Alopecia areata

• Celsus 30-60 AD
• Sauvages 1706

Pélade, Area Celsi.

Circular, often reversible, acute-onset, non-scarring hair loss.

• Lifetime incidence: approx. 1.7%
• Prevalence: approx. 0.1-0.2% per year
• Men = women (in some studies, women have a higher incidence)
• Peak in incidence: 15-30 y.

• Genetics
  • Familial clustering in about 25%
  • Association with the TRAF1/C5 gene locus
  • Association with HLA markers: DR-4, DR-5, DR-6, DR-7, DR-11, DQ3, DQB-1
  • Atopy
  • Trisome 21: Occurs in about 10% of all people with trisomy 21
• Autoimmunological influences
  • Autoimmune diseases
    • Autoimmune thyroid: 20% have elevated thyroid antibodies
    • Morbus Addison
    • Vitiligo
    • Diabetes mellitus type I
• Immunodeficiency syndromes
  • APECED (Autoimmune Polyendocrinopathy-Candidiasis-Ectodermal Dystrophy)
  • CVID (Common Variable Immunodeficiency Syndrome)
  • IPEX (immunodysregulation polyendocrinopathy enteropathy X-linked syndrome)
  • DiGeorge syndrome
• Psychological factors (depression or anxiety)

• At the capillitium, eyebrows, whiskers, axillary or genital almost foudroyant, centrifugally spreading, circular, hairless areas. The follicles remain visible. Cadaver hairs (comedone-like "points noirs")
• In a few cases, the eyelashes may also come out
• Pulling test: if AA is active, hairs from the marginal area can be painlessly plucked out

• Initially, grey and white hairs are spared. If sudden alopecia areata totalis occurs, only the white/grey hairs can survive. This results in "greying overnight"

• In the acute episode, locoregional lymph node swelling may occur

• Special form: ophiasis
  • Alopezia areata, which are localised at the hairy edges

• Severe degrees of alopecia areata
  • Grade 1: < 30% of capillitium
  • Grade 2: > 30% of the capillitium
  • Grade 3: Alopezia areata totalis
  • Grade 4: Alopezia areata universalis

• Dermatoscopically: comma hairs, exclamation mark hairs

• Alopecia areata and nails
  • In 10-50% of patients with alopecia areata
  • Coilonychia, trachyonychia, beau lines, onychorrhexis, onychomadesis and onycholysis

• Anamnesis
• Dermoscopy: exclude scarring, look for yellow dots, look for cadaver hairs
• Clinic: pluck test, nail involvement
• Biopsy 4mm (instead of obsolete trichogram)
• Ruling out autoimmune thyroid disease
  • TSH, tfT3,fT4, thyroid antibodies (anti-TPO-Ak = thyroperoxidase antibodies, TAK or Tg-Ak = thyroglobulin antibodies, TRAK =TSH receptor antibodies).

• Atopia?
• Thyroid disease?

Swarm-like lymphocytic, perifollicular, sometimes intrabulbar, arranged infiltrate with follicular infiltration (anagen phase). Follicle reduction in the late stage. Inverse anagen/telogen ratio.

• Remission:
  • After 6 months: in 30%
  • After 12 months: in 50%
  • After 5 years: 75%

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