What is the recommended first‑line treatment for alopecia areata?

Treatment of Alopecia Areata

For limited patchy alopecia areata, intralesional triamcinolone acetonide (5–10 mg/mL) injected monthly is the first-line treatment when intervention is desired, achieving 62% full regrowth in appropriately selected patients with fewer than five patches less than 3 cm in diameter. 1, 2

Initial Management Decision: Observation vs. Active Treatment

• Reassurance without active therapy is the evidence-based first approach for limited patchy disease of short duration (< 1 year), because spontaneous remission occurs in up to 80% of these patients. 1, 2
• Between 34% and 50% of patients achieve spontaneous remission within one year, though visible regrowth is unlikely within the first 3 months after a new patch appears. 1, 2
• Active treatment should be reserved for patients who specifically request intervention or have cosmetically significant disease. 1
• Critical caveat: No available treatment modifies the long-term natural history of alopecia areata—all interventions produce only temporary hair growth with high relapse rates. 1, 2, 3

First-Line Active Treatment: Intralesional Corticosteroids

• Intralesional triamcinolone acetonide (5–10 mg/mL) has the strongest evidence (Strength B, Quality III) and is the first-line pharmacologic therapy. 1, 2, 3
• Each 0.05–0.1 mL injection produces approximately a 0.5 cm diameter tuft of new hair. 2
• Optimal candidates: Patients with ≤ 5 patches, each < 3 cm in diameter, achieve full regrowth in approximately 62% of cases. 1, 2, 3
• Inject just beneath the dermis and repeat monthly until satisfactory response is obtained. 2
• The therapeutic effect typically lasts about 9 months, after which maintenance injections are often required. 1, 2
• Main adverse effect: Skin atrophy at injection sites is a consistent side effect. 1, 3
• A novel approach diluting triamcinolone to 2.5 mg/mL in 1% lidocaine with epinephrine 1:100,000 (instead of normal saline) may potentiate efficacy through local vasoconstriction, though this requires further validation. 4

Second-Line Treatment: Potent Topical Corticosteroids

• Clobetasol propionate 0.05% foam or cream applied twice daily is a second-line option, but evidence is limited (Strength C, Quality III). 1, 2, 3
• Achieved ≥50% hair regrowth in only 21% of treated sites versus 3% with placebo after 12 weeks. 1, 2
• A separate RCT of 0.25% desoximetasone cream in 70 patients showed no significant benefit over placebo. 1, 2
• Most common adverse effect: Folliculitis. 1, 2
• Topical corticosteroids are safer and better tolerated than intralesional injections, making them appropriate for children and adults who cannot tolerate IL injections, though efficacy is moderate and recurrence is common. 5

Adjunctive Therapy

• Topical minoxidil 5% can be added to intralesional or topical steroid regimens but should never be used as monotherapy for alopecia areata. 1, 2
• Minoxidil monotherapy shows limited efficacy with variable response rates of only 32–33%. 3

Treatment Selection Algorithm by Disease Extent

• Limited patchy disease (< 5 patches, each < 3 cm): Intralesional triamcinolone acetonide monthly. 1, 2, 3
• Extensive patchy disease: Contact immunotherapy with diphenylcyclopropenone (DPCP) is recommended as first-line, though it stimulates cosmetically worthwhile regrowth in less than 50% of patients. 3
• Patients unable to tolerate injections: Potent topical corticosteroids (clobetasol propionate 0.05%). 1, 2
• Comparative efficacy: Topical corticosteroid monotherapy, intralesional corticosteroid monotherapy, and combined topical plus intralesional therapy show no significant differences in treatment outcomes. 6

Prognostic Factors and Counseling

• Disease severity at presentation is the strongest predictor: 68% of patients with < 25% scalp hair loss become disease-free at follow-up, compared with only 8% of those with > 50% loss. 1
• Treatment duration matters: Alopecia areata duration longer than 6 months is associated with significantly lower probability of achieving significant hair regrowth (>80%). 6
• Nearly all patients experience more than one disease episode, and between 14% and 25% progress to alopecia totalis or universalis, with full recovery uncommon (< 10%). 1
• Hair follicles remain preserved even in longstanding disease, maintaining the potential for regrowth. 1

Diagnostic Confirmation

• Diagnosis is primarily clinical, based on round or oval patches of complete hair loss, short "exclamation-point" hairs at margins, slightly reddened skin, and yellow dots on dermoscopy. 1, 2
• Nail involvement (pitting or ridging) occurs in approximately 10% of cases. 1
• Laboratory investigations (fungal culture, skin biopsy, serology for lupus or syphilis) are reserved only for atypical cases where diagnosis is uncertain. 1, 2
• Differential diagnoses to exclude: Trichotillomania, tinea capitis, telogen effluvium, systemic lupus erythematosus, and secondary syphilis. 1, 2

Common Pitfalls to Avoid

• Do not use systemic corticosteroids routinely—they have inadequate evidence of efficacy and potential serious side effects. 3
• Do not promise permanent cure—all treatments provide only temporary hair growth with high relapse rates, and ongoing maintenance therapy is usually needed. 1, 2, 3
• Do not delay treatment beyond 6 months in patients desiring intervention, as longer disease duration significantly reduces treatment success. 6
• Do not overlook psychological impact—patients frequently experience self-consciousness, embarrassment, anger, or feelings of rejection that require specific attention. 1, 2