Alopecia Areata Treatment & Management
See the treatment algorithm below.
Treatment is not mandatory because the condition is benign, and spontaneous remissions and recurrences are common. Treatments used are believed to stimulate hair growth, but no evidence indicates they can influence the ultimate natural course of alopecia areata. Treatment modalities usually are considered first according to the extent of hair loss and the patient's age.
Assessment of the efficacy of a treatment must be considered with care because the condition is highly unpredictable in presentation, evolution, and response to treatment. Little data exist regarding the natural evolution of the condition. For example, in patients with less than 40% scalp involvement, a study showed no benefit with treatment (minoxidil 1% and topical immunotherapy) over placebo.  The high spontaneous remission rate makes clearly assessing the true efficacy of a therapy difficult unless appropriate controls with placebo treatment are studied.
For patients with extensive alopecia areata (>40% hair loss), little data exist on the natural evolution. The rate of spontaneous remission appears to be less than in patients with less than 40% involvement. Vestey and Savin  reviewed 50 patients with extensive alopecia areata. Of the 50 patients, 24% experienced spontaneous complete or nearly complete regrowth at some stage during the observation period of 3-3.5 years. The relapse rate is high in patients with severe forms of alopecia areata.
Patients with alopecia totalis or alopecia universalis usually have a poorer prognosis, and treatment failure is seen in most patients with any therapy.
Because alopecia areata is believed to be an autoimmune condition, different immunomodulators have been used to treat this condition. Additional treatment options for alopecia areata include minoxidil and other treatment modalities.
Corticosteroid therapies can include intralesional injections or topical application.For intralesional steroids, few
studies are available regarding efficacy; however, they are used widely in the treatment of alopecia areata.
- Intralesional steroids are the first-line treatment in localized conditions.
- In a study including 84 patients, regrowth on treated areas was present in 92% of patients with patchy alopecia areata and 61% of patients with alopecia totalis. Regrowth persisted 3 months after treatment in 71% of patients with patchy alopecia areata and 28% of patients with alopecia totalis. Regrowth usually is seen within 4-6 weeks in responsive patients. Patients with rapidly progressive, extensive, or long-standing alopecia areata tend to respond poorly.
- Another study showed regrowth in most patients (480) treated with intralesional steroids, except in 2 patients with alopecia universalis.
- Hair growth may persist for 6-9 months after a single injection.
- 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. The lowest concentration is used on the face. A concentration of 5 mg/mL is usually sufficient on the scalp.
- 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; see image below). Corticosteroid injection.
- Adverse effects mostly include pain during injection and minimal transient atrophy (10%). The presence of atrophy should prompt a reduction in the triamcinolone acetonide concentration and avoidance of the atrophic site.
- Injections are administered every 4-6 weeks.
- Although intralesional injections of triamcinolone acetonide are usually recommended for alopecia areata with less than 50% involvement, a report showed that 6 of 10 patients had regrowth.  Although injections may work in extensive alopecia areata, results are unlikely if no response is observed at 6 months (personal observation).