Treatment algorithm

Please note that formulations/routes and doses may differ between drug names and brands, drug formularies, or locations. Treatment recommendations are specific to patient groups: see disclaimer

ACUTE

limited hair loss (treatment desired)

1st line – topical corticosteroid

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ACUTE
|
limited hair loss (treatment desired)
1st line – 

topical corticosteroid

Topical corticosteroids are the initial treatment for children, as intralesional corticosteroids are a difficult option to administer in this group. They are also used for patients who do not want intralesional injection. Topical corticosteroids carry minimal risk and adverse effects.

A vehicle should be chosen that is appropriate for the site of administration (i.e., solution or gel may be preferred in the scalp). Cream is also an appropriate option, as areas affected often have no hair.

Super-potent topical corticosteroids (e.g., clobetasol proprionate 0.05%) are used.

Some clinicians recommend application with occlusion but this method has greater risks of complications, including skin atrophy.

Topical corticosteroid treatment needs to be trialled for several months but with close monitoring for potential adverse effects.

Primary options

clobetasol topical: (0.05%) apply sparingly to the affected area(s) twice daily

Plus – cosmetic camouflage + patient support

Back
ACUTE
|
limited hair loss (treatment desired)
Plus – 

cosmetic camouflage + patient support

Treatment recommended for ALL patients in selected patient group

This is an important part of management, not only for the patient who does not respond to treatment but also for the initial patient when starting treatment before determining whether they will respond. If hair loss is diffuse or incomplete in areas, then powders can be used. However, most areas affected usually have no terminal hairs, in which case coloured scalp sprays or pastes can be tried. For more extensive loss, hair pieces or wigs can be used. Wigs can be synthetic or real hair constructed on a mesh base or as a vacuum wig for alopecia totalis. Patient support groups can be very helpful in providing information regarding these services. Psychological counselling or support are also important, given the significant impact that this disease can have because of drastic and sometimes rapid change in appearance, as well as the unpredictable nature of this condition.

1st line – topical minoxidil ± topical corticosteroid

Back
ACUTE
|
limited hair loss (treatment desired)
1st line – 

topical minoxidil ± topical corticosteroid

Topical minoxidil has been used in Europe and the US as a first-line treatment option for children and for adults who do not want intralesional corticosteroid therapy or who prefer this option; however, it is not clear that many patients get cosmetically acceptable regrowth.

Topical minoxidil 5% solution has been shown to regrow hair in patients with AA, although the mechanism of action is unclear.[24] The 2% solution may also be used. It is safe to use in adults and children, with the most common adverse effect of the solution being skin irritation.

Prescribing a topical corticosteroid along with minoxidil is useful to prevent any scalp irritation; another alternative is to use the foam, which is free of the irritant vehicle.

Once there is full hair regrowth, minoxidil use can be stopped (unlike for hereditary thinning).

Primary options

minoxidil topical: (2% or 5% solution) apply 1 mL to the affected area(s) twice daily; (5% foam) apply half a capful to the affected area(s) twice daily

Secondary options

minoxidil topical: (2% or 5% solution) apply 1 mL to the affected area(s) twice daily; (5% foam) apply half a capful to the affected area(s) twice daily

and

clobetasol topical: (0.05%) apply sparingly to the affected area(s) twice daily

Plus – cosmetic camouflage + patient support

Back
ACUTE
|
limited hair loss (treatment desired)
Plus – 

cosmetic camouflage + patient support

Treatment recommended for ALL patients in selected patient group

This is an important part of management, not only for the patient who does not respond to treatment but also for the initial patient when starting treatment before determining whether they will respond. If hair loss is diffuse or incomplete in areas, then powders can be used. However, most areas affected usually have no terminal hairs, in which case coloured scalp sprays or pastes can be tried. For more extensive loss, hair pieces or wigs can be used. Wigs can be synthetic or real hair constructed on a mesh base or as a vacuum wig for alopecia totalis. Patient support groups can be very helpful in providing information regarding these services. Psychological counselling or support are also important, given the significant impact that this disease can have because of drastic and sometimes rapid change in appearance, as well as the unpredictable nature of this condition.

1st line – intralesional corticosteroid

Back
ACUTE
|
limited hair loss (treatment desired)
1st line – 

intralesional corticosteroid

Intralesional corticosteroids are appropriate initial treatment for adults with localised disease (limited areas of patchy hair loss).

Generally, triamcinolone acetonide is used until either full density is reached or there is no regrowth by about 6 months. High doses have not been found to be more effective, and the chance of developing side effects increases.

Intralesional corticosteroids can be painful; the discomfort can be minimised with application of a topical anaesthetic before injections and use of a 30-gauge needle.

Skin atrophy, localised folliculitis, and acne can be temporary adverse effects.[2][6][9]

Any area with hair loss can be injected, including brows and beard. Lower doses are generally used for the brow, frontal scalp, and beard area, as there is an increased risk of atrophy here.

This should be done by a dermatologist.

Primary options

triamcinolone acetonide: 2.5 to 5 mg intralesionally to brows, beard, or scalp every 4-6 weeks until full regrowth

Consider – topical minoxidil ± topical corticosteroid

Back
ACUTE
|
limited hair loss (treatment desired)
Consider – 

topical minoxidil ± topical corticosteroid

Additional treatment recommended for SOME patients in selected patient group

Topical minoxidil has been used in Europe and the US; however, it is not clear that many patients get cosmetically acceptable regrowth.

Topical minoxidil 5% solution has been shown to regrow hair in patients with AA, although the mechanism of action is unclear.[24] The 2% solution may also be used. It is safe to use in adults and children, with the most common adverse effect of the solution being skin irritation.

Prescribing a topical corticosteroid along with minoxidil is useful to prevent any scalp irritation; another alternative is to use the foam, which is free of the irritant vehicle.

Once there is full hair regrowth, minoxidil use can be stopped (unlike for hereditary thinning).

Primary options

minoxidil topical: (2% or 5% solution) apply 1 mL to the affected area(s) twice daily; (5% foam) apply half a capful to the affected area(s) twice daily

Secondary options

minoxidil topical: (2% or 5% solution) apply 1 mL to the affected area(s) twice daily; (5% foam) apply half a capful to the affected area(s) twice daily

and

clobetasol topical: (0.05%) apply sparingly to the affected area(s) twice daily

Plus – cosmetic camouflage + patient support

Back
ACUTE
|
limited hair loss (treatment desired)
Plus – 

cosmetic camouflage + patient support

Treatment recommended for ALL patients in selected patient group

This is an important part of management, not only for the patient who does not respond to treatment but also for the initial patient when starting treatment before determining whether they will respond. If hair loss is diffuse or incomplete in areas, then powders can be used. However, most areas affected usually have no terminal hairs, in which case coloured scalp sprays or pastes can be tried. For more extensive loss, hair pieces or wigs can be used. Wigs can be synthetic or real hair constructed on a mesh base or as a vacuum wig for alopecia totalis. Patient support groups can be very helpful in providing information regarding these services. Psychological counselling or support are also important, given the significant impact that this disease can have because of drastic and sometimes rapid change in appearance, as well as the unpredictable nature of this condition.

2nd line – oral corticosteroid

Back
ACUTE
|
limited hair loss (treatment desired)
2nd line – 

oral corticosteroid

Oral corticosteroids are used in the acute setting when the disease is active and stopping the activity is attempted. Oral corticosteroids can be used to halt the inflammatory assault even in patients with extensive hair loss, but are used with reservation because of potential adverse effects.[25] Patients should be referred to a specialist if oral corticosteroid treatment is required. Because of potential adverse effects, long-term oral corticosteroid treatment is not an option. Short-term adverse effects include altered appetite, mood, and sleep patterns; gastritis; hypertension; and elevated blood glucose in patients with diabetes.

Primary options

prednisolone: 1 mg/kg/day orally for two weeks, then taper dose gradually over the next four weeks for a total of six weeks treatment

Consider – topical minoxidil ± topical corticosteroid

Back
ACUTE
|
limited hair loss (treatment desired)
Consider – 

topical minoxidil ± topical corticosteroid

Additional treatment recommended for SOME patients in selected patient group

Topical minoxidil has been used in Europe and the US; however, it is not clear that many patients get cosmetically acceptable regrowth.

Topical minoxidil 5% solution has been shown to regrow hair in patients with AA, although the mechanism of action is unclear.[24] The 2% solution may also be used. It is safe to use in adults and children, with the most common adverse effect of the solution being skin irritation.

Prescribing a topical corticosteroid along with minoxidil is useful to prevent any scalp irritation; another alternative is to use the foam, which is free of the irritant vehicle.

Once there is full hair regrowth, minoxidil use can be stopped (unlike for hereditary thinning).

Primary options

minoxidil topical: (2% or 5% solution) apply 1 mL to the affected area(s) twice daily; (5% foam) apply half a capful to the affected area(s) twice daily

Secondary options

minoxidil topical: (2% or 5% solution) apply 1 mL to the affected area(s) twice daily; (5% foam) apply half a capful to the affected area(s) twice daily

and

clobetasol topical: (0.05%) apply sparingly to the affected area(s) twice daily

Plus – cosmetic camouflage + patient support

Back
ACUTE
|
limited hair loss (treatment desired)
Plus – 

cosmetic camouflage + patient support

Treatment recommended for ALL patients in selected patient group

This is an important part of management, not only for the patient who does not respond to treatment but also for the initial patient when starting treatment before determining whether they will respond. If hair loss is diffuse or incomplete in areas, then powders can be used. However, most areas affected usually have no terminal hairs, in which case coloured scalp sprays or pastes can be tried. For more extensive loss, hair pieces or wigs can be used. Wigs can be synthetic or real hair constructed on a mesh base or as a vacuum wig for alopecia totalis. Patient support groups can be very helpful in providing information regarding these services. Psychological counselling or support are also important, given the significant impact that this disease can have because of drastic and sometimes rapid change in appearance, as well as the unpredictable nature of this condition.

3rd line – intramuscular or intravenous corticosteroid

Back
ACUTE
|
limited hair loss (treatment desired)
3rd line – 

intramuscular or intravenous corticosteroid

Long-acting corticosteroids can be administered intramuscularly or intravenously as an alternative route when there is a contraindication to oral therapy.[2] Due to the potential severity of short- and long-term adverse effects of systemic corticosteroids, long-term maintenance therapy is not recommended.[2][23]

Primary options

methylprednisolone sodium succinate: consult specialist for guidance on dose

Consider – topical minoxidil +/- topical corticosteroid

Back
ACUTE
|
limited hair loss (treatment desired)
Consider – 

topical minoxidil +/- topical corticosteroid

Additional treatment recommended for SOME patients in selected patient group

Topical minoxidil has been used in the US and Europe; however, it is not clear that many patients get cosmetically acceptable regrowth. Topical minoxidil 5% solution has been shown to regrow hair in patients with AA, although the mechanism of action is unclear.[24] The 2% solution may also be used. It is safe to use in adults and children, with the most common adverse effect of the solution being skin irritation.

Prescribing a topical corticosteroid along with minoxidil is useful to prevent any scalp irritation; another alternative is to use the foam, which is free of the irritant vehicle.

Once there is full hair regrowth, minoxidil use can be stopped (unlike for hereditary thinning).

Primary options

minoxidil topical: (2% or 5% solution) apply 1 mL to the affected area(s) twice daily; (5% foam) apply half a capful to the affected area(s) twice daily

Secondary options

minoxidil topical: (2% or 5% solution) apply 1 mL to the affected area(s) twice daily; (5% foam) apply half a capful to the affected area(s) twice daily

and

clobetasol topical: (0.05%) apply sparingly to the affected area(s) twice daily

Plus – cosmetic camouflage + patient support

Back
ACUTE
|
limited hair loss (treatment desired)
Plus – 

cosmetic camouflage + patient support

Treatment recommended for ALL patients in selected patient group

This is an important part of management, not only for the patient who does not respond to treatment but also for the initial patient when starting treatment before determining whether they will respond. If hair loss is diffuse or incomplete in areas, then powders can be used. However, most areas affected usually have no terminal hairs, in which case coloured scalp sprays or pastes can be tried. For more extensive loss, hair pieces or wigs can be used. Wigs can be synthetic or real hair constructed on a mesh base or as a vacuum wig for alopecia totalis. Patient support groups can be very helpful in providing information regarding these services. Psychological counselling or support are also important, given the significant impact that this disease can have because of drastic and sometimes rapid change in appearance, as well as the unpredictable nature of this condition.

limited hair loss (no treatment desired)

1st line – cosmetic camouflage + patient support only

Back
ACUTE
|
limited hair loss (no treatment desired)
1st line – 

cosmetic camouflage + patient support only

It is also a valid option for the patient to decide to take no pharmacological treatment, as AA does not cause any harm to health apart from possible psychological distress, and some of the treatments available have side effects.

Cosmetic camouflage and patient support is an important part of management, not only for the patient who does not respond to treatment but also for the initial patient when starting treatment before determining whether they will respond. If hair loss is diffuse or incomplete in areas, then powders can be used. However, most areas affected usually have no terminal hairs, in which case coloured scalp sprays or pastes can be tried. For more extensive loss, hair pieces or wigs can be used. Wigs can be synthetic or real hair constructed on a mesh base or as a vacuum wig for alopecia totalis. Patient support groups can be very helpful in providing information regarding these services. Psychological counselling or support are also important, given the significant impact that this disease can have because of drastic and sometimes rapid change in appearance, as well as the unpredictable nature of this condition.

ONGOING

extensive hair loss (treatment desired)

1st line – topical immunotherapy

Back
ONGOING
|
extensive hair loss (treatment desired)
1st line – 

topical immunotherapy

Patients who have extensive hair loss or who do not respond well to the above measures should be referred to a specialist for further treatment.

Topical immunotherapy may be tried with either DNCB (1-chloro-2,4-dinitrobenzene), DPCP (diphenylcyclopropenone), or SADBE (squaric acid dibutyl ester).

First the patient needs to be sensitised to the compound chosen. This is done by applying the compound to a small area of skin on the shoulder, thigh, or scalp in a concentration of 2%. After waiting a minimum of 2 weeks to allow for an allergic reaction to develop, the patient may either be treated or tested further to determine which concentration to use. One method is to patch test with the application of strengths ranging from 0.1% to 0.000001% under occlusion for 2 days, then the weakest strength that causes erythema can be prescribed for the patient to apply at home.

Some physicians prefer to just pick a strength with which to begin treatment and adjust the concentration based on the reaction. Some prefer to apply the medication in the office on a weekly basis.

Side effects include contact dermatitis, lymphadenopathy, and hyperpigmentation or hypopigmentation. It may be 1 month to a year to begin growing hair, but the average is 5 to 6 months.

These therapies may need to be compounded by a pharmacist.

Plus – cosmetic camouflage and patient support

Back
ONGOING
|
extensive hair loss (treatment desired)
Plus – 

cosmetic camouflage and patient support

Treatment recommended for ALL patients in selected patient group

This is an important part of management, not only for the patient who does not respond to treatment but also for the initial patient when starting treatment before determining whether they will respond. If hair loss is diffuse or incomplete in areas, then powders can be used. However, most areas affected usually have no terminal hairs, in which case coloured scalp sprays or pastes can be tried. For more extensive loss, hair pieces or wigs can be used. Wigs can be synthetic or real hair constructed on a mesh base or as a vacuum wig for alopecia totalis. Patient support groups can be very helpful in providing information regarding these services. Psychological counselling or support are also important, given the significant impact that this disease can have because of drastic and sometimes rapid change in appearance, as well as the unpredictable nature of this condition.

extensive hair loss (no treatment desired)

1st line – cosmetic camouflage + patient support only

Back
ONGOING
|
extensive hair loss (no treatment desired)
1st line – 

cosmetic camouflage + patient support only

It is also a valid option for the patient to decide to take no pharmacological treatment, as AA does not cause any harm to health apart from possible psychological distress, and some of the treatments available have side effects.

Cosmetic camouflage and patient support is an important part of management, not only for the patient who does not respond to treatment but also for the initial patient when starting treatment before determining whether they will respond. If hair loss is diffuse or incomplete in areas, then powders can be used. However, most areas affected usually have no terminal hairs, in which case coloured scalp sprays or pastes can be tried. For more extensive loss, hair pieces or wigs can be used. Wigs can be synthetic or real hair constructed on a mesh base or as a vacuum wig for alopecia totalis. Patient support groups can be very helpful in providing information regarding these services. Psychological counselling or support are also important, given the significant impact that this disease can have because of drastic and sometimes rapid change in appearance, as well as the unpredictable nature of this condition.

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Choose a patient group to see our recommendations

Please note that formulations/routes and doses may differ between drug names and brands, drug formularies, or locations. Treatment recommendations are specific to patient groups. See disclaimer

Use of this content is subject to our disclaimer