Alopecia areata and its homoeopathic management

Dr Swasthik Jain

ABSTRACT
Alopecia areata (AA) is an autoimmune disease that causes hair loss. It can affect children and adults. Alopecia areata is a complex genetic disease that targets anagen hair follicles. It can cause round or oval patches of hair loss, loss of all scalp hair, or loss of body hair.

Alopecia areata is usually diagnosed based on clinical manifestations, but dermoscopy and histopathology can be helpful. It has many variants or patterns, including: Diffuse type, Patchy type, Alopecia areata totalis, Alopecia areata universalis.

Alopecia areata is a common form of non-scarring alopecia. It’s usually transient and preserves the hair follicle. the management of Alopecia areata includes only temporary measures. In homoeopathy there are many literatures and remedies which shows its application in Alopecia areata which gives huge benefits for the patients.

KEY WORDS: Alopecia areata, Hair follicle, Autoimmune,

INTRODUCTION
Alopecia areata is considered as hair follicle specific autoimmune disease, triggered by environmental factors in genetically susceptible individuals. Besides genetical susceptibility various triggering factors like stress, hormones, diet, infectious agents, vaccinations and many others were incriminated in the pathogenesis of alopecia areata. Stress, emotional trauma of a family death or accidents has been reported as precipitating factors in individual cases. [1] [2]

Alopecia areata accounts for 2-3% of the new dermatology cases in UK and USA, 3.8% in China, and 0.7% in India. In general population the prevalence was estimated at 0.1-0.2% with a lifetime risk of 1.7%. Both males and females are equally affected. [1]

The peak age of onset for either sex was 20-29 years, constituting 32.3% of the total cases. In a sizeable number of 37.6% of patients the Alopecia areata started before 20 years of age. Girls or women had lower mean age at onset (19.8 years) than boy’s or men (24.4 year). [3]

Hair is essential to the identity of many of men and women. Feminity, sexuality, attractiveness and personality are symbolically linked to a women’s hair more so than for a man. Hair loss can therefore seriously affect self-esteem and image. About 40% of women with alopecia areata have had marital problems. The extent of alopecia is one of the predictors of psychological distress. [4]

In contemporary science the management of Alopecia areata includes only temporary measures. But due to the economic conditions of the family they don’t adopt these treatments.

DEFINITION

Alopecia areata (AA) is a common form of non-scarring alopecia involving the scalp or body, characterized by hair loss without any clinical inflammatory signs. It is one of the most common forms of hair loss seen by dermatologists and accounts for 25% of all the alopecia cases.[1]

AETIOLOGY [5]

• Genetic factors

Although many workers report a positive family history in 10—20% of cases, others obtained such a history in only 6.3% or in none. Identical twins have been affected simultaneously and in the same site. HLA studies tend to confirm the heterogeneity of the disorder; in Finland HLA B12 was associated with AA, but not with alopecia universalis. In Jews in Israel, AA was significantly associated with particular HLA types.

• Immunological factor

The Atopic state: The significant association of the atopic state with AA in some populations has been stressed only relatively recently. The criteria for the diagnosis of the atopic state has varied and the published figures are not comparable. Eczema or Asthma or both were present in 18% of the children with AA and 9% OF adults.

Autoimmunity: The association of AA with certain endocrine disorders, some cases of which are of autoimmune origin, been recognized. The reported association of thyroid disease with AA has ranged from 2.8% to 8%. An increased incidence of diabetes has been noted in relatives of patients themselves. Vitiligo, which is associated with AA in about 4% of cases as compared with 1% of control subjects, is also significantly associated with pernicious anaemia, diabetes mellitus and Addison’s disease.

• Endocrine factors

Endocrine influences on the course of alopecia areata have been little studied by modern methods, but valid clinical observations have established that, although pregnancy usually does not influence the course of alopecia, there are patients in whom regrowth occurs only during pregnancy, the hair being shed after parturition.

• Psychological factors

Some investigators consider that emotional factors play no significant role in alopecia areata, whereas others claim that most patients are psychologically abnormal. A very detailed psychosomatic study of eight patients does not convincingly resolve the problem. stress may precipitate attacks.

PATHOPHYSIOLOGY [6]
Studies aimed at elucidating the complex genetics of alopecia areata have been undertaken by a number of groups using techniques ranging from candidate-gene association studies to transcriptional profiling of affected skin to large GWAS. The initial genetic studies

concentrated on single genes that were known to be involved in related autoimmune diseases. Interestingly, many of these genes did in fact play a role in alopecia areata in addition to inflammatory bowel disease, multiple sclerosis, psoriasis, and type 1 diabetes mellitus. Owing to the focus on an autoimmune aetiology, the HLA region, which encodes MHC molecules in humans, was initially identified as a major contributor to the alopecia areata phenotype. The HLA region is one of the most gene-dense regions of the genome and encodes for key immune regulators. Recent GWAS meta-analyses have localized the HLA signal largely to the HLA-DRB1 region.

Subsequent large-scale genetic studies have added to the list of genes associated with alopecia areata and further validated the role of the HLA region genes. For example, the several GWAS analysis in humans have identified 14 genetic loci associated with alopecia areata, many of which are known to be involved in immune function. One locus, in particular, harbouring the genes encoding the natural killer (NK) cell receptor D (NKG2D; encoded by KLRK1) ligands NKG2DL3 (encoded by ULBP3) and retinoic acid early transcript 1L protein (encoded by RAET1L; also known as ULBP6), was uniquely implicated in AA and not in other autoimmune diseases, which suggests a key role in pathogenesis. Indeed, this has been borne out of functional studies showing that CD8+NKG2D+T cells are the major effectors of AA disease pathogenesis. The dependency of these cells on IL15 signalling for their survival provided a rationale for using Janus Kinase (JAK) inhibitors to target the downstream effectors of this pathway in developing new therapeutic approaches.

In addition, gene expression studies have been used to validate these genetic studies and to assess local gene expression changes in affected areas. These studies have also identified more genes whose expressions are changed during disease progression. Gene expression profiling studies have revealed predominant signatures of the Interferon gamma pathway and its related cytokines, as well as a predominant signature for cytotoxic T cells, both of which

are mediated by JAK kinases as them downstream effectors. The emergence of these signatures further refined the focus using small-molecule JAK inhibitors. Recently, associations between alopecia areata and copy number variations (CNV) were found using genome-wide scans.

Although most genetic studies in both humans and mice focus on the autoimmune aspects of alopecia areata, the hair loss is largely due to hair shaft fragility and breakage. In the mouse model for alopecia areata, cysteine-rich secretory protein 1 (Crisp1) was identified as a candidate gene within the major alopecia areata locus Alaa1 using a combination of QTL analysis, shotgun proteomics, and in situ hybridization. Although the autoimmune-based inflammation might dysregulate hair shaft, the lack of development and growth of the hair shaft, lack of CRISP1 in C3H/HeJ mice, the inbred strain most severely affected by spontaneous alopecia areata, suggested that CRISP1 might be an important structural component of mouse hair that predisposes the hair shaft to diseases. Whether this protein plays a role in severity of human disease remains to be determined. Such findings suggest an even more complex genetic involvement, with genetic factors not only involved in disease initiation but also in the pleomorphic clinical presentation.

CLINICAL FEATURES [7]

• The alopecia commonly develops without subjective symptoms and is often first noticed by a relative or a hairdresser.
• Occasionally there may be paraesthesiae. The primary patch, which may appear anywhere but is usually on the scalp, is circumscribed and clearly defined, and is often rounded or oval in shape.
• Characteristically, the skin is smooth, soft and ivory white, and is totally devoid of hair. Rarely, slight erythema or oedema may be found at an early stage.
• Around the margins of the patch exclamation-mark hairs may be present, where the patch is actively extending, together with many easily extracted normal club hairs.
• Extension may continue for a few weeks. The patch may regrow after 4—10 months. More often, after 2-6 weeks a succession of further patches appears more or less simultaneously in any part of the scalp.
• The course is infinitely variable. Further patches may develop whilst the earlier ones are regrowing, or gradual extension may lead to total alopecia.
• Particularly in children the clinical form known as ophiasis occurs. The primary patch usually develops in the occipital region and the alopecia extends in a band along the scalp margins. Like other forms it may be followed by total alopecia.

DIFFERENTIAL DIAGNOSIS
Though alopecia areata is a form of nonscarring alopecia, it is sometimes confused with different varieties of scarring alopecia as well. This is also because many alopecia types are biphasic in their natural history. The first step, therefore, is to distinguish between scarring and nonscarring alopecia. Scarring alopecia has loss of follicular ostia, or atrophy. Clinical inflammation is frequently, but not always, present.

• TRICHOTILLOMANIA – This condition probably causes most confusion and it is possible that it coexists with alopecia areata in some cases. The incomplete nature of the hair loss in trichotillomania and the fact that the broken hairs are firmly anchored in the scalp (i.e., they remain in the growing phase, anagen, unlike exclamation mark hairs) are distinguishing features.
• TELOGEN EFFLUVIUM – Telogen effluvium is a form of nonscarring alopecia characterized by diffuse, often acute hair shedding. It is excessive shedding of resting or telogen hair after some metabolic stress, hormonal changes, or medication.
• TRACTION ALOPECIA
• ANAGEN EFFLUVIUM – (Drug-induced) may mimic diffuse alopecia areata.
• SECONDARY SYPHILIS
• SYSTEMIC LUPUS ERYTHEMATOSUS
• LOOSE ANAGEN HAIR SYNDROME – This is a disorder of abnormal anagen hair anchorage. It is commonly found in children and has an autosomal dominant inheritance
• TINEA CAPITIS – The scalp is inflamed in tinea capitis and there is often scaling but the signs may be subtle.
• ACUTE DIFFUSE AND TOTAL ALOPECIA (ADTA) – It is a new subtype of alopecia areata with favourable prognosis. ADTA has been reported to have a short clinical course ranging from acute hair loss to total baldness, followed by rapid recovery, sometimes even without treatment.
• SISAPHO – This is an unusual form of alopecia in which a band-like pattern is found on the frontal hairline. This can be clinically confused with frontal fibrosing alopecia. The opposite of ophiasis type, where hairs are lost centrally and spared at the margins of the scalp, is called sisiapho. It may mimic androgenetic alopecia.

INVESTIGATIONS [1][5][8]
Most of the AA cases are typical and obvious; therefore, laboratory tests are not necessary. Thyroid screening is not mandatory as thyroid disease and AA are not correlated clinically or causally.

Clinical examination include: 1. Physical examination – Most characteristic diagnostic finding is the presence of circumscribed hairless patches or large alopecia areas in otherwise normal appearing skin areas.

HOMOEOPATHIC RESEARCH ARTICLE

• An evidence based Homoeopathic case report of Alopecia areata is done in an 11-year-old boy, by Dr Ashish Pandurang Shivadikar, Department of Dermatology, Regional Research Institute of Homoeopathy, Gudivada, krishna, Andra Pradesh.Based on the totality of case First prescription was done on 20th October 2012 on constitution basis and Lycopodium 30C was given. Follow up of the patient was assessed monthly or as required. The bald patches on the head showed new hair growth initially with Lycopodium 30C, but much significant improvement was observed with higher potency of same Medicine that is Lycopodium 1M. [9]
• In a case report study conducted at CCRH Bhubaneswar and West Bengal on a 19-year-old unmarried female girl who reported with complaint of loss of hair in patch on Vertex region. She tried all sort of treatment but failed and was advised for the hair transplantation which she could not afford. Then based on symptomatology, complete repertory was preferred. After repertorization many medicines were competing with each other namely Phosphorus, Argentum-Nitricum, Graphitis, kali-carb and Sulphur.
• Medicine and given in LM potency. Complete resolution of complaint was observed Over a period of 5 months. [10]
• In a case study published at International Journal of Advanced Ayurveda Yoga Unani Siddha and Homoeopathy done by Homoeopathic physicians from Government homoeopathic medical College Bihar. Here a 16-year-old girl with complaint of hair loss in patches from 8 months seen, and on detailed case taking and repertorization Phosphorus came out as the constitutional remedy and given it in 200 potency. Over a period of 6 months hair loss stopped and new hair started to grow in the region of patchy baldness and it was observed in regular follow-ups. [11]
• In an article published by the International Journal of Homoeopathic Sciences on role of anti-miasmatic remedy in case of alopecia areata. Here they mentioned a case of 6-year-Old male patient with alopecia areata where they prescribed Tuberculinum as a constitutional medicine, and in a period of 6 months rapid growth of hair in those patchy area is seen. [12]

INDICATIONS OF SOME HOMOEOPATHIC MEDICINES [13]

Ammonium-muriaticum – large accumulation of barnlike scales, with falling off the hair, which has a deadened and lustreless of appearance, with great itching of the scalp.

Arsenicum album- Touching the hair is painful; bald patches at or near the forehead, bregma, sides, scalp covered with dry scabs and scales, looking rough and dirty extending sometimes even to forehead, face and ears. Brittle and stiff hair. Dandruff.

Cantharis– Hair falls out in bunches, spots when combing, especially during confinement and lactation; scales on scalp, enormous dandruff, stiff hair.

Carbo-vegetabilis – Falling out of hair after severe diseases or abuse of mercury, with great sensitiveness of scalp to pressure; hair falls out more on back of head, after severe illness or parturition. Hair falls worse from warmth of head, cold sweat on forehead.

Fluoricum acidum – Hair fall after syphilis, fevers. Large patches entirely denuded of hair; new hair brittle, dry and breaks off; must comb the hair often; it mats so at the end; baldness. Hair in tangle, congestion of blood to the head.

Graphites – Even the hair on the sides of the head, vertex and nostrils falls out. Dry, tangled, matted or brittle hair. Perspiration of scalp, greying of hair. Dandruff, like milk crusts.

Kalium-carbonicum– Alopecia after nervous fevers; dry brittle hair, rapidly falling off from eyebrow, temple, beard, moustache and sides with much dandruff. Greying of hair.

Lycopodium– Hair fall from temples and vertex. Hair becomes grey early; hair falls off after abdominal disease after parturition, with burning, scalding, itching of the scalp, especially on getting warm from exercise during the day.

Natrium muriaticum – Hair fall after nursing. Hair falls out if touched: mostly on forepart of head, bregma, moustache, temples and beard; scalp very sensitive; face shining as if greasy. Dandruff on occiput.

Phosphorus – Hair fall after mental emotion or sickness. Round patches on scalp completely deprived of hair; falling off the hair in large bunches on the tuft’s occiput, forehead and on the sides above the ears; the roots of the hair seem to be dry; the denuded scalp looks clear white and smooth; dandruff copious, falls out in clouds. Itching of the scalp.

Sulphur – Hair fall after parturition. Hair falls from occiput and eyelashes. Dandruff, hair dry, falling off, scalp sore to touch, itching violently < when getting warm in bed and ‘washing. Hair grey, offensive, dry, cold and hard.

REPRESENTATION OF ALOPECIA AREATA IN REPERTORY

Murphy’s Repertory: [14]

• Generals – HAIR, general, head and body- falling, out, of hair- AUR., CARB.V., CARBN.S., FL.AC., GRAPH., KALI.C., KALI.S., LACH, LYC., NAT.M., NIT.AC., PHOS., SEP., SIL., SULPH., THUJ.
• Generals – HAIR, general, head and body- falling, out, of hair- all over- sel
• Generals – HAIR, general, head and body- falling, out, of hair-childbirth, after- LYC., SEP., SULPH.
• Generals – HAIR, general, head and body- falling, out, of hair-children, in- bar.c., ph.ac.
• Generals – HAIR, general, head and body- falling, out, of hair-dandruff, due to- am.m., kali.c., thuj.
• Generals – HAIR, general, head and body- falling, out, of hair-diseases, after- ph.ac.
• Generals – HAIR, general, head and body- falling, out, of hair-extending all over body- alum.
• Generals – HAIR, general, head and body- falling, out, of hair-forehead- Hep., Merc., Nat.m, Phos.
• Generals – HAIR, general, head and body- falling out, of hair- grief, from- Ph.ac.
• Generals – HAIR, general, head and body- falling out, of hair- handfuls, in- PHOS.
• Generals – HAIR, general, head and body- falling out, of hair- headache, with- ant.c., nat.m., nit.ac., sep., sil.
• Generals – HAIR, general, head and body- falling out, of hair- menopause- Sep.
• Generals – HAIR, general, head and body- falling out, of hair- occiput, on- Carb.v. Chel., Petr.
• Generals – HAIR, general, head and body- falling out, of hair- pregnancy, during- LACH.
• Generals – HAIR, general, head and body- falling out, of hair- sides- Graph., Staph.
• Generals – HAIR, general, head and body-, falling out, of hair- skin, general- Alum., Calc., Carb.v., Graph., Nat.m., Sec., Sil.
• Generals – HAIR, general, head and body-, falling out, of hair- spots, in – FL.AC.
• Generals – HAIR, general, head and body-, falling out, of hair- spots, in – and comes in white- vinc.
• Generals – HAIR, general, head and body- falling out, of hair- syphilis, from- merc., nit.ac., ust,
• Generals – HAIR, general, head and body- falling out, of hair- temples: Kali.c., Nat.m.

CONCLUSION
Alopecia areata is an autoimmune disorder most commonly seen in both males and females. The only available option for the condition in contemporary medicine is Corticosteroid, which is not as a curative medicine. Prolong intake of corticosteroids has its own side-effects over the body. There are some studies conducted in homoeopathy for the management of Alopecia areata. Individualized homoeopathic medicines and also specific medicines were used for the treatment and it showed significant improvement in the cases. So Homoeopathic medicines are found effective in the treatment of Alopecia areata.

REFERENCES

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8.Rossi A, Muscianese M, Piraccini BM, Starace M, Carlesimo M, Mandel VD, et al. Italian Guidelines in diagnosis and treatment of alopecia areata. G Ital DermatolVenereol. 2019;154(6):609–23. [Cited 2021 AUG 10] Available from:https://www.researchgate.net/publication/336262897_Italian_Guidelines_in_diagnosis_and_treatment_of_alopecia_areata

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Dr Swasthik Jain
PG Scholar Department of Practice of Medicine
Under the Guidance of Dr Praveen Kumar P.D (HOD of Dept of Medicine)
Government Homoeopathic Medical College and Hospital
Dr. Siddhaiah Puranik Road, Basaveshwar Nagar, Bengaluru,560079