Should topical steroids be applied to the full scalp or only areas of alopecia in children with alopecia?

Application of Topical Steroids in Children with Alopecia Areata

Topical steroids should be applied only to the areas of alopecia, not to the entire scalp, in children with alopecia areata. 1

Treatment Approach for Pediatric Alopecia Areata

Assessment and Initial Management

• Alopecia areata in children often presents as well-defined patches of hair loss with normal-appearing skin
• Up to 80% of patients with limited patchy hair loss of short duration (<1 year) experience spontaneous remission 1
• "No treatment" is a legitimate option for many children with limited patchy alopecia areata 1

Topical Corticosteroid Application

• When treatment is indicated, potent topical corticosteroids are the first-line therapy for children with limited patchy alopecia areata 2
• Application should be targeted specifically to the areas of hair loss:
  • Apply a thin layer of potent topical steroid (such as clobetasol propionate 0.05% cream or ointment) directly to the affected areas only 2
  • Apply twice daily to affected areas only 2
  • Treatment cycles of 6 weeks followed by 6 weeks of rest are recommended 2

Evidence for Localized Application

• In clinical trials, topical steroids have been applied specifically to affected areas:
  • In one study, clobetasol propionate was applied to one side of the scalp with vehicle to the other side, demonstrating that hair regrowth occurred only in treated areas 1
  • Another study showed that when clobetasol propionate was applied under occlusion to only one side of the scalp, no hair regrowth occurred on the untreated side 1

Rationale for Localized Application

1. Minimizes side effects: Folliculitis is a common side effect of potent topical steroids 1
2. Reduces risk of skin atrophy: Limiting application to affected areas reduces the risk of skin atrophy, which is a consistent side effect of topical steroid therapy 1
3. Prevents unnecessary medication exposure: Children should not be exposed to more medication than necessary 1, 2

Special Considerations for Children

• Intralesional steroids are often poorly tolerated in children 1
• Many clinicians are reluctant to use aggressive treatments in children due to potential side effects 1
• The most commonly prescribed treatment for children with alopecia areata is topical steroids (69.1% of cases) 3
• Potent topical steroids have shown the best results for hair regrowth in children 3

Monitoring and Follow-up

• Monitor for side effects, particularly folliculitis and skin atrophy 1
• Assess response after 6-12 weeks of treatment
• If using occlusion techniques (plastic wrap), limit to 6 days per week to reduce side effects 4

Treatment Efficacy

• In a study of children with alopecia areata, 84.3% had some hair regrowth at 3-month follow-up 3
• Best results were seen with potent topical and intralesional steroids 3

Remember that alopecia areata has no direct impact on general health, and treatments with significant side effects should be avoided unless benefits clearly outweigh risks 2.