What are the treatment options for alopecia areata?

Treatment of Alopecia Areata

For limited patchy alopecia areata, use intralesional corticosteroids as first-line therapy; for extensive disease, contact immunotherapy is most effective though success rates remain under 50%; and for severe alopecia areata, baricitinib is the only treatment proven to significantly increase hair regrowth. 1, 2

Treatment Algorithm Based on Disease Severity

Limited Patchy Hair Loss (<50% scalp involvement)

Intralesional corticosteroids are the recommended first-line treatment with triamcinolone acetonide 5-10 mg/mL or hydrocortisone acetate 25 mg/mL injected just beneath the dermis in the upper subcutis. 3, 1

• Monthly injections achieve up to 62% full regrowth rates, making this the most effective option for localized disease. 1, 4
• Skin atrophy is a consistent side effect that must be monitored, particularly with triamcinolone. 4
• The injections are painful and often poorly tolerated in children, limiting their use in pediatric populations. 1

Observation without treatment is a legitimate alternative, especially for disease duration less than 1 year, since spontaneous remission occurs in up to 80% of patients with limited patchy hair loss. 1, 4

• Counsel patients that regrowth cannot be expected within 3 months of any individual patch developing. 1
• No treatment has been shown to alter the long-term course of the disease. 1

Topical corticosteroids are widely prescribed but have limited evidence of efficacy and should be reserved for patients who cannot tolerate intralesional injections. 3, 4, 5

Extensive Patchy Hair Loss (>50% scalp involvement)

Contact immunotherapy with diphenylcyclopropenone (DPCP) is the first-line treatment for extensive disease, though it requires multiple hospital visits over several months. 3, 1

• Success rates range from 50-60% for cosmetically worthwhile regrowth, though reported ranges vary widely from 9-87%. 1, 4
• The treatment causes temporary local inflammation but serious side effects are rare. 3
• This is not widely available and requires specialized centers with experience in contact immunotherapy. 3

Baricitinib (JAK 1/2 inhibitor) results in significant hair regrowth compared to placebo and is the only systemic treatment with high-certainty evidence of efficacy. 2

• Baricitinib increases short-term hair regrowth ≥75% (RR 7.54,95% CI 3.90 to 14.58) based on 1200 participants in high-quality trials. 2
• This is EMA-approved for adults with severe alopecia areata. 6
• The small incidence of serious adverse events must be balanced against expected benefits. 2

Alopecia Totalis/Universalis (Complete scalp or body hair loss)

Contact immunotherapy remains the only treatment likely to be effective, though response rates drop to approximately 17% in these severe cases. 1

Baricitinib demonstrates sustained long-term efficacy with an RR of 8.49 (95% CI 4.70 to 15.34) for hair regrowth ≥75% beyond 26 weeks. 2

• Ritlecitinib (JAK 3/TEC inhibitor) is EMA-approved for individuals aged 12 and older with severe alopecia areata. 6

A wig or hairpiece is often the most effective solution for managing extensive hair loss and should be discussed as a practical option. 1

Treatments to Avoid or Use with Caution

Systemic corticosteroids (oral prednisolone, betamethasone) cannot be recommended due to potentially serious side effects and inadequate evidence of efficacy despite widespread historical use. 3, 1

Topical minoxidil has limited efficacy with variable response rates of 32-33% and no convincing evidence of long-term benefit. 3, 4, 7

PUVA therapy cannot be recommended given potentially serious side effects and inadequate efficacy data. 3, 1

Cyclosporine, methotrexate, and azathioprine are used off-label but lack robust evidence and carry significant side effect profiles. 6

Special Populations

Children may be treated similarly to adults with important modifications: 1

• Intralesional corticosteroids are often poorly tolerated due to pain. 1
• Many clinicians are reluctant to use aggressive treatments like contact immunotherapy in children. 1
• Topical corticosteroids become the preferred option when intralesional injections cannot be tolerated. 5
• Referral for psychological support should be considered, especially with behavioral changes including withdrawal, low self-esteem, or failing at school. 1

Critical Pitfalls and Caveats

The high spontaneous remission rate makes treatment efficacy difficult to assess, particularly in mild forms where up to 80% may remit without intervention. 1

Patients with extensive disease tend to be resistant to all forms of treatment, making realistic expectations crucial for patient counseling. 1

Recurrence is common after treatment cessation even when initial regrowth is achieved. 5

Psychological support may be necessary as alopecia areata can cause considerable psychological and social disability, with children and adolescents often experiencing bullying including physical aggression. 1, 6