Alopecia areata

There are multiple variants of alopecia areata. The most common form, known as patchy or focal alopecia areata, is characterised by hair loss in one or several well-defined areas of the scalp, resulting in round or oval patches without hair. Typically, no more than three or four patches are present.

When multiple areas are affected, the condition is referred to as multifocal alopecia areata. More severe forms involve extensive hair loss, which may affect the entire scalp (alopecia areata totalis) or extend to the eyelashes, eyebrows and body hair (alopecia areata universalis).

There are no reliable predictive factors that allow the prognosis or clinical course to be determined in advance. As an autoimmune condition, alopecia areata often shows spontaneous periods of improvement, even in the absence of treatment. Conversely, inflammation may remain active for prolonged periods, leading to sustained hair loss. In such cases, treatment may induce regrowth, but hair loss can recur when therapy is withdrawn.

Limited forms of alopecia areata, affecting one or a few patches, generally respond more favourably to treatment. In contrast, more extensive variants—multifocal, total or universal alopecia areata—tend to have a less predictable response and often require prolonged treatment, with variable outcomes.

The diagnosis of alopecia areata is primarily clinical. During the consultation, a detailed medical history is obtained, including a thorough assessment of family history.

Digital trichoscopy is performed to obtain magnified, high-resolution images of the scalp, hair follicles and hair shafts. In patients with active inflammatory alopecia areata, microscopic examination may reveal characteristic findings such as “exclamation mark” hairs and small black dots in the affected areas.

The documentation of trichoscopic images also allows objective monitoring of treatment efficacy. When the condition is controlled, early regrowth appears as fine vellus hair, which can be detected microscopically before it becomes visible to the naked eye. This enables timely adjustment of treatment if necessary.

Digital trichoscopy is also useful for monitoring disease progression and for the early detection of relapses, contributing to higher rates of therapeutic success.

During the physical examination, a hair pull test is performed. This gentle traction test helps assess active inflammation by evaluating the ease with which hairs are extracted and the condition of their roots.

In selected cases, a scalp biopsy may be required to differentiate alopecia areata from other forms of alopecia, of which more than one hundred have been described. Depending on the clinical findings and patient history, additional blood tests and immunological studies may be indicated.

Laboratory investigations commonly include thyroid function tests, given the frequent association between alopecia areata and autoimmune hypothyroidism. In rare cases, allergy testing or analysis of autoimmune markers may also be required.

These treatments act on the autoimmune process responsible for weakening the hair follicle and promoting hair loss. They are usually administered as topical formulations or local injections, which allow targeted control of hair regrowth in limited areas of the scalp. Injected treatment does not require prior preparation and is performed in the outpatient clinic whenever necessary.

It consists of administering the medication directly into the scalp through multiple microinjections covering the affected area. Although it may cause mild discomfort, it is generally well tolerated and can be performed quickly. This option is particularly useful for controlling the disease when small areas of hair loss reappear after tapering or discontinuation of oral medication.

When clinically indicated, oral anti-inflammatory drugs may be prescribed in weekly mini-pulse regimens. This dosing schedule improves treatment adherence—usually requiring only two doses per week—and significantly reduces the risk of adverse effects typically associated with daily administration. Some patients, especially postmenopausal women, may require additional calcium and vitamin D supplementation.

When first-line options are insufficient or contraindicated, the dermatologist may consider systemic medications aimed at modulating the abnormal immune response, or topical immunotherapy. The latter involves the controlled application of an irritant substance to redirect inflammation from the hair follicle to the skin surface, thereby reducing immune-mediated damage to the hair root.

As an adjunct, medications aimed at reducing hair shedding, stimulating new hair growth and improving hair density may also be prescribed.

In addition, members of the Grupo Pedro Jaén Hair Disorders Unit are actively involved in research into new therapies that have shown promising results in clinical trials, although further studies are still required to fully establish their efficacy and safety profiles.

Several cosmetic options are available to camouflage areas affected by alopecia areata. In cases involving eyebrow hair loss, many patients choose micropigmentation or microblading to restore facial expression, as eyebrows play a key role in non-verbal communication and facial aesthetics.

The content of this page has been prepared by the Communication Department and the Medical Team of Grupo Pedro Jaén, in line with our editorial commitment to ensuring the accuracy and up-to-date nature of the information provided.

References on alopecia areata:

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2. Saceda-Corralo D, Grimalt R, Fernández-Crehuet P, Clemente A, Bernárdez C, García-Hernandez MJ, Arias-Santiago S, Rodrigues-Barata AR, Rodríguez-Pichardo A, García-Lora E, Jaén P, Camacho FM, Vañó-Galván S.Beard alopecia areata: a multicentre review of 55 patients. J Eur Acad Dermatol Venereol. 2017;31(1):187-192.

3. Vañó-Galván S1, Hermosa-Gelbard Á2, Sánchez-Neila N2, Miguel-Gómez L2, Saceda-Corralo D2, Rodrigues-Barata R3, Jaén P3.Treatment of recalcitrant adult alopecia areata universalis with oral azathioprine. J Am Acad Dermatol. 2016;74(5):1007-8.

4. Vañó-Galván S1, Hermosa-Gelbard Á2, Sánchez-Neila N2, Miguel-Gómez L2, Saceda-Corralo D2, Rodrigues-Barata R3, Ma DL4, Jaén P3. Pulse corticosteroid therapy with oral dexamethasone for the treatment of adult alopecia totalis and universalis. J Am Acad Dermatol. 2016;74(5):1005-7.

5. Moreno-Arrones OM, Serrano-Villar S, Perez-Brocal V, Saceda-Corralo D, Morales-Raya C, Rodrigues-Barata R, Moya A, Jaen-Olasolo P, Vano-Galvan S. Analysis of the gut microbiota in alopecia areata: identification of bacterial biomarkers. J Eur Acad Dermatol Venereol. 2019 Aug 16. doi: 10.1111/jdv.15885.

6. Phan K, Sebaratnam DF. JAK inhibitors for alopecia areata: a systematic review and metaanalysis. Journal of the European Academy of Dermatology and Venereology. J Eur Acad Dermatol Venereol. 2019 May;33(5):850-856.