We don’t talk about beard hair loss enough. Most conversations around hair loss focus on the scalp with little support for men suffering with beard patchiness. However, facial hair plays a significant role in identity, masculinity and self-expression for many men. As such losing it unexpectedly can be a genuinely upsetting experience. One of the most common causes of patchy beard hair loss is alopecia barbae. This is a form of alopecia areata that specifically targets the beard area. Despite being relatively common, affecting around 28% of all alopecia areata cases, alopecia barbae is often poorly understood and underdiagnosed. In this article, we explain what alopecia barbae is, what causes it and how to recognise it. We’ll also review the best available treatment options for beard alopecia.
What iss Alopecia Barbae?
Alopecia barbae is a specific subtype of the autoimmune disorder alopecia areata. Whilst alopecia areata can affect any hair-bearing area of the body like the scalp, eyebrows and eyelashes, beard alopecia refers specifically to cases where the hair loss occurs in the facial hair. Crucially, alopecia barbae can occur alongside hair loss on the scalp or other parts of the body or it can also present in isolation.
This form of alopecia typically presents as one or more small, circular, well-defined patches of hair loss in the beard. These patches are usually smooth and the skin within them appears normal. There’s not usually any scarring, scaling or redness. This distinguishes it from conditions such as fungal infections or folliculitis which can also cause beard hair loss). The patches can range from small, coin-sized spots to larger areas. In some cases, the patches may expand and merge, leading to more extensive loss of facial hair. In severe cases, all you can lose all facial hair entirely.
Alopecia barbae can affect men of any age or ethnicity. However, it tends to present most commonly in men in their twenties and thirties. Research has shown that the neck region tends to be the most commonly and severely affected area, followed by the sides of the beard. The course of the condition is also highly unpredictable. Some men experience a single episode with spontaneous regrowth. Others may have recurring episodes of loss and regrowth over months or years.
What Causes Alopecia Barbae?
Alopecia barbae occurs when the body’s immune system mistakenly identifies the beard hair follicles as foreign invaders and attacks them. This immune attack, primarily driven by T-cell lymphocytes, causes inflammation around the hair follicle which disrupts the normal hair growth cycle and leads to the hair falling out. The follicle itself is not permanently destroyed which is why regrowth is possible especially if treated early. It is not clear why the immune system begins targeting beard hair follicles. However, a number of factors are likely to play a role in triggering it:
- Genetics: Having a family history of alopecia areata or other autoimmune conditions increases your risk. Research shows that a number of the genes involved in immune regulation that are associated with an increased susceptibility to alopecia areata. However, unlike scalp alopecia areata, some research suggests that beard alopecia areata may not follow as clear a genetic inheritance pattern.
- Other inflammatory conditions: There is a frequent association between alopecia barbae and other autoimmune disorders. These include thyroid disease (both hypothyroidism and hyperthyroidism), type 1 diabetes, vitiligo, psoriasis, atopic dermatitis and lupus. In some cases, the diagnosis of alopecia barbae may lead to the discovery of previously undiagnosed autoimmune conditions.
- Stress: Whilst stress does not directly cause alopecia barbae, both physical and psychological stress are potential triggers in people who are already genetically susceptible. Many patients report that their beard hair loss began following a period of significant stress, illness or a major life event.
- Environmental triggers: Certain infections, medications and environmental factors may also trigger the immune response in susceptible individuals. However the evidence remains limited.
What are the Symptoms of Alopecia Barbae?
There are a number of characteristic features that can help distinguish alopecia barbae from other causes of beard hair loss. The cardinal symptoms and signs of alopecia barbae include:
- Circular patches of hair loss: The most recognisable feature is one or more smooth, round or oval bald patches in the beard area. These patches are typically well-defined with clear borders.
- Exclamation mark hairs: These are short, broken hairs that are thicker at the top and taper towards the base. They are a classic sign of alopecia areata and you can often see them at the edges of the bald patches. They indicate active hair loss.
- Black dots: Visible hair shafts broken at the skin surface within the follicular openings are sometimes visible on close inspection or trichoscopy (dermoscopy of the hair).
- White or grey hairs: In some cases, the hairs that grow back within or around the patches may initially be white or grey before eventually regaining their normal colour.
- Itching or tingling: Some people experience a mild itching, tingling or burning sensation in the area before or during an episode of hair loss. However, the patches themselves are usually symptom-free.
- Sudden onset: Alopecia barbae tends to appear quite suddenly. You may notice a patch developing over a period of just days to weeks, which can be alarming.
It’s important to note that unlike scalp alopecia areata, alopecia barbae does not typically cause changes to the fingernails such as pitting or ridging. If you are experiencing patchy beard hair loss, it’s worth seeing a doctor or dermatologist to confirm the diagnosis and rule out other possible causes such as fungal infections (tinea barbae), folliculitis, or scarring conditions like frontal fibrosing alopecia which can occasionally involve the beard.
How do You Diagnose it?
In most cases, a doctor can diagnose alopecia barbae based on a clinical examination of the beard hair loss. The characteristic smooth, round patches, exclamation mark hairs and absence of scarring or scaling are usually sufficient to make the diagnosis. In some cases, your doctor may use trichoscopy to examine the hair follicles more closely. Common trichoscopic findings in alopecia barbae include tapered hairs, yellow dots, black dots, thin regrowing hairs and exclamation mark hairs.
If there is any diagnostic uncertainty, your doctor may also take a small skin biopsy from the edge of a patch to examine under the microscope. This can help differentiate alopecia barbae from other causes of beard hair loss. Additionally, because of the well-established link between alopecia barbae and other autoimmune conditions, your doctor will usually recommend blood tests to screen for thyroid disease, diabetes and other autoimmune markers. This is particularly important as some cases of alopecia barbae have led to the discovery of previously undiagnosed thyroid disease or early diabetes.
Treatments for Alopecia Barbae
There is currently no cure for alopecia barbae and the condition can be unpredictable with spontaneous remissions and relapses. However, a number of treatments can help encourage regrowth, reduce the duration of episodes and manage symptoms. It’s worth noting that many alopecia barbae treatments are actually off-label uses of ones for scalp alopecia areata. The main treatment options for hair regrowth in alopecia barbae include:
- Corticosteroids: Steroids are the most common treatment for alopecia barbae. They work by suppressing the local immune response that is attacking the hair follicles. Intralesional injections involve injecting small amounts of corticosteroid such as triamcinolone acetonide directly into the bald patches. They are usually the first-line approach for limited alopecia barbae. Sessions are typically every 4 to 6 weeks. Topical corticosteroids (serums, creams or ointments) such as clobetasol propionate or triamcinolone acetonide can also be applied to the patches daily for up to 3-6 months. Although topical steroids are less potent than injections, they are non-invasive and suitable for use at home to manage mild to moderate cases. In severe cases, oral steroids like prednisolone may be necessary to suppress the immune system. To reduce side effects oral steroids use is usually for shorter periods of up to 3 months.
- Minoxidil: This promotes hair growth by widening blood vessels, improving blood flow to the follicle and prolonging the anagen (growth) phase of the hair cycle. Topical minoxidil can be applied to the affected areas of the beard up to twice daily. It does not address the underlying autoimmune cause but can help support and accelerate hair regrowth. It is often best to use it in combination with corticosteroids for a more comprehensive approach. Results may take several months to become visible and the treatment needs ingoing use to maintain benefit. Minoxidil does carry some side effects to be aware of, including local skin irritation and the possibility of unwanted hair growth in areas where the product inadvertently comes into contact with the skin.
- Topical Immunotherapy: Diphencyprone (DPCP) is a topical immunotherapy agent that works by deliberately causing a controlled allergic reaction on the skin. This “distracts” the immune system from attacking the hair follicles by redirecting the immune response towards the allergic reaction instead. It is typically used for more extensive or treatment-resistant cases of alopecia barbae. The treatment is applied in clinic and involves initial sensitisation followed by regular applications at increasing concentrations. Side effects include redness, swelling, itching and blistering at the application site. Results can take 3 months or more to become visible.
- JAK Inhibitors: Janus kinase (JAK) inhibitors represent a newer class of treatment for alopecia areata and barbae. These medications work by blocking specific immune signalling pathways (the JAK-STAT pathway) that are involved in the autoimmune attack on hair follicles. Oral JAK inhibitors such as baricitinib and ritlecitinib have approval for the treatment of severe alopecia areata from the FDA and MHRA. Topical tofacitinib (compounded at 2%) has also been studied specifically for beard alopecia areata with promising results, achieving complete regrowth in 22% of patients and partial regrowth in 55%. JAK inhibitors are generally reserved for more severe cases or where other treatments have failed. This is because they can carry systemic side effects and require careful monitoring.
- Platelet Rich Plasma (PRP): This procedure involves drawing a small amount of the patient’s own blood, processing it to concentrate the platelets and growth factors then injecting this concentrated plasma into the affected areas. PRP is thought to promote healing and stimulate hair follicle activity. There is sparse but promising evidence for its use in alopecia barbae. It can be a standalone treatment or more commonly use is in combination with other therapies.
Can You Get a Beard Transplant for Alopecia Barbae?
This is a common question and the short answer is that a beard transplant is generally not a great idea for alopecia barbae. This is because the condition is autoimmune in nature. As such the immune system will continue to attack hair follicles after the transplant. This means transplanted hairs are likely to be lost just as the original hairs were. However, beard transplants can be very effective for men who have naturally sparse or patchy beard growth where there is no underlying autoimmune condition,
Will Alopecia Barbae Go Away on Its Own?
One of the most challenging aspects of alopecia barbae is its unpredictability. Some men experience a single episode with complete spontaneous regrowth within months without any treatment at all. Others have recurring episodes that come and go over years. In some cases, the condition can become chronic and resistant to treatment. There are currently no reliable ways to predict how any individual case will progress. Factors that may indicate a poorer prognosis include extensive or rapidly progressing hair loss, early age of onset, a long duration of the condition before treatment, and the presence of other autoimmune disorders. Even in cases where regrowth occurs, the initial regrowth is often white or grey before gradually regaining its normal pigmentation. This is why early diagnosis and regular monitoring by a doctor are important.
When Should You See a Doctor About Beard Hair Loss?
If you notice one or more smooth, round patches of hair loss in your beard, it’s worth seeing a doctor. Whilst alopecia barbae is not physically harmful, getting a proper diagnosis is important for several reasons. Firstly, it allows you to rule out other causes of beard hair loss such as fungal infections which require different treatment. Also, the association between alopecia barbae and other autoimmune conditions means that a diagnosis can prompt screening for conditions like thyroid disease or diabetes that may otherwise go undetected. Lastly, early treatment tends to produce better outcomes than waiting for the condition to progress.
Alopecia barbae is an autoimmune condition that causes patchy hair loss in the beard. Whilst it is not physically dangerous, it can have a significant impact on self-confidence and quality of life. The good news is that there are a number of treatment options available. These include topical corticosteroids, medicated beard serums and newer therapies like JAK inhibitors. The condition can also have episodes of spontaneous regrowth, particularly in milder cases. If you notice unexplained bald patches in your beard, seek medical help early. This gives you the best chance of a good outcome and ensures you manage any underlying conditions.
We offer personalised beard growth treatments through our online skin clinic. Our doctors create custom beard growth treatments using actives such as Minoxidil, Melatonin, Caffeine and Tretinoin where appropriate. Start your virtual consultation and begin your journey to great hair today.
This article is intended for general informational purposes only and is not a substitute for medical advice, diagnosis or treatment. Always consult a qualified medical professional with any concerns about your hair or treatment options.
