What are the NICE (National Institute for Health and Care Excellence) guidelines for treating alopecia areata?

NICE Guidelines for Alopecia Areata Treatment

Critical First Point: No Treatment is Often the Best Treatment

For patients with limited patchy alopecia areata of short duration (<1 year), watchful waiting with reassurance is the recommended first-line approach, as spontaneous remission occurs in up to 80% of these patients, and no treatment has been proven to alter the long-term disease course. 1, 2, 3

Treatment Algorithm Based on Disease Severity

Mild Disease (Limited Patchy Alopecia, <50% Scalp Involvement)

Intralesional corticosteroids are the first-line active treatment when intervention is warranted (Strength of recommendation B). 1, 4, 3

• Use triamcinolone acetonide 5-10 mg/mL or hydrocortisone acetate 25 mg/mL injected just beneath the dermis 1, 3
• Each 0.05-0.1 mL injection produces approximately 0.5 cm diameter tuft of hair growth 1, 4
• Administer monthly injections until satisfactory response is achieved 4
• Success rate: 62% achieve full regrowth, with better outcomes in patients having fewer than five patches <3 cm in diameter 1, 4, 3
• Skin atrophy at injection sites is a consistent and expected side-effect 1, 2

Alternative: Topical clobetasol propionate 0.05% foam or cream applied twice daily (Strength of recommendation C, Quality of evidence III) 4

• Achieves ≥50% hair regrowth in 21% of treated sites versus 3% with placebo at 12 weeks 4
• Folliculitis is the most common side-effect 1, 4
• Evidence for potent topical corticosteroids remains limited; one randomized controlled trial of 0.25% desoximetasone cream failed to show significant effect over placebo 1

Severe Disease (Alopecia Totalis/Universalis, >50% Scalp Involvement)

Contact immunotherapy with diphenylcyclopropenone (DPCP) is the only treatment likely to be effective, though response rates remain disappointingly low (Strength of recommendation C). 3

• Achieves cosmetically worthwhile hair regrowth in <50% of patients with severe disease 3
• Response rate in alopecia totalis/universalis is only 17% 3
• DNCB should not be used due to mutagenicity; SADBE and DPCP are non-mutagenic alternatives 1

Treatments NOT Recommended by British Guidelines

Avoid continuous or pulsed systemic corticosteroids, PUVA therapy, and oral prednisolone courses due to potentially serious side-effects and inadequate efficacy evidence. 3

• One small study showed 30-47% of patients treated with 6-week tapering oral prednisolone (starting at 40 mg daily) achieved >25% hair regrowth, but this does not justify routine use 1

Critical Caveats and Pitfalls

No treatment alters the long-term course of alopecia areata; all interventions only induce temporary hair growth with high relapse rates. 1, 2, 4, 3

• Patients must be warned about possible relapse during or following initially successful treatment 2
• The high rate of spontaneous remission makes efficacy assessment difficult, particularly in mild disease 1
• Do not change any topical treatment sooner than 3 months after starting; early regrowth may first appear at 3 months 5
• Cosmetic regrowth may take a year or more to achieve 5
• The prognosis for long-standing extensive alopecia is generally poor, with all treatments having high failure rates in this group 1, 2

Disease severity at presentation is the strongest predictor of long-term outcome: 68% of patients with <25% initial hair loss report being disease-free at follow-up. 4

Diagnostic Confirmation

The diagnosis can be made clinically without laboratory testing in most cases. 2, 4

Key clinical features include:

• Round/oval patches of complete hair loss 4
• Short broken hairs with tapered ends ("exclamation point hairs") 4
• Slightly reddened skin 4
• Yellow dots on dermoscopy indicating active disease 2, 4, 3

Investigations are only necessary when diagnosis is uncertain: 2, 4

• Fungal culture (to exclude tinea capitis)
• Skin biopsy
• Serology for lupus erythematosus or syphilis

Differential diagnoses to exclude: trichotillomania, tinea capitis, early scarring alopecia, telogen effluvium, systemic lupus erythematosus, and secondary syphilis 2, 4

Psychosocial Management

Addressing the psychological impact is essential, as alopecia areata can cause serious psychological effects including anxiety, depression, and social difficulties despite having no direct impact on general health. 1, 2, 4, 3

• Recommend psychological support and contact with patient support groups 2
• Patients may feel self-conscious, conspicuous, angry, rejected, or embarrassed 4
• Children and adolescents often experience bullying, including physical aggression 6

Additional Considerations

Routine screening for other autoimmune diseases is not justified despite the association between alopecia areata and other autoimmune conditions. 3

Topical minoxidil 5% can be added as adjunctive therapy but should not be used as monotherapy. 4