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 (2):

• 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, e.g. a short course of UVB. If treatment is preferred by the patient:
  • referral to a dermatologist for the use of intralesional corticosteroids (ILCs) - ILCs are the most effective treatment option 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 counselling

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 (e.g. contact sensitisers 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 want treatment in primary care only
• Psychological counselling
• Wigs may be indicated for more severe and extensive hair loss

Study evidence revealed that efalizumab was not effective in promoting hair regrowth in a small cohort of patients with moderate-to-severe alopecia areata (3).

Baricitinib, an oral Janus kinase (JAK) inhibitor, is the first systemic drug to be approved by the US Food and Drug Administration and the European Medicines Agency to treat adults with severe alopecia areata. The approval is based on two randomised placebo-controlled phase 3 trials, which demonstrated that oral baricitinib increased hair regrowth at 36 weeks, compared with placebo, in people with severe alopecia areata. (4)

NICE has recommended ritlecitinib as an option for treating severe alopecia areata in people 12 years and over. Evidence from clinical trials shows that it is more effective than placebo for improving hair regrowth for up to 24 weeks (5).

References:

1. Hillmann K, Blume-Peytavi U. Diagnosis of hair disorders. Semin Cutan Med Surg. 2009;28:33–38.
2. Delamere F, Sladden M, Dobbins H, et al. Interventions for alopecia areata. Cochrane Database Syst Rev. 2008;(2):CD004413.
3. 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.
4. King B, Ohyama M, Kwon O, et al. Two phase 3 trials of baricitinib for alopecia areata. N Engl J Med. 2022 May 5;386(18):1687-99.
5. Ritlecitinib for treating severe alopecia areata in people 12 years and over. NICE Technology appraisal guidance, March 2024.