What is the workup for alopecia areata (autoimmune hair loss condition)?

From the Guidelines

The workup for alopecia areata should begin with a thorough history and physical examination to determine the pattern, onset, and progression of hair loss, and may include laboratory testing such as complete blood count, thyroid function tests, iron studies, and vitamin D levels, as well as a pull test and dermoscopy to guide treatment decisions 1. The physical examination should assess the scalp for inflammation, scarring, and pattern of hair loss.

• Key elements of the history include:
  • Recent illnesses
  • Medications
  • Nutritional status
  • Family history of hair disorders
  • Psychological stressors In cases where diagnosis remains unclear, a scalp biopsy may be necessary to differentiate between scarring and non-scarring forms of alopecia.
• Treatment options may include intralesional corticosteroids, such as triamcinolone acetonide, which have been shown to stimulate hair regrowth in some patients with alopecia areata 1. Intralesional corticosteroids are a recommended treatment option for alopecia areata, particularly for patchy hair loss of limited extent and cosmetically sensitive sites such as the eyebrows, with a response rate of 62% in patients with fewer than five patches of < 3 cm in diameter 1. The use of topical corticosteroids, such as clobetasol propionate, may also be considered, although the evidence for their effectiveness is limited 1.
• Potential side effects of treatment, such as folliculitis, should be carefully monitored and managed. Overall, a comprehensive approach to the workup and treatment of alopecia areata is necessary to identify underlying causes and develop targeted treatment strategies, taking into account the potential for spontaneous remission and the importance of minimizing adverse effects on general health 1.

From the Research

Diagnostic Approach for Alopecia Areata

• The diagnostic approach for alopecia areata is not clearly established, with indirect evidence and expert opinion suggesting that a careful history and thorough physical examination can usually suggest the underlying cause of alopecia 2.
• Ancillary laboratory evaluation and scalp biopsy may be necessary to make or confirm the diagnosis 2.

Treatment Options for Alopecia Areata

• Current management of alopecia areata is guided by the degree of scalp and body involvement, with topical and intralesional steroid injections as primarily first-line for mild cases and broad immunosuppressants as the mainstay for more severe cases 3.
• Intralesional triamcinolone acetonide is considered a first-line treatment for patchy alopecia areata, with concentrations of 5 mg/mL and 10 mg/mL showing similar efficacy and safety 4.
• Intralesional methotrexate may be a promising alternative to triamcinolone acetonide, with comparable effectiveness and safety in the treatment of localized alopecia areata 5.
• Janus kinase inhibitors, such as baricitinib and ritlecitinib, have shown promise in the treatment of severe alopecia areata cases 3, 6.

Factors Affecting Treatment Response

• Disease duration exceeding 6 months may correlate with poor treatment response 4.
• The psychosocial aspects of alopecia areata, including depression and anxiety, should be evaluated and addressed to provide appropriate psychological support when needed 6.