Alopecia areata (AA) is an autoimmune disorder characterized by nonscarring hair loss. While a definitive cure remains elusive, various treatments aim to stimulate hair regrowth. This article delves into the diverse range of treatment options available, focusing on topical applications and their role in managing AA.
Alopecia areata (AA) is a form of autoimmune-mediated nonscarring alopecia that does not result in hair-follicle destruction. The lifetime incidence of AA is about 1.7% to 2.1%, appears to increase linearly with age, and affects males and females at a similar rate. The impact of AA on health-related quality of life (QOL) may be significant, affecting psychological, emotional, or social realms. Factors affecting the impact of AA on QOL include stress, stress preceding onset of AA, age of onset, changes in social status (family stress and job changes), changes in physical appearance, and female sex. The prevalence of depression and anxiety ranges from 25% to 60%.
Hair undergoes constant regeneration through a three-phase process that consists of anagen (growth), catagen (regression), and telogen (rest). Up to 85% to 90% of the 80,000 to 150,000 hair follicles located in the scalp are in the anagen phase. The remaining follicles may be in the catagen phase (<1%) or in the telogen phase (≤10%). Owing to inflammation, the telogen phase becomes more prominent in AA.
How AA occurs has not yet been fully elucidated, but one proposed mechanism is dysregulation of immune function at the hair follicle. Given the multitude of hair-loss causes, the patient interview is important in evaluation and diagnosis. Pertinent information includes duration, rate, progression, location, and pattern of hair loss. A visual inspection should be performed to determine whether the alopecia is scarring or nonscarring and to determine scalp-hair distribution and density. A handheld magnifier used to evaluate the scalp and hair (trichoscopy) may assist in determining the alopecia type.
Asymptomatic hair loss that presents as one or more oval or round skin-colored patches that are well demarcated and smooth is typical of AA. Exclamation-point hairs are often found on the peripheral edge of the patch and occur primarily in acute versus chronic AA. Subtypes of AA include alopecia totalis, in which hair loss affects the whole scalp, and alopecia universalis, which describes loss of all body hair. Spontaneous remission may occur within 1 year in up to 34% to 50% of patients, although many will experience multiple occurrences.
Read also: Hair Loss Solutions for Black Men
For patients with moderate disease, treatment for alopecia areata may include topical corticosteroids with or without topical or oral minoxidil. Several topical treatments can help prevent further hair loss and stimulate hair growth on their own but may also be paired with oral medications.
Topical steroids, applied directly to the skin, are available in creams, foams, and ointments. They are safer for long-term use than oral steroids. Topical scalp therapy with once-daily potent or ultrapotent corticosteroids can achieve hair regrowth in 6 weeks to 3 months in 30% to 57% of patients. Topical corticosteroids should be considered in patients who cannot tolerate intralesional corticosteroids, and they are considered first-line therapy in children aged ≤12 years. Beard and eyelash areas should be avoided because of concerns about skin atrophy.
Corticosteroids, or steroids, reduce inflammation around hair follicles, helping hair grow. Effective treatments for alopecia areata block the immune system attack on the hair follicles so hair can regrow. Corticosteroids are often combined with other treatments for alopecia areata.
A single-center, randomized, blinded, two-arm, parallel-group superiority trial was conducted in 42 children aged 2 to 16 years with AA affecting ≥10% of scalp surface area who were treated with clobetasol propionate 0.05% cream or hydrocortisone 1% cream. Compared with hydrocortisone cream, clobetasol propionate demonstrated a statistically significant decrease in area of hair loss (P <.001) at 12, 18, and 24 weeks when applied two times daily for two cycles of 6 weeks on/6 weeks off. At 24 weeks, 85% of the clobetasol group versus 33.3% of the hydrocortisone group achieved at least 50% reduction in hair-loss surface area. In a small investigator-blinded, parallel-group study of 61 adults with hair loss of <26%, the hair-regrowth rate with betamethasone valerate foam versus betamethasone dipropionate lotion applied two times daily for 12 weeks was evaluated. The hair-regrowth rate was based on the regrowth score, with a range of 0 (<10% regrowth) to 4 (>75% regrowth). The regrowth rate was 3.1 ± 1.5 and 1.8 ± 1.6 for foam and lotion, respectively (P <.01).
Possible side effects include minor discomfort, scalp atrophy, and hypopigmentation. Side effects include folliculitis, telangiectasia, local atrophy, and rare hypothalamic-pituitary-adrenal axis suppression.
Read also: Treating Traction Alopecia
Available over the counter for pattern hair loss, minoxidil (Rogaine) is sometimes recommended to help stimulate hair regrowth in alopecia areata. Minoxidil works by relaxing the blood vessels, making it easier for blood circulation to get to the scalp. The increased blood flow strengthens the hair follicle, promoting growth. It also has the benefit of maintaining the hair you currently have. Minoxidil is applied to the scalp two or three times a day. It can take a few months to see any effects. In some cases, minoxidil may also be applied to the beard and eyebrow areas to help stimulate hair growth. It’s also used in combination with other treatments, such as JAK inhibitors and intralesional corticosteroids.
Like monixidil, anthralin (Drithocreme HP) is a topical medication that’s applied directly to your scalp. Although traditionally used for psoriasis, anthralin may help treat alopecia areata when used in conjunction with minoxidil.
Vitamin D has a multitude of biological effects that interact with the innate and adaptive immune system, most of which lead to its downregulation. Vitamin D has direct effects on T and B cells and shapes their responses to activation. The effect of 1, 25-dihydroxycholecalciferol [1, 25(OH)2D3] on the acquired antigen-specific immune response is T lymphocyte proliferation inhibition, particularly of the Th1 arm9. The addition of 1, 25(OH)2D3 to CD4 T cells inhibits Th1 cell proliferation and cytokine production10 and leads to decreased secretion of interleukin (IL)-2 and interferon-γ by CD4 T cells and promotes IL-5 and IL-10 production, which further tilts the T cell response toward Th2 dominance11. Dendritic cells play a central role in regulating immune activation and responses to self9. Dendritic cell maturation is central to the outcome of antigen presentation to T cells9. In vitro, 1, 25(OH)2D3 inhibits the differentiation of monocytes into dendritic cells and impedes T cell-induced stimulatory activity13. It has been shown that 1, 25(OH)2D3 is one of the most powerful blockers of dendritic cell differentiation and of IL-12 secretion. IL-12 inhibition is achieved through the direct interaction of 1, 25(OH)2D3 bound to the VDR, which interferes with nuclear factor-kappaB-induced transcription of IL-1214.
A 7-year-old otherwise healthy boy presented with a 2-month history of sudden hair loss on the vertex region of the scalp. After obtaining written informed consent from the patient's parents, we prescribed calcipotriol solution (Daivonex, 50µg/ml) to be applied once daily for 3 months. Initial new hair growth was found at 6 weeks after initial application of calcipotriol. After 3 months of calcipotriol therapy, complete regrowth was observed in the affected area.
This treatment works similarly to oral immunotherapy agents but is applied directly to the skin by a dermatologist. Like other types of immunotherapy, such as allergy shots, contact immunotherapy works by purposely triggering an allergic reaction in your skin. The immunotherapy agent causes an allergic rash (allergic contact dermatitis) where it is applied. This changes your body’s immune response around the hair follicles, though researchers don’t understand why this promotes hair regrowth. While you may have side effects at first, such as a rash and scaly skin, the hope with this treatment is that your hair will regrow within a few months. There are reports that 40 to 55% of patients experience significant regrowth. An estimated 17 to 75 percent of individuals have hair regrowth after use.
Read also: Hair Loss in Women
The rash can look like poison oak or ivy. The treatment can be uncomfortable, causing redness and rash where it is applied. If hair regrowth is successful, treatment usually needs to continue to maintain the regrowth.
The most common treatment for adults with patchy alopecia areata is intralesional injection of corticosteroids (meaning injection within the bald patch). A very fine needle injects the medication into the areas of missing hair on the scalp or face. Some find the injections painful, while others feel only slight discomfort. If the injections are successful, you may see new hair growth within six to eight weeks. You can repeat them every four to six weeks, stopping treatment when the hair regrows. Corticosteroid injections don’t prevent further hair loss.
This option is the mainstay of therapy for limited AA. Triamcinolone acetonide 2.5 mg/mL to 10 mg/mL at a volume of 0.1 mL may be injected into the dermis and/or subcutis of each patch of scalp AA, with a maximum total dosage of 10 mg to 20 mg per session. Injections should be separated by 1 cm. Hair-tuft growth of about 0.5 cm in diameter is anticipated to occur, and clinical improvement is expected within 2 to 6 weeks. Sessions should occur no more than every 4 to 6 weeks, and treatment should be discontinued once growth is complete (or after 6 months if there is no response). Studies evaluating the efficacy of intralesional corticosteroid therapy indicate that up to 62% of patients will achieve hair regrowth; however, many studies have been small in size and of short duration.
Oral medications are one of the first treatment methods your dermatologist may consider for treating alopecia areata.
Immunosuppressants work by tamping down the immune system’s attack on healthy hair follicles, which helps prevent further hair loss. If hair follicles are restored, hair regrowth may also be possible. Oral immunosuppressants include corticosteroids, such as prednisone, which can also be combined with other immunosuppressants for maximum effect. It may take up to six weeks until you see hair regrowth with oral immunosuppressants. The treatment works best for rapid or widespread alopecia areata.
Oral steroids cause side effects like weight gain, thinning bones (osteoporosis), rising blood sugar levels, and high blood pressure, among others, and can not be used as a long term treatment.
JAK inhibitors block enzymes that may contribute to inflammation in the body. These medications include baricitinib (Olumiant), deuruxolitinib (Leqselvi), and ritlecitinib (Litfulo), though others can be prescribed off label, including ruxolitinib (Jakafi) and tofacitinib (Xeljanz). Hair regrowth, when it occurs, tends to happens after 6 to 18 months on the drug. JAK inhibitors may treat extensive hair loss related to alopecia areata, but many people have recurring hair loss once they stop taking these medications.
JAK inhibitors are among the newest therapies for AA. The oral agents baricitinib (Olumiant) and ritlecitinib (Litfulo), which were approved for AA treatment in 2022 and 2023, respectively. JAK inhibitors modulate the immune-mediated response that causes hair loss. JAK inhibitors block the cytokine-induced regulatory signaling pathway, activating signal transducers and activators of transcription by inhibiting JAK phosphorylation. This inhibition blocks IFN-gamma and multiple cytokines (IL-2, -4, -7, -9, -15, -21, and -23) and inhibits the production of inflammatory helper T cells, stimulating hair growth. Additionally, hair-follicle stem cells are activated, restoring anagen.
The inhibitory effects of baricitinib are specific to JAK1, JAK2, JAK 3, and tyrosine kinase (TYK) 2, with less inhibitory effect at JAK3. The phase II portion of BRAVE-AA1, a randomized, placebo-controlled trial of baricitinib in patients with ≥50% scalp hair loss (N = 110), found that baricitinib doses of 2 mg and 4 mg were effective in achieving a Severity of Alopecia Tool (SALT) score of ≤20 compared with placebo. SALT scores comprise a range of 0 (no scalp-hair loss) to 100 (complete scalp-hair loss). The subsequent BRAVE-AA1 (phase III portion) and phase III BRAVE-AA2 randomized, placebo-controlled trials evaluated baricitinib’s efficacy in treating severe AA in adult patients (N = 654 and N = 546, respectively) with SALT scores of ≥50 and a current AA episode lasting 6 months to 8 years without spontaneous improvement in the preceding 6 months. At week 36, the proportion of patients with a SALT score of ≤20 was 35.9% to 38.8% with baricitinib 4 mg, 19.4% to 22.8% with baricitinib 2 mg, and 2.2% to 6.2% with placebo. The percentage-point change between each dose and placebo was statistically significant (P <.001).
This medication inhibits JAK3 and the TYK expressed in the hepatocellular carcinoma kinase family. The efficacy of ritlecitinib for the treatment of AA was assessed in ALLEGRO, a 48-week phase IIb/III, randomized, double-blind, placebo-controlled multicenter trial involving 718 patients aged ≥12 years with scalp-hair loss of ≥50%. Seven treatment regimens were used. All ritlecitinib dosing groups were found to have a higher likelihood (14%-31%) of achieving SALT scores of ≤20 versus placebo (2%). A post hoc analysis of the ALLEGRO trial revealed that ritlecitinib was effective regardless of hair-loss profile (presentation and location).
The most common adverse effects reported in clinical trials of baricitinib and ritlecitinib include upper respiratory infection, headache, acne, and nasopharyngitis. Instances of elevated creatinine phosphokinase were identified, typically with higher doses.
Methotrexate (Rheumatrex) is traditionally used to treat severe psoriasis and certain cancers, such as leukemia and lymphoma. Your dermatologist may consider methotrexate for alopecia areata if you have extensive hair loss and no other treatment has worked. One study showed that methotrexate, when combined with low-dose prednisone, stimulated complete or almost complete hair regrowth. Methotrexate itself has immunosuppressant effects and may pose life-threatening risks that you should discuss carefully with a doctor before use.
Systemic corticosteroids are typically reserved for severe AA based on concerns regarding long-term side effects and high relapse rates upon therapy cessation. Daily administration is optimal, and prednisone or prednisolone is preferred. Most studies investigating the efficacy and safety of oral corticosteroids in AA management are small and provide insufficient data. Studies conducted to examine the use of pulsed oral or IV corticosteroid therapy with prednisolone, methylprednisolone, and dexamethasone have demonstrated hair regrowth, but their sample sizes have been small.
Some people with mild alopecia areata decide not to have any treatment.
Alopecia areata often happens once and then there is regrowth of normal hair. Sometimes, hair loss followed by periods of re-growth may happen again and again. Alopecia universalis is the name for complete loss of hair on the head, face and body. For limited areas of alopecia, the affected hairs shed and new hair may regrow. Your doctor may prescribe a few medications to try to help the hair to grow. However, there is no good evidence that any of these treatments will guarantee the hair will regrow. Follow the instructions for use very carefully. Hair may or may not regrow. Hair that is trying to regrow may respond to treatment and continue to regrow. If you are interested in wigs or hairpieces, you may wish to contact Locks of Love.
Novel developments in treating alopecia areata include understanding Type 2 inflammation and why it is important. JAK inhibitors are immunomodulatory drugs. Immune cells and hair follicles interact through cellular mechanisms that utilize Janus kinase proteins (or JAKs) to transmit signals in the immune system. JAK inhibitors are considered the first-line treatment for severe alopecia areata, including universalis and totalis.
tags: #alopecia #areata #treatment #ointment
