Topical corticosteroids

Topical steroids are creams, ointment, lotions, or foams that are applied directly to the scalp or skin surface. The aim of topical steroids is to dampen down the inflammation within the skin. There are different strengths and formulations available. Usually a potent or very potent topical corticosteroid is needed to treat Alopecia Areata, as weaker products tend to be less effective. The formulation prescribed is important, as some preparations (e.g. ointments or creams) are often too greasy to be tolerated regularly on the scalp.

Advantages

Studies have demonstrated hair regrowth with the regular use of potent topical steroids. They are commonly used in children and adults, as they are easy and painless to apply.

Disadvantages 

Their effectiveness is limited by their absorption through the scalp. If used excessively over a long period of time, there is the potential risk of skin thinning and enlarged blood vessels in the skin, causing it to look red.


Intralesional corticosteroids

These are steroids that are injected into the affected areas just underneath the skin using a fine needle. Examples of intralesional corticosteroids are hydrocortisone acetate and triamcinolone acetonide.

Advantages 

Intralesional corticosteroids have shown to be more effective than topical corticosteroids for hair regrowth. When intralesional corticosteroids are effective, hair growth is usually seen at the site of injection within four to six weeks.

Disadvantages

There is a risk of skin thinning that can cause a temporary depression (or dint) at the site of injection. The needle prick can be uncomfortable and the whole area that can be treated in one go is quite small; therefore, it is usually only used for fairly localised patches and smaller areas of Alopecia Areata. Intralesional corticosteroids are not routinely offered to patients with Alopecia Totalis or Alopecia Universalis. Steroid injections can only be performed by medically qualified practitioners.


Systemic corticosteroids

These are steroids that are taken orally as a pill or injection in the muscle (intramuscularly). Examples are oral prednisolone or intramuscular triamcinolone acetonide (Kenalog). Systemic corticosteroids mimic the effects of hormones your body produces naturally. When systemic corticosteroids are given in doses that exceed your body's usual levels, they suppress the immune system, which can allow hair to re-grow. Systemic steroids are often used as a short-term measure to try to stop the hair from falling rapidly or “kick-start” the hair to regrow. Long-term systemic steroids are usually avoided as they can cause serious side effects when taken for too long.

Advantages 

It is a tablet taken every day, therefore easy to take. This treatment can be used for patchy Alopecia Areata and more extensive hair loss (Alopecia Totalis or Universalis). Treatment with systemic corticosteroids will produce hair re-growth in some patients.

Disadvantages 

Most young patients tolerate this well with no side-effects. Some side-effects include heartburn, increase risk of infection, weight gain and restlessness/mood disturbance. Long-term systemic corticosteroid use is associated with serious side effects including diabetes, high blood pressure and bone thinning. This treatment also has a high rate of hair loss recurring once the treatment is stopped.


Dithranol (Anthralin)

This is a tar-like cream or ointment (licensed for the treatment of Psoriasis) that is applied regularly to the affected scalp skin to produce irritation and stimulate hair growth. By adjusting the concentration and duration of application, the desired level of irritation can be achieved.

Advantages 

It can be applied at home. It is usually applied topically once a day to the affected area and washed off after a specific amount of time. Hair regrowth may be seen within 8 to 12 weeks but can take up to 6 months to come through. Dithranol is safe to use in children and pregnancy.

Disadvantages 

The aim of dithranol treatment is to cause irritation of the scalp, causing redness and itchy on the affected skin. However, it may cause a more serious reaction if the cream gets onto other (more sensitive) areas of the skin or into the eyes. Also, due to the tar-like properties it will cause a brown staining to the skin being treated, but this is usually temporary. It can be messy and may stain other things as well such as your clothes, towels or bathroom furniture if you are not careful!


Contact Immunotherapy

The aim of this form of treatment is to induce a local allergic skin reaction (contact dermatitis) that stimulates hair re-growth by distracting the immune system from attacking the hair follicles. In the UK Diphenylcyclopropenone (DPCP) is the most commonly used treatment.

In contact immunotherapy, the treatment is initially applied at a higher concentration to a small area of the scalp or the arm, in a process called sensitisation – this makes the person allergic to the solution. Two weeks later a weaker concentration is then applied to the affected areas on the scalp. The solution usually remains on the skin for up to 24 hours and is then washed off. The aim of treatment is to cause a low-level reaction lasting 24-36 hours, with the scalp feeling a little itchy, red and flaky. The strength of the medication is gradually increased, depending on the level of the reaction.

Advantages 

Current research shows that 50-60% of patients with Alopecia Areata achieve a worthwhile response, although those with more extensive hair loss (e.g. Alopecia Totalis and Alopecia Universalis) do less well. Treatment is usually continued weekly until the hair has re-grown, which may take up to 12 months to achieve.

Disadvantages 

This treatment requires a significant time commitment as usually it is only available in hospital departments and requires repeated applications over a period of months; home treatment is not widely available in the UK at the moment.  The side effects of contact immunotherapy include dryness/ redness of the skin (appears like Eczema), hives, small itchy blisters on the feet/ hands (called Pompholyx) and the loss of pigment in some areas leading to white patches (called Vitiligo). The lymph glands in the neck and armpits may become enlarged as a response to the treatment. It is important to avoid these medications touching other areas of the body; therefore, gloves and other PPE should be worn by the practitioner applying it.