What is the drug of choice for treating alopecia areata?

Drug of Choice for Alopecia Areata

For alopecia areata, intralesional corticosteroids are the drug of choice for limited patchy hair loss, while contact immunotherapy is recommended for extensive patchy hair loss. 1

Treatment Selection Based on Disease Extent

Limited Patchy Hair Loss

• First-line: Intralesional corticosteroids (triamcinolone acetonide 5-10 mg/mL) 1
  • Most effective for patients with fewer than five patches, each less than 3 cm in diameter 1, 2
  • Success rates of up to 62% have been reported with monthly injections 1, 2
  • Administer 0.05-0.1 mL per injection just beneath the dermis in the upper subcutis 1
  • Each injection produces a tuft of hair growth approximately 0.5 cm in diameter 1
  • Effect typically lasts about 9 months 2

Extensive Patchy Hair Loss

• First-line: Contact immunotherapy (diphenylcyclopropenone [DPCP]) 1
  • Best-documented treatment for severe alopecia areata 1
  • Stimulates cosmetically worthwhile hair regrowth in <50% of patients 1
  • Requires multiple hospital visits over several months 1
  • May cause temporary local inflammation, but serious side effects are rare 1

Alopecia Totalis/Universalis

• First-line: Contact immunotherapy 1
  • Only treatment likely to be effective, though response rates are lower than for patchy hair loss 1
  • Consider that no treatment is also a legitimate option due to poor prognosis 1

Alternative Treatments

• Topical corticosteroids: Widely prescribed but limited evidence of efficacy 1

  • Very potent topical steroids (e.g., clobetasol propionate) may be considered 1
  • Folliculitis is a common side effect 1

• JAK inhibitors: Emerging treatment option for severe cases 3

  • Baricitinib and ritlecitinib have received FDA approval 3
  • Consider for refractory cases not responding to conventional therapy 3

• Systemic corticosteroids: Not recommended for routine use due to potential serious side effects and inadequate evidence of efficacy 1

  • Pulsed administration may be considered in select cases of widespread alopecia areata 4

Treatment Considerations and Caveats

• No treatment is a legitimate option for many patients, especially those with limited disease of short duration (<1 year) 1

  • Spontaneous remission occurs in up to 80% of patients with limited patchy hair loss 1

• Side effects to monitor:

  • Skin atrophy is a consistent side effect of intralesional corticosteroids, particularly with triamcinolone 1, 2
  • Pain during injection is the main limitation of intralesional therapy 1, 5

• Treatment response evaluation:

  • Regrowth cannot be expected within 3 months of the development of any individual patch 1
  • If no response is seen after several treatments, consider alternative therapies 2

• Special populations:

  • Children may be treated similarly to adults, but intralesional corticosteroids are often poorly tolerated 1
  • Many clinicians are reluctant to use aggressive treatments such as contact immunotherapy in children 1

• Combination therapy: A combined approach using intralesional corticosteroids with carboxy therapy has shown higher efficacy (79.2% hair regrowth) compared to intralesional corticosteroids alone (69.5%) 6