What is alopecia areata and how is it managed?

woman lit from behind has a concerned expression as she holds a hairbrush in front of her with a substantial amount of hair in it, suggesting hair loss

Alopecia has been in the news recently. But what does it mean to have alopecia? Alopecia is a catch-all term that encompasses all types of hair loss. Hair loss is a common problem for many men and women, and most people will experience some type of hair loss during their lifetimes.

Alopecia areata (AA) occurs when the body’s immune system attacks hair follicles, resulting in hair loss. AA can affect the scalp, eyebrows, eyelashes, or anywhere hair grows on the body.

What causes alopecia areata?

The immune system protects the body against foreign invaders like bacteria or allergens. When the immune system isn’t working as it should, it can attack hair follicle cells, making them prematurely enter their “resting” phase (called telogen), stopping hair growth.

The exact trigger for this immune response is unknown, although environmental factors, genetics, and stress may all play a role.

AA affects patients of all ethnicities and genders. It is one of the most common hair loss disorders. Most people who develop AA are younger than 30, but AA can occur at any age.

What does alopecia areata look like?

AA usually starts as a sudden appearance of small, round patches of hair loss without redness or scarring. Rarely, this can progress to a complete absence of body and scalp hair, including eyebrows and eyelashes.

The diagnosis is often made through an examination by a doctor (usually a dermatologist), and may involve use a of a dermoscope (skin surface microscope) to help. If it’s not clear that AA is the cause of hair loss, the doctor make take a scalp biopsy (removal of a small amount of skin) to help get a clearer diagnosis.

Nail changes are found in approximately 10% to 20% of patients, and may occur more commonly in children or those with severe cases.

Because AA is an autoimmune condition, it is not surprising that it may be associated with other immune-driven conditions such as vitiligo, autoimmune hemolytic anemia, celiac disease, lupus, allergic rhinitis, asthma, atopic dermatitis, and thyroid diseases. Blood tests for thyroid dysfunction are often done to rule out thyroid conditions that affect hair loss.

AA frequently causes psychological and emotional distress and can negatively impact people’s self-esteem. People with AA have an increased risk for anxiety, depression, and obsessive-compulsive disorder.

What is the prognosis for alopecia areata?

The natural course of AA is unpredictable; however, most people with AA achieve hair regrowth within a few years. Regrowth is most likely to occur in patients with milder hair loss. The AA subtype also contributes to the prognosis: the risk of progression from limited alopecia areata to complete scalp hair loss (alopecia totalis) or whole-body hair loss (alopecia universalis) is approximately 5% to 10%.

The most important indicators for prognosis are the extent of hair loss and the age when AA starts. People who develop AA at a younger age usually have the worst outcomes. Certain subtypes of AA may also be less responsive to treatment options.

What are current treatments for alopecia areata?

Before treatment is started, it is essential to have realistic expectations, and to know that at this time there is no cure for AA and that the goals of treatment are to suppress hair loss and promote regrowth. Due to the unpredictable nature of AA, recurrence can happen, with only 30% of patients experiencing long-lasting remissions.

The first treatment choice for patients with limited, patchy AA is topical steroids (applied at home by the patient) or locally injected steroids (applied by the doctor), because of the minimal side effects, ease of application, and excellent response in most low-severity cases. Occasionally, specific topical irritating medications are applied to the scalp to try to reset the autoimmune process and regrow hair. Some of these prescriptions are squaric acid or anthralin (which may have other brand names), and they are also applied during doctor’s office visits.

For rapidly progressing or more widespread alopecia, systemic steroids or other immunosuppressants can be used. Recently, a newer class of medications called JAK inhibitors has shown promise at improving even advanced AA, but there has been a high relapse rate if treatment is stopped. Nevertheless, many clinical trials are being done for new AA treatments.

Family and patient education, as well as psychological support, are essential in the management of AA. Prosthetic and cosmetic options, like wigs, are also options in more extensive or nonresponsive cases. Support groups can be found on the National Alopecia Areata Foundation website.

LATE: A common cause of dementia you’ve never heard of

photo of human brain scans on a computer screen

If dementia is a general term that means thinking and memory has deteriorated to the point that it interferes with day-to-day function, what are the top three disorders that cause dementia in older individuals?

Did you think of Alzheimer’s disease? Good! Alzheimer’s is the most common cause of dementia. Did you also think of vascular dementia or strokes? Excellent! Vascular dementia is the second most common cause. What about the third?

It’s not Lewy body dementia, although Lewy body dementia (encompassing both dementia with Lewy bodies and Parkinson’s disease dementia) is the fourth most common cause. Individuals with this disorder often have features of Parkinson’s disease, visual hallucinations of people and animals, fluctuations in attention and alertness, and they may act out their dreams in bed.

It’s not frontotemporal dementia. Individuals with this disorder are often in their 60s or younger. They generally have problems with behavior or language.

So what’s the answer? It’s LATE, which stands for limbic-predominant age-related TDP-43 encephalopathy.

What’s LATE?

In LATE, a protein called TDP-43 (which stands for transactive response DNA binding protein of 43 kDa) accumulates in brain cells. Once it accumulates, it injures and ultimately destroys the cells.

LATE generally damages many of the same areas affected by Alzheimer’s disease. These regions include

  • the amygdala, involved in emotional regulation
  • the hippocampus, involved in learning and memory
  • the temporal lobe, involved in words and their meanings
  • portions of the frontal lobes, involved with keeping information in mind and manipulating it.

What are the symptoms of LATE?

Because LATE affects many of the same brain regions as Alzheimer’s disease, it often presents with similar symptoms, including

  • memory loss (impairment in episodic memory)
  • trouble finding and understanding words (impairment in semantic memory)
  • trouble keeping information in mind (impairment in working memory)

How common is LATE?

By itself, LATE is estimated to cause about 15% to 20% of all dementias. Many people with dementia also have LATE pathology in addition to one or more other pathologies in their brain. For example, an individual may have the plaques and tangles of Alzheimer’s pathology, plus LATE pathology, plus ministrokes (vascular pathology). It turns out that about 40% of people with dementia have at least some LATE pathology in their brain. All of this means that LATE is, indeed, very common.

How is LATE diagnosed and why haven’t you heard of it before?

LATE can only be diagnosed with certainty at autopsy. However, we can get a hint that LATE might be present when an older individual shows the memory loss and word-finding problems common in Alzheimer’s disease, but special tests used to confirm the diagnosis of Alzheimer’s come up negative.

The reason that you — and most clinicians — haven’t heard about LATE before is that we didn’t realize just how common it is. It was only when we began obtaining results of special tests to diagnose Alzheimer’s disease in living individuals (such as with a lumbar puncture or amyloid PET scan) that we began seeing the prevalence of LATE.

Can LATE be treated?

Because LATE was (and still is) often confused with Alzheimer’s disease, it is almost certain that when the main drugs that are FDA-approved to treat Alzheimer’s disease were evaluated, individuals with LATE were included in those studies. This means that there is every reason to believe that drugs like donepezil (brand name Aricept), rivastigmine (Exelon), memantine (Namenda), and galantamine will all be effective for individuals with dementia due to LATE.

How can you find out more about LATE?

There has been an explosion of scientific papers about LATE in just the last few years. If you have a science background, you might want to peruse them or watch the wonderful scientific symposium on this disorder held by the National Institute on Aging (NIA). If you don’t have a science background, take a look at the NIA or Wikipedia pages on LATE.