What are the treatment options for alopecia?

Treatment Options for Alopecia Areata

For limited patchy alopecia areata, intralesional corticosteroid injections are the first-line treatment, achieving 62% full regrowth in patients with fewer than five patches less than 3 cm in diameter. 1

Initial Assessment and Treatment Selection

Limited Patchy Disease (< 5 patches)

Intralesional corticosteroids are the gold standard for localized disease:

• Use triamcinolone acetonide 5-10 mg/mL or hydrocortisone acetate 25 mg/mL injected just beneath the dermis in the upper subcutis 1
• Each 0.05-0.1 mL injection produces approximately 0.5 cm diameter tuft of hair growth 1
• Administer monthly injections, with effects lasting approximately 9 months 1
• Particularly effective for cosmetically sensitive sites like eyebrows 1
• Main limitation is patient discomfort during injection 1
• Skin atrophy at injection sites is a consistent side effect 1

Alternative: Topical corticosteroids (second-line):

• Very potent topical steroids (clobetasol propionate 0.05% foam or ointment) are widely used but have limited evidence 1
• In one RCT, 7 of 34 sites treated with clobetasol foam achieved ≥50% regrowth versus 1 of 34 with vehicle 1
• Clobetasol propionate under occlusive dressing for 6 nights weekly showed 18% long-term regrowth in severe cases 1
• Folliculitis is a common side effect 1
• Recommended for children and adults who cannot tolerate intralesional injections 2

Extensive Patchy Disease

Contact immunotherapy with diphenylcyclopropenone (DPCP) is the treatment of choice:

• Sensitize with 2% DPCP solution to small scalp area, then apply weekly starting at 0.001% concentration 1
• Increase concentration at each treatment until mild dermatitis reaction occurs 1
• 50-60% of patients achieve worthwhile response, though range is wide (9-87%) 1
• In one large series, 78% showed clinically significant regrowth after 32 months of treatment (30% at 6 months) 1
• Patients with extensive hair loss are less likely to respond 1
• Store solutions in dark; patients should wear hat/wig for 24 hours post-application 1

Common adverse effects of DPCP:

• Most patients develop occipital/cervical lymphadenopathy (usually temporary) 1
• Severe dermatitis (minimized by careful concentration titration) 1
• Cosmetically disabling pigmentary changes (hyper/hypopigmentation, vitiligo) particularly in racially pigmented skin 1
• Relapse occurs in 62% following successful treatment 1

Adjunctive Therapy

Topical minoxidil has limited evidence:

• One early double-blind study showed benefit with 1% minoxidil in patchy disease, but subsequent trials in extensive disease failed to confirm 1
• Response rates of 32-33% reported, but <10% experienced sustained benefit 1
• FDA-approved minoxidil 5% solution is applied twice daily (morning and 2-4 hours before bed) 3
• Results may take 2-4 months to appear 3

No Treatment Option

Observation alone is legitimate for many patients:

• Spontaneous remission occurs in up to 80% of patients with limited patchy hair loss of duration <1 year 1
• Advise patients that regrowth cannot be expected within 3 months of any individual patch development 1
• For long-standing extensive alopecia, prognosis is poor and wigs may be better than treatments unlikely to succeed 1

Treatment Approaches by Severity

Mild Disease (SALT score <20)

• Start with intralesional corticosteroids for patches 1
• Consider topical corticosteroids if injections not tolerated 1
• Reassurance and observation is acceptable given high spontaneous remission rate 1

Moderate to Severe Disease (SALT score ≥20)

• Contact immunotherapy with DPCP is preferred for extensive patchy disease 1
• Consider systemic therapy (JAK inhibitors like baricitinib or ritlecitinib) for severe cases 4
• Wigs are appropriate for alopecia totalis/universalis where treatment response is poor 1

Critical Counseling Points

Set realistic expectations:

• No treatment alters the long-term course of disease 1
• High relapse rates occur during or after initially successful treatment 1
• Treatment can be time-consuming, uncomfortable, and may alter patient's attitude toward their hair loss 1
• Alopecia areata has no direct impact on general health, so hazardous treatments of unproven efficacy are not justified 1

Psychological support is essential:

• Disease may have serious psychological effects despite no impact on general health 1
• Contact with patient support groups helps individuals cope and find self-acceptance 1
• For children showing withdrawal, low self-esteem, or behavioral changes, refer to pediatric clinical psychologist 1

Common Pitfalls to Avoid

• Do not use PUVA therapy—retrospective reviews show low response rates no better than natural disease course, with high relapse rates and unacceptably high cumulative UVA doses 1
• Avoid systemic corticosteroids except in specific circumstances—one small study showed 30-47% with >25% regrowth on 6-week tapering course of oral prednisolone 40 mg daily, but long-term use causes significant adverse effects 1
• Do not apply minoxidil and wash hair within 4 hours—allow solution to stay on scalp for proper absorption 3
• Warn patients with racially pigmented skin about risk of cosmetically disabling pigmentary complications with DPCP before starting treatment 1