Alopecia areata: 5 patterns seen in clinic

One of the things I have come to value most in clinic is the ability to step back and look for patterns. When you work closely with clients over time, you begin to notice that even when each case feels very different at first, there are often recurring themes underneath. This is particularly true when it comes to alopecia areata.

On the surface, alopecia can feel unpredictable. Hair may fall out suddenly, regrowth can be slow or inconsistent, and it is not always clear what has triggered it. For many, this creates a cycle of trying different approaches without really understanding what the body is responding to.

It was something I experienced myself as well, and I remember how confusing that felt at the time. But looking back now, I can see how many of these underlying factors were present for me too. It was only when I started to address them properly, rather than focusing on the hair alone, that things began to shift.

When you begin to look a little deeper, the picture often becomes clearer. Not in a simplistic way, and not as a single cause, but as a set of contributing factors that shape the internal environment in which hair follicles exist.

Over time, I have found that many clients tend to fall into a combination of a few key patterns.

The hidden infection

For some clients, there is an underlying infectious burden that has not been fully addressed.

This might present as ongoing digestive symptoms, a history of travel, or more subtle signs that something is not quite right within the gut. In these cases, parasites, bacteria, or other microbes can contribute to ongoing immune activation.

There is growing research exploring the connection between the gut microbiome and immune-mediated conditions, including alopecia areata, with changes in microbial balance being associated with altered immune signalling.

In clinic, this is something I often explore through stool testing, which can help to identify imbalances such as bacterial overgrowth, opportunistic organisms, or, in some cases, parasites that may otherwise go unnoticed.

Through mechanisms such as molecular mimicry and histamine signalling, this ongoing immune activation can contribute to dysregulation, where the immune system begins to target tissues it would normally leave alone, including the hair follicle.

Nutrient deficiencies and methylation issues

This is often the client who appears to be doing everything “right” nutritionally, yet is still experiencing hair loss.

When we look more closely, there are often deficiencies or imbalances in key nutrients such as iron, zinc, and B vitamins. These nutrients play essential roles in energy production, repair processes, and methylation pathways.

In some cases, it is not just about what someone is eating, but what they are able to digest and absorb. Low stomach acid, reduced pancreatic enzyme output, or issues with bile flow can all impact how effectively nutrients are broken down and utilised.

This can contribute not only to nutrient deficiencies but also to impaired methylation and, in some cases, increased immune reactivity. Poorly digested proteins, for example, may place additional strain on the immune system and potentially act as a trigger in susceptible individuals.

Hair follicles are highly metabolically active structures. When the body does not have the resources it needs, this can be reflected in slower or less stable regrowth.

The chronic stress picture

Chronic stress is one of the most common drivers I see in clinic, but it does not always look the way people expect.

It is not just about obvious or acute stress. More often, it is the client who appears to be coping on the surface, but is internalising a great deal, taking on too much, and not fully processing or releasing what they have been through.

This was something I experienced myself for many years. Looking back, I can see how much I was holding, and it was only when I began to address this, finding ways to process emotions and change how my body responded to stress, that things started to shift and my stress levels began to normalise.

Physiologically, ongoing stress can alter hormone signalling, affect the nervous system, and disrupt the hair growth cycle itself. Over time, follicles may be pushed out of the active growth phase more quickly, and regrowth can become slower or less consistent as a result.

The gut barrier

There is often a strong gut component. An imbalanced microbiome or a compromised gut lining can influence immune regulation in a significant way. When the gut barrier is not functioning as it should, the immune system is exposed to a greater number of triggers, which can contribute to ongoing inflammation and dysregulation.

In clinic, this is something I frequently see reflected in stool testing. Many of my alopecia clients show lower levels of beneficial short-chain fatty acids such as butyrate, which play an important role in maintaining the integrity of the gut lining and regulating inflammation.

At the same time, markers such as secretory IgA (SIgA) can be elevated, which suggests that the immune system within the gut is more activated and responding to ongoing triggers. I also often see low levels of Akkermansia, a key species involved in supporting the gut lining and mucosal barrier.

When you start to put these pieces together, it helps to build a clearer picture. Not just that the gut barrier may be impaired, but also why.

In the context of alopecia areata, this ongoing immune activation can contribute to dysregulation, where the immune system begins to target the hair follicle.

Mould and toxic load

Another pattern I see, often slightly further down the line, is a higher overall toxic burden, particularly linked to environmental exposures such as mould.

There is not yet a clear or direct link in the research between mould exposure and alopecia areata specifically. However, in clinic, I have found that when we have explored other key areas such as gut health, nutrient deficiencies, and stress, and progress still feels limited, this is sometimes a piece worth considering.

When we investigate further, often through mycotoxin testing, mould can emerge as a contributing factor.

These exposures can influence immune signalling, increase oxidative stress, and place additional demand on detoxification pathways. Over time, this can disrupt immune balance and affect the environment in which hair follicles function, making consistent regrowth more difficult.

It is rarely just one thing

What is important to emphasise is that most clients are not neatly placed into one category. More often than not, there is an overlap. A degree of gut dysfunction alongside nutrient depletion, or chronic stress layered on top of an already sensitised immune system. This is often why progress can feel slow or confusing when you are trying to approach it in a fragmented way. 

The work, therefore, is not simply about trying to stimulate hair growth directly. It is about understanding what the body is responding to, where there may be ongoing imbalance, and gradually addressing those factors in a structured and consistent way.

This is where a more personalised approach becomes so important. Because when you begin to work with the body in this way, rather than against it, you create the conditions for hair to grow back in a way that is more stable and sustainable over time.

If your hair is not growing back as you expected, it does not necessarily mean that nothing is working. More often, it suggests that there is a piece of the picture that has not yet been fully uncovered. And sometimes, that shift in perspective can make all the difference.

References

Severino A, Porcari S, Rondinella D, Capuano E, Rozera T, Kaitsas F, Gasbarrini A, Cammarota G, Ianiro G. The Multi-Faceted Role of Gut Microbiota in Alopecia Areata. Biomedicines. 2025 Jun 4;13(6):1379. doi: 10.3390/biomedicines13061379. PMID: 40564097; PMCID: PMC12189539.

Liu Z and Liu X (2023) Gut microbiome, metabolome and alopecia areata. Front. Microbiol. 14:1281660. doi: 10.3389/fmicb.2023.1281660.

Ahn D, Kim H, Lee B, Hahm DH. Psychological Stress-Induced Pathogenesis of Alopecia Areata: Autoimmune and Apoptotic Pathways. Int J Mol Sci. 2023 Jul 20;24(14):11711. doi: 10.3390/ijms241411711. PMID: 37511468; PMCID: PMC10380371.

Park H, Kim CW, Kim SS, Park CW. The therapeutic effect and the changed serum zinc level after zinc supplementation in alopecia areata patients who had a low serum zinc level. Ann Dermatol. 2009 May;21(2):142-6. doi: 10.5021/ad.2009.21.2.142. Epub 2009 May 31. PMID: 20523772; PMCID: PMC2861201.

Carrington AE, Maloh J, Nong Y, Agbai ON, Bodemer AA, Sivamani RK. The Gut and Skin Microbiome in Alopecia: Associations and Interventions. J Clin Aesthet Dermatol. 2023 Oct;16(10):59-64. PMID: 37915336; PMCID: PMC10617895.