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

Management of Alopecia Areata

Initial Assessment and Observation

For patients with limited patchy alopecia areata of short duration (<1 year), reassurance without active treatment is a legitimate first-line approach, as spontaneous remission occurs in up to 80% of these patients. 1

• Hair regrowth cannot be expected within 3 months of any individual patch developing, so patients should be counseled about this timeline 1
• No laboratory investigations are necessary when the diagnosis is clinically clear 1, 2
• The prognosis is strongly related to disease severity at presentation: 68% of patients with less than 25% hair loss initially will be free of disease at follow-up 2

First-Line Active Treatment: Intralesional Corticosteroids

When intervention is desired, intralesional triamcinolone acetonide injections are the first-line treatment for limited patchy alopecia areata. 2

Injection Technique

• Use triamcinolone acetonide at 5-10 mg/mL concentration 1, 3
• Inject just beneath the dermis in the upper subcutaneous tissue 1, 3
• 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 achieved 1, 3

Expected Efficacy

• 62% of patients achieve full regrowth with monthly injections, with best results in those having fewer than five patches less than 3 cm in diameter 1, 2
• Hair regrowth effects last approximately 9 months 1
• Success rates are higher in mild-to-moderate disease compared to extensive alopecia 4

Adverse Effects

• Skin atrophy at injection sites is the most consistent side effect, particularly with triamcinolone 1
• Mild pain during injection is common 3

Second-Line Treatment: Topical Corticosteroids

For patients who cannot tolerate intralesional injections or prefer topical therapy, clobetasol propionate 0.05% foam or cream applied twice daily is recommended. 2

• Apply to affected areas twice daily 2
• Clobetasol propionate 0.05% foam achieved ≥50% hair regrowth in 21% of treated sites versus 3% with placebo at 12 weeks 2
• Evidence for topical corticosteroids remains limited overall, with one randomized trial of desoximetasone cream showing no significant benefit over placebo 1
• 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

• The FDA label indicates minoxidil 5% is not approved for alopecia areata and specifically states it will not improve hair loss due to autoimmune conditions 5
• Limited evidence suggests 2% topical minoxidil three times daily may help limit post-corticosteroid hair loss 6
• Minoxidil has limited efficacy in alopecia areata according to the British Association of Dermatologists 7

Systemic Therapy for Extensive Disease

For patients with severe alopecia areata (SALT score ≥20 or extensive involvement):

• A 6-week tapering course of oral prednisone (starting at 40 mg daily) produces >25% hair regrowth in 30-47% of patients 1, 6
• Primary side effects include weight gain and mood changes/emotional lability 6
• JAK inhibitors (baricitinib for adults, ritlecitinib for age 12+) are EMA-approved for severe alopecia areata 8
• Other off-label systemic options include cyclosporine, methotrexate, and azathioprine 8

Critical Prognostic Factors

• Disease duration longer than 6 months is associated with significantly lower probability of achieving significant hair regrowth 9
• Long-standing extensive alopecia typically has poor prognosis, with high treatment failure rates 1
• Hair follicles remain preserved even in longstanding disease, maintaining potential for recovery 2

Important Caveats

• No treatment has been shown to alter the long-term course of alopecia areata—all treatments induce hair growth but do not prevent future episodes 1
• High relapse rates occur even with initially successful treatment 2
• The disease has no direct impact on general health, which does not justify hazardous treatments of unproven efficacy 1
• Addressing psychological impact is essential, as patients often experience significant emotional distress 2