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Filtering by Category: Alopecia Areata

Hair loss of the beard: What are the considerations?


I have had beard alopecia areata/alopecia barbae since the age of 21, I am now 33. It began with one small bald patch under the chin and later in this period either simultaneously or after the bald batch grew back (which was within say the first couple of years) developed numerous very small bald patches throughout the entire beard (which on the cheeks appear slightly jagged) however are barely noticeable throughout. One bald patch larger than these very small patches developed on one cheek say 5 years ago and remains to this day. In summary, the condition has never dissipated however has remained static in its behaviour for a number of years to the present day.

My questions are as follows.

1. What is the likelihood of the condition progressing to other hair bearing areas? (I am aware of the study you quote at however this only followed up with patients after 12 months)

2. In the event that the condition did not progress to other hair bearing areas would hair transplantation surgery on the scalp (I have had male pattern hair loss since 2015/2016 and have been advised that it would be not until around age 35 when surgery could sensibly be considered - using FDA approved medications have only slowed down the condition rather than halted, or to any extent, caused its reverse) increase the risk of the condition (alopecia barbae) progressing to other hair bearing areas, especially the scalp?


The key here is …. what exactly is your diagnosis? It may or may not be alopecia areata and without actually seeing your scalp and beard up close myself, it would be a mistake to assume that it is. There are many mimickers of alopecia areata that need to be ruled out here - especially autoimmune cicatricial alopecia. If the areas are relatively unchanged for an extended period of time, the chances this is alopecia areata goes down.

Of course alopecia areata is on the list (and quite high up on the list of possibilities), but true classic alopecia areata of the beard does not stay unchanged over an extended period of time. You might consider seeing a dermatologist for expert review. A full review of your history and review of your hair loss pattern via dermoscopy is needed. A biopsy might be needed as well.

As far as chances of progression to other areas, it really depends on the precise diagnosis. If the disease has an immune basis, there is most certainly a chance of progression to the scalp. Hair transplantation of the scalp could be associated with an increased risk of the disease developing in the scalp - but it depends entirely on the precise diagnosis. For patients with isolated beard alopecia, my feeling is that there is about a 65-70 % risk over 10 years of alopecia areata being identified in the scalp. This too may be only one patch or may be more severe- but the presence of beard AA sets the stage for scalp AA to develop. Having a transplant is a small risk but only a small one. 2 % of the world will develop alopecia areata and so one generally expects 2 % of hair transplant patients to develop alopecia areata in their lifetimes. In 60-70 % of patients who do develop alopecia areata of the scalp in the years following their hair transplant regrowth happens quite readily with conventional treatments. Some do, however, have a more refractory course.

If the cause of the beard alopecia is actually a variant of immune based primary scarring alopecia (i.e. lichen planopilaris, folliculitis decalvans, lupus) or secondary scarring alopecias (sarcoid, scarring folliculitis etc), a hair transplant carries the risk of actually triggering scarring alopecia on the scalp. The concerns about proceeding with hair transplantation become magnified if the diagnosis actually turns out to be scarring alopecia.

All in all, alopecia areata is still at the top of the list here in the question that has been posed - but there are features of the story that are a bit unusual. You should be absolutely certain before moving on that this is alopecia areata and not something else. There is a risk over the next 10 years of alopecia areata developing on the scalp but in a majority of cases conventional treatments can help maintain the density. It largely comes down to understanding the risks and benefits (so called risk benefit ratio) …. and making an educated decision together with one’s dermatologist and surgeon. Making sure one has as much information as possible before moving forward with surgery is key.

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Are JAK Inhibitors Recommended for Patients with Alopecia Areata?



QUESTION: I’ve heard alot about the new JAK inhibitors for alopecia areata. Do you recommend them to patients?


Thanks for the question. JAK inhibitors are a groups of medications that inhibit a pathway inside cells known as the janus kinase pathway. There are actually an increasing number of JAK inhibitors being studied for human disease. The best studied by far are tofacitinib (Xeljanz) and ruxolitinib (Jakafi/Jakavi). Tofacitinib is FDA approved for the treatment of rheumatoid arthritis. Ruxolitinib is FDA approved for the treatment of myelofibrosis.

There is little doubt that the JAK inhibitors are among the more consistently effective of the 26-28 medications to date that we use for alopecia areata. However, the current high cost of the drug limits their widespead use. Furthermore they are not first line for most people meaning that they are not the first treatment to consider. The first line treatment for patient with several patches of alopecia areata remains topical steroids and/or steroid injections - not a JAK inhibitor.

Nevertheless, JAK inhibitors are finding their way into the treatment algorithms for alopecia areata. Patients not responding to topical steroids or steroid injections may consider options such as diphencyprone (DPCP), anthralin, methotrexate and prednisone. However JAK inhibitors are positioning themselves as reasonable evidence-based second or third line options.

Topical JAK inhibitors are also finding a role in the  treatment of alopecia. 2 % Tofactiinib liposomal cream and 0.6 % ruxolitinib have both shown promise. These are compounded from the pill form at a compounding pharmacy. These agents are also quite expensive and require some skill and experience from the perspective of the pharmacist in how best to make up. 

In summary, I rarely recommend a JAK inhibitor as a “first line” option to a patient who has newly diagnosed alopecia areata. However for those with refractory or progressive disease, it most certainly becomes an option to consider.

You may find these previous articles of mine helpful as well:

Tofacitinib for AA: How fast does regrowth occur?

The Topical JAK Inhibitors for AA: Update on Progress

How long do we need to use tofacitininib in AA?

Topical Tofacitininib for Alopecia Areata: How much does it help?

How does the safety of tofacitinib compare to other drugs?

Why do patients stop tofacitinib?

Tofacitinib (Xeljanz) for Children and Teens

Xeljanz in Children: How young is too young?

The JAK Inhibitors for AA: More Data

A look at Inflammatory Markers in AA Treated with Tofacitinib

What blood tests do we need to monitor for patients using tofacitinib?

Ruxolitinib for AA

Topical ruxolitinib promotes eyebrow regrow

Are responses to stress altered in users of tofacitinib?

Nail alopecia areata helped by tofacitinib



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What causes hair texture changes?




QUESTION: What causes hair texture changes? I used to have very soft and glossy hair. However, now after years of hairless (androgenetic, FFA & LPP) and treatments (injections, topical clobetasol & oral medications) my hair is very dry, dull, almost straw-like. Are these texture changes due to aging, the hair loss conditions or perhaps the treatments? Conditioners do not seem to help. Thank you.



Thanks for the great question. There are many causes of hair textural changes. In your case specifically, the causes are probably "multi-factorial" rather than a single cause.  Let’s take a look at some of the more common causes of textural changes and how they apply to the question you have raised. 


Consideration 1: Scarring alopecia

Many patients with scarring alopecia notice changes in their hair texture, especially a change to a drier, more brittle and slightly curlier hair texture. As the name suggests, scarring alopecia is associated with the development of scar tissue or ‘fibrosis’ under the scalp. Such fibrosis affects how hairs emerge from the scalp. Hair frequently twist and turn as they emerge from the scalp and sometimes even rotate 180 degrees. We call this twisting and turning ‘pili torti.’ Individuals with pili torti will notice a hair textural change.

Scarring alopecias are universally associated with loss of the oil glands (sebaceous glands) in the scalp. One can not have a scarring alopecia without having a reduction in the oil glands. These oil glands lubricate the hair follicle.  The destruction of sebaceous glands during the process of scarring alopecia contributes in part to the drier texture. 

Scarring alopecia also affects the quality of the hair that is produced. Commonly there is hair breakage on account of the much weaker fibers. 


Consideration 2: Hormonal changes

A variety of hormonal changes can lead to drier, coarser hair.  About 15 % of women are affected by thyroid disease and this a common cause of textural changes. The incidence fo thyroid disease is much more common in the conditions that you mention including lichen planopilaris (LPP) and frontal fibrosing alopecia (FFA) and so thyroid status should always be carefully evaluated in patients with scarring alopecia.

With approaching menopause, the declining estrogen levels and  imbalances in the ratio of androgens to estrogens also results in drier hair. Women who are predisposed to develop androgenetic alopecia may notice that the hair becomes finer and some may notice the texture changes too. About 40 % - 50% of women with frontal fibrosing alopecia (FFA) and lichen planopilaris (LPP) have androgenetic alopecia. 


Consideration 3: Heat and chemicals

A variety of products that are applied to the scalp can lead to the hair becoming drier, and more brittle. Products containing alcohol are frequently a culprit. This includes hairsprays but many other alcohol containing cosmetic products as well. Products such as minoxidil lotion, and topical steroids may contain alcohol-based ingredients which also dry out the hair.


Consideration 4: Inflammatory scalp diseases

A variety of scalp conditions that are associated with inflammation can lead to altered hair texture over time. Conditions such as seborrheic dermatitis and psoriasis can lead to drier duller hair. Many individuals with FFA and LPP have co-existent seborrheic dermatitis and if present, this should be treated. 


Consideration 5: Androgenetic alopecia (AGA)

Androgenetiic alopecia (AGA) is also a cause of hair textural changes. Although we discussed AGA in the context of hormonal changes above (see "Consideration 2"), androgenetic alopecia can also cause textural changes irrespective of any hormonal abnormalities. In fact, 85 % of women with androgenetic alopecia have normal hormone levels. In women, androgenetic alopecia is also known as female pattern hair loss and in men, male pattern balding. 

Women with AGA often notice the hair is finer and some notice the hair becomes curlier. Others notice the hair becomes flatter and less likely to hold it's original shape, curl or wave. 


Consideration 6: Aging

Hair "aging" is a poorly researched area and poorly defined in general.  Age-related changes in hair, independent of the hormonal changes that can occur with age, can also lead to textural changes in the hair. 



There are a variety of reasons for hair textural changes. One can usually determine the cause of the textural changes with a full review of one's story (i.e. the medical history) along with an up close examination of the scalp. Most of the time blood tests are also needed. 

Thanks again for the great question.  



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How does an exclamation mark hair differ from a regrowing hair?


I have alopecia areata and see many short hairs on my scalp and wonder if they are exclamation mark hair or regrowing hairs. How can I tell?



It's generally quite easy to tell an exclamation mark hair from a regrowing hair. A regrowing hair is thick at the bottom and 'pointy' at the top. Regrowth gets longer and longer over time. In contrast, an exclamation mark hair is wider at the top and thinner at the bottom where it enters the scalp. The exclamation hair does not get longer and longer over time. In fact, it usually falls out of the scalp.

You may wish to review these helpful articles (below) I've written in the past. Thanks again for the question. 

Exclamation mark hairs

Pointy regrowing hairs

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For alopecia areata, what treatments should I consider to boost growth?


I have alopecia areata and am currently getting steroid injections from my dermatologist. What treatments can I also be using or discussing with my doctor that could help me get back my hair faster?



There are many treatments that are possible for alopecia areata. In fact, at last count there were 26. The so called first-line "top 3" starting points for anyone with alopecia areata are steroid injections, topical steroids and minoxidil. These should not be abandoned before they have at least been given consideration. Combining them can often help get the hair back more readily if use of one alone seems to not be giving robust regrowth. There treatments are not appropriate for everyone, but are appropriate for those with 1-8 distinct patches of alopecia that cover less than one-half the scalp. Of course, these treatments should only be considered after someone has had blood tests to check their iron (ferritin), vitamin D and thyroid levels. If these are abnormal, treatments of any kind might not work as well.

Topical steroids, steroid injections and minoxidil are helpful for many people with 'patchy' alopecia areata (which is a form of alopecia where the hair loss occurs in circles). These treatments become less helpful the more hair loss a person has. Individuals with widespread alopecia areata, alopecia totalis or alopecia universals typically require other treatments that steroid injections, topical steroids and minoxidil. Such treatments included DPCP, anthralin, methotrexate, prednisone or tofacitinib. 

You may wish to review these helpful articles (below) I've written in the past. Thanks again for the question. 


Treating alopecia areata: More than shots?

Cortisone injections: What are they and how are they used?

General articles on alopecia areata


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