From the Guidelines
The workup for alopecia areata primarily involves a thorough clinical examination and history taking, as the diagnosis is typically clinical, and should include screening for associated conditions such as atopy, thyroid disease, vitiligo, and other autoimmune disorders, as well as assessment for psychological impact and consideration of vitamin D levels, given the potential link between vitamin D deficiency and alopecia areata, as suggested by studies such as 1. The clinical examination should begin with a detailed scalp examination to identify the characteristic well-demarcated, smooth, round or oval patches of hair loss without visible inflammation or scarring.
- Look for "exclamation mark" hairs (short broken hairs that taper at the base) at the periphery of lesions, which are pathognomonic.
- A gentle hair pull test at the periphery of lesions can help assess disease activity.
- Consider dermoscopy to visualize yellow dots, black dots, broken hairs, and exclamation mark hairs. Laboratory testing is not routinely necessary but may include:
- Thyroid function tests (TSH, free T4)
- Antinuclear antibodies
- Complete blood count if there is suspicion of associated autoimmune conditions. A scalp biopsy is rarely needed but may be performed in atypical cases to rule out other causes of hair loss. Given the potential role of vitamin D in alopecia areata, as suggested by studies such as 1, consideration of vitamin D levels and supplementation may be warranted, although the evidence is not yet conclusive, and more research is needed to fully understand the relationship between vitamin D and alopecia areata, as noted in studies such as 1. The workup should prioritize the patient's quality of life and psychological well-being, as alopecia areata can significantly impact these aspects, and management strategies should be guided by the most recent and highest quality evidence, such as the guidelines provided by 1 and 1.
From the Research
Alopecia Areata Workup
- The workup for alopecia areata typically involves a clinical diagnosis based on the appearance of hairless patches with normal skin and preserved follicular ostia 2.
- Exclamation mark hairs and a positive pull test can signal active disease, while dermoscopy may reveal yellow dots 2.
- The differential diagnosis includes trichotillomania, scarring alopecia, and other nonscarring hair loss disorders such as tinea capitis and syphilis 2.
Diagnostic Considerations
- The clinical presentation of alopecia areata can vary from patchy, circumscribed scalp involvement to total body and scalp hair loss 3, 2.
- The disorder may be associated with atopy, autoimmune thyroid disease, and vitiligo, and the course of the disease is unpredictable 2.
- Early, long-lasting, and severe cases have a less favorable prognosis, and an alopecia areata treatment duration of longer than 6 months may be associated with a lower probability of significant hair regrowth 4.
Treatment Options
- Topical and intralesional corticosteroids are considered first-line treatments for patch-type alopecia areata, with comparable response rates for initial and significant hair regrowth 4.
- Oral prednisolone pulses have been shown to be effective and safe for the treatment of widespread alopecia areata, with cosmetically acceptable hair growth achieved in some patients 5.
- Janus kinase inhibitors, such as baricitinib and ritlecitinib, are a promising new class of drugs for treating severe alopecia areata cases, with recent US FDA approval 3.