Can corticosteroid (CS) injections cause hair loss?

Corticosteroid Injections and Hair Loss

Corticosteroid injections can both treat hair loss (specifically alopecia areata) and potentially cause hair loss as a side effect, depending on the context and administration. 1, 2

Corticosteroids for Treating Hair Loss

Intralesional Corticosteroid Injections

• Intralesional corticosteroid injections are considered first-line treatment for limited patchy hair loss in alopecia areata, with success rates of up to 62% reported with monthly injections 1, 2
• Triamcinolone acetonide (5-10 mg/mL) is commonly used, injected just beneath the dermis in the upper subcutis 1, 3
• An injection of 0.05-0.1 mL will produce a tuft of hair growth about 0.5 cm in diameter 1, 3
• The effect typically lasts about 9 months 1, 3
• Most suitable for treating patchy hair loss of limited extent (fewer than five patches of < 3 cm in diameter) and for cosmetically sensitive sites such as the eyebrows 1, 3

Efficacy

• Studies show that tufts of hair grew in 33 out of 34 sites injected with triamcinolone hexacetonide and in 16 of 25 sites injected with triamcinolone acetonide 1
• Response is better in localized alopecia compared to extensive hair loss 3, 4
• Patients with exclamation mark hairs and a positive hair pull test may be more likely to respond to treatment 4

Corticosteroids Causing Hair Loss

Systemic Corticosteroids and Hair Loss

• Systemic corticosteroids can cause telogen effluvium, a form of hair loss that becomes evident 2-4 months after starting treatment 5
• In telogen effluvium, corticosteroids precipitate hair follicles into premature rest phase 5
• This type of hair loss is usually reversible after interruption of treatment 5

Local Side Effects of Corticosteroid Injections

• Skin atrophy at the injection site is a consistent side effect of intralesional corticosteroids, particularly with triamcinolone 3, 2
• Other potential local adverse effects include pigmentary changes and telangiectasias 6
• Folliculitis is a common side effect of treatment with potent topical steroids 1

Treatment Considerations

When to Consider Corticosteroid Injections

• Best for patients with limited patchy hair loss rather than extensive hair loss 1, 3, 2
• Consider no treatment as a legitimate option for many patients with limited disease of short duration (<1 year), as spontaneous remission occurs in up to 80% of such patients 1, 2
• For extensive alopecia areata (>50% scalp involvement), intralesional injections have shown some success but are generally not first-line 4, 7

Alternative Approaches

• For extensive patchy hair loss, contact immunotherapy (diphenylcyclopropenone [DPCP]) is recommended as first-line treatment 2
• Topical corticosteroids are widely prescribed but have limited evidence of efficacy 2
• Systemic pulse corticosteroid therapy may be effective for widespread alopecia areata but carries more side effects 7, 8

Monitoring and Follow-up

• Monitor for local skin atrophy and consider repeated injections for sustained effect 3
• If no response is seen after several treatments, consider alternative therapies 3
• Pain during injection is a limitation; topical anesthetic agents applied under occlusion prior to the procedure may help minimize discomfort 4

Special Considerations

• The prognosis in longstanding extensive alopecia is poor, and alternative approaches may be more appropriate 1
• Drug-induced hair loss is usually reversible after interruption of treatment 5
• Combining corticosteroids with other medications can increase efficacy while potentially reducing side effects 9, 7