What are the treatment options for alopecia?

Treatment Options for Alopecia

Intralesional corticosteroid injections are the most effective first-line treatment for limited patchy alopecia, with up to 62% of patients achieving full regrowth when treated with monthly injections of triamcinolone acetonide. 1, 2

Types of Alopecia and First-Line Treatments

Limited Patchy Alopecia Areata

• Intralesional corticosteroids (triamcinolone acetonide 5-10 mg/mL or hydrocortisone acetate 25 mg/mL) injected just beneath the dermis produce hair growth in a 0.5 cm diameter area per 0.05-0.1 mL injection 3
• Most suitable for patients with fewer than five patches of <3 cm in diameter 3
• Skin atrophy is a common side effect at injection sites, particularly with triamcinolone 3
• For cosmetically sensitive areas like eyebrows, intralesional corticosteroids are particularly effective 2

Extensive Alopecia Areata

• Contact immunotherapy with diphenylcyclopropenone (DPCP) shows 50-60% response rates, though results vary widely (9-87%) 3, 1
• Protocol involves sensitization with 2% DPCP solution, followed by weekly applications starting at 0.001% concentration, gradually increasing until mild dermatitis occurs 3
• Less effective for alopecia totalis/universalis, with only 17% response rate 3
• Adverse effects include lymphadenopathy, severe dermatitis, and pigmentary changes (including vitiligo) 3

Androgenetic Alopecia

• Topical minoxidil is FDA-approved and should be applied twice daily (morning and night) 4, 5
• Each application should be 1 mL applied directly to the scalp in the affected area 4
• Allow minoxidil to remain on scalp for at least 4 hours before washing 4
• Results may take 2-4 months to appear with consistent twice-daily usage 4

Second-Line and Systemic Treatments

For Refractory Alopecia Areata

• Topical corticosteroids have limited evidence of effectiveness but are widely used 3, 1
• Systemic options include:
  • Methotrexate (15-25 mg weekly) - shown effective in some cases of alopecia totalis/universalis 2, 6
  • Cyclosporine - has immunosuppressive and hypertrichotic properties 2, 6
  • Oral JAK inhibitors - baricitinib and ritlecitinib are EMA-approved for severe alopecia areata 6
  • Sulfasalazine - some evidence of efficacy in uncontrolled studies 2

Important Considerations

• Spontaneous remission occurs in up to 80% of patients with limited patchy hair loss of short duration (<1 year), making no treatment a legitimate option 3, 1
• The prognosis for long-standing extensive alopecia is poor, and wigs may be a better option than pursuing treatments with low likelihood of success 3, 1
• For androgenetic alopecia, minoxidil must be used consistently and indefinitely; hair loss will recur if treatment is stopped 4, 5
• Unwanted hair growth on face or body is a rare but possible side effect of minoxidil that resolves when treatment is discontinued 4
• Psychological impact of alopecia can be significant; patients often experience anxiety, depression, and reduced quality of life 5, 6

Treatment Algorithm

1. Determine alopecia type and extent:

   • Limited patchy alopecia areata: Intralesional corticosteroids 3, 1
   • Extensive alopecia areata: Contact immunotherapy (DPCP) if available 3, 1
   • Androgenetic alopecia: Topical minoxidil 4, 5

2. If first-line treatment fails after 3-6 months:

   • For alopecia areata: Consider systemic treatments (methotrexate, cyclosporine, JAK inhibitors) 2, 6
   • For androgenetic alopecia in men: Consider adding oral finasteride 5

3. For chronic, severe, or treatment-resistant cases:

   • Consider combination therapies 7
   • Evaluate for psychological impact and provide appropriate support 5, 8
   • Discuss cosmetic options such as wigs, especially for extensive long-standing alopecia 3, 9