Available Treatments Here is an overview of the more common treatments for alopecia areata you may encounter depending on the severity of your disease. It is not an extensive review of all possible treatments and your dermatologist may recommend a combination of treatments in a different order than listed here. Discuss your treatment options with your dermatologist to see what is right for you. Learn how dermatologists determine disease severity. Mild or limited alopecia areata Some people with mild alopecia areata decide not to have any treatment. Instead, they leave it as is or use different products, such as scarves and hair pieces, or camouflage techniques like hairstyles to hide the affected areas. However, if you do want to try treatment to stimulate hair regrowth, here are some of the most commonly available treatments: Learn about options for hiding hair loss. INTRALESIONAL CORTICOSTEROIDS Corticosteroids, frequently called steroids, help decrease inflammation around the hair follicles to encourage hair growth. They are often used with other treatments for alopecia areata for maximum effect. The most common treatment for adults is intralesional injections. The medication is injected with a very fine needle directly into the areas where hair is missing on your scalp or face. The injections can also be used in newly forming patches of alopecia areata. Some people don’t feel too uncomfortable when they get the injections, while others find them painful. The treatment is best for people with less than 25% hair loss because larger areas require more injections. This can become painful and time-consuming. Whether the injections are uncomfortable depends a lot on the drug concentration (how strong it is), if there is any scar tissue in the target area, or if the spot is in a particularly sensitive part of the body. Some dermatologists recommend a topical anesthetic, like lidocaine, to numb the skin before the procedure. If you use a numbing medication, ask your dermatologist when you should apply it before your treatment. Usually, it is a couple of hours before. Not everyone can have intralesional injections. For example, you should not get them if you have an active infection in the area, such as cellulitis. Some adults can’t tolerate the injections, and they are generally not used for children. You may see new hair growth within six to eight weeks if the injections are successful. They can be repeated every four to six weeks, stopping treatment when the hair regrows. If there is no regrowth after six months, treatment should stop. Corticosteroid injections don’t prevent further hair loss. Some people develop temporary depressions or “dents” (called dells) from the injections. TOPICAL CORTICOSTEROIDS TOPICAL CORTICOSTEROIDS Corticosteroid topical treatment with either lotion, foam, cream, or ointment is usually the first choice for children and adults who can’t have intralesional injections. The medication, which comes in different strengths, is applied directly to the skin where the hair is missing. The advantages to these treatments for alopecia areata is that they can be applied at home. The drugs also provide high concentrations directly to the affected areas and they can be applied to larger areas than the injections. Highly potent (strong) doses seem to improve hair regrowth by about 25%. They frequently provide good results for children with alopecia areata. However, for the face (beard and eyebrows), the medication has to be a weaker concentration. Stronger doses can cause the delicate skin to atrophy, or break down. Finally, how well the topical corticosteroids work is limited by how well the scalp absorbs them. TOPICAL MINOXIDIL Minoxidil (Rogaine®) solutions are one of the few drugs approved to help treat hair loss, though not specifically for alopecia areata. The FDA first approved topical minoxidil in 2006 for hair loss in men and in 2014 for women. It can be combined with intralesional injections. Minoxidil is applied at home, once or twice a day, to help stimulate hair regrowth on the scalp, eyebrows, and beard area. There are 2% and 5% topical minoxidil solutions. They are often used in combination with topical corticosteroids. This medication is considered easy to use. However, topical minoxidil is generally not effective on its own for the treatment of extensive hair loss. ORAL MINOXIDIL Minoxidil (Rogaine®) was approved several years ago for topical use to treat hair loss. There is also an oral form, a tablet, that is FDA-approved to treat hypertension, high blood pressure. Although not FDA-approved for alopecia areata, some dermatologists prescribe it off-label. Studies have shown that low doses of oral minoxidil have helped hair regrow. Researchers aren’t sure why the treatment works for some people, but it may help suppress the overactive immune response. It is frequently used in conjunction with other therapies to enhance hair regrowth. A pill is easier for people to take than applying a cream or ointment. It’s cleaner and it’s also more portable. This helps increase compliance, meaning that someone with alopecia areata may be more likely to take the medication consistently. This increases their chances of hair regrowth. Moderate alopecia areata For patients with moderate disease, treatment for alopecia areata may include topical corticosteroids with or without topical or oral minoxidil. (See available treatments for mild alopecia areata for specifics.) In addition, there are: ORAL MINOXIDIL Like with mild alopecia areata, people with moderate disease may respond to oral minoxidil. (See treatment for mild alopecia areata for specifics.) PULSE CORTICOSTEROIDS Pulse corticosteroids are corticosteroids given by mouth or intravenously (by IV) at regular intervals, not continuously. Oral steroids cause side effects like weight gain, thinning bones (osteoporosis), rising blood sugar levels, and high blood pressure, among others. Pulsed steroids appear to have fewer of these side effects. There are some drawbacks to this treatment, most of all convenience. Intravenous medications must be given in a doctor’s office or clinic. This means returning for treatment for the duration of the therapy. It is also not for everyone. Pulse corticosteroids should not be given to people with uncontrolled high blood pressure or who are pregnant or nursing. TOPICAL OR CONTACT IMMUNOTHERAPY Topical immunotherapy, also called contact immunotherapy, is used to treat more extensive alopecia areata, but may be used for milder disease as well. The immunotherapy agents cause an allergic rash (allergic contact dermatitis) where they are applied. This changes your body’s immune response around the hair follicles, though researchers don’t understand why this promotes hair regrowth. The rash can look like poison oak or ivy. The drugs most commonly used include: Squaric acid dibutyl ester (SADBE) Diphencyprone (DPCP) This treatment can be effective. There are reports that 40 to 55% of patients experience significant regrowth. If hair regrowth is successful, treatment usually needs to continue to maintain the regrowth. The treatment can be uncomfortable, causing redness and rash where it is applied. Topical immunotherapy is typically performed and prescribed by dermatologists. Severe Alopecia Areata First-line treatment for alopecia areata with extensive hair loss (including alopecia universalis and alopecia totalis) is generally a JAK inhibitor. In addition, dermatologists may use oral minoxidil and/or intralesional injections along with the JAK inhibitor. (See treatment for mild alopecia areata for specifics.) JANUS KINASE (JAK) INHIBITORS After decades of no new treatments, there is hope for people with moderate to severe alopecia areata: Janus kinase (JAK) inhibitors. These are immunomodulatory drugs. They modify the immune system by curbing certain enzymes called cytokines. When you have alopecia areata, your immune system attacks your hair follicles, disrupting the growth cycle. JAKs are blood protein messengers that stimulate the immune cells, producing blood proteins called cytokines. If there are too many cytokines, you get inflammation. Taking a JAK inhibitor decreases the number of cytokines, decreasing inflammation. If the inflammation decreases enough, the hair may grow back. A case report published in 2014 was the first to show a JAK inhibitor, tofacitnib (Xeljanz), could successfully treat alopecia areata. Since then, many studies have shown that JAK inhibitors can effectively promote hair regrowth in alopecia areata. Doctors already prescribe JAK inhibitors for a number of conditions, including rheumatoid arthritis, atopic dermatitis, and ulcerative colitis. Since 2022, the FDA has approved three JAK inhibitors— Olumiant® (baricitinib,) Litfulo® (ritlecitinib,) and Leqselvi® (deuruxolitinib)—as treatments for severe alopecia areata (see below). Xeljanz® (tofacitinib), another JAK inhibitor, is an older medication still prescribed off-label for alopecia areata. Other JAK inhibitors, such as upadacitinib (RINVOQ®), are currently in clinical trials. JAK inhibitors are sometimes combined with other treatments, such as oral minoxidil or intralesional (meaning an injection directly into the area of hair loss) corticosteroids. Olumiant® (baricitinib) In June 2022, the FDA approved the JAK inhibitor baricitinib (Olumiant®), a daily pill, for adults with severe alopecia areata. This is the first time the FDA has specifically approved an oral drug for this condition. Olumiant was first approved in 2018 to treat rheumatoid arthritis. Clinical trials showed that 32% to 35% of patients with extensive alopecia areata who took Olumiant at the 4 mg/kg dose had hair regrowth covering 80% or more of their scalp after 36 weeks of treatment. Longer term studies showed that hair regrowth continued over time with Olumiant treatment. Some people showed a delayed response to treatment initially but achieved hair regrowth over a longer period of time. After continuous treatment with Olumiant for 2 years (104 weeks), 90% of patients had hair regrowth covering 80% or more of their scalp. Read the clinical trials for Olumiant Read the clinical trial results on the long-term effectiveness and safety of Olumiant Read the frequently asked questions about Olumiant Litfulo® (ritlecitinib) In June 2023, the FDA approved another JAK inhibitor, Litfulo® (ritlecitinib), for the treatment of severe alopecia areata in adults and adolescents ages 12 and up. Litfulo is the first approved treatment for individuals under the age of 18. It is an oral medication taken once daily. In a clinical trial, treatment with Litfulo was significantly more effective in achieving hair regrowth to 80% or more scalp hair coverage compared to placebo Read about the clinical trials for Litfulo Read the a plain language summary of the clinical trial results Read frequently asked questions about Litfulo Read an analysis on the safety and efficacy data for Litfulo in adolescents (ages 12 – 17) Other JAK inhibitors may be prescribed off-label for children, and several investigations have shown their effectiveness in children. Leqselvi® (deuruxolitinib) In July 2024, the FDA approved a third JAK inhibitor, Lequseli® (deuruxolitinib), for the treatment of alopecia areata in adults 18 years and older. Leqselvi is an oral medication taken two times per day. Leqselvi was testing in two large placebo-controlled Phase 3 clinical trials of more that 1,200 patients with at least 50% scalp hair loss. In one of the clinical trials, one-third of the study participants (33%) receiving 8 mg of Leqselvi twice daily for 24 weeks achieved 80% or greater scalp hair regrowth, compared to less than 1% of the participants taking the placebo. Read about the clinical trials for Leqselvi As of November 2024, Leqselvi’s commercial release is on hold due to a court injunction following a patent infringement lawsuit. ● JAK inhibitors in children LITFULO® (ritlecitinib) is the first FDA-approved treatment for adolescents ages 12 and up. Approved in June 2023, LITFULO is a once-daily medication for the treatment of severe alopecia areata. Other JAK inhibitors may be prescribed off label for children. There are a number of investigations in children showing their effectiveness. ● Learn more about JAK inhibitor treatments Hear from leading dermatologists on the use of JAK inhibitors for the treatment of alopecia areata in the NAAF webinars linked below. November 2024, Dr. Maryanne Senna, “Alopecia Areata Treatment Update” January 2024, Dr. Britt Craiglow: What’s New In Pediatric Alopecia Areata Treatment? October 2023, Dr. Brett King: Alopecia areata treatment updates and lessons learned from recent clinical trials January 2023, Dr. Maryanne Senna: JAK Inhibitor Treatment for Alopecia Areata: Understanding Side Effects and Monitoring October 2022, Dr. Britt Craiglow: Pediatric Alopecia Areata: Treatment Options for Children July 2022, Dr. Brett King: Alopecia Areata Treatment Update: A New Future Awaits DUPILUMAB (DUPIXENT) About one-third of people with alopecia areata also have atopic dermatitis, or eczema. Dupilumab (Dupixent), a monoclonal antibody drug, is FDA-approved for atopic dermatitis for adults and children as young as six months. Dermatologists may prescribe dupilumab as first-line treatment for alopecia areata for people who also have atopic dermatitis or a family history of atopic dermatitis. Learn more about research studies on dupilumab as a potential treatment for alopecia areata in this webinar: July 2024, Dr. Emma Guttman and Dr. Benjamin Ungar, Novel developments in treating alopecia areata: What is Type 2 inflammation and why is it important? Learn more about other available treatments for alopecia areata.
