What is the recommended treatment approach for alopecia areata, including first‑line and second‑line options for adults and children?

Treatment of Alopecia Areata

Initial Management Decision

For limited patchy alopecia areata of recent onset (< 1 year), watchful waiting without treatment is a legitimate and often preferred approach, as spontaneous remission occurs in up to 80% of these patients within 3 months per patch. 1

Treatment Algorithm by Disease Extent

Limited Patchy Disease (Few Small Patches)

First-line treatment:

• Intralesional corticosteroids (triamcinolone acetonide 5-10 mg/mL or hydrocortisone acetate 25 mg/mL) injected monthly into affected areas achieve full regrowth in 62% of patients, particularly those with fewer than five patches < 3 cm in diameter. 1
• Inject 0.05-0.1 mL just beneath the dermis in the upper subcutis, producing hair growth tufts approximately 0.5 cm in diameter per injection site 1
• Effects last approximately 9 months 1
• This approach is most suitable for cosmetically sensitive sites such as eyebrows 1

Second-line treatment:

• Very potent topical corticosteroids (0.05% clobetasol propionate foam) can be used, though evidence for effectiveness is limited 1
• In one trial, clobetasol propionate foam achieved ≥50% regrowth in 7 of 34 treated sites versus 1 of 34 vehicle-treated sites after 12 weeks 1
• Folliculitis is a common side effect 1

Extensive Patchy Disease or Rapidly Progressive Disease

First-line treatment:

• Contact immunotherapy is recommended as first-line treatment for extensive disease (Strength of Recommendation B), though it stimulates cosmetically worthwhile regrowth in less than 50% of patients 2
• Many clinicians are reluctant to use this in children due to concerns about aggressive treatment 2

Alopecia Totalis/Universalis (Complete Scalp or Body Hair Loss)

The prognosis in long-standing extensive alopecia is poor, and a wig may be a better option than treatments that are unlikely to be effective in this group. 1

• Contact immunotherapy can be attempted (Strength of Recommendation C), though response rates are low 2
• JAK inhibitors (baricitinib and ritlecitinib) are FDA-approved for severe alopecia areata and represent the most promising treatment for extensive disease 3, 4

Pediatric Considerations

Watchful waiting without treatment is the best initial approach for pediatric alopecia areata due to high spontaneous remission rates and significant risks of aggressive treatments in children. 2

• Intralesional corticosteroids are often poorly tolerated in children due to injection pain 2
• Topical corticosteroids represent a safer alternative, though evidence for efficacy is limited 2
• If a child shows significant psychological changes (withdrawn behavior, low self-esteem, failing at school, behavioral changes), referral to a pediatric clinical psychologist, educational psychologist, or social worker is needed 1

Treatments to Avoid

The following treatments cannot be recommended due to inadequate efficacy evidence or potentially serious side effects:

• Continuous or pulsed systemic corticosteroids 2
• PUVA therapy 2
• Dithranol (anthralin) and minoxidil lotion lack convincing evidence of efficacy 2
• Oral zinc and isoprinosine have inadequate evidence 2

Critical Management Principles

No treatment has been shown to alter the long-term course of alopecia areata—treatments can induce hair growth but do not change disease trajectory. 1

• Do not expect regrowth within 3 months of any individual patch developing 1
• Do not change topical treatments sooner than 3 months after starting; cosmetic regrowth may take a year or more to achieve 5
• Patients should be forewarned about possible relapse during or following initially successful treatment 1
• Treatment can be uncomfortable, time-consuming, and may alter the patient's attitude toward their hair loss 1

Counseling and Psychological Support

An explanation of alopecia areata, including discussion of the disease nature, course, and available treatments, is essential for all patients. 1

• Many patients find it difficult to disclose their alopecia to family and friends 1
• Contact with patient support groups can help individuals cope with changing aspects of alopecia and find self-acceptance 1
• The psychological effects may lead to higher levels of anxiety, greater risk of depression, and social, work-related, and personal problems 1

Common Pitfalls

• Treating the entire scalp instead of "chasing" patches maximizes potential for cosmetic hair growth in extensive or flaring disease 5
• Avoid using hazardous treatments for a disease that has no direct impact on general health, despite its serious psychological effects 1
• Maintenance treatment increases the likelihood of maintaining cosmetic hair growth, but patches may still come and go 5