Hair loss types: Alopecia areata diagnosis and treatment

Dermatologists have expertise in diagnosing hair loss and counseling their patients on what may help them regrow their hair

This dermatologist is using a dermatoscope to examine a patient’s scalp.

How do dermatologists diagnose alopecia areata?

A board-certified dermatologist can often diagnose this disease by looking carefully at the area(s) with hair loss and your nails.

To get a closer look, your dermatologist may use a tool called a dermatoscope. This tool magnifies, giving your dermatologist a better view of what’s happening.

Your dermatologist will also ask you about your health and what diseases close blood relatives have. Be sure to tell your dermatologist if a blood relative has alopecia areata.

Sometimes your dermatologist will need to remove a few hairs or perform a biopsy of the bald area. To perform a biopsy, your dermatologist will remove a small amount of skin, so it can be examined under a microscope.

You may also need a blood test to look for thyroid disease and check if you have healthy levels of iron and vitamins.

Once your dermatologist has all the necessary information, you’ll find out if you have alopecia areata. If you do, your dermatologist will talk with you about how the disease is affecting your life and whether treatment is recommended.

How do dermatologists treat alopecia areata?

It’s important to know that no one treatment works for everyone — and treatment is not always recommended.

Your dermatologist will determine what’s best for you based on:

• How much hair you’ve lost

• How long you’ve had hair loss

• Where you’ve lost hair

• Your age (children can require different treatment)

Based on these and other considerations, here’s what a treatment plan may look like:

One or two bald spots that have been there for less than one year: Your dermatologist may recommend a wait-and-see approach. Many people, especially children, regrow their hair without treatment.

Regrowth can be slow, and some people do not see the regrowth they expect.

If you’re unhappy with the regrowth, your dermatologist may prescribe medication that you apply to the areas that need more regrowth. A common treatment plan involves applying a corticosteroid to regrow your hair and later minoxidil (Rogaine®) to keep the hair that’s regrown.

Children 10 years old and younger: In children, hair may regrow without treatment. When a young child needs treatment, a dermatologist may recommend the following:

• Corticosteroid you apply to the bald spots: Prescription-strength corticosteroids can help regrow hair. This medication is applied once or twice a day. For children, this alone can be an effective treatment.

• Minoxidil: This medication can help patients keep the hair that regrows. Most patients start applying minoxidil after they stop the corticosteroid. Minoxidil has few side effects, so it’s considered a good option for children.

For children older than 10 years of age, treatment options are often based on the amount of hair they’ve lost.

For older children who have extensive hair loss, a dermatologist may prescribe contact immunotherapy or a JAK inhibitor that’s approved to treat alopecia areata in patients 12 years of age and older.

Patchy hair loss: For adults and children older than 10 years of age, dermatologists may recommend one or more of the following treatments:

• Injections of corticosteroids: For adults, this can be an effective treatment. Your dermatologist will inject the corticosteroids directly into the spots with hair loss. You will need several shots every 4 to 6 weeks.
  
  When effective, patients usually see some hair regrowth within 3 months of getting the first injection.
  
  This is considered the most effective treatment for people who have a few patches of hair loss. In one study of 127 patients with patchy hair loss, more than 80% who were treated with these injections had at least half of their hair regrow within 12 weeks.
  
  Due to the pain caused by injecting this medication, this treatment is usually only given to adults.

• Corticosteroids you apply: You apply this medication to the bald spots once or twice a day as instructed by your dermatologist. This medication tends to be more effective in children than adults.

• Anthralin: You apply this medication to the bald spots, let it sit on the skin for as long as your dermatologist says, and then wash it off. It will cause some skin irritation. To get the best results, you’ll also use minoxidil after your hair regrows.

• Minoxidil: After your hair regrows, minoxidil can help you keep the regrowth. To be effective, you will need to apply this medication 2 to 3 times a day. It can be helpful for the scalp, beard area, and eyebrows.

Extensive hair loss: Sometimes hair loss progresses beyond causing a few bald patches. Alopecia areata can lead to widespread hair loss, complete loss of hair on the scalp (alopecia totalis), or loss of all hair on the body (alopecia universalis).

Few people with extensive hair loss regrow their hair without help. A treatment plan for extensive hair loss may include:

• Contact immunotherapy: Also called topical immunotherapy, the goal of this treatment is to get your immune system to stop attacking your hair follicles. This attack is what causes alopecia areata.
  
  Dermatologists have used this treatment for many years to treat widespread alopecia areata. Success in growing hair ranges from 17% to 75%.
  
  If contact immunotherapy is an option, you will need to return to your dermatologist’s office weekly for treatment. It’s important that you keep every appointment. Missed appointments can cause this treatment to stop working, causing the regrown hair to fall out.
  
  The treatment itself involves your dermatologist (or nurse) applying a chemical to your skin with hair loss. The first time you receive this treatment, a small amount will be applied so that your body can start to develop a reaction to the chemical.
  
  Once you develop a reaction, the chemical will be applied weekly to the areas with hair loss and left on for 48 hours. During this time, you must keep the treated skin covered. A rash should develop that lasts about 36 hours.
  
  Contact immunotherapy is given weekly until one of the following happens:

  • You completely regrow your hair.
  • At the end of 6 months, the treatment fails to regrow hair.
  To increase the effectiveness of this treatment, your dermatologist may prescribe another treatment that you use at home.

• JAK inhibitor: This type of medication calms the overactive immune system, which may allow your hair to regrow. It’s a promising treatment for people with widespread hair loss. Many studies show that a JAK inhibitor can give patients 50% or greater regrowth.
  
  JAK inhibitors can also help some patients regrow eyebrows and eyelashes.
  
  The U.S. Food and Drug Administration (FDA) has approved three JAK inhibitors to treat alopecia areata.
  
  Barcitinib is used to treat adults who have severe alopecia areata. It’s a once-daily pill.
  
  Deuruxolitinib has been approved to treat adults with severe alopecia areata. It’s a pill that you take twice a day.
  
  Ritlecitinib has been approved to treat adults and children 12 years of age and older who have alopecia areata that has caused extensive hair loss. It’s a pill that you take once a day.

• Other medications that work throughout the body: No one treatment is right for everyone. Your dermatologist may prescribe another oral (taken by mouth) medication. This could include prednisone, methotrexate, cyclosporine, or other medication that works on your immune system to help your hair regrow.

Loss of eyelashes: If you lose some (or all) your eyelashes, your dermatologist may include one or more of the following in your treatment plan:

• Artificial eyelashes: These can fill in areas where you have missing eyelashes.

• Glasses: Wearing glasses helps to protect your eyes and can make loss of eyelashes less noticeable.

• Bimatoprost (or a similar medication): This is a prescription medication that’s approved to treat a type of glaucoma and high eye pressure. The FDA has also approved it to help eyelashes grow longer.

• JAK inhibitor: If you’ve lost most of the hair on your scalp and eyelashes, your dermatologist may prescribe this medication. In studies, dermatologists have found that patients who’ve lost a substantial amount of their eyelashes, eyebrows, or both can see regrowth.

Loss of eyebrows: If alopecia areata causes you to lose some or all your eyebrows, your dermatologist may recommend one of the following:

• Intralesional corticosteroids: A dermatologist can inject this medication to help the eyebrows start growing again. If the injections work, applying minoxidil as directed may help you keep the regrowth.

• JAK inhibitor: If you’ve lost most of the hair on your scalp and some of your eyebrows, your dermatologist may prescribe this medication. In studies, dermatologists have found that patients who’ve lost a substantial amount of their eyelashes, eyebrows, or both can see noticeable regrowth.

• Artificial eyebrows: These can hide lost eyebrows. You apply and remove them every day.

• Semi-permanent tattoo: Also called microblading, this uses micro-pigments instead of tattoo ink to create natural-looking eyebrows. Unlike a tattoo, the result isn't permanent.

How do dermatologists treat nail changes caused by alopecia areata?

Nail changes tend to be less noticeable than hair loss, so many patients never tell their dermatologist that these changes bother them

If you’re bothered by nail changes, tell your dermatologist.

Some people who have alopecia areata develop nail changes like tiny dents, brittle nails, or crumbling.

To treat these changes in an adult, a dermatologist may prescribe medication like a corticosteroid or tazarotene, which you apply to the nails. Another option is to inject the changed nails with a corticosteroid or prescribe corticosteroid pills for a short time.

If a child has nails changes, a dermatologist may recommend waiting to see what happens. In children, nail changes may improve on their own.

Wigs, shaving, and other options for hiding hair loss

There are plenty of options for covering up hair loss, and patients ask about these options because:

• Treatment takes time.

• Some people want to avoid the possible side effects of treatment.

• Treatment isn’t working or their hair continues to fall out after treatment.

Options for hiding hair loss include the following:

Styling products like gels, mousses, powders, and sprays: These help to keep hair in place, which can hide hair loss. These products can also add volume.

Wig, hairpiece, or scalp prosthesis: These can hide hair loss on the scalp. Some look like your natural hair.

What exactly is a scalp prosthesis?

It’s a wig that’s custom-made to help ensure a perfect fit. Other names for a scalp prosthesis are:

• Hair prosthesis
• Cranial prosthesis

All wigs are usually held on with a wig cap, such as the one this woman is wearing.

Shaving: Instead of covering up, some people prefer to shave so they can get rid of that patchy or diffuse look. Shaving can hide areas of hair loss on your scalp, beard area, or anywhere on your body.

Artificial eyelashes: Available as individual lashes, clusters, and strips, you apply these with a special glue.

To fill in areas, you can glue individual lashes to your existing lashes. If you need more coverage, clusters work well and can blend in with the rest of your lashes. Strips can hide complete loss of eyelashes.

To prevent irritation and loss of more eyelashes, dermatologists recommend that you remove artificial eyelashes before going to bed.

Eyebrow powder: This is a makeup that can help fill in thin brows, making them look naturally full. Like most makeup, you need to remove the powder before bed and reapply it the next day.

Artificial eyebrows: Made of synthetic or human hair, these can hide extensive hair loss. You attach them with wig glue. You’ll need to remove them before bed and reapply them the next day.

Microblading for eyebrows: If you’re looking for a more permanent solution to thin or missing eyebrows, you may want to consider microblading. It’s like a semi-permanent tattoo.

The key difference between microblading and tattooing is that microblading uses micropigments rather than tattoo ink. Using micropigments helps to create natural-looking eyebrows.

Microblading lasts about 6 months to a year, so it’s not permanent like a tattoo.

With microblading, complications can occur. These include the artist misapplying the pigment, the pigment moving beyond the eyebrow after it’s applied, and pigments changing color.

If microblading sounds appealing, talk with your dermatologist first.

What is the outcome for someone who has alopecia areata?

For many people, their hair regrows on its own without treatment. This regrowth happens more often when someone has a few patches of alopecia areata, which have been there for less than a year.

Hair loss can also stop for long periods or come and go. Sometimes, hair doesn’t regrow. With so much uncertainty, it can be helpful to see a board-certified dermatologist who can evaluate your situation and recommend a course of action.

Most people who develop alopecia areata are otherwise healthy. However, some people with alopecia areata may be at risk for other autoimmune diseases, so it’s important to keep appointments with your dermatologist.

Self-care also plays an important role in the lives of people who have alopecia areata. To find out what dermatologists recommend, go to: Alopecia areata: Self-care.

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References
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Freitas E, Guttman-Yassky E, et al. “Baricitinib for the treatment of alopecia areata.” Drugs. 2023 Jun;83(9):761-70.

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King B, Zhang X, et al. “Efficacy and safety of ritlecitinib in adults and adolescents with alopecia areata: A randomised, double-blind, multicentre, phase 2b–3 trial.” The Lancet. 2023;0(0). doi:10.1016/S0140-6736(23)00222-2.

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Otberg N, Shapiro J. “Alopecia areata.” In: Kang S, et al. Fitzpatrick’s Dermatology. (ninth edition) McGraw Hill Education, United States of America, 2019:1517-9.

Piliang M, Lynde C, et al. “Sustained scalp, eyebrow, and eyelash hair regrowth with ritlecitinib through week 48 in patients with alopecia areata: Post hoc analysis of the ALLEGRO phase 2b/3 study.” Presented at: American Academy of Dermatology Annual Meeting 2023; March 17-21, New Orleans, LA. Poster 42005.

Pratt CH, King LE Jr, et al. “Alopecia areata.” Nat Rev Dis Primers. 2017 Mar 16;3:17011.

Santoro C. "FDA approves deuruxolitinib for alopecia areata" Am J Manag Care. 2024 Jul 26; (news article). Last accessed 8/21/2024.

Written by:
Paula Ludmann, MS

Reviewed by:
Elizabeth M. Damstetter, MD, FAAD
DiAnne Davis, MD, FAAD
Arturo Dominguez, MD, FAAD
Elisa Gallo, MD, FAAD
William Warren Kwan, MD, FAAD
Shari Lipner, MD, PhD, FAAD

Last updated: 8/22/24