Treatment Guidelines for Alopecia Areata
Initial Management Decision
For patients with limited patchy alopecia areata of short duration, reassurance without active treatment is a legitimate first-line approach, as spontaneous remission occurs in up to 80% of these patients, with regrowth typically not expected within 3 months of patch development 1, 2.
Treatment Algorithm Based on Disease Extent
Limited Patchy Disease (< 5 patches, each < 3 cm diameter)
Intralesional triamcinolone acetonide injections are the first-line treatment when intervention is desired 2:
- Inject triamcinolone acetonide 5-10 mg/mL just beneath the dermis in the upper subcutis 1, 3
- Each 0.05-0.1 mL injection produces approximately 0.5 cm diameter tuft of hair growth 1, 3
- Repeat monthly injections until satisfactory response is achieved 2
- This approach achieves 62% full regrowth rates in appropriately selected patients 2
- Main limitation is patient discomfort from multiple injections 1
- Cutaneous atrophy at injection sites is the most consistent adverse effect 3
Moderate to Extensive Disease
Topical clobetasol propionate 0.05% foam or cream applied twice daily to affected areas 2:
- Achieved ≥50% hair regrowth in 21% of treated sites versus 3% with placebo at 12 weeks 2
- However, evidence quality remains limited (Strength of recommendation C, Quality of evidence III) 1, 2
- Folliculitis is the most common side-effect 1, 4
- Tinea versicolor of the neck area can develop after 3-4 months of prolonged high-potency topical steroid use under occlusion 4
Topical minoxidil 5% can be added as adjunctive therapy but should not be used as monotherapy 2.
Severe Disease (SALT score ≥ 20)
Systemic therapy should be considered, with baricitinib (JAK 1/2 inhibitor) and ritlecitinib (JAK 3/TEC inhibitor) being the only EMA-approved medications 5:
- Baricitinib is approved for adults with severe alopecia areata 5
- Ritlecitinib is approved for individuals aged 12 and older with severe disease 5
- Off-label systemic options include glucocorticosteroids, cyclosporine, methotrexate, and azathioprine 5
Critical Caveats and Pitfalls
No treatment has been shown to alter the long-term course of alopecia areata; all interventions only induce temporary hair growth 1, 2:
- High relapse rates occur even with initially successful treatment 2
- The prognosis in long-standing extensive alopecia is usually poor, with high failure rates for all treatments 1, 2
- Do not change any topical treatment sooner than 3 months after starting it, as early regrowth may first appear at 3 months 6
- Cosmetic regrowth may take a year or more to achieve 6
Disease severity at presentation is the strongest predictor of long-term outcome: 68% of patients with less than 25% initial hair loss report being disease-free at follow-up 2.
Diagnostic Confirmation
The diagnosis can be made clinically without laboratory testing in most cases 2:
- Key features include round/oval patches of complete hair loss, short broken hairs with tapered ends ("exclamation point hairs"), slightly reddened skin, and yellow dots on dermoscopy 2
- Investigations are only necessary when diagnosis is in doubt 1, 2
- Appropriate tests include fungal culture, skin biopsy, serology for lupus erythematosus, or serology for syphilis 1, 2
Differential diagnoses to exclude: trichotillomania, tinea capitis, telogen effluvium, systemic lupus erythematosus, and secondary syphilis 1, 2.
Psychosocial Considerations
Addressing the psychological impact is important, as patients may feel self-conscious, conspicuous, angry, rejected, or embarrassed 2. The disease has serious psychological effects despite having no direct impact on general health, which does not justify the use of hazardous treatments of unproven efficacy 1.