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

Initial Workup and Treatment for Alopecia Areata

For patients with alopecia areata, the initial workup should focus on clinical diagnosis through identification of well-defined patches of hair loss with normal-appearing skin, while treatment should be based on the extent of hair loss, with intralesional corticosteroids being the first-line treatment for limited patchy alopecia areata. 1

Diagnosis and Initial Assessment

• Clinical Features to Identify:

  • Well-defined patches of hair loss with normal-appearing skin
  • Short broken hairs ("exclamation mark hairs") at the periphery of patches
  • Absence of scarring or atrophy
  • Possible nail involvement (in approximately 10% of cases) 1

• Prognostic Factors to Assess:

  • Age of onset (childhood onset has poorer prognosis)
  • Pattern of hair loss (ophiasis pattern has worse prognosis)
  • Extent of hair loss at presentation
  • Duration of hair loss
  • Associated nail changes 1

Treatment Algorithm Based on Extent of Hair Loss

1. Limited Patchy Alopecia Areata (< 5 patches, < 3 cm diameter)

• First-line: Intralesional corticosteroids 2, 1

  • Triamcinolone acetonide (5-10 mg/mL)
  • Inject 0.05-0.1 mL just beneath the dermis
  • Monthly injections (62% achieve full regrowth)
  • Expected response: initial regrowth at ~2.4 months, cosmetically acceptable regrowth at 4 months 1

• Alternative/Adjunctive:

  • Potent topical corticosteroids (e.g., clobetasol propionate 0.05% cream/ointment)
  • Apply thin layer twice daily
  • Consider occlusion with plastic film to increase efficacy
  • Monitor for folliculitis (common side effect) 1

2. Extensive Patchy Hair Loss

• First-line: Contact immunotherapy 2, 1
  • Difenciprone (DPCP) is the preferred agent
  • Protocol: Sensitization with 2% solution, followed by weekly applications starting at 0.001%
  • Effective in <50% of patients with extensive hair loss
  • Requires multiple hospital visits over several months 2, 1

3. Alopecia Totalis/Universalis

• First-line: Contact immunotherapy (though response rates are low) 2
• Alternative: Consider JAK inhibitors (baricitinib for adults, ritlecitinib for ages 12+) for severe cases 3
• Practical solution: Wigs or hairpieces 2, 1

Important Considerations

• Spontaneous Remission: Up to 80% of patients with limited patchy hair loss of short duration (<1 year) experience spontaneous remission 2
• "No Treatment" Option: A legitimate approach for many patients, especially those with limited patchy hair loss 2, 1
• Treatment Duration: If no significant regrowth after 6 months, treatment success is less likely 1
• Psychological Impact: Consider psychological support and referral to patient support groups 1

Monitoring and Follow-up

• Assess response after 6-12 weeks of treatment
• Monitor for side effects:
  • With intralesional corticosteroids: skin atrophy
  • With topical corticosteroids: folliculitis, skin atrophy
  • With contact immunotherapy: local inflammation 2, 1

Referral Criteria for Dermatology

• Diagnostic uncertainty
• Extensive hair loss
• Severe psychological distress
• Patient desires a wig 4

The high rate of spontaneous remission in limited alopecia areata makes it difficult to assess treatment efficacy, but intralesional corticosteroids have demonstrated the most consistent results for limited patchy disease, while contact immunotherapy remains the best option for extensive disease despite its limitations.