The term Alopecia refers to the “lack of hair or hair in all body districts”, secondary to the various mechanisms defining its etypathogenesis

The term derives from the Latin alopecias, meaning fox or foxy, in relation to the fact that the fox is wont to lose its hair in patches.

Alopecia, which maỳ be circumscribed or diffuse, is in certain cases accompanied by atrophy and destruction of the hair follicle.

Although alopecia means the loss of all types of hair and can affect any district, the scalp is the most affected.

Based on the etiopathogenesis, we can distinguish four major forms of alopecia: androgenetic, areata, scarring and post-chemotherapy alopecia

Androgenetic alopecia is a genetically determined condition that, however, requires the presence of male steroid hormones (androgens) for its realisation. In the absence of one of these factors, baldness does not occur: family predisposition and androgens must probably both be present, hence the name androgenetic alopecia. (Heilmann-Heimbach et al., 2016, Heilmann-Heimbach et al., 2017; Inui and Itami, 2013; Marcińska et al., 2015; Pirastu et al., 2017).

Alopecia areata, on the other hand, is considered an autoimmune disease limited to hair follicle components mediated by T lymphocytes. (Bodemer et al., 2000; Kalish, Johnson, & Hordinsky, 1992).

The latter manifests itself in most cases spontaneously and asymptomatically, so that hair loss is sudden and abrupt and may occur within a few days or weeks, making individuals who contract it more prone to psychological discomfort.

The area most affected by alopecia is the scalp, so much so that it is known to most as the ‘hair loss disease’.

In places where hair does not grow back, completely hairless areas are formed, where, however, the skin appears healthy and normal in colour.

A condition with a very ancient history, alopecia is said to have been known as far back as the Egyptians and the Greek and Roman philosophers, who spoke of it in their scientific writings, searching for a solution and cure.

Alopecia areata of inflammatory origin: definition and what it consists of

For this type of alopecia one cannot speak of a chronic disease as in some situations the inflammation is temporary and disappears by itself, without affecting the hair-generating papillae permanently.

It derives from autoimmune disorders that cause white blood cells to attack the hair follicle, preventing hair growth.

It occurs mainly on the scalp (temples and nape of the neck are the most affected areas), leaving rounded areas completely bald, and may also affect other anatomical parts such as eyelashes, eyebrows, armpits and pubis.

In addition to hair loss, alopecia areata is often accompanied by nail changes, areas that are also rich in keratin.

Disease prevalence rates of 0.1% to 0.2% have been estimated for the United States. (Gilhar, et al., 2012).

Although the disease most frequently begins in childhood and adolescence, it can appear at any stage of life.

In 60% of cases, alopecia areata occurring at an early age showed a more severe prognosis. (Gilhar et al., 2012).

Individuals with Down syndrome or autoimmunity problems are affected.

It is often a condition with a temporary course. After careful diagnosis and correct treatment, the hair or hairs in the affected areas can grow back.

Alopecia: the symptoms

In addition to the common loss of hair and body hair, as already mentioned alopecia can cause nail disorders such as nail pitting (cup-shaped or transverse depressions of the nails) and Leuconichia (outer coating of one or more nails takes on a different colour than usual).

It should be noted that a noticeable increase in these symptoms can be caused and aggravated by severe physical and emotional stress, but can also be associated with existing pathologies such as vitiligo and thyroid problems.

Where hair falls out, the skin affected by alopecia is usually very similar to healthy skin.

The condition is asymptomatic and is rarely associated with localised itching, tingling and burning (sometimes appearing a few days before hair loss).

The causes of alopecia areata

The origin of the disease is not yet fully elucidated, The presence of autoantibodies against the hair follicle is strongly suggested, but not yet confirmed (Gilhar & Kalish, 2006 ; Leung, et al 2010 ; Tobin, Hann et al 1997; Wang et al. , 2016).

However, severe physical or emotional stress appears to be one of the triggers for the manifestation of symptoms.

Other diseases, such as atopic dermatitis, thyroiditis, systemic lupus erythematosus, rheumatoid arthritis, chronic atrophic gastritis, coeliac disease, vitiligo, diabetes, would appear to be strongly associated with alopecia areata.

Alopecia areata is not contagious, but can be an unpleasant inheritance.

Types of alopecia

In addition to the alopecias already described, among the alopecias proper, androgenetic alopecia is the most common form of the disease: it affects around 40-50% of women, especially after menopause, and 70% of European men, with a lower incidence in the Asian and African race (Heilmann-Heimbach et al., 2017; Marcinska et al., 2015; Pirastu et al., 2017).

One can therefore speak of male androgenetics and female androgenetics.

In men, the manifestation is typical (male pattern hair loss) and consists of a progressive thinning of hair starting from the temples and the clitoris and extending over the entire skull, with the exception of the region above the ears, while in women, it manifests itself with diffuse thinning in the upper part of the head.

It is a genetically determined condition in which numerous genes, hormones and environmental factors play a key role in the development of the disease, showing a polyvalent aetiology (Heilmann- Heimbach et al., 2016, Heilmann-Heimbach et al., 2017; Inui and Itami, 2013; Marcińska et al., 2015; Pirastu et al., 2017).

Temporary alopecia

Non-scarring forms of alopecia may be temporary.

This means that, if properly treated (or if the action that generates it is stopped), the symptoms disappear by themselves after a short time.

Post-pregnancy alopecia belongs to this category, as do alopecia due to malnutrition (which goes away when food values return to normal), alopecia due to psycho-physical traumas (it disappears with the end of the period of stress), alopecia areata and alopecia due to medication, which ends once their intake is interrupted.

Scarring forms, on the other hand, are permanent.

The hair follicle, with the hair-generating papilla inside it, ceases to function and disappears.

Scleroderma, discoid lupus erythematosus, lichen planus, folliculitis decalvans, mycosis and neoplasms lead to scarring alopecia.

Classification according to anatomical area of occurrence

Alopecia Areata Monolocularis affects only one point of the scalp where hair loss occurs.

On the contrary, Alopecia Areata Multilocularis may affect several points of the scalp at the same time.

Total Alopecia generates hair loss on the entire scalp.

On the other hand, one speaks of Universal or Absolute Alopecia when, to be affected by the dysfunction, it is not only the follicles of the scalp but those of the whole body, generating hair loss everywhere.

The most affected areas seem to be eyelashes, eyebrows, armpits and pubis. Universal alopecia is the rarest, and is difficult to resolve completely.

The last two cases that can be encountered are Alopecia Barbae, which affects the beard, and Alopecia Areata Ophiasis, which is found only in certain external areas of the scalp, e.g. those closest to the ears, temples and nape of the neck.

Alopecia: diagnosis

Diagnosis is clinical with observation of the manifestation and type of alopecia in the various areas of the body.

In order to make a detailed diagnosis of the type of alopecia, however, more in-depth diagnostic techniques are required.

Among these, the most accredited are the “pulling” and the “trichogram”.

In some cases the specialist may decide to prescribe or directly perform a biopsy of the affected skin.

This procedure leaves a small scar, but is certainly much more effective for diagnostic purposes.

For all types of alopecia, in order to offer as truthful a diagnosis as possible and effective treatments, the doctor will make his observations also considering the age of onset, and other factors such as possible heredity, course of the disease and its manifestations, response to any treatments already undergone, presence or absence of autoimmune diseases.

What treatments to combat alopecia

As with all pathologies, it is the doctor who chooses the right therapy for alopecia, depending on the diagnosis of the type of alopecia, the severity of symptoms, related pathologies and the characteristics of the specific patient.

Today’s therapies aim at resolving the symptom by accelerating the regrowth of hair.

In addition to the parenteral route (injections), the oral or topical route (application of ointments, creams, lotions) is preferred.

Depending on the type of alopecia diagnosed, many types of drugs and therapies may be prescribed. Some of these are:

• corticosteroids (betamethasone, fluocinonide, clobetasol) to be taken mainly orally or topically, as side effects are greater with systemic therapy. The latter is preferred only in more severe and advanced cases;
• minoxidil. This active ingredient promotes hair regrowth when used topically for a few months;
• immunosuppressive drugs (Cyclosporine, Triamcinolone). These are used in serious and relapsing cases. The doctor prescribes them after other therapies have failed to provide the desired effects. The intention is to directly affect the cells of the immune system so as to reduce their ‘attack’ on the hair follicles and regrow hair;
• UVA-based phototherapy combined with drugs with photosensitising principles. It has been observed that sun exposure, carried out in a healthy and prolonged manner (with the right protection), has beneficial effects on the skin and the course of the disease;
• alternative therapies. Their appeal has grown in recent years and exploits the benefits that hypnosis and acupuncture have on the whole organism.

Hormone and cortisone-based therapies are often the last resort and are not recommended for younger patients due to the side effects.

For the latter, non-hormonal topical methods that do not indirectly affect growth and proper hormonal activity are preferred.

Implications for daily life

Alopecia is not an aggressive and physically debilitating disease, as the loss of hair and hair is not in itself painful.

What not everyone is aware of, however, are the negative implications it has on the life of those who contract it, especially in the psychological and relational spheres of the individual.

Alopecia, whether areata or androgenetic, leads to a loss of self-esteem and distortion of one’s image.

Hair not only falls out and leaves completely bald areas, but also grows back white in some cases, before returning to its natural colour.

The sudden change in one’s body image can lead to depression and anxiety, (especially in women) while waiting for one’s hair to grow back.

Therefore, psychological help is often needed for those affected.

However, there are good solutions on the market that help patients feel temporarily better.

The use of a wig that hides the problem from prying eyes and allows the trauma of the aesthetic change to be overcome can be one such solution.

However, alopecia is a serious condition that needs to be treated because it can hide other underlying causes.

At the first signs, it is a good idea to visit a specialist immediately for a consultation.

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