Alopecia areata: Management

Author:
Andrew G Messenger, MD, FRCP
Section Editors:
Robert P Dellavalle, MD, PhD, MSPH
Maria Hordinsky, MD
Deputy Editor:
Abena O Ofori, MD
Contributor Disclosures
All topics are updated as new evidence becomes available and our peer review process is
complete.
Literature review current through: Nov 2020. | This topic last updated: Mar 09, 2020.

INTRODUCTION Alopecia areata is a chronic, relapsing, immune-

mediated inflammatory disorder affecting hair follicles resulting in nonscarring

hair loss. The severity of the disorder ranges from small patches of alopecia on
any hair-bearing area to the complete loss of scalp, eyebrow, eyelash, and body
hair.
Although up to 50 percent of patients who present with patchy alopecia areata
experience spontaneous hair regrowth within one year, most will relapse
months or years after remission [1]. The unpredictable course of the disease
and the psychologic distress associated with hair loss prompt many patients to
seek therapy. (See "Alopecia areata: Clinical manifestations and diagnosis",
section on 'Disease course'.)
The management of alopecia areata involves both addressing the psychologic
needs of the patient and offering treatment to patients who desire intervention.
A variety of topical, intralesional, and systemic agents, as well as devices, have
been used for alopecia areata, but the response to treatment varies widely; few
well-designed clinical trials have evaluated these therapies [2].
Options for the management of alopecia areata will be discussed here. The
clinical manifestations and diagnosis of the disorder are reviewed separately.
(See "Alopecia areata: Clinical manifestations and diagnosis".)

COUNSELING Educating patients about alopecia areata, discussing

realistic expectations for treatment, and offering resources for psychologic

support are important components of therapy [1].
Psychosocial support — For the majority of patients, alopecia areata is a
cosmetic concern, although it can occasionally cause physical disability, such
as when there is eyelash involvement, loss of nasal hairs, or marked nail
dystrophy. Nevertheless, the cosmetic importance of hair is such that alopecia
areata can cause severe emotional problems, particularly in children,
adolescents, and young women, though by no means restricted to these
groups. Studies of adolescents suffering from alopecia areata have found
increased rates of psychiatric symptoms [3,4].
In view of the variable efficacy of current forms of treatment, the clinician has an
important role in helping patients adapt to hair loss. Input from other health
professionals, such as a clinical psychologist, may be needed. Many patients
are helped by involvement in patient support groups [5]. With children, it is often
the parents whose reactions must be addressed for the child to adjust to the
hair loss.
The National Alopecia Areata Foundation (NAAF) is a useful resource for
support for children and adults with alopecia areata and their family members.
NAAF maintains an informative website, publishes a newsletter, and provides
names of local support groups. (See 'Information for patients' below.)
Decision to treat — Treatment of alopecia areata is not mandatory. The
decision to treat is a shared decision with the patient that involves careful
consideration of the patient's preferences and the risks and benefits of
treatment.

The discussion with the patient should involve a review of the course of the
disease and the various treatment options and their respective side effects. The
following general principles should be reviewed:

●The course of alopecia areata varies, including spontaneous resolution,

persistence, recurrence, and progression. (See "Alopecia areata: Clinical
manifestations and diagnosis", section on 'Disease course'.)
●Responses to treatment vary, and there is no curative treatment.
●Even if a treatment is effective, the disease often recurs once the
treatment is discontinued.
Cosmetic options — Some patients who elect to forgo treatment or who have
incomplete responses desire products or techniques to address persistent
scalp, eyebrow, or eyelash hair loss. Wigs, hairpieces, shaving of the scalp, and
protein powders, sprays, or lotions designed to make hair appear more full may
be helpful for scalp hair loss. Eyebrow tattooing can be helpful for loss of
eyebrows. Patients with alopecia of the eyelashes may choose to apply false
eyelashes. False eyelashes are widely available in pharmacies and beauty
supply stores. (See 'Eyelash loss' below.)

FIRST-LINE THERAPIES The treatment approach for patients who

desire medical intervention differs based upon the clinical presentation. Initial
interventions for patients with limited (not strictly defined, but generally less than
50 percent) patchy scalp hair loss and extensive (generally more than 50
percent) scalp hair loss are reviewed below. (See 'Limited patchy hair
loss' below and 'Extensive hair loss' below.)
Limited patchy hair loss — Intralesional and topical corticosteroids are the
preferred initial treatment for patients with limited patchy alopecia areata. This is
based upon relative safety and the available, although limited, evidence for
efficacy [1]. Often, patients with <25 percent scalp hair loss are the best
candidates because of difficulty tolerating the high number of injections required
to treat larger areas. Children and other patients who cannot tolerate injections
can be treated with topical corticosteroids. (See 'Potent topical
corticosteroids' below.)
Intralesional corticosteroids — We suggest intralesional corticosteroids as
the preferred therapy for adults with isolated patches of hair loss.
Efficacy — There are no randomized trials of intralesional corticosteroids for
alopecia areata. One nonrandomized comparative study found regrowth of tufts
of hair at 33 of 34 sites injected with triamcinolone hexacetonide in 11 patients
and at 16 of 25 sites injected with triamcinolone acetonide in 17 patients [6].
Another study reported complete regrowth of hair after four months in 40 of 62
patients (63 percent) treated with monthly injections of triamcinolone acetonide
[7].
Administration — Intralesional injections should be performed on both existing
and newly forming patches of alopecia. The goals of treatment are to promote
regrowth and limit hair loss. (See "Intralesional corticosteroid injection".)
●The affected area may be pretreated with a topical anesthetic cream
(eg, lidocaine 2.5% and prilocaine 2.5% cream). The cream is applied
generously and is placed under occlusion with a tightly fitting shower cap or
plastic wrap 1.5 to 2 hours before treatment. The cream is removed
immediately before injection.
●Triamcinolone 2.5 to 5 mg/mL is injected into the upper subcutis on the
face for eyebrow or beard involvement; concentrations of 5 to 10 mg/mL
are injected into the upper subcutis on the scalp. Small volumes (0.1 mL or
less) are injected into multiple sites 1 cm apart (picture 1). The dose per
visit is largely determined by the extent of disease and patient tolerance but
is usually around 20 mg or less on the scalp. The dose of triamcinolone
administered should not exceed 40 mg per treatment session.
●New growth is usually visible within six to eight weeks. The treatment may
be repeated as necessary every four to six weeks and is stopped once
regrowth is complete. If there is no response after six months, treatment
should be discontinued [8] and alternative treatments may be attempted.
Adverse effects — Local skin atrophy is a consistent side effect but usually
resolves within a few months. Other cutaneous side effects include
telangiectasias and hypopigmentation. Facial injection should be approached
cautiously, particularly in patients with pigmented skin, in whom
hypopigmentation can be prominent. Nondermatologists should consider
referring patients who need facial injections to a dermatologist. The risk for
adrenal suppression in patients treated with intralesional corticosteroid
injections into the skin has not been formally studied [9-11]. (See "Intralesional
corticosteroid injection", section on 'Side effects, complications, and
pitfalls' and "Topical corticosteroids: Use and adverse effects", section on
'Adverse effects'.)
Potent topical corticosteroids — While potent topical corticosteroids are
frequently used to treat alopecia areata, evidence for their effectiveness is
limited. We usually reserve first-line therapy with topical corticosteroids for
children and adults who cannot tolerate intralesional injections [12-14].
Efficacy — Examples of studies investigating the efficacy of topical
corticosteroids for alopecia areata include the following:
●A trial in 70 patients with patchy alopecia areata randomly assigned
patients to apply either 0.25% desoximetasone cream or placebo twice
daily [15]. After 12 weeks of therapy, a larger number of patients treated
with desoximetasone experienced complete regrowth of hair (58 versus 39
percent, relative risk 1.5, 95% CI 0.83-2.59); however, the difference was
not statistically significant. More patients treated with the corticosteroid
 experienced at least mild improvement, and this result did achieve
statistical significance.
●A 12-week randomized trial in which 105 patients with localized alopecia
areata were randomized to treatment with betamethasone valerate 0.1%
foam applied twice daily, intralesional triamcinolone acetonide (10 mg/mL)
administered every three weeks, or topical tacrolimus 0.1% ointment
applied twice daily found >75 percent hair regrowth in 54, 60, and 0 percent
of patients, respectively [16]. Of note, 27 patients dropped out of the study
prior to completion and were not included in the analysis of data.
Preferential use of a potent topical corticosteroid over lower-potency
corticosteroids is supported by the findings of a 24-week randomized trial
performed in 41 children with alopecia areata involving at least 10 percent of the
scalp surface area. The trial found that twice-daily treatment
with clobetasol propionate 0.05% cream (a high-potency topical corticosteroid)
for two six-week cycles separated by six weeks was more effective for
decreasing the area of scalp hair loss than hydrocortisone 1% cream (a low-
potency topical corticosteroid) administered via the same regimen [12]. After 24
weeks, 85 percent of children treated with clobetasol propionate had at least a
50 percent reduction in the surface area with hair loss, compared with only 33
percent of children treated with hydrocortisone.
Administration — We typically treat scalp involvement with a high-potency
topical corticosteroid, such as betamethasone dipropionate 0.05% (cream,
lotion, ointment), applied to affected areas and 1 cm beyond once daily (table
1). The entire scalp is treated if a large area is involved.

The response to treatment should be evaluated after three months of use. We

discontinue the topical corticosteroid and consider alternative therapies at this
point if patients do not have hair regrowth. For patients who have hair regrowth,
we continue the topical corticosteroid and gradually taper the frequency of
application.

The best regimen for tapering and discontinuing topical corticosteroids in

patients who respond is unclear. We tend to individualize our approach and
taper more quickly for patients with robust hair regrowth than for patients with
slower, less dramatic improvement. In general, we are able to taper and
discontinue topical corticosteroid therapy over the course of three to six months.

Application under occlusion increases the potency of topical corticosteroids.

Given the potential for increasing side effects, we do not recommend this
method of application in the absence of additional studies demonstrating safety
and long-term efficacy. (See 'Adverse effects' below.)
Long-term treatment with high-potency topical corticosteroids is usually avoided
for beard and eyebrow involvement because of the potential for corticosteroid-
induced skin atrophy in this area [17]. When utilizing topical corticosteroid
therapy in these areas, we typically opt for a medium-potency topical
corticosteroid initially and assess for a response after approximately six weeks,
rather than three months (table 1). If there is no response, a high-potency
topical corticosteroid can be tried, with reassessment for signs of response after
six weeks. Topical corticosteroid therapy is subsequently discontinued if hair
regrowth is absent. (See "Topical corticosteroids: Use and adverse effects",
section on 'Adverse effects'.)
Adverse effects — Similar to intralesional corticosteroids, side effects of topical
therapy include local skin atrophy, telangiectasias, hypopigmentation, and
adrenal suppression. (See "Topical corticosteroids: Use and adverse effects",
section on 'Adverse effects'.)
Extensive hair loss — Topical immunotherapy is the preferred first-line
treatment for patients with extensive disease. We typically reserve intralesional
and topical corticosteroid therapy for treatment of strategic sites (eg, frontal
hairline, eyebrows) in these patients. Systemic glucocorticoids are occasionally
used for temporarily slowing rapid, extensive hair loss, but side effects limit use
of this therapy. (See 'Systemic glucocorticoids' below.)
Topical immunotherapy — Topical immunotherapy is probably the most
effective treatment for patients with extensive or recurrent scalp involvement
[1,18]. The procedure is usually performed by dermatologists.
A potent contact allergen is applied weekly to the scalp to precipitate hair
regrowth [19,20]. The reason for this response remains unknown, but an
immunomodulatory effect on the inflammatory infiltrate surrounding affected hair
follicles is thought to play a role. Theories for the mechanism of action have
focused on the inhibition of the pathologic immune response via antigenic
competition [21], the induction of lymphocyte apoptosis [22], or an effect on the
type or function of lymphocytes in the inflammatory infiltrate [23-25].
Efficacy — Randomized trials evaluating topical immunotherapy are lacking,
and uncontrolled studies have found variable rates of response. A systematic
review and meta-analysis of studies evaluating contact immunotherapy with
diphenylcyclopropenone (DPCP) or squaric acid dibutyl ester (SADBE) for
patchy alopecia areata, alopecia totalis, and/or alopecia universalis found an
overall rate of complete (90 to 100 percent) hair regrowth of 32.3 percent (95%
CI 25.3-40.2) [26]. Patients with patchy alopecia areata had better response
rates than patients with either alopecia totalis or universalis (25 versus 43
percent for complete regrowth). Factors associated with poorer hair regrowth
outcomes included a Severity of Alopecia Tool (SALT) score ≥50 (odds ratio
[OR] 3.05, 95% CI 2.26-4.11), atopic disease (OR 1.61, 95% CI 1.03-2.50), and
nail involvement (OR 2.06, 95% CI 1.26-3.36). Although longer disease duration
is often considered a negative prognostic factor, disease duration ≥1 year was
not a statistically significant prognostic factor in this study (OR 1.56, 95% CI
0.95-2.55). Relapse after treatment was common. Analysis of studies reporting
treatment status at the time of relapse revealed recurrence rates among
patients not receiving and receiving maintenance treatment of 38 and 49
percent, respectively.
Administration — Topical immunotherapy can be performed with DPCP or
SADBE. The agents for topical immunotherapy are typically purchased from a
chemical distributor. The solutions are subsequently prepared by a pharmacy or
the clinician. Careful handling during preparation and treatment is essential to
avoid inadvertent contact with the skin that results in sensitization of
pharmacists or clinicians.

When both agents are available, DPCP is often favored over SADBE because it
is less expensive and more stable in solution. SADBE must be refrigerated.
DPCP is degraded by light and should be stored in an amber glass bottle or
another protective container.
 ●Topical immunotherapy with DPCP begins with the application of a 2%
solution to a small (eg, 4x4 cm) area, usually on the scalp, to sensitize the
patient [1]. One to two weeks later, treatment is initiated with the application
of a 0.001% concentration of the allergen to the affected areas.
●Patients should be instructed to wash off DPCP after 24 to 48 hours.
While the product is on the skin, the treated areas should be protected from
sun exposure with an opaque scarf or hat.
●For patients who exhibit a severe eczematous response to sensitization,
an additional week should pass before starting treatment and an even
lower initial concentration of DPCP should be used.
●Treatments are usually repeated once weekly with slowly increasing
concentrations of DPCP to a maximum concentration of 2%. Typically, the
concentration that induces a mild dermatitis is utilized for all subsequent
treatments. A retrospective study suggests that the development of
clinically evident dermatitis may not be necessary for efficacy of DPCP;
however, additional study is necessary to confirm this finding [27].
Signs of hair growth are expected by approximately three months, and the
frequency of treatment is reduced once maximal hair growth is attained [6,28].
Most clinicians discontinue therapy if there is no response after six months [29];
however, improvement requiring longer courses of DPCP therapy has been
reported [28]. Further study is necessary to confirm the results of a
retrospective study that suggest that combination therapy with DPCP
and anthralin is more effective than DPCP monotherapy [30].
(See 'Anthralin' below.)
The procedure for sensitization and treatment with SADBE is similar.
Sensitization is performed with a 2% solution and is followed by weekly 24-hour
applications of the agent. Treatment begins with a low concentration solution
(such as 0.0001%) that is increased until mild dermatitis is elicited. Further
study is necessary to confirm the findings of a small retrospective study that
suggest an initial eczematous reaction to sensitization is not always necessary
for successful treatment [31].
Opinions vary on whether patients should be allowed to apply SADBE or DPCP
at home [1]. Limited data suggest that treatment can be safe and effective;
however, additional study is necessary to clarify which patients are the best
candidates for home treatment [32].
Adverse effects — Severe dermatitis is a potential side effect of topical
immunotherapy. If a vesicular or bullous reaction occurs, the contact allergen
should be washed from the skin and treatment with a topical corticosteroid
should be initiated. Other potential side effects include lymphadenopathy,
urticaria, vitiligo, and dyschromia [8]. Use in pregnant women is not
recommended [8].
Local corticosteroids — We typically reserve intralesional and topical
corticosteroid therapy for treatment of strategic sites (eg, frontal hairline,
eyebrows) in patients with extensive disease. Although a minority of patients
with extensive alopecia areata may have significant regrowth with local
corticosteroid therapy, these interventions are less frequently used alone due to
concern for lower efficacy in this subgroup [33-35]. One retrospective study
reported superior efficacy of topical immunotherapy over intralesional
corticosteroids for patients with patches of hair loss exceeding 50 cm 2 in size
[18]. An additional concern for intralesional corticosteroid therapy is the large
number of injections required. (See 'Intralesional corticosteroids' above
and 'Potent topical corticosteroids' above.)
Systemic glucocorticoids — Most patients with extensive hair loss are most
appropriately treated with topical immunotherapy and local corticosteroids as
initial treatment; however, systemic glucocorticoids are occasionally prescribed
as a temporary measure to slow hair loss in patients with rapidly progressing,
extensive hair loss. These patients may be subsequently transferred to topical
immunotherapy or an alternative therapy, if available.
Although systemic glucocorticoids appear to stimulate hair growth, the adverse
effects associated with these agents limit the duration of therapy, and
recurrence of hair loss frequently occurs after the discontinuation of treatment
[36,37]. Various regimens involving daily dosing or pulsed dosing have been
utilized. A common daily treatment regimen is 40 to 60 mg per day in adults or 1
mg/kg per day in children tapered over four to six weeks. Evidence of hair
regrowth is expected within this period. Regimens that involve pulsed oral
glucocorticoids may also induce hair regrowth [38,39].
The efficacy of a prednisone taper (from 40 mg to 0 mg over the course of six
weeks in patients weighing at least 40 kg) was investigated in a prospective
study of 32 children and adults with alopecia areata, including 16 patients with
alopecia totalis or universalis [40]. After six weeks, 13 patients achieved at least
50 percent hair regrowth, including four patients with 75 to 99 percent hair loss
at baseline and four patients with alopecia universalis. Two patients worsened
during prednisone therapy.

SECOND-LINE THERAPY Patients with limited disease who do not

respond to local corticosteroid therapy can be treated with topical

immunotherapy. The treatment regimen is identical to patients with more
extensive disease. (See 'Topical immunotherapy' above.)
Topical anthralin is an additional second-line treatment option for limited or
extensive alopecia areata. Anthralin may be used alone or in combination with
first-line interventions. (See 'First-line therapies' above.)
Anthralin — Anthralin is an irritant agent that is mainly used to treat patients
with psoriasis. Evidence of its effectiveness for alopecia areata is limited to case
series without adequate controls [1,41]. Compared with intralesional
corticosteroids and topical immunotherapy, anthralin appears to be less
effective. Children may also have difficultly tolerating the irritation caused by
anthralin.
Short-contact therapy with anthralin is performed by applying anthralin 0.5 or
1% cream to the affected areas for 20 to 30 minutes daily, followed by rinsing
the cream off with cool to lukewarm water, and washing the treated area with
any shampoo [8]. The time of contact is increased by 10 minutes every two
weeks up to one hour or to the time required to elicit a mild dermatitis. Therapy
is then continued at that exposure time.
Alternatively, treatment can be initiated with application of a 0.1% concentration
of anthralin to the scalp for 10 to 20 minutes. Tolerance to irritation is built up by
gradually increasing (over a period of days) the time that the anthralin is left on
the affected area, eventually reaching tolerance for leaving anthralin on
overnight. The concentration of anthralin can be increased up to 2% as
tolerated.
An irritant reaction with erythema and scaling is desired but should not be
allowed to become frankly vesicular. Mild irritation is expected and preferred
over severe irritation. Anthralin should be used for at least three months before
re-evaluating for treatment effectiveness.
Anthralin will stain hair, skin, and clothing brown. Patients should wash their
hands with cool to lukewarm water immediately after application.

REFRACTORY DISEASE Systemic therapies are occasionally

used for severe alopecia areata. A high likelihood of relapse, limited efficacy
data, and the potential adverse effects of these drugs limit their use to refractory
cases.
Azathioprine — Data from small, uncontrolled studies suggest
that azathioprine induces hair regrowth in some patients with moderate to
severe alopecia areata [42,43]. In a prospective study of 14 adult patients with
alopecia universalis, six patients regrew hair during treatment with azathioprine
(2.5 mg/kg per day adjusted according to thiopurine methyltransferase [TMPT]
levels), all achieving regrowth on 75 percent or more of the scalp [42].
Responses occurred four to six months after the start of treatment, and four of
the six responders had persistent improvement after the discontinuation of
treatment. Adverse effects (diarrhea, liver enzyme elevation, pancreatitis, or
bone marrow suppression) occurred in 5 of the 14 treated patients, resulting in
treatment cessation in four patients.
Additional study is necessary to confirm the efficacy of azathioprine therapy.
(See "Overview of pharmacogenomics", section on 'Thiopurines and
polymorphisms in TPMT and NUDT15'.)
Janus kinase inhibitors — Janus kinase (JAK) inhibitors appear to induce hair
growth in alopecia areata; however, further study is necessary prior to
conclusions about efficacy and safety. Oral tofacitinib is the JAK inhibitor that
has been most studied for the treatment of alopecia areata:
●Oral tofacitinib – Regrowth of hair during treatment with tofacitinib (a small
molecule selective JAK 1/3 inhibitor) has been documented in patients with
alopecia areata [44-50]. Patients are typically treated with 5 to 10 mg twice
daily.
A retrospective study of 90 adults with severe alopecia areata (at least 40
percent scalp hair loss, alopecia totalis, or alopecia universalis) who had
stable or worsening disease for at least six months and received
oral tofacitinib (5 to 10 mg twice daily) for at least four months (with or
without adjuvant prednisone) supports benefit [44]. Of the 65 patients with
a duration of the current disease episode of 10 years or less, 77 percent
had a clinical response (at least 6 percent improvement in the Severity of
Alopecia Tool [SALT] score) and 58 percent achieved greater than 50
percent improvement in the SALT score over 4 to 18 months of treatment.
Patients with a disease episode longer than 10 years appeared less likely
to respond to treatment; the clinical response rate in this population was 32
percent (8 of 25 patients). No serious adverse effects occurred during
treatment.
 Data on oral tofacitinib use in children are limited [51,52]. In a series of four
children (ages 8 to 10 years) with refractory alopecia totalis or alopecia
universalis treated with tofacitinib, two had complete regrowth of scalp hair,
one had partial regrowth, and one failed to respond [52]. Responses
occurred within three to six months. The three responders received 5 mg
twice daily, and the child who failed treatment received 5 mg once daily,
which was subsequently increased to 5 mg twice daily after three months.
In another series, partial hair regrowth occurred in all of eight adolescents
with alopecia universalis treated with tofacitinib 5 mg twice daily for 5 to 18
months [51]. Initial signs of regrowth occurred within the first three months.
No adverse events occurred in either series.
A beneficial effect of tofacitinib on alopecia areata may result from inhibition
of T lymphocyte activation. Further study is necessary to confirm the
efficacy of this treatment. Tofacitinib therapy is associated with increased
risk for infection, including serious infections [53,54]. The development of
malignancy and laboratory abnormalities has also been reported in patients
receiving tofacitinib therapy for other diseases [55].
●Oral ruxolitinib – Further support for a potential role for JAK inhibitors in
the treatment of alopecia areata stems from an open-label pilot study, case
series, and case reports describing the use of oral ruxolitinib [56-60]. In the
open-label study, 9 of 12 patients (75 percent) with moderate to severe
alopecia areata treated with 20 mg of ruxolitinib twice daily for three to six
months achieved at least 50 percent hair regrowth by the end of treatment
[60].
●Topical JAK inhibitors – In addition, limited data suggest topical
formulations of ruxolitinib and tofacitinib may be beneficial, although these
are not yet commercially available [61-65]. A 28-week phase 1 trial in which
16 adults with alopecia universalis applied tofacitinib 2% ointment,
ruxolitinib 1% ointment, clobetasol dipropionate 0.05% ointment, or vehicle
to one of four randomly assigned areas of the scalp and eyebrows twice
daily found hair regrowth in the treated area in 6, 5, 10, and 0 patients,
respectively [61]. In addition, in a 24-week, open-label study, hair regrowth
occurred in 3 of 10 adults with alopecia areata or alopecia totalis during use
of tofacitinib 2% ointment [62].
Case series support potential benefit of topical JAK inhibitors in children
[63,66]. In the larger series, tofacitinib 2% ointment therapy in 11 children
with alopecia areata, alopecia totalis, or alopecia universalis refractory to
oral and topical corticosteroids was associated with improvement in the
SALT score in 8 children, including 3 children who had sufficient hair
regrowth to cover the scalp or conceal residual areas of hair loss [63].
Methotrexate — A systematic review and meta-analysis of primarily
retrospective observational studies suggests there may be benefit
of methotrexate, particularly when used in adults or in conjunction with systemic
glucocorticoids [67]. Patients were generally treated with doses between 7.5
and 25 mg per week. The pooled rate of good or complete response (at least 50
percent hair regrowth) was 63 percent. Initial hair regrowth with methotrexate
may be evident after approximately three months, and 6 to 12 months of
therapy may be necessary for complete regrowth. However, recurrence appears
common upon tapering of methotrexate.
Additional study is necessary to confirm efficacy of methotrexate. In addition,
methotrexate therapy requires close laboratory monitoring and has important
toxicities. (See "Major side effects of low-dose methotrexate".)
Sulfasalazine — Sulfasalazine is a drug with immunosuppressive and
immunomodulatory properties. Uncontrolled studies and a retrospective chart
review have reported successful therapy in approximately one-quarter of
patients with alopecia areata [68-70]. However, relapse rates of up to 45
percent have been reported [69]. Side effects of sulfasalazine may include
gastrointestinal distress, headache, fever, rash, and, less frequently,
hematologic disorders and hepatotoxicity.
Starting therapy with a low dose may decrease gastrointestinal symptoms.
Patients can be treated with 0.5 g twice daily for one month, followed by 1 g
twice daily for one month and 1.5 g twice daily for at least three months [68,69].
Complete blood cell counts and liver function tests should be closely monitored
during the first three months of therapy and every three to six months thereafter
[68].

EYELASH LOSS There are no established local treatments for

eyelash disease. False eyelashes are a cosmetic option for patients.

(See 'Cosmetic options' above.)
Topical prostaglandin analogues have been studied for eyelash involvement,
but their efficacy remains uncertain and use cannot be recommended. The
majority of studies of topical prostaglandin analogues, including a 16-week
randomized trial of 11 patients, have shown no benefit [71-73]. However, a
nonrandomized, prospective study reported benefit with a longer course of
therapy. Of 44 patients with eyelash alopecia treated
with latanoprost ophthalmic solution for two years, complete or moderate
regrowth occurred in 17.5 and 27.5 percent, respectively [74]. None of the 10
patients in the control group attained similar levels of response.

OTHER THERAPIES Improvement following treatment with a variety

of additional local and systemic therapies has been reported. However, further
studies are necessary before any of these agents can be routinely
recommended.
Local therapies
●Bexarotene – In a phase I/II, randomized, single-blind trial, patients with
alopecia areata applied topical bexarotene, a retinoid, to one side of the
scalp [75]. After 24 weeks, 5 out of 42 patients (12 percent) exhibited at
least 50 percent hair regrowth on the treated side of the scalp. An
additional six patients (14 percent) had regrowth on both sides of the scalp.
The reason for the bilateral hair growth is unclear.
●Excimer laser – The excimer laser emits monochromatic ultraviolet B
(UVB) light at a wavelength of 308 nm. Its mechanism of action in alopecia
areata is thought to involve the induction of T cell apoptosis [76,77]. In a
few small studies and case reports, treatment with the excimer laser was
associated with improvement in patchy alopecia areata of the scalp [76,78-
 81]. Patients with lesions on the extremities, alopecia totalis, or alopecia
universalis have not responded to therapy [76,78,81].
●Minoxidil – Randomized trials of minoxidil have been small, and some, but
not all, trials have found evidence of benefit, at least for patients with
limited alopecia areata [82-84]. Minoxidil does not appear to be effective in
patients with total loss of scalp hair [84].
Topical minoxidil is used twice daily alone or in combination with
intralesional or topical corticosteroids. While there may be a dose response
effect with the 5% solution being more effective than the 2% solution [85],
few patients achieve cosmetically significant regrowth, and continued
application is required to maintain growth. If used, minoxidil should be tried
for three months before evaluating effectiveness.
Topical minoxidil is generally well tolerated but can lead to unwanted
growth of facial hair in approximately 3 percent of women [86]. Pruritus or
dermatitis is an occasional adverse event [87]; a foam formulation is less
likely to induce these symptoms [88]. Unlike the solution formulation,
propylene glycol (a common allergen and irritant) is not present in minoxidil
foam.
●Platelet-rich plasma – Platelet-rich plasma, which contains growth
factors that are important for cell proliferation and differentiation and has
anti-inflammatory properties, may be beneficial in alopecia areata. In a trial
in which 45 patients with chronic, recurring alopecia areata of at least two
years duration were randomly assigned to intralesional injections of
autologous platelet-rich plasma, triamcinolone acetonide, or placebo
administered once per month for three months, platelet-rich plasma
injection was most effective for inducing hair regrowth [89]. Platelet-rich
plasma therapy also was associated with reductions in symptoms of
burning or itching in affected areas. Additional studies are necessary to
validate the findings of this trial.
●Photochemotherapy – Psoralen plus ultraviolet A (PUVA)
photochemotherapy involves topical or oral administration of a psoralen, a
photosensitizing agent, followed by exposure to ultraviolet A (UVA) light.
Several uncontrolled series suggest efficacy rates of 60 to 65 percent,
though with a high relapse rate [90-93]. Other series have found efficacy
rates no higher than might be expected without therapy [94,95]. PUVA
photochemotherapy has the potential for long-term adverse effects,
including cutaneous malignancy. PUVA is generally avoided in children for
this reason. In our practices, we avoid PUVA photochemotherapy for both
adult and pediatric patients. (See "Psoralen plus ultraviolet A (PUVA)
photochemotherapy".)
Topical pimecrolimus [96], topical tacrolimus [97,98],
topical cyclosporine [99,100], and photodynamic therapy [101-103] are not
effective for alopecia areata.
Systemic therapies
●Cyclosporine – Cyclosporine may induce hair growth in patients with
alopecia areata. However, cyclosporine therapy is associated with the
potential for serious adverse effects that preclude long-term therapy;
therefore, we tend to avoid use of cyclosporine for alopecia areata.
Efficacy data for cyclosporine are limited. A 12-week trial in which 36 adults
with moderate to severe alopecia areata (including 21 adults with alopecia
totalis or alopecia universalis) were randomly assigned to either
cyclosporine (4 mg/kg per day) or placebo found a nonstatistically
significant trend favoring benefit of cyclosporine; at week 12, 31 versus 6
percent of patients treated with cyclosporine or placebo, respectively,
achieved at least 50 percent improvement in the Severity of Alopecia Tool
(SALT) score [104]. Additional studies with larger sample sizes or longer
treatment durations may be useful for confirming benefit of cyclosporine.
Data from case series and uncontrolled studies also suggest benefit
of cyclosporine given with or without systemic glucocorticoids [105-108].
Cyclosporine doses higher than 4 mg/kg have also been utilized [105].
(See "Pharmacology of cyclosporine and tacrolimus", section on 'Side
effects'.)
The development of alopecia areata during cyclosporine therapy has also
been reported [109-112].
●Ezetimibe-simvastatin – A prospective study of 29 adults with alopecia
areata involving 40 to 70 percent of the scalp suggests that ezetimibe-
simvastatin (10 mg/40 mg) may be beneficial for alopecia areata [113]. Of
the 19 patients who completed 24 weeks of once-daily therapy (10 patients
were lost to follow-up), 14 had at least 20 percent hair regrowth and 9 had
at least 70 percent hair regrowth. A second phase of the study compared
responders who continued treatment for an additional 24 weeks with
responders who stopped therapy. Of the seven patients who continued
treatment, five had continued regrowth or stable disease, one had new hair
loss, and one was lost to follow-up. In contrast, among the seven patients
who stopped therapy, one had stable disease, five relapsed, and one was
lost to follow-up. Treatment benefit for alopecia totalis and alopecia
universalis is also documented in case reports [114,115]. A controlled trial
is necessary to confirm efficacy of this therapy.
●Low-dose recombinant interleukin-2 – The finding that impairment of
the inhibitory function of regulatory T cells may play a role in alopecia
areata [116] led to a small pilot study that evaluated the efficacy of
interleukin (IL)-2, a cytokine involved in regulatory T cell homeostasis
indicated for the treatment of advanced melanoma and renal cell
carcinoma, as a treatment for alopecia areata. In the study, five women
with severe alopecia areata (>50 percent of the scalp surface affected)
were given one course of subcutaneous recombinant IL-2 (1.5 million
international units per day) for five days, followed by three five-day courses
of 3 million international units per day at weeks 3, 6, and 9 [117]. Although
none of the patients achieved the primary outcome (90 percent
improvement in the SALT score by two or six months after treatment), four
of five had a partial response, and continued improvement was observed
between two and six months after the completion of treatment.
Immunohistochemical studies were also performed and revealed an
increase in the regulatory T cell count in scalp biopsy specimens from all
patients who exhibited clinical improvement, suggesting that the promotion
of regulatory T cells is a factor in clinical improvement.
Severe toxicity is a limiting factor for the high doses of recombinant IL-2
used for the treatment of melanoma and renal cell carcinoma. However,
adverse effects during low-dose recombinant IL-2 therapy for alopecia
areata were mild to moderate and included asthenia, arthralgia, urticaria,
 and injection site reactions [117]. Further study is necessary to determine
whether low-dose recombinant IL-2 therapy should have a role in the
treatment of alopecia areata.
Biologic tumor necrosis factor (TNF)-alpha inhibitors are not effective for
alopecia areata [118]. In addition, patients who have been treated with the TNF-
alpha inhibitors adalimumab, infliximab, or etanercept for other autoimmune
disorders have developed alopecia areata during the course of treatment [119-
126]. Data on the efficacy of hydroxychloroquine are limited and conflicting
[127-129].

SOCIETY GUIDELINE LINKS Links to society and government-

sponsored guidelines from selected countries and regions around the world are
provided separately. (See "Society guideline links: Alopecia".)

INFORMATION FOR PATIENTS

UpToDate offers two types of patient education materials, "The Basics" and
"Beyond the Basics." The Basics patient education pieces are written in plain
language, at the 5th to 6th grade reading level, and they answer the four or five
key questions a patient might have about a given condition. These articles are
best for patients who want a general overview and who prefer short, easy-to-
read materials. Beyond the Basics patient education pieces are longer, more
sophisticated, and more detailed. These articles are written at the 10 th to
12th grade reading level and are best for patients who want in-depth information
and are comfortable with some medical jargon.

Here are the patient education articles that are relevant to this topic. We
encourage you to print or e-mail these topics to your patients. (You can also
locate patient education articles on a variety of subjects by searching on
"patient info" and the keyword(s) of interest.)

●Basics topics (see "Patient education: Hair loss in men and women (The
Basics)")
●Beyond the Basics topics (see "Patient education: Alopecia areata
(Beyond the Basics)")

SUMMARY AND RECOMMENDATIONS

●Alopecia areata is a chronic, relapsing disorder that results in nonscarring

hair loss. Not all patients with alopecia areata require treatment; up to 50
percent of patients with limited alopecia areata of less than one year's
duration will experience spontaneous regrowth of hair.
(See 'Introduction' above.)
●The cosmetic effects of alopecia areata can cause severe emotional
distress; counseling in such patients is essential. (See 'Counseling' above.)
●There is relatively little evidence on treatment from well-designed clinical
trials. The response to treatment is variable, and some patients may elect
not to treat this condition. For patients who desire treatment, we suggest
the following:
•We suggest that limited scalp alopecia areata be treated with
intralesional injections of corticosteroids (Grade 2B).
(See 'Intralesional corticosteroids' above.)
•In children or adults with limited disease who are unlikely to tolerate
intralesional therapy, we suggest treatment with topical corticosteroids
(Grade 2B). (See 'Potent topical corticosteroids' above.)
•We suggest that patients with extensive alopecia areata, including
alopecia totalis, as well as patients with more limited disease who do
not respond to the above therapies be treated with topical
immunotherapy (Grade 2C). Patients should generally be referred to a
dermatologist for such therapy and any additional management.
(See 'Topical immunotherapy' above.)
●Patients who do not desire treatment may benefit from cosmetic
interventions. Wigs or shaving the scalp may produce an acceptable
cosmetic result. Temporary tattooing can be helpful for loss of eyebrows.
False eyelashes are available for patients with alopecia of the eyelashes.
(See 'Cosmetic options' above.)
●Systemic glucocorticoid therapy may induce hair regrowth, and short
courses of treatment are occasionally utilized to temporarily halt disease
progression in patients with rapidly progressing, widespread, active
disease. The potential adverse effects of systemic glucocorticoids make
them unfavorable options for long-term management. (See 'Systemic
glucocorticoids' above.)