only to the parents, and suggest psychological support when needed. More about seeing children on the Pediatric consultations page.

Associated diseases

More than half of the adult patients in Professor Serbina's study had other conditions: atopic diseases, autoimmune thyroiditis and other thyroid disorders, vitiligo, anaemia and iron deficiency, low vitamin D, anxiety disorders and sleep problems. With associated diseases, alopecia areata ran a more severe course ("Comorbidity in alopecia areata").

Outlook and follow-up

Hair may grow back after several months or years, or it may stay absent for a long time despite treatment. The outlook is more guarded with a large affected area, nail involvement and coexisting atopy. The disease is chronic, so regular control visits and long-term follow-up in the clinical trichology department matter.

Doctors

Prices

Consultation of a trichologist using digital trichoscopy	2000/1500 UAH
Consultation of the trichologist, follow up (up to 2 months after the first one)	800 UAH
Online consultation with trichologist	2000 UAH
Quantitative trichoscopy using TrichoLab	1500 UAH

Frequently Asked Questions

Can alopecia areata be cured for good?

The honest answer: there is currently no method, here or anywhere, that guarantees the disease will not come back. At the same time, the hair follicles usually survive in alopecia areata, so the hair is able to regrow, and for many patients it does.

Treatment aims to stop active inflammation, restore hair growth and lengthen the quiet period. Because relapses are possible, we advise you not to disappear once the hair has grown back: control visits with trichoscopy let us spot a new wave early, when it is easier to manage.

How can I tell whether my alopecia areata is active right now?

Signs of an active stage are patches that are getting bigger, new bald areas, short broken hairs at the edge and a band where hair pulls out easily. Some patients feel itching, burning or tingling where a patch is about to appear.

The doctor assesses activity more precisely with trichoscopy: exclamation-mark hairs, black dots and broken hairs mean the process is ongoing. Pigmented hairs growing back upright point to recovery. The choice of treatment depends on the stage, so the assessment is repeated at control visits.

Can stress trigger alopecia areata?

Stress can be a trigger, but not the only cause: the disease rests on a genetic predisposition and an autoimmune reaction against the hair follicles. In a study by our scientific consultant, about a third of adult patients linked the onset to stress, while more than a quarter could not link it to anything.

Emotional state also affects the course. Studies show that patients with higher depression scores respond to stress with a more severe course of alopecia areata. So besides treating the patches, we pay attention to sleep and anxiety and suggest a psychologist's support when needed.

Injections into the patches: who gets them and do they hurt?

Intralesional corticosteroid injections are considered first-line therapy for adults with a mild, limited form of alopecia areata. The medicine goes straight into the patch, so it works where it is needed. In children such injections are usually considered once they are over 10.

The procedure is unpleasant but tolerable: very fine needles are used, and an anaesthetic cream can be applied beforehand. Temporary thinning of the skin at the injection site is possible. Whether you need injections, how often and how many sessions, the doctor decides after the examination. More in the publication "Injection options in the therapy of hair pathology".

Which tests are needed for alopecia areata?

There is no single test that confirms alopecia areata: the diagnosis is made by examination and trichoscopy. Tests are needed to find associated conditions that are common in these patients and can make the course heavier: thyroid disease, anaemia and iron deficiency, low vitamin D, atopy.

The doctor draws up the exact list after the examination, taking into account your complaints, age and previous results. The clinic works with leading laboratories, so you can have the tests done without searching elsewhere. More about laboratory diagnostics.

Does alopecia areata affect the nails?

Yes, in some patients. Most often small pits appear on the nail plates; less often the whole plate becomes rough and dull. These changes come from damage to the nail matrix and are also seen in psoriasis, eczema and lichen planus.

Doctors regard nail involvement as an unfavourable prognostic sign, so the nails are always checked at the visit and counted in the SBN severity score, where N stands for nails. More in the publication "Onychodystrophies: differential diagnostic markers".

Can I have a scalp peel or other scalp procedures during a flare?

Scalp peels are contraindicated in chronic scalp diseases during a flare, and alopecia areata in its active phase is on that list. Irritating the skin at this time is undesirable.

For other care and aesthetic procedures, the decision belongs to the doctor who manages your treatment, since they know the stage of the disease and the therapy plan. If you have booked a procedure in another department or a salon, tell the specialist about your diagnosis.

Can I have a hair transplant, or hide the patches during treatment?

Hair transplantation is contraindicated if you have had alopecia areata: transplanted follicles can come under the same immune attack.

Other methods help conceal the patches. Trichopigmentation with a shaved-hair effect gives the look of a closely cropped head; the pigment gradually fades over 2 to 3 years, and the procedure is compatible with treatment. For extensive forms during long treatment, hair replacement systems are an option. Cosmetic correction matters for psychological comfort, and we discuss it together with treatment.

My child's hair may grow back on its own. Does it need treatment?

Not always straight away. In young children with a mild form the hair often regrows without treatment, so observation with control visits can be a sound choice. A diagnosis is still needed, since a fungal infection or the habit of pulling out hair can look the same.

If there are many patches or they grow quickly, the doctor discusses treatment options with the parents and weighs the risks, as some methods are used with restraint in children. How the disease affects the child's well-being and friendships matters too. The approach is described in "Modern approaches to treating alopecia areata in children".

How can I support a child with alopecia areata?

In a study by Institute doctors, children with alopecia areata suffered most in their social and school life, and parents rated their children's well-being higher than the children themselves did. So it is worth asking the child how they feel rather than deciding for them.

A calm and honest talk about the disease helps, as does support from teachers, a psychologist when needed and, if the child wants it, careful concealment of the patches. Conflicts and overload can worsen the course, so routine and a calm atmosphere at home matter too. More in "Study of quality of life in children with alopecia areata".

Who treats alopecia areata at the Institute?

Patients with alopecia areata are seen by Professor Inessa Serbina, who leads the Alopecia School project and has published on the immune mechanisms, severity, associated diseases and treatment of the disease in children, and Professor Yuliya Ovcharenko, who devoted her doctoral thesis and clinical guidelines to alopecia areata and is a member of the international GRASS consensus on a patient registry.

Associated skin conditions in adults and children are managed with the help of Yulia Kachuk, head of the dermatology department. Complex cases are discussed jointly, and when needed at an international consilium.