What is the primary treatment goal and typical treatment regimen for a patient with alopecia areata?

Treatment of Alopecia Areata

Primary Treatment Goal and First-Line Approach

For limited patchy alopecia areata (fewer than 5 patches, <3 cm diameter), intralesional corticosteroid injections with triamcinolone acetonide 5-10 mg/mL are the first-line treatment, achieving 62% complete regrowth with monthly injections. 1, 2, 3

However, observation without treatment is equally legitimate, as spontaneous remission occurs in up to 80% of patients with limited hair loss of short duration (<1 year). 1, 3

Treatment Algorithm Based on Disease Extent

Limited Patchy Disease (<5 patches, <3 cm)

Intralesional corticosteroids are optimal:

• Use triamcinolone acetonide 5-10 mg/mL injected just beneath the dermis in the upper subcutis 1, 3
• Each 0.05-0.1 mL injection produces regrowth of approximately 0.5 cm diameter 1
• Repeat monthly injections until satisfactory response is achieved 2
• Effects last approximately 9 months 1

Alternative topical therapy (less effective):

• Clobetasol propionate 0.05% foam applied twice daily achieves ≥50% regrowth in 21% versus 3% with placebo 2
• British Association of Dermatologists assigns this a strength of recommendation C with quality of evidence III, indicating limited efficacy 2, 3
• Folliculitis is the most common side effect 2

Extensive Patchy Disease or Multiple Patches

Contact immunotherapy with diphenylcyclopropenone (DPCP) is most effective:

• Response rate of 50-60% achieving cosmetically acceptable results 1, 3
• British Association of Dermatologists recommendation strength B with evidence quality II-ii 1, 3
• Wide variability in response rates (9-87%) across studies 3

Alopecia Totalis/Universalis

Contact immunotherapy remains first-line but with lower expectations:

• Response rate drops to approximately 17% 3
• Patients with extensive disease tend to be resistant to all forms of treatment 3
• A wig or hairpiece is often the most effective solution for quality of life 3

Emerging Systemic Therapies

Baricitinib (JAK 1/2 inhibitor) is the only treatment with high-certainty evidence for efficacy:

• Results in significant increase in short-term hair regrowth ≥75% compared to placebo (RR 7.54,95% CI 3.90-14.58) 4
• Also increases long-term hair regrowth ≥75% (RR 8.49,95% CI 4.70-15.34) 4
• EMA-approved for adults with severe alopecia areata 5
• May result in little to no difference in serious adverse events versus placebo, though small incidence of serious events should be balanced against benefits 4

Ritlecitinib (JAK 3/TEC inhibitor):

• EMA-approved for individuals aged 12 and older with severe alopecia areata 5

Other systemic options (off-label, limited evidence):

• Oral betamethasone may increase short-term regrowth compared to prednisolone or azathioprine 4
• Methotrexate 15-25 mg/week showed complete regrowth in 14 of 22 patients in retrospective review 1
• Cyclosporine has convincing evidence for stimulating regrowth but side effects may outweigh benefits 1

Adjunctive Therapies

Topical minoxidil 5%:

• Can be added as adjunctive therapy but should not be used as monotherapy 2
• Evidence suggests it may increase regrowth (RR 2.31,95% CI 1.34-3.96) but with very low-certainty evidence 4

Critical Treatment Considerations

No treatment alters the long-term course of alopecia areata:

• All interventions only induce temporary hair growth 2, 3
• Patients should be warned about high relapse rates even with initially successful treatment 2, 3
• Regrowth cannot be expected within 3 months of any individual patch development 3

Disease severity predicts outcome:

• 68% of patients with less than 25% initial hair loss report being disease-free at follow-up 2
• Prognosis in long-standing extensive alopecia is usually poor with high failure rates for all treatments 2

Systemic treatment indications:

• SALT score ≥20 constitutes commonly accepted indication for systemic therapy 5
• Moderate to severe disease on Alopecia Areata Scale should be considered for systemic treatment 5

Psychological Support

Addressing psychological impact is essential:

• Alopecia areata causes considerable psychological and social disability 3
• Children and adolescents often experience bullying, including physical aggression 5
• Psychological support should be offered, especially for children showing behavioral changes (withdrawal, low self-esteem, failing at school) 3

Common Pitfalls

Avoid aggressive treatment in mild disease:

• High spontaneous remission rates make efficacy assessment difficult 3
• Observation is legitimate and often appropriate for limited disease of short duration 1, 3

Do not use systemic corticosteroids routinely:

• Continuous or pulsed systemic corticosteroids cannot be recommended due to potentially serious side effects and inadequate evidence of efficacy 3

Children require special consideration:

• Intralesional corticosteroids are often poorly tolerated in children 3
• Many clinicians are reluctant to use aggressive treatments like contact immunotherapy in pediatric patients 3