DERMATOLOGY: 07/2009

Alopecia areata

In the right clinical topic?
Age from 2 years onwards
This Topic Minibite covers the management of children and adults presenting with alopecia areata.
This Topic Minibite does not cover the management of other causes of hair loss (including male pattern baldness), or more extensive alopecia (alopecia universalis).
There are separate CKS topics on Fungal skin infection - scalp, and Seborrhoeic dermatitis.
The target audience for this Topic Minibite is healthcare professionals working within the NHS in England, and providing first contact or primary health care.
How up-to-date is this topic?
Changes
Version 1.0, revision planned in 2012.
Last revised in June 2009
February to June 2009 — converted from PRODIGY guidance to CKS Topic Minibite structure. The evidence-base has been reviewed in detail, and recommendations are more clearly justified and transparently linked to the supporting evidence.
Minoxidil is no longer offered as a primary-care treatment option.
Previous changes
October–December 2005 — written. Validated in March 2006 and issued in May 2006.
View previous versions of this topic

Knowledge update
New evidence
Evidence-based guidelines
No new evidence-based guidelines since 1 February 2009.
HTAs (Health Technology Assessments)
No new HTAs since 1 February 2009.
Economic appraisals
No new economic appraisals relevant to England since 1 February 2009.
Systematic reviews and meta-analyses
No new systematic review or meta-analysis since 1 February 2009.
Primary evidence
No new randomized controlled trials published in the major journals since 1 February 2009.
New policies
No new national policies or guidelines since 1 February 2009.
New safety alerts
No new safety alerts since 1 February 2009.
Changes in product availability
No changes in product availability since 1 February 2009.
Management
Goals and outcome measures
Goals
• To make an accurate diagnosis and exclude other conditions that present with hair loss
• To making an accurate assessment (e.g. of severity, impact on person)
• To watch and wait for hair regrowth appropriately
• To offer referral to secondary care or other specialist service appropriately
• To providing appropriate advice
Quick answers
Scenario: Alopecia areata

Introduction
• Alopecia areata is a chronic, inflammatory, usually relapsing condition which affects the hair follicles (and which may also affect the nails) [Messenger, 2004].
• It leads to non-scarring hair loss that most commonly involves the scalp or beard and, less frequently, the eyebrows and eyelashes [Bolduc and Shapiro, 2001; Messenger, 2004].
o Hair loss is usually patchy, producing circular areas of loss. Diffuse hair loss occurs occasionally but this is usually caused by other conditions [MacDonald Hull et al, 2003].
o Total loss of scalp hair (alopecia totalis) or scalp and body hair (alopecia universalis) occurs less commonly [Delamere et al, 2008].
• The exact cause is unknown but factors that have been suggested include genetics, autoimmune reactions, emotional stress, and changes in the peripheral nervous system (which may alter the release of neuropeptides and influence inflammatory reactions) [Madani and Shapiro, 2000; Messenger, 2004].
• Alopecia areata is a relatively common condition and it has been estimated that it affects 15 people in 10,000 of the UK population [Delamere et al, 2008].
• Alopecia areata can present at any age but children and adolescents are most commonly affected, with 60% of people developing their first bald patch before 20 years of age, and the peak incidence occurring between 15 years and 29 years of age [Madani and Shapiro, 2000; Bolduc and Shapiro, 2001].
• The progress of alopecia areata is unpredictable. Patchy alopecia areata involving less than 40% of the scalp is usually self-limiting and regrowth can be expected within a year, regardless of whether the person is treated or not [Bolduc and Shapiro, 2001]. People may present with several episodes of hair loss and hair regrowth through their lifetimes [Madani and Shapiro, 2000].
• A poor prognosis is associated with onset in childhood, extensive alopecia, involvement of the scalp margin (ophiasis), nail involvement, atopy, and a history of other autoimmune diseases [Bolduc and Shapiro, 2001; MacDonald Hull et al, 2003; Messenger, 2004; Delamere et al, 2008; Garg and Messenger, 2009].
How should I diagnose alopecia areata?
• Diagnosis is usually made from the presence of typical clinical features and excluding other causes of hair loss.
• Hair loss affects any hair-bearing area (most commonly the scalp and the beard) and is usually patchy and of abrupt onset.
o Bald patches are round, well-circumscribed, and smooth, and appear on the scalp or within facial hair. The skin is normal-coloured or slightly red without scarring (follicular openings are still present). Scaling is unusual and should raise the possibility of an alternative diagnosis.
o Exclamation mark hairs (short broken hairs which taper proximally) might be seen around the margin, or in any part of the patch, during active disease.
• Nail changes affect 10–15% of people and include pitting, onycholysis (loosening), splitting, beau lines (transverse grooves), koilonychia (concave outer surface), and leukonychia (white patches under the nails).
• Hair loss is usually asymptomatic, although occasionally itch, tenderness, burning, or pain may occur before the patches appear.
• To identify if there is active hair shedding, consider performing the 'pull test'.
o This involves grasping a small section of hairs at the periphery of a lesion between the finger and thumb and tugging gently but firmly (it should not be painful). This test is positive (confirming active shedding) when a few hairs are obtained.
o This test is not accurate, particularly when used by people who are not familiar with it.
• Factors such as previous episodes of hair loss, family history, the presence of atopy or autoimmune disease, and emotional stress may help to confirm the diagnosis.
• Routine investigations are not recommended, but if the diagnosis is in doubt, consider:
o Skin scrapings, hair samples, and fungal culture. See the CKS topic on Fungal skin infection - scalp.
o Systemic lupus erythematosus autoantibodies and syphilis serology.
o Full blood count, thyroid function tests.
o Skin biopsy (this will usually require referral to secondary care unless the expertise is available in primary care).
Differential diagnosis
• Differential diagnoses for patchy alopecia areata include:
o Tinea capitis — a contagious, fungal scalp infection mostly found in children (4–14 years of age), who present with patchy hair loss and often complain of itch and scaling [National Guideline Clearinghouse, 2004]. See the CKS topic on Fungal skin infection - scalp.
o Trichotillomania — a psychiatric condition which can be associated with obsessive-compulsive disorder, in which people pull their own hair out. Hair loss is asymmetrical and has an unusual shape. Single or multiple areas can be affected, including eyebrows and eyelashes [National Guideline Clearinghouse, 2004].
o Androgenic alopecia — there is a typical pattern of balding over the crown where pigmented terminal hairs are progressively replaced by finer hairs. Both men and women can be affected, although the pattern of hair loss in women may be more diffuse [Messenger, 2004].
o Scarring (cicatricial) alopecia in its early stages (for example caused by scleroderma, lichen planus, shingles, discoid lupus) [MacDonald Hull et al, 2003; Messenger, 2004].
o Traction alopecia — hair loss secondary to pulling on the roots, commonly caused by hair styling techniques (for example tight braids, pony tails) and usually involving the scalp margins [Messenger, 2004].
o Secondary syphilis — a moth-eaten, patchy hair loss is characteristic but is not always present [Messenger, 2004].
• Alopecia areata occasionally presents as diffuse hair loss. Many conditions can cause this, but the main differential diagnoses are:
o Telogen effluvium — loss of individual hairs earlier than normal because of a more rapid hair growth cycle.
 Acute, generalized hair loss over the whole scalp can occur about 3 months after a significant event, such as physical or psychological stress. Bi-temporal recession is a common sign in women. Hair loss lasts for 3–6 months and then the hair regrows [National Guideline Clearinghouse, 2004; Messenger, 2004]. Telogen gravidarum is telogen hair loss seen 2–3 months after childbirth [Messenger, 2004].
 Chronic diffuse telogen hair loss can occur as a result of stress, thyroid disorders, profound iron deficiency anaemia, and malnutrition, but often no cause is found [Messenger, 2004].
o Anagen effluvium (drug-induced, for example cancer chemotherapy) may mimic diffuse alopecia areata [MacDonald Hull et al, 2003].
o Female androgenic alopecia has a different appearance from that in men, with diffuse reduction of hair density over the crown and frontal scalp. Usually the frontal hairline is preserved [Messenger, 2004].
Basis for recommendation
This recommendation is based on expert opinion from a guideline published by the British Association of Dermatologists [MacDonald Hull et al, 2003], and expert opinion in reviews of the literature [Drake et al, 1992; Bertolino, 2000; Madani and Shapiro, 2000; Messenger, 2004].
How should I assess a person with alopecia areata?
• Consider factors that may affect choice of treatment.
o Determine the extent of hair loss. Loss of over 50% of the hair is generally considered as 'extensive'.
o Enquire about current and past treatments and their effectiveness.
• If the person has clinical signs or symptoms suggestive of other autoimmune disorders (or a family history of these) consider further investigations (for example, for pernicious anaemia or hypothyroidism).
• Ask how the alopecia is affecting the person; psychologically and socially. Alopecia areata has no effect on general health but can cause psychological distress.
Basis for recommendation
This recommendation is based on expert opinion from a British Association of Dermatologists guideline [MacDonald Hull et al, 2003], and expert opinion in reviews of the literature [Drake et al, 1992; Bolduc and Shapiro, 2001].
What information and advice should I give about alopecia areata?
• Reassure that most people with mild hair loss can expect hair regrowth within a year.
• Explain that alopecia areata is an unpredictable condition which is difficult to treat successfully. Treatments may help to control the problem by inducing hair growth, but will not cure the underlying condition. Future episodes of hair loss may occur.
• Advise use of sunblock or a hat on sunny days to protect bald patches from sun damage.
Basis for recommendation
The recommendation to give advice, an explanation of alopecia areata, and the limitations of treatment is based on expert opinion from the British Association of Dermatologists [MacDonald Hull et al, 2005] and the opinion of other experts [Shapiro and Madani, 1999; Madani and Shapiro, 2000].
How should I treat a person with alopecia areata?
• If there is evidence of hair regrowth (short, fine, tapered hair or white hair), there is no need for treatment.
• If there is no hair regrowth and the person has less than 50% hair loss, discuss the option of watching and waiting, with no treatment.
• If there is no hair regrowth and the person has more than 50% hair loss, or treatment is preferred:
o Refer to a dermatologist.
 If the person has less than 50% hair loss, there is better evidence to support the use of intralesional corticosteroids than other treatments.
 If the person has more than 50% hair loss, there is better evidence to support the use of topical immunotherapy than other treatments, although its availability may be limited.
 For more information on these and other treatments, see Specialist treatments.
o For an adult who is not pregnant and who is waiting to see a specialist or declines referral, consider a trial of a potent or very potent topical corticosteroid for 3 months (not licensed for this purpose), only if the diagnosis is certain.
 Do not use on the face (such as beard or eyebrows).
 For recommended potent and very potent corticosteroids, see Prescriptions.
o For children, or pregnant or breastfeeding women, discuss with a dermatologist before starting interim treatment.
• If the person is treated in primary care, explain the benefits and risks of treatment and what effect the person should expect.
o All treatments have a high failure rate.
o Hair regrowth may not be seen for at least 3 months, so improvement will often take time.
o If hair regrows, it is often initially fine and depigmented (white) before it returns to its original colour — inform people that hair can be dyed with a simple wash-in hair dye if it is slow to pigment, but that peroxide-based dyes should be avoided.
• Consider the need for counselling and psychological support, especially in people in whom areas of visible hair loss are causing psychological distress.
Prescribing information
Topical corticosteroids
• Topical corticosteroids are contraindicated in untreated bacterial, fungal, or viral skin lesions [BNF 56, 2008].
• Adverse effects of topical corticosteroids can be:
o Localized (for example skin atrophy, exacerbation of skin infection, and acne at the site of application). Reversible growth of excess hair on the face and neck may develop in young children [Fiedler and Alaiti, 1996].
o Systemic (for example hypophyseal-pituitary-adrenal [HPA] suppression).
Basis for recommendation
The approach to management is based on expert opinion from the British Association of Dermatologists [MacDonald Hull et al, 2003] and an expert review [Shapiro and Madani, 1999].
No treatment
• Offering the option of no treatment is based on expert opinion from the British Association of Dermatologists [MacDonald Hull et al, 2003; MacDonald Hull et al, 2005].
o Mild alopecia areata has a high spontaneous remission rate and treatments may be inconvenient and time-consuming, and may have adverse effects [Madani and Shapiro, 2000; MacDonald Hull et al, 2003]. Up to 80% of people with less than 40% or mild hair loss can expect regrowth within 1 year, even without treatment [Bolduc and Shapiro, 2001; MacDonald Hull et al, 2003].
o There are a number of treatments that may induce hair growth, but none has been shown to alter the overall course of the disease [MacDonald Hull et al, 2003].
Intralesional corticosteroids
• There is limited evidence that intralesional corticosteroids (in a secondary care setting) are an effective treatment for non-extensive alopecia areata, but they are recommended by experts [MacDonald Hull et al, 2003; MacDonald Hull et al, 2005].
Topical immunotherapy
• There is limited evidence that topical immunotherapy (in a specialist secondary care setting) is an effective option for people with extensive or chronic alopecia areata [Madani and Shapiro, 2000; MacDonald Hull et al, 2003]. However, topical immunotherapy is not widely available.
Topical corticosteroids
• Corticosteroids are likely to be effective because of their immunosuppressive effects [Bolduc and Shapiro, 2001].
• There is conflicting evidence on the efficacy of potent and very potent topical corticosteroids for the treatment of alopecia areata. No trials using moderate- or low-potency corticosteroids were found.
• Although topical corticosteroids are widely prescribed for alopecia areata [MacDonald Hull et al, 2003], expert opinion is divided on their effectiveness, with some choosing to use them [Fiedler and Alaiti, 1996; Delamere et al, 2008] and others of the view that they are of no great benefit [Madani and Shapiro, 2000; Bolduc and Shapiro, 2001].
• If topical corticosteroids are used, expert opinion suggests 3 months of uninterrupted use [Fiedler and Alaiti, 1996].
• Prescriptions for potent or very potent topical corticosteroids in a lotion, scalp application, gel, or foam have been included, as experts consider these formulations to be more user-friendly than creams and ointments (easier to use, easier to wash out) and better tolerated. However, individual preference should always be taken into consideration.
Children, and pregnant or breastfeeding women
• Seeking specialist advice regarding the management of children is suggested because of concern about the adverse effects of using potent corticosteroid preparations in this age group.
• Specialist advice is recommended before initiating treatment for women who are pregnant or breastfeeding because the limited benefit of topical corticosteroids may not outweigh the risks, although safety concerns of corticosteroids are mainly associated with oral preparations [ABPI Medicines Compendium, 2008; BNF 56, 2008].
Explanation of treatment
• The recommendation to give advice about the limitations of treatment, and what to expect from it, is based on expert opinion [Shapiro and Madani, 1999; Madani and Shapiro, 2000; MacDonald Hull et al, 2003].
Dyeing hair regrowth
• This recommendation is based on the opinion of expert CKS reviewers.
Counselling
• Considering counselling is recommended on the basis of expert opinion. People with alopecia areata may suffer considerable psychological distress [MacDonald Hull et al, 2003], which can affect socializing and employment.
What other treatments may be offered by a specialist for alopecia areata?
• Treatment options for alopecia areata which might be used by a specialist, but are not recommended for use in primary care, include:
o Intralesional corticosteroids.
o Topical immunotherapy.
o Topical minoxidil.
o Topical dithranol (now rarely used).
o Topical or systemic psoralen plus ultraviolet A light therapy (PUVA).
o Oral ciclosporin.
o Dermatography (tattooing).
o Wigs.
• For more detail, see Additional information.
Additional information
• Intralesional corticosteroids — multiple intradermal injections of corticosteroid (commonly hydrocortisone acetate and triamcinolone acetonide) are given into the areas of hair loss and repeated every few weeks [Madani and Shapiro, 2000]. Intralesional corticosteroid injections can also be used for sensitive areas, for example eyebrows [MacDonald Hull et al, 2003; MacDonald Hull et al, 2005]. Adverse effects of intralesional steroids include local pain at the injection site, skin atrophy, and, rarely, follicular atrophy [Fiedler and Alaiti, 1996].
• Topical immunotherapy — this is only available in a limited number of centres. It causes an allergic contact dermatitis by application of potent contact allergens, for example diphencyprone. The exact mechanism of action is unknown [Bolduc and Shapiro, 2001]. Topical immunotherapy involves multiple visits to hospital over several months and stimulates cosmetically-worthwhile hair regrowth in less than 50% of people with extensive patchy hair loss. It may cause troublesome temporary inflammation, but serious adverse effects are rare [MacDonald Hull et al, 2003].
• Topical minoxidil — the mechanism of action is unknown [Madani and Shapiro, 2000] and there is conflicting evidence on its efficacy for the treatment of alopecia areata [Bolduc and Shapiro, 2001]. Some specialists prefer not to use it because of the uncertain efficacy and because minoxidil is not licensed for this purpose. If there is a response to treatment, initial hair regrowth is usually seen after 12 weeks, with a maximum response seen after approximately 1 year [Fiedler and Alaiti, 1996; Madani and Shapiro, 2000].
• Topical dithranol is now rarely used. To be effective, it needs to be applied sufficiently frequently and in a high enough concentration to produce a brisk irritant reaction. Administration is cumbersome (the drug is applied at night, to the whole scalp if the disease is widespread, and left for 20–60 minutes before shampooing). Staining of clothes, skin, and fair hair can be a problem. A cosmetic response has been reported in 20–30% of people with non-extensive alopecia areata [Fiedler and Alaiti, 1996; Madani and Shapiro, 2000] which may take up to 60 weeks to achieve.
• PUVA (psoralen plus ultraviolet A light therapy) — this treatment may be beneficial in alopecia areata [Fiedler and Alaiti, 1996]. Two to three treatments a week are required and the time to response is 20–40 sessions. A maximum response is generally achieved within 1 year, although variable responses and high relapse rates have been reported [Healy and Rogers, 1993; Madani and Shapiro, 2000]. However, PUVA has a number of adverse effects (including nausea, pigment changes to the skin, and a risk of skin cancer).
• Oral ciclosporin is effective in extensive alopecia areata but its use is limited due to its adverse effect profile, and relapse occurs after discontinuation of treatment [Fiedler and Alaiti, 1996; Shapiro et al, 1997].
• Oral minoxidil is not recommended for people with alopecia areata. Although there is some evidence that it is effective, the risks outweigh any benefits [Fiedler and Alaiti, 1996].
• Dermatography (tattooing) can be used to create the appearance of eyebrows. One study with a 4-year follow up showed that 77% had excellent results and 8% had good results with a cosmetic approach [Bolduc and Shapiro, 2001].
• Wigs are a common treatment choice and can be very beneficial, particularly in women with extensive alopecia areata [MacDonald Hull et al, 2005]. They can be obtained on the NHS or bought privately.
o Acrylic wigs are cheaper than real hair, costing about £60–200, and are easier to look after. They can be itchy and hot, and require frequent replacement (every 6–9 months).
o Real-hair wigs are cosmetically very good, but they are considerably more expensive than acrylic wigs. They last for 3–4 years but require a lot more maintenance.
o NHS wigs can only be prescribed on the recommendation of a specialist.
 Prescribing of wigs varies according to locality, but most people will be entitled to two acrylic wigs per year on the NHS.
 People will only rarely qualify for a human-hair wig on prescription, for example if they are allergic to acrylic or have a skin condition requiring the use of human-hair wigs [MacDonald Hull et al, 2003].
Basis for recommendation
This recommendation is based on expert opinion in the literature [Healy and Rogers, 1993; Fiedler and Alaiti, 1996; Shapiro et al, 1997; Madani and Shapiro, 2000; Bolduc and Shapiro, 2001] and guidelines from the British Association of Dermatology [MacDonald Hull et al, 2003; MacDonald Hull et al, 2005].
Prescriptions
For information on contraindications, cautions, drug interactions, and adverse effects, see the Medicines Compendium (www.medicines.org.uk), or the British National Formulary (www.bnf.org).
Potent topical corticosteroids
Age from 16 years onwards
Betamethasone valerate 0.1% scalp application (Betacap®)
Betamethasone valerate 0.1% scalp application
Apply a few drops to the affected area(s) of the scalp twice a day. Massage in gently and thoroughly until the lotion disappears.
Supply 100 ml.
Age: from 16 years onwards
NHS cost: £3.81
Licensed use: no - off-label indication
Patient information: Allow hair to dry naturally. Wash your hands after using this scalp application.
Betamethasone valerate 0.1% lotion (Betnovate®)
Betamethasone valerate 0.1% lotion
Apply a few drops to the affected area(s) of the scalp twice a day. Massage in gently and thoroughly until the lotion disappears.
Supply 100 ml.
Age: from 16 years onwards
NHS cost: £4.67
Licensed use: no - off-label indication
Patient information: Allow hair to dry naturally. Wash your hands after using this lotion.
Betamethasone valerate 0.12% foam (Bettamousse®)
Betamethasone 0.1% foam
Apply thinly to the affected area(s) of the scalp twice a day. Massage in gently and thoroughly until the mousse disappears. Do not use more than a golf-ball sized amount of mousse at each application.
Supply 100 grams.
Age: from 16 years onwards
NHS cost: £9.37
Licensed use: no - off-label indication
Patient information: Allow hair to dry naturally. Wash your hands after using this mousse.
Betamethasone dipropionate 0.05% lotion (Diprosone®)
Betamethasone dipropionate 0.05% scalp lotion
Apply a few drops to the affected area(s) of the scalp twice a day. Massage in gently and thoroughly until the lotion disappears.
Supply 100 ml.
Age: from 16 years onwards
NHS cost: £7.95
Licensed use: no - off-label indication
Patient information: Allow hair to dry naturally. Wash your hands after using this lotion.
Fluocinolone acetonide 0.025% gel (Synalar®)
Fluocinolone 0.025% gel
Apply thinly to the affected area(s) of the scalp twice a day.
Supply 30 grams.
Age: from 16 years onwards
NHS cost: £5.56
Licensed use: no - off-label indication
Patient information: Allow hair to dry naturally. Wash your hands after using this cream.
Hydrocortisone butyrate 0.1% scalp lotion (Locoid®)
Hydrocortisone butyrate 0.1% scalp lotion
Apply a small amount to the affected area(s) of the scalp once or twice a day. Massage in gently and thoroughly until the lotion disappears.
Supply 100 ml.
Age: from 16 years onwards
NHS cost: £9.76
Licensed use: no - off-label indication
Patient information: Allow hair to dry naturally. Wash your hands after using this lotion.
Hydrocortisone butyrate 0.1% scalp emulsion (Locoid Crelo ®)
Hydrocortisone 0.1% topical emulsion
Apply a few drops to the affected area(s) of the scalp twice a day. Massage in gently and thoroughly until the emulsion disappears.
Supply 100 grams.
Age: from 16 years onwards
NHS cost: £8.44
Licensed use: no - off-label indication
Patient information: Allow hair to dry naturally. Wash your hands after using this emulsion.
Mometasone furoate 0.1% scalp lotion (Elocon®)
Mometasone 0.1% scalp lotion
Apply a few drops to the affected area(s) of the scalp once a day. Massage in gently and thoroughly until the lotion disappears.
Supply 60 ml.
Age: from 16 years onwards
NHS cost: £8.90
Licensed use: no - off-label indication
Patient information: Allow hair to dry naturally. Wash your hands after using this lotion.
Very potent topical corticosteroids
Age from 16 years onwards
Clobetasol propionate 0.05% scalp application (Dermovate®)
Clobetasol 0.05% scalp application
Apply a few drops to the affected area(s) of the scalp twice a day. Massage in gently and thoroughly until the lotion disappears. Do not use more than half a bottle (50ml) per week.
Supply 100 ml.
Age: from 16 years onwards
NHS cost: £11.06
Licensed use: no - off-label indication
Patient information: Allow hair to dry naturally. Wash your hands after using this lotion. This product should be used for a maximum of 3 months only.
Clobetasol propionate 0.05% foam (Carelux®)
Clobetasol 500micrograms/g foam
Apply a teaspoon-sized amount directly onto the affected area(s) of the scalp twice a day. Massage in gently and thoroughly until the foam disappears. Do not use more than half a can (50ml) per week.
Supply 100 grams.
Age: from 16 years onwards
NHS cost: £11.06
Licensed use: no - off-label indication
Patient information: Allow hair to dry naturally. Wash your hands after using this foam. This product should be used for a maximum of 3 months only.
Evidence
Supporting evidence
Problems interpreting the evidence
• Although there is some trial evidence on treatments for alopecia areata, it is difficult to draw firm conclusions for a number of reasons:
o The high rate of spontaneous remission of alopecia areata makes it difficult to assess the efficacy of interventions, particularly in mild forms of the disease [Messenger, 2004].
o There are very few controlled trials and most of the studies are small [MacDonald Hull et al, 2005; Delamere et al, 2008].
o It is difficult to compare results between trials because they include people with different degrees of alopecia, or with poorly-defined disease, and there is no universal measure of successful hair growth [Delamere et al, 2008].
Evidence on topical corticosteroids
Evidence is conflicting regarding the use of topical corticosteroids for alopecia areata, but there is some weak evidence to support their use. The trials should be interpreted with caution as they were limited by a number of factors (see Problems interpreting the evidence).
• Interventions for alopecia areata were discussed in a Cochrane systematic review (initial search date: February 2006) [Delamere et al, 2008], and a further literature search for this review in December 2007 found no new evidence to necessitate an update to the text. Three relevant randomized controlled trials (RCTs) of short-term (less than 6 months) topical corticosteroid use for alopecia areata were identified.
o Topical corticosteroid compared with placebo
 In one RCT (n = 70), short-term hair growth at 12 weeks was not significantly better in people using desoximetasone (not available in the UK) compared with those using placebo (RR 1.00, 95% CI 0.67 to 1.5).
 A second RCT (n = 68) found that at 12 weeks, 7/34 people using clobetasol propionate foam had more than 50% hair regrowth compared with 1/34 people using placebo. No statistical analysis was published.
o Comparison of topical corticosteroid preparations
 In another RCT (n = 61), at 20 weeks, 23/31 people with mild-to-moderate alopecia areata using betamethasone valerate foam reported more than 50% hair regrowth compared with 9/30 people using betamethasone dipropionate lotion (RR 2.47, 95% CI 1.38 to 4.44). No vehicle-only controls were used, so some of the observed effect may have been due to the vehicle rather than the active ingredient.
• CKS identified two other studies, although these were not RCTs.
o Fluocinolone acetonide cream compared with placebo: a two-part trial investigated the effect of fluocinolone acetonide 0.2% cream (Synalar HP®) versus placebo (vehicle component), each applied twice a day to half of the scalp, in 28 people with alopecia areata and alopecia totalis [Pascher et al, 1970]. The first part of the trial was a single-blind, comparison in 15 people. This was followed by a double-blind study comparing the same treatments in 13 people. With the two studies combined, the participants applied the topical preparations for at least 6 months.
 Satisfactory-to-excellent hair regrowth was obtained in 17/28 people with fluocinolone.
 Of the 17 people who responded to fluocinolone, 12 people had satisfactory regrowth for at least 3 months after treatment was discontinued.
 Relapses occurred in 11/17 people, either during the trial or within 3 months of the end of the trial.
 Fluocinolone acetonide strengths available in the UK vary from 0.0025–0.025%, whereas fluocinolone acetonide 0.2% was used in this trial.
o Clobetasol propionate compared with no treatment: another trial included 28 people (19 with alopecia totalis and 9 with alopecia totalis/alopecia universalis, none of whom had responded to topical immunotherapy). They applied 2.5 g of clobetasol propionate 0.05% ointment to one side of the scalp every night for 6 months (under occlusion with a plastic film), leaving the other side untreated and therefore acting as the control. Initially, eight people (29%) were treated successfully but three relapsed and were not able to maintain hair regrowth [Tosti et al, 2003].
Evidence on intralesional corticosteroids
Intralesional corticosteroids may be effective for treating alopecia areata, particularly in people with less extensive hair loss. However, the trials should be interpreted with caution as they were limited by a number of factors (see Problems interpreting the evidence).
• Interventions for alopecia areata were discussed in a Cochrane systematic review (initial search date: February 2006) [Delamere et al, 2008], and a further literature search for this review in December 2007 found no new evidence to necessitate an update to the text.
o No randomized controlled trials were found on intralesional corticosteroids for alopecia areata.
• CKS identified two other studies, although these were not randomized controlled trials.
o Intralesional corticosteroid compared with placebo
 A study of 66 people with alopecia areata who were all treated with intralesional triamcinolone acetonide using a Porto-Jet (needleless) injector found that 47/66 people (71%) showed regrowth of hair at 12 weeks after three injections, compared with 1/15 (7%) of the people injected with isotonic saline (the control treatment) [Abell and Munro, 1973]. After the corticosteroid injections were stopped, 14 people (21%) had a relapse. The study was neither randomized nor double blind and was unable to distinguish whether hair regrowth was due to the corticosteroid or to the natural history of the disease. Intralesional corticosteroids were more useful in people with alopecia areata than in an additional 18 people with alopecia totalis who were also treated.
o Comparison of different corticosteroids
 In one trial comparing intralesional corticosteroids of different solubilities, triamcinolone hexacetonide (more soluble) was compared with triamcinolone acetonide (less soluble) [Porter and Burton, 1971]. In the triamcinolone hexacetonide group (n = 11) tufts of hair grew in 33/34 sites and in the triamcinolone acetonide group (n = 17) hair grew in 16/25 sites. The effect was seen within 2–4 weeks, and was temporary and lasted for about 9 months. The trial was neither randomized nor controlled, and no statistical analysis was performed because of the small numbers of participants.
o Comparison of intralesional corticosteroids on different severities of alopecia areata
 Other research has found that monthly injections of triamcinolone acetonide produced a better response in people with fewer than five patches of alopecia less than 3 cm in diameter, compared with people who had more extensive alopecia areata [Kubeyinje, 1994]. Cosmetic regrowth was achieved in 35/45 people with fewer than five patches (78%). The study had a small number of participants (n = 62), and was neither randomized nor controlled.
Evidence on topical immunotherapy
Topical immunotherapy may be effective for treating people with alopecia areata, including those with extensive hair loss. However, the trials should be interpreted with caution as they were limited by a number of factors (see Problems interpreting the evidence).
• Interventions for alopecia areata were discussed in a Cochrane systematic review (initial search date: February 2006) [Delamere et al, 2008], and a further literature search for this review in December 2007 found no new evidence to necessitate an update to the text.
o No randomized controlled trials comparing topical immunotherapy with placebo were found.
• CKS identified a number of studies, although these were not randomized controlled trials.
o A review of published studies of contact immunotherapy in people with alopecia areata concluded that 50–60% of people achieved a cosmetically-acceptable result over a period of about 6 months, although the range of response rates was very wide (9–87%) for people treated with squaric acid dibutylester and diphencyprone [Rokhsar et al, 1998]. Available data on long-term follow up indicates a significant relapse rate.
o A large, retrospective case series studied 148 Canadian people with alopecia areata with more than 25% hair loss. After 6 months of treatment with diphencyprone clinically significant improvement was reported in 30% of people, which increased to 78% of people after 32 months [Wiseman et al, 2001]. A cosmetically-acceptable endpoint was achieved in 17% of people with alopecia totalis or alopecia universalis, in 60% of people with 75–99% hair loss, in 88% of people with 50–74% hair loss, and in 100% of people with 25–49% hair loss. Poor prognostic factors were early age of onset and extensive baseline hair loss. Three months from initiation of treatment was needed for significant hair regrowth and relapse was seen in 62% of people.
o In a study of 64 people with extensive or long-lasting alopecia areata, each person had half of their scalp treated with diphencyprone 2% while the other half of their scalp was used as a control. Of the 54 people completing treatment, 45 showed regrowth (83.3%). The mean time for treatment to achieve a maximum response was 6.1 +/– 1.5 months. Around two thirds of people relapsed and were re-treated [Avgerinou et al, 2008].
o A prospective, open trial (n = 41) studied the use of topical diphencyprone for alopecia areata. Of these, 24 people had severe alopecia and 17 had either alopecia totalis or alopecia universalis. All were treated with increasing concentrations of diphencyprone until a reaction occurred. Thirty-eight people completed treatment and 15 of these had significant hair regrowth at 6 months [Sotiriadis et al, 2007].
References
All references with links to [Free Full-text] are freely available online to users in the UK. This includes the full text of Department of Health papers, UK PubMed Central articles and Cochrane Library reviews. In addition, a link to the PubMed abstract is provided where this is available.
Free Full-text links are to dynamic documents that may have been updated since the CKS topic was last revised. These links are checked regularly by CKS Information Specialists. [Accessed:] refers to the date a link was last confirmed as valid.
1. Abell, E. and Munro, D.D. (1973) Intralesional treatment of alopecia areata with triamcinolone acetonide by jet injector. British Journal of Dermatology 88(1), 55-59.
2. ABPI Medicines Compendium (2008) Summary of product characteristics for Regaine for men regular strength. Electronic Medicines Compendium. Datapharm Communications Ltd. www.emc.medicines.org.uk [Accessed: 14/05/2009]. [Free Full-text]
3. Avgerinou, G., Gregoriou, S., Rigopoulos, D. et al. (2008) Alopecia areata: topical immunotherapy treatment with diphencyprone. Journal of the European Academy of Dermatology and Venereology: JEADV 22(3), 320-323. [Abstract] [Free Full-text]
4. Bertolino, A.P. (2000) Alopecia areata: a clinical overview. Postgraduate Medicine 107(7), 81-90. [Abstract]
5. BNF 56 (2008) British National Formulary. 56th edn. London: British Medical Association and Royal Pharmaceutical Society of Great Britain.
6. Bolduc, C. and Shapiro, J. (2001) The treatment of alopecia areata. Dermatologic Therapy 14(4), 306-316.
7. Delamere, F.M., Sladden, M.J., Dobbins, H.M. and Leonardi-Bee, J. (2008) Interventions for alopecia areata (Cochrane Review). Issue 2. John Wiley & Sons, Ltd. www.thecochranelibrary.com [Accessed: 14/05/2009]. [Free Full-text]
8. Drake, L.A., Ceilley, R.I., Cornelison, R.L. et al. (1992) Guidelines of care for alopecia areata. Journal of the American Academy of Dermatology 26(2 Pt 1), 247-250.
9. Fiedler, V.C. and Alaiti, S. (1996) Treatment of alopecia areata. Dermatologic Clinics 14(4), 733-737. [Abstract]
10. Garg, S. and Messenger, A.G. (2009) Alopecia areata: evidence-based treatments. Seminars in cutaneous medicine and surgery 28(1), 15-18. [Abstract]
11. Healy, E. and Rogers, S. (1993) PUVA treatment for alopecia areata - does it work? A retrospective review of 102 cases. British Journal of Dermatology 129(1), 42-44. [Abstract]
12. Kubeyinje, E.P. (1994) Intralesional triamcinolone acetonide in alopecia areata amongst 62 Saudi Arabs. East African Medical Journal 71(10), 674-675. [Abstract]
13. MacDonald Hull, S.P., Wood, M.L., Hutchinson, P.E. et al. (2003) Guidelines for the management of alopecia areata. British Journal of Dermatology 149(4), 692-699. [Free Full-text]
14. MacDonald Hull, S.P., Wood, M.L., Hutchinson, P.E. et al. (2005) Guidelines for the management of alopecia areata. British Association of Dermatologists. www.bad.org.uk [Accessed: 14/05/2009]. [Free Full-text]
15. Madani, S. and Shapiro, J. (2000) Alopecia areata update. Journal of the American Academy of Dermatology 42(4), 549-566. [Abstract]
16. Messenger, A.G. (2004) Alopecia areata. In: Burns, T., Breathnach, S., Cox, N. and Griffiths, C. (Eds.) Rook's textbook of dermatology. 7th edn. Oxford: Blackwell Science. 63.36-63.37.
17. National Guideline Clearinghouse (2004) Summary of: recommendations to diagnose and treat adult hair loss disorders or alopecia in primary care settings (non pregnant female and male adults). National Guideline Clearinghouse. www.guideline.gov [Accessed: 14/05/2009]. [Free Full-text]
18. Pascher, F., Kurtin, S. and Andrade, R. (1970) Assay of 0.2 percent fluocinolone acetonide cream for alopecia areata and totalis. Efficacy and side effects including histologic study of the ensuing localized acneform response. Dermatologica 141(3), 193-202.
19. Porter, D. and Burton, J.L. (1971) A comparison of intra-lesional triamcinolone hexacetonide and triamcinolone acetonide in alopecia areata. British Journal of Dermatology 85(3), 272-273.
20. Rokhsar, C.K., Shupack, J.L., Vafai, J.J. and Washenik, K. (1998) Efficacy of topical sensitizers in the treatment of alopecia areata. Journal of the American Academy of Dermatology 39(5 Pt 1), 751-761. [Abstract]
21. Shapiro, J. and Madani, S. (1999) Alopecia areata: diagnosis and management. International Journal of Dermatology 38(Suppl 1), 19-24.
22. Shapiro, J., Lui, H., Tron, V. and Ho, V. (1997) Systemic cyclosporine and low-dose prednisone in the treatment of chronic severe alopecia areata: a clinical and immunopathologic evaluation. Journal of the American Academy of Dermatology 36(1), 114-117.
23. Sotiriadis, D., Patsatsi, A., Lazaridou, E. et al. (2007) Topical immunotherapy with diphenylcyclopropenone in the treatment of chronic extensive alopecia areata. Clinical and Experimental Dermatology 32(1), 48-51. [Abstract]
24. Tosti, A., Piraccini, B.M., Pazzaglia, M. and Vincenzi, C. (2003) Clobetasol propionate 0.05% under occlusion in the treatment of alopecia totalis/universalis. Journal of the American Academy of Dermatology 49(1), 96-98. [Abstract]
25. Wiseman, M.C., Shapiro, J., MacDonald, N. and Lui, H. (2001) Predictive model for immunotherapy of alopecia areata with diphencyprone. Archives of Dermatology 137(8), 1063-1068. [Abstract] [Free Full-text]
Search strategy
Scope of search
A literature search was conducted for guidelines, systematic reviews and randomized controlled trials on primary care management of alopecia, with additional searches in the following areas:
• Investigations and assessment
• Primary and secondary care treatment
• When to refer
The search excluded male pattern baldness.
Search dates
July 2005 – January 2009
Key search terms
Various combinations of searches were carried out. The terms listed below are the core search terms that were used for Medline and these were adapted for other databases. Further details are available on request via the Feedback link at the top of this page.
• exp Alopecia Areata/, exp Alopecia/, alopecia.tw
Table 1. Key to search terms.
Search commands Explanation
/ indicates a MeSH subject heading with all subheadings selected
.tw indicates a search for a term in the title or abstract
exp indicates that the MeSH subject heading was exploded to include the narrower, more specific terms beneath it in the MeSH tree
$ indicates that the search term was truncated (e.g. wart$ searches for wart and warts)
Topic specific literature search sources
• British Association of Dermatologists
Sources of guidelines
• National Institute for Health and Clinical Excellence (NICE)
• Scottish Intercollegiate Guidelines Network (SIGN)
• National Guidelines Clearinghouse
• New Zealand Guidelines Group
• British Columbia Medical Association
• Canadian Medical Association
• Institute for Clinical Systems Improvement
• Guidelines International Network
• National Library for Health Guideline Finder
• National Health and Medical Research Council (Australia)
• Alberta Medical Association
• University of Michigan Medical School
• Michigan Quality Improvement Consortium
• Royal College of Nursing
• Singapore Ministry of Health
• Health Protection Agency
• National Resource for Infection Control
• CREST
• World Health Organization
• NHS Scotland National Patient Pathways
• Agency for Healthcare Research and Quality
• TRIP database
• Patient UK Guideline links
• UK Ambulance Service Clinical Practice Guidelines
• RefHELP NHS Lothian Referral Guidelines
• Medline (with guideline filter)
Sources of systematic reviews and meta-analyses
• The Cochrane Library:
o Systematic reviews
o Protocols
o Database of Abstracts of Reviews of Effects
• Medline (with systematic review filter)
• EMBASE (with systematic review filter)
Sources of health technology assessments and economic appraisals
• National Coordinating Centre for Health Technology Assessment (NCCHTA)
• The Cochrane Library:
o NHS Economic Evaluations
o Health Technology Assessments
• Canadian Agency for Drugs and Technologies in Health
• International Network of Agencies for Health Technology Assessment
Sources of randomized controlled trials
• The Cochrane Library:
o Central Register of Controlled Trials
• Medline (with randomized controlled trial filter)
• EMBASE (with randomized controlled trial filter)
Sources of evidence based reviews and evidence summaries
• Bandolier
• Drug & Therapeutics Bulletin
• MeReC
• NPCi
• DynaMed (access via the CKS website)
• TRIP database
• Central Services Agency COMPASS Therapeutic Notes
Sources of national policy
• Department of Health
• Health Management Information Consortium (HMIC)
Drugs in this topic
Scenario: Alopecia areata
Betamethasone 0.1% foam
Age from 16 years onwards
Betamethasone 0.1% foam: Apply thinly to the affected area(s) of the scalp twice a day. Massage in gently and thoroughly until the mousse disappears. Do not use more than a golf-ball sized amount of mousse should be used at each application.
Betamethasone 0.1% foam
Apply thinly to the affected area(s) of the scalp twice a day. Massage in gently and thoroughly until the mousse disappears. Do not use more than a golf-ball sized amount of mousse at each application.
Supply 100 grams.
Age: from 16 years onwards
NHS cost: £9.37
Licensed use: no - off-label indication
Patient information: Allow hair to dry naturally. Wash your hands after using this mousse.
Betamethasone dipropionate 0.05% scalp lotion
Age from 16 years onwards
Betamethasone dipropionate 0.05% scalp lotion: Apply a few drops to the affected area(s) of the scalp twice a day. Massage in gently and thoroughly until the lotion disappears.
Betamethasone dipropionate 0.05% scalp lotion
Apply a few drops to the affected area(s) of the scalp twice a day. Massage in gently and thoroughly until the lotion disappears.
Supply 100 ml.
Age: from 16 years onwards
NHS cost: £7.95
Licensed use: no - off-label indication
Patient information: Allow hair to dry naturally. Wash your hands after using this lotion.
Betamethasone valerate 0.1% scalp application
Age from 16 years onwards
Betamethasone valerate 0.1% scalp application: Apply a few drops to the affected area(s) of the scalp twice a day. Massage in gently and thoroughly until the lotion disappears.
Betamethasone valerate 0.1% scalp application
Apply a few drops to the affected area(s) of the scalp twice a day. Massage in gently and thoroughly until the lotion disappears.
Supply 100 ml.
Age: from 16 years onwards
NHS cost: £3.81
Licensed use: no - off-label indication
Patient information: Allow hair to dry naturally. Wash your hands after using this scalp application.
Clobetasol 0.05% scalp application
Age from 16 years onwards
Clobetasol 0.05% scalp application: Apply a few drops to the affected area(s) of the scalp twice a day. Massage in gently and thoroughly until the lotion disappears. Do not use more than half a bottle (50ml) per week.
Clobetasol 0.05% scalp application
Apply a few drops to the affected area(s) of the scalp twice a day. Massage in gently and thoroughly until the lotion disappears. Do not use more than half a bottle (50ml) per week.
Supply 100 ml.
Age: from 16 years onwards
NHS cost: £11.06
Licensed use: no - off-label indication
Patient information: Allow hair to dry naturally. Wash your hands after using this lotion. This product should be used for a maximum of 3 months only.
Clobetasol 500micrograms/g foam
Age from 16 years onwards
Clobetasol 500micrograms/g foam: Apply a teaspoon-sized amount directly onto the affected area(s) of the scalp twice a day. Massage in gently and thoroughly until the foam disappears. Do not use more than half a can (50ml) per week.
Clobetasol 500micrograms/g foam
Apply a teaspoon-sized amount directly onto the affected area(s) of the scalp twice a day. Massage in gently and thoroughly until the foam disappears. Do not use more than half a can (50ml) per week.
Supply 100 grams.
Age: from 16 years onwards
NHS cost: £11.06
Licensed use: no - off-label indication
Patient information: Allow hair to dry naturally. Wash your hands after using this foam. This product should be used for a maximum of 3 months only.
Fluocinolone 0.025% gel
Age from 16 years onwards
Fluocinolone 0.025% gel: Apply thinly to the affected area(s) of the scalp twice a day.
Fluocinolone 0.025% gel
Apply thinly to the affected area(s) of the scalp twice a day.
Supply 30 grams.
Age: from 16 years onwards
NHS cost: £5.56
Licensed use: no - off-label indication
Patient information: Allow hair to dry naturally. Wash your hands after using this cream.
Hydrocortisone 0.1% topical emulsion
Age from 16 years onwards
Hydrocortisone 0.1% topical emulsion: Apply a few drops to the affected area(s) of the scalp twice a day. Massage in gently and thoroughly until the emulsion disappears.
Hydrocortisone 0.1% topical emulsion
Apply a few drops to the affected area(s) of the scalp twice a day. Massage in gently and thoroughly until the emulsion disappears.
Supply 100 grams.
Age: from 16 years onwards
NHS cost: £8.44
Licensed use: no - off-label indication
Patient information: Allow hair to dry naturally. Wash your hands after using this emulsion.
Hydrocortisone butyrate 0.1% scalp lotion
Age from 16 years onwards
Hydrocortisone butyrate 0.1% scalp lotion: Apply a small amount to the affected area(s) of the scalp once or twice a day. Massage in gently and thoroughly until all the lotion disappears.
Hydrocortisone butyrate 0.1% scalp lotion
Apply a small amount to the affected area(s) of the scalp once or twice a day. Massage in gently and thoroughly until the lotion disappears.
Supply 100 ml.
Age: from 16 years onwards
NHS cost: £9.76
Licensed use: no - off-label indication
Patient information: Allow hair to dry naturally. Wash your hands after using this lotion.
Mometasone 0.1% scalp lotion
Age from 16 years onwards
Mometasone 0.1% scalp lotion: Apply a few drops to the affected area(s) of the scalp once a day. Massage in gently and thoroughly until the lotion disappears. (b)
Mometasone 0.1% scalp lotion
Apply a few drops to the affected area(s) of the scalp once a day. Massage in gently and thoroughly until the lotion disappears.
Supply 60 ml.
Age: from 16 years onwards
NHS cost: £8.90
Licensed use: no - off-label indication
Patient information: Allow hair to dry naturally. Wash your hands after using this lotion.

DERMATOLOGY

http://ckdl.blogspot.com; FACEBOOK: VN Dermatology

Thursday, July 30, 2009

Pandemic Flu updates from BMJ group

Tuesday, July 28, 2009

Clinical Photo Sharing from DermQuest.com

Share Your Photos

Tuesday, July 21, 2009

Non-Surgical Cosmetic Procedures for the Face Slideshow: Before-and-After Pictures

Thursday, July 16, 2009

Tình nhớ (Trịnh Công Sơn)

Tuesday, July 14, 2009

Cosmetic Surgery Slideshow: Before and After Pictures

Before You Tattoo Pictures Slideshow: Tattoo Types, Safety, Removal

Monday, July 06, 2009

Alopecia areata

Live Traffic Feed

BLOOD TEST NORMAL VALUES

Listening skills

PIANO

TRỊNH CÔNG SƠN

About Me

ABOUT US

Visitor Locations

Blog Archive

Dermatologic Topics

Hot spots & Contributors

Links

Musics

MediLexicon Search Box

FACEBOOK: VN Dermatology

Blogger Archive Calendar

Medical Terms

Dermatology News

Public Library of Science

Medical news today

Moreover.com News

Google News - Health

Flickr Badge