Stress and Alopecia Areata – Is There A Link?

Quick Summary: Alopecia Areata and Stress

What’s Alopecia Areata: Alopecia Areata (AA) is an autoimmune disorder where the immune system mistakenly attacks hair follicles, leading to hair loss. This can be triggered or exacerbated by various forms of stress.

Impact of Stress: AA is influenced by various forms of stress — psychological, physical, and oxidative — each affecting the disease’s onset and progression through distinct mechanisms. These stressors activate the neuroendocrine system, impacting immune responses and exacerbating hair loss. Additionally, AA brings significant psychosocial stress due to the emotional toll of unpredictable hair loss, and it also poses substantial financial challenges.

Treatment Approaches: While there is no cure for AA, treatments such as corticosteroids, immunotherapy, and lifestyle adjustments can manage symptoms. It’s essential to consult healthcare providers to tailor treatment plans to individual needs.

Support Systems: Managing AA effectively involves not only medical treatments but also psychosocial support through counselling, support groups, and educational resources to help cope with the condition’s emotional and psychological impacts.

Key Takeaway: Understanding the complex relationship between stress and AA is crucial for effective management. We recommend a holistic approach that combines medical, psychological, and lifestyle strategies to navigate this variable condition and improve quality of life.

Knowingly or unknowingly, we often associate stress with hair loss. When you notice an unusual amount of hair shedding, you might wonder if stress is to blame. Research has indicated that psychological stress can indeed be a factor in hair loss. In the case of alopecia areata (AA), there are established links between stress and the disease, although the extent to which stress influences its onset and progression remains unclear.

Understanding Alopecia Areata

Alopecia areata is an autoimmune condition. This means the immune system mistakenly identifies hair follicles and surrounding skin cells, like keratinocytes, as foreign objects. This triggers an inflammatory response that disrupts the hair growth cycle, pushing it from the active growth phase (anagen) to the resting phase (telogen). This shift results in temporary bald patches on the scalp, which typically regrow within 6-12 months, although sometimes it can take longer.

One of the unique aspects of alopecia areata is its variability. Each patient’s experience, timeline of hair loss and regrowth, and the pattern of hair loss can be different. While there is no cure, symptoms such as patchy hair loss, nail disorders, and occasional scalp discomfort can be managed with medications like topical or oral corticosteroids to reduce inflammation and suppress the overactive immune system.

Causes of Alopecia Areata

• Autoimmune Nature: Alopecia areata is primarily an autoimmune disorder. The immune system attacks hair follicles, leading to hair loss.

• Genetic Predisposition: About 20% of individuals with alopecia areata have a family history of the condition, indicating a genetic component.

• Other Autoimmune Conditions: Alopecia areata can be associated with other autoimmune disorders such as thyroid diseases, lupus, vitiligo, psoriasis, and atopic dermatitis.

• Stress-associated: Studies have shown a significant correlation between stress and the development or exacerbation of alopecia areata. We’ll explore some of these studies to understand this connection better.

The Role of Stress

Stress in the body can manifest in various forms, including external physical stress and internal emotional stress. Both types can lead to chemical changes in the body, resulting in oxidative stress and hormonal imbalances. We’ll explore these types of stress and how it may be associated with alopecia areata episodes. Research suggests a significant correlation between stress and alopecia areata. Let’s break it down into the different types of stress we may experience:

How Our Body Perceives Stress

Oxidative stress

Numerous studies link oxidative stress to accelerated hair thinning and loss, and researchers are increasingly recognising its broader impacts on our overall health and well-being.¹ 

Oxidative stress occurs when harmful molecules known as free radicals build up faster than our body’s antioxidants can neutralise them. This imbalance not only damages our cells (including hair follicles) but also plays a significant role in both physical and mental health issues, including hair loss. In the case of AA, an autoimmune condition, oxidative stress exacerbates the situation by causing damage to hair follicles, especially since these individuals already have an overactive immune system and reduced antioxidant defences.² This leads to the hair growth cycle being prematurely pushed into the resting phase, making it difficult for hair to re-enter the growth phase and contributing to hair loss. 

The diagram below might help you understand the effect of oxidative stress on the hair follicles.

Physical stress

We experience physical stress when our bodies are strained by factors like injuries, fatigue, or excessive exertion. This kind of stress can activate our immune system and potentially worsen conditions like AA, which we know is an autoimmune disorder where the immune system mistakenly attacks hair follicles leading to hair loss.

It’s also well known how a bodily strain can activate the different hormones in the brain and body. Here’s how physical stress is theorised to affect AA, they are mostly thought to alter the immune environment around hair follicles negatively: 

• Immune System Activation: Physical stress can trigger inflammation and make the immune system more active. In people with AA, this heightened immune response could directly target hair follicles, disrupting normal hair growth.

• Cortisol and Hormones: During physical stress, the body releases more cortisol, often referred to as the “stress hormone.” Increased cortisol can disrupt the balance of the immune system, which is crucial in managing an autoimmune condition like AA.

While more commonly studied in psychological contexts, physical stress and its impact on AA are gaining attention. Early studies, including those in animal models, indicate that stress can significantly affect hair growth by influencing how long hair follicles remain dormant.³ We’ll delve deeper into this topic below, exploring how the brain and hormonal systems react to stress from both neuroendocrine and hormonal perspectives.

How Our Mind Perceives Stress

Psychological stress

For instance, one study found that 23% of alopecia areata cases were attributed to psychological stress.⁴ This study suggested that normally immune-privileged hair follicles become vulnerable in the context of alopecia areata, potentially triggered by stress, leading to the development and exacerbation of the condition. Additionally, an older study found that patients with stress-reactive alopecia areata—those who experience stressful events or periods before the onset or worsening of their hair loss—typically had higher depression scores.⁵ Another recent 2023 study in the US found that 33.9% of its participants with AA also screened positive for post-traumatic stress disorder (PTSD). These studies highlight the strong psychological impact of AA, suggesting that stress might not only contribute to but even cause the development of AA.⁶

Psychosocial Stress

In today’s demanding and often isolating world, we believe it’s important to focus on psychosocial stress as a significant concern, especially for people living with Alopecia Areata. AA has the capability to profoundly affect both physical appearance and mental well-being. 

Socioeconomic Factors: The World Health Organization (WHO) defines socioeconomic factors as the social and economic elements that affect our lives, including our income, education, job status, and access to health services. These factors, which are key components of the broader concept known as ‘social determinants of health,’ play a crucial role in determining our health and our ability to handle illnesses. 

Research shows that individuals in socially underprivileged areas experience a higher incidence of AA. An epidemiological study in the UK revealed that while people with AA from these areas frequently visit local clinics, they are less often referred to dermatological specialists.⁷ The study suggested that this disparity might be because of the complex health issues these patients face, which can overshadow concerns like hair loss. In contrast, patients from areas with greater resources often have the capacity to pursue specialist referrals for single issues, reflecting a difference in healthcare access expectations based on socioeconomic status.⁷ 

Emotional distress, including anxiety and depression, significantly impacts work productivity in AA patients. A study using the Quality of Life (QoL) Index revealed that even moderate scalp hair loss had a substantial impact on QoL, with participants reporting significant declines in work performance and productivity​.⁸

Living with AA is not only emotionally draining but also financially taxing, according to survey responses gathered by Alopecia UK. This variability and unpredictability of AA intensify the psychosocial stress for those affected. Here are some key highlights from the survey⁹: 

• Cost Variability: The annual cost of managing AA ranges dramatically from £4.60 to £21,300, underscoring the significant financial disparities among patients.
• Gender-Specific Expenditures: Women predominantly invest in wigs, while men are more likely to purchase hats. Additionally, both genders commonly spend on vitamins and supplements.
• Financial Burden: The financial strain is more pronounced among women, individuals of Asian descent, and those with severe symptoms or lower disposable incomes.
• Mental Health Impact: A staggering 70% of AA patients report experiencing depression, and 65% report anxiety. The risk is higher among younger individuals and those with more severe forms of AA.
• Work Productivity: The condition’s impact on mental well-being significantly affects work productivity, with 21% of survey participants being signed off work due to their symptoms.

As the cost-of-living crisis continues, the financial pressures dramatically increase stress, anxiety, and depression for those living with alopecia areata (AA). What we can take away from this section is that there is a critical need for stronger support systems and more accessible care options to help alleviate the socioeconomic and psychological challenges that individuals with AA face.

Neuroendocrine and Hormonal Perspectives of Stress:  

When we encounter any kind of stress, our neuroendocrine system, which includes our brain and hormones, quickly springs into action. A key component of this system, the hypothalamic-pituitary-adrenal (HPA) axis, releases hormones that help our bodies manage stress. While each type of stress impacts us in unique ways, they all trigger this same pathway of hormonal and neuroendocrine activation. However, this response can also unintentionally stimulate the immune system, potentially creating a cycle that exacerbates conditions like Alopecia Areata (AA).

For example, stress can prolong the resting phase of hair follicles, delaying hair growth.¹⁰ Research suggests that stress increases certain hormones like corticotropin-releasing hormone (CRH), which can lead to more inflammation around hair follicles. Increased inflammation can make the scalp environment even more hostile to hair growth, as stressed individuals often have more CRH receptors at hair follicle sites.^11,12  

Other similarly acting hormones you might come across are substance P (SP), adrenocorticotropic hormone (ACTH) and melanocyte stimulating hormones (MSH).¹³ They can also influence hair health, contributing to the cycle of stress and hair loss.

Management and Treatment

It’s important to note that while we’ve separated the topics of body and mind to simplify our explanation, they are deeply interconnected. Therefore, to manage AA effectively, we need a comprehensive approach that combines medical treatments with lifestyle adjustments. This condition is variable in nature, affecting individuals differently, so adhering to one management plan is challenging. The best course of action is to have a chat with your healthcare provider, and they will be able to tailor your treatment plan to your needs. 

However, here is a list of some currently employed methods to get an idea of the available options.

Medications:

• Topical Corticosteroids – Available as creams, ointments, and injections, these help suppress the overactive immune response at the area it’s applied to, reducing the symptoms and eventually aiding hair regrowth. 
• Systemic corticosteroids – similar to their topical alternatives but with a widespread effect in the body, which may lead to more side effects affecting other parts of the body as well.
• Minoxidil – Well-known for its ability to stimulate hair growth, this treatment is available in topical and oral forms, though its effectiveness varies from person to person. You can read more about minoxidil here.
• Immunotherapy – There are topical immunotherapies available that provoke an allergic reaction to the area applied, diverting the immune attack away from hair follicles. 
• Other medications – Includes methotrexate and the recently approved Ritlecitinib for severe AA, both of which suppress immune system hyperactivity and promote hair regrowth.
• Additional therapies – This includes photochemotherapy (PUVA) for skin and Platelet-Rich Plasma (PRP) therapy to stimulate hair growth, though it’s not suitable for everyone and needs to be considered under guidance of a professional.

Lifestyle Changes: 

Given this blog’s focus on the connection between stress and Alopecia Areata (AA), and the understanding that stress indeed influences both the development and exacerbation of AA, it’s essential to address this through lifestyle changes. 

• Though it’s easier said than done, adopting techniques such as meditation, yoga¹⁴, and therapies could help mitigate stress’s impact on AA. 

• Trying to get into habits that reduce oxidative stress and also generally prevent a hyperinflammatory state in the body can be beneficial. This has been proven to alleviate not only oxidative but also psychological stress.¹⁵ For example:
  • Maintaining a balanced diet rich in anti-inflammatory foods
  • Reducing alcohol intake and smoking
  • Establishing healthy sleep habits
  • Engaging in regular, moderate exercise 

Support Systems: 

Psychosocial and psychological support is also important, and trying your best to actively take part in support groups and counselling can be very beneficial in navigating the challenges of AA. This includes: 

• Counselling and therapy services – Counsellors and therapists can help manage the emotional stress from hair loss, offering strategies to handle psychological impacts effectively.

• Support groups – Engaging with others who have AA can be incredibly supportive. While everyone’s experience with the condition is unique, sharing common challenges can help alleviate feelings of isolation and anxiety. These groups offer a platform for understanding among peers. 

• Online forums and communities – These easily accessible platforms are great for connecting with others globally, sharing tips, and gaining support from those who understand the challenges of AA.

• Educational workshops – Attending workshops led by experts can increase your understanding of AA, keep you informed about the latest treatments, and help reduce anxiety about the condition.

You can have a read of our more comprehensive guide on alopecia areata here to learn more about the condition. 

Conclusion 

To wrap up, we believe that it’s important to understand the complex interplay between stress and Alopecia Areata, to be able to manage the condition better. Stress is widely recognised as a significant factor that can trigger or worsen Alopecia Areata by affecting the body’s immune responses. 

By taking a holistic approach which includes medical treatments, lifestyle adjustments, and solid support systems, people living with AA can better navigate the challenges that come with this variable condition. Every person’s journey with AA is unique, and personalised care from healthcare professionals is essential. At The Treatment Rooms, we encourage our patients to be well-informed about their conditions and to take proactive steps in managing both the physical and psychological aspects of hair loss. 

While we generally do not recommend hair transplants for individuals with alopecia areata, feel free to reach out to us if you have any concerns about your hair loss and would like to explore your treatment options. We’re more than happy to help you, and point you in the right direction.

References

1. Pizzino, G., Irrera, N., Cucinotta, M., Pallio, G., Mannino, F., Arcoraci, V., Squadrito, F., Altavilla, D., & Bitto, A. (2017). Oxidative Stress: Harms and Benefits for Human Health. Oxidative medicine and cellular longevity, 2017, 8416763. https://doi.org/10.1155/2017/8416763 
2. Shakoei, S., Mirmiranpoor, H., Nakhjavani, M., Nasimi, M., Bakhshi, G., & Azizpour, A. (2023). Oxidative stress and antioxidant markers in patients with alopecia areata: A comparative cross-sectional study. Indian journal of dermatology, venereology and leprology, 89(3), 411–415. https://doi.org/10.25259/IJDVL_228_20 
3. Zhang, X., Yu, M., Yu, W., Weinberg, J., Shapiro, J., & McElwee, K. J. (2009). Development of alopecia areata is associated with higher central and peripheral hypothalamic-pituitary-adrenal tone in the skin graft induced C3H/HeJ mouse model. The Journal of investigative dermatology, 129(6), 1527–1538. https://doi.org/10.1038/jid.2008.371 
4. Ahn, D., Kim, H., Lee, B., & Hahm, D. H. (2023). Psychological Stress-Induced Pathogenesis of Alopecia Areata: Autoimmune and Apoptotic Pathways. International journal of molecular sciences, 24(14), 11711. https://doi.org/10.3390/ijms241411711 
5. Gupta, M. A., Gupta, A. K., & Watteel, G. N. (1997). Stress and alopecia areata: a psychodermatologic study. Acta dermato-venereologica, 77(4), 296–298. https://doi.org/10.2340/0001555577296298 
6. Drake, L., Li, S. J., Reyes-Hadsall, S., Lee, K., Huang, K., & Mostaghimi, A. (2023). Post-Traumatic Stress Disorder in Patients with Alopecia Areata: A Survey Study in the USA. Skin appendage disorders, 9(5), 342–345. https://doi.org/10.1159/000530356 
7. Harries, M., Macbeth, A. E., Holmes, S., Chiu, W. S., Gallardo, W. R., Nijher, M., de Lusignan, S., Tziotzios, C., & Messenger, A. G. (2022). The epidemiology of alopecia areata: a population-based cohort study in UK primary care. The British journal of dermatology, 186(2), 257–265. https://doi.org/10.1111/bjd.20628 
8. Mesinkovska, N., Craiglow, B., Ball, S.G. et al. The Invisible Impact of a Visible Disease: Psychosocial Impact of Alopecia Areata. Dermatol Ther (Heidelb) 13, 1503–1515 (2023). https://doi.org/10.1007/s13555-023-00941-z 
9. Montgomery K, Zucchelli F. The Socioeconomic Burden of Alopecia Areata – What Are the True Costs of Hair loss? [Internet]. Alopecia UK. 2023. Available from: https://www.alopecia.org.uk/blog/the-socioeconomic-burden-of-alopecia-areata-what-are-the-true-costs-of-hair-loss 
10. Paus, R., & Arck, P. (2009). Neuroendocrine perspectives in alopecia areata: does stress play a role?. The Journal of investigative dermatology, 129(6), 1324–1326. https://doi.org/10.1038/jid.2009.111 
11. Katsarou-Katsari, A., Singh, L. K., & Theoharides, T. C. (2001). Alopecia areata and affected skin CRH receptor upregulation induced by acute emotional stress. Dermatology (Basel, Switzerland), 203(2), 157–161. https://doi.org/10.1159/000051732 
12. Ahn, D., Kim, H., Lee, B., & Hahm, D. H. (2023). Psychological Stress-Induced Pathogenesis of Alopecia Areata: Autoimmune and Apoptotic Pathways. International journal of molecular sciences, 24(14), 11711. https://doi.org/10.3390/ijms241411711 
13. Grymowicz, M., Rudnicka, E., Podfigurna, A., Napierala, P., Smolarczyk, R., Smolarczyk, K., & Meczekalski, B. (2020). Hormonal Effects on Hair Follicles. International journal of molecular sciences, 21(15), 5342. https://doi.org/10.3390/ijms21155342 
14. Woodyard C. (2011). Exploring the therapeutic effects of yoga and its ability to increase quality of life. International journal of yoga, 4(2), 49–54. https://doi.org/10.4103/0973-6131.85485 
15. Sharifi-Rad, M., Anil Kumar, N. V., Zucca, P., Varoni, E. M., Dini, L., Panzarini, E., Rajkovic, J., Tsouh Fokou, P. V., Azzini, E., Peluso, I., Prakash Mishra, A., Nigam, M., El Rayess, Y., Beyrouthy, M. E., Polito, L., Iriti, M., Martins, N., Martorell, M., Docea, A. O., Setzer, W. N.,Sharifi-Rad, J. (2020). Lifestyle, Oxidative Stress, and Antioxidants: Back and Forth in the Pathophysiology of Chronic Diseases. Frontiers in physiology, 11, 694. https://doi.org/10.3389/fphys.2020.00694 
16. Diagram of Stress’s Impact on Alopecia Areata illustrated using biorender.com