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Jada Pinkett Smith's Alopecia

— The condition at the center of this year's Academy Awards drama

Last Updated April 2, 2022
MedpageToday
  A photo of Jada Pinkett Smith

The 2022 Oscars may be noted for its many historic firsts -- including the first deaf man to win an acting Oscar (Troy Kotsur; Best Supporting Actor), among others. Unfortunately, though, the evening may be more likely remembered for another first -- when actor Will Smith slapped Chris Rock on live TV.

Rock had just taken the stage to present the award for Best Documentary, when he noticed Smith and wife Jada Pinkett Smith sitting at the front of the audience. Rock , "Jada, I love ya. G.I. Jane 2, can't wait to see ya" in response to Pinkett Smith's extremely short hairstyle. Pinkett Smith has been open about suffering from the autoimmune disease alopecia areata, which has caused her to lose much of her hair.

Shortly after the remark, Smith got out of his seat, walked up to Rock and slapped him across the face. A shocked Rock replied, "Wow, dude, it was a G.I. Jane joke." Smith then yelled at him to "Keep my wife's name out your f -- ing mouth!" (The exchange was muted by the network for about 30 seconds.)

Pinkett Smith revealed her diagnosis in 2018 on her series. She recalled how scary it was when she began to lose her hair. "I was in the shower one day and had just handfuls of hair in my hands and I was just like, 'Oh my god, am I going bald?'" She started wearing turbans and cutting her hair short. She is currently getting steroid injections, "seem to be helping," she said.

What Is Alopecia Areata?

Alopecia areata is a common disorder that causes hair loss. In most people with the condition, hair falls out in small, round patches, leaving coin-sized areas of bare skin. This patchy hair loss occurs most often on the scalp but can affect other parts of the body as well. Uncommonly, the hair loss involves the entire scalp (in which case the condition is known as alopecia totalis) or the whole body (alopecia universalis). Other rare forms of alopecia areata, which have different patterns of hair loss, have also been reported.

Alopecia areata affects people of all ages, although it most commonly appears in adolescence or early adulthood. Hair loss occurs over a period of weeks. The hair usually grows back after several months, although it may fall out again. In some cases, unpredictable cycles of hair loss followed by regrowth can last for years. In addition to hair loss, some affected individuals have fingernail and toenail abnormalities, such as pits on the surface of the nails.

Alopecia areata affects one in every 500 to 1,000 people in the U.S. It is one of many recognized forms of alopecia; alopecia areata is the second most common form after androgenetic alopecia (male- and female-pattern baldness). Alopecia areata affects men and women equally, and it can occur in people of any ethnic background.

The inheritance pattern of alopecia areata is unclear because multiple genetic and environmental factors appear to be involved. Overall, the risk of developing the condition is greater for first-degree relatives of affected individuals than it is in the general population. People with alopecia areata are also more likely to have family members with other autoimmune disorders (see below).

What Causes Alopecia Areata?

The causes of alopecia areata are complex and not well understood. A combination of factors likely underlie the disorder, including changes in many genes that function in the hair and skin and in the immune system.

Alopecia areata is one of a large group of immune system diseases classified as autoimmune disorders. For reasons that are unclear, in alopecia areata the immune system targets hair follicles, stopping hair growth. However, the condition does not permanently damage the follicles, which is why hair may later regrow.

Many of the genes that have been associated with alopecia areata participate in the body's immune response. These include several genes belonging to a gene family called the human leukocyte antigen complex, which distinguishes the body's own proteins from proteins made by foreign invaders.

Some of the genetic variations associated with alopecia areata have been identified in people with other autoimmune disorders, which suggests that this group of diseases may share some genetic risk factors. People with alopecia areata have an increased risk of developing other autoimmune disorders, including , , , , and autoimmune thyroid diseases (such as and Graves' disease). Similarly, people with those autoimmune disorders have an increased risk of developing alopecia areata.

In many cases, it is unknown what triggers hair loss in people with alopecia areata. It is possible that environmental factors, such as emotional stress, physical injury, or illness, provoke an abnormal immune response in people who are at risk. However, in most affected people, the onset of hair loss has no clear explanation.

How Is Alopecia Areata Treated?

Although up to 50% of people with alopecia areata will have spontaneous hair regrowth, most will relapse at some point. Currently, there is no cure for alopecia, and there are few well-designed studies that look at the efficacy of current forms of therapy.

Although for most patients, alopecia is a cosmetic problem, for some it can cause major emotional problems. For these patients, clinical psychologists or support groups may play an important role in helping patients adapt to hair loss. In addition, the can be an important resource for patients and their families.

A few first-line therapies are available for patients who would like to try treatment. In general, these work best for patients with limited, patchy hair loss, and may not be permanent solutions. Intralesional corticosteroids (using triamcinolone) have been found to have some success in regrowing hair in patients with isolated patches of hair loss. Local skin effects such as skin atrophy, telangiectasias, and hypopigmentation limit long-term use, however.

Potent topical corticosteroids have also been used to treat patches of hair loss, despite limited evidence of effectiveness. Side effects similar to those of intralesional corticosteroids are possible.

For individuals with extensive or recurrent scalp involvement, topical immunotherapy may be the most effective treatment. This involves applying chemicals such as diphencyprone, dinitrochlorobenzene, or squaric acid dibutyl ester to the scalp. These act by inducing a contact dermatitis in the involved area, and in so doing may modulate the immune response surrounding affected hair follicles.

A 2018 retrospective study of 252 patients, by , found that 112 patients (44.05%, P<0.001) had a good response to one of these topical agents. The "main prognostic factors influencing the clinical results were the severity of hair loss at the beginning of therapy, the duration of [alopecia areata], a history of atopy (particularly eczema), and the early development of sensitization to the three sensitizers," the researchers reported.

For patients who do not wish to try treatment, cosmetic interventions are available. These can include wigs, head scarfs, and shaving the head. Temporary tattoos can help with missing eyebrows, and artificial eyelashes can be used for patients with missing eyelashes.

A list of current clinical trials can be found at .

Michele R. Berman, MD, is a pediatrician-turned-medical journalist. She trained at Johns Hopkins, Washington University in St. Louis, and St. Louis Children's Hospital. Her mission is both journalistic and educational: to report on common diseases affecting uncommon people and summarize the evidence-based medicine behind the headlines.