How is autoimmune hair loss treated?

Treatment of Autoimmune Hair Loss (Alopecia Areata)

For limited patchy alopecia areata, intralesional corticosteroid injections are the most effective first-line treatment, while observation without treatment is entirely appropriate for many patients given the high spontaneous remission rate. 1

Initial Management Decision

The first critical decision is whether to treat at all. Not treating is a legitimate and often preferred option for many patients with alopecia areata because: 1

• Spontaneous remission occurs in up to 80% of patients with limited patchy hair loss of short duration (<1 year) 1
• The disease has no direct impact on general health that justifies hazardous treatments 1
• No treatment has been shown to alter the long-term course of the disease 1
• Regrowth cannot be expected within 3 months of any individual patch developing 1

Reassurance and psychological support alone are appropriate management for patients with limited disease and recent onset. 1, 2

Treatment Algorithm by Disease Severity

Limited Patchy Disease (<50% scalp involvement)

Intralesional corticosteroids are the treatment of choice for localized patches: 1

• Use triamcinolone acetonide 5-10 mg/mL or hydrocortisone acetate 25 mg/mL 1
• Inject just beneath the dermis in the upper subcutis 1
• Each 0.05-0.1 mL injection produces a tuft of hair growth approximately 0.5 cm in diameter 1
• Repeat monthly injections achieve full regrowth in 62% of patients, with better response in those with fewer than five patches <3 cm in diameter 1
• Strength of recommendation: B 1

Important caveat: Skin atrophy at injection sites is a consistent side-effect, particularly with triamcinolone 1

Alternative options for limited disease (though less evidence-based):

• Topical corticosteroids are widely used but have little evidence of efficacy - a randomized controlled trial of 0.25% desoximetasone cream failed to show significant effect over placebo 1
• Minoxidil lotion is safe but lacks convincing evidence of effectiveness 1
• Dithranol (anthralin) is safe but similarly lacks convincing efficacy data 1

Extensive Disease (Alopecia Totalis/Universalis)

Contact immunotherapy with diphenylcyclopropenone (DPCP) is the only treatment likely to be effective, though response rates remain low: 1

• Achieves cosmetically worthwhile hair regrowth in <50% of patients with severe disease 1
• Response rate in alopecia totalis/universalis is only 17% 1
• Strength of recommendation: C 1

Protocol for contact immunotherapy: 1

• Sensitize with 2% DPCP solution applied to small scalp area 1
• Two weeks later, begin weekly applications starting at 0.001% concentration 1
• Increase concentration at each treatment until mild dermatitis reaction occurs 1
• Treatment may need to continue for 32 months, as 78% of responders achieved regrowth only after prolonged therapy (vs. 30% at 6 months) 1
• Relapse occurs in 62% of patients following successful treatment 1

Common adverse effects to warn patients about: 1

• Occipital/cervical lymphadenopathy (usually temporary) 1
• Severe dermatitis if concentration not carefully titrated 1
• Cosmetically disabling pigmentary changes (hyper- and hypopigmentation, including vitiligo) especially in patients with darker skin 1
• Rare but serious: severe urticaria 1

Wig use is recommended for extensive disease (Strength of recommendation: D) 1

Treatments NOT Recommended

The following should be avoided due to potentially serious side-effects and inadequate efficacy evidence: 1

• Continuous or pulsed systemic corticosteroids 1
• PUVA therapy 1
• Oral prednisolone courses (one small study showed only 30-47% achieved >25% regrowth with 6-week tapering course starting at 40 mg daily) 1

Special Considerations for Children

Children may be treated similarly to adults, but: 1

• Intralesional steroids are often poorly tolerated 1
• Many clinicians are reluctant to use aggressive treatments like contact immunotherapy 1

Emerging Therapies

JAK inhibitors represent a promising new treatment class: 3, 4

• Baricitinib and ritlecitinib have received FDA approval for severe alopecia areata 4
• These represent the first major advancement in treatment options for this challenging disease 4

Diagnostic Considerations

Routine screening for other autoimmune diseases is not justified despite the association between alopecia areata and other autoimmune conditions 1

Dermoscopy aids diagnosis by identifying: 1, 5

• Regular round yellow dots indicating active disease 1
• Exclamation mark hairs (dystrophic hairs with fractured tips) 1
• Cadaverized hairs (fractured before scalp emergence) 1

Critical Pitfall to Avoid

Do not promise or expect rapid results. Hair regrowth cannot be expected within 3 months of patch development, and the prognosis in long-standing extensive alopecia is usually poor. 1 Setting realistic expectations is essential to avoid patient disappointment and maintain therapeutic alliance.