Alopecia Areata: Causes and Treatment of Patchy Hair Loss

Alopecia areata is an autoimmune condition in which the immune system attacks hair follicles, causing sudden, smooth, round bald patches, most often on the scalp or beard. Because the follicles stay alive, hair often grows back, and a dermatologist can offer treatments that may speed up regrowth, although the condition can return.

Finding a bald coin sized patch while combing, or having a barber point one out, is frightening. In India it is often blamed on insects, curses or lice, none of which are true. Here is what is actually happening and what you can do.

What is alopecia areata?

The immune system normally protects the body. In alopecia areata, immune cells gather around hair follicles in their growth phase and switch off hair production. The follicle is not scarred, which is why regrowth remains possible even after many months.

Key facts:

• It can begin at any age, including childhood, though it often starts before the age of 30.
• It affects men and women of all skin types.
• It tends to run in families.
• It is more common in people with other autoimmune or atopic conditions, such as thyroid disease, vitiligo, eczema, asthma or allergic rhinitis.

What does alopecia areata look like?

• Patchy alopecia areata: one or more smooth, round or oval bald patches, with normal looking skin. This is the most common form.
• Beard involvement: round patches in the beard, often first noticed by men while shaving.
• Eyebrows and eyelashes: partial or complete loss.
• Ophiasis pattern: a band of loss along the back and sides of the scalp, which tends to be harder to treat.
• Alopecia totalis: loss of all scalp hair.
• Alopecia universalis: loss of all body hair.
• Nail changes: tiny pits or ridges on the nails in some people.

At the edges of an active patch, a dermatologist may see short broken hairs that are narrower at the base, often called exclamation mark hairs.

What can trigger it?

The underlying cause is a mix of genes and immune activity. Possible triggers that some people notice before a patch appears include:

• Severe emotional stress
• A viral illness, including fevers such as dengue or COVID-19
• Other autoimmune flares

Often there is no identifiable trigger at all, and it is not your fault.

Is it alopecia areata or something else?

Other conditions can cause patchy hair loss and need different treatment.

Condition	How it looks	Who it affects	Why it matters
Alopecia areata	Smooth, round, clean bald patch	All ages	Autoimmune, regrowth possible
Tinea capitis (scalp ringworm)	Scaly patch, broken hairs, sometimes swelling or pus	Mostly children	Needs oral antifungals
Trichotillomania	Irregular patch with hairs of different lengths	Children, teens, adults under stress	Hair pulling behaviour, needs gentle support
Traction alopecia	Thinning at hairline and temples	Tight braids, buns, turbans	Change of hairstyle
Scarring alopecia	Shiny skin with no follicle openings	Adults	Urgent treatment to prevent permanent loss
Telogen effluvium	Diffuse shedding, no patches	After illness or childbirth	Usually self limiting

If your hair is thinning all over rather than in patches, read our guides on hair fall in women and male pattern baldness.

How is alopecia areata diagnosed?

Most cases are diagnosed by examining the scalp, usually with a dermatoscope, which shows typical features such as yellow dots and exclamation mark hairs. Your dermatologist may also consider:

• Thyroid tests and other blood tests, since autoimmune thyroid disease is more common.
• A scraping to rule out fungal infection, especially in children.
• Rarely, a scalp biopsy if the diagnosis is uncertain.

How is alopecia areata treated?

Treatment is chosen based on how much hair is lost, how long it has been present, age and personal preference. Your dermatologist may consider:

For a few small patches

• Watchful waiting, since many small patches regrow on their own.
• Steroid injections into the patch, given in clinic every few weeks. This is a common first option for adults with limited patches.
• Prescription steroid creams or lotions, used as directed for a limited period. These should not be bought over the counter for self use.
• Topical minoxidil as an add-on to support regrowth.

For more extensive hair loss

• Contact immunotherapy, where a chemical is applied to provoke a mild allergic reaction that can redirect the immune response.
• Oral immune modulating medicines in selected cases, chosen and monitored by a specialist.
• JAK inhibitors, a newer class of oral medicines, some of which are approved for severe alopecia areata in several countries. They need careful selection, blood test monitoring and a discussion about cost, benefits and risks.

Short courses of oral steroids are sometimes used for rapidly spreading cases, but relapse after stopping is common and long term use carries significant side effects, so they should only be used under close medical supervision.

What results can I expect?

It is honest to say that alopecia areata is unpredictable.

• Many people with limited patches see regrowth within months to a year.
• New patches can appear while old ones regrow.
• Extensive loss, ophiasis pattern, childhood onset and loss lasting many years tend to be harder to treat.
• Regrowth with treatment may not last after stopping, and the condition can recur years later.

No treatment can promise a permanent result, so a good plan includes realistic expectations and follow up.

Can children get alopecia areata?

Yes. Alopecia areata often begins in childhood or the teenage years. Parents are often told the cause is lice, worms or a curse, which adds worry and blame. A few points for families:

• A scaly patch with broken hairs in a child is more likely to be scalp ringworm, which needs different treatment, so examination is important.
• Treatment for children is chosen more gently. Your dermatologist may prefer creams and lotions to injections, depending on age and comfort.
• Children may need support at school, especially if eyebrows or eyelashes are affected.
• Keep routines normal, and let your child decide how much they want to share with friends.

How can I cope with the emotional impact?

Hair is tied to identity, and sudden hair loss can affect confidence, relationships and work. Some things that help:

• Learning about the condition, so myths and blame lose their power.
• Talking to family about it, especially for children facing teasing at school.
• Cosmetic options such as hairstyles, scarves, caps, brow pencils, hair fibres or wigs while you wait for regrowth.
• Asking for support from a counsellor if you feel anxious or low.
• Protecting bare scalp skin from the sun with a cap or sunscreen. See our sunscreen guide for India.

When to see a dermatologist

See a dermatologist if:

• You find a new bald patch on the scalp, beard or eyebrows.
• Patches are spreading or joining together.
• You lose eyebrows or eyelashes.
• A child has patchy hair loss, especially with scaling, which may be ringworm.
• The skin in the patch is red, scaly, painful or shiny.
• Hair loss is affecting your mood or daily life.

Early treatment gives more options. If you would like an assessment, Dr. Maria offers online consultations where she can review photos of the patches and guide you on next steps, including whether an in-person procedure is needed.