Alopecia areata: treatment, causes, symptoms and outlook

The British Association of Dermatologists (BAD) says people with mild alopecia areata may not need treatment because their hair may regrow on its own. There is currently no cure for this condition, and the aim of treatment is to help with symptoms of hair loss. Some treatments can induce hair growth, but none can alter the overall course of the disease, and the treatments that can be considered depend on the severity of hair loss.

The NHS hair loss page adds that no treatment is 100% effective, that not all treatments are available on the NHS so you may have to pay, and that you should see a GP to get an idea about what is causing hair loss before thinking about going to a commercial hair clinic.

Oral JAK inhibitors are the first tablet class licensed for severe alopecia areata. They work by blocking Janus kinase proteins that drive inflammation, which damps down the immune system and carries a risk of infection. The British Association of Dermatologists notes that tofacitinib, used for other conditions, has been linked with more heart-related events, cancers, blood clots and serious infections, and that regulators have issued a warning for JAK inhibitors generally, although it is unclear whether the same risks apply in alopecia areata.

Topical JAK inhibitors have not been shown to regrow scalp hair and are not available on the NHS. These are prescription medicines that need specialist assessment, so this page does not recommend any product.

BAD says hair loss in this condition is caused by inflammation of the hair follicle: the immune system mistakenly attacks the hair follicle, stopping it from growing hair. The exact cause of why this happens is not fully understood. Alopecia UK says certain immune cells mistakenly attack the hair follicles, and that both environmental factors and genetics are believed to play a role.

BAD says there is a genetic predisposition, with a family history of the condition in about 2 out of 10 people affected. It says triggers such as previous infections and stress have been suggested, but this link may be coincidental because it has been impossible to identify such triggers in many people. Alopecia UK lists a family history of alopecia areata, atopic conditions (eczema, asthma or hay fever) and certain genetic or chromosomal disorders such as Down's syndrome as higher risk, and says alopecia areata cannot spread to others and is not connected to diet (BAD).

Hair loss is typically sudden. Some people feel itching, burning or tingling before or after the hair falls out. The bald patches are smooth and not scaly. Short, tapered hairs called exclamation mark hairs may sit at the edge of a patch. Regrowing hair often comes in fine and white first, and usually gradually regains its colour.

• Nail changes: pitting like the dimples on a thimble, ridging or brittleness. Alopecia UK says up to 50% of people with the condition have nail changes.

• Eyelash loss can cause dry, sore eyes in dry or windy weather.

• Family history: about 2 in 10 people with alopecia areata have a relative with it, according to the British Association of Dermatologists.

BAD describes alopecia areata as a common condition of non-scarring hair loss that can occur at any age. It usually causes small, coin-sized, round patches of baldness on the scalp, although hair on other parts of the body, such as the beard, eyebrows, eyelashes and body, can be affected. Occasionally it can involve the whole scalp (alopecia totalis) or the entire scalp, face and body (alopecia universalis).

Alopecia UK also describes diffuse thinning spread evenly across the scalp, ophiasis (a pattern along the hairline at the front, sides and back that can be more difficult to treat) and alopecia barbae (affecting the beard and moustache area). It says approximately 1 in every 1,000 people have alopecia areata at any given time, and that as many as 1 in 50 people will experience it at some point in their lives.

It is not possible to predict how much hair will be lost. The British Association of Dermatologists explains that hair can regrow on its own over months, rarely over years, and that for 4 out of 5 people with limited loss complete regrowth happens within a year. There can be further episodes later, and most people have more than one.

Outlook is less favourable when more than half of the hair is lost at the start or when hair loss is complete at any stage, when it starts in young children, when there is a family history of alopecia areata or other autoimmune disease, when it affects the hairline at the back of the scalp, or when nails are involved.

BAD says the condition is normally diagnosed following assessment by your doctor, and that most patients do not require any tests to confirm the diagnosis. If the diagnosis is uncertain, a scalp biopsy may be considered. Alopecia UK says a GP or dermatologist can diagnose it, and that a doctor may use a tool to look at the scalp up close (trichoscopy) or take a small piece of skin (skin biopsy) to be analysed in a laboratory.

Because alopecia areata is autoimmune and has been linked with other conditions, BAD says that if you experience symptoms other than hair loss you should consult your healthcare professional, who may suggest further tests.

BAD says wigs and hair pieces can be a vital treatment for some people in helping them regain confidence. They can be bought privately or obtained through the NHS on a consultant's prescription, usually with a financial contribution in England, and availability and provision are very variable across the UK. Alopecia UK and BAD have created a Charter for Best Practice for NHS Wigs Provision, which advocates offering a minimum of two acrylic wigs a year.

The NHS hair loss page says synthetic wigs last 6 to 9 months and real-hair wigs 3 to 4 years, and that some wigs are available on the NHS but you may have to pay unless you qualify for financial help. BAD adds that hair fibres or cosmetics can help camouflage areas of hair loss, and microblading for eyebrows can help in severe or permanent eyebrow loss.

The British Association of Dermatologists cites a UK study showing higher rates of depression and anxiety in people with alopecia areata, and encourages people to talk to a healthcare professional about the social and emotional effects. Support can include therapy, medication where appropriate, and contact with others with the same experience. Alopecia UK is a patient charity that provides information and support.

The NHS says to see a GP if you are worried about your hair loss, and that the GP may be able to tell you what is causing it by looking at your hair. BAD says that if hair loss is more extensive, the options are discussed with your healthcare professional, and says contact sensitisation treatment is only available in specialised centres.

If you consider a private dermatology appointment, check what is licensed and evidence-based. BAD notes that baricitinib is licensed for severe alopecia areata but, at the time of its April 2024 leaflet, was not approved for NHS funding for alopecia and was available on private prescription, so ask your clinician for the current position.