Alopecia areata which is commonly known as spot baldness is a condition resulting in a hair loss from specific areas or all the body. Commonly it affects the scalp leaving multiple bald spots of a coin size. The main triggers for alopecia involve psychological stress as well as illness however, in majority of cases the cause remains unknown. In a few instances a complete hair loss from the scalp is possible referred to as alopecia totalis or else a full body hair loss alopecia universalis. Hair loss can be both temporary and permanent. It is important to differentiate alopecia from pattern hair loss, which occurs commonly among males.

It is believed that alopecia areata is one of the autoimmune disorders in which a breach of the immune privilege of the hair follicles can be observed. The underlying mechanism shows failure of the body to identify its own cells which leads to immune-mediated hair follicle destruction. The major risk factor involves family history of the condition. With regards to identical twins if one is affected by the condition the other one has approximately 50% risk of also acquiring alopecia.

With regards to sudden onset localized patchy presentation hair regrowth was observed in more than 50% of cases. In individuals with only one or two patches the 1- year recovery happened in up to 80%. Unfortunately, majority will experience more than one episode throughout a lifetime. It is recommended to apply sunscreen, use head covering to protect the scalp from cold and sun and sunglasses especially in cases of lash loss.

It is estimated that approximately 15% of individuals are affected at any one time and 2% are affected in some point in time. The onset is commonly observed in childhood. Females are more frequently affected than males.

Causes

The condition is brought about by white blood cells attacking cells contained within hair follicles leading to their shrinkage and dramatic regression of hair production. The cause behind alopecia is unknown. Even though scientists remain unsure why these changes take place it was shown that genetics play a great role in alopecia areata making it much more likely to occur in a person who has a close relative with the condition. One in five suffering has a family member who has also developed alopecia.

Additionally, it was shown that individuals with a family history of alopecia also have a personal or a family history of different autoimmune disorders including atopy (hyperallergic), thyroiditis and vitiligo. Moreover, alopecia shares genetic risk factors with conditions such as rheumatoid arthritis, type 1 diabetes mellitus and celiac disease. Interestingly, alopecia can present as exclusive manifestation of celiac disease.

Alopecia areata is not a contagious disorder.

Signs and symptoms

The first typical symptom of alopecia to be observed includes multiple small bold patches. The underlying skin remains unscarred looking normal. Even though the patches can form various shapes the most common ones include round and oval. Most frequently affected areas involve the scalp and beard however any areas containing hair can undergo damage. Various skin zones may present hair loss and regrowth happening at the same time. The affected area can tingle and cause mild pain sensation. Hair loss happens over a short period of time with hair loss greatly affecting lateral areas of the scalp.

Sometimes the very first changes alarming of alopecia development affect fingernails and toenails. The little alternations include white spots and lines, pinpoint dents, loss of shine and fragility. There are also a few clinical signs which can be observed such as exclamation mark hair (short hair narrower at the bottom growing in or around the edges of bald spots), cadaver hair (breakage of hair before reaching skin surface) as well as white hair (growing in areas affected by hair loss).

Diagnosis

The typical diagnosis of alopecia areata is based on clinical features. Trichoscopy is useful when it comes to diagnosis confirmation showing steady distribution of 'yellow dots' (hyperkeratotic plugs), small exclamation mark hairs as well as 'black dots' (damaged hairs localised within the hair follicle opening). In some cases, zones of hair loss surrounded by exclamation mark hairs are enough for diagnosis confirmation. Occasionally, skin reddening (erythema) can be observed in the affected area. There is a negligible use of biopsy when it comes to diagnosis or help in the management of alopecia areata. With relation to histologic findings peribulbar lymphocytic infiltration 'swarm of bees' together with follicular infundibulae and shift of the antigen to telogen ratio can be observed. Different significant signs include pigment incontinence within hair bulb as well as follicular stelae. Inactive alopecia presents no inflammatory infiltrates.

Treatment

There are many treatments available for treatment of alopecia including natural remedies which are growing in their popularity. For centuries aloe vera was the treatment of choice for various skin conditions involving hair loss. Enzymes responsible for hair growth enhancement and reduction of scalp inflammation can be found within aloe vera gel. Therefore, application of aloe vera gel is considered as a natural and efficient treatment for alopecia.

Essential oils such as rosemary, lavender and peppermint stimulate hair growth as well as lead to improvement of blood circulation in the scalp. Thus, a mixture of few drops of essential oils together with a carrier oil for instance coconut or jojoba oil is a great natural treatment. Such mixture should be massaged into the scalp.  Onion juice is another great alternative treatment which enhances hair growth. The sulphur which is found within onions aids production of collagen which leads to healthy hair growth. It is recommended to apply onion juice directly onto the scalp leaving it on for 30 minutes before washing it off. For best results it is suggested to repeat such treatment once a week.

Healthy diet is crucial when it comes to hair growth. A dietary routine rich in protein such as eggs, fish and lean meat can contribute to further promotion of hair growth. Food products rich in vitamins including leafy greens, seeds and nuts also contribute to great stimulation of hair growth. With regards to stress, it is known to be a well-known contributor to hair loss. Thus, stress management through meditation, yoga or other stress-reducing techniques is highly beneficial especially for individuals suffering from hair loss due to alopecia.

Fish oil contains omega 3 acids which have anti-inflammatory properties. It is recommended to take fish oil supplements or add fish oil rich foods (salmon, sardines, tuna) into diet as they aid hair growth. Green tea is also considered one of the natural treatments for alopecia, as it is full in antioxidants which promote hair growth and decrease hair loss. Brew green tea should be applied onto the scalp, left for an hour and rinsed off. This treatment should be repeated once a week.

Renald Blundell is a biochemist and biotechnologist with a special interest in Natural and Alternative Medicine. He is a professor at the Faculty of Medicine and Surgery, University of Malta.

Andrea Weronika Gieleta is a registered nurse and is currently a medical student at the University of Malta.