Alopecia Treatment

• Most effective in males aged 18-41 with Norwood/Hamilton stage II-V hair loss
• Early intervention, when thinning is first noticed hairs are incompletely miniaturized, optimizes treatment
• Neither Finasteride nor Minoxidil can regrow hair in areas of total hair loss
• No well-controlled studies on combination treatment with Finasteride and Minoxidil
• Switching treatment
  
  • Continue using the original medication in addition to the new agent for at least 3 months before discontinuing

• Recommended for treatment of male patients >18 years old with mild to moderate (Hamilton-Norwood stage II-V) androgenic alopecia
• Effects: Studies have shown up to 66% of men show improved scalp coverage after 24 months of treatment and up to 83% showed hair loss stabilization
  • ~20-30% of patients do not respond to therapy
  • One study showed that 5 years of continuous intake showed no further visible hair loss in 90% of male subjects

• Combination therapy with topical Minoxidil (2% or 5% solution or 5% foam) may be considered for better therapeutic effects
• Treatment response should be evaluated at 6-12 months and if successful, therapy must be continued indefinitely to maintain benefit
• Discontinuation of therapy leads to reversal of effect within 12 months

• Alternative therapy for male patients >18 years old with mild to moderate (Hamilton-Norwood stage II-V) androgenic alopecia when previous treatment with Finasteride is ineffective after 12 months

• Recommended to improve or prevent progression of androgenic alopecia in males >18 years old with mild to moderate (Hamilton-Norwood stage II-V) and females >18 years old
  • 2% solution applied twice daily was found to be effective in preventing progression and improve androgenic alopecia in the frontotemporal and vertex regions in males
  • 5% topical solution or foam applied twice daily has shown greater efficacy than 2% solution in males
  • In females, 50% have minimal regrowth and 13% moderate regrowth using 2% solution 

• Treatment response should be evaluated at 6 months and if successful, therapy must be continued indefinitely to maintain benefit
• Discontinuation of therapy leads to reversal of effect within 3-6 months

• An oral antiandrogen that suppresses luteinizing hormone (LH) and follicle-stimulating hormone (FSH) release
• May be used for female patients clinically diagnosed with hyperandrogenism

Spironolactone

• An aldosterone antagonist that competitively blocks androgen receptors and inhibits androgen synthesis
• May be used for female patients with hyperandrogenism

Platelet-rich Plasma (PRP)

• Have been utilized in the treatment of androgenic alopecia in males and females
• More studies are needed to confirm effectivity and determine optimal regimen

• Effects: The treatments used stimulate hair growth but do not prevent hair loss
  • It is unlikely that they influence the course of the disease
  • Treatment tends to be the most effective in mild disease

• Continue treatment until remission occurs or until alopecia patches are concealed by hair regrowth (may take a month to a year)

• Intralesional
  • Eg Triamcinolone acetonide
  • First-line treatment for adult patients with <50% (limited patchy) hair loss
  • Recommended when there is patchy hair loss of limited extent and for cosmetically sensitive sites such as eyebrows and beard
  • Effects: Patients with rapidly progressive, extensive or long-standing alopecia areata responds poorly
  • Regrowth usually seen within 4-8 weeks in responsive patients

• Intravenous (pulse therapy)
  • Studies showed that patients achieved >50% hair growth after 3 consecutive days of pulsed IV corticosteroid courses

• Oral
  • Eg Prednisolone, Prednisone
  • May be considered in severe alopecia areata
  • Use of systemic corticosteroids is controversial because long-term therapy may be necessary which increases risk of adverse effects
  • Based on a small number of studies, short-taper or pulse corticosteroid delivery may be used in cases of advancing alopecia areata
  • Effects: Promotes hair growth but hair shedding occurs soon after the drug is discontinued

• Topical
  • Eg 0.12% Betamethasone valerate, 0.05% Betamethasone dipropionate, 0.2% Fluocinolone, 0.05% Clobetasol propionate
  • May be used as initial therapy for adults and children with limited patchy alopecia areata who are intolerant of intralesional corticosteroids
  • First-line treatment for patients with alopecia of the scalp, eyebrow or beard
  • Treatment of choice in children with alopecia areata
  • Used as 2nd line treatment for alopecia areata totalis/universalis, as an adjunct with other treatments
  • Can be combined with Minoxidil
  • Signs of regrowth can take 6 weeks to 3 months
  • High relapse rate (38-63%) during treatment and after treatment cessation

• Used as short-term contact immunotherapy
  • Usually discontinued after maximum response has been achieved

• Second-line treatment for patients >10 years old with <50% hair loss who responded poorly to intralesional corticosteroid/Minoxidil/topical corticosteroid treatment
  • Administered with or without Minoxidil

• Also used as second-line treatment for unresponsive patients >10 years old with ≥50% hair loss, given with Minoxidil and topical corticosteroids
• Effects: Safely stimulates hair growth in patients with extensive and total scalp hair loss and is useful in children
  • Cosmetically acceptable hair growth was seen in 50-60% of patients in 6 months
  • Clinical irritation is not necessary for effectiveness

• Azathioprine
  • Treatment option for patients with extensive alopecia areata

• Cyclosporine
  • An immunosuppressant that acts on T-lymphocytes to inhibit the production of lymphokines thereby suppressing cell-mediated immune responses
  • Alternative monotherapy agent to high-dose systemic corticosteroids for severe alopecia areata
  • Several studies have shown 25-76.7% success rate but with numerous noted side effects

• Inosiplex (Inosine pranobex/Isoprinosine)
  • Alternative treatment for patients with treatment-resistant alopecia areata

• Janus kinase (JAK) inhibitors (eg Baricitinib, Tofacitinib, Ruxolitinib)
  • Alternative monotherapy agent to high-dose systemic corticosteroids for alopecia areata; may be used in combination with systemic corticosteroids
  • Studies have shown its efficacy in inducing hair growth in patients with severe alopecia areata

• Methotrexate
  • Treatment option for patients with severe alopecia areata, alopecia areata totalis or universalis
  • May be given with low-dose oral corticosteroids
  • Supplementation with Folic acid is recommended during treatment

• Sulfasalazine
  • Treatment option for patients with severe alopecia areata
  • Studies have shown that 23-27% of patients on Sulfasalazine treatment exhibited hair regrowth

• Eg Diphenylcyclopropenone (DPCP), Squaric acid dibutyl ester
• Recommended treatment for chronic extensive alopecia areata, alopecia areata totalis and universalis
• First-line treatment for adult patients with >50% (extensive) hair loss
• A contact allergen commonly used as topical immunotherapy
• Decreases lymphocytic inflammation of the anagen follicle, promoting follicular recovery
• Topical immunotherapy without DPCP has shown to be effective in up to 100% of patients without<50% hair loss; 60-88% of patients with 50-99% hair loss; and 17% of patients with alopecia totalis or alopecia universalis
  • Regrowth was apparent after 3-12 months of treatment
  • No benefit is achieved with continuing therapy after 24 months in the absence of regrowth
  • Relapse rate is 62% during treatment
• Treatment may be discontinued only if complete hair regrowth has been achieved

• Topical
  • 1%-5% solution has been shown to be the most effective in alopecia areata patients
  • Effects: Hair growth is stimulated in patients with extensive and patchy hair loss but not in patients with complete hair loss
  • Hair growth may be seen within 12 weeks and maximal growth is seen at 1 year
  • Continue application until full remission
• Oral
  • Several studies showed significant response with Minoxidil intake

• Eg Bimatoprost, Latanoprost
• Treatment option for eyelash universalis alopecia areata
  
  • Further studies are needed to establish the efficacy of Bimatoprost/Latanoprost for alopecia areata

Other Treatment Options

• Topical calcineurin inhibitors (eg Tacrolimus) may only be considered if other 1st-line agents are ineffective

Platelet-rich Plasma

• A study has shown its effectivity in inducing hair growth
• More studies are needed to establish efficacy in the treatment of alopecia areata

Photochemotherapy

• Psoralen plus ultraviolet A (UVA) (PUVA) has been used for severe alopecia areata
• Whole body UVA irradiation may also be used
• Psoralens may be given orally or topically
• Effects: Effectiveness varies from 20-65% although relapse rate is high
• There is concern about the promotion of skin cancer from long-term PUVA use

• Eyebrow pencil may be suggested to cover alopecia areata patches on eyebrows
• Waterproof eyebrow pencils are highly recommended

• Reassure patients with >50% hair loss that this does not mean that hair will not regrow, but it may be comforting to have it available for periods of more extensive hair loss
• Wigs, hair extensions, hairpieces, headscarves, hats, and false eyelashes have been used to cover patches/areas with hair loss
• Wigs are highly recommended for patients with extensive patchy alopecia and alopecia areata totalis and universalis

• Eg Infrared diode laser, 308-nm excimer laser, low-level laser
• Produces cosmetically acceptable hair regrowth with 60% response rate

Low-level Laser (Light) Therapy (LLLT)

• Also known as laser phototherapy or photobiomodulation therapy
• Stimulate cell proliferation by increasing endogenous growth factors and cutaneous microcirculation by exposing tissues to low levels of visible or near infrared light
• May be used as an ancillary procedure for male or female patients with androgenic alopecia
• Generally well tolerated with mild adverse effects such as scalp dryness, itching, tenderness and warm sensation
• More studies are needed to determine optimal treatment regiment and duration of effect

• Permanent/semi-permanent tattooing of the eyebrows may be suggested
• Recoloring may be needed every 1-2 years