What is the diagnosis and treatment for alopecia areata (autoimmune hair loss)?

From the Guidelines

Alopecia areata treatment should prioritize topical corticosteroids as the first-line therapy for limited disease, with intralesional corticosteroids being a suitable option for patchy hair loss of limited extent. The condition is an autoimmune disorder that causes hair loss in patches, typically on the scalp but can affect any hair-bearing area. Treatment depends on the extent of hair loss, and for small patches, triamcinolone acetonide 5-10mg/ml injected into the affected areas every 4-6 weeks is effective, as shown in a study where 62% of patients achieved full regrowth with monthly injections of triamcinolone acetonide 1. Topical minoxidil 5% solution applied twice daily can also stimulate regrowth. For extensive hair loss, systemic treatments like oral corticosteroids (prednisone 0.5-1mg/kg/day for 1-2 months with tapering) or immunosuppressants such as methotrexate (10-25mg weekly) may be necessary. Newer JAK inhibitors like tofacitinib and baricitinib have shown promising results for severe cases 2.

Some key points to consider in the treatment of alopecia areata include:

• The use of very potent topical steroids, such as 0.05% clobetasol propionate foam, which has been shown to be effective in promoting hair regrowth in some patients 2
• The potential side effects of treatment, such as folliculitis, which is a common side-effect of potent topical steroids 2
• The importance of counseling and emotional support, as the unpredictable nature of the condition can cause psychological distress, and some patients may require referral to a pediatric clinical psychologist, educational psychologist, or social worker 3
• The consideration of both the positive and negative aspects of active treatment in this chronic condition, and the need to forewarn patients of the possibility of relapse following or during initially successful treatment 3

In terms of specific treatment options, the following may be considered:

• Topical corticosteroids, such as 0.25% desoximetasone cream or 0.05% clobetasol propionate foam, for limited disease
• Intralesional corticosteroids, such as triamcinolone acetonide 5-10mg/ml, for patchy hair loss of limited extent
• Systemic treatments, such as oral corticosteroids or immunosuppressants, for extensive hair loss
• Newer JAK inhibitors, such as tofacitinib and baricitinib, for severe cases.

From the Research

Treatment Options for Alopecia Areata

• Topical corticosteroids, such as clobetasol propionate 0.05% under occlusion, have been shown to be effective in inducing hair regrowth in patients with alopecia areata totalis or universalis 4
• Systemic corticosteroids, topical immunotherapy with diphenylcyclopropenone or squaric acid dibutylester, and minoxidil may also be recommended for the treatment of alopecia areata 5, 6
• A comparison of three corticosteroid treatment regimens (topical corticosteroids, intralesional corticosteroids, and combined topical and intralesional corticosteroids) found that all three regimens were effective and safe, with no significant differences in treatment outcomes 7
• Treatment of alopecia areata is dependent on the age of the patient, as well as the extent and duration of scalp involvement, and may include customized individual treatments such as steroids, topical immunotherapy, and immunosuppressants 8

Efficacy of Treatment

• The efficacy of clobetasol propionate 0.05% under occlusion in inducing hair regrowth in patients with alopecia areata totalis or universalis was found to be 28.5% 4
• The response rates of initial and significant hair regrowth were comparable among the three corticosteroid treatment regimens (topical corticosteroids, intralesional corticosteroids, and combined topical and intralesional corticosteroids) 7
• An alopecia areata treatment duration of longer than 6 months was associated with a lower probability of significant hair regrowth 7

Adverse Effects

• A small proportion of patients experienced adverse effects from the three corticosteroid treatment regimens (topical corticosteroids, intralesional corticosteroids, and combined topical and intralesional corticosteroids) 7