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Therapeutic Strategies

Alopecia Areata

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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.

First Steps

Limited Hair Loss

  1. The initial strategy may be no treatment, as regrowth, particularly in paucilesional first-episode alopecia areata, is common in 2 to 6 months.
  2. 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

  1. A reliable, standard, low-risk therapy is not available.
  2. 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 eyebrows.

Alternative Steps

Limited or Extensive Hair Loss

Multiple modalities have been described, but none is clearly superior.

  1. Application of minoxidil 2-5% or 3% every day or two times daily may be attempted.
  2. 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.
  3. 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 acetone.


  1. Corticosteroid injections may cause focal reversible scalp depressions and has been rarely reported to cause blindness if injecting around the eyes.
  2. 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.
  3. Alopecia areata is associated with other autoimmune disorders, including thyroid disease, vitiligo, pernicious anemia, and Addison's disease.
  4. Contact immunotherapy may result in widespread dermatitis and lymphadenopathy.
  5. Anthralin therapy may cause cutaneous staining.
  6. In severe cases, stopping immunotherapy or other treatments is often associated with return of the alopecia, so maintenance therapy is required.

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