What are the treatment options for facial alopecia?

Treatment Options for Facial Alopecia

For facial alopecia, intralesional corticosteroid injections are the most effective first-line treatment, particularly for limited patchy hair loss in cosmetically sensitive areas such as eyebrows. 1

Treatment Algorithm Based on Pattern of Hair Loss

Limited Patchy Facial Alopecia

• Intralesional corticosteroids are the treatment of choice for limited patchy facial alopecia, with evidence supporting their efficacy 1
• Hydrocortisone acetate (25 mg/mL) or triamcinolone acetonide (5-10 mg/mL) can be injected just beneath the dermis in the upper subcutis 1
• An injection of 0.05-0.1 mL will produce a tuft of hair growth about 0.5 cm in diameter 1
• Response rates of up to 62% have been reported with monthly injections of triamcinolone acetonide 1

Eyebrow Alopecia

• Intralesional corticosteroids are particularly suitable for cosmetically sensitive sites like eyebrows 1
• Prostaglandin F2α analogues (latanoprost, bimatoprost) may be considered for eyelash alopecia, with one study showing 45% of patients achieved complete or moderate regrowth of eyelashes when treated with topical latanoprost for 2 years 1

Extensive Facial Alopecia

• Contact immunotherapy is recommended for extensive patchy hair loss 1
• The protocol involves sensitization with 2% solution of diphenylcyclopropenone (DPCP) followed by weekly applications of increasing concentrations until a mild dermatitis reaction is obtained 1
• This treatment requires multiple hospital visits over several months and stimulates cosmetically worthwhile hair regrowth in <50% of patients 1

Second-Line Treatment Options

• Topical minoxidil (1-5%):

  • Has been used for alopecia areata with mixed results 1
  • Early studies showed some efficacy, but subsequent controlled trials reported response rates of only 32-33% 1
  • Limited evidence for sustained benefit in facial alopecia 2, 3

• Dithranol (anthralin):

  • Limited evidence for efficacy in facial alopecia 1
  • Only about 18% of patients with extensive alopecia areata achieve cosmetically worthwhile hair regrowth 1
  • Must be applied frequently and in high enough concentration to produce a brisk irritant reaction 1
  • Staining of hair limits its use in fair-haired individuals 1

Systemic Options for Refractory Cases

• Methotrexate (15-25 mg per week):

  • May be considered in severe cases unresponsive to other treatments 1
  • A retrospective review showed 14 of 22 patients with alopecia totalis/universalis achieved complete regrowth 1

• Sulfasalazine:

  • Some evidence of efficacy in uncontrolled studies 1
  • In one study of 26 patients with severe alopecia areata, 15 showed partial or complete recovery, though 10 later relapsed 1

• Ciclosporin:

  • Has immunosuppressive and hypertrichotic properties 1
  • Evidence suggests it can stimulate hair regrowth in some patients 1
  • Side effects are a major consideration, and the cosmetically worthwhile response rate may be too low to justify the risks 1

Important Considerations and Caveats

• The tendency for spontaneous remission in alopecia areata means that not treating is sometimes the best option 1

• Treatment selection should be guided by:

  • Extent of hair loss (patchy vs. extensive) 1
  • Location (eyebrows, beard, scalp) 1
  • Duration of disease 1

• Common pitfalls to avoid:

  • Continuous or pulsed systemic corticosteroids and PUVA have been used but cannot be recommended due to potentially serious side effects and inadequate evidence of efficacy 1
  • Topical tacrolimus showed no response in a case series of 11 patients with moderate to severe alopecia areata treated for 24 weeks 1
  • Treatments that were ineffective in controlled trials include oral zinc and isoprinosine 1

• For patients with extensive facial alopecia where treatments are ineffective, cosmetic camouflage may be the most practical solution 1