Alopecia and Hair Loss


Alopecia areata is a chronic inflammatory disease that affects the hair follicle causing patchy non-scarring hair loss on the scalp. Total loss of scalp hair is known as alopecia totalis, and loss of the entire scalp and body hair is known as alopecia universalis.  Alopecia areata is likely to be an autoimmune disorder, and around 20% of patients have a family history of the condition.  The onset may be at any age with a peak incidence between the second and fourth decades


Referral and Treatment Criteria applies:see RaTC - Hair transplant / hair graft / hair replacement



NOTE Diagnosis is usually made from the presence of typical clinical features and by excluding other causes of hair loss

Consider the following clinical features:

  • Hair loss - most commonly the scalp and the beard and is usually patchy and of abrupt onset:
    • Bald patches are round, well-circumscribed, and smooth, and appear on the scalp or within facial hair. The skin is normal-coloured or slightly red without scarring (follicular openings are still present)
    • Exclamation mark hairs (short broken hairs which taper proximally) might be seen around the margin, or in any part of the patch, during active disease
  • Nail changes affect 10–15% of people and include pitting, onycholysis (loosening), splitting, beau lines (transverse grooves), koilonychia (concave outer surface), and leukonychia (white patches under the nails)


To identify if there is active hair shedding, consider performing the 'pull test'

Routine investigations are not recommended, but if the diagnosis is in doubt, consider:

  • Skin scrapings, hair samples, and fungal culture.
  • Systemic lupus erythematosus autoantibodies and syphilis serology
  • Full blood count and thyroid function tests
  • Skin biopsy (this will usually require referral to secondary care unless the expertise is available in primary care)



Consider factors that may affect choice of treatment:

  • Determine the extent of hair loss. Loss of over 50% of the hair is generally considered as 'extensive'
  • Enquire about current and past treatments, and their effectiveness


If the person has clinical signs or symptoms suggestive of other autoimmune disorders (or a family history of these) consider further investigations (for example, for pernicious anaemia or hypothyroidism)

Ask how the alopecia is affecting the person; psychologically and socially. Alopecia areata has no effect on general health but can cause psychological distress


Information and advice

Reassure that most people with mild hair loss can expect hair regrowth within a year

  1. Explain that alopecia areata is an unpredictable condition, which is difficult to treat successfully. Treatments may help to control the problem by inducing hair growth, but will not cure the underlying condition. Future episodes of hair loss may occur
  2. Advise use of sunblock or a hat on sunny days to protect bald patches from sun damage


Treatment and referral

Refer to a dermatologist if there is no hair regrowth and the person has more than 50% hair loss, or treatment is preferred:

  • If the person has less than 50% hair loss, the use of intralesional corticosteroids over other treatments is recommended
  • If the person has more than 50% hair loss, the use of topical immunotherapy over other treatments is recommended


If there is no hair regrowth and the person has more than 50% hair loss and the diagnosis is certain, for those either waiting to see a specialist or who decline a referral:

  • Consider a trial of a potent topical corticosteroid (such as betamethasone valerate 0.1%, fluocinolone acetonide 0.025%, or hydrocortisone butyrate 0.1%) or very potent topical corticosteroids (such as clobetasol propionate 0.05% scalp application) for 3 months (off-label use)


If the person is treated in primary care, explain the benefits and risks of treatment and what effect the person should expect

Consider the need for counselling and psychological support

NOTE:  In certain circumstances, people may be eligible for free or reduced cost wigs by the NHS. More information on buying wigs and NHS policy is available here


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Advice and Guidance is being made available for all specialties, and is being provided by consultant specialists at East Kent Hospitals.  To make a request or to check to if a query has been answered, you will need to log in via the electronic Referral System (eRS)

Click here for the "how to access" e-Referral Advice and Guidance Manual for instructions on how to make a request and check responses

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