Study Identifies Underrecognized Alopecia Variant Titled ‘Macular Alopecia’

A new analysis has identified a variant of alopecia areata and proposed the term “macular alopecia” for this version of the disease, with the variant characterized by spontaneous resolution within several months and the appearance of small macules.1

These results followed an institutional review board-approved, single-center retrospective chart review authored by a team of investigators, such as Molly Thapar, from the Medical College of Wisconsin in Milwaukee. Thapar and colleagues noted that patients living with alopecia areata, the prototypical non-scarring alopecia observed among children, can see their disease present in various forms on different areas of the body in various ways.2

“Not included within current classification systems is a variant of alopecia characterized by macules < 1 cm in diameter,” Thapar and colleagues wrote.1 “We conducted a study to characterize this group of patients and propose the term macular alopecia (MA), which may be an [alopecia areata] variant versus a distinct entity.”

After it was approved by the institutional review board, the investigative team’s retrospective chart review was carried out. At Children’s Wisconsin, the team set out to assess and make comparisons between regions with patchy alopecia areata and macular alopecia.

Individuals deemed eligible for inclusion in the study were those with an onset of disease that took place between ages 0 - 21 years, specifically who presented with at least a single alopecic macule or patch. "Patchy AA" was used a descriptor for individuals who had been diagnosed with patchy, ophiasis, or sisaipho variants of alopecia areata.

In contrast, individuals who identified with alopecia areata but were only shown to have macules or patches that measured 14 mm or smaller in diameter were classified as having macular alopecia. The threshold of 14 mm in size had been previously established using clinical observations in the field of pediatric dermatology.

Both the patchy and macular alopecia cohorts were defined by Thapar and colleagues as mutually exclusive. The team did not include individuals in their study who were found to have totalis, diffuse, or universalis subtypes of alopecia areata, suspected cases of macular alopecia lacking clear classification, or other forms of alopecia.

Throughout their analysis, the investigators looked through the electronic medical records of trial subjects via ICD-9 and ICD-10 codes for alopecia areata, along with codes for alopecia unspecified and other non-scarring alopecias. They evaluated those who had recorded ambulatory dermatology visits spanning over 13 years, from February 2011 - February 2024.

Frontal, temporal, parietal, and occipital zones were the classified regions of the scalp the research team assessed. They also looked at a variety of demographic variables such as race and self-reported sex at birth, along with clinical data.

Overall, Thapar and the other investigators concluded with a review of 471 subjects, with 397 having been identified as showing patchy AA. In the other cohort, they categorized 74 as having macular alopecia. Compared to the patchy AA arm of the study, those in the macular alopecia arm were found by the team to be more frequently Hispanic/Latinx in ethnicity (62%) and to be female (77%).1

This cohort's subjects also showed a lower median age of onset at 5.9 years.1 Patchy AA lesions were found by the investigators to be commonly located on the occipital scalp, whereas lesions in macular alopecia tended to be clustered in the parietal scalp region.

For cases in which follow-up information was accessible to the investigative team, they found that 63% of those in the macular alopecia arm had spontaneous resolution of hair loss without recurrence (median time to resolution: 5.0 months).1 This was compared to only 20% of those in the patchy AA arm (median time to resolution: 8.0 months), and the team highlighted this as a statistically significant difference (P < .001).

“Reassurance may be provided to patients and families, who may have otherwise been alarmed by an [alopecia areata] diagnosis with its risk for comorbidities and progression to complete hair loss,” they concluded.1 “Further study is necessary to better characterize [macular alopecia's] pathogenic mechanisms, histopathologic features, long-term outcomes, sociocultural implications, and relationship to [alopecia areata].”

References

1. Thapar M, Feng J, Zhang L, et al (2025). Macular Alopecia: A Single-Center Retrospective Cohort Study to Describe an Underrecognized Pattern of Alopecia. Pediatric Dermatology. https://doi.org/10.1111/pde.15946.

2. LC Strazzulla, EH C Wang, L Avila, et al. “Alopecia Areata: Disease Characteristics, Clinical Evaluation, and New Perspectives on Pathogenesis,” Journal of the American Academy of Dermatology 78 (2018): 1–12.