Alopecia, what is it? Symptoms, causes and treatments
Alopecia areata is an autoimmune disorder that affects the skin and causes round patches of hair loss on a patient’s body. The hair loss can be partial or complete and can last anywhere from a few months to the rest of a patient’s life. One upside for those diagnosed with alopecia is that their hair follicles stay alive and spontaneous hair growth  can occur at any time. According to the National Alopecia Areata Foundation, alopecia affects up to 6.8 million people  in the U.S. alone, and the body of research on the symptoms, diagnosis and treatment of this condition is growing.
User question: I am a 29 year old male. I’m trying to determine whether I’m exhibiting symptoms of male pattern baldness or just a mature hairline and whether I should be beginning a treatment such as Finasteride if I am I. The early stages. My brother is bald (started at 16 and advanced quickly) and my maternal grandfather was bald. My mom’s brother is bald but my father and his father are not.
Online Dermatologist answer: Thank you for sending your case. Based on the information and images of your scalp, this is possibly ANDROGENIC AOLOPECIA (male pattern hair loss). Hair loss resulting in thinning is known as alopecia. When it is related to hormones (androgens) and genetics, it is known as androgenetic alopecia. Male pattern hair loss is characterized by a receding hairline and/or hair loss on the top and front of the head. Male pattern hair loss affects nearly all men at some point in their lives. It affects different populations at different rates, probably because of genetics. Male pattern hair loss is caused by a sensitivity to the effects of dihydrotestosterone, or DHT in some areas of the scalp. DHT is believed to shorten the growth and cause miniaturization of the follicles, and progressively produces fewer and finer hairs. Eventually when all the hairs in the tuft are gone, bald scalp appears between the hairs. Various treatment options are available. Some are over the counter (rogaine for example) and others, like finasteride, require an evaluation with a dermatologist. Hair replacement/transplant, hairpieces, hair/scalp lasers, minoxidil solution (rogaine), Finasteride tablets (prescription only) are the mainstay of treatment options available at this time and can help.
Despite the basic understanding of how alopecia functions in patients, much is still unknown about its causes. Because of the unpredictability of the disease, many physicians and patients alike find it a frustrating condition to treat. The National Institutes of Health explicitly notes that the exact cause of alopecia areata is unknown . Research suggests the condition is multifactorial and the root causes of an onset or relapse are likely a combination of genetic predisposition, trauma, viral infection, hormonal changes, and extreme emotional or physical stress. This report seeks to further explore each of these factors and describe how physicians can work with their patients to holistically approach treatment of alopecia areata.
Pharmacologically, some potential treatments  for alopecia exist, although the rate of effectiveness varies greatly among patients. The American Association of Dermatologists has reported alopecia treatment using medications such as minoxidil (approved for hair regrowth), and diphencyprone (DPCP) , which triggers an allergic reaction in the scalp that can sometimes stimulate hair growth. Because it is thought to be an autoimmune disorder, some prescribers suggest using corticosteroids either orally or topically to suppress a patient’s immune system. However, there are serious side effects associated with corticosteroid use and they may not be a good fit for all alopecia patients . There are no therapies specifically targeted for alopecia that are currently authorized by the Food and Drug Administration .
Although there are pharmaceutical options for patients hoping to treat the symptoms of alopecia, holistic assessment of the root causes behind alopecia areata may be necessary to ensure a successful patient recovery.
Potential genetic predisposition
The first major factor physicians must look for in alopecia patients is a potential genetic predisposition. Predispositions can be inherited, but a family history alone does not guarantee a patient will suffer from alopecia, and the condition itself is widely considered to not be inherited  (National Institutes of Health). Ultimately, although patients can be genetically susceptible to an onset of alopecia, its genesis remains largely mysterious.
Another factor that may contribute to the development of alopecia is a change in hormones. Some case studies  have noted a link between hormonal levels and the onset or resolution of alopecia areata. However, no direct association has been noted between testosterone, estrogen, or human chorionic gonadotropin (hCG) and alopecia. Because testosterone is connected to increased hair growth, a lowered level in men is thought to be a potential contributor to alopecia. Further research is necessary in this area to discover if hormonal supplements could be an efficacious treatment route for alopecia patients.
A 2013 study by Taisuke Ito (published in the Journal of Immunology Research  notes several possible causes of alopecia, including a key finding connecting viral infections to the condition. Ito’s research points to the role of viruses such as influenza in creating an excess of interferons. This excess can cause immune privilege to collapse, thus leading to autoimmune reactions against the patient’s own hair follicles. Ito concludes that although immune system failure can be initiated by environmental factors such as viral infections, emotional stress may also play a major role. Furthermore, Ito notes that earlier studies definitively show an association between alopecia areata and psychiatric conditions such as major depression and anxiety disorder.
User question: I am a 29 year old female. I’ve had an itchy scalp for about 8 years now. It usually gets really flaky and smelly. After washing the itching usually reduces but then several hours after the itch comes back. Severity of the itching increases with how high the temperature is and the number of days after the last wash. I’ve used hair relaxers before in the past and I’m not sure wether it contributed to this. I recently got tired of the itching and shaved my head yesterday with a shaving stick. I have noticed bald patches of the scalp at some point where the hair just feel off and regret in the past. This happened twice. I suspect that this is some kind of fungal infection. I’m hoping it’s not skin cancer. I’ve noticed hair loss before but the same time I think the rate of hair regrowth is healthy and normal. Now that I’ve shaved my head it only feels sore from the shaving but no itching yet. I’ve ordered some anti fungal cream online to start applying . I should probably see a dermatologist but these are the steps I’ve taken so far. I hope it’s not scalp cancer. And the black spots are not hairs they’re actually spots. They don’t hurt and they don’t come off with scratching but I think some of the spots came off when I used the shaving stick
Online Dermatologist answer: Thank you for sending your case. You do not have skin cancer in the scalp. Based on the information and images, this is possibly a CICATRICIAL ALOPECIA : An intermittent chronic inflammation in the scalp’s hair follicles result in hair loss and scarring. The cause of this inflammation is normally unknown; the disease is not contagious. Treatment with over the counter products doesn’t normally work. You need potent topical and maybe systemic therapy and I recommend that you see a dermatologist in person.
Depression and anxiety
The link between depression or anxiety and emotional trauma is well established, which may explain alopecia’s association with mental stress. However, physical trauma can also be a root cause of alopecia. Traumatic alopecia occurs when the hair shafts are structurally damaged, often by hair care practices . Curling irons, straighteners, blow dryers, and chemicals applied to the hair can all lead to hair loss and sometimes traumatic alopecia. Physical or chemical injuries can also be root causes of alopecia.
In addition to physical trauma being a possible underlying cause of alopecia, the condition itself can worsen trauma for the patient. Physically, hair loss can be problematic for patients because of skin sensitivity, increased risk of sunburn, risk of eye injury due to protective eyelashes missing, and dry nose due to lack of nostril hair. Emotionally, developing alopecia can be traumatic for patients as well. Mental distress can both cause and exacerbate the symptoms of alopecia, presenting a confounding situation for patients and care providers.
Treatment outlook and research
Modern research shows us that many factors may play a role in the development of alopecia, and successful treatment approaches must take a multifaceted, patient-centered approach. Some preventative measures are simpler than others; avoiding hair damage and physical injury may be possible. However, genetic predisposition and emotional stress may be impossible to evade. Some dermatological studies encourage dual treatment for the mental and physical components of alopecia by co-locating services .
Additionally, new medical treatments have come to light in recent years that may revolutionize treatment for alopecia. Photodynamic therapy (PDT), which is the application of red light or daylight, has shown promise in other countries for treating alopecia. Small research trials have examined response from alopecia patients to topical latanoprost, nitrogen mustard, massage and relaxation, Isoprinosine, acupuncture, and aromatherapy. However, to present significant evidence for their efficacy, larger controlled studies must be performed with these variables.
While researchers continue to look for definitive causes and effective treatments in the fight against alopecia, it is critical to reassure patients that their new or recurring struggle with the condition does not isolate them. There are national support groups dedicated to those with various types of alopecia in order to help ensure quality attention to patients’ psychosocial wellbeing, including The American Hair Loss Association, The Children’s Alopecia Project, and The National Alopecia Areata Foundation.
About the Author: Kathrina Jeorgette Flores graduated Doctor of Medicine from Dona Remedios Trinidad Romualdez Medical Foundation (RTRMF), Tacloban City, Philippines last May 2017. She is currently a Post Graduate Intern at Remedios Trinidad Romualdez Hospital. Alongside her medical studies, she is passionate about supporting causes related to children, education, health, and disaster/humanitarian relief.
Additional information about Kathrina can be found on her LinkedIn profile.
Medical Doctor and PhD candidate