Alopecia Areata Medication

  • Author: Chantal Bolduc, MD, FRCP(C); Chief Editor: Dirk M Elston, MD   more...
 
Updated: Apr 3, 2012
 

Medication Summary

Therapies most commonly include corticosteroid injections, corticosteroid creams, minoxidil, anthralin, topical immunotherapy, and phototherapy. The choice of one agent over the others depends on patient age (children do not always tolerate adverse effects), extent of condition (localized vs extensive), and the patient's personal preference. The University of California (San Francisco) and University of British Columbia have devised a treatment algorithm that can guide the physician in the treatment of alopecia areata (see image below).

Treatment algorithm for alopecia areata. Treatment algorithm for alopecia areata.

For patients younger than 10 years, options include corticosteroid creams, minoxidil, and anthralin. For adults with less than 50% scalp involvement, the first option usually is an intralesional corticosteroid, followed by corticosteroid cream, minoxidil, and anthralin. For adults with greater than 50% scalp involvement, topical immunotherapy and phototherapy are additional options.

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Immunomodulators

Class Summary

Because alopecia areata is believed to be an autoimmune condition, different immunomodulators have been used to treat the condition. Exact mechanism of action of topical immunotherapy is unknown. Antigenic competition was hypothesized (ie, introduction of a second antigen can initiate a new infiltrate containing T-suppressor cells and suppressor macrophages that may modify preexisting infiltrate and allow regrowth).

Commonly used agents for immunotherapy include SADBE and DPCP.

Squaric acid dibutylester and diphencyprone

 

May modulate key factors of the immune system.

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Cyclosporine (Sandimmune, Neoral)

 

Used both topically and systemically for the treatment of alopecia areata. Topical cyclosporine has shown limited efficacy. Although systemic CsA appears to be effective in alopecia areata, the adverse effect profile, recurrence rate after treatment discontinuation, and inability to produce long-term remissions make CsA unattractive for the treatment of alopecia areata.

Mechanism by which cyclosporine stimulates hair growth remains unknown. May act through its immunosuppressive effect because patients who regrew hair had clearance of immune cells from the hair follicles and alteration in the balance of regulatory lymphocytes (ie, decreased CD4/CD8 ratio). Causes hypertrichosis in patients treated for conditions unrelated to hair loss.

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Methoxsalen (8-MOP, Oxsoralen)

 

Inhibits mitosis by binding covalently to pyrimidine bases in DNA when photoactivated by UV-A.

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Anthralin (Dritho-Scalp 0.5% cream, Anthra-Derm 1% cream, Drithocreme 1%, Micanol 1% cream)

 

Synthetic derivative of a tree bark extract. Mechanism of action in alopecia areata is unknown. Most likely creates inflammation by generating free radicals, which have antiproliferative and immunosuppressive actions. Both short-contact and overnight treatments have been used. High concentration (1-3%) is used for short-contact treatments. Lower concentrations (0.1-0.4%) are used for overnight treatments. Applications in excessive amounts may stain clothing.

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Glucocorticoids

Class Summary

Have anti-inflammatory properties and cause profound and varied metabolic effects. In addition, these agents modify the body's immune response to diverse stimuli.

Topical corticosteroids (including intralesional corticosteroids) are safe and easy to use. They are acceptable cosmetically and allow patients to wear hats or wigs shortly after application. They also are relatively inexpensive. While the usefulness of high-potency topical corticosteroids is under debate, they remain a good (painless) option in children.

Intralesional steroids are first-line treatment in localized conditions.

Oral prednisone usually is reserved for patients with rapidly progressive alopecia areata. The relapse rate is high, and the potential for multiple severe adverse effects when used long term limits its usefulness.

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Clobetasol propionate (Temovate)

 

Class I superpotent topical steroid. Suppresses mitosis and increases synthesis of proteins that decrease inflammation and cause vasoconstriction. Treatment should continue until cosmetically acceptable regrowth is achieved or for a minimum of 3-4 mo.

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Prednisone (Deltasone, Meticorten, Sterapred)

 

Immunosuppressant occasionally used in rapidly progressive alopecia areata in an attempt to halt condition, but relapse rate is high. Use of systemic steroids for treatment of alopecia areata is under much debate. Stabilizes lysosomal membranes and suppresses lymphocytes and antibody production.

Many drug doses and regimens have been used in treatment of alopecia areata, but no formal recommendation exists.

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Triamcinolone (Kenalog 10 mg/mL or 40 mg/mL)

 

In alopecia areata, intralesional triamcinolone is believed to suppress the immune system locally and thereby allow hair to regrow. Injections are administered with 3-mL syringe and 30-gauge needle intralesionally.

Pediatric patients generally are less tolerant of intralesional injections because of local discomfort.

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Betamethasone dipropionate cream 0.05% (Diprosone)

 

For inflammatory dermatosis responsive to steroids. Decreases inflammation by suppressing migration of polymorphonuclear leukocytes and reversing capillary permeability.

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Vasodilators

Class Summary

Relax arteriolar smooth muscle, causing vasodilation; hair growth effects are secondary to vasodilation.

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Minoxidil topical (Rogaine Extra Strength)

 

Stimulates hair growth in general and is effective in many types of hair loss. Exact mechanism of action remains unclear, but does not appear to have either hormonal or immunosuppressant effects. The 5% solution appears to be more effective.

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Contributor Information and Disclosures
Author

Chantal Bolduc, MD, FRCP(C)  Assistant Professor, Department of Dermatology, University of Montreal Faculty of Medicine; Physician, Innovaderm Research, Inc

Chantal Bolduc, MD, FRCP(C) is a member of the following medical societies: Canadian Dermatology Foundation

Disclosure: Nothing to disclose.

Coauthor(s)

Harvey Lui, MD, FRCPC  Professor and Head, Department of Dermatology and Skin Science, Vancouver General Hospital, University of British Columbia; Medical Director, The Skin Centre, Lions Laser Skin Centre and Psoriasis and Phototherapy Clinic, Vancouver General Hospital

Harvey Lui, MD, FRCPC is a member of the following medical societies: American Academy of Dermatology, American Dermatological Association, American Society for Laser Medicine and Surgery, American Society for Photobiology, Canadian Dermatology Association, Canadian Dermatology Foundation, Canadian Medical Association, College of Physicians and Surgeons of British Columbia, European Academy of Dermatology and Venereology, National Psoriasis Foundation, North American Hair Research Society, and Photomedicine Society

Disclosure: Astellas Consulting fee Review panel membership; Amgen/Wyeth Consulting fee Speaking and teaching; LEO Pharma Honoraria Speaking and teaching; LEO Pharma Grant/research funds Investigator; Galderma Grant/research funds Other

Jerry Shapiro, MD, FRCP(C)  Clinical Associate Professor, Department of Medicine, Division of Dermatology, University of British Columbia, Canada

Disclosure: Nothing to disclose.

Specialty Editor Board

Leonard Sperling, MD  Chair, Professor, Department of Dermatology, Uniformed Services University of the Health Sciences

Leonard Sperling, MD is a member of the following medical societies: American Academy of Dermatology

Disclosure: Nothing to disclose.

Richard P Vinson, MD  Assistant Clinical Professor, Department of Dermatology, Texas Tech University Health Sciences Center, Paul L Foster School of Medicine; Consulting Staff, Mountain View Dermatology, PA

Richard P Vinson, MD is a member of the following medical societies: American Academy of Dermatology, Association of Military Dermatologists, Texas Dermatological Society, and Texas Medical Association

Disclosure: Nothing to disclose.

Lester F Libow, MD  Dermatopathologist, South Texas Dermatopathology Laboratory

Lester F Libow, MD is a member of the following medical societies: American Academy of Dermatology, American Society of Dermatopathology, and Texas Medical Association

Disclosure: Nothing to disclose.

Joel M Gelfand, MD, MSCE  Medical Director, Clinical Studies Unit, Assistant Professor, Department of Dermatology, Associate Scholar, Center for Clinical Epidemiology and Biostatistics, University of Pennsylvania

Joel M Gelfand, MD, MSCE is a member of the following medical societies: Society for Investigative Dermatology

Disclosure: AMGEN Consulting fee Consulting; AMGEN Grant/research funds Investigator; Genentech Grant/research funds investigator; Centocor Consulting fee Consulting; Abbott Grant/research funds investigator; Abbott Consulting fee Consulting; Novartis investigator; Pfizer Grant/research funds investigator; Celgene Consulting fee DMC Chair; NIAMS and NHLBI Grant/research funds investigator

Chief Editor

Dirk M Elston, MD  Director, Ackerman Academy of Dermatopathology, New York

Dirk M Elston, MD is a member of the following medical societies: American Academy of Dermatology

Disclosure: Nothing to disclose.

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Alopecia areata affecting the beard.
Alopecia areata affecting the arms.
Patchy alopecia areata.
Ophiasis pattern of alopecia areata.
Sisaipho pattern of alopecia areata.
Alopecia totalis.
Diffuse alopecia areata.
Corticosteroid injection.
Treatment algorithm for alopecia areata.
 
 
 
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