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Medical Treatments for Patients with Alopecia Areata

Am Fam Physician. 2000 Feb 15;61(4):1162-1164.

Alopecia areata can range in severity from a few small bald patches to total loss of scalp and body hair. This autoimmune disease affects both sexes equally, but children and young adults are affected more often than other age groups. Most persons with this disorder have no underlying medical conditions. Atopy, thyroid disease and vitiligo are more common in patients with alopecia areata than in the general population. In a review article on the treatment of hair loss, Price discusses the treatment of alopecia areata.

Intralesional glucocorticoid injection is the most common therapy for limited scalp involvement. Brow and beard areas may also be injected. Triamcinolone acetonide, in a dosage of 10 mg per mL, is the preferred agent. The author recommends injecting 0.1 mL or less into the mid-dermis at 1-cm intervals. New hair growth usually is visible in about four weeks. Localized skin atrophy may occur if the injections are administered too deeply into the dermis or into the fat.

Some authorities advocate the use of topical steroids in children, although the author states that she has not found this therapy to be so effective when used alone. The author states that topical therapy may be beneficial when it is combined with other therapies, such as minoxidil, anthralin or injected steroids.

Oral steroid therapy may be effective, but potential adverse effects normally preclude its use. Oral therapy is seldom used in the treatment of alopecia areata.

Topical minoxidil has been evaluated in several studies for use in adults and children with more that 25 percent hair loss related to alopecia areata. The 5 percent solution was reported to be most effective in stimulating hair growth on the scalp, eyebrows and beard area. Minoxidil solution is applied twice daily and stimulates hair growth within 12 weeks. Maximal response is seen by one year, and treatment must be maintained until full remission occurs. In one study of patients who had 25 to 99 percent loss of scalp hair, treatment with topical 5 percent minoxidil produced cosmetically acceptable hair growth in about 40 percent of patients after one year.

Anthralin cream works through an immunomodulating effect on Langerhans cells. Because of its safety profile, it is commonly used in children. New hair growth may occur within two to three months after initiation of topical anthralin therapy. In one study, 25 percent of patients had cosmetically acceptable results by six months. Side effects of anthralin include redness, itching and scaling. Removal of the cream after application for 20 to 60 minutes is often recommended. However, overnight application has been shown to be well tolerated by some patients.

The investigational technique called topical immunotherapy, or contact sensitization, may be effective. This treatment involves application of a potent contact allergen to the affected area, which elicits contact dermatitis. Mild itching, erythema and scaling follow and subsequently induce hair growth. The contact allergen is applied to only one half of the scalp at a time. After hair growth is reestablished (usually within three to 12 months), the other side is treated. Used in Europe, topical immunotherapy has been successful in children as young as seven years of age. The reported success rate from several published clinical trials is 40 to 60 percent in patients who had 50 to 99 percent loss of scalp hair. Adverse effects of this therapy include cervical lymphadenopathy, blistering and disseminated eczema.

Price VH. Treatment of hair loss. N Engl J Med. September 23, 1999;341:964–71.


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