What is the recommended treatment for an adult with uncomplicated patchy alopecia areata?

Treatment of Patchy Alopecia Areata

Primary Recommendation

For adults with uncomplicated patchy alopecia areata, reassurance without active treatment is the most appropriate initial approach, as spontaneous remission occurs in up to 80% of patients with limited patchy hair loss of short duration (< 1 year). 1, 2 If intervention is desired or the patient requests treatment, intralesional triamcinolone acetonide injections are the first-line therapy. 3, 2

Treatment Algorithm Based on Patient Preference

Option 1: Observation (Preferred Initial Approach)

• Reassurance alone is a legitimate and evidence-based first-line management strategy for limited patchy alopecia areata. 1, 2
• Patients should be counseled that regrowth cannot be expected within 3 months of any individual patch developing. 1
• This approach is justified because no treatment has been shown to alter the long-term course of the disease—all interventions only induce temporary hair growth. 1, 2
• The disease has no direct impact on general health that justifies hazardous treatments. 1

Option 2: Active Treatment (When Patient Desires Intervention)

First-Line: Intralesional Corticosteroids

• Intralesional triamcinolone acetonide is the treatment with the strongest evidence (Strength of recommendation B, Quality of evidence III). 1, 3
• Use triamcinolone acetonide 5-10 mg/mL or hydrocortisone acetate 25 mg/mL injected just beneath the dermis in the upper subcutis. 1
• Each 0.05-0.1 mL injection produces approximately 0.5 cm diameter tuft of hair growth. 1, 2
• Repeat monthly injections until satisfactory response is achieved. 2
• This approach achieves 62% full regrowth rates in patients with fewer than five patches less than 3 cm in diameter. 1, 3, 2
• The effect typically lasts about 9 months. 1
• This method is most suitable for treating patchy hair loss of limited extent. 1

Second-Line: Topical Corticosteroids (Limited Evidence)

• Topical clobetasol propionate 0.05% foam or cream applied twice daily can be considered, though evidence is limited (Strength of recommendation C, Quality of evidence III). 3, 2
• This achieved ≥50% hair regrowth in only 21% of treated sites versus 3% with placebo at 12 weeks. 3, 2
• A randomized controlled trial of 0.25% desoximetasone cream in 70 patients failed to show significant benefit over placebo. 1, 3
• Potent topical corticosteroids are widely used but there is little convincing evidence that they promote hair regrowth. 1
• Folliculitis is the most common side-effect. 1, 3, 2

Adjunctive Therapy

• Topical minoxidil 5% can be added as adjunctive therapy but should not be used as monotherapy. 3, 2

Critical Caveats and Pitfalls

High Relapse Rates

• Patients must be forewarned that relapse rates are high even with initially successful treatment. 3, 2
• Continued maintenance treatment is usually needed to maintain hair growth. 1
• No treatment alters the underlying disease course—only temporary hair growth is induced. 1, 2

Prognostic Factors

• 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. 3, 2
• The prognosis in long-standing extensive alopecia is usually poor, with high failure rates for all treatments. 1, 3

Diagnostic Confirmation

• The diagnosis can be made clinically without laboratory testing in most cases. 3, 2
• Key diagnostic 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. 3
• Investigations are only necessary when diagnosis is in doubt and may include fungal culture, skin biopsy, or serology for lupus/syphilis. 1, 2
• Exclude trichotillomania, tinea capitis, telogen effluvium, systemic lupus erythematosus, and secondary syphilis. 1, 3, 2

Psychosocial Considerations

• Addressing the psychological impact is essential, as patients may feel self-conscious, conspicuous, angry, rejected, or embarrassed. 1, 2
• The disease may have serious psychological effects despite having no direct impact on general health. 1, 2
• For extensive disease unresponsive to treatment, wigs may be the most effective solution. 1