Treatment Options for Alopecia Areata
Intralesional corticosteroids are the first-line treatment for limited patchy alopecia areata, while contact immunotherapy is recommended for extensive patchy hair loss. 1
Treatment Selection Based on Disease Extent
Limited Patchy Hair Loss
- Intralesional corticosteroids are the first-line treatment for limited patchy alopecia areata (fewer than five patches of <3cm diameter) 2, 1
- Triamcinolone acetonide (5-10mg/mL) or hydrocortisone acetate (25mg/mL) are commonly used 2
- Inject 0.05-0.1mL just beneath the dermis in the upper subcutis to produce a tuft of hair growth about 0.5cm in diameter 2, 3
- Success rates of up to 62% have been reported with monthly injections 2, 3
- Skin atrophy at the injection site is a consistent side effect, particularly with triamcinolone 2
Extensive Patchy Hair Loss
- Contact immunotherapy with diphenylcyclopropenone (DPCP) is the first-line treatment 1, 3
- Protocol: Patient is sensitized with 2% DPCP solution on a small area of scalp, then treated weekly with increasing concentrations starting at 0.001% until mild dermatitis is achieved 2
- Response rates of 50-60% have been reported, though results vary widely (9-87%) 2
- Patients with extensive hair loss, nail changes, early onset, or positive family history have poorer prognosis 2
- DPCP should be stored in the dark and patients should wear a hat for 24 hours after application 2
- Common side effects include occipital/cervical lymphadenopathy and dermatitis; less common are urticaria and pigmentary complications 2
Alternative Treatments
Topical Corticosteroids
- Very potent topical steroids (e.g., clobetasol propionate) are widely used but have limited evidence of efficacy 2, 1
- Clobetasol propionate 0.05% foam showed better response than vehicle in one study (7/34 vs 1/34 sites with ≥50% regrowth) 2
- Clobetasol propionate under occlusion may be more effective, with 18% long-term regrowth in patients with alopecia totalis/universalis 2
- Folliculitis is a common side effect 2
Minoxidil
- Not considered first-line therapy for alopecia areata 1
- Limited efficacy with response rates of 32-33% in studies 2, 1
- Less effective in extensive alopecia areata 2
Other Treatments
- Photochemotherapy (PUVA): Uncontrolled studies claim success rates up to 60-65%, but retrospective reviews suggest response is no better than natural course 2
- Dithranol (anthralin): Limited evidence from case series 2
- Systemic corticosteroids: Not recommended for routine use due to potential serious side effects and inadequate evidence of long-term efficacy 1, 4
No Treatment Option
- No treatment is a legitimate option, especially for limited patchy hair loss of short duration (<1 year) 2, 3
- Spontaneous remission occurs in up to 80% of patients with limited patchy hair loss of short duration 2, 1
- For severe or long-standing alopecia, wigs may be a better option than pursuing treatments with low likelihood of success 3
Treatment Algorithm
Assess extent and duration of hair loss:
- Limited patchy (<5 patches, <3cm): Consider intralesional corticosteroids
- Extensive patchy: Consider contact immunotherapy (DPCP)
- Recent onset (<1 year) with limited patches: Consider observation for spontaneous remission
- Alopecia totalis/universalis: Lower expectations for treatment success, consider wigs 2, 3
For limited patchy alopecia:
For extensive patchy alopecia:
For refractory cases:
Important Caveats
- None of the treatments has been shown to alter the long-term course of the disease 2, 5
- Relapse is common after discontinuation of treatment 2, 4
- Treatment expectations should be realistic—complete hair restoration is unlikely in extensive disease 3
- Check for underlying causes of hair loss before starting treatment 6