risk) of individuals in the United States, with a spectrum of hair loss ranging from a small isolated patch of hair loss, multiple focal patches of hair loss (patchy alopecia), complete scalp hair loss (alopecia totalis [AT]) to universal body hair loss (alopecia universalis [AU]).1
Alopecia areata (localized patches)
Alopecia totalis (entire scalp)
Alopecia universalis (all body hair)
ALGORITHM 7.1.1 Treatment algorithm for alopecia areata. DPCP, diphenylcyclopropenone; IL-TAC, intralesional triamcinolone acetonide; JAK, Janus kinase; SADBE, squaric acid dibutylester.
desirable or tolerated. The most widely studied medications in this class of agents include diphenylcyclopropenone (DPCP) and squaric acid dibutylester (SADBE).7 DPCP treatment should begin with application of 2% concentration for sensitization, applied to a 4 × 4 cm area of the scalp. Two weeks later, DPCP should be applied at a lower concentration (0.0001%) for 48 hours. The concentration should be incrementally increased until a low-grade tolerable eczematous dermatitis reaction is observed. If after 6 months of therapy there is no improvement in disease severity, it should be considered a failure and another agent or class of medication should be considered.
discomfort, especially in pediatric patients. This therapy should be paired with topical minoxidil and topical corticosteroids for more rapid, effective results. Local skin atrophy, telangiectasia, and hypopigmentation are common side effects with intralesional therapies but are usually transient and well tolerated.
TABLE 7.1.1 Causes of Chemotherapy-Induced Anagen Effluvium
After significant safety data from Europe as well as clinical studies within the United States, there are now scalp cooling devices cleared by the US Food and Drug Administration (FDA). They are safe and efficacious in reducing hair loss in patients receiving taxanes or anthracyclines for breast cancer.22,23,24 Patients with prolonged infusion times or those receiving high doses of anthracyclines are likely to receive smaller benefit.
classification patterns.27 In contrast, FPHL manifests as diffuse central thinning or more prominent frontal thinning in a “Christmas tree” pattern with preservation of the anterior hairline.
Diffuse alopecia areata
discussion should emphasize the lengthy period of time required for visible changes in hair patterns, as some patients may be discouraged by the initial lack of effect. Patients should be evaluated at 6 months after starting treatment before a decision is made on patient response. Few clinical studies directly compare the efficacy of minoxidil vs finasteride or combination therapy, but small comparative trials suggest that combination therapy is more efficacious and should be attempted as long as medications are tolerated29 (Figure 7.1.2).
placebo.33 The relative benefit of 5α-reductase inhibitors was studied in a randomized, placebo-controlled clinical trial conducted comparing dutasteride at increasing doses with finasteride 5 mg. Dutasteride exhibited dose-dependent changes with the greatest response achieved at 2.5 mg daily.34 As expected, there was an associated increase in patients experiencing decreased libido with 12.5% in the 2.5-mg dutasteride group versus 1.5% in the 0.5-mg dutasteride group. Side-effect rates in the 0.5-mg dutasteride group were similar to those in the 5-mg finasteride group. The long-term safety data for dutasteride are more limited than for finasteride, and more data are needed to evaluate its long-term efficacy. A trial of dutasteride is most reasonable in patients who are dissatisfied with finasteride results and do not wish to explore follicular transplantation.
are no studies comparing efficacy over FDA-approved medications (eg, minoxidil, finasteride) or improved efficacy as an adjuvant therapy. Other critiques of LLLT have pointed out that there are limited long-term studies showing growth beyond 6 months.39 Generally, LLLT is not considered a first-line therapy and should not be selected over current FDA-approved medications.
trial of finasteride 1 mg orally daily is reasonable. This medication is generally well tolerated in women but is teratogenic and considered an X class medication, and therefore women of childbearing age should receive appropriate contraception and counseling.
Classic TE (typically resolves within a few months)
Chronic TE (lasting >4 months)
Diffuse alopecia areata