Alopecia areata often starts with a surprise: a hairdresser or partner points out a smooth, round patch the size of a coin that was not there a month ago. It can be frightening, but it is common, it is not contagious and in many people the hair grows back. Treatment has also changed a lot in recent years, with the first medicines approved specifically for severe cases.
What alopecia areata is
Alopecia areata is an autoimmune condition. The immune system mistakenly attacks the hair follicles, which then stop producing hair. The follicles are not destroyed, which is why regrowth is possible even after years. According to the U.S. National Institute of Arthritis and Musculoskeletal and Skin Diseases, about 2 percent of people will have it at some point in their lives. It affects children and adults, men and women, and all ethnic groups.
Genes play a role, and alopecia areata is more common in people who have other autoimmune or allergic conditions, such as thyroid disease, vitiligo, asthma or eczema, or relatives with alopecia. Severe stress or an illness sometimes comes before a flare, although it is rarely the only cause.
Signs to look for
- One or more round or oval bald patches with smooth, normal-looking skin
- Short broken hairs at the edge of a patch that are narrower at the bottom, often called exclamation mark hairs
- Patches in the beard, eyebrows or eyelashes
- Small dents or ridges in the fingernails
- Sometimes mild tingling or itching before a patch appears
Most people have a few patches. A smaller group loses all hair on the scalp (alopecia totalis) or on the whole body (alopecia universalis). The course is hard to predict and often comes in waves, with regrowth in one place while a new patch appears elsewhere.
Will the hair grow back
When there are only a few small patches, the hair often regrows within a year, sometimes without any treatment. The first new hairs may be fine and white before the normal color returns. The outlook is less certain when the condition begins in childhood, covers large areas, affects the hairline at the back of the head, or has lasted for many years.
Treatment options
A dermatologist chooses treatment based on how much hair is affected, the person’s age and how long the condition has lasted.
- Corticosteroid injections into the patches every four to six weeks are the usual first choice for adults with limited patches.
- Corticosteroid creams, foams or lotions are used in children and in areas where injections are uncomfortable.
- Minoxidil is sometimes added to support regrowth.
- Contact immunotherapy with a chemical such as diphencyprone deliberately causes mild irritation on the scalp to redirect the immune response. It is used for extensive hair loss in specialist clinics.
- JAK inhibitors are tablets that calm the immune signals attacking the follicles. In 2022 the FDA approved baricitinib (Olumiant) for adults with severe alopecia areata, the first drug approved for the condition. Ritlecitinib (Litfulo) followed in 2023 for people aged 12 and over, and deuruxolitinib (Leqselvi) in 2024. They require regular blood tests and the hair may fall out again if the medicine is stopped.
Living with alopecia areata
The emotional side is often harder than the physical one. Many people feel anxious about new patches or uncomfortable in public. Support groups, such as the National Alopecia Areata Foundation, connect people who know what it is like. A good hairdresser can suggest a cut that hides small patches, and wigs, hairpieces, brow pencils or microblading help when hair loss is extensive. Sunscreen or a hat protects bare scalp skin from sunburn.
See a doctor when you notice the first patch. The diagnosis is usually easy to make by looking at the scalp, and the doctor may suggest checking your thyroid. Other conditions, such as fungal infection or hair pulling, can look similar and need different treatment.
Sources
- National Institute of Arthritis and Musculoskeletal and Skin Diseases, Alopecia Areata. niams.nih.gov
- American Academy of Dermatology, Alopecia areata, diagnosis and treatment. aad.org
- King B. et al. Two phase 3 trials of baricitinib for alopecia areata. New England Journal of Medicine, 2022. PubMed
- National Alopecia Areata Foundation. naaf.org
