Alopecia Areata: Diagnosis & Treatment by Consultant Dermatologist in London

Understanding Alopecia Areata

Alopecia areata (AA) is a non-scarring hair loss disorder. “Non-scarring” means hair follicles remain alive beneath the skin, so regrowth is possible. The hallmark is one or more smooth, round or oval patches that appear suddenly over days to weeks. The skin usually looks normal — not red, scaly or painful — and you may notice short, tapered exclamation-mark hairs at the edges of patches. While any hair-bearing site can be affected, the scalp is most common. Beards (alopecia barbae), eyebrows and eyelashes can also be involved.

AA is caused by a temporary mis-direction of immune surveillance that focuses on the hair follicle, particularly during its growth phase. The tendency can run in families and often coexists with other “immune-flavoured” histories such as eczema, hay fever or autoimmune thyroid disease, but many people with AA are otherwise completely well. Crucially, nothing you did caused it — hair products, washing frequency and common styling practices are not the cause — and with the right plan, many people see meaningful regrowth.

Patterns and Variants

• Patchy AA: one or several coin-sized patches that may join or resolve.
• Ophiasis pattern: a band-like pattern along the sides and back of the scalp; can be more stubborn.
• Sisaipho (“ophiasis reversed”): preferential loss at the crown/vertex.
• Alopecia totalis: loss of hair on the scalp.
• Alopecia universalis: loss of hair on the scalp and body.
• Alopecia barbae/brows/lashes: beard or peri-ocular involvement that may affect shaving or eye comfort.
• Nails: fine pitting, ridging or roughness (trachyonychia) can accompany AA and help confirm the diagnosis.

AA behaviour varies. Some people experience a single episode that regrows and never returns; others have intermittent flares separated by long quiet periods. A smaller group has more persistent or extensive disease. Our role is to define your pattern and match treatment intensity accordingly.

What Causes Alopecia Areata?

AA is an autoimmune process where immune cells temporarily target growing hair follicles. Genetics set the stage, and environmental factors can act as triggers: intercurrent illness, periods of stress, skin irritation or, less commonly, certain medicines. Stress does not “cause” AA alone, but it can influence timing and recovery. Because the follicle is not destroyed, regrowth is possible once the immune attack settles.

Diagnosis: Getting Alopecia Areata Right First Time

Diagnosis is usually clinical. We look at patch shape and feel for regrowing hairs; dermoscopy (a magnified light examination) reveals characteristic tapered/exclamation hairs, “black dots” and short regrowth. A gentle hair-pull test at the margins may help gauge activity. Where the diagnosis is uncertain — for example, in very scaly or tender patches, or when infection is possible — we consider investigations to exclude tinea capitis (fungal infection), traction alopecia or trichotillomania. Biopsy is rarely needed but can confirm non-scarring hair loss patterns.

Our Treatment Approach for Alopecia Areata

Treatment aims to calm the autoimmune activity, encourage regrowth and support comfort and confidence. We balance effectiveness with practicality and tailor choices for site (scalp vs brows), age, skin tone, pain tolerance and personal goals. Plans are typically reviewed every 6–12 weeks initially so we can adjust promptly.

1) Intralesional Corticosteroids (Scalp & Beard)

Tiny amounts of corticosteroid are injected into the affected patches at spaced points to dampen local inflammation. This is one of the most effective options for small to moderate patches on the scalp or beard. Sessions are quick; discomfort is brief and can be eased with cooling or topical anaesthetic cream. Early regrowth often appears as fine, pale hairs within 4–8 weeks, thickening with time. We avoid over-treating the same spot to minimise temporary skin thinning or pigment change, particularly in darker skin tones.

2) Potent Topical Corticosteroids

For children, needle-averse adults or sensitive areas, a carefully chosen topical corticosteroid can be used in structured cycles. Application technique matters; we demonstrate how to target active edges and schedule rest periods to keep the skin comfortable. For eyelids or brows, we prefer non-thinning options and light touch.

3) Minoxidil (Topical)

Topical minoxidil supports follicle activity and can speed visible regrowth when used alongside anti-inflammatory measures. It is not a cure for AA, but it helps emerging hairs thicken and extend their growth phase. We match strength and vehicle (solution/foam) to your scalp and styling preferences.

4) Adjunctive Measures

Emollients soothe any scalp dryness; anti-dandruff shampoos are used only if flaking is present. Where brows or lashes are involved, specialist guidance on protective eye care and careful cosmetic camouflage can help comfort and confidence while regrowth begins.

5) Options for Extensive or Rapidly Progressive AA

When patches are widespread, fast-moving or recurrent, we discuss additional steps. These may include short courses of systemic corticosteroids to interrupt a surge (balanced against side-effects), or specialist therapies such as contact immunotherapy (a medically supervised technique that retrains the immune response on the scalp). In selected cases, other systemic medicines may be considered under consultant care with monitoring and eligibility criteria. We will always explain expected benefits, timelines, safety checks and alternatives so you can make an informed choice.

Alopecia Areata in Children and Young People

AA commonly begins in childhood. We keep plans simple and gentle, prioritising topical regimens, careful monitoring and age-appropriate support. Injections can be considered for small patches if well tolerated, but many families prefer topical cycles and watchful follow-up. School letters can help with uniform policies (e.g., hats), and we can advise on sensitive conversations to reduce unwanted attention.

Skin of Colour Considerations

AA affects all skin tones. In higher-melanin skin, transient post-treatment pigment change (light or dark) is more visible, particularly where injections are used; we reduce this risk with spacing, conservative dosing and excellent aftercare. Differentials such as traction alopecia (from tight styles) and central centrifugal cicatricial alopecia must be ruled out because they behave differently and can scar; our assessment is tailored accordingly.

Eyebrows, Lashes and Beard

Loss of brows or lashes can impact expression and eye comfort. Options include carefully selected topical anti-inflammatories, supportive lash/brow care and, in some cases, procedures or cosmetic solutions timed to your goals. We discuss safety around the eyes in detail. Beard patches often respond well to intralesional therapy and patient-led grooming adjustments in the short term.

Camouflage and Practical Support

Camouflage is not “giving up” — it is a practical tool while medical treatment works. Parting changes, volumising fibres, sensitive adhesives and well-fitted hair systems or wigs can restore confidence quickly. We can signpost reputable suppliers and provide documentation where discounts are available. UV protection for exposed scalp (SPF, hats) prevents burn and protects fragile regrowing hairs.

Timelines and What to Expect

Because AA targets growing follicles, response takes time. After injections or topical cycles, first regrowth is often visible by 4–8 weeks, initially fine and pale, then thickening and repigmenting across subsequent months. Some patches regrow without treatment; others need repeat cycles. Relapses can occur — especially during life stressors or illness — but having a plan for early action keeps confidence high and limits spread.

Relapse, Maintenance and Prevention

No strategy prevents every flare, but we can reduce frequency and impact. We map your pattern, agree early-warning signs (increased shedding, tingling at patch edges), and set a clear route back to care. A simple maintenance plan might include periodic review, prompt treatment of small new patches, and scalp-care routines that are easy to maintain. General wellbeing (sleep, movement, stress management) supports resilience; dietary variety is encouraged, but specific restrictive diets are not necessary unless advised for other reasons.

When to Seek Prompt Review

• Rapid expansion of patches over days to weeks.
• Loss of brows/lashes affecting eye comfort or safety.
• Nail pain, splitting or dramatic change.
• New symptoms (e.g., scalp redness, scaling, tenderness) that suggest an alternative diagnosis such as fungal infection or scarring alopecia.

Why Choose Skinhorizon?

We provide high-quality advanced dermatology and aesthetic services with consultant oversight. For AA, precision and sensitivity matter: a clear diagnosis, honest expectations, treatments matched to your pattern and comfort, and practical support for appearance and wellbeing. You will leave with written steps, realistic timelines, and a direct path for advice between visits.

Your First Visit — What to Expect

1. Assessment: full scalp and hair-bearing skin check; dermoscopy; mapping of patch size and activity.
2. Plan: agree first-line therapy (e.g., intralesional corticosteroids and/or topical cycles) and whether adjuncts like minoxidil will help.
3. Comfort & care: discuss anaesthetic options; demonstrate application techniques; scalp/eye protection tips.
4. Milestones: what to expect at 4–8 weeks and beyond; photographs for comparison.
5. Follow-up: review and refine; add or step down treatments according to response; relapse plan.