Treatments for Alopecia Areata

Treatment Options for Alopecia AreataA number of treatments can help hair regrow but none alter the long-term course of the disorder. Spontaneous remission occurs in up to 80% of patients with limited patchy hair loss of short duration (< 1 year) making it difficult to assess efficacy, particularly in mild forms of alopecia areata.[3]

Some trials have been limited to patients with severe alopecia areata where spontaneous remission is unlikely. However, these patients tend to be resistant to all forms of treatment and the failure of a treatment in this setting does not exclude efficacy in mild alopecia areata. There are numerous case reports and uncontrolled case series claiming response of alopecia areata to diverse treatments. However, few treatments have been subjected to randomized controlled trials and, except for contact immunotherapy, there are few published data on long-term outcomes.

Corticosteroids

Topical corticosteroid therapy can be useful, especially in children who cannot tolerate injections. It is administered as follows:

  • Fluocinolone acetonide cream 0.2%, betamethasone dipropionate cream 0.05%, or clobetasol 0.05% foam are the most common forms prescribed
  • Topical cream or foam should be applied to the affected area and 1 cm beyond the circumference of the bald patch daily
  • Treatment must be continued for a minimum of 3 months before regrowth can be expected, and maintenance therapy is often necessary
  • For alopecia totalis or alopecia universalis, 2.5 g of clobetasol propionate covered with a plastic film 6 days/wk for 6 months helped a minority of patients
  • Side effects include skin atrophy, folliculitis, or telangiectasia
  • 28.5%-61% of patients achieve regrowth — 37.5% of patients experience relapse[4]

Intralesional corticosteroid therapy is usually recommended for patients with alopecia areata who have less than 50% scalp involvement and are over 10 years of age. Administration is as follows:

  • Injections are administered intradermally using a 3-mL syringe and a 30-gauge needle
  • Triamcinolone acetonide (Kenalog) is used most commonly; concentrations vary from 2.5-10 mg/mL with a concentration of 5mg/mL usually being sufficient on the scalp and the lowest concentration used on the face
  • Less than 0.1 mL is injected per site, and injections are spread out to cover the affected areas (approximately 1 cm between injection sites)
  • Injections are administered every 4-6 weeks
  • Not appropriate treatment in rapidly progressive alopecia or in extensive disease
  • Side effects include skin atrophy, hypopigmentation, telangiectasia, heightened cataract/intra-ocular pressure, or anaphylaxis (rarely)
  • 60-75% efficacy rate with remission seen most commonly within 4 weeks

Systemic corticosteroids (ie, prednisone) are not an agent of choice for alopecia areata because of the adverse effects associated with both short- and long-term treatment. Some patients may experience initial benefit, but the dose needed to maintain cosmetic growth is usually so high that adverse effects are inevitable, and most patients relapse after discontinuation of therapy.

Immunotherapy

  • Topical immunotherapy [1] is defined as the induction and periodic elicitation of an allergic contact dermatitis by topical application of potent contact allergens
  • Commonly used agents include squaric acid dibutylester (SADBE), dinitrochlorobenzene (DNCB), and diphencyprone (DPCP) [2]
  • Side effects include occipital and/or cervical lymphadenopathy during therapy. This is usually temporary but may persist throughout treatment. Severe dermatitis is the most common adverse effect. Uncommon side effects include urticaria, vitiligo, hyper- and hypopigmentation.
  • 36% acceptable regrowth with DNCB, 50%/60% success with DPCP/SADBE
  • Relapses may occur following or during treatment with 62-90% of patients reporting relapse.

Anthralin

  • Both short-contact and overnight treatments have been used
  • Anthralin concentrations varied from 0.2-1%
  • Efficacy is not well established and side effects include folliculitis, regional lymphadenopathy, or irritation

Minoxidil

  • Minoxidil appears to be effective in the treatment of extensive disease (50-99% hair loss) but is of little benefit in alopecia totalis or alopecia universalis
  • The 5% solution appears to be more effective
  • Combination with corticosteroids promotes efficacy
  • Initial regrowth can be seen within 12 weeks, but continued application is needed to achieve cosmetically acceptable regrowth
  • Side effects include dermatitis or pruritus and 3% of female patients grew undesired facial hair

Psoralen plus UV-A

  • Both systemic and topical PUVA therapies have been used
  • 20-40 treatments usually are sufficient in most cases
  • Most patients relapse within a few months (mean, 4-8 months) after treatment is stopped

Other agents

  • Topical cyclosporine has shown limited efficacy
  • Topical tacrolimus
  • Methotrexate, with or without systemic corticosteroids, has shown mixed results

Cosmetic treatment

  • Dermatography has been used to camouflage the eyebrows of patients with alopecia areata; on average, 2-3 sessions lasting 1 hour each were required for each patient
  • Hairpieces are useful for patients with extensive disease


Sources:

  1. Hoffmann R, Happle R. Topical immunotherapy in alopecia areata. What, how, and why?. Dermatol Clin. 1996 Oct. 14(4):739-44. [Abstract].
  2. Rokhsar CK, Shupack JL, Vafai JJ, Washenik K. Efficacy of topical sensitizers in the treatment of alopecia areata. J Am Acad Dermatol. 1998 Nov. 39(5 Pt 1):751-61. [Abstract].
  3. Messenger AG, McKillop J, Farrant P, Mcdonagh A.J., Sladden M. British Association of Dermatologists’ guidelines for the management of alopecia areata 2012. British Journal of Dermatology. 166, pp916–926. [Full Publication].
  4. Naseeha Islama, Patrick S.C. Leunga, Arthur C. Huntley b, M. Eric Gershwina. The autoimmune basis of alopecia areata: A comprehensive review. Autoimmunity Reviews. Volume 14, Issue 2, Pages 81-89. [Abstract].
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  1. Alopecia Areata - World Alopecia Community, Inc.
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