Alopecia Areata: Clinical Presentation, Investigation and Management in Outpatient Practice

Mayta
7 hours ago
3 min read

1️⃣ Presentation

A patient presents with:

Sudden onset patchy hair loss
One or multiple well-demarcated smooth bald patches
No pain
No scaling
No scarring
No erythema

On examination:

Smooth round or oval patches
“Exclamation mark hairs” at margins (short broken hairs that taper proximally)
Possible nail pitting

🧠 Pathophysiology:Alopecia areata is an autoimmune T-cell–mediated attack on the hair follicle, specifically targeting the anagen phase follicle.The follicle remains viable → therefore non-scarring and potentially reversible.

Common associations:

Autoimmune thyroid disease
Vitiligo
Atopic disease
Type 1 diabetes

2️⃣ Management Setting

Based on stable presentation without systemic involvement:

✅ Outpatient Department (OPD)

Alopecia areata is not life-threatening and does not require admission.

3️⃣ Patient Problem List

• Problem 1: Patchy hair loss (suspected Alopecia Areata) • Problem 2: Possible associated autoimmune condition (to be evaluated)

🔬 Laboratory Investigation

According to American Academy of Dermatology (AAD) and UpToDate recommendations:

✅ Routine labs are NOT mandatory in classic alopecia areata.

However, screening for associated autoimmune disease is recommended if clinically indicated.

Labs to Consider:

1️⃣ Thyroid Function Test (TSH, Free T4)

Because alopecia areata is associated with autoimmune thyroid disease.

2️⃣ Anti-TPO antibody

If thyroid abnormal → evaluate autoimmune thyroiditis.

3️⃣ CBC

Rule out iron deficiency or anemia.

4️⃣ Ferritin

Hair growth requires adequate iron stores.

5️⃣ ANA

Only if SLE suspected clinically.

❌ Do NOT send fungal culture unless scaling or infection signs present.

If scaling + broken hairs + lymphadenopathy → think tinea capitis, not alopecia areata.

4️⃣ Plan of Management

Management Setting: OPD

✅ Definitive Treatment

According to American Academy of Dermatology Guidelines

First-line (localized disease <50% scalp involvement):

🔹 Intralesional corticosteroid

Triamcinolone acetonide (2.5–10 mg/mL)Inject intradermally every 4–6 weeks. Reason:

Suppresses autoimmune attack on hair follicle
Highest evidence for localized disease
Superior to topical steroids for small patches

📌 How do % and mg/mL convert?

Remember this formula: 1% = 10 mg/mL

% concentration	mg/mL equivalent
0.1%	1 mg/mL
0.25%	2.5 mg/mL
0.5%	5 mg/mL
1%	10 mg/mL

If patient refuses injection:

Topical clobetasol 0.05%Apply bid for 6–12 weeks

Extensive disease (>50% scalp):

Topical immunotherapy (e.g., DPCP)
Systemic therapy (dermatology referral)
Consider JAK inhibitors (emerging therapy)

❌ Oral steroids are NOT routine first-line

Reason:

High relapse rate
Systemic side effects
Not curative

(Exam pearl: steroids may regrow hair temporarily but relapse common after taper.)

✅ Supportive Treatment

• Psychological support (high emotional burden) • Cosmetic advice (hair styling, camouflage, wigs) • Stress reduction (stress can exacerbate autoimmune activity)

5️⃣ Monitoring

• Reassess every 4–6 weeks • Look for vellus hair regrowth • Monitor for steroid-induced skin atrophy • Evaluate progression

🧠 High-Yield Exam Pearl

Alopecia areata:

✔ Smooth bald patch ✔ No scaling ✔ No scarring ✔ Exclamation mark hairs

If scaling present → think tinea capitis

If scarring present → think cicatricial alopecia

📅 Follow-up

Re-evaluate every 4–6 weeks Continue therapy up to 6 months before labeling treatment failure.

⚠️ Complications to Monitor

• Nail pitting• Progression to alopecia totalis• Progression to alopecia universalis• Psychological distress

🎓 USMLE Style Question

Why don’t we give antifungal?

Because alopecia areata:

❌ Has NO scaling ❌ Has NO infection ❌ Is autoimmune

Giving antifungal would be incorrect unless fungal signs are present.

🔥 Clinical Pearl Mnemonic

“AREATA”

A – Autoimmune R – Round smooth patches E – Exclamation hairs A – Associated thyroid disease T – T-cell mediated A – Anagen follicle attacked