Patchy hair loss (alopecia areata): causes and treatment

Key takeaways

• It usually shows up as one or more smooth, coin-shaped bald patches that appear quickly. Often the barber or someone at home spots it first.
• It is autoimmune. It is not contagious, and it is not caused by your shampoo, your water or how you look after your hair.
• With small patchy disease, hair comes back on its own within a year in roughly a third to half of people. Relapses are common.
• What we use depends on how much hair is lost: steroid creams or injections for limited patches, stronger options for extensive loss.
• Regrown hair may come back white or fine at first, and usually gets its colour back over time.

What does alopecia areata look like?

Normally the person walks in and says, "Doctor, my barber found this." It is a smooth, round or oval bald patch, about the size of a coin, and the skin looks normal. No scaling, no scarring, usually no pain. Some people feel a little tingling or itch before the patch appears. The common places are the scalp, the beard in men, and sometimes the eyebrows or eyelashes.

When I look under magnification, I often see short broken hairs at the edge of the patch that taper towards the root. We call them "exclamation mark hairs". A StatPearls review describes these as characteristic of the condition. About 10 to 15% of people also have nail changes, like tiny pits on the nail surface, so I check the nails too.

Less common patterns I look out for: - A band of hair loss along the back and sides of the scalp (the ophiasis pattern). - Diffuse thinning over the whole scalp, which can be confused with other types of hair fall. - Loss of all scalp hair (alopecia totalis) or all body hair (alopecia universalis). These are uncommon.

What causes it?

See, what happens is, the immune system mistakes the growing hair follicle for something it should attack. The follicle stops making hair. But the stem cells that can regrow the hair are left alone. That is why there is no scarring, and that is why regrowth is possible. There is a significant genetic component as well.

People always ask me what triggered it. The medical literature mentions stress, viral infections and some medicines, but honestly, often we find no trigger at all. It is more common in people who have other autoimmune or allergic conditions, like thyroid disease, vitiligo, psoriasis, eczema or allergic rhinitis.

The lifetime risk is about 2%, and it can start at any age. In one review the average age of onset was the early to mid 30s, but I see children and young adults with it too.

Is it alopecia areata or something else?

Not every bald patch is alopecia areata. Before I talk about treatment, I want to be sure of the diagnosis, because the treatments are completely different.

Will my hair grow back?

For many people, yes, especially with one or a few small patches. A StatPearls review reports spontaneous regrowth within a year in 34 to 50% of people with patchy disease. But here is the other half of the truth. The American Academy of Dermatology notes that hair often falls out again after regrowing, with many relapses within a year and most within five years.

Things that are linked with a harder course: - Starting in childhood - The ophiasis band pattern - Extensive loss, or loss lasting more than a year - Nail changes - Eczema or other autoimmune conditions - A family history of alopecia areata

That is very important to understand. A good response to treatment is not the same as a cure. This condition can come and go, so when I make a plan, I also plan for what we do if it comes back.

How is alopecia areata treated?

I choose according to your age, how many patches you have, how big they are, how long they have been there, and what you prefer. All of these are prescription decisions after I have examined you.

• Wait and watch. For one or two small, recent patches, some people prefer to wait, because regrowth can happen on its own. That is a perfectly fair choice.
• Steroid injections into the patch. For adults with limited patches, we give small injections of a corticosteroid such as triamcinolone every four to six weeks. The AAD says regrowth usually appears within three months of the first injection. The skin at the injection site can thin, which is why the dose and spacing matter. The dose is the skill.
• Steroid creams or lotions. Often used for children, or for people who cannot tolerate injections.
• Minoxidil. Sometimes added, mainly to support and maintain regrowth.
• Contact immunotherapy. For extensive disease, a chemical is applied weekly to provoke a mild allergic reaction that redirects the immune response. It needs regular clinic visits.
• Oral JAK inhibitors. Medicines such as baricitinib and ritlecitinib have been approved by the US FDA for severe alopecia areata. They need careful selection and blood monitoring, and they carry safety warnings, so they are considered for extensive disease after specialist assessment.
• Other oral immune-suppressing medicines are sometimes used for severe or rapidly spreading disease.

People sometimes come with a bag of hair oils, onion juice and growth serums. I tell them plainly: these do not address the immune process, so they are not reliable for alopecia areata. And if someone says, "Doctor, just do a transplant," my answer is that a transplant is generally not recommended here. The follicles are not permanently lost, and the condition is unpredictable. Moving hair into a patch the immune system may attack again does not make sense.

Living with it day to day

I know these patches can be very upsetting, especially for teenagers, brides-to-be, or anyone in a public-facing job. Some practical things help. A good barber can style around a beard patch. A stylist can change your parting. Caps, scarves, hairpieces and eyebrow pencils are all fine to use. Tell your family it is not contagious and not caused by anything you did. And if stress, anxiety or low mood follow the hair loss, that deserves attention too; see can stress cause hair loss?.

When to see a doctor

Come and see a doctor promptly if you notice a bald patch, especially if it is spreading, if there are several patches, if your eyebrows or eyelashes are affected, or if your child has a scaly patch. At a hair diagnosis at Dr Tvacha, I examine the patch with a trichoscope to confirm the type of hair loss, look for signs of other conditions, and go through the options that suit your situation. Some extensive or fast-moving cases need specialist dermatology care, and if that is you, I will say so plainly. The hair plan page explains how the diagnosis works at our Thane, Andheri, Bandra and Dahisar centres.

Written by

Dr Amit KarkhanisAesthetic Physician · MBBS, Dip. Dermatology (UK) · Reg. No. 2001/02/1124

Founder of Dr Tvacha, practising in Thane since 2005. Leads the weight loss and hair programmes.