What is the treatment protocol for alopecia areata?

Treatment Protocol for Alopecia Areata

For patients with alopecia areata, intralesional corticosteroids are the first-line treatment for limited patchy hair loss, while contact immunotherapy is the most effective option for extensive patchy hair loss or alopecia totalis/universalis, though with limited success rates. 1

Initial Assessment and Management

• Alopecia areata has no direct impact on general health, making observation without treatment a legitimate option, especially for mild cases where spontaneous remission occurs in up to 80% of patients with limited patchy hair loss of short duration (<1 year) 1
• Patients should be counseled that regrowth cannot be expected within 3 months of the development of any individual patch 1
• Psychological support may be necessary as alopecia areata can cause considerable psychological and social disability 1

Treatment Algorithm Based on Disease Severity

Limited Patchy Hair Loss

1. First-line: Intralesional corticosteroids (Strength of recommendation B, Quality of evidence III) 1

   • Hydrocortisone acetate (25 mg/mL) or triamcinolone acetonide (5-10 mg/mL) injected just beneath the dermis in the upper subcutis 1
   • Dosage: 0.05-0.1 mL per injection, producing a tuft of hair growth about 0.5 cm in diameter 1
   • Response rate: Up to 62% of patients achieve full regrowth with monthly injections 1
   • Best for: Patients with fewer than five patches of <3 cm in diameter 1
   • Caution: Skin atrophy is a consistent side effect, particularly with triamcinolone 1

2. Alternative options:

   • Potent topical corticosteroids (Strength of recommendation C, Quality of evidence III) - widely used but limited evidence of efficacy 1
   • Topical minoxidil - safe but no convincing evidence of effectiveness 1
   • Dithranol (anthralin) - safe but limited evidence of efficacy 1

Extensive Patchy Hair Loss

1. First-line: Contact immunotherapy (Strength of recommendation B, Quality of evidence II-ii) 1
   • Agent: Diphenylcyclopropenone (DPCP) is most commonly used (more stable in solution) 1
   • Protocol: Sensitization with 2% DPCP, followed by weekly applications starting at 0.001% and increasing concentration until mild dermatitis is achieved 1
   • Response rate: 50-60% of patients achieve worthwhile response, though range varies widely (9-87%) 1
   • Duration: Continue treatment for at least 6 months; some patients may benefit from treatment up to 32 months 1
   • Side effects: Lymphadenopathy, dermatitis, rarely urticaria or vitiligo 1

Alopecia Totalis/Universalis

1. First-line: Contact immunotherapy (Strength of recommendation C) 1

   • Only treatment likely to be effective, though response rates are lower (approximately 17%) 1
   • Consider discontinuing if no response after 9 months 1

2. Alternative: Wig or hairpiece (Strength of recommendation D) 1

   • Most effective solution for extensive hair loss 1
   • Options include acrylic wigs (cheaper, easier maintenance) or bespoke real hair wigs (better fit, more natural appearance) 1

Special Considerations

• Children: May be treated similarly to adults, but intralesional corticosteroids are often poorly tolerated, and many clinicians are reluctant to use aggressive treatments like contact immunotherapy 1
• Psychological impact: Consider referral for psychological support, especially for children showing behavioral changes (withdrawal, low self-esteem, failing at school) 1
• Treatment duration: Do not change any topical treatment sooner than 3 months after starting; early regrowth may first appear at 3 months, while cosmetic regrowth may take a year or more 2
• Maintenance therapy: Increases likelihood of maintaining cosmetic hair growth, though patches may still come and go 2

Treatment Pitfalls and Caveats

• No treatment has been shown to alter the long-term course of the disease 1
• High spontaneous remission rate makes it difficult to assess treatment efficacy, particularly in mild forms 1
• Patients with extensive disease tend to be resistant to all forms of treatment 1
• 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
• Recent developments include JAK-STAT inhibitors (baricitinib, ritlecitinib), which are now approved in some regions for severe alopecia areata, but long-term data is still limited 3