Prednisone for Alopecia Areata
Oral prednisone pulse therapy (200 mg once weekly) is effective for extensive, rapidly progressive alopecia areata, but should be reserved for patients with multifocal disease of short duration (≤3 months) who have failed topical therapies, as intralesional triamcinolone remains the evidence-based first-line treatment for limited disease. 1, 2, 3
When to Consider Systemic Prednisone
Reserve oral corticosteroids for specific clinical scenarios:
- Patients with rapidly evolving, multifocal alopecia areata (>50% scalp involvement) who have failed topical therapies 4, 3
- Disease duration ≤3 months before treatment initiation predicts the best response 3
- Plurifocal type with 4-6 months duration may also respond 3
- Do not use in alopecia totalis/universalis—response rates are disappointing and do not justify systemic steroid risks 4, 5
Recommended Prednisone Regimen
Oral pulse therapy protocol:
- Dose: 200 mg prednisolone once weekly (given as 5 × 40 mg tablets) 2
- Duration: 3 months of active therapy, followed by 3 months observation 2
- Alternative regimen: 100 mg IV methylprednisolone on 3 consecutive days at 1-month intervals for 3 courses 4
- Expected response: Significant hair regrowth occurs in approximately 35% of patients with extensive disease; 84% of multifocal cases improve 4, 2
- Relapse rate: 25% of responders relapse within 3-7 months after treatment completion 4, 2
Monitoring Requirements
- Assess response monthly using SALT score (Severity of Alopecia Tool) 5, 6
- Monitor for typical corticosteroid adverse effects: weight gain, mood changes, hyperglycemia, hypertension 4
- No major side effects were observed in pulse therapy studies, but continuous monitoring remains essential 4
Contraindications
- Alopecia totalis/universalis (poor response rates do not justify risks) 4, 5
- Standard systemic corticosteroid contraindications: uncontrolled diabetes, active infection, peptic ulcer disease, severe osteoporosis 4
- Long-standing disease (>6 months) shows significantly reduced response rates 3
Critical Treatment Algorithm
Step 1: Limited patchy disease (<5 patches, each <3 cm, duration <1 year)
- Reassurance alone—80% spontaneous remission rate 1, 7
- If intervention desired: intralesional triamcinolone 5-10 mg/mL achieves 62% full regrowth 1, 7
Step 2: Extensive multifocal disease (>50% scalp involvement, rapidly progressive, duration ≤3 months)
- Oral prednisolone 200 mg weekly pulse for 3 months 2, 3
- Add topical minoxidil 5% and short-contact anthralin 1.15% for synergistic effect—this combination achieved 80% cosmetic response in treatment-resistant cases 5
Step 3: Maintenance after response
- Transition to intralesional triamcinolone for localized areas 5
- Continue topical minoxidil as adjunctive therapy 5
- Expect high relapse rates; no treatment alters long-term disease course 1, 7
Alternative Systemic Options When Prednisone Fails
- Methotrexate 15-25 mg weekly (with or without low-dose prednisolone 10-20 mg daily) achieved complete regrowth in 64% of alopecia totalis/universalis cases 8
- JAK inhibitors (baricitinib, ritlecitinib) are now EMA-approved for severe alopecia areata and represent the most effective systemic option for extensive disease 6
- Cyclosporine, sulfasalazine, and azathioprine have limited evidence and significant side-effect profiles 8, 6
Common Pitfalls to Avoid
- Do not use prednisone in long-standing disease (>6 months)—response rates plummet and risks outweigh benefits 3
- Never use topical minoxidil as monotherapy for alopecia areata—it is only effective as adjunctive treatment 1, 7
- Avoid systemic steroids in alopecia totalis/universalis—combination therapy with betamethasone mini-pulse + anthralin + minoxidil is more appropriate 5
- Warn patients that no treatment modifies long-term disease course; all interventions produce only temporary hair growth 1, 7
- Disease severity at presentation is the strongest prognostic factor: 68% with <25% hair loss become disease-free vs. only 8% with >50% loss 1