Approach
Current treatments are either immunosuppressive, immunomodulating, or biologic response modifiers. Treatments stimulate hair growth, but do not prevent hair loss and are unlikely to influence the course of the disease.[6] Alopecia areata (AA) frequently relapses and remits. Therefore, trials of therapies are difficult to interpret. Therapies are continued until remission occurs or until cosmetically acceptable regrowth occurs, which may take months or years. Choice of therapy depends primarily on the patient's age, extent of hair loss, extent of psychological distress caused, and motivation of the patient. Treatment is more likely to be effective in patients with mild disease of shorter duration. Hair follicles are not destroyed in AA by the inflammation, so there is generally potential for regrowth, although, in longstanding, chronic cases, it is likely that potential for regrowth is diminished. It is also a valid option for the patient to decide to take no pharmacologic treatment, as AA does not cause any harm to health apart from possible psychological distress, and some of the treatments available have side effects.
Cosmetic camouflage and patient support
This is an important part of management, not only for the patient who does not respond to treatment but also for the initial patient when starting treatment before determining whether they will respond. If hair loss is diffuse or incomplete in areas, then powders can be used. However, most areas affected usually have no terminal hairs, in which case colored scalp sprays or pastes can be tried. For more extensive loss, hair pieces or wigs can be used. Wigs can be synthetic or real hair constructed on a mesh base or as a vacuum wig for alopecia totalis. Patient support groups can be very helpful in providing information regarding these services. Psychological counseling or support are also important, given the significant impact that this disease can have because of drastic and sometimes rapid change in appearance, as well as the unpredictable nature of this condition.
Limited hair loss
In mild hair loss approximately 5% to 25% of the scalp is affected, while in moderate hair loss approximately 25% to 50% is affected. For mild-to-moderate hair loss, topical corticosteroids are first-line treatment for children and for adults who do not wish to undergo intralesional corticosteroid therapy. Skin atrophy can be a temporary adverse effect.
Intralesional corticosteroids are appropriate initial treatment for adults with localized disease (limited areas of patchy hair loss) and may also be injected into brows and beard. Intralesional corticosteroids can be painful; the discomfort can be minimized with application of a topical anesthetic before injections and use of a 30-gauge needle. Skin atrophy, localized folliculitis, and acne can be temporary adverse effects.[2][6][8] Regrowth may typically begin in 1 to 6 months with intralesional corticosteroids. Generally, triamcinolone acetonide is used until either full density is reached or there is no regrowth by about 6 months. High doses have not been found to be more effective, and the chance of developing side effects increases.
Topical minoxidil treatment has been used in the US and Europe as a first-line treatment option for children and for adults who do not want intralesional corticosteroid therapy or who prefer this option; however, it is not clear whether many patients get cosmetically acceptable regrowth.
Some physicians use oral corticosteroids in an attempt to stop the rapid progression of hair loss that happens in some cases. Intramuscular or intravenous injection may be an option when there is a contraindication to oral therapy.[2] However, due to the potential severity of short and long-term side effects of systemic corticosteroids, long-term maintenance therapy is not recommended.[2][21]
Extensive hair loss
Patients who have extensive hair loss or who do not respond well to the above measures should be referred to a specialist for further treatment.
Topical immunotherapy may be tried with either DNCB (1-chloro-2,4-dinitrobenzene), DPCP (diphenylcyclopropenone), or SADBE (squaric acid dibutyl ester). First the patient needs to be sensitized to the compound chosen. This is done by applying the compound to a small area of skin on the shoulder, thigh, or scalp in a concentration of 2%. After waiting a minimum of 2 weeks to allow for an allergic reaction to develop, the patient may either be treated or tested further to determine which concentration to use. One method is to patch test with the application of strengths ranging from 0.1% to 0.000001% under occlusion for 2 days, then the weakest strength that causes erythema can be prescribed for the patient to apply at home. Some physicians prefer to just pick a strength with which to begin treatment and adjust the concentration based on the reaction. Some prefer to apply the medication in the office on a weekly basis. Side effects include contact dermatitis, lymphadenopathy, and hyperpigmentation or hypopigmentation. It may be 1 month to a year to begin growing hair, but the average is 5 to 6 months.
Other trialed treatments
Anthralin is an irritant and, because of adverse effects of irritation and staining and uncertainty regarding effectiveness, it is infrequently used. Psoralen and ultraviolet A have fallen out of favor because of uncertainty regarding effectiveness and a long-term increased risk of skin cancer. There have been several reports of biologic agents being used in AA with disappointing results, including alefacept, efalizumab, and etanercept.
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