Alopecia areata symptoms: What are the early signs of alopecia areata?

Overview: What does alopecia areata feel/look like?

Alopecia areata is an autoimmune disorder. The immune system attacks hair follicles during their growth phase, causing them to fall out in small patches. During a flare-up, hair will fall out in clumps, leaving a bald patch the size of a quarter or a half dollar, usually on the scalp or face. However, hair can fall out anywhere on the body. In many cases, the hair eventually grows back. Most people will eventually experience another episode of hair loss. The course of the disorder is unpredictable. Some people with alopecia areata may have only one or two episodes of hair loss throughout their lives. But 14% to 25% of people with alopecia areata will eventually lose all the hair on their scalp or body. Fingernails and toenails can also be affected. The nails can become pitted, ridged, or discolored.

RELATED: What causes alopecia? Diagnosis, prevention, and treatment 

What are the early signs of alopecia areata?

The early signs of alopecia are patchy hair loss, usually on the scalp. They are usually round or oval in shape and about the size of a quarter. There may be one, two, or more small spots on the scalp.

Other alopecia areata symptoms

Alopecia areata primarily affects the hair but can also affect fingernails and toenails.

Hair symptoms primarily consist of patchy hair loss. There are several courses the disease can take:

• Some people may have only one or a few episodes involving a few patches on the hair or scalp, though other places can be affected. New hair regrows in a few months to a year, and flare-ups rarely recur.

• Some people may have multiple skin areas affected, and flare-ups are regular. Small bald patches may be joined by other bald patches so that larger areas of the scalp or the body are hairless. Hair often regrows on some of these patches, but hair loss may be permanent in some affected areas. 

• In some cases, alopecia areata affects the entire scalp or body, progressing to total loss of hair. Less than 10% of those with total hair loss show some recovery.

Nail symptoms occur in 10% to 15% of cases. Affected nails can be pitted, ridged, brittle, or discolored. Nail symptoms are more common in people who experience extensive hair loss.

RELATED: Why is my hair falling out? Learn the causes of hair loss

Alopecia areata vs. androgenetic alopecia symptoms 

Male-pattern and female-pattern baldness, called androgenic alopecia, are easily distinguished from alopecia areata. Patterned baldness typically involves just the top of the head. Hair thins gradually, usually taking years or decades to progress. On the other hand, alopecia areata causes patchy and unpredictable hair loss. The hair can fall out anywhere on the head or the rest of the body. During flare-ups, hair falls out suddenly and in clumps. It can often grow back in a few months to a year, a marked difference from male-pattern or female-pattern baldness.

Types of alopecia areata: How can I tell which one I have? 

There is only one type of alopecia areata, but people can experience different degrees of severity. Treatment will depend on the severity, so clinicians generally classify alopecia areata as mild, moderate, or severe, but there’s no agreed-upon scale. One generally accepted scale classifies the severity of alopecia areata based on the amount of skin affected:

• Mild alopecia areata involves less than 20% of the scalp

• Moderate alopecia areata involves 21% to 49% of the scalp

• Severe alopecia areata involves more than half the scalp

• Very severe alopecia areata involves the entire scalp

Clinicians also classify alopecia based on the extent and location of hair loss:

• Patchy alopecia areata is patchy hair loss on the head or body

• Alopecia totalis describes a total loss of scalp hair

• Alopecia universalis involves a total loss of body hair

• Diffuse alopecia areata involves sudden hair thinning all over the head 

• Ophiasis alopecia is the loss of hair along a band on the sides or back of the head

When to see a doctor for alopecia areata symptoms

Patchy or rapid hair loss is a possible symptom of other medical conditions, so see a doctor when hair starts to fall out without an explanation. Alopecia areata is not a health-threatening medical condition, but treatment can shorten flare-ups and increase the likelihood that new hair will grow back in the affected area. Unless there are other severe symptoms, hair loss does not warrant a trip to the emergency room.

A healthcare professional diagnoses alopecia areata primarily through a medical history and examination of the affected skin. Some people may be referred to a dermatologist for a more detailed evaluation or treatment. In taking a medical history, the clinician will be most interested in the hair loss symptoms. When did they start? Did the hair fall out in clumps or gradually? Where did the hair fall out? The clinician will want to know about medications being taken, hair products being used, family history of hair loss, and any history of autoimmune diseases. The clinician will also ask if you pull at your hair as a nervous habit.

When examining patches of hair loss, the clinician will look for “exclamation point” hairs around the edges of the bald spot. These are hairs that are thin at the roots and are a telltale sign of active alopecia areata. The clinician will also examine the fingernails and toenails to look for pitting or discoloration. They may order other tests, such as blood tests, skin biopsy, or culture. 

Complications of alopecia areata

The complications of alopecia areata involve mental health and social concerns. The most likely complications of alopecia areata are stress, depression, anxiety, and social withdrawal.

How to treat alopecia areata symptoms

Alopecia areata treatment focuses on modulating or suppressing the immune system:

• Topical and injected corticosteroids suppress the inflammatory response in the area affected. Both are considered first-line treatments for active alopecia areata. Steroid injections are particularly successful—most people will experience new hair growth in 12 weeks.

• Immunosuppressant creams or gels may be used in people experiencing flare-ups with more extensive hair loss. Hair regrowth occurs in more than half of people getting topical immunosuppressants for extensive alopecia areata.

• Severe alopecia areata flare-ups may be treated with oral corticosteroids, immunosuppressants, and JAK inhibitors like Xeljanz (tofacitinib) or Olumiant (baricitinib), the first drug FDA-approved to treat alopecia areata.

• A significant fraction of people with alopecia areata also have eczema or atopic dermatitis, so eczema or atopic dermatitis treatments such as Dupixent (dupilumab) may also be used. 

• Hair regrowth drugs like Rogaine (minoxidil) are a treatment option after a flare-up.

RELATED: Hair loss treatments and medications

Living with alopecia areata 

Alopecia areata is a lifelong condition. Living with alopecia areata means taking care of your physical and mental health with special attention to your hair and scalp.

To keep your hair and scalp healthy:

• Eat a healthy diet

• Consider supplements such as iron, biotin, riboflavin, folate, vitamin B12, and vitamin D

• Manage stress

• Wear sunscreen, hats, scarves, or wigs on the head when exposed to the sun

To keep yourself healthy:

• Follow medical advice in scheduling physicals—people with alopecia areata are more likely to develop other disorders such as thyroid disease or other autoimmune conditions

• Protect your head from the cold

• Join a support group

• See a mental health professional to help with social and emotional symptoms that may occur with the condition

FAQs about alopecia areata symptoms

How long does an alopecia episode last?

Most alopecia areata episodes last from a few months to less than a year. The hair usually grows back, but it can be unpredictable. 

What foods should you avoid if you have alopecia areata?

There is much advice but little conclusive research about the relationship between diet and alopecia areata flare-ups. Research has not definitively found specific foods that precipitate alopecia areata episodes. However, since alopecia areata is an inflammatory disorder, healthcare professionals believe that foods that cause an inflammatory response may bring on or worsen alopecia areata. That’s why some healthcare providers may suggest avoiding inflammatory foods like processed foods, sugar, dairy, or gluten. 

How do I know if my alopecia areata is active?

During active alopecia areata, hair will fall out, usually in patches. It may occur in one or several places on the scalp or body. The telltale sign of active alopecia areata is the presence of “exclamation point” hairs on the margins of the bald patch. They look like normal hair except for the part of the hair that is right near the scalp. They will be very thin there like they’re barely attached to the scalp. During an examination, a clinician will look for this telltale sign of active alopecia areata.

What’s next? Additional resources for people with alopecia areata symptoms

Test and diagnostics

• Alopecia areata, StatPearls

• Alopecia areata: diagnosis, treatment, and steps to take, NIH National Institute of Arthritis and Musculoskeletal and Skin Diseases 

Treatments

• Alopecia areata, StatPearls

• Alopecia areata treatments, National Alopecia Areata Foundation (NAAF)

• Hair loss treatments and medications, SingleCare

• Hair loss types: alopecia areata self-care, American Academy of Dermatology (AAD)

• Intralesional steroids for alopecia areata, International Journal of Trichology

Scientific studies and clinical trials

• Combined diet and supplementation therapy resolves alopecia areata in a pediatric patient: a case study, Cureus

• Lifestyle factors involved in the pathogenesis of alopecia areata, International Journal of Molecular Sciences

• The role of micronutrients in alopecia areata: a review, American Journal of Clinical Dermatology

More information on related health conditions

• Eczema treatments and medications, SingleCare

• What causes alopecia? Diagnosis, prevention, and treatment, SingleCare