What are the recommended first‑line and subsequent therapies, including topical corticosteroids, intralesional triamcinolone, minoxidil, systemic steroids or Janus kinase inhibitors, and nutritional supplements such as vitamin D, iron, zinc, biotin, and omega‑3 fatty acids, for a patient with alopecia areata?

Treatment of Alopecia Areata: Evidence-Based Approach

First-Line Treatment Strategy

For limited patchy alopecia areata (fewer than five patches, each less than 3 cm), intralesional triamcinolone acetonide injections are the first-line treatment when intervention is desired, achieving 62% full regrowth rates. 1

When to Observe Without Treatment

• Reassurance alone is appropriate for limited patchy disease of short duration (< 1 year), as spontaneous remission occurs in up to 80% of patients with small circumscribed patches. 1
• Between 34-50% of patients achieve spontaneous remission within one year without any intervention. 1
• Hair follicles remain preserved even in longstanding disease, maintaining regrowth potential. 1

Intralesional Corticosteroid Protocol (First-Line Active Treatment)

• Inject triamcinolone acetonide 5-10 mg/mL just below the dermis into the upper subcutaneous tissue. 1, 2
• Administer 0.05-0.1 mL per injection site, producing approximately 0.5 cm diameter hair regrowth per tuft. 3
• Space injections 0.5-1 cm apart across affected patches. 1
• Repeat monthly until satisfactory response is obtained, typically requiring 3-6 months of treatment. 1, 3
• The therapeutic effect lasts approximately 9 months before maintenance injections may be needed. 1
• Treatment duration beyond 6 months of active disease is associated with lower probability of significant regrowth. 4

Common pitfall: Skin atrophy at injection sites is a consistent adverse effect, particularly with triamcinolone—counsel patients about this expected outcome. 1, 2

Second-Line Topical Therapy

Potent topical corticosteroids (clobetasol propionate 0.05% foam or cream) applied twice daily are second-line options, but evidence is limited. 1

• Achieves ≥50% hair regrowth in 21% of treated sites versus 3% with placebo at 12 weeks. 1
• Folliculitis is the most common side effect. 1
• The evidence quality is weak (Strength C, Quality III). 1

Adjunctive Therapy

Topical minoxidil 5% may be added to intralesional or topical steroid regimens, but should never be used as monotherapy for alopecia areata. 1, 2

• Intradermal minoxidil injections show limited efficacy comparable to microneedling alone and add no benefit when combined with steroids. 5
• Minoxidil may accelerate recovery timing but does not improve final outcomes. 5

Extensive Disease (> 50% Scalp Involvement)

For extensive patchy alopecia areata, contact immunotherapy with diphenylcyclopropenone (DPCP) is first-line treatment, though it stimulates cosmetically worthwhile regrowth in less than 50% of patients. 2

Systemic Corticosteroids

• Routine systemic corticosteroids are not recommended due to serious side effects and inadequate efficacy evidence. 2
• However, intramuscular triamcinolone acetonide monthly for 3-6 months achieved 63% response rates in refractory cases, particularly in male patients. 6
• Adverse effects (dysmenorrhea, osteoporosis) occurred predominantly in females. 6
• Adrenocortical reserve recovered completely within 3 months after discontinuation. 6

Treatment Comparison and Equivalence

Topical corticosteroids, intralesional corticosteroids, and combined therapy show no significant differences in treatment outcomes, though all are effective and safe. 4

Prognostic Counseling

• Disease severity at presentation is the strongest predictor: 68% of patients with < 25% scalp hair loss become disease-free, compared with only 8% of those with > 50% loss. 1
• Nearly all patients experience more than one disease episode. 1
• Between 14-25% progress to alopecia totalis or universalis, with full recovery uncommon (< 10%). 1
• No current therapy modifies the long-term disease course—all interventions provide only temporary hair growth with high relapse rates. 1, 2

Nutritional Supplements

There is no guideline or research evidence supporting vitamin D, iron, zinc, biotin, or omega-3 fatty acids as effective treatments for alopecia areata. These supplements are not recommended as therapeutic interventions for this autoimmune condition.

Predictors of Treatment Response

• Presence of exclamation mark hairs and positive hair pull test at initial examination predict better response to intralesional steroids. 7
• Initial scalp involvement negatively correlates with final hair regrowth (Spearman r = -0.595). 6
• Early improvement during initial treatment months indicates likely continued response. 7