How should a 28-year-old male with alopecia areata totalis presenting with patchy hair loss on the scalp, beard, eyebrows, moustache, and abdominal hair for 7 months, who is a chronic smoker (4–5 cigarettes per day), be approached in terms of treatment?

Treatment Approach for Alopecia Areata Totalis

For this 28-year-old male with alopecia areata totalis, contact immunotherapy with DPCP (diphenylcyclopropenone) is the only treatment likely to be effective, though response rates are low (<50%), and a wig should be offered as the most reliable cosmetic solution. 1

Initial Assessment and Documentation

Document the following key elements:

• Duration: 7 months (important for prognosis—longer duration predicts poorer response)
• Pattern: Totalis involving scalp, beard, eyebrows, mustache, and body hair
• Nail changes: Check for pitting, trachyonychia, or other nail dystrophy (indicates more severe disease)
• Family history: Autoimmune conditions in relatives
• Associated conditions: Screen for thyroid disease, vitiligo, atopic dermatitis
• Smoking status: 4-5 cigarettes/day (may exacerbate immune dysregulation) 2

Treatment Algorithm for Alopecia Totalis

First-Line: Contact Immunotherapy

DPCP (Diphenylcyclopropenone) Protocol 1:

• Sensitize with 2% DPCP solution to small scalp area
• After 2 weeks, begin weekly applications starting at 0.001% concentration
• Increase concentration weekly until mild dermatitis occurs
• Patient must wear hat/wig for 24 hours post-application (DPCP degrades in light)
• Continue for several months minimum

Critical Caveats:

• Only ~40-50% achieve cosmetically acceptable regrowth 1
• Requires multiple hospital visits over months
• Not widely available
• Temporary local inflammation expected; serious side effects rare
• This is the ONLY treatment with documented efficacy in totalis/universalis 1

Adjunctive Therapy

Oral Minoxidil 3, 4:

• Consider low-dose oral minoxidil (LDOM) 1-2.5 mg daily as adjunct
• Preferred over topical for extensive scalp involvement
• Prolongs anagen phase and may enhance response to immunotherapy
• Well-tolerated with minimal cardiovascular effects at low doses

Second-Line Options (If JAK Inhibitors Become Available)

JAK Inhibitors 5, 4, 6:

• Baricitinib, ritlecitinib, or deuruxolitinib (FDA/EMA approved for severe AA)
• Reserved for SALT score ≥50 (which totalis qualifies for)
• Most effective systemic option but requires insurance approval and monitoring
• Consider if contact immunotherapy fails or unavailable

What NOT to Do

Avoid these treatments in totalis 1:

• Intralesional steroids: Impractical for extensive disease
• Topical steroids alone: Insufficient for totalis
• Systemic corticosteroids: Inadequate evidence, serious side effects, high relapse rates
• PUVA: Poor response rates, high relapse rates
• Dithranol/anthralin: No convincing efficacy evidence

Wig Provision (Strength of Recommendation D) 1

Immediate action: Refer for wig fitting while pursuing treatment

• Synthetic acrylic: £50-500, needs replacement every 3-4 months, damaged by heat
• Human hair: £1000-5000, lasts 1-2 years, more natural appearance
• NHS coverage: Only if allergic to acrylic or skin condition worsened by it
• This provides immediate quality of life improvement regardless of treatment outcome

Smoking Cessation Counseling

Address smoking (4-5 cigarettes/day):

• Smoking may exacerbate autoimmune response 2
• Offer cessation support as part of holistic management
• May improve treatment response, though direct evidence limited

Setting Realistic Expectations

Critical discussion points:

• Spontaneous remission in totalis is rare
• Even with best treatment (contact immunotherapy), <50% achieve worthwhile regrowth 1
• Treatment requires months of commitment
• Relapse common even after successful regrowth
• Wig may be the most reliable long-term solution
• Psychological support essential given 7-month duration and extensive involvement

Monitoring and Follow-up

• SALT score: Document baseline (will be 100 for totalis)
• AASc score: Include eyebrow/eyelash loss and psychosocial impact 5
• Response assessment: Every 3 months during active treatment
• Screen for depression/anxiety: High psychosocial burden with totalis 2, 6

The harsh reality: Alopecia totalis has poor prognosis with current treatments. Contact immunotherapy offers the only realistic chance of regrowth but succeeds in less than half of patients. A high-quality wig provides immediate, reliable cosmetic rehabilitation while pursuing treatment. 1