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Alopecia areata in line with 2017 guidelines


Illustration of alopecia areata on the back of the head

Symptoms/characteristics of alopecia areata


what kind of disease

Alopecia areata is a disease in which circular or oval patches of hair loss suddenly appear. Generally, it is thought that the hair loss is about the size of a 10-yen coin, but there are various symptoms, from those that spread over the entire head to severe ones that affect the eyebrows, eyelashes, and body hair.

In some cases, even if hair grows completely, it may recur.


Features

Alopecia areata has several characteristic symptoms, including: Alopecia areata is suspected if more than one of these items match.


[Initial symptoms]

Hair loss started suddenly without any symptoms.

There is a place where the skin is visible on the head.

I have small bumps on my nails.

Atopic disease (either atopic dermatitis, bronchitis, or allergic rhinitis)

Alopecia areata are round or oval with relatively sharp boundaries.


* If any of the above “initial symptoms” are met and the following symptoms are observed, it is considered that alopecia areata is progressing.


[ongoing symptoms]

When you wake up in the morning, you can see more than a few missing hairs on your pillow.

When the hair around the bald spot is pulled, it comes off easily, and there is almost no pain.

The hair root portion of the hair that has fallen out is thin and pointed.

Alopecia areata has spread.


[Convalescent symptoms]

Thin and short hairs are growing in part of the bald spots.

Pores can be seen dotted in the bald spots.

Even if the hair around the bald spot is pulled, it does not come off easily

When people get alopecia areata for the first time, their hair suddenly falls out, and many people are surprised and confused. Some people seem to be so preoccupied with hiding things that they think "time will heal" and try their own remedies rather than committing to treatment. As a result, it may take longer to heal or even worsen.



When my hair fell out for the first time

What should I do when my hair is falling out for the first time or patches appear?

First, let's deepen our understanding of alopecia areata.

In particular, the mildest symptoms of "single-shotThere is also data that about 80% of people are cured within a year, so there is no need to worry excessively.

The important thing is to see a dermatologist as soon as possible if you suspect that you have alopecia areata.


In addition, there are cases where hair loss is caused by a disease other than alopecia areata.

especially,ChildrenThere is also a case of "trichotillomania" in which the hair is pulled out by oneself due to stress.


What is alopecia areata?Now, the characteristics of alopecia areata are described, so if you are interested, you may want to check it yourself.


Types of alopecia areata

There are several types of alopecia areata. Here, we will explain from the relatively common "single type" to "multiple type", "serpentine type", "whole head type" and "generalized type".


>single-shot

Alopecia areata is the most common type of alopecia areata, which causes sudden, circular or oval patches of hair loss on the scalp. Hair loss can occur not only on the scalp, but also on the eyebrows and body hair.

The age of onset ranges from childhood to the elderly and is seen equally in men and women.

Approximately 80% of patients are said to be cured within a year, but in rare cases, the disease progresses to the next stage, the multiple type.


>Multiple type

A type in which two or more circular patches of hair loss occur.

Even with proper treatment, it often takes six months to two years to fully recover. In addition, the bald spots may combine and expand (multiple fusion type).


>Serpentine

It is a type in which the bald patches are joined together and elongated, spreading like a snake along the hairline from the back of the head to the side of the head. Treatment may last for several years.


>Whole head type

Alopecia areata spread over the entire scalp, and eventually the hair falls out completely. Many cases are very difficult to cure, and treatment is often long-term. Therefore, in addition to treatment, it is necessary to devise ways to deal with alopecia areata using wigs.


>Generalized type

As the symptoms progress further, not only the hair on the head, but also the eyebrows, eyelashes, and body hair fall out.

It is said to be the most severe type of alopecia areata. As with the full-head type, the treatment is often long-term, so it is also necessary to devise ways to deal with alopecia areata by using wigs as well as continuing treatment.


CAUSE of alopecia areata


Temporal region of a man with alopecia areata

Various theories have been proposed as to the cause of alopecia areata. In recent years, there is a strong theory that it is caused by an “autoimmune disease” in which “abnormal immune function occurs in the hair root tissue of the hair”.


Factors that cause immune function abnormalities include physical and mental stress such as fatigue and infectious diseases, and constitutional predispositions.

Here are some of the things that are thought to cause alopecia areata, including those listed below.


>autoimmune disease

In recent years, an autoimmune disease has been identified as the leading cause of alopecia areata. "Autoimmune disease" is an abnormal function of the immune system that protects our body by attacking invaders from the outside, and attacks a part of our body as a foreign body.


Alopecia areata is thought to be caused by T-lymphocytes mistakenly attacking the hair roots as foreign substances, and the intense attack damages the hair roots, causing even healthy hair to suddenly fall out. However, it is not yet clear why such an anomaly occurs.


In addition, alopecia areata may be associated with various autoimmune diseases such as thyroid disease represented by Hashimoto's disease, vitiligo vulgaris, SLE, rheumatoid arthritis, or myasthenia gravis. In particular, it is said that about 8% of patients with thyroid disease and about 4% of patients with vitiligo vulgaris have alopecia areata.


>Atopic predisposition

Atopic predisposition refers to a person who has an atopic disease (either atopic dermatitis, bronchitis, or allergic rhinitis). More than 40% of patients with alopecia areata are said to have atopic predisposition, and more than half of them have atopic predisposition in themselves or in their families, suggesting a close relationship.


>Effects of mental stress

Mental stress is one of the causes of alopecia areata.

When we receive mental stress, the sympathetic nervous system is activated in order to resist it. The sympathetic nervous system prepares the body to fight stress by making the heart and lungs move faster and raising the body temperature.


At this time, if the stress is too strong or lasts for a long time, the sympathetic nerve will be abnormal. As a result, blood vessels constrict, blood flow to the head deteriorates, and it is thought that hair loss is caused by lack of nutrition to the hair roots.

In addition, stress not only prevents the supply of nutrients to the hair roots, but also induces various diseases such as "autoimmune diseases" and "endocrine disorders".


>genetic component

A large-scale survey conducted in China reported that approximately 8.4% of patients with alopecia areata have family members with the same disease. The closer the relatives are to each other, the higher the incidence. According to a survey in Europe and the United States, the incidence rate for first-degree relatives of patients with alopecia areata is 10 times higher than for families with second-degree or higher relatives. From this, it is thought that there is a high possibility that genetic factors are involved in alopecia areata.


>Changes in female hormone levels after childbirth

Decrease in female hormones after pregnancy and childbirth is also said to be one of the causes.

During pregnancy, female hormone levels in the body increase more than 100 times than normal. It returns to normal once you give birth. Female hormones have the effect of promoting hair growth, and conversely, if it decreases, it will lead to hair loss.


In many cases, it is postpartum hair loss that reduces the volume of the entire hair, but at this time, alopecia areata may occur. In addition, there is data that it is easy to accelerate if you have atopic predisposition.


It is important to pay special attention to postpartum hair loss because it can be caused not only by hormonal imbalance, but also by the stress of childbirth and an unbalanced diet due to the busyness of childcare.


Treatment of alopecia areata

Alopecia areata has yet to be completely cured. However, various treatment methods have been tried so far, and the effectiveness and risks of each treatment method have been clarified.

We will introduce each treatment method based on the “Alopecia Areata Treatment Guidelines 2017”.


Recommended treatment

>topical steroid injection

It is a treatment that injects steroids, which are effective in suppressing inflammation and immune function, into the hair loss spots.

It may be used in adults with unifocal and multifocal forms who do not improve. Although it has a high level of hair growth effect, considering the side effects of steroids, it is not used for children. In addition, it is necessary to pay attention to the fact that there is a strong pain at the time of injection and that the injection site may collapse as a side effect.


>local immunotherapy

It is a treatment method that promotes hair growth by causing a rash using a chemical agent that causes an artificial rash, dibutyl squalate (SADBE) or diphenylcyclopropenone (DPCP). In the beginning, a high concentration of 1% or 2% is applied for sensitization, and after 2 weeks, a low concentration is applied, and then the concentration is gradually increased to the optimal concentration for treatment.


This treatment is for patients with relatively extensive hair loss. It can also be used by children. It is said to have a hair growth effect in about 90% of people, but it may cause side effects such as rashes, hives, and lymphadenopathy.


In addition, people with atopic dermatitis, eczema, and hives. should be used with caution as it may temporarily worsen the symptoms. Also, the treatment period is from half a year to a year or more, and it is necessary to work carefully.

Although it is a treatment that is said to be effective, it is not approved for insurance coverage in Japan, so it is self-funded.


>JAK (Janus kinase) inhibitor

It is a drug that suppresses the pathological condition of alopecia areata, "attack of lymphocytes to hair follicles by the action of autoimmunity," and is a new oral drug for the treatment of severe or extremely severe alopecia areata.

Possible treatment


>Use of oral medicine (oral medicine)

The following oral medicines (oral medicines) may be used to treat alopecia areata, and their efficacy has been confirmed.

Oral steroid

Antiallergic drugs (second-generation antihistamines)

Cepharanthine

Glycyrrhizin, methionine, glycine compound drugs




>use of topical drugs

The following topical agents (such as poultices and ointments) may be used to treat alopecia areata, and their efficacy has been confirmed.

topical steroid

carpronium chloride topical

topical minoxidil




>cooling therapy

It is a treatment method that applies dry ice or liquid nitrogen to the hair loss spots to suppress the function of immune cells that have malfunctioned and regenerate the hair. During treatment, dry ice is applied directly, liquid nitrogen is applied with absorbent cotton or a cotton swab, or sprayed.

There is slight pain during the treatment, but it is a simple method with few side effects.



>UV therapy

It is also used to treat skin diseases such as atopic dermatitis and psoriasis vulgaris.

There are PUVA therapy, narrow band UVB therapy, excimer laser therapy, etc.

The number and frequency of treatments vary depending on the symptoms, but treatment is performed once to six times every two weeks for several months. Side effects include tingling and itching due to inflammation of the skin due to the irradiation of ultraviolet rays, and in severe cases, blisters may occur.

As for its efficacy, it has been reported that it was effective in the whole head type and the generalized type, which cause hair loss over a wide area, so it is sometimes used in severely ill patients. It is not recommended for treating children.


>Linearly polarized near-infrared radiation therapy (superizer therapy)

This is a treatment method that uses a device called a "superizer" to irradiate the hair loss spots with special infrared rays that reach deep into the skin. Since the wavelength of this light reaches deep into the body, it has an analgesic and anti-inflammatory effect that reduces pain and swelling, so it is also used for treatment of muscles and joints.


In addition, direct irradiation to the autonomic nerves improves blood circulation throughout the body, so it is sometimes used to treat autonomic imbalance.

Because it is easy to treat and has mild side effects, it is sometimes used to treat single- and multiple-onset cases.


>Intravenous steroid pulse therapy

It is a treatment method in which large doses of steroids are administered over a short period of about 3 days by intravenous drip.


An effective treatment for rapidly progressing severe disease in adults within 6 months of onset. About 60% of the patients within 6 months after the onset showed an effect, but only about 16% of the patients after 6 months after the onset showed an effect.


While it has been proven to be highly effective for severely ill patients in the early stages of onset, it may cause growth disorders in children, so it is not used.

Because of the high dose of steroids, hospitalization is required. Side effects such as insomnia, palpitation, headache, slight fever, and malaise may occur.


Medications used for alopecia areata

There are multiple treatments for alopecia areata, but no cure has been established as well as treatment methods. However, past clinical results have clarified its effectiveness and risks.


New Oral Medication to Treat Severe Alopecia Areata

>JAK (Janus kinase) inhibitor

It is a drug that suppresses the pathological condition of alopecia areata, "attack of lymphocytes to hair follicles by the action of autoimmunity," and is a new oral drug for the treatment of severe or extremely severe alopecia areata.

The internal use prevents the hair follicles from being attacked, and hair growth can be expected. In addition to alopecia areata, it is also used for atopic dermatitis and rheumatoid arthritis, for which conventional treatments are inadequate.


It is known that one of the causes of alopecia areata is that immune cells attack the pores due to the excessive action of substances called cytokines. By suppressing these cytokines, JAK inhibitors eliminate the immune response that attacks the pores and promotes hair growth. It suppresses not only cytokines but also the function of immune cells themselves.


Hair will start to grow as early as a few months after taking it, but it may take more than half a year. Since there are individual differences in the effect, it is important to carefully monitor the symptoms and select the treatment method that suits the patient.


Before taking JAK inhibitors, it is necessary to undergo tests such as a medical interview, a blood test, and a chest X-ray. In order to continue treatment with peace of mind, regular examinations are necessary even after administration. In addition, although the frequency is low, side effects such as pharyngitis, shingles, and anemia may occur, so caution is required.


Oral medicines (oral medicines) that may be considered

>Antiallergic drugs (second-generation antihistamines)

It is a therapeutic agent that relieves allergic symptoms such as hay fever.

A reduction in the area of ​​​​hair loss has been observed in single and multiple type patients with atopic predisposition (atopic disease "atopic dermatitis", "bronchitis", or "allergic rhinitis").


>Cepharanthine

It is a therapeutic agent that suppresses allergic reactions and promotes blood flow.

Although the evidence for reduction of bald spots is said to be thin, it is used in combination with other treatments in the treatment of single and multiple types, as there are many clinical results in Japan.

Side effects may include stomach discomfort and loss of appetite.




>Glycyrrhizin, methionine, glycine compound drugs

The drug Glycyron® works by reducing inflammation and allergies.

Although scientific verification is inadequate, it is used in the treatment of single and multiple types because of its extensive clinical experience in Japan. The most commonly reported adverse reactions include increased blood pressure and abdominal pain.


>Oral steroid

It is a steroidal drug that has the effect of suppressing inflammation and immune function.

Although highly effective, it is not used for children. In addition, there is a high probability that hair loss will recur after stopping taking steroids. Therefore, it is an oral drug that is used only for adult patients with extensive hair loss.


Side effects may include obesity, diabetes, menstrual irregularities, and digestive organ failure.


Topical medicines that may be considered (such as ointments)

>topical steroid

It is a topical steroid that is effective in suppressing inflammation and immune function.

It is used by many dermatologists as a general treatment method, and has a wealth of treatment results in Japan.

It is one of the treatment methods whose effectiveness has been confirmed, with a number of research reports providing scientific evidence.




>Topical carpronium chloride (Frozin solution)

It is an ingredient that is also included in commercially available hair growth medicines, and is recognized for its hair growth effect.

It is said that the verification of the hair growth effect is insufficient, but there is a huge clinical record in Japan. Side effects may include sweating, itching, rashes, and inflammation.


>topical minoxidil

It is a drug that is recognized for its hair growth effect and has the effect of dilating blood vessels.

The evidence for reducing the area of ​​hair loss is said to be weak, but there are many clinical results around the world.


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