What are the treatment options for a patient with alopecia areata?

Management of Alopecia Areata

Initial Assessment and Treatment Decision

For patients with limited patchy alopecia areata of short duration, reassurance alone is a legitimate first-line approach, as spontaneous remission occurs in up to 80% of these patients within one year. 1, 2 However, if intervention is desired for cosmetically significant disease, intralesional triamcinolone acetonide injections represent the first-line treatment. 2

When to Observe vs. Treat

• Observation is appropriate for patients with fewer than 5 patches, each less than 3 cm in diameter, and disease duration under 1 year, as these patients have the highest spontaneous remission rates. 1, 2
• Counsel patients that regrowth cannot be expected within 3 months of any individual patch developing. 1
• Active treatment should be considered when patients desire intervention, have cosmetically significant disease, or have more extensive involvement. 2

First-Line Treatment: Intralesional Corticosteroids

Intralesional triamcinolone acetonide achieves 62% full regrowth rates in patients with fewer than five patches less than 3 cm in diameter, making it the most effective first-line intervention. 2

Administration Protocol

• Use triamcinolone acetonide at 5-10 mg/mL concentration. 1, 3
• Inject 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, 3
• Administer multiple injections across affected areas, limited primarily by patient discomfort. 1
• Repeat monthly until satisfactory response is obtained. 3

Expected Outcomes and Side Effects

• Hair regrowth typically lasts approximately 9 months after successful treatment. 1
• Skin atrophy at injection sites is the most consistent side effect, particularly with triamcinolone. 1, 3
• Pain during injection is common but can be minimized with topical anesthetic under occlusion before the procedure. 3

Second-Line Treatment: Topical Corticosteroids

For patients who cannot tolerate intralesional injections or prefer topical therapy, clobetasol propionate 0.05% foam or cream can be used, though efficacy is limited. 2

Application and Efficacy

• Apply twice daily to affected areas. 2
• Clobetasol propionate 0.05% foam achieved ≥50% hair regrowth in only 21% of treated sites versus 3% with placebo at 12 weeks. 2
• The British Association of Dermatologists notes that evidence for topical steroids remains limited despite widespread use. 2
• Folliculitis is the most common side effect. 1, 2

Adjunctive Therapy: Topical Minoxidil

Topical minoxidil 5% can be added as adjunctive therapy but should not be used as monotherapy for alopecia areata. 2

• Minoxidil appears to help limit post-steroid hair loss when used after systemic corticosteroid tapers. 4
• The British Association of Dermatologists states that minoxidil has limited efficacy in alopecia areata. 5

Systemic Therapy for Severe Disease

For patients with SALT score ≥20 or severe alopecia areata (alopecia totalis/universalis), systemic therapy should be considered. 6

Oral Corticosteroids (Short-term Use)

• A 6-week tapering course of oral prednisone starting at 40 mg daily achieved >25% hair regrowth in 30-47% of patients. 1, 4
• Side effects include weight gain and mood changes/emotional lability. 4
• This approach offers potential for regrowth with predictable and transient side effects. 4

JAK Inhibitors (EMA-Approved)

• Baricitinib (JAK 1/2 inhibitor) is approved for adults with severe alopecia areata. 6
• Ritlecitinib (JAK 3/TEC inhibitor) is approved for individuals aged 12 and older with severe disease. 6

Prognostic Factors

Disease severity at presentation is the strongest predictor of long-term outcome, with 68% of patients having less than 25% initial hair loss reporting disease-free status at follow-up. 2

Poor Prognostic Indicators

• Long-standing extensive alopecia (duration >6 months) has poor prognosis and lower treatment response rates. 1, 7
• Alopecia totalis and universalis are resistant to most treatments. 1
• Treatment duration longer than 6 months is associated with lower probability of significant hair regrowth. 7

Important Caveats

• No treatment has been shown to alter the long-term course of alopecia areata—all interventions only induce temporary hair growth. 1
• High relapse rates occur even with initially successful treatment. 2
• Hair follicles remain preserved even in longstanding disease, maintaining potential for recovery. 2
• The disease has no direct impact on general health that justifies hazardous treatments of unproven efficacy. 1

Psychosocial Support

Address the psychological impact, as patients may feel self-conscious, conspicuous, angry, rejected, or embarrassed. 2 For extensive disease unresponsive to treatment, wigs represent a legitimate management option. 1