‘Alopecia’ means hair loss. Alopecia areata describes a problem whereby a circular bald patch (or patches) appears very quickly. The patch begins as a very small one, about the size of your fingernail, and, if it remains this way before the regrowth of hair occurs, may go completely unnoticed. Whether discovered or not, it is a problem that need not give rise to any anxiety because the bald spot is usually soon covered by a new growth of hair.
The bald patches of alopecia areata are very distinctive, because they are almost perfect, sharply defined circular patches. Within the patch, the hair follicles can all be seen as small holes in the skin. The skin usually appears quite normal, but can take on a glossy appearance. As the conditions clears up, fine white hairs or pigmented hairs emerge from the follicles. The white hairs will eventually take on the normal colour of the other hairs on the scalp.
Alopecia areata is not restricted to the scalp. The eyebrows can be affected and, in fact, all the hairs on the body can be affected and lost. However, this is rare.
The cause of Alopecia Areata
Alopecia areata is an auto-immune problem. This means that one group of white blood cells is attacking some cells in the skin or hair, causing the baldness. (Millions of different white blood cells circulate in the blood and the lymphatic system. They help protect the body from bacterial and viral infections etc.)
People who experience alopecia areata have a genetic predisposition for the problem. However, it still takes something to trigger the problem. The trigger could be viral or bacterial infection, a vaccination, stress, trauma to the skin or exposure to a substance not previously encountered.
What is Stress?
Stress is anything unusual experienced by the body. So stress is experienced in times of excitement, anxiety, fear, during and following operations, or when an injury is incurred. A death in the family, a financial crisis, an important sporting event or a plane journey are all events that could create a stressful situation. We say ‘could’, because the same event bring about different reactions in different people depending on their experiences.
Stress can influence alopecia areata through its effects on the sympathetic nervous system. Stress causes sympathetic nerves to increase their production of chemicals in the skin termed neuropeptides. These neuropeptides can increase auto-immune reactions in the skin.
Unfortunately, any type of hair loss is in itself very stressful. Therefore, when stress is a factor with alopecia areata, the hair loss only creates more stress. There is no way this extra stress can be avoided.
Treatment for Alopecia Areata
Treatment for alopecia areata attempt to reduce the white blood cells associated with the problem. If this can be done, the hair will regrow. However, the hair often regrows without any treatment at all. It must also be emphasized that no treatment works 100% of the time. What helps one person may not help another.
The other main treatments for alopecia areata include the topical application or an oral intake of corticosteroids, injections of steroids into the bald area, the application of regaine or dithranol, and ultraviolet therapy. All these treatments can sometimes correct the auto-immune problem, allowing the hair to regrow.
Lichen Planopilaris (Lichen Planus)
LICHEN PLANOPILARIS (LICHEN PLANUS) Lichen refers to the specific type of skin lesion, which is a solid papule or pimple. Lichenisation describes the development of the lichen-like lesions of the skin. Lichen planus is a general term describing the eruption of lichen on the surface (plane) of the skin. Lichen planopilaris draws its name from the piliary apparatus, or hair follicle, and is the term applied to follicular lichen planus occurring in adults.
A similar problem to lichen planus is termed frontal fibrosing alopecia, which is characterized by scarring at the front and sides of the scalp, and is usually seen in women in their 50s and 60s. At a glance, it can look similar to genetic recession in women, but a careful examination will quickly indicate that the follicles have been destroyed.
CAUSE The cause of lichen Planopilaris is unknown, but the problem is sometimes drug-induced. Immunological mechanisms may play a part in the cause. A perifollicular lymphocytic infiltrate at the level of the infundibulum and the hair bulge results in necrotic changes within keratinocytes, which causes the scarring.
Folliculitis means inflammation of the follicles. Decalvans is the latin for “to cause baldness”. Folliculitis decalvans is baldness associated with folliculitis. It is a slowly spreading inflammatory condition whereby destruction of the hair follicles gives rise to round or oval patches of permanent baldness.
A distinctive variant of folliculitis decalvans is tuffed hair folliculitis whereby several hair shafts emerge from one hair follicle. This is because the deeper parts of some follicles are spared when their mid portions are destroyed by the inflammatory process. The hairs therefore find an intact follicle through which to emerge. Scarring is evident between the emerging tufts.
Psoriasis is the most common scaly problem you will see in the trichology clinic, and is a problem that seems to be increasing. Both children and adults are affected, but it is rare in children younger than three. The scalp is a common site, but it is a problem that can affect skin on any part of the body; the elbows and knees, for example. It affects about 2% of Caucasians.
Psoriasis is an autoimmune problem that can be triggered by such events as viral or bacterial infections, trauma or injury to the skin, or stress. (The koebner phenomenon refers to the triggering of psoriasis by injury to the skin.) CD8 T cells play an active role in the pathogenic process. A result of the autoimmune process is that the cells of the epidermis move from the stratum germinativum to the stratum corneum at an abnormally high rate.
Sufferers have a genetic predisposition for the problem, but it still takes something to trigger psoriasis.
Stress, lithium, B-blockers, indomethacin and anti-malarials can aggravate psoriasis. Studies have also indicated that psoriasis is worsened by smoking and by excessive alcohol intake.
Genetic Thinning in women
Genetic thinning in women (androgenetic alopecia) is a condition characterized by thinning of hair in the front/top areas of the scalp. This thinning does not lead to baldness. What happens is that the growing phase of many of the hairs in the area becomes shorter, producing shorter finer hairs. However, many of the hairs in the front/top areas are untouched by this process so that the general appearance of the scalp is of a thinning in the area in question.
The thinning usually begins at the time of menopause or after a hysterectomy. At these times, the change in the sex hormonal balance gives the male sex hormones (androgens) more influence and brings about the thinning. But, as with genetic baldness in men, the hairs in question must have inherited the tendency to regress in response to the hormonal changes.
Occasionally, genetic thinning can be triggered by oral contraceptives or hormone replacement therapy (HRT); progesterones in contraceptives or HRT can have an effect on the hair similar to androgens. They can trigger the thinning in those women with the genetic tendency. Genetic thinning can also be triggered after pregnancy but this must not be confused with the temporary diffuse hair loss that can occur after giving birth.
In the past, women in their twenties or thirties seldom suffered genetic thinning unless a hormonal imbalance was present. However, more younger women with genetic thinning are now being seen and one reason for this increase is the oral contraceptive.
Extreme stress can trigger genetic thinning in those women with the predisposition. Stress increases cortisone levels, and these can have the same adverse effect on hair as androgens.
The relative infrequency with which genetic thinning occurs in women suggests that the trait must be inherited by the daughter from BOTH parents in order for her to exhibit it.
Genetic Thinnung & a Hormonal Imbalance
Both the ovaries and the adrenal glands produce androgens. A problem of the ovaries or adrenal glands, such as cysts or tumours, can give rise to an increase in androgens, which, in turn, can trigger genetic thinning in those women so predisposed. Excessive facial hair and an increase in oiliness of the skin are other signs of an overproduction of androgens.
Blood tests can be run that establish whether the ovaries or adrenal glands are at fault. Once the problem can be pinpointed, corrective action can be taken.
Hereditary hair loss in men
The most common type of hair loss in men is termed ‘male pattern thinning’ (MPT) or ‘androgenetic alopecia’. This is where recession of the hair occurs at the temples and/or thinning of hair occurs in the front/crown areas of the scalp. The final stage of such a loss leaves a band of hair around the back and sides of the scalp and baldness over the rest of the scalp.
MPT is easily recognized by its location on the scalp and by the manner in which it occurs. It is not marked by a rapid loss of hair. What happens is that, with each new hair cycle, the affected hairs do not grow as long and they become finer in diameter. Eventually, very small fine hairs, termed vellus hairs, remain. Usually, the whole process takes at least ten years and as long as forty years.
MPT usually begins during the late teens and early 20’s and affected men are well on the way to baldness by the age of 30.