What is the recommended treatment approach for a typical case of alopecia areata?

Treatment of Alopecia Areata

Initial Management: Watchful Waiting is Often Best

For most patients with limited patchy alopecia areata, watchful waiting without treatment is the recommended initial approach, as spontaneous remission occurs in 34-50% of cases within one year, and no treatment has been shown to alter the long-term course of the disease. 1, 2

The British Association of Dermatologists emphasizes that alopecia areata has no direct impact on general health that justifies hazardous treatments, making observation with reassurance a legitimate and often preferred option, particularly for patients with disease duration less than one year. 2

Treatment Algorithm Based on Disease Extent

Limited Patchy Disease (<50% scalp involvement, <5 patches)

Intralesional corticosteroids are the treatment of choice for localized patches when treatment is desired. 2

• Use triamcinolone acetonide 5-10 mg/mL or hydrocortisone acetate 25 mg/mL injected directly into affected areas. 2
• This achieves full regrowth in 62% of patients, with best response in those with fewer than five patches <3 cm in diameter. 1, 2
• Strength of recommendation: B. 2
• Common pitfall: Intralesional steroids are often poorly tolerated in children due to injection pain, making them impractical in pediatric populations. 1

Alternative for limited disease: Topical corticosteroids are safer but have limited evidence for efficacy. 1

Extensive Patchy Disease (>50% scalp involvement)

Contact immunotherapy with diphenylcyclopropenone (DPCP) is the first-line treatment for extensive disease. 1, 2

• Stimulates cosmetically worthwhile regrowth in less than 50% of patients with extensive disease. 1, 2
• Requires multiple hospital visits over months for sensitization and maintenance. 3
• Strength of recommendation: B II-ii for extensive patchy disease. 1
• Important caveat: Many clinicians are reluctant to use this in children due to concerns about aggressive treatment. 1

Alopecia Totalis/Universalis (Complete scalp or body hair loss)

Contact immunotherapy remains the only treatment likely to be effective, though response rates are disappointingly low at only 17%. 2

• Strength of recommendation: C. 2
• Practical consideration: Wigs provide immediate cosmetic benefit and should be offered to all patients with extensive disease. 3

FDA-Approved JAK Inhibitors (Most Recent Development)

Baricitinib (JAK 1/2 inhibitor) and ritlecitinib (JAK 3/TEC inhibitor) are now FDA and EMA-approved for severe alopecia areata. 4, 5

• Baricitinib is approved for adults with severe disease. 5
• Ritlecitinib is approved for individuals aged 12 and older with severe disease. 5
• These represent the most significant advancement in alopecia areata treatment, particularly for severe cases where traditional therapies have failed. 4
• Indication threshold: A SALT score ≥20 constitutes a commonly accepted indication for systemic therapy. 5

Treatments to AVOID

The following treatments should not be used due to inadequate efficacy evidence and potentially serious side effects: 1, 2

• Continuous or pulsed systemic corticosteroids (serious side effects, inadequate efficacy). 1, 2
• PUVA therapy (serious side effects, inadequate efficacy). 1, 2
• Oral zinc or isoprinosine (ineffective in controlled trials). 3
• Dithranol (anthralin) and minoxidil lotion (lack convincing evidence of efficacy). 1

Diagnostic Workup: Keep It Simple

Investigations are unnecessary in most cases when the diagnosis is clinically evident. 3, 2

• Look for exclamation mark hairs at patch margins—these are pathognomonic for alopecia areata. 3
• Dermoscopy aids diagnosis by identifying regular round yellow dots (active disease), exclamation mark hairs, and cadaverized hairs. 2
• Avoid this pitfall: Do not order extensive autoimmune panels in straightforward alopecia areata cases. 3
• Routine screening for other autoimmune diseases is not justified despite the association. 2

Critical Counseling Points

Patients must understand that no treatment alters the long-term course of alopecia areata, and relapse is possible during or following initially successful treatment. 1, 3

• Regrowth cannot be expected within 3 months of any individual patch development. 3
• Treatment must be continuous to maintain results; stopping will result in hair loss resuming. 3
• Psychological support is crucial, particularly for adolescents, to address anxiety, depression, and social difficulties. 1

Special Considerations for Children

Watchful waiting is the best initial approach for pediatric cases due to high spontaneous remission rates and significant risks of aggressive treatments in children. 1

• Topical corticosteroids represent a safer alternative in children, though evidence for efficacy is limited. 1
• Intralesional steroids and contact immunotherapy are often impractical or avoided in pediatric populations. 1