What are the management options for scalp alopecia (hair loss)?

From the Guidelines

For the management of scalp alopecia, particularly alopecia areata, intralesional corticosteroids such as triamcinolone acetonide (5-10mg/ml) injected into affected areas every 4-6 weeks are often recommended. This approach is supported by evidence from the British Association of Dermatologists' guidelines for the management of alopecia areata 2012 1, which suggests that intralesional corticosteroids can stimulate hair regrowth at the site of injection in some patients. The guidelines mention that 62% of patients achieved full regrowth with monthly injections of triamcinolone acetonide, with better responses in those with fewer than five patches of < 3 cm in diameter.

Key Considerations for Treatment

• Intralesional corticosteroids are most suitable for treating patchy hair loss of limited extent and for cosmetically sensitive sites such as the eyebrows.
• Hydrocortisone acetate (25 mg mL) and triamcinolone acetonide (5–10 mg mL) are commonly used, with the corticosteroid injected just beneath the dermis in the upper subcutis.
• Multiple injections may be given, with the main limitation being patient discomfort.
• Topical corticosteroids, such as very potent topical steroids, may also be used but the evidence for their effectiveness is limited 1.
• For extensive cases of alopecia areata, systemic treatments such as oral JAK inhibitors like baricitinib or tofacitinib may be considered.

Additional Recommendations

• Gentle hair care practices are important: avoid harsh chemicals, tight hairstyles, excessive heat styling, and use mild shampoos.
• Nutritional support with adequate protein, iron, zinc, and vitamins (especially biotin and vitamin D) can improve hair health.
• Treatment success depends on early intervention, consistent application of therapies, and addressing underlying causes, as hair regrowth takes time and patience.
• For scarring alopecias, early intervention with anti-inflammatory medications is crucial.
• Children may be treated similarly to adults, but intralesional corticosteroids are often poorly tolerated, and many clinicians are reluctant to use aggressive treatments such as contact immunotherapy in children 1.

From the FDA Drug Label

When do I use minoxidil topical solution 5%? Apply minoxidil topical solution 5% once in the morning and once at night. Directions for Use

1. Remove the cap. To remove, push down and turn in direction of the arrows on the cap.
2. Part your hair in the area of hair thinning/loss Follow the instructions below for using the dropper applicator and apply one mL 2 times a day directly onto the scalp in the hair loss area.

To manage scalp alopecia, apply minoxidil topical solution 5% twice a day, once in the morning and once at night, directly onto the scalp in the hair loss area. Use the dropper applicator to apply one mL of the solution, and spread it evenly over the hair loss area. Allow the solution to stay on the scalp for at least 4 hours before washing your hair.

• Use a mild shampoo if you wash your scalp before applying minoxidil topical solution 5%.
• Avoid using the solution more than twice a day, as it will not work faster or better and may increase the chance of side effects.
• If you miss a dose, do not make up for it, just continue with your next dose. 2

From the Research

Management of Scalp Alopecia

To manage scalp alopecia, several treatment options are available, including:

• Finasteride and minoxidil, which are Food and Drug Administration-approved treatments that offer stability and in some cases improvement in scalp coverage 3
• Platelet-rich plasma, which exhibits positive results as an off-label alopecia therapy 3
• Hair transplantation, which is effective for eligible individuals, using healthy follicular units to restore hair-bearing areas 3
• Corticosteroids, such as intralesional or topical steroids, which are often used as first-line treatment for mild cases of alopecia areata 4
• Topical immunotherapy with diphenylcyclopropenone or squaric acid dibutylester, which may be used in severe cases of alopecia areata 4
• Minoxidil and bimatoprost, which may be recommended, usually in combination with another treatment 4
• Janus kinase (JAK) inhibitors, such as baricitinib and ritlecitinib, which are a promising drug class for treating severe alopecia areata cases 5

Treatment Approaches

The treatment approach for scalp alopecia depends on the underlying cause and severity of the condition. For example:

• Androgenetic alopecia can be diagnosed clinically and treated with minoxidil 6
• Alopecia areata is diagnosed by typical patches of hair loss and is self-limited, but may require treatment with corticosteroids or other immunosuppressants 6, 4
• Telogen effluvium is a nonscarring, noninflammatory alopecia of relatively sudden onset caused by physiologic or emotional stress, and typically resolves once the precipitating cause is removed 6
• Trichotillomania is an impulse-control disorder, and treatment is aimed at controlling the underlying psychiatric condition 6

Importance of Physician Support

Physician support is especially important for patients with scalp alopecia, as the condition can have substantial psychological consequences and a negative impact on quality of life 7. A thorough examination is needed to rule out other causes of hair loss, and the ability to recognize and distinguish between different conditions is crucial for providing adequate and timely treatment 7.