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Medication

Medication Summary

The first systemic immunotherapy, baricitinib (Olumiant), was approved by the FDA in June 2022 for adults with severe alopecia areata.^[2] Therapies commonly prescribed 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.

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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.

Class Summary

Glucocorticoids 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.

Clobetasol propionate (Temovate)

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Clobetasol propionate is a class I superpotent topical steroid. It suppresses mitosis and increases the 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 months.

Prednisone (Deltasone, Meticorten, Sterapred)

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

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

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

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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.

Betamethasone dipropionate cream 0.05% (Diprosone)

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Betamethasone dipropionate is used for inflammatory dermatoses responsive to steroids. It decreases inflammation by suppressing the migration of polymorphonuclear leukocytes and reversing capillary permeability.

Class Summary

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

Minoxidil topical (Rogaine Extra Strength)

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

Class Summary

These agents inhibit Janus kinase 3 (JAK3) and the tyrosine kinase expressed in hepatocellular carcinoma (TEC) kinase family by blocking adenosine triphosphate (ATP) binding site.

Baricitinib (Olumiant)

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Indicated for adults with severe alopecia areata.

Ritlecitinib (Litfulo)

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Indicated for patients aged 12 years and older with severe alopecia areata.

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. These are compounded investigational agents not approved by the US Food and Drug Administration for use in alopecia.

Cyclosporine (Sandimmune, Neoral)

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Cyclosporine is 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. The mechanism by which cyclosporine stimulates hair growth remains unknown. It 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). Cyclosporine causes hypertrichosis in patients treated for conditions unrelated to hair loss.

Methoxsalen (8-MOP, Oxsoralen)

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

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

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Anthralin is a synthetic derivative of a tree bark extract. Its mechanism of action in alopecia areata is unknown. Most likely, it 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.

Questions

Darwin E, Hirt PA, Fertig R, Doliner B, Delcanto G, Jimenez JJ. Alopecia Areata: Review of Epidemiology, Clinical Features, Pathogenesis, and New Treatment Options. Int J Trichology. 2018 Mar-Apr. 10 (2):51-60. [QxMD MEDLINE Link].
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King B, Zhang X, Harcha WG, Szepietowski JC, Shapiro J, Lynde C, et al. Efficacy and safety of ritlecitinib in adults and adolescents with alopecia areata: a randomised, double-blind, multicentre, phase 2b-3 trial. Lancet. 2023 May 6. 401 (10387):1518-1529. [QxMD MEDLINE Link].
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Media Gallery

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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Author

Chantal Bolduc, MD, FRCPC Assistant Professor, Department of Dermatology, University of Montreal Faculty of Medicine; Physician, Innovaderm Research, Inc

Chantal Bolduc, MD, FRCPC 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: Canadian Medical Association, American Society for Photobiology, Photomedicine Society, European Academy of Dermatology and Venereology, National Psoriasis Foundation, Canadian Dermatology Association, College of Physicians and Surgeons of British Columbia, North American Hair Research Society, Canadian Dermatology Foundation, American Academy of Dermatology, American Society for Laser Medicine and Surgery

Disclosure: Received consulting fee from Astellas for review panel membership; Received consulting fee from Amgen/Wyeth for speaking and teaching; Received honoraria from LEO Pharma for speaking and teaching; Received grant/research funds from LEO Pharma for investigator; Received grant/research funds from Galderma for other.

Jerry Shapiro, MD, FAAD, FRCPC Professor, Director, Disorders of the Hair and Scalp, The Ronald O Perelman Department of Dermatology, New York University School of Medicine

Disclosure: Nothing to disclose.

Specialty Editor Board

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, Texas Medical Association, Association of Military Dermatologists, Texas Dermatological Society

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, Texas Medical Association

Disclosure: Nothing to disclose.

Chief Editor

Dirk M Elston, MD Professor and Chairman, Department of Dermatology and Dermatologic Surgery, Medical University of South Carolina College of Medicine

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

Disclosure: Nothing to disclose.

Additional Contributors

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.

Alopecia Areata Medication

Medication Summary

Glucocorticoids

Class Summary

Clobetasol propionate (Temovate)

Clobetasol propionate (Temovate)

Prednisone (Deltasone, Meticorten, Sterapred)

Prednisone (Deltasone, Meticorten, Sterapred)

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

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

Betamethasone dipropionate cream 0.05% (Diprosone)

Betamethasone dipropionate cream 0.05% (Diprosone)

Vasodilators

Class Summary

Minoxidil topical (Rogaine Extra Strength)

Minoxidil topical (Rogaine Extra Strength)

Dermatologics, JAK Inhibitors

Class Summary

Baricitinib (Olumiant)

Baricitinib (Olumiant)

Ritlecitinib (Litfulo)

Ritlecitinib (Litfulo)

Immunomodulators

Class Summary

Cyclosporine (Sandimmune, Neoral)

Cyclosporine (Sandimmune, Neoral)

Methoxsalen (8-MOP, Oxsoralen)

Methoxsalen (8-MOP, Oxsoralen)

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

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

Alopecia Areata Medication

Medication Summary

Glucocorticoids

Class Summary

Clobetasol propionate (Temovate)

Prednisone (Deltasone, Meticorten, Sterapred)

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

Betamethasone dipropionate cream 0.05% (Diprosone)

Vasodilators

Class Summary

Minoxidil topical (Rogaine Extra Strength)

Dermatologics, JAK Inhibitors

Class Summary

Baricitinib (Olumiant)

Ritlecitinib (Litfulo)

Immunomodulators

Class Summary

Cyclosporine (Sandimmune, Neoral)

Methoxsalen (8-MOP, Oxsoralen)

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

References

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