Alopecia areata (AA) is an autoimmune disease that causes loss of hair around the scalp, face, and other parts of the body. The extent and pattern of hair loss can vary amongst affected people, but the most common pattern of AA is small annular or patchy lesions of hair loss (patchy alopecia areata) that are most common on the scalp. These can progress to total loss of scalp hair only (alopecia totalis) or total loss of all body hair (alopecia universalis). 

Almost 7 million people in the United States and 160 million people worldwide are impacted by this unpredictable immune condition that can be psychologically difficult to live with. 

Fortunately, an integrative and complementary approach to AA can help to uncover and address underlying factors that contribute to the autoimmune attack that drives hair loss. Treatment works to rebalance the immune system and support hair regrowth using nutrition, supplements, and lifestyle approaches that can work in conjunction with conventional medications.

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What is Alopecia Areata?

Alopecia areata is a chronic autoimmune condition where the body’s immune system attacks the hair follicles causing hair to fall out. Around 2% of people will experience AA at some point during their lifetime.

In Latin, alopecia means bald and areata means patchy, which reflects the typical pattern of hair loss that occurs in this condition. People with AA commonly lose hair on the scalp, face, and sometimes other body areas, like under the arms or on the legs, in circular, coin-sized patches. In more severe cases, the entire scalp may lose all hair.

While the autoimmune attack of the hair follicle causes hair to fall out, it does not cause scarring, and the hair follicle is preserved. Therefore, the hair loss is transient and can usually grow back. 

Although AA can begin at any age, it is most common to experience symptoms starting in childhood or early adulthood. Over 80% of impacted individuals develop signs of the condition before age 40, and 40% experience symptoms by age 20. This type of hair loss is more common in women and among Asian, Black, and Hispanic individuals than among whites.

Alopecia Areata Signs & Symptoms

• Hair loss

The pattern, distribution, and persistence of hair loss that occurs in AA can vary between individuals. The loss of hair can occur anywhere, most commonly on the scalp. It can happen in more than one place at the same time. Hair loss with AA occurs more frequently during ​​colder weather.

In patchy alopecia areata, it is common to have small, round, or oval patches of hair loss on the scalp and facial beard area, as well as other areas of the body with hair, like the armpits and legs. Since the follicles are not usually scarred or permanently damaged, hair loss and regrowth can occur at the same time in different areas of the body. In other cases, hair loss can occur quickly over a short period and be significant. When the entire scalp is impacted, alopecia totalis occurs. When hair loss is even more extensive across the scalp and entire body, including the eyebrows and eyelashes, this is deemed alopecia universalis.

In addition to the characteristic hair loss, AA may also cause symptoms and signs such as:

• Tingling, itching, or burning just before losing the hair and after hair loss in affected areas
• Loss of pigmentation with gray or white hairs remaining in spots where most of the hair is lost 
• “Exclamation point” hairs that started regrowing but broke off after a few millimeters of growth 
• Rows of tiny dents (stippling or pitting) on the fingernails and/or rough ridges running lengthwise down the nails (trachyonychia)

Alopecia Areata Possible Causes 

Many complex factors contribute to the development of AA. Several genetic factors increase risk, with around 20% of impacted people having at least one family member who also has the disease, with even greater risk if that relative lost their hair before age 30. 

An autoimmune process underlies AA with the immune system attacking hair follicles. This results in inflammatory cells entering and becoming concentrated in and around the bulbar region of hair follicles which causes degeneration and fragility. In addition, oxidative stress and damage to the antioxidant superoxide dismutase (SOD) play roles in the hair follicle damage that occurs in AA. 

Those who have other autoimmune conditions like inflammatory bowel disease, Hashimoto’s thyroiditis, celiac disease, vitiligo, rheumatoid arthritis, and type 1 diabetes are at a greater risk of developing AA, as are people with allergic conditions such as asthma and eczema.

The normal dynamics of hair growth seem to be altered in patients with AA so that hair follicles rapidly progress from the anagen phase, when a hair follicle is normally actively growing to the catagen transition and telogen resting or dormant phases. This causes the hair shafts to become more fragile (dystrophic hairs) and fall out more readily. Due to this fragility, exclamation point hairs (a type of dystrophic hair) are frequently seen in AA.

An emerging factor that seems to impact the development of AA is the microbiome of both the skin and gut. Microbes throughout the body influence systemic levels of inflammation and the activity of innate and adaptive immune cells. The skin and gut are closely connected and influence each other in a communication network coined the gut-skin axis. Imbalances or dysbiosis in either microbiome contribute to increased activity of immune cells that produce inflammatory cytokines in an autoimmune response that leads to a collapse of the hair follicle in AA. 

Imbalances in the skin microbiome, such as a higher abundance of pathogenic types of bacteria like C. acnes in combination with a decrease in S. epidermidis and imbalances in Cutibacterium/Staphylococcus spp. in the hair follicles and scalp can contribute to inflammation and play a role in alopecia areata.

In the gut, genetic factors that contribute to AA can also skew the microbiome towards microorganisms that induce a Th1 immune response in the digestive tract and further throughout the body, which may lead to the production of inflammatory cytokines and abnormal growth of hair follicle cells that can progress to hair loss. Studies suggest that fecal microbiota transplant (FMT) may induce hair growth in patients with AA.

Nutrient deficiencies can also impact hair growth and hair follicle structure. For example, deficiencies of metals like iron and zinc and vitamins niacin, biotin, and vitamins A and D can cause hair loss. Vitamin A helps to activate hair follicle stem cells while vitamin D takes part in hair follicle cycling, with deficiencies in both of these vitamins associated with hair loss and AA. 

Environmental and lifestyle factors may also contribute to flare-ups of AA. Studies suggest that emotional or physical stressors, such as grief, an injury, or febrile illness, may precipitate AA flares. 

Functional Medicine Labs to Test for Root Cause of Alopecia Areata

Functional medicine laboratory testing can help to uncover root causes contributing to the inflammation and autoimmunity that underlies alopecia areata. This testing can help shape an individualized approach to bringing the body back into balance.

Comprehensive Gut Testing

A comprehensive gut health test like the GI-MAP measures the abundance of different gut microbes, along with markers of dysbiosis, inflammation, and intestinal permeability, via measuring zonulin, a protein that impacts the permeability of the gut lining. This assessment of the gut microbiome can allow for the identification of any imbalances which may be contributing to inflammation, autoimmunity, and hair loss.

Thyroid Testing 

Hair loss is common with hypothyroidism like Hashimoto’s thyroiditis. A Complete Thyroid Panel measuring thyroid-stimulating hormone (TSH), T3 (free and total), T4 (free and total), and reverse T3 should be assessed using functional medicine ranges to rule out thyroid disease as another cause of hair loss. 

Iron Levels

Too little iron in the blood (iron-deficiency anemia) can commonly cause hair loss, so a blood test can measure your iron levels to help rule out other causes of hair loss. Low serum ferritin is more common in patients with AA. An iron panel provides a comprehensive analysis of iron status.

Micronutrients

Deficiencies of several micronutrients can contribute to hair loss and AA. For example, studies show that deficiencies of niacin and biotin can cause AA. Low levels of vitamins A and D also impact hair growth. A micronutrient panel measures vitamins, minerals, and other nutrients to look for deficiencies or surpluses of various micronutrients that can contribute to hair loss. For example, the Spectracell micronutrient test assesses 31 markers to give a comprehensive view of nutritional status, including evaluating micronutrients that may be contributing to hair loss. 

Other Lab Tests to Check 

A swab can be taken from affected areas to culture for fungal infections like tinea capitis (scalp ringworm) that can cause similar-looking patches of hair loss.

If the diagnosis remains uncertain after testing and examination, a skin biopsy may be taken from the affected areas. This involves taking a small sample of skin to examine under the microscope. 

Conventional Treatment for Alopecia Areata 

Alopecia areata treatments can help hair regrowth and slow hair loss. They are individualized depending on the type or form and severity of hair loss and other individual factors. 

Conventional treatments generally focus on two approaches to AA. Corticosteroids, given as injections into the scalp or other areas, orally as a pill, or applied topically to the skin, are used to modulate the immune response and reduce inflammation. To help stimulate hair regrowth, Rogaine ® (minoxidil) is applied topically over at least 12 weeks.

In severe cases, the oral janus kinase (JAK) inhibitor Baricitinib may be used to modulate the immune response, but it is used with caution as it has several potentially concerning side effects, including infections, cancer, blood clots, and cardiovascular events.

Functional Medicine Treatment for Alopecia Areata

Since these conventional treatment options often have variable efficacy and the risk of concerning side effects, an integrative approach using functional and complementary medicine may offer some additional options. A functional medicine approach to AA treatment works to rebalance the immune system and support hair regrowth using nutrition, supplements, and lifestyle approaches.

Nutrition for Alopecia Areata

Nutrition plays a key role in the development of autoimmunity and inflammatory skin conditions like AA. AA involves inflammation, dysregulated immune responses, and oxidative stress that can be triggered by imbalanced gut bacteria, infections, food allergies, and/or leaky gut.

A personalized anti-inflammatory diet like the Mediterranean Diet is rich in raw vegetables, high-quality protein, and fresh herbs that can potentially help AA. This way of eating emphasizes whole fresh vegetables and fruits while limiting processed foods and additives, caffeine, and alcohol to nourish the microbiome and balance inflammation. Personalizing the diet to individual allergies and sensitivities can increase its effectiveness. For example, research suggests that a gluten-free diet can stimulate hair growth in patients with AA that also have celiac disease.

Adequate nutrient intake is important for healthy hair growth. Sufficient levels of vitamins A and D, biotin, niacin, zinc, and iron are required for hair to grow normally. For example, good sources of biotin include chard, romaine lettuce, carrots, and tomatoes, while niacin (vitamin B3) is found in red meats like beef, poultry, fish, brown rice, nuts, seeds, legumes, and bananas. Good food sources of zinc include oysters, beef, lentils, and sardines.

If hypothyroidism and/or specific micronutrient deficiencies are identified with functional medicine testing as a potential contributing factor to hair loss with AA, restoring micronutrients like vitamin A, vitamin D, zinc, omega-3 fatty acids, and selenium can help to reduce inflammation and prevent hypothyroidism due to nutrient deficiencies. 

Rebalancing the microbiome and healing the gut can help restore balance to the immune system and tame autoimmunity to address some of the factors underlying AA and any accompanying hypothyroidism or other autoimmune conditions. Incorporating a variety of whole foods and probiotic-rich foods like kimchi and sauerkraut that contain naturally-occurring probiotics and prebiotic-rich foods like artichokes, garlic, and beans that nourish healthy bacteria help to reduce excess inflammation that can contribute to hair loss by repairing the mucosal barrier and bringing the microbiome back into balance.

Adequate high-quality protein from sources like free-range, grass-fed, organically grown meats, non-GMO plant proteins like tofu, tempeh, beans, legumes, mushrooms, and various protein powders, and wild-caught fish are crucial for hair growth and health.

Supplements & Herbs

In addition to dietary approaches, targeted supplementation offers ways to reduce inflammation and the autoimmune attack involved with hair loss in AA. Korean red ginseng, peony, and glycyrrhizin extracted from licorice have all been studied for treating AA and restoring hair growth. 

Korean Red Ginseng

Studies show that Korean red ginseng has anti-allergic and anti-inflammatory effects that promote hair growth by stimulating the recovery of hair follicles. Research shows that adding Korean red ginseng to intralesional corticosteroid injections resulted in statistically significant improvement in patients with AA compared to the control group treated with corticosteroid injections alone after 12 weeks of treatment with increased hair density and thickness.

Peony and Licorice Glycyrrhizin

A combination of extracts from the root of the peony plant and glycyrrhizin extracted from the root of the licorice plant is used in traditional Chinese medical therapy to help with AA due to their anti-inflammatory and immunosuppressive impacts. A randomized control trial showed that twelve months of treatment with this combination resulted in statistically significant improvement in AA severity in children. 

Complementary and Integrative Medicine

An integrative approach to AA often incorporates additional modalities to help bring the body back into balance and address hair loss. Research suggests that cryotherapy, acupuncture, and scalp massage with essential oils can improve hair growth in people with AA.

Cryotherapy

Cryotherapy utilizes cold temperatures for therapeutic purposes. Studies have shown that inducing inflammation using targeted cold therapy may alter the immune processes and structural components of hair follicles responsible for hair loss in AA, while hypnotherapy seems to reduce anxiety and improve quality of life.

Acupuncture

Acupuncture may help reduce hair loss in AA by calming inflammation at the hair bulb and help with hair regrowth by stimulating hair follicles and activating blood circulation.

Essential oils

A randomized placebo-controlled double-blind study of 86 subjects showed that daily topical application of a blend of cedarwood, lavender, thyme, and rosemary oils within a carrier oil significantly decreased areas of hair loss in patients with AA at 3- and 7-month assessments compared to daily massage with the carrier oil alone.

Hypnosis

Hypnosis performed by a therapist and conducted at home with self-hypnosis sessions can reduce the anxiety and depression that many patients with AA experience to help improve their quality of life.

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Summary

Alopecia areata is an autoimmune disease that causes hair loss that often occurs in circular patches. It can occur on the scalp and facial area and also spread more extensively to impact most or all of the hair on the scalp and body. 

While conventional treatment focuses on steroid injections and/or topical and oral medications to help suppress the immune system and stimulate hair regrowth, an integrative approach assesses underlying factors which contribute to autoimmunity, like imbalances in the microbiome. A functional medicine approach addresses these root causes with nutrition, supplements, and complementary therapies to help bring the body back in balance and improve quality of life.