What are the treatment options for alopecia areata?

Treatment Options for Alopecia Areata

Intralesional corticosteroid injections (triamcinolone acetonide) are the first-line treatment for limited patchy alopecia areata, with a 62% success rate. 1

Understanding Alopecia Areata

Alopecia areata is a non-scarring autoimmune condition causing hair loss that affects approximately 2% of the population worldwide 2. It can present as:

• Limited patchy hair loss
• Extensive patchy hair loss
• Total scalp hair loss (alopecia totalis)
• Complete body hair loss (alopecia universalis)

Treatment Algorithm Based on Disease Extent

Limited Patchy Hair Loss

1. First-line treatment:

   • Intralesional corticosteroid injections (triamcinolone acetonide) 1, 2
   • These are more effective than topical steroids due to better penetration to the dermis where hair follicles reside 2

2. Alternative options:

   • Topical corticosteroids (if intralesional injections are not tolerated) 1, 2
   • Consider "no treatment" approach, as up to 80% of patients with limited patchy hair loss of short duration (<1 year) experience spontaneous remission 1, 3

Extensive Patchy Hair Loss

1. First-line options:

   • Contact immunotherapy with diphenylcyclopropenone (DPCP) - 50-60% response rate 1
   • Be aware of side effects: occipital/cervical lymphadenopathy, severe dermatitis, and pigmentary complications in racially pigmented skin

2. Second-line options:

   • Topical minoxidil 5% (limited efficacy with 32-33% response rate) 1
   • Methotrexate (15-25 mg/week) with or without prednisolone 1
   • Sulfasalazine (partial response but high relapse rate) 1

3. Other systemic options:

   • Cyclosporine (limited evidence for severe disease) 1
   • Systemic corticosteroids (pulse or continuous therapy) 1, 4
     • Note: While systemic corticosteroids can achieve hair regrowth in about 39% of patients with severe alopecia areata, relapse typically occurs when therapy is discontinued 4

Special Considerations

• Children: Intralesional corticosteroids are often poorly tolerated; clinicians may be reluctant to use aggressive treatments like contact immunotherapy 1
• Treatment duration: AA treatment duration longer than 6 months is associated with lower probability of significant hair regrowth 5
• Combination therapy: Combined topical and intralesional corticosteroids show comparable efficacy to either treatment alone 5

Non-Pharmacological Approaches

• Psychological support and referral to patient support groups 1
• Wigs or hairpieces for extensive hair loss 1
  • Acrylic wigs: cheaper and easier to maintain
  • Human hair wigs: better fit and wider range of activities

Important Caveats and Pitfalls

1. Limited evidence base: A Cochrane review found that few treatments for alopecia areata have been well evaluated in randomized trials, with most being small and poorly reported 6

2. Misdiagnosis risk: Alopecia areata can be misdiagnosed as trichotillomania or tinea capitis, leading to inappropriate treatment 1

3. Relapse after treatment: Hair loss commonly recurs after discontinuation or tapering of corticosteroid therapy 4

4. Treatment expectations: Even with treatment, there is a high rate of relapse, and patients should be counseled about realistic outcomes 1, 6

5. Monitoring: Follow-up visits with repeat photography are important to document treatment response 1

The treatment approach should be guided by the extent and duration of hair loss, with consideration of the high spontaneous remission rate in limited disease and the psychological impact of this condition.