What is the initial workup and treatment for a patient presenting with alopecia areata?

Initial Workup and Treatment for Alopecia Areata

For patients presenting with alopecia areata, the initial workup should be minimal, with most cases requiring no laboratory investigations, and treatment should begin with intralesional corticosteroids for limited patchy hair loss, as this has the best evidence for effectiveness with acceptable safety. 1

Diagnosis

The diagnosis of alopecia areata is typically made clinically based on characteristic findings:

• Well-defined patches of hair loss with normal-appearing skin
• Short broken hairs ("exclamation mark hairs") at the periphery of expanding patches
• No scarring or atrophy of the affected skin
• Possible nail involvement in about 10% of cases 1

Differential Diagnosis

Several conditions may mimic alopecia areata and should be ruled out:

1. Trichotillomania: Distinguished by incomplete hair loss and firmly anchored broken hairs that remain in anagen phase
2. Tinea capitis: Shows subtle inflammation and scaling
3. Early scarring alopecia: Look for signs of scarring/atrophy
4. Telogen effluvium: More diffuse hair loss pattern
5. Anagen effluvium: Drug-induced hair loss
6. Systemic lupus erythematosus: Look for other signs of lupus
7. Secondary syphilis: Consider risk factors 1

Diagnostic Tools

• Dermoscopy: Helpful to identify yellow dots, which indicate active disease progression 1
• Skin biopsy: Rarely needed but can be useful when diagnosis is uncertain 1

Laboratory Investigations

Investigations are unnecessary in most cases of alopecia areata. 1

When the diagnosis is in doubt, consider:

• Fungal culture (if tinea capitis is suspected)
• Skin biopsy (if diagnosis remains unclear)
• Serology for lupus erythematosus (if suspected)
• Serology for syphilis (if risk factors present) 1

Despite the increased frequency of autoimmune diseases in patients with alopecia areata, routine screening for autoimmune conditions is not recommended 1.

Treatment Algorithm

1. Limited Patchy Alopecia Areata (< 50% scalp involvement)

First-line treatment:

• Intralesional corticosteroids: Triamcinolone acetonide (5-10 mg/mL) injected into the affected areas 1
  • Inject 0.05-0.1 mL just beneath the dermis in the upper subcutis
  • Each injection produces a tuft of hair growth about 0.5 cm in diameter
  • Repeat every 4-6 weeks as needed
  • Response rate: Up to 62% achieve full regrowth 1

Alternative/adjunctive treatments:

• Potent topical corticosteroids (e.g., clobetasol propionate 0.05%)
  • Limited evidence of efficacy but widely used
  • Consider occlusive application for better penetration 1
• Minoxidil solution (2% or 5%)
  • Limited evidence but safe to use as adjunctive therapy 1

2. Extensive Alopecia Areata (>50% scalp involvement), Alopecia Totalis, or Alopecia Universalis

Management options:

• Consider referral to dermatology
• Contact immunotherapy (where available)
• Wigs or hairpieces as a practical solution 1
• Newer JAK inhibitors (baricitinib, ritlecitinib) may be considered in severe cases, though these were not available when the guidelines were published 2, 3

Prognosis and Patient Counseling

• Spontaneous remission occurs in up to 80% of patients with limited patchy hair loss of short duration (<1 year) 1
• Regrowth typically cannot be expected within 3 months of development of any individual patch 1
• Poor prognostic factors include:
  • Childhood onset
  • Ophiasis pattern (hair loss at scalp margin)
  • Extensive hair loss at presentation
  • Long duration of hair loss
  • Associated nail changes 1

Important Considerations and Pitfalls

1. Avoid hazardous treatments: Alopecia areata has no direct impact on general health, so treatments with significant side effects should be avoided unless benefits clearly outweigh risks 1

2. Psychological impact: The condition can cause significant psychological distress despite not affecting physical health. Consider psychological support and referral to patient support groups 1

3. Manage expectations: No treatment has been shown to alter the long-term course of the disease, and relapse is common even after successful treatment 1

4. Children with alopecia areata: May require special consideration and psychological support. Intralesional steroids may be poorly tolerated in children 1

5. "No treatment" is a legitimate option: Particularly for mild cases with good prognostic factors, where spontaneous remission is likely 1