What are some treatment options for diffuse alopecia?

Treatment Options for Diffuse Alopecia

For diffuse alopecia, the treatment approach depends critically on the underlying cause: observation alone is appropriate for telogen effluvium with spontaneous remission expected in up to 80% of cases within one year, while diffuse alopecia areata requires active intervention with intralesional corticosteroids or systemic therapy, and androgenetic alopecia responds to topical minoxidil as first-line treatment. 1, 2, 3

Diffuse Alopecia Areata

Corticosteroid Therapy

Intralesional corticosteroids are the primary treatment for localized diffuse alopecia areata, using triamcinolone acetonide 5-10 mg/mL injected just beneath the dermis in the upper subcutis. 1, 2 Each 0.05-0.1 mL injection produces a tuft of hair growth approximately 0.5 cm in diameter, with effects lasting about 9 months. 1 In one study, 62% of patients achieved full regrowth with monthly injections, with better responses in those having fewer than five patches less than 3 cm in diameter. 1

• Topical corticosteroids (clobetasol propionate 0.05% foam or ointment) show limited but measurable efficacy. 1 After 12 weeks, 7 of 34 sites treated with clobetasol foam achieved at least 50% regrowth versus only 1 of 34 placebo sites. 1
• Occlusive therapy with clobetasol propionate 0.05% ointment under plastic film for 6 out of 7 nights over 6 months resulted in long-term regrowth in 18% of patients with severe disease. 1
• Folliculitis is a common side-effect of potent topical steroids that must be monitored. 1

Systemic Corticosteroids

Oral prednisolone starting at 40 mg daily with a 6-week tapering course may produce greater than 25% regrowth in 30-47% of patients with diffuse alopecia areata. 2 However, no treatment has been shown to alter the long-term course of the disease. 1

Telogen Effluvium

Observation and Trigger Removal

No active treatment is required for most cases of telogen effluvium, as spontaneous remission occurs in up to 80% of patients with limited hair loss of short duration (less than 1 year). 1, 2 The key is identifying and removing the triggering cause—whether physiologic stress, emotional stress, nutritional deficiency, or endocrine imbalance. 4, 5

• Regrowth cannot be expected within 3 months of the triggering event, and patients should be counseled accordingly. 1
• Resolution typically occurs in 3-6 months once the trigger is removed or treated. 6

Nutritional Supplementation

Check and correct nutritional deficiencies including vitamin D, zinc, and folate levels, as supplementation may be beneficial when deficiencies are identified. 2 Serum ferritin and thyroid function (TSH, T3, T4) should be checked in all cases without a discernible cause, as iron deficiency and thyroid disorders are commonly associated with diffuse hair loss. 6

Androgenetic Alopecia (Female Pattern Hair Loss)

Topical Minoxidil

Topical minoxidil 2% is the first-line treatment for female pattern hair loss presenting as diffuse thinning. 3, 6 This can be used with or without antiandrogens depending on the clinical scenario. 6

Additional Options

• Oral finasteride is available for male patients with androgenetic alopecia. 3
• Hair prosthesis, hair cosmetics, and hair surgery are additional therapeutic options for management. 6

Critical Diagnostic Considerations

Laboratory testing should include: fungal culture if tinea capitis is suspected, skin biopsy when diagnosis is uncertain (particularly to differentiate chronic telogen effluvium from androgenetic alopecia), serology for lupus erythematosus or syphilis if clinically indicated, and TSH with vitamin D, zinc, and folate levels. 1, 2, 6

Biopsy findings distinguish entities: normal histology in chronic telogen effluvium versus miniaturization with terminal to vellus hair ratio less than 4:1 in androgenetic alopecia. 6

Psychological Support

Counseling and psychological support are essential components of management, as patients with moderate to severe hair loss commonly experience anxiety, depression, and reduced quality of life. 1, 3 Contact with patient support groups can help individuals cope with altered body image. 1

Important Caveats

• No treatment alters the long-term course of alopecia areata, though many can induce temporary hair growth. 1
• Prognosis is poor in longstanding extensive alopecia, and a wig may be a better option than pursuing treatments unlikely to be effective. 1
• Patients should be forewarned about potential relapse following initially successful treatment, as some find this difficult to cope with. 1
• Avoid hazardous treatments of unproven efficacy, as hair loss has no direct impact on general health that justifies such risks. 1