What are the treatment options for alopecia?

Treatment Options for Alopecia

For patients with alopecia, treatment selection should be based on the type and extent of hair loss, with intralesional corticosteroids being the most effective first-line treatment for limited patchy alopecia, while considering that no treatment is also a legitimate option for many patients due to high spontaneous remission rates. 1

Types of Alopecia and Treatment Approach

Alopecia Areata (Patchy Hair Loss)

• Limited patchy hair loss:

  • Intralesional corticosteroids are the first-line treatment with strongest evidence (Strength of recommendation B) 1, 2
  • Hydrocortisone acetate (25 mg/mL) or triamcinolone acetonide (5-10 mg/mL) injected beneath the dermis can produce hair growth in 62% of patients 1
  • Each injection of 0.05-0.1 mL produces a tuft of hair growth about 0.5 cm in diameter 1

• Extensive patchy hair loss:

  • Contact immunotherapy is recommended (Strength of recommendation B) 1
  • This treatment stimulates cosmetically worthwhile hair regrowth in <50% of patients with extensive patchy hair loss 1

Alopecia Totalis/Universalis

• Contact immunotherapy is the only treatment likely to be effective, though response rates are lower than for patchy alopecia 1
• Clobetasol propionate 0.05% ointment applied under occlusive plastic film on six out of seven nights for 6 months resulted in long-term hair regrowth in 18% of patients with alopecia totalis/universalis 1

Androgenetic Alopecia

• Topical minoxidil (FDA-approved) applied twice daily 3, 4
• Oral minoxidil at low doses (0.25-5 mg daily) has shown 61-100% objective improvement in off-label use 5, 6
• A recent randomized controlled trial found 1 mg daily oral minoxidil to be comparable in efficacy to standard topical minoxidil 7

Treatment Algorithm

1. First consider whether treatment is necessary:

   • Spontaneous remission occurs in up to 80% of patients with limited patchy hair loss of short duration (<1 year) 1
   • For many patients, especially those with limited disease, observation and reassurance is appropriate 1

2. For limited patchy alopecia areata:

   • Intralesional corticosteroids (first-line) 1, 2
   • Topical potent corticosteroids (second-line, limited evidence of efficacy) 1
   • Topical minoxidil (mixed results, response rates of 32-33%) 2, 8

3. For extensive patchy alopecia areata:

   • Contact immunotherapy 1
   • Consider wigs or hairpieces, especially for women with extensive hair loss 1

4. For refractory cases:

   • Methotrexate (15-25 mg per week) - complete regrowth reported in some patients with alopecia totalis/universalis 2
   • Sulfasalazine - partial or complete recovery in some patients with severe alopecia areata 2
   • Ciclosporin - has immunosuppressive and hypertrichotic properties 1, 2

Important Considerations and Caveats

• No treatment has been shown to alter the long-term course of alopecia areata 1
• The psychological impact of alopecia can be significant, but this does not justify hazardous treatments with unproven efficacy 1
• Patients should be warned about possible relapse following initially successful treatment 1
• Folliculitis is a common side effect of potent topical steroids 1
• For oral minoxidil, common side effects include hypertrichosis and postural hypotension 5
• When using topical minoxidil, allow it to stay on the scalp for about 4 hours before washing for best results 3
• Wigs may be the most effective solution for many patients with extensive alopecia, particularly women 1