What are the evidence‑based treatment options for the different types of alopecia (androgenetic alopecia in men and women, alopecia areata, telogen effluvium, and cicatricial alopecia)?

Treatment of Alopecia

Androgenetic Alopecia (Male and Female Pattern Hair Loss)

For androgenetic alopecia, initiate combination therapy with oral finasteride 1 mg daily (men only) and topical minoxidil 5% twice daily, as these are the only FDA-approved treatments proven to halt progression and stimulate regrowth. 1

First-Line Treatment Algorithm

Men with androgenetic alopecia:

• Start oral finasteride 1 mg daily (inhibits 5-alpha reductase and DHT production) 1
• Add topical minoxidil 5% twice daily to affected areas 1, 2
• Use standardized photographs at baseline and follow-up to objectively track response 1
• Expect to see results after 6-12 months of consistent use 2

Women with androgenetic alopecia:

• Topical minoxidil 5% solution twice daily is the best treatment option for Ludwig stage I and II 3, 2
• Finasteride is contraindicated in women of childbearing potential 1
• If minoxidil fails after 1 year, antiandrogens can be considered, though evidence is limited and side effects are considerable 3

Adjunctive and Second-Line Options

Platelet-rich plasma (PRP) for suboptimal responders:

• Treatment phase: 3-5 sessions at 1-month intervals using 5-7 mL PRP injected at 90-degree angle, 2-4 mm depth, 1 cm apart 1
• Maintenance phase: 1 session every 6 months 1
• Evidence shows improvement in hair count when added to finasteride/minoxidil 1

Oral minoxidil (emerging option):

• Doses of 0.625-2.5 mg once daily showed 52.4% clinical improvement and 42.9% stabilization in androgenetic alopecia and telogen effluvium 4
• Significant difference compared to controls (p < 0.001) 4

Hair transplantation (follicular unit extraction):

• Consider for inadequate response to medical therapy after 1 year 1
• Combining with PRP pre-treatment and follicle soaking improves outcomes 1

Critical Pitfalls to Avoid

• Do not use topical corticosteroids for androgenetic alopecia—they are ineffective and indicated only for alopecia areata 1
• Do not recommend saw palmetto—lacks robust high-quality data per American Academy of Dermatology and British Association of Dermatologists 1
• Do not delay effective treatment with finasteride and minoxidil while trying unproven supplements, as this may result in irreversible hair loss 1
• Spontaneous improvement is rare in androgenetic alopecia, unlike alopecia areata 1

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Alopecia Areata (Autoimmune Patchy Hair Loss)

For limited patchy alopecia areata (fewer than 5 patches, each <3 cm), intralesional triamcinolone acetonide injections are first-line treatment if intervention is desired, achieving 62% full regrowth rates. 5

Initial Management Based on Disease Extent

Limited patchy disease (<25% scalp involvement, short duration):

• Reassurance without active treatment is legitimate first-line approach 5
• Spontaneous remission occurs in 34-50% within one year and up to 80% of patients with limited patches 5
• 68% of patients with <25% hair loss initially become disease-free at follow-up 5

Active treatment for limited patchy disease (if patient desires intervention):

• Intralesional triamcinolone acetonide 5-10 mg/mL monthly until satisfactory response 5
• Achieves 62% full regrowth in patients with up to 5 small patches 5
• Therapeutic effect lasts approximately 9 months, requiring maintenance injections 5
• Skin atrophy at injection sites is a consistent adverse effect 5

Extensive patchy hair loss:

• Contact immunotherapy is first-line treatment (Strength of recommendation B II-ii) 6
• Stimulates cosmetically worthwhile regrowth in <50% of patients 6
• Many clinicians are reluctant to use this in children due to concerns about aggressive treatment 6

Alopecia totalis/universalis:

• Contact immunotherapy is recommended (Strength of recommendation C) 6
• Response rate is low, and prognosis is usually poor 5
• Only 8% of patients with >50% initial hair loss become disease-free 5
• Full recovery occurs in <10% of cases 5

Second-Line Topical Therapy

Potent topical corticosteroids (limited evidence):

• Clobetasol propionate 0.05% foam or cream twice daily to affected areas 5
• Achieved ≥50% hair regrowth in 21% of treated sites versus 3% with placebo at 12 weeks 5
• Evidence remains limited (Strength C, Quality III) 5
• Folliculitis is the most common side effect 5

Topical minoxidil 5%:

• May be added as adjunctive therapy to intralesional or topical steroids 5
• Should not be used as monotherapy for alopecia areata 5

Treatments to Avoid

• Dithranol (anthralin) and minoxidil lotion as monotherapy—lack convincing evidence of efficacy 6
• Continuous or pulsed systemic corticosteroids—potentially serious side effects and inadequate efficacy evidence 6
• PUVA therapy—potentially serious side effects and inadequate efficacy evidence 6
• Oral zinc and isoprinosine—inadequate evidence of efficacy 6

Pediatric Considerations

Watchful waiting is the best initial approach for children with alopecia areata due to common spontaneous remission and significant risks of aggressive treatments 6

• Intralesional corticosteroids are often poorly tolerated in children due to injection pain 6
• Contact immunotherapy for extensive disease has strength of recommendation B II-ii, but many clinicians are reluctant to use it in children 6
• Topical corticosteroids represent a safer alternative, though evidence for efficacy is limited 6

Critical Counseling Points

• No treatment alters the long-term course of alopecia areata—all interventions provide only temporary hair growth with high relapse rates 5
• Hair follicles remain preserved, maintaining potential for regrowth even in longstanding disease 5
• Disease severity at presentation is the strongest predictor of outcome 5
• Nearly all patients experience more than one disease episode 5
• 14-25% progress to alopecia totalis or universalis 5
• Psychological support is crucial, particularly for adolescents, to address anxiety, depression, and social difficulties 6

Diagnostic Confirmation

Clinical diagnosis without laboratory testing:

• Round or oval patches of complete hair loss 5
• Short "exclamation-mark" hairs at margins with tapered ends 6, 5
• Slightly reddened but otherwise normal-appearing skin 5
• Yellow dots visible on dermoscopy 6, 5
• Nail involvement (pitting or ridging) in approximately 10% of cases 6, 5

Differential diagnoses to exclude:

• Trichotillomania, tinea capitis, telogen effluvium, systemic lupus erythematosus, secondary syphilis 5
• If diagnosis is in doubt, consider fungal culture, skin biopsy, or serology 5
• Skin biopsy is recommended when early scarring alopecia is a concern 5

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Telogen Effluvium

Telogen effluvium often resolves spontaneously once the triggering factor is removed, but oral minoxidil 0.625-2.5 mg daily can be effective for persistent cases. 4

• Oral minoxidil showed 52.4% clinical improvement and 42.9% stabilization in telogen effluvium patients treated for ≥52 weeks 4
• Topical minoxidil 5% can also be used 7
• Identify and address underlying triggers (stress, nutritional deficiencies, medications, hormonal changes, systemic illness) 5

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Cicatricial (Scarring) Alopecia

Skin biopsy is essential when scarring alopecia is suspected, as hair follicles are permanently destroyed and treatment focuses on halting progression rather than regrowth. 5

• Treatment depends on the specific type of cicatricial alopecia (lichen planopilaris, frontal fibrosing alopecia, central centrifugal cicatricial alopecia, discoid lupus, etc.)
• Early diagnosis and aggressive treatment are critical to prevent irreversible follicle loss
• Intralesional or systemic corticosteroids, hydroxychloroquine, and other immunosuppressants may be used depending on the specific diagnosis
• Hair transplantation is generally not recommended in active scarring alopecia