Alopecia areata (auto-immune hair loss)

Alopecia means hair loss. Alopecia areata is a common disorder and usually happens on the scalp. In severe forms, it can also involve hair all over the body.

It affects about 1.7 per cent of people by the age of 50.

Three forms of alopecia

The form of alopecia areata depends on how much hair is lost. 

• Patch type: This is the most common type. People with alopecia areata have round, well-defined patches of hair loss.
• Alopecia totalis: Loss of all hair on the scalp.
• Alopecia universalis: Loss of all scalp and body hair.

Signs and symptoms of alopecia areata

Children with alopecia areata may experience the following signs and symptoms:

• Well-defined area(s) of hair loss, which can be anywhere on the body.
• Nail changes, such as small dents in the nail or brittle nails.
• Often no symptoms, although some children have burning or tingling in areas of hair loss either just before or during loss.

Causes of alopecia areata

Skin cross section

The course for alopecia areata is different in each child. It is hard to predict all the causes in your child's case.

We are still learning more about what causes alopecia areata, but it involves an auto-immune process. This means that the immune system attacks the hair follicles by mistake. The follicle is the pocket at the base of the skin that grows and holds the hair. When it is attacked, it lets go of the hair. The damage does not last forever. The follicle can still work and grow hair.

Will my child’s hair grow back?

Most children with alopecia areata need some form of treatment to re-grow hair, but some experience spontaneous regrowth. As of right now, it is not possible to predict which children will continue to have new areas affected by alopecia or have changes in their condition. What is known is that the longer and more widespread the areas of hair loss are, the more challenging it may be to achieve regrowth.

How alopecia areata is diagnosed

Your child's health-care provider will diagnose alopecia areata by examining your child and talking to your family. Other tests are usually not needed to diagnose alopecia areata.

With alopecia areata, an overactive immune system may also affect other organs, such as the thyroid and adrenal glands. So, your child's health-care provider will order some tests to see if they have been affected.

Medical treatment for alopecia areata

Your child’s health-care provider may decide not to give your child any treatment for alopecia areata at first. Sometimes, the hair can grow back by itself. A "wait and see" approach may be the best option.

Most smaller, single patches of alopecia have a good chance to grow again with treatment. New patches may develop over a period of weeks to months. Even with good response to treatment, though, the hair may fall out again after a period of re-growth at first.

Topical treatments may help treat the bald patches that exist but cannot prevent new ones from forming. The following are some of the treatments that may be used:

• Steroid cream on the bald patches.
• Steroid injections between the layers of the skin. 
• Minoxidil, used topically or orally to help stimulate hair growth. The medication is often used alongside other treatments for alopecia areata.
• Some children with more significant alopecia or alopecia that is challenging to manage will be prescribed oral or systemic medications to help control the immune system’s activity. These include medications such as oral corticosteroids, oral Janus kinase (JAK) inhibitors, dupilumab and low-dose methotrexate, among others. 

It should be noted that alopecia universalis does not respond as well to medical treatment as other types of alopecia areata.

How to prevent alopecia areata

There are no specific ways to prevent alopecia areata from occurring, as is it an autoimmune condition.

Possible complications of alopecia areata

Children with alopecia areata are more at risk of mental health conditions because of their disease, including generalized anxiety disorder, social anxiety disorder and major depressive disorder. These may impact your child’s self-esteem, school and social life, and other activities. If you are noticing significant impacts on your child’s mental health, speak to your child’s health-care provider about a psychological assessment and support.

Supporting your child with alopecia areata

These are some of the things you can do to help your child cope.

• Educate your child about alopecia areata. Be honest and open and support your child. Knowledge is power and comfort.
• Discuss the situation with your child's principal and teacher. If they know what your child has, they will be more likely to support your child. Give your child the option of informing classmates.
• It may be helpful to role play your child’s response to other children or adults who ask about why they are missing hair. This can help empower them to answer questions about their condition.
• Model good problem-solving and ways to cope. This means that it is alright to show and share your feelings. It is important that you address the feelings of both you and your child. If you and your child have a hard time coping and it affects your everyday life, you may want to consider speaking with a counselor.
• Listen to your child. It is important that your child has someone that they trust and talk to. The person can be a family member, friend or a counselor.
• Encourage your child to pursue things they love and guide them towards activities that will help them feel good about themselves. Provide your child with positive messages and praise. Your words have a great impact on how your child feels about themself. Self-esteem is crucial.
• Give your child the choice to interact with other children who have alopecia areata. This will allow them to share their experiences and know they are not alone.
• Another way to cope with the disease is to minimize its effect on your child's appearance. Your child may want to wear a wig or bandana.

Follow-up care for alopecia areata

Children with mild alopecia areata, or alopecia that is responsive to topical treatments, may be followed by their primary care provider. Often, children with more significant or difficult to treat alopecia areata will be followed regularly by their dermatologist.

When to see a health-care provider

Contact your child’s health-care provider if your child has rapidly progressive loss of hair. In some cases, children require oral medications to help stop a rapid progression of hair loss. Often, in this case, your child’s health-care provider will refer your child to a dermatologist for care.

Alopecia resources

DermNet NZ: The Dermatology Resource: https://www.dermnetnz.org/

Locks of Love: https://locksoflove.org/

Canadian Alopecia Areata Foundation: https://www.canaaf.org

National Alopecia Areata Foundation: https://www.naaf.org/

Society for Pediatric Dermatology – Alopecia Areata Patient/Family Handout: https://pedsderm.net/site/assets/files/1028/spd_aa_color_web-final.pdf

References

Sibbald C. (2023). Alopecia areata: An updated review for 2023. Journal of cutaneous medicine and surgery, 27(3), 241–259. https://doi.org/10.1177/12034754231168839

Patel HA et al. (2024). A clinician’s guide to pediatric and adolescent alopecia areata treatments. JAAD Reviews, 2, 57–66. https://doi.org/10.1016/j.jdrv.2024.08.013