Alopecia areata (patchy hair loss): a clear explainer

Finding a smooth, round bald patch on your scalp, beard or eyebrows can be frightening. One common cause is alopecia areata. In Malay it is often called botak tompok, and in Chinese 斑秃 or 鬼剃头. This guide explains what is known about the condition and what you can do.

What alopecia areata is

Alopecia areata is a condition in which the immune system attacks hair follicles, causing hair to fall out, usually in patches ^{1 2}. The follicles are not destroyed, so hair can grow back, and in many people it does ³. It can start at any age and affects people of all ethnic backgrounds.

It is not contagious. It is not caused by poor hygiene, and it is not a sign that you are generally unwell.

Signs and symptoms

Common features include ⁴:

• One or more round or oval smooth bald patches, often on the scalp
• Patches in the beard, eyebrows or eyelashes
• Short broken hairs, sometimes described as exclamation-mark hairs, at the edge of a patch
• Tingling or itching before a patch appears, in some people
• Pitting or ridges on the nails

Less commonly, hair loss spreads to the whole scalp (alopecia totalis) or the whole body (alopecia universalis) ².

What causes it

The exact cause is not known. Genes play a part, and the condition is more common in people who have a family history of it or of other autoimmune conditions such as thyroid disease or vitiligo ^{5 6}. People often notice a patch after a stressful time, but it is not clear that stress causes it ⁵.

How it is diagnosed

A doctor or dermatologist can usually diagnose alopecia areata by looking at the patches and the hairs at their edges, sometimes using a handheld magnifier called a dermatoscope ^{7 8}. Blood tests may be suggested to check for related conditions such as thyroid problems. Occasionally a small scalp sample (biopsy) is needed.

It is important to get a diagnosis because other conditions can cause patchy hair loss, including fungal infection (tinea capitis) and hair-pulling (trichotillomania) ^{9 10}.

What happens next

The course of alopecia areata is hard to predict. In many people with a few small patches, hair grows back without treatment within a year, although new patches may appear later ^{3 2}. New hair may at first be fine and white before its usual colour returns. More extensive hair loss, onset in childhood and nail changes are associated with a more persistent course ¹¹.

Treatment options

There is no cure, but there are treatments that may help hair grow back or slow new patches ^{7 12}. A dermatologist will choose based on your age, how much hair is affected and your preferences:

• Corticosteroid injections into the patches are commonly used for limited patchy hair loss in adults.
• Topical corticosteroids in creams, lotions or foams may be used, especially in children.
• Topical minoxidil is sometimes used alongside other treatment.
• Contact immunotherapy, in which a chemical is applied to provoke a mild allergic reaction, may be used for extensive hair loss.
• JAK inhibitor tablets such as baricitinib and ritlecitinib have been studied in severe alopecia areata, and clinical trials found that more people on these medicines saw significant hair growth than on placebo ^{13 14 15}. They need specialist prescribing and monitoring for side effects.

Hair may fall out again when treatment stops. Treatment is not compulsory; some people choose to wait or to use camouflage.

Camouflage and coping

Options include changing your hairstyle, hats or scarves, wigs, and cosmetic options for eyebrows. Some people consider scalp micropigmentation for stable, long-standing hair loss, but because alopecia areata can come and go, discuss this carefully with a dermatologist first ¹⁶.

Alopecia areata can affect confidence and mood. If you feel anxious or low, tell your doctor. Talking to others with the condition can also help ².

When to see a doctor

See a doctor if you notice a bald patch, especially if it is red, scaly, sore or spreading, or if you have hair loss with other symptoms. In Malaysia, a GP can refer you to a dermatologist, and you can check a doctor's registration with the Malaysian Medical Council ^{17 18}. For other causes of hair loss, read what to do about hair loss.

Frequently asked questions

Does alopecia areata last forever?

Usually not. The follicles are not destroyed, and in many people with a few patches hair grows back within a year, although new patches can appear ^{3 2}.

Is alopecia areata caused by stress?

The exact cause is unknown. It involves the immune system and genes. People often notice patches after stress, but it is not clear that stress causes it ⁵.

Is alopecia areata contagious?

No. It cannot be passed from one person to another ¹.

What is the treatment for alopecia areata?

Options include steroid injections or creams, minoxidil, contact immunotherapy and, for severe cases, JAK inhibitor tablets prescribed by a specialist ^{7 15}.

Educational content. Not medical advice.