diagnosis and treatment

Last reviewed 08/2023

Diagnosis and treatment

Fungal infections should be excluded especially when the lesion is slightly atypical (when scaling is present) (1).

Active hair shedding can be demonstrated by the "pull test" - grasping and pulling around 60 hairs from the periphery of the lesion between the finger and thumb. If 2-10 hairs are obtained the test is positive (1) Treatment options depend on the extent of hair loss and the patients' preference (1).

Treatment of non-extensive alopecia areata (less than 50% hair loss) includes:

• Watchful waiting - the condition is self-limiting so the best plan is to reassure the patient and to encourage patience since spontaneous regrowth may not be visible for up to 3 months. A placebo is often useful eg. a short course of UVB. If treatment is preferred by the patient
• Referral to a dermatologist for the use of intralesional corticosteroids (ILCs) - ILCs is the most effective treatment options for patients with non-extensive alopecia areata
• topical corticosteroids and topical minoxidil - can be used on patients (over 16 years of age) who are waiting for a dermatologist referral or on patients who want treatment in primary care only
• Psychological counseling (1)

Treatment of extensive alopecia areata (more than 50% hair loss) includes:

• Watchful waiting - spontaneous remission may occur, but is less likely than non-extensive alopecia areata
• Early dermatological referral for treatment with topical immunotherapies (eg, contact sensitizers such as diphencyprone or squaric acid dibutylester), topical minoxidil, and cyclosporin
  • however, for many patients, therapy is limited by poor efficacy and/or problems with toxicity ¢ topical corticosteroids and topical minoxidil - can be considered for patients who are waiting for dermatologist referral or for patients who wants treatment in primary care only
• Psychological counseling
• A wig is indicated for more severe and extensive hair loss (1).

Study evidence revealed that efalizumab was not effective in promoting hair regrowth in a small cohort of patients with moderate-to-severe alopecia areata (2).

Reference:

• 1. Clinical Knowledge Summaries 2006. Alopecia areata
• 2. Price VH et al. Subcutaneous efalizumab is not effective in the treatment of alopecia areata. J Am Acad Dermatol. 2008 Mar;58(3):395-402.