What are the treatment options for alopecia?

Treatment of Alopecia

Treatment Selection Based on Alopecia Type

The treatment approach for alopecia depends critically on whether you are treating androgenetic alopecia (pattern hair loss) versus alopecia areata (autoimmune patchy hair loss), as these conditions require completely different therapeutic strategies.

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For Androgenetic Alopecia (Pattern Hair Loss)

First-Line Treatment: Topical Minoxidil

Apply topical minoxidil 5% solution, 1 mL twice daily to the affected scalp areas—this is the only FDA-approved treatment specifically recommended for androgenetic alopecia. 1

• Women should use 2-5% minoxidil solution 1, while men should use 5% minoxidil 2
• Apply once in the morning and once at night, with the nighttime application occurring 2-4 hours before bed to allow for drying 2
• Treatment must continue indefinitely—discontinuation reverses all hair growth benefits 1
• Allow minoxidil to stay on the scalp for about 4 hours before washing for optimal absorption 2
• Hair regrowth typically begins at 2 months, but some patients may need 4 months of twice-daily use before seeing results 2

Enhanced Treatment: Combination Therapy

For superior efficacy, combine topical minoxidil 5% (1 mL twice daily) with monthly platelet-rich plasma (PRP) injections for at least 3 sessions—this combination is significantly more effective than minoxidil alone. 1, 3

• The combination of minoxidil and topical finasteride 0.25% spray also shows significantly higher efficacy than either monotherapy, with 79% of patients achieving excellent results (GPAS score ≥2) at 6 months 4
• 83% of patients achieve a negative hair pull test (indicating reduced hair fragility) with PRP combined with minoxidil 3

PRP Treatment Protocol

Initial phase: 3-5 sessions spaced 1 month apart, using 5-7 mL of PRP per session, injecting 0.05-0.1 mL/cm² at 1 cm intervals and 2-4 mm depth. 1, 3

• Use the manual double-spin method for PRP preparation, with platelet concentration of 1 to 1.5 million platelets per µL 3
• PRP activation is NOT required for androgenetic alopecia 3
• Use 30G × 4 mm needles at a 90-degree angle to minimize discomfort 3
• Apply pharmaceutical-grade topical anesthetic cream before injection due to significant pain 3
• Maintenance phase: 1 session every 6 months after completing initial treatment 1, 3

Alternative Treatment Option

• Low-level 655-nm laser devices demonstrate efficacy, requiring continuous use 3 times per week 1, 3

Monitoring Treatment Response

Evaluate treatment efficacy after one year using standardized before-and-after photographs, trichoscopy to assess hair density and diameter, and patient self-assessment questionnaires. 1, 3

• Key indicators of positive response include increased hair density, increased hair shaft diameter, decreased proportion of telogen hairs, and improved patient satisfaction scores 3

Critical Pitfalls to Avoid

• Do NOT confuse androgenetic alopecia with alopecia areata—these require completely different treatment algorithms 1
• Do NOT routinely test for iron deficiency—no published studies demonstrate treatment response to iron replacement therapy in androgenetic alopecia 1
• Treatment efficacy decreases with severity and duration of alopecia, so early initiation is crucial 1, 3
• Inadequate follow-up leads to suboptimal outcomes—schedule regular monitoring appointments 1, 3
• Do NOT use minoxidil more than twice daily—more frequent use does not speed hair growth and may increase side effects 2

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For Alopecia Areata (Autoimmune Patchy Hair Loss)

Treatment Selection Based on Disease Extent

For limited patchy hair loss: Use intralesional corticosteroids (triamcinolone acetonide 5-10 mg/mL) as first-line treatment, with success rates up to 62% with monthly injections. 5, 6

• Inject 0.05-0.1 mL just beneath the dermis in the upper subcutis, producing a tuft of hair growth about 0.5 cm in diameter 6
• This method is most suitable for fewer than five patches of <3 cm in diameter and for cosmetically sensitive sites such as eyebrows 6
• Monitor for skin atrophy, a consistent side effect of intralesional corticosteroids 5
• The effect typically lasts about 9 months 6

For extensive patchy hair loss: Use contact immunotherapy with diphenylcyclopropenone (DPCP) as first-line treatment, stimulating cosmetically worthwhile hair regrowth in less than 50% of patients. 5, 6

• Sensitize the patient using 2% DPCP solution applied to a small area of scalp 6
• Two weeks later, paint the scalp with 0.001% DPCP solution, repeating at weekly intervals 6
• Increase concentration at each treatment until mild dermatitis reaction is obtained 6
• DPCP is degraded by light—store solutions in the dark and have patients wear a hat or wig for 24 hours following application 6
• Most patients will develop occipital and/or cervical lymphadenopathy during treatment, which is usually temporary 6

Systemic Treatment for Severe Disease

For severe alopecia areata (SALT score ≥20 or moderate-to-severe on AAS scale): Consider JAK inhibitors—baricitinib (JAK 1/2 inhibitor) for adults or ritlecitinib (JAK 3/TEC inhibitor) for individuals aged 12 and older. 7

• These are the only EMA-approved medications for severe alopecia areata 7
• Other systemic medications used off-label include glucocorticosteroids, cyclosporine, methotrexate, and azathioprine 7

Treatments with Limited or No Efficacy

• Topical corticosteroids are widely prescribed but have limited evidence of efficacy 5
• Topical minoxidil has limited efficacy in alopecia areata, with variable response rates of only 32-33%—neither minoxidil nor spironolactone is considered first-line therapy 5, 6
• PUVA (psoralen plus ultraviolet A) shows low response rates no better than the natural course of disease, with high relapse rates 6
• Systemic corticosteroids should NOT be routinely used due to potential serious side effects and inadequate evidence of efficacy 5

Important Consideration: No Treatment May Be Appropriate

No treatment is a legitimate option for many patients, especially those with limited disease of short duration (<1 year), as spontaneous remission occurs in up to 80% of patients with limited patchy hair loss. 5

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Common Side Effects and Safety Considerations

For Minoxidil

• Most common side effects are itching and skin irritation of the treated scalp area 2
• If scalp irritation continues, stop use and see a doctor 2
• Unwanted facial hair growth can occur but is rare and reversible with discontinuation 2
• Avoid contact with eyes—if accidental contact occurs, rinse with large amounts of cool tap water 2
• Stop use immediately if chest pain, rapid heartbeat, faintness, dizziness, sudden unexplained weight gain, or swelling of hands/feet occurs 2

For Hair Treatments During Minoxidil Use

• Hair coloring, perming, and relaxers can be used, but ensure all minoxidil is washed off before applying chemicals 2
• Do not apply minoxidil on the same day as chemical hair treatments 2
• Do not use minoxidil for 24 hours after chemical treatments to ensure no scalp irritation 2
• Hair sprays, mousses, and styling products may be used after minoxidil has soaked into the scalp 2