What are the treatment options for alopecia areata?

Treatment Options for Alopecia Areata

Intralesional corticosteroids are the first-line treatment for limited patchy alopecia areata, while contact immunotherapy is recommended for extensive patchy hair loss, although success rates are lower for alopecia totalis/universalis. 1, 2

Treatment Algorithm Based on Disease Extent

Limited Patchy Hair Loss (<5 patches, <3cm diameter)

• First-line: Intralesional corticosteroids 1, 2

  • Triamcinolone acetonide 5-10 mg/mL
  • Inject 0.05-0.1 mL per site just beneath the dermis in the upper subcutis
  • Multiple injections may be given (limited by patient discomfort)
  • Success rate: approximately 62% of patients achieve regrowth 2
  • Treatment typically involves monthly injections until satisfactory response
  • Each injection may produce a tuft of hair growth about 0.5 cm in diameter 1

• Alternative/adjunctive options:

  • Potent topical corticosteroids (though evidence of efficacy is limited) 1
  • Short-contact anthralin therapy (especially useful in children) 3
  • Topical minoxidil (limited success in stimulating regrowth) 3

Extensive Patchy Hair Loss

• First-line: Contact immunotherapy 1, 2
  • Agents: Diphenylcyclopropenone (DPCP) preferred over squaric acid dibutyl ester (SADBE)
  • Protocol: Initial sensitization with 2% solution, followed by weekly applications starting at 0.001% concentration
  • Increase concentration at each treatment until mild dermatitis reaction is obtained
  • Response rate: 50-60% achieve worthwhile response, though range is wide (9-87%) 1
  • Treatment duration: Consider continuing for at least 6 months, potentially up to 32 months for maximum benefit 1

Alopecia Totalis/Universalis

• First-line: Contact immunotherapy 1

  • Only treatment likely to be effective, though response rates are lower than for patchy disease
  • Response rate: approximately 17% 1
  • Treatment beyond 9 months may not improve outcomes in these severe cases

• Newer options (for severe cases):

  • JAK inhibitors (baricitinib, ritlecitinib) for severe disease 4
  • Baricitinib results in increased short and long-term hair regrowth compared to placebo (high-certainty evidence) 5

Monitoring and Side Effects

Intralesional Corticosteroids

• Common side effects:
  • Skin atrophy at injection sites (consistent side effect, particularly with triamcinolone) 1, 2
  • Pain during injection 6
• Monitoring: Assess response after 6-12 weeks of treatment 2

Contact Immunotherapy

• Common side effects:
  • Occipital/cervical lymphadenopathy (usually temporary)
  • Severe dermatitis (risk minimized by careful titration)
• Uncommon side effects:
  • Urticaria (may be severe)
  • Vitiligo
  • Pigmentary complications (hyper/hypopigmentation) in racially pigmented skin 1

Prognostic Factors

• Favorable prognosis:

  • Limited patchy hair loss of short duration (<1 year)
  • Spontaneous remission occurs in up to 80% of these cases 2

• Poor prognostic factors:

  • Extensive hair loss at presentation
  • Presence of nail changes
  • Early onset
  • Positive family history
  • Long disease duration (>6 months) 7

Important Caveats

1. Treatment expectations: Results take months to appear, and recurrence is common after treatment cessation 6

2. Children considerations:

   • Intralesional corticosteroids are often poorly tolerated in children
   • Many clinicians are reluctant to use aggressive treatments like contact immunotherapy in children 1
   • Short-contact anthralin therapy may be particularly useful in children 3

3. Psychological impact:

   • Hair loss can cause significant emotional distress
   • Consider psychological support and referral to patient support groups 2

4. Treatment limitations:

   • No treatment alters the unpredictable course of alopecia areata definitively 3
   • Different treatments provoke regrowth to variable extents but may not prevent further hair loss 3
   • For extensive hair loss, wigs or hairpieces may be a practical solution 2

5. Treatment duration:

   • AA treatment duration longer than 6 months is associated with lower probability of significant hair regrowth 7
   • For contact immunotherapy, treatment should be continued for at least 6 months before determining efficacy 1