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Alopecia areata

Topic: Medicine

 From HandWiki - Reading time: 20 min
Short description: Medical condition

Alopecia areata
Other namesAlopecia Celsi, vitiligo capitis, Jonston's alopecia[1]
Alopecia areata seen on the back of the scalp
Pronunciation
SpecialtyDermatology Immunology[6]
SymptomsAreas of hair loss, usually on the scalp[7]
Usual onsetChildhood[7]
CausesAutoimmune[7]
Risk factorsFamily history, female sex, rheumatoid arthritis, type 1 diabetes, celiac disease[7][8][9]
Differential diagnosisTrichotillomania, alopecia mucinosa, postpartum alopecia[1]
TreatmentSunscreen, head coverings to protect from sun and cold[7]
Medicationtopical minoxidil[10] and triamcinolone injections[11]
PrognosisDoes not affect life expectancy[7][1]
Frequency~2% (US)[7]

Alopecia areata (AA), also known as spot baldness, is a condition in which hair is lost from some or all areas of the body.[12][1] It often results in a few bald spots on the scalp, each about the size of a coin.[7] Psychological stress and illness are possible factors in bringing on alopecia areata in individuals at risk, but in most cases there is no obvious trigger.[7] People are generally otherwise healthy.[7] In a few cases, all the hair on the scalp is lost (alopecia totalis), or all body hair is lost (alopecia universalis). Hair loss can be permanent or temporary.[7][1]

Alopecia areata is believed to be an autoimmune disease resulting from a breach in the immune privilege of the hair follicles.[12][13] Risk factors include a family history of the condition.[7] Among identical twins, if one is affected, the other has about a 50% chance of also being affected.[7] The underlying mechanism involves failure by the body to recognize its own cells, with subsequent immune-mediated destruction of the hair follicle.[7]

No cure for the condition is known.[7] Some treatments, particularly triamcinolone injections and 5% minoxidil topical creams,[11][10] are effective in speeding hair regrowth.[7][1] Sunscreen, head coverings to protect from cold and sun, and glasses, if the eyelashes are missing, are also recommended.[7] In more than 50% of cases of sudden-onset localized "patchy" disease, hair regrows within a year.[14][15][7] In patients with only one or two patches, this one-year recovery will occur in up to 80%.[16][17] However, many people will have more than one episode over the course of a lifetime.[15] In many patients, hair loss and regrowth occurs simultaneously over the course of several years.[7] Among those in whom all body hair is lost, fewer than 10% recover.[18]

About 0.15% of people are affected at any one time, and 2% of people are affected at some point in time.[7][18] Onset is usually in childhood.[7] Females are affected at higher rates than males.[9]

Signs and symptoms

Alopecia areata

Typical first symptoms of alopecia areata are small bald patches. The underlying skin is unscarred and looks superficially normal. Although these patches can take many shapes, they are usually round or oval.[19] Alopecia areata most often affects the scalp and beard, but may occur on any part of the body with hair.[20] Different areas of the skin may exhibit hair loss and regrowth at the same time. The disease may also go into remission for a time, or may be permanent. It is common in children. The area of hair loss may tingle or be mildly painful.[21] The hair tends to fall out over a short period of time, with the loss commonly occurring more on one side of the scalp than the other.[22]

Exclamation point hairs, narrower along the length of the strand closer to the base, producing a characteristic "exclamation point" appearance, are often present.[22] These hairs are very short (3–4 mm), and can be seen surrounding the bald patches.[17]

When healthy hair is pulled out, at most a few should come out, and ripped hair should not be distributed evenly across the tugged portion of the scalp. In cases of alopecia areata, hair tends to pull out more easily along the edge of the patch where the follicles are already being attacked by the body's immune system than away from the patch where they are still healthy.[23]

Nails may have pitting or trachyonychia.[20] Onychoptosis defluvium, also known as alopecia unguium, is casting off the nail seen in association with alopecia areata.[24]: 660 

Causes

In alopecia areata, a hair follicle is attacked by the immune system. T-cells swarm the roots, killing the follicle. This causes the hair to fall out and parts of the head to become bald.

Alopecia areata is thought to be a systemic autoimmune disorder in which the body attacks its own anagen hair follicles and suppresses or stops hair growth.[22] For example, T cell lymphocytes cluster around affected follicles, causing inflammation and subsequent hair loss. Hair follicles in a normal state are thought to be kept secure from the immune system, a phenomenon called immune privilege. A breach in this immune privilege state is considered as the cause of alopecia areata.[13] A few cases of babies being born with congenital alopecia areata have been reported.[25] It is recognized as a type 1 inflammatory disease.[26]

Alopecia areata is not contagious.[22] It occurs more frequently in people who have affected family members, suggesting heredity may be a factor.[22] Strong evidence of genetic association with increased risk for alopecia areata was found by studying families with two or more affected members. This study identified at least four regions in the genome that are likely to contain these genes.[27] In addition, alopecia areata shares genetic risk factors with other autoimmune diseases, including rheumatoid arthritis, type 1 diabetes, and celiac disease.[8] It may be the only manifestation of celiac disease.[28][29]

Lifestyle factors such as smoking, sleep quality, and obesity may also contribute to the onset and progression of alopecia areata.[30] Studies indicate that smokers have a higher risk of developing the condition, potentially due to tobacco-induced Th17-mediated inflammation in hair follicles.[31][32] While some research suggests a link between sleep disorders and alopecia areata, findings remain inconclusive.[30] However, since sleep disturbances impact immune function, they may play a role in disease pathogenesis.[33] Additionally, obesity is associated with an increased risk of alopecia areata, likely due to adipokine dysregulation, which promotes chronic low-grade inflammation and alters immune response, as seen in other inflammatory skin conditions.[34][35]

Endogenous retinoids metabolic defect is a key part of the pathogenesis of the alopecia areata.[36]

In 2010, a genome-wide association study was completed that identified 129 single nucleotide polymorphisms that were associated with alopecia areata. The genes that were identified include those involved in controlling the activation and proliferation of regulatory T cells, cytotoxic T lymphocyte-associated antigen 4, interleukin-2, interleukin-2 receptor A, and Eos (also known as Ikaros family zinc finger 4), as well as the human leukocyte antigen. The study also identified two genes, PRDX5 and STX17, that are expressed in the hair follicle.[37]

There is emerging evidence suggesting a possible link between AA and vaccinations, including influenza, zoster, and human papillomavirus (HPV) vaccines.[38] One possible explanation is that vaccinations could trigger immune system activation, which has been observed to exacerbate preexisting autoimmune or autoinflammatory conditions in at-risk populations.[39] A small study observed hair loss exacerbation in three patients following COVID-19 mRNA vaccinations (Pfizer-BioNTech and Moderna).[40] These patients, who were younger on average (30.6 years) compared to unaffected individuals (37.2 years), experienced worsening hair loss within two weeks post-vaccination.[40] Similar cases have been reported with the AstraZeneca and Johnson & Johnson COVID-19 vaccines.[41] However, AA flares have also been linked to SARS-CoV-2 infection, either as an exacerbation of preexisting disease or a new diagnosis.[40] In the study's non-vaccinated AA cohort, the only observed case of hair loss worsening occurred after a COVID-19 infection.[40] While causality remains unclear, these findings emphasize the need for further research into the relationship between vaccinations and AA progression.

A psychodermatological connection is noted with impairment in psychiatric comorbidities including mental well-being, self esteem and mental disorders acting as pathogenic triggers for alopecia areata.[42][43][44][45]

Diagnosis

Alopecia areata is usually diagnosed based on clinical features.

Trichoscopy may aid in establishing the diagnosis. In alopecia areata, trichoscopy shows regularly distributed "yellow dots" (hyperkeratotic plugs), small exclamation-mark hairs, and "black dots" (destroyed hairs in the hair follicle opening).[46]

Oftentimes, however, discrete areas of hair loss surrounded by exclamation mark hairs is sufficient for clinical diagnosis of alopecia areata. Sometimes, reddening of the skin, erythema, may also be present in the balding area.[18]


Classification

Varying degrees of alopecia areata, along with alopecia totalis

Commonly, alopecia areata involves hair loss in one or more round spots on the scalp.[22][47]

  • Hair may also be lost more diffusely over the whole scalp, in which case the condition is called diffuse alopecia areata.[22]
  • Alopecia areata monolocularis describes baldness in only one spot. It may occur anywhere on the head.
  • Alopecia areata multilocularis refers to multiple areas of hair loss.
  • Ophiasis refers to hair loss in the shape of a wave at the circumference of the head.
  • The disease may be limited only to the beard, in which case it is called alopecia areata barbae.[22]
  • If the person loses all the hair on the scalp, the disease is then called alopecia areata totalis.[7]
  • If all body hair, including pubic hair, is lost, the diagnosis then becomes alopecia areata universalis.[7]

Alopecia areata totalis and universalis are rare.[48]

Treatment

Determining if a treatment is effective is difficult because of spontaneous remission. If the affected area is patchy, the hair may regrow spontaneously in many cases.[49] None of the existing therapeutic options are curative or preventive.[49] A 2020 systematic review showed greater than 50% hair regrowth in 80.9% of patients treated with 5 mg/mL triamcinolone injections.[11] A Cochrane-style systematic review published in 2019 showed 5% topical minoxidil was more than eight times more associated with >50% hair regrowth at 6 months compared to placebo.[10] In cases of severe hair loss, limited success has been achieved by using the corticosteroid medications clobetasol or fluocinonide as an injection or cream. Application of corticosteroid creams to the affected skin is less effective and takes longer to produce results. Steroid injections are commonly used in sites where the areas of hair loss on the head are small or especially where eyebrow hair has been lost. Whether they are effective is uncertain. Some other medications that have been used are minoxidil, Elocon (mometasone) ointment (steroid cream), irritants (anthralin or topical coal tar), and topical immunotherapy ciclosporin, sometimes in different combinations. Topical corticosteroids frequently fail to enter the skin deeply enough to affect the hair bulbs, which are the treatment target,[20] and small lesions typically also regrow spontaneously. Oral corticosteroids may decrease the hair loss, but only for the period during which they are taken, and these medications can cause serious side effects.[20] No one treatment is effective in all cases, and some individuals may show no response to any treatment.[50]

For more severe cases, studies have shown promising results with the individual use of the immunosuppressant methotrexate or adjunct use with corticosteroids.[51]

When alopecia areata is associated with celiac disease, treatment with a gluten-free diet allows for complete and permanent regrowth of scalp and other body hair in many people, but in others, remissions and recurrences are seen.[28] This improvement is probably due to the normalization of the immune response as a result of gluten withdrawal from the diet.[28]

In June 2022, the U.S. Food and Drug Administration (FDA) authorized baricitinib, a Janus kinase (JAK) inhibitor, for the treatment of severe alopecia areata.[52]

Ritlecitinib (Litfulo) was approved for medical use in the United States in June 2023.[53]

Fecal matter transplants (FMT) have been shown to reverse AA and support hair growth, with long lasting results, even going as far as growing additional hair on arms and face while grey hairs even regained colour. This supports the idea of a connection between gut microbiota having a part in hair loss.[54]

Hair transplantation may be an alternative for patients with chronic local alopecia areata. The fact that the disease is autoimmune and progresses with relapses is one of the biggest question marks before surgery. There have been case reports in the literature since the early 2000s. However, in an article published long-term follow-up; It is reported that the hair transplanted to the eyebrow area falls out again due to the recurrence of the disease.[55] A similar situation was not mentioned in previous studies on this subject. Perhaps the long-term follow-ups of other studies were not sufficient.

Deuruxolitinib (Leqselvi) was approved for medical use in the United States in July 2024.[56]

Prognosis

In most cases that begin with a small number of patches of hair loss, hair grows back after a few months to a year.[21] In cases with a greater number of patches, hair can either grow back or progress to alopecia areata totalis or, in rare cases, alopecia areata universalis.[21]


Hair may grow back and then fall out again later. This may not indicate a recurrence of the condition, but rather a natural cycle of growth-and-shedding from a relatively synchronised start; such a pattern will fade over time. Episodes of alopecia areata before puberty predispose to chronic recurrence of the condition.[20]

Alopecia can be the cause of psychological stress. Because hair loss can lead to significant changes in appearance, individuals with it may experience social phobia, anxiety, and depression.[57]

Epidemiology

The condition affects 0.1%–0.2% of the population, with a lifetime risk of 1%-2%,[58] and is more common in females.[9]

Alopecia areata occurs in people who are otherwise healthy and have no other skin disorders.[20] Initial presentation most commonly occurs in the early childhood, late teenage years, or young adulthood, but can happen at any ages.[22] Patients also tend to have a slightly higher incidence of conditions related to the immune system, such as asthma, allergies, atopic dermatitis, and hypothyroidism.

Ethnic and socioeconomic disparities

The prevalence and impact of AA vary across different ethnic groups and socioeconomic backgrounds.[59] Studies indicate that people of Asian descent have the highest risk, with nearly 6 cases per 100 people, compared to fewer than 2 cases per 100 people among White individuals.[59] People living in urban or economically disadvantaged areas face a higher likelihood of developing AA.[59] The effects of the condition also differ by ethnicity: individuals of Black descent with AA are more likely to experience anxiety and require medical leave from work.[59] These findings suggest that genetic, environmental, and social factors may influence both the likelihood of developing AA and its broader personal and professional impact.[59]

Society and culture

The term "alopecia", used by physicians dating back to Hippocrates, originates from the Greek word for fox, "alopex", and was so-named due to fur loss seen in fox mange. "Areata" is derived from the Latin word, "area", meaning a vacant space or patch.[60]

Alopecia areata and alopecia barbae have been identified by some as the biblical nethek condition that is part of the greater tzaraath family of skin disorders; the said disorders are purported to being discussed in the Book of Leviticus, chapter 13.[61]

Notable people

NASCAR driver Joey Logano, obstacle athlete Kevin Bull,[62] politicians Peter Dutton[63] and Ayanna Pressley,[64] K-pop singer Peniel Shin of BtoB,[65] actors Christopher Reeve,[66] Anthony Carrigan,[67] Greg Grunberg and Alan Fletcher,[68] and actresses Jada Pinkett Smith,[69] May Calamawy,[70] and Lili Reinhart[71] all have some form of alopecia areata. Molly Tuttle is a spokesperson for the National Alopecia Areata Foundation.

Research

Many medications are being studied.[72]

In 2014, preliminary findings showing that oral ruxolitinib, a drug approved by the US Food and Drug Administration (FDA) for bone marrow disorder myelofibrosis, restored hair growth in three individuals with long-standing and severe disease.[73]

In March 2020, the US FDA granted breakthrough therapy designation to baricitinib for the systematic treatment of alopecia areata[74] and granted approval in June 2022,[52] with a 32% efficacy rate for people with 50% hair loss reaching 80% scalp coverage in 36 weeks.[75] It acts as an inhibitor of janus kinase (JAK), blocking the subtypes JAK1 and JAK2.[76]

References

  1. ↑ 1.0 1.1 1.2 1.3 1.4 1.5 "Alopecia Areata - NORD (National Organization for Rare Disorders)". 2004. https://rarediseases.org/rare-diseases/alopecia-areata/. 
  2. ↑ "alopecia". The Chambers Dictionary (9th ed.). Chambers. 2003. ISBN 0-550-10105-5. 
  3. ↑ "alopecia". Collins English Dictionary (13th ed.). HarperCollins. 2018. ISBN 978-0-008-28437-4. 
  4. ↑ "Definition of alopecia". https://www.dictionary.com/browse/alopecia. 
  5. ↑ "Alopecia". Merriam-Webster Dictionary. https://www.merriam-webster.com/dictionary/alopecia. Retrieved 25 March 2022. 
  6. ↑ "Alopecia Areata". 4 April 2017. https://www.niams.nih.gov/health-topics/alopecia-areata. 
  7. ↑ 7.00 7.01 7.02 7.03 7.04 7.05 7.06 7.07 7.08 7.09 7.10 7.11 7.12 7.13 7.14 7.15 7.16 7.17 7.18 7.19 7.20 7.21 7.22 "Questions and Answers About Alopecia Areata". May 2016. https://www.niams.nih.gov/health-topics/alopecia-areata. 
  8. ↑ 8.0 8.1 "Alopecia areata update". Seminars in Cutaneous Medicine and Surgery 34 (2): 72–75. June 2015. doi:10.12788/j.sder.2015.0160. PMID 26176283. open access
  9. ↑ 9.0 9.1 9.2 "Gender differences in alopecia areata". Journal of Drugs in Dermatology 13 (4): 409–413. April 2014. PMID 24719059. 
  10. ↑ 10.0 10.1 10.2 "Minoxidil for patchy alopecia areata: systematic review and meta-analysis". Journal of the European Academy of Dermatology and Venereology 33 (9): 1792–1799. September 2019. doi:10.1111/jdv.15545. PMID 30835901. 
  11. ↑ 11.0 11.1 11.2 "Efficacy of different concentrations of intralesional triamcinolone acetonide for alopecia areata: A systematic review and meta-analysis". Journal of the American Academy of Dermatology 82 (4): 1018–1021. April 2020. doi:10.1016/j.jaad.2019.11.066. PMID 31843657. 
  12. ↑ 12.0 12.1 "Whole exome sequencing in Alopecia Areata identifies rare variants in KRT82". Nature Communications 13 (1). February 2022. doi:10.1038/s41467-022-28343-3. PMID 35145093. Bibcode: 2022NatCo..13..800E. 
  13. ↑ 13.0 13.1 "Alopecia areata: a review of disease pathogenesis". The British Journal of Dermatology 179 (5): 1033–1048. November 2018. doi:10.1111/bjd.16808. PMID 29791718. 
  14. ↑ "Alopecia Areata: Case report and review of pathophysiology and treatment with Jak inhibitors". Journal of Autoimmunity 133. December 2022. doi:10.1016/j.jaut.2022.102926. PMID 36335798. 
  15. ↑ 15.0 15.1 "Alopecia areata update: part I. Clinical picture, histopathology, and pathogenesis". Journal of the American Academy of Dermatology 62 (2): 177–88, quiz 189–90. February 2010. doi:10.1016/j.jaad.2009.10.032. PMID 20115945. 
  16. ↑ "Alopecia areata: Part 1: pathogenesis, diagnosis, and prognosis". Canadian Family Physician 61 (9): 751–755. September 2015. PMID 26371097. 
  17. ↑ 17.0 17.1 "Diagnosing and treating hair loss". American Family Physician 80 (4): 356–362. August 2009. PMID 19678603. https://www.aafp.org/pubs/afp/issues/2009/0815/p356.html. Retrieved 16 November 2022. 
  18. ↑ 18.0 18.1 18.2 Alopecia Areata: A Clinician's Guide. Springer. 2018. p. 14. ISBN 978-3-319-72134-7. https://books.google.com/books?id=DtNeDwAAQBAJ&q=978-3-319-72133-0&pg=PA14. Retrieved 1 October 2020. 
  19. ↑ Fitzpatrick's dermatology in medicine. New York: McGraw-Hill, Medical Pub. Division. 2003. ISBN 978-0-07-138076-8. 
  20. ↑ 20.0 20.1 20.2 20.3 20.4 20.5 Alopecia Areata at Merck Manual of Diagnosis and Therapy Professional Edition
  21. ↑ 21.0 21.1 21.2 "Alopecia Areata". American Osteopathic College of Dermatology. http://www.aocd.org/skin/dermatologic_diseases/alopecia_areata.html.  Dermatologic Disease Database. Aocd.org. Retrieved on 3 December 2007.
  22. ↑ 22.0 22.1 22.2 22.3 22.4 22.5 22.6 22.7 22.8 "Alopecia Areata". MedicineNet.com. 30 August 2007. http://www.medicinenet.com/alopecia_areata/article.htm. 
  23. ↑ "Alopecia areata". International Journal of Dermatology 46 (2): 121–131. February 2007. doi:10.1111/j.1365-4632.2007.03193.x. PMID 17269961. 
  24. ↑ Fitzpatrick's dermatology in general medicine (6th ed.). New York: McGraw-Hill, Medical Pub. Division. 2003. ISBN 0-07-138076-0. 
  25. ↑ "Congenital alopecia areata". Journal of the American Academy of Dermatology 52 (2 Suppl 1): 8–11. February 2005. doi:10.1016/j.jaad.2004.06.024. PMID 15692503. "We believe AA should be classified not only as an acquired, but also a congenital form of nonscarring hair loss. It may well be more common than is thought because of lack of recognition". 
  26. ↑ "Alopecia areata: Current understanding of the pathophysiology and update on therapeutic approaches, featuring the Japanese Dermatological Association guidelines". The Journal of Dermatology 49 (1): 19–36. January 2022. doi:10.1111/1346-8138.16207. PMID 34709679. 
  27. ↑ "Genomewide scan for linkage reveals evidence of several susceptibility loci for alopecia areata". American Journal of Human Genetics 80 (2): 316–328. February 2007. doi:10.1086/511442. PMID 17236136. 
  28. ↑ 28.0 28.1 28.2 "Celiac disease and dermatologic manifestations: many skin clue to unfold gluten-sensitive enteropathy". Gastroenterology Research and Practice 2012. 2012. doi:10.1155/2012/952753. PMID 22693492. 
  29. ↑ "The spectrum of celiac disease: epidemiology, clinical aspects and treatment". Nature Reviews. Gastroenterology & Hepatology 7 (4): 204–213. April 2010. doi:10.1038/nrgastro.2010.23. PMID 20212505. 
  30. ↑ 30.0 30.1 "How Our Microbiome Influences the Pathogenesis of Alopecia Areata". Genes 13 (10): 1860. October 2022. doi:10.3390/genes13101860. PMID 36292745. 
  31. ↑ "Cigarette Smoking, Alcohol Consumption, and Risk of Alopecia Areata: A Population-Based Cohort Study in Taiwan". American Journal of Clinical Dermatology 21 (6): 901–911. December 2020. doi:10.1007/s40257-020-00547-7. PMID 32761499. 
  32. ↑ "T helper 17 cell/regulatory T-cell imbalance in hidradenitis suppurativa/acne inversa: the link to hair follicle dissection, obesity, smoking and autoimmune comorbidities". The British Journal of Dermatology 179 (2): 260–272. August 2018. doi:10.1111/bjd.16561. PMID 29573406. 
  33. ↑ "The Sleep-Immune Crosstalk in Health and Disease". Physiological Reviews 99 (3): 1325–1380. July 2019. doi:10.1152/physrev.00010.2018. PMID 30920354. 
  34. ↑ "Dietary Habits in Japanese Patients with Alopecia Areata". Clinical, Cosmetic and Investigational Dermatology 14: 1579–1591. October 2021. doi:10.2147/CCID.S335440. PMID 34737597. 
  35. ↑ "The complex role of adipokines in obesity, inflammation, and autoimmunity". Clinical Science 135 (6): 731–752. March 2021. doi:10.1042/CS20200895. PMID 33729498. 
  36. ↑ "Endogenous retinoids in the pathogenesis of alopecia areata". The Journal of Investigative Dermatology 133 (2): 334–343. February 2013. doi:10.1038/jid.2012.344. PMID 23014334. 
  37. ↑ "Genome-wide association study in alopecia areata implicates both innate and adaptive immunity". Nature 466 (7302): 113–117. July 2010. doi:10.1038/nature09114. PMID 20596022. Bibcode: 2010Natur.466..113P. 
  38. ↑ "Alopecia Areata After Vaccination: Recurrence with Rechallenge". Pediatric Dermatology 33 (3): e218–e219. May 2016. doi:10.1111/pde.12849. PMID 27071855. 
  39. ↑ "Flare of rheumatoid arthritis after COVID-19 vaccination". The Lancet. Rheumatology 3 (7): e469–e470. July 2021. doi:10.1016/S2665-9913(21)00108-9. PMID 33817664. 
  40. ↑ "Alopecia areata after ChAdOx1 nCoV-19 vaccine (Oxford/AstraZeneca): a potential triggering factor?". Journal of Cosmetic Dermatology 20 (12): 3727–3729. December 2021. doi:10.1111/jocd.14459. PMID 34559937. 
  41. ↑ "Alopecia areata: Disease characteristics, clinical evaluation, and new perspectives on pathogenesis". Journal of the American Academy of Dermatology (Elsevier BV) 78 (1): 1–12. January 2018. doi:10.1016/j.jaad.2017.04.1141. PMID 29241771. 
  42. ↑ "Comorbidities in alopecia areata: A systematic review and meta-analysis". Journal of the American Academy of Dermatology (Elsevier BV) 80 (2): 466–477.e16. February 2019. doi:10.1016/j.jaad.2018.07.013. PMID 30031145. 
  43. ↑ "Alopecia areata: A psychodermatological perspective". Journal of Cosmetic Dermatology 21 (6): 2318–2323. June 2022. doi:10.1111/jocd.14416. PMID 34449973. 
  44. ↑ "Lifestyle Factors Involved in the Pathogenesis of Alopecia Areata". International Journal of Molecular Sciences 23 (3): 1038. January 2022. doi:10.3390/ijms23031038. PMID 35162962. 
  45. ↑ "Trichoscopy: a new method for diagnosing hair loss". Journal of Drugs in Dermatology 7 (7): 651–654. July 2008. PMID 18664157. 
  46. ↑ Lookingbill and Marks' Principles of Dermatology (4th ed.). Elsevier Inc.. 2006. ISBN 978-1-4160-3185-7. .
  47. ↑ "Skin Conditions: Alopecia Areata". WebMD. http://www.webmd.com/skin-problems-and-treatments/alopecia-areata. 
  48. ↑ 49.0 49.1 "Current treatment of alopecia areata". The Journal of Investigative Dermatology. Symposium Proceedings 16 (1): S42–S44. December 2013. doi:10.1038/jidsymp.2013.14. PMID 24326551. open access
  49. ↑ "Alopecia areata: a new treatment plan". Clinical, Cosmetic and Investigational Dermatology 4: 107–115. July 2011. doi:10.2147/CCID.S22767. PMID 21833161. 
  50. ↑ "Efficacy and Safety of Methotrexate Combined with Low- to Moderate-Dose Corticosteroids for Severe Alopecia Areata". Dermatology 232 (2): 242–248. 2016. doi:10.1159/000441250. PMID 26735937. 
  51. ↑ 52.0 52.1 "FDA Approves Lilly and Incyte's Olumiant (baricitinib) As First and Only Systemic Medicine for Adults with Severe Alopecia Areata" (Press release). Eli Lilly and Company. 13 June 2022. Archived from the original on 14 June 2022. Retrieved 13 June 2022 – via PR Newswire.
  52. ↑ "FDA Approves Pfizer's Litfulo (Ritlecitinib) for Adults and Adolescents With Severe Alopecia Areata" (Press release). Pfizer. 23 June 2023. Retrieved 24 June 2023 – via Business Wire.
  53. ↑ "Alopecia and the Microbiome: A Future Therapeutic Target?". Actas Dermo-Sifiliográficas (Elsevier BV) 112 (6): 495–502. 2021. doi:10.1016/j.adengl.2021.03.011. ISSN 1578-2190. 
  54. ↑ "Long-term result of hair transplantation for therapy resistant alopecia areata of eyebrows". Indian Journal of Dermatology, Venereology and Leprology 83 (5): 618–619. 2017. doi:10.4103/ijdvl.IJDVL_913_16. PMID 28731020. 
  55. ↑ "U.S. FDA Approves Leqselvi (deuruxolitinib), an Oral JAK Inhibitor for the Treatment of Severe Alopecia Areata" (Press release). Sun Pharmaceutical. 25 July 2024. Retrieved 26 July 2024 – via PR Newswire.
  56. ↑ "The psychological impact of alopecia". BMJ 331 (7522): 951–953. October 2005. doi:10.1136/bmj.331.7522.951. PMID 16239692. 
  57. ↑ "Incidence of alopecia areata in Olmsted County, Minnesota, 1975 through 1989". Mayo Clinic Proceedings 70 (7): 628–633. July 1995. doi:10.4065/70.7.628. PMID 7791384. 
  58. ↑ 59.0 59.1 59.2 59.3 59.4 "Lifetime incidence and healthcare disparities in alopecia areata: a UK population-based cohort study". The British Journal of Dermatology 191 (6): 924–935. November 2024. doi:10.1093/bjd/ljae307. PMID 39104082. 
  59. ↑ "Nosological Nightmare and Etiological Enigma: A History of Alopecia Areata". International Journal of Trichology 10 (3): 140–141. 2018. doi:10.4103/ijt.ijt_23_18. PMID 30034197. 
  60. ↑ Alopecia Areata: Jewish Answers to a Modern Disease. CreateSpace Independent Publishing Platform. September 2016. pp. 18–33. ISBN 978-1-5375-2975-2. 
  61. ↑ "American alopecia ninja attacks awareness". 8 July 2016. https://www.dermatologytimes.com/view/american-alopecia-ninja-attacks-awareness. 
  62. ↑ "Peter Dutton officially launches Liberal leadership campaign, reveals skin condition is alopecia". news.com.au. 27 May 2022. https://www.news.com.au/national/politics/peter-dutton-officially-launches-liberal-leadership-campaign/news-story/05fde1957cb005342fd05d11d189fe60. 
  63. ↑ "Exclusive: Rep. Ayanna Pressley Reveals Beautiful Bald Head and Discusses Alopecia for the First Time". 16 January 2020. https://theglowup.theroot.com/exclusive-rep-ayanna-pressley-reveals-beautiful-bald-1841039847. 
  64. ↑ Kang Hee-jung (15 November 2016). ""탈모인 파이팅!" 프니엘, '안녕하세요' 출연 후기 게재" (in Korean). News1. https://www.news1.kr/articles/?2831564. 
  65. ↑ "The Reeve Effect". The New Yorker. 2 November 2003. https://www.newyorker.com/magazine/2003/11/10/the-reeve-effect. 
  66. ↑ "Gotham's Anthony Carrigan Talks Acting, Alopecia, And Learning To Love His Look". BuzzFeed. 27 February 2015. https://www.buzzfeed.com/alexisnedd/gothams-anthony-carrigan-talks-acting-alopecia-and-learning. 
  67. ↑ "Alan Fletcher reveals alopecia to fans". TV Tonight. 20 May 2022. https://tvtonight.com.au/2022/05/alan-fletcher-reveals-alopecia-to-fans.html. 
  68. ↑ "How Jada Pinkett Smith is uplifting Black women with alopecia". 7 January 2022. https://www.nbcnews.com/news/nbcblk/jada-pinkett-smith-uplifting-black-women-alopecia-rcna11273. 
  69. ↑ "Sharing My Alopecia Helped Me Set New Expectations for Myself". 11 June 2020. https://www.glamour.com/story/may-calamawy-sharing-my-alopecia-helped-me-set-new-expectations-for-myself. 
  70. ↑ "Lili Reinhart Reveals She Was Diagnosed With Alopecia". Hollywood Reporter. 31 January 2024. https://www.hollywoodreporter.com/news/general-news/lili-reinhart-diagnosed-alopecia-1235811063/. 
  71. ↑ "Search - clinicaltrials.gov for alopecia areata". National Institutes of Health. https://clinicaltrials.gov/ct2/results?term=alopecia+areata&recr=Open&rslt=&type=&cond=&intr=&titles=&outc=&spons=&lead=&id=&state1=&cntry1=&state2=&cntry2=&state3=&cntry3=&locn=&gndr=&rcv_s=&rcv_e=&lup_s=&lup_e=. 
  72. ↑ "A ray of hope for alopecia areata patients". The Pharmaceutical Journal 296 (7889). 2016. doi:10.1211/PJ.2016.20201092. 
  73. ↑ "Lilly Receives FDA Breakthrough Therapy Designation for Baricitinib for the Treatment of Alopecia Areata" (Press release). Eli Lilly and Company. 16 March 2020. Archived from the original on 17 March 2020. Retrieved 16 March 2020 – via PR Newswire.
  74. ↑ "FDA Approves First Systemic Treatment for Alopecia Areata". U.S. Food and Drug Administration (FDA) (Press release). 13 June 2022. Archived from the original on 14 June 2022. Retrieved 13 June 2022. Public Domain This article incorporates text from this source, which is in the public domain.
  75. ↑ "Summary of opinion for Olumiant". European Medicines Agency (EMA). 15 December 2016. http://www.ema.europa.eu/docs/en_GB/document_library/Summary_of_opinion_-_Initial_authorisation/human/004085/WC500218183.pdf. 
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