What are the treatment options for managing hair fall (alopecia)?

Treatment Options for Hair Fall (Alopecia)

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

Types of Alopecia and First-Line Treatments

Alopecia Areata

• First-line treatment: Intralesional corticosteroid injections 1
• Alternative first-line options:
  • Topical minoxidil 5% solution (results typically take 3-6 months) 1, 2
  • Topical corticosteroids (if intralesional steroids aren't tolerated) 1
• Important note: For limited patchy hair loss, "no treatment" is a reasonable option due to high spontaneous remission rates (up to 80% for cases <1 year duration) 1

Androgenetic Alopecia (Pattern Hair Loss)

• First-line treatment: Topical minoxidil 5% solution 3, 4
• For men only: Oral finasteride 1mg daily (80% efficacy rate compared to 52% for topical minoxidil) 3
• Recent alternative: Low-dose oral minoxidil (1mg daily) shows comparable efficacy to topical formulations with better compliance 5, 6

Proper Application of Topical Minoxidil

1. Apply twice daily (morning and night)
2. Nighttime application should be 2-4 hours before bedtime to allow drying
3. Use 1mL per application directly on scalp in affected areas
4. Allow to remain on scalp for at least 4 hours before washing 2

Second-Line Treatment Options for Alopecia Areata

For cases not responding to first-line therapy:

• Contact immunotherapy: 50-60% response rate for extensive patchy hair loss 1
• Systemic options:
  • Methotrexate (15-25 mg/week) with or without prednisolone 1
  • Sulfasalazine 1
  • Cyclosporine (limited long-term use due to side effects) 1
  • Systemic corticosteroids (pulse or continuous therapy) 1

Diagnostic Approach

For proper treatment selection, diagnosis is critical:

• Diagnostic tools:
  • Pull test: Gently tug on hair cluster to assess fragility and shedding
  • Trichoscopy: Magnified examination of scalp and hair follicles
  • Hair count: Quantitative assessment before and after treatment 1

Side Effects and Monitoring

Topical Minoxidil

• Common side effects: Scalp irritation, itching
• Rare side effect: Unwanted hair growth (especially in women)
• Avoid eye contact 2

Oral Finasteride (Men Only)

• Side effects: Decreased libido (reported in 6 of 40 patients)
• Laboratory changes: Increased total testosterone, decreased free testosterone and PSA 3

Intralesional Corticosteroids

• Generally well-tolerated
• May be poorly tolerated in children 1

Special Considerations

1. Hair styling and chemical treatments:

   • Hair sprays, mousses, gels can be used with minoxidil
   • Allow minoxidil to dry before applying styling products
   • For hair coloring/perming: Wash off minoxidil before chemical treatments
   • Avoid minoxidil for 24 hours after chemical treatments 2

2. Children:

   • Limited treatment options as intralesional corticosteroids are often poorly tolerated
   • Clinicians often avoid aggressive treatments like contact immunotherapy 1

3. Practical solutions for extensive hair loss:

   • Wigs or hairpieces
   • Acrylic wigs: More affordable, easier maintenance
   • Human hair wigs: Better fit, wider range of activities 1

Treatment Algorithm

1. Identify type of alopecia:

   • Patchy (alopecia areata)
   • Diffuse pattern (androgenetic alopecia)
   • Diffuse non-pattern (telogen effluvium)

2. For alopecia areata:

   • Limited patches: Intralesional corticosteroids
   • If not tolerated: Topical corticosteroids or minoxidil 5%
   • Extensive patches: Consider contact immunotherapy or systemic options

3. For androgenetic alopecia:

   • Men: Topical minoxidil 5% or oral finasteride 1mg daily
   • Women: Topical minoxidil 5%
   • Poor compliance with topical: Consider low-dose oral minoxidil

4. For all patients:

   • Regular follow-up to assess response
   • Photography to document changes
   • Consider quality of life measures 1

Common Pitfalls to Avoid

• Inconsistent application: Topical minoxidil requires consistent twice-daily application for effectiveness
• Insufficient treatment duration: Results may take 2-4 months to appear; some patients need at least 4 months before seeing results 2
• Unrealistic expectations: Hair regrowth varies between individuals; treatment won't work for everyone
• Stopping treatment prematurely: Hair loss will recur if treatment is discontinued
• Overuse: Using more than recommended amount doesn't improve results and increases side effect risk 2