Management of Alopecia Areata in Children
In most pediatric cases of alopecia areata, watchful waiting without treatment is the best initial approach, as spontaneous remission is common and aggressive treatments carry significant risks in children. 1
Treatment Algorithm Based on Disease Extent
Limited Patchy Hair Loss
- Intralesional corticosteroids are the first-line treatment option for limited patchy disease, achieving full regrowth in 62% of patients with monthly injections 2
- However, this approach is often poorly tolerated in children due to pain from injections, making it less practical in pediatric populations 1
- Topical corticosteroids are widely prescribed and represent a safer alternative, though evidence for their efficacy is limited 1
Extensive Patchy Hair Loss
- Contact immunotherapy is recommended as first-line treatment for extensive disease, with strength of recommendation B II-ii 1, 2
- This therapy stimulates cosmetically worthwhile regrowth in less than 50% of patients and requires multiple hospital visits over several months 1
- Many clinicians are reluctant to use contact immunotherapy in children due to concerns about aggressive treatment in this age group 1
Alopecia Totalis/Universalis
- Contact immunotherapy remains the only treatment likely to be effective, though response rates are even lower than in extensive patchy disease (strength of recommendation C) 1, 2
- Wigs should be offered as a practical cosmetic solution (strength of recommendation D) 1
Treatments to Avoid
Insufficient Evidence
- Dithranol (anthralin) and minoxidil lotion are widely prescribed but lack convincing evidence of efficacy 1
- Potent topical corticosteroids are safe but similarly lack strong evidence for effectiveness 1
Not Recommended Due to Risk-Benefit Profile
- Continuous or pulsed systemic corticosteroids cannot be recommended due to potentially serious side effects and inadequate efficacy evidence 1
- PUVA therapy is not recommended for the same reasons 1
Emerging Therapies
- Ritlecitinib (JAK 3/TEC inhibitor) is EMA-approved for individuals aged 12 and older with severe alopecia areata 3
- Baricitinib (JAK 1/2 inhibitor) is EMA-approved for adults only 3
- Topical corticosteroids hold the highest level of evidence as first-line treatment in systematic reviews of pediatric AA 4
Critical Management Principles
Psychological Support
- Psychological support is crucial, particularly for adolescents, as children with alopecia areata often experience bullying, including physical aggression, along with anxiety, depression, and social difficulties 2, 3
Setting Realistic Expectations
- No treatment has been shown to alter the long-term course of alopecia areata 2
- Patients and families should be warned about possible relapse during or following initially successful treatment 2
- The tendency toward spontaneous remission is an important consideration that often makes observation the most appropriate choice 1
Common Pitfalls
- Avoid using aggressive systemic immunosuppression (methotrexate, cyclosporine, azathioprine) as first-line therapy, as evidence supporting their use in pediatric AA is extremely limited 5
- Do not prescribe treatments with inadequate efficacy evidence, such as oral zinc and isoprinosine 2
- Recognize that intralesional steroids, while evidence-based, are often impractical in children due to poor tolerance 1