Evaluation
Severity of Hair Loss
Severity of Alopecia Tool (SALT)
SALT is commonly used to assess the severity of alopecia based on the area of scalp hair loss. It is also used to evaluate treatment response. The SALT score reflects the percentage of the scalp surface that is hairless. A SALT score greater than 50 indicates severe alopecia areata, while a score below 50 corresponds to mild to moderate disease.
Alternative classification:
- None (grade 0): Zero percent scalp hair loss
- Limited/mild (grade 1): 1-20% scalp hair loss
- Moderate (grade 2): 21-49% scalp hair loss
- Severe (grade 3): 50-94% scalp hair loss
- Very severe (grade 4): 95-100% scalp hair loss
Alopecia Areata Scale (AAS)
The AAS is a proposed tool to assess the severity of alopecia areata that is not limited to the scalp area but considers other areas to disease severity.
This contains the following additional criteria in classifying severity of alopecia areata:
- The presence of hair loss in the eyebrows or eyelashes
- Not enough response to 6 months of treatment
- Pull test shows positive diffuse (multifocal) consistent with rapidly progressive alopecia areata
- Negative impact on psychosocial functioning resulting from alopecia areata
Psychological Status
It is important that the patient’s quality of life and psychological status should be assessed. Brief screening tools that can be used to assess mental health and quality of life in patients with alopecia areata include the Patient Health Questionnaire-4 (PHQ-4), Patient Health Questionnaire-9 (PHQ-9), Generalized Anxiety Disorder 7 (GAD-7), Mood and Feelings Questionnaire, and the Dermatology Life Quality Index (DLQI). In addition, disease-specific measures such as the Alopecia Areata Symptom Impact Scale (AASIS) and the Alopecia Areata Patient Priority Outcome (AAPPO) may also be used.
Pharmacological therapy
Treatments for Androgenic Alopecia
Pharmacological treatment in androgenic alopecia is most effective in males aged 18 to 41 Hamilton-Norwood stage II to IV hair loss. Early intervention, when thinning is first noticed hairs are incompletely miniaturized, optimizes treatment. Neither Finasteride nor Minoxidil can regrow hair in areas of total hair loss. There are no well-controlled studies on combination treatment with Finasteride and Minoxidil. Switching treatment involves continuing using the original medication in addition to the new agent for at least 3 months before discontinuing.
Finasteride (Oral)
Oral Finasteride is recommended for the treatment of male patients >18 years old with mild to moderate (Hamilton-Norwood stage II to IV) androgenic alopecia. Regarding its effects, studies have shown up to 66% of males show improved scalp coverage after 24 months of treatment and up to 83% showed hair loss stabilization. It must be noted that around 20 to 30% of patients do not respond to therapy. One study showed that 5 years of continuous intake showed no further visible hair loss in 90% of male subjects. Combination therapy with topical Minoxidil (2% or 5% solution or 5% foam) may be considered for better therapeutic effects. Treatment response should be evaluated at 6 to 12 months and if successful, therapy must be continued indefinitely to maintain benefit. Lastly, discontinuation of therapy leads to reversal of effect within 12 months.
Dutasteride (Oral)
Oral Dutasteride is an alternative therapy for male patients >18 years old with mild to moderate (Hamilton-Norwood stage II-V) androgenic alopecia when previous treatment with Finasteride is ineffective after 12 months.
Minoxidil (Topical)
Topical Minoxidil is recommended to improve or prevent progression of androgenic alopecia in males >18 years old with mild to moderate (Hamilton-Norwood stage II-V) and females >18 years old. The 2% solution applied twice daily was found to be effective in preventing progression and improve androgenic alopecia in the frontotemporal and vertex regions in males. Notably, the 5% topical solution or foam applied twice daily has shown greater efficacy than 2% solution in males. In females, 50% have minimal regrowth and 13% moderate regrowth using 2% solution, The treatment response should be evaluated at 6 months and if successful, therapy must be continued indefinitely to maintain benefit. The discontinuation of therapy leads to reversal of effect within 3 to 6 months.
Alopecia_Management 1Cyproterone acetate
Cyproterone acetate is an oral antiandrogen that suppresses luteinizing hormone (LH) and follicle-stimulating hormone (FSH) release. It may be used for female patients clinically diagnosed with hyperandrogenism.
Spironolactone
Spironolactone is an aldosterone antagonist that competitively blocks androgen receptors and inhibits androgen synthesis. It may be used for female patients with hyperandrogenism.
Platelet-rich Plasma (PRP)
PRP has been utilized in the treatment of androgenic alopecia in males and females. However, more studies are needed to confirm effectiveness and determine optimal regimen.
Treatments for Alopecia Areata
The treatment goal of pharmacological therapy in alopecia areata is the complete terminal hair regrowth on the scalp and any other body site that is affected. The effect is to stimulate hair growth but does not prevent hair loss. It is unlikely that they will influence the course of the disease. It must be noted that treatment tends to be most effective in mild disease. Treatment is continued until remission occurs or until alopecia patches are concealed by hair regrowth (may take a month to a year).
Corticosteroids
Systemic corticosteroids monotherapy should only be used in patients whose combined therapy is not possible or contraindicated.
Intralesional Corticosteroids
Example drug: Triamcinolone acetonide
Intralesional corticosteroid is the first-line treatment for adult patients with <50% (limited patchy) hair loss. It is recommended when there is patchy hair loss of limited extent and for cosmetically sensitive sites such as eyebrows and beard. It may be considered in older children and adolescents with limited mild to moderate alopecia areata. Effects include patients with rapidly progressive, extensive or long-standing alopecia areata respond poorly. Notably, regrowth is usually seen within 4-8 weeks in responsive patients. It is used with caution in patients with Fitzpatrick V and VI skin tones. With regards to intravenous (pulse therapy), studies showed that patients achieved >50% hair growth after 3 consecutive days of pulsed IV corticosteroid courses.
Alopecia_Management 2Oral Corticosteroids
Example drugs: Prednisolone, Prednisone
Oral corticosteroids may be considered in moderate to severe alopecia areata and rapidly progressive disease. The use of systemic corticosteroids is controversial because long-term therapy may be necessary which increases risk of adverse effects. Based on a small number of studies, short-taper or pulse corticosteroid delivery may be used in cases of advancing alopecia areata. Its effect promotes hair growth but hair shedding occurs soon after the drug is discontinued.
Topical Corticosteroids
Example drugs: 0.12% Betamethasone valerate, 0.05% Betamethasone dipropionate, 0.2% Fluocinolone, 0.05% Clobetasol propionate
Topical Corticosteroids may be used as initial therapy for adults and children with limited patchy alopecia areata who are intolerant of intralesional corticosteroids. They are the first-line treatment for patients with alopecia of the scalp, eyebrow or beard. They are also the treatment of choice in children and adolescents with scalp alopecia areata. They are used as second-line treatment for alopecia areata totalis or universalis, as an adjunct with other treatments. They can be combined with Minoxidil. It must be noted that signs of regrowth can take 6 weeks to 3 months. They are used with caution in patients with Fitzpatrick V and VI skin tones. Lastly, topical corticosteroids have a high relapse rate (38-63%) during treatment and after treatment cessation.
Systemic Immunotherapy
Azathioprine
Azathioprine is a treatment option for patients with extensive (moderate to severe) alopecia areata. It is used as a steroid-sparing agent and may be combined with glucocorticosteroids.
Cyclosporine (Ciclosporin)
Cyclosporine is an immunosuppressant that acts on T-lymphocytes to inhibit the production of lymphokines thereby suppressing cell-mediated immune responses. It is an alternative monotherapy agent to high-dose systemic corticosteroids for moderate to severe alopecia areata. It may also be used in combination with glucocorticosteroids. Lastly, several studies have shown 25 to 76.7% success rate but with numerous noted side effects
Inosiplex (Inosine pranobex/Isoprinosine)
Inosiplex is an alternative treatment for patients with treatment-resistant alopecia areata.
Janus Kinase (JAK) Inhibitors
Example drugs: Baricitinib, Deuruxolitinib, Ritlecitinib, Ruxolitinib, Tofacitinib
JAK inhibitors are approved for patients with severe alopecia areata. Baricitinib and Deuruxolitinib are used for adults, and Ritlecitinib for patients aged ≥12 years old. JAK inhibitors may be used as an alternative monotherapy agent to high-dose systemic corticosteroids for alopecia areata. They may also be used in combination with systemic corticosteroids. Studies have shown its efficacy in inducing hair growth in patients with severe alopecia areata.
Methotrexate
Methotrexate is a treatment option for patients with severe alopecia areata, alopecia areata totalis or universalis. It may be given with low-dose oral corticosteroids. It may be taken orally or subcutaneously. It must be noted that supplementation with Folic acid is recommended during treatment.
Mycophenolate Mofetil
Mycophenolate mofetil may be considered in adults with moderate to severe alopecia areata.
Sulfasalazine
Sulfasalazine is a treatment option for patients with severe alopecia areata. Studies have shown that 23 to 27% of patients on Sulfasalazine treatment exhibited hair regrowth.
Topical Dithranol/Anthralin
Topical Dithranol/Anthralin is used as short-term contact immunotherapy. It is usually discontinued after maximum response has been achieved. It is a second-line treatment for patients >10 years old with <50% hair loss who responded poorly to intralesional corticosteroid/Minoxidil/topical corticosteroid treatment. It is administered with or without Minoxidil. It is also used as second-line treatment for unresponsive patients >10 years old with ≥50% hair loss, given with Minoxidil and topical corticosteroids. One of its effects is that it safely stimulates hair growth in patients with extensive and total scalp hair loss and is useful in children. It is cosmetically acceptable hair growth was seen in 50 to 60% of patients in 6 months. Notably, clinical irritation is not necessary for effectiveness.
Topical Immunotherapy
Example drugs: Diphenylcyclopropenone (DPCP), Squaric acid dibutyl ester (SADBE)
Topical immunotherapy is a recommended treatment for chronic extensive alopecia areata, alopecia areata totalis and universalis. It is the first-line treatment for adult patients with >50% (extensive/moderate to severe) hair loss. It is a contact allergen commonly used as topical immunotherapy. It decreases lymphocytic inflammation of the anagen follicle, promoting follicular recovery. Topical immunotherapy with DPCP has shown to be effective in up to 100% of patients with <50% hair loss; 60 to 88% of patients with 50 to 99% hair loss; and 17% of patients with alopecia totalis or alopecia universalis. Notably, regrowth was apparent after 3 to 12 months of treatment; no benefit is achieved with continuing therapy after 24 months in the absence of regrowth. The relapse rate is 62% during treatment, It is used with caution in patients with Fitzpatrick V and VI skin tones. Treatment may be discontinued only if complete hair regrowth has been achieved.
Minoxidil
Topical Minoxidil 1 to 5% solution has been shown to be the most effective in alopecia areata patients. It is used as an adjuvant to other treatment modalities. Effects include: Hair growth is stimulated in patients with extensive and patchy hair loss but not in patients with complete hair loss. Hair growth may be seen within 12 weeks and maximal growth is seen at 1 year. Application is continued until full remission. Several studies showed significant response with oral Minoxidil intake. It is used as adjuvant therapy with limited data on efficacy.
Topical Prostaglandin Analogues
Example drugs: Bimatoprost, Latanoprost
Topical prostaglandin analogues are the treatment option for eyelash universalis alopecia areata. However, further studies are needed to establish the efficacy of Bimatoprost or Latanoprost for alopecia areata.
Other Treatment Options
Topical calcineurin inhibitors (eg Tacrolimus) may only be considered if other first-line agents are ineffective. Simvastatin/Ezetimibe may be considered for patients with severe refractory alopecia areata A case report showed near-complete remission with Simvastatin/Ezetimibe administration when combined with Prednisolone and Minoxidil therapy.
Platelet-rich Plasma
A study has shown the effectivity of platelet-rich plasma in inducing hair growth. However, more studies are needed to establish efficacy in the treatment of alopecia areata.
Photochemotherapy
Psoralen plus ultraviolet A (UVA) (PUVA) has been used for severe alopecia areata. While whole body UVA irradiation may also be used. Psoralens may be given orally or topically. The effectiveness of photochemotherapy varies from 20 to 65% although relapse rate is high. There is concern about the promotion of skin cancer from long-term PUVA use.
Nonpharmacological
Patient Education
Androgenic Alopecia (Males and Females)
It must be noted that androgenic alopecia affects a large percentage of the population. It is important to educate the patient on his/her treatment options. Patients may choose not to treat when presented with their options. Reassurance and supportive counseling are provided to assist patients in overcoming their hair loss. Patients may use hairstyling techniques (eg hairspray, teasing, coloring, etc) as a way to deal with hair loss. Frequent shampooing does not increase hair loss. Avoiding hair care products that are likely to damage scalp or hair is important. Adequate diet, especially one with adequate protein, is also important; the National Institute of Health (NICE) recommends a protein intake of 0.8 g/kg daily. Lastly, drugs that could negatively affect hair growth are discontinued.
Alopecia Areata
It is important to educate the patient about alopecia areata. For example, in autoimmune disease, the trigger factors are unknown. Treatment options are palliative and do not alter the ultimate course of the disease. Alopecia areata is a dynamic condition and quite often undergoes spontaneous resolution. Lastly, explain to the patient that the condition does not affect one’s general health.
Camouflage Cosmetics
Eyebrow pencil may be suggested to cover alopecia areata patches on the eyebrows; waterproof eyebrow pencils are highly recommended.
Hairpiece/Scalp Prostheses
Patients with >50% hair loss are reassured that this does not mean that the hair will not regrow, but it may be comforting to have hairpieces or scalp prostheses available for periods of more extensive hair loss. They have been shown to improve patient quality of life. Wigs, hair extensions, hairpieces, headscarves, hats, and false eyelashes have been used to cover patches or areas with hair loss. Wigs are highly recommended for patients with extensive patchy alopecia and alopecia areata totalis and universalis.
Alopecia_Management 3Laser Therapy
Examples of laser therapy include infrared diode laser, 308-nm excimer laser, and low-level laser. Laser therapy produces cosmetically acceptable hair regrowth with 60% response rate.
Low-level Laser (Light) Therapy
Low-level laser therapy, also known as laser phototherapy or photobiomodulation therapy, stimulates cell proliferation by increasing endogenous growth factors and cutaneous microcirculation by exposing tissues to low levels of visible or near infrared light. It may be used as an ancillary procedure for male or female patients with androgenic alopecia. It is generally well tolerated with mild adverse effects such as scalp dryness, itching, tenderness, and warm sensation. More studies are needed to determine optimal treatment regimen and duration of effect.
Alopecia_Management 4Micropigmentation/Tattooing
Permanent or semi-permanent tattooing of the eyebrows may be suggested. Recoloring may be needed every 1 to 2 years.
Psychological Intervention
Provide psychosocial support for patients with mild psychological distress due to alopecia. Patients with moderate to severe psychological distress due to alopecia should be referred to specialists for psychological intervention and support.
Surgery
Hair Transplantation
Hair transplantation is a surgical option for androgenic alopecia and androgenic alopecia where hairs from the back and sides of the scalp are transplanted to balding areas in the front. It usually needs 2 to 4 sessions depending on the number of grafts transplanted per session. Success depends on the viability of grafts harvested and inserted into areas with hair loss. Mini-grafts and micro-grafts with 2 to 4 follicles allows for a more natural looking result.
Follicular unit transplantation (FUT), which is the standard technique in hair transplantation, may be considered for both males and females with androgenic alopecia with sufficient donor hair. FUT may be combined with Finasteride to achieve a better clinical outcome. It is indicated in patients with androgenic alopecia with fine or light hair, who do not want to shave their head as needed while taking follicular unit grafts, those who do not mind covering the linear scar with longer adjacent hair, and for maximum donor yield without visible thinning of the donor area.
Follicular unit extraction (FUE) involves removal of individual follicular units, one by one from the occipital area. It is indicated for smaller graft numbers, in patients with thick hair, patients who want to wear a short occipital haircut or patients who do not want a linear scar, and in cases of tight occipital scalp elasticity. It is associated with greater risk of follicle injury and impairment of graft viability.
Hair transplantation can permanently improve androgenic alopecia by up to 3 stages on Hamilton-Norwood scale when performed by a skilled surgeon in suitable candidates with a good donor hair supply. The best long-term results are seen in patients with medically-controlled or spontaneously stabilized androgenic alopecia. It has limited aesthetic benefit for MPHL with Hamilton-Norwood stages I to II. Not optimal surgical candidate for FPHL with Ludwig I stage; the best candidates are patients with Ludwig stage II with sufficient permanent donor hair available and no overlying diffuse telogen effluvium.
Alopecia_Management 5Scalp Reduction (Alopecia Reduction Surgery)
Scalp reduction (alopecia reduction surgery) is a treatment option for male patients with hair loss at the back of the scalp. In this procedure, the area with hair loss is surgically removed and hair-bearing scalp is stretched to fill in the void left by the excised scalp. It may be performed with hair transplantation or scalp expansion. This procedure has limited aesthetic benefit for MPHL with Hamilton-Norwood stages I to III because of potential for scarring.