Patchy Hair Loss — Free SCA Practice Case

1. Distinguishing Alopecia Areata from Other Causes of Patchy Hair Loss

• ●Alopecia areata presents as a well-defined, round or oval patch of hair loss with smooth, non-scarred skin — no scaling, redness, or broken hairs at the surface. This is the key clinical picture to recognise.
• ●Tinea capitis is the most important differential to exclude: it causes scaling, itching, inflammation, and broken or fragile hairs. The absence of all these features effectively rules it out — antifungal treatment is not indicated when the skin is smooth and pale.
• ●Trichotillomania produces irregular patch borders, hairs of varying lengths, and broken stubble. It is associated with hair-pulling behaviour (which the patient will typically deny). The distribution is often on the dominant hand side.
• ●Traction alopecia follows the line of tight hairstyles; the history of hair styling habits and a consistent anatomical pattern are diagnostic clues.
• ●Telogen effluvium causes diffuse shedding — generalised thinning rather than discrete patches — typically 2–3 months after a physiological stressor (illness, surgery, significant weight loss, childbirth). It does not cause a single well-defined bald patch.
• ●On close inspection or dermatoscopy, look for exclamation mark hairs at the patch periphery — short hairs that are narrower at the base than the tip — which are pathognomonic of alopecia areata.

2. Autoimmune Associations and Investigations

• ●Alopecia areata is a T-cell mediated autoimmune condition causing reversible inflammation around the hair follicle. The follicle itself is not destroyed, which is why regrowth is possible.
• ●It is associated with a cluster of other autoimmune conditions: thyroid disease (Hashimoto's and Graves'), vitiligo, atopic eczema, and type 1 diabetes. A personal or family history of any of these should raise clinical suspicion and inform the working diagnosis.
• ●In this patient — known hypothyroidism, childhood eczema, and a first-degree relative with vitiligo — the autoimmune context strongly supports alopecia areata as the diagnosis.
• ●Check thyroid function (TSH ± free T4) even if the last result was normal: alopecia areata can be an indicator of suboptimal thyroid control or a harbinger of evolving autoimmune thyroid disease. Arrange repeat TFTs at this appointment.
• ●Check FBC and ferritin: iron deficiency is common in women of reproductive age and, while not a direct cause of alopecia areata, contributes to hair shedding and may impair treatment response. A poor diet (as in this case) makes nutritional deficiency worth excluding.
• ●Vitamin D is reasonable to check given the autoimmune context and its association with several autoimmune conditions, though evidence for its specific role in alopecia areata is limited.
• ●Routine immunological workup (ANA, anti-TPO antibodies) is not indicated for a single patch in primary care unless there are other clinical concerns.

3. First-Line Treatment: Topical Corticosteroids

• ●Spontaneous regrowth occurs in 50–80% of patients with limited alopecia areata (a single small patch, <50% scalp involvement) within 12 months. This is the basis for offering a watch-and-wait approach as a valid, evidence-based option.
• ●Where the patient requests active treatment, potent or super-potent topical corticosteroids are the recommended first-line option in primary care (NICE CKS):
  • ●Clobetasol propionate 0.05% (Dermovate) — super-potent
  • ●Betamethasone valerate 0.1% (Betnovate) — potent
• ●Apply a thin layer to the affected patch only, once or twice daily. Use a scalp formulation (foam, lotion, or scalp application) — creams are impractical on hair-bearing skin and are harder to apply precisely.
• ●Trial duration: at least 3 months before assessing response. If there is no regrowth after 3 months, reassess rather than continuing indefinitely.
• ●Key safety points: potent topical steroids can cause skin thinning (atrophy) with prolonged or excessive use. Apply only to the patch — not to surrounding normal scalp. Review use at 3 months and do not leave the patient on an unsupervised long-term course.
• ●Topical minoxidil (2% or 5%) is sometimes used as an adjunct to topical steroids, though evidence in alopecia areata is weaker than in androgenetic alopecia. It may be considered where topical steroids alone have not produced regrowth.
• ●Intralesional corticosteroid injections (triamcinolone acetonide, administered by a dermatologist or trained GP) are more effective than topical treatment for resistant patches but are not routine primary care first-line management — they require referral or specific training.
• ●Oral corticosteroids are not appropriate for a single small patch. The benefit does not outweigh the systemic risk, and any regrowth achieved tends to be lost once the course is completed.

4. Referral Criteria

• ●A single small patch managed in primary care does not require immediate dermatology referral.
• ●Refer to dermatology if:
  • ●The patch enlarges significantly or multiple new patches develop
  • ●Eyebrows, eyelashes, or body hair are lost (indicating more extensive disease)
  • ●There is no response to potent topical corticosteroids after 3 months
  • ●There is diagnostic uncertainty (e.g. scarring alopecia is suspected — these require early specialist assessment as scarring is irreversible)
  • ●The patient's psychological distress is severe and not improving with primary care support
• ●Alopecia totalis (total scalp hair loss) and alopecia universalis (total body hair loss) should be referred promptly — these have a poorer prognosis for spontaneous regrowth.

5. Safety Netting and Follow-Up

• ●Arrange a review at 6–8 weeks to assess the patient's wellbeing, check blood results, and confirm the treatment plan is being followed correctly.
• ●A 3-month review is the appropriate interval to formally assess treatment response.
• ●Advise the patient to return sooner if:
  • ●New patches appear on the scalp or elsewhere
  • ●Eyebrow or eyelash hair is lost
  • ●Nail changes develop (pitting, ridging)
  • ●Mood or anxiety is worsening significantly
• ●Regrowing hair may initially appear fine, white, or depigmented before regaining its normal texture and colour — this is expected and not a sign of treatment failure.
• ●Inform the patient that alopecia areata can be a relapsing-remitting condition: even after full regrowth, future episodes are possible. This is not a cause for alarm but is worth communicating at diagnosis.

6. Psychological Impact and Holistic Management

• ●Do not underestimate the psychological burden of alopecia areata — even a single small patch can cause significant distress, avoidance behaviour, and functional impairment. This is not a disproportionate reaction; it reflects the close relationship between hair and identity, and should be addressed explicitly.
• ●Stress is commonly cited as a trigger by patients, and while psychosocial stress can modulate immune function, it is not the sole or certain cause. Acknowledge the patient's perception without attributing the condition entirely to stress — this risks unhelpful self-blame.
• ●Alopecia UK (alopeciauk.org) is the recommended patient support charity: it provides reliable condition information, peer support networks, and practical guidance including camouflage options. Signpost all patients at diagnosis.
• ●For patients with significant and persistent psychological distress, consider referral to IAPT or psychology input via the PCN mental health team.

7. Common Mistakes to Avoid

• ●Prescribing a mild topical steroid (e.g. hydrocortisone 1%) is a frequent error — it is ineffective for alopecia areata. A potent or super-potent preparation is required.
• ●Being swayed by the hairdresser's suggestion of fungal infection: the smooth, non-scaly skin makes tinea capitis clinically implausible. Do not prescribe antifungals without clinical evidence of infection.
• ●Failing to check thyroid function: in a patient with known autoimmune hypothyroidism presenting with another autoimmune condition, a repeat TFT is mandatory.
• ●Omitting ferritin: nutritional deficiency is common and modifiable — it is a simple check that is frequently missed.
• ●Imposing watch-and-wait without explanation: patients seeking active management need the rationale for observation explained clearly. Saying "let's see what happens" without context is likely to damage the therapeutic relationship.
• ●No follow-up plan: leaving a patient without a specific review date after prescribing a potent topical steroid is a prescribing safety failure. Always arrange a defined review.