Alopecia Areata Clinical Case Review

Britt Craiglow, MD, an Associate Professor Adjunct of Dermatology at the Yale School of Medicine, discusses the baseline characteristics of the case:

"Hi everybody. My name is Dr. Britt Craiglow. I am an associate adjunct professor of dermatology at Yale, and I see patients in private practice in Fairfield, Connecticut.

Today we are going to review a case of an adolescent male with severe alopecia areata. He’s 15 years old. As you can see, he has now complete scalp hair loss, but it started about 6 months ago with patchy disease initially affecting the eyebrows, and then sort of rapidly progressed over the subsequent 6 months or so to what we see now. He has a history of just mild atopic dermatitis. That’s something we often do see in patients with alopecia areata. His review of systems is totally negative. His mother does have a history of hypothyroidism, but no other autoimmune disease, including alopecia areata in the family.

And he’s having a hard time. And that’s something that I think is really common with our patients with alopecia areata that we really need to ask about. Sometimes it’s really obvious, as in this case, when he quit the soccer team actually, because his teammates were making fun of him, he wasn’t allowed to wear a hat while he was playing, and it was just really getting to be too much. But other times, patients I think are kind of keeping it all in. And one of our jobs, not only in terms of treating them medically, is to really treat the whole person, right? And ask and say, “Hey, how are you doing? Are you holding up okay? This is really hard.” And just normalizing that this can be a really difficult experience, I think, is super important.

So, alopecia areata in dermatology, most of us know it quite well. It’s the most common cause of inflammation-induced hair loss. It actually affects about 2% of the population in the United States. And it is often a disease of young people. So more than half of patients will have an onset in the first 4 decades of life. But it’s also really unpredictable. And I’ve seen patients as young as 9 months of age all the way up to a 70-year-old presenting for the very first time. So, it really knows no bounds. As I often say, the only predictable thing about it is that it’s unpredictable. So fortunately, most cases are mild but it can be very severe as in this patient. And most commonly we see it affecting the scalp, but any hair-bearing site can be affected. So, eyebrows and eyelashes often also affected and those are a really big deal. I think it’s sort of easy to just not understand the importance of eyebrows and eyelashes until you actually lose them. And they really give emotion to our face and they shape our face and they’re very human feature. And it’s hard when you don't have them. And this patient also lost eyebrows and eyelashes. And it’s one thing to just say, oh, this is a hard thing for people, but we have lots of data to support that.

So, health-related quality of life in patients with alopecia areata is significantly impacted. Not surprisingly, mental health, emotional and social functioning are kind of the most affected domains in clinical studies. But the impact is similar to that of atopic dermatitis and psoriasis. And I often point that out because atopic dermatitis and psoriasis are two diseases that we really view as real diseases [that] we would never dismiss. We treat them with systemic medicines and we don’t have a hard time with that. And I think, unfortunately, patients with alopecia areata often feel dismissed, including by health care providers. They’re told that, “Oh, it’s just hair” or “At least you’re not sick.” You know, we kind of balk at using more serious medicines in these patients. But really this is a population very deserving of treatment because it has a huge impact on a person’s life."