What are the treatment options for a girl with alopecia?

Treatment Options for Alopecia in Girls

For girls with alopecia areata, treatment should be tailored based on the extent of hair loss, with intralesional corticosteroids recommended for limited patchy hair loss and contact immunotherapy for extensive patchy hair loss or alopecia totalis/universalis. 1

Assessment and Classification

• Determine the type and extent of alopecia: patchy, total (complete scalp hair loss), universal (complete body hair loss), or ophiasis (band-like pattern) 1, 2
• Consider differential diagnoses including trichotillomania, tinea capitis, early scarring alopecia, telogen effluvium, anagen effluvium, systemic lupus erythematosus, and secondary syphilis 2
• Most cases of alopecia areata do not require investigations, but when diagnosis is uncertain, consider fungal culture, skin biopsy, or serology for lupus or syphilis 2

Treatment Algorithm Based on Extent of Hair Loss

Limited Patchy Hair Loss

• First-line: Intralesional corticosteroids - stimulate hair regrowth at injection sites, with 62% of patients achieving full regrowth with monthly injections 1, 2
  • Note: Skin atrophy is a consistent side effect 2
  • May be poorly tolerated in children 1
• Alternative options:
  • Potent topical corticosteroids - safe but limited evidence of efficacy 1
  • Minoxidil lotion - safe but limited evidence of efficacy 1
  • Dithranol (anthralin) - safe but limited evidence of efficacy 1
  • "Watch-and-wait" approach with reassurance for short duration cases 2

Extensive Patchy Hair Loss

• First-line: Contact immunotherapy (strength of recommendation B II-ii) 1
  • Best-documented treatment but not widely available
  • Requires multiple hospital visits over several months
  • Stimulates cosmetically worthwhile hair regrowth in <50% of patients 1
  • May cause temporary local inflammation but serious side effects are rare 1
  • Many clinicians are reluctant to use this aggressive treatment in children 1

Alopecia Totalis/Universalis

• First-line: Contact immunotherapy (strength of recommendation C) 1
  • Only treatment likely to be effective in AT/AU, although response rate is low 1
• Alternative: Wig or hairpiece (strength of recommendation D) 1
  • For many female patients, this is the most effective solution 1
  • Acrylic wigs are cheaper and easier to maintain than real hair wigs 1
  • Human hair wigs look more natural and last longer (1-2 years) but are more expensive 1

Special Considerations for Children and Adolescents

• Intralesional corticosteroids are often poorly tolerated in children 1
• Many clinicians are reluctant to use aggressive treatments like contact immunotherapy in children 1
• Psychological support is crucial as alopecia can cause anxiety, depression, and social difficulties, particularly in adolescents experiencing physical and emotional transitions 2, 3
• Consider referral to patient support organizations 1

Treatment Pitfalls and Caveats

• No treatment has been shown to alter the long-term course of alopecia areata 2
• Warn patients about possible relapse during or following initially successful treatment 2
• Treatments that have shown ineffectiveness in controlled trials include oral zinc and isoprinosine 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
• The prognosis for long-standing extensive alopecia is generally poor 2
• The tendency for spontaneous remission and lack of adverse effects on general health are important considerations - not treating is the best option in many cases 1