Alopecia Areata and Scarring Hair Loss: Patchy Loss Needs Evaluation

Why patchy loss needs a clinician

Round or irregular bald patches are different from general shedding or thinning, and different causes need different care. Only an examination can sort them out. This page describes two groups so you know what to ask about; it is not for self-diagnosis. For other causes see Hair shedding and thinning and Pattern hair loss. Evidence labels: established recommendation, promising but limited, mixed, insufficient evidence.

Alopecia areata

Alopecia areata happens when the immune system attacks hair follicles and causes hair loss. [1] Hair typically falls out in small round patches about the size of a quarter, though loss can be more extensive. [1] Most people are otherwise healthy. [1] There is usually no rash, redness or scarring on the bare patches, and short broken "exclamation point" hairs may sit at the edges. [1] Some people feel tingling, burning or itching just before hair falls out, and nails may show pits. [1]

The course is unpredictable. Hair may regrow within months, new patches may appear, or small patches may join. [1] Types include patchy alopecia areata (the most common), alopecia totalis (all or nearly all scalp hair) and alopecia universalis (rare, loss across the scalp, face and body). [1] It can start at any age but most people get it in their teens, twenties or thirties. [1] People with psoriasis, thyroid disease, vitiligo, hay fever or eczema are more likely to get it. [1] Emotional stress or illness may bring it on in people at risk, but often there is no obvious trigger. [1]

NIAMS says there is no cure, but there are treatments that help hair grow back more quickly, and resources to help people cope. [1] The NHS lists steroid injections or creams, immunotherapy, light treatment and other options for bald patches, noting some are not available on the NHS. [2] Treatment choice belongs with a dermatologist.

Scarring (cicatricial) hair loss

Primary cicatricial alopecias are a group of rare inflammatory scalp disorders that result in permanent hair loss. [3] In scarring alopecia, follicle damage is enough to replace hair-producing structures with scar tissue. [4] The group includes conditions such as lichen planopilaris, frontal fibrosing alopecia, central centrifugal alopecia and folliculitis decalvans. [4] Because the loss can be permanent, prompt assessment by a dermatologist is the sensible next step for patchy loss, especially if the scalp is also sore, itchy or inflamed. This is a prompt to be examined, not a checklist for diagnosis. I did not read a patient-facing guideline on scarring-alopecia treatments for this page, so treatment details are left to your dermatologist.

What about natural remedies?

Proper evidence not found in the sources checked for herbal or supplement treatment of alopecia areata or scarring alopecia. Do not delay evaluation to try home products. See Natural skin-care ingredients, essential oil safety, and medication interactions.

When to get help

See a GP or dermatologist for any patchy hair loss, sudden loss, or loss with scalp pain, redness or scarring. Hair loss can be hard emotionally; the NHS says a GP may help you get counseling and support groups exist. [2] See Skin and hair safety.