Alopecia areata

Treatment of alopecia areata is directed at producing regrowth of hair. Although there is no cure for alopecia areata at present, the hair may sometimes return by itself. In some cases, it may also fall out again after returning. The course of this disorder varies among individuals and is difficult to predict.

For mild, patchy alopecia areata, in which less than 50% of the scalp hair is gone, cortisone may be injected locally into areas of bare skin. These injections are done with tiny needles and are repeated once a month. Topical solutions, creams, and ointments may also help.

Triamcinolone acetonide 5-10 mg per milliliter given every 2 – 6 weeks, stimulates localized? re-growth in 60 – 67% of cases.[rx]  A study comparing different concentrations of intralesional triamcinolone acetonide (2.5 mg/ml, 5 mg/ml, 10 mg/ml) for the treatment of AA on the scalp, demonstrated similar rates of hair regrowth regardless of the concentration. However, the risk of cutaneous atrophy? was higher at a higher concentration (10mg/ml).[rx] The use of intralesional betamethasone has been proposed, however, further studies are needed to evaluate its efficacy.[rx] Side effects include localized? skin atrophy?, pain?, and depigmentation. Local skin atrophy might resolve within a few months. Relapses are frequent after cessation of treatment.

Potent topical glucocorticoids find frequent utilization in the treatment of alopecia areata; however, evidence of effectiveness is limited.  Topical steroids can be a reasonable therapeutic option in patients unlikely to tolerate intralesional injections. Utilization of occlusive dressings confers a higher response, leading to improvement in greater than 25% of patients. Glucocorticoid-induced folliculitis is a relatively common adverse effect? of this approach.[rx]

Patients with extensive disease, often defined as greater than 50% scalp hair loss, may be treated with topical immunotherapy. This approach avoids the large number of injections that would be otherwise required when using intralesional corticosteroids. Moreover, one retrospective study reported superior efficacy of topical immunotherapy over intralesional corticosteroids for patients with patches of hair loss exceeding 50 cm2 in size.[rx] A potent contact allergen such as diphenylcyclopropenone (DPCP) or squaric acid dibutyl ester (SADBE.) SADBE is applied weekly to the scalp to precipitate hair regrowth. Recently, a metanalysis looked at clinical outcomes of contact immunotherapy for alopecia areata.[rx] The rate of hair regrowth was 74.6% in the patchy alopecia subgroup, and 54.4% in the alopecia totalis/universalis subgroups. Recurrence rates were 38.2% in patients receiving maintenance treatment vs. 49% among those not receiving maintenance treatment.

Second-line therapies include minoxidil, anthralin, and PUVA.

Systemic? therapies are generally only for patients with severe alopecia areata. Systemic glucocorticoids may induce hair growth. However, they are not widely used, mainly because of their side effects. Additionally, relapse? occurs within a year in one-third of responsive patients, and the number of relapses increases with time. [rx] Other systemic? therapies include methotrexate, cyclosporine, azathioprine, and etanercept, all of which have shown variable clinical responses.

Current investigational treatments include platelet?-rich plasma, recombinant IL-2, hydroxychloroquine, JAK inhibitors (tofacitinib), simvastatin with ezetimibe, and excimer laser.[rx][rx][rx][rx][rx]

For more extensive alopecia areata, cortisone pills are sometimes given. However, these pills may have undesirable side effects that should be discussed with a physician beforehand.

Treatment tends to be less effective for more extensive alopecia areata than in cases of mild, patchy alopecia areata.

For cosmetic reasons, wigs and hairpieces may be necessary, especially for affected women and children.