Systemic Lupus Erythematosus (SLE), commonly known as lupus, is a chronic autoimmune disease where the immune system mistakenly attacks the body’s healthy tissues and organs. This systemic inflammation frequently targets the scalp and hair follicles. Alopecia, the medical term for hair loss, is a common manifestation of lupus, affecting a significant number of people with the disease. The immune response disrupts the normal hair growth cycle, causing hair loss that ranges from temporary shedding to permanent bald patches.
Types of Alopecia Associated with Lupus
Lupus-related hair loss is categorized by whether it causes permanent damage to the hair follicle, which determines the potential for regrowth. The most common form in people with active lupus is non-scarring alopecia, often presenting as diffuse thinning across the scalp. This temporary hair loss is sometimes called “lupus hair” or classified as telogen effluvium, caused by inflammatory activity shifting hairs into the resting phase.
Non-scarring alopecia typically presents as generalized fragility and thinning, sometimes with short, broken hairs visible near the hairline. It is considered an SLE-specific criterion for diagnosis and a strong indicator of underlying disease activity. Because the hair follicle structure remains intact, this type of hair loss is generally reversible once systemic inflammation is controlled through treatment.
The more severe form is scarring alopecia, strongly associated with Discoid Lupus Erythematosus (DLE), a chronic form of cutaneous lupus. DLE lesions on the scalp cause intense inflammation that destroys the hair follicle, replacing it with fibrotic scar tissue. This irreversible damage leads to permanent, coin-shaped patches of baldness.
DLE lesions appear as scaly, red or purplish plaques, often with follicular plugging and changes in skin color, such as hypo- or hyperpigmentation. Prompt intervention is necessary because once scarring occurs, the hair loss is permanent, meaning regrowth in those specific areas is not possible.
Identifying the Cause: Diagnosis and Differentiation
Determining that alopecia is caused by lupus, and not by other factors like stress or thyroid issues, requires a systematic approach. Diagnosis begins with a thorough physical examination of the scalp, looking for signs of inflammation, scaling, or scarring. A gentle pull test assesses hair shedding, and a dermatoscope is often used to examine the hair follicles in detail.
Patient history is reviewed to correlate hair loss episodes with lupus flares or new medications. Laboratory tests are essential for assessing systemic lupus activity and ruling out other causes of hair loss. Bloodwork often includes tests for antinuclear antibodies (ANA) and anti-dsDNA antibodies, which are markers for lupus, along with inflammatory markers like the erythrocyte sedimentation rate (ESR).
The gold standard for confirming the type of lupus-related alopecia, especially the scarring form, is a scalp biopsy. This procedure involves taking a small sample of skin and hair follicles for analysis under a microscope. A biopsy helps differentiate between non-scarring and scarring alopecia by revealing inflammation around the hair follicle and the extent of follicular destruction or fibrosis.
In cases of non-scarring alopecia that resemble other conditions, like alopecia areata, the biopsy can uncover specific features characteristic of lupus, such as deep dermal mucin deposition. A prompt and accurate diagnosis is essential because the prognosis and treatment strategy for reversible non-scarring hair loss are vastly different from those for permanent scarring alopecia.
Treatment Strategies for Lupus-Related Hair Loss
The primary goal in treating lupus-related hair loss is controlling the underlying autoimmune disease activity, which reduces inflammation attacking the hair follicles. Systemic treatment is the foundation of management, especially for non-scarring alopecia, where suppressing the lupus flare allows for hair regrowth. Antimalarial drugs, particularly hydroxychloroquine, are a first-line systemic therapy effective in decreasing overall disease activity and treating both systemic and cutaneous lupus manifestations.
For more aggressive or severe flares, stronger systemic medications may be necessary. These include oral corticosteroids, immunosuppressive drugs like methotrexate or mycophenolate mofetil, and sometimes biologic therapies. These medications halt the inflammatory process, and patients with non-scarring hair loss often notice reduced shedding within two months, with visible regrowth beginning within three to six months.
Local, topical treatments are often used alongside systemic therapy, particularly for managing specific lesions associated with Discoid Lupus Erythematosus (DLE). High-potency topical corticosteroids or intralesional steroid injections directly into active DLE plaques help to quickly reduce localized inflammation. Topical calcineurin inhibitors can also be used to target specific lesions and prevent the progression to permanent scarring.
Managing the cosmetic impact is a significant consideration alongside medical stabilization. For non-scarring alopecia, topical minoxidil may be recommended as an adjuvant therapy to stimulate hair regrowth. In cases where DLE has led to permanent scarring, cosmetic solutions like hair systems or wigs may be explored. Hair transplantation may be considered for scarred areas, but only after the underlying lupus has been stable and inactive for an extended period, often two to five years, to minimize the risk of the disease recurring in the transplanted follicles.