Saturday, January 01, 2011
Alopecia Totalis and Alopecia Universalis
Alopecia areata is characterized by nonscarring hair loss of
unknown etiology. Manifestations are most frequently limited to a
few oval bald patches. However, a minority of individuals develop
extensive areas of hair loss or even loss of all body hair
(alopecia totalis or universalis). The pathogenesis of alopecia
areata is poorly understood; however, biopsy of active lesions
demonstrates peribulbar lymphocytic infiltration and therapy is
intended to suppress this inflammation.
Limited Hair Loss
- The initial strategy may be no treatment, as regrowth,
particularly in paucilesional first-episode alopecia areata, is
common in 2 to 6 months.
- If treatment is instituted, eradication of inflammation by
topical application or intralesional injection of corticosteroids
is of value. Topical clobetasol 0.05% in a cream vehicle applied to
the bald patch twice daily, with assessment of response in 4 to 6
weeks. If intralesional injection is selected, use triamcinolone
2.5-10 mg per cc, and if necessary repeat treatment every 4 to 6
weeks until response is complete.
Extensive Hair Loss
- A reliable, standard, low-risk therapy is not available.
- Intralesional corticosteroid injections are not practical for
patients with alopecia totalis, but may be used in this setting to
induce hair growth in cosmetically important areas, such as the
Limited or Extensive Hair Loss
Multiple modalities have been described, but none is clearly
- Application of minoxidil 2-5% or 3% every day or two times
daily may be attempted.
- Anthralin-induced irritant dermatitis is safe and may be
beneficial. Application of anthralin 0.25%-1.0% in petrolatum or
paste to the scalp for 20 to 30 minutes nightly at bedtime to
induce an irritant dermatitis. Continue the therapeutic trial for 2
to 4 months.
- Contact allergen application may be efficacious. Diphencyprone
may be used, sensitizing at 2% on a 4-cm diameter spot on the inner
arm and starting applications to the scalp at 0.0001%, with gradual
escalation to induce slight reaction (mild erythema and pruritus
lasting about 36 hours). Squaric acid dibutyl ester, another potent
topical allergen, may be used. Sensitize with a 2% solution in
acetone, and elicit dermatitis with a 0.2-0.4% solution in
- Corticosteroid injections may cause focal reversible scalp
depressions and has been rarely reported to cause blindness if
injecting around the eyes.
- Systemic steroids induce hair growth in patients with extensive
alopecia areata, but such therapy is not recommended. High doses
are usually required, and hair loss recurs after steroid
discontinuation. The complications of long-term high-dose steroid
therapy are not justified.
- Alopecia areata is associated with other autoimmune disorders,
including thyroid disease, vitiligo, pernicious anemia, and
- Contact immunotherapy may result in widespread dermatitis and
- Anthralin therapy may cause cutaneous staining.
- In severe cases, stopping immunotherapy or other treatments is
often associated with return of the alopecia, so maintenance
therapy is required.