What are the treatment options for Alopecia Areata?

Treatment Options for Alopecia Areata

Intralesional corticosteroid injections are the first-line treatment for limited patchy alopecia areata, with a success rate of approximately 62% of patients achieving regrowth. 1

First-Line Treatment Options

Limited Patchy Alopecia Areata

1. Intralesional corticosteroids

   • Gold standard for limited patchy alopecia areata
   • Success rate: ~62% of patients achieve regrowth 1
   • More effective than topical steroids due to better dermal penetration where hair follicles reside 2
   • Limitation: Pain during procedure 2

2. Topical corticosteroids

   • Alternative if intralesional injections are not tolerated
   • Moderate efficacy in mild AA with common recurrence after treatment cessation 2
   • Recommended for children and adults with mild AA who cannot tolerate injections 2
   • Evidence for efficacy is limited compared to intralesional options 1

3. Topical minoxidil 5% solution

   • Results typically take 3-6 months to become visible
   • Hair regrowth effects last up to 48 weeks in clinical trials
   • May cause scalp irritation 1
   • Evidence suggests topical minoxidil 1% and 2% may increase short-term hair regrowth compared to placebo (RR 2.31) 3

4. Consider "no treatment" option

   • Appropriate for limited patchy hair loss
   • High rate of spontaneous remission (up to 80% of patients with limited patchy hair loss of <1 year duration) 1

Second-Line and Alternative Treatment Options

For Extensive Patchy Hair Loss

1. Contact immunotherapy

   • Recommended for extensive patchy hair loss
   • Agents: diphenylcyclopropenone
   • Response rate: 50-60% achieve worthwhile response
   • Side effects: occipital/cervical lymphadenopathy, severe dermatitis, pigmentary complications in racially pigmented skin 1

2. Systemic treatments for moderate-to-severe disease

   • JAK inhibitors

     • Baricitinib (JAK 1/2 inhibitor): EMA-approved for adults with severe AA
       • High-certainty evidence shows increased short-term and long-term hair regrowth compared to placebo (RR 7.54 and 8.49 respectively) 3, 4
     • Ritlecitinib (JAK 3/TEC inhibitor): EMA-approved for individuals aged 12 and older 4

   • Other systemic options (off-label)

     • Methotrexate (15-25 mg/week) with/without prednisolone
       • Retrospective data: 14 of 22 patients with AT/AU achieved complete regrowth 1
     • Sulfasalazine: Partial response but high relapse rate 1
     • Cyclosporine: Limited evidence of efficacy in severe disease; side effects limit long-term use 1, 4
     • Systemic corticosteroids: Used as pulse or continuous therapy
       • Monthly oral prednisolone pulses (300 mg) showed cosmetically acceptable hair growth in 58.3% of patients with widespread AA 5
       • Concerns about side effects vs. efficacy ratio 1
     • Azathioprine: Used off-label 4

3. Adjunctive treatments

   • Prostaglandin F2α analogues (latanoprost, bimatoprost)
     • Mixed results: One study showed 45% achieved complete/moderate regrowth after 2 years
     • Other studies show minimal response in shorter timeframes 1
   • Oral minoxidil: Considered adjuvant therapy with limited efficacy data 4
   • Dithranol (anthralin): Limited efficacy (18% achieve cosmetically worthwhile regrowth) 1

Special Considerations

For Children

• Intralesional corticosteroids often poorly tolerated
• Many clinicians reluctant to use aggressive treatments like contact immunotherapy
• Topical corticosteroids may be preferred 1
• Ritlecitinib is approved for individuals aged 12 and older with severe AA 4

For Extensive Hair Loss

• Wigs or hairpieces are practical solutions
  • Acrylic wigs: Cheaper and easier to maintain
  • Human hair wigs: Better fit and wider range of activities 1

Treatment Selection Algorithm

1. Assess disease severity:

   • Limited patchy AA: <20% scalp involvement
   • Moderate-to-severe AA: ≥20% scalp involvement (SALT score) 4

2. For limited patchy AA:

   • First choice: Intralesional corticosteroids
   • If not tolerated: Topical corticosteroids or topical minoxidil 5%
   • Consider "no treatment" if duration <1 year due to high spontaneous remission rate

3. For extensive/severe AA, AT, or AU:

   • First choice for adults: Baricitinib (JAK inhibitor)
   • First choice for ages 12+: Ritlecitinib
   • Alternative options: Methotrexate, cyclosporine, systemic corticosteroids, or contact immunotherapy

Common Pitfalls and Caveats

• Unrealistic expectations: Inform patients that treatment response varies and may take months to become visible
• Discontinuation of treatment: Many treatments require continuous use to maintain results, with high relapse rates after cessation
• Overlooking psychological impact: Consider psychological support and referral to patient support groups 1
• Inadequate follow-up: Regular assessment with repeat photography to document changes is important 1
• Limited evidence base: Despite numerous treatment options, many have limited high-quality evidence supporting their efficacy 3