Corticosteroid injections are the first-line treatment for limited alopecia areata, while the JAK inhibitor baricitinib is now FDA-approved for severe cases. This autoimmune condition, which causes round patches of hair loss in about 2% of the population, has multiple medication options with varying levels of evidence. Here is what works, what does not, and what the research says.
This article is for informational purposes only and does not constitute medical advice.
Corticosteroids: The First-Line Treatment
Corticosteroids suppress the immune response that attacks hair follicles in alopecia areata. They are the most widely used and best-established treatment for this condition.
Intralesional Corticosteroid Injections
Intralesional injections of triamcinolone acetonide directly into alopecia patches are the standard first-line treatment for adults with limited disease. A dermatologist injects small amounts of corticosteroid solution into and around the bare patches, typically at 4 to 6 week intervals.
Response rates are approximately 60 to 70% for localized patches. Regrowth usually begins within 4 to 8 weeks after the first injection. The treatment works best for patients with fewer than 50% total scalp hair loss.
Side effects of intralesional injections include temporary pain at injection sites, localized skin atrophy (thinning) that is usually reversible, and small depressions in the skin at injection sites.
Topical Corticosteroids
High-potency topical corticosteroids such as clobetasol propionate are used for patients who cannot tolerate injections or for children. They are applied directly to affected patches once or twice daily. Evidence for topical corticosteroids is weaker than for injections, with lower response rates. They are most useful for mild cases and as maintenance therapy after injections produce initial regrowth.
Systemic Corticosteroids
Oral corticosteroids like prednisone can produce rapid regrowth but are not suitable for long-term use due to serious side effects including weight gain, bone density loss, elevated blood sugar, and immune suppression. Short pulse courses are sometimes used for rapidly progressing disease, but relapse rates after discontinuation are high.
JAK Inhibitors: The Newer Option
JAK inhibitors represent the most significant advance in alopecia areata treatment in recent years. These medications block Janus kinase enzymes involved in the immune signaling pathway that drives the autoimmune attack on hair follicles.
Baricitinib (Olumiant)
Baricitinib became the first FDA-approved systemic treatment for severe alopecia areata in June 2022. Clinical trials showed that approximately 35 to 40% of patients with severe alopecia areata achieved 80% or greater scalp hair coverage after 36 weeks of treatment at the 4mg dose.
The medication is taken as a daily oral pill. It is specifically indicated for adults with severe alopecia areata, defined as 50% or greater scalp hair loss. Patients typically begin seeing improvement after 3 to 6 months of daily use.
Ritlecitinib and Other JAK Inhibitors
Ritlecitinib (Litfulo) received FDA approval in 2023 for adults and adolescents aged 12 and older with severe alopecia areata. Other JAK inhibitors including tofacitinib and ruxolitinib have been used off-label with varying results, though they lack formal FDA approval for alopecia areata.
JAK Inhibitor Safety Considerations
JAK inhibitors carry a boxed warning from the FDA. Potential risks include increased susceptibility to infections (including serious infections), elevated cholesterol levels, increased risk of cardiovascular events in higher-risk populations, rare cases of blood clots, and potential increased cancer risk based on data from rheumatoid arthritis studies.
Regular blood monitoring including complete blood counts and lipid panels is required. These medications require prescribing and monitoring by a physician experienced with their use. For a comprehensive comparison of all treatment approaches, see our guide on alopecia areata treatments ranked.
Minoxidil: Supporting Regrowth
Minoxidil is not an immune-modulating treatment but can support hair regrowth in alopecia areata by directly stimulating follicle activity. Studies show moderate improvement in approximately 40 to 60% of patients when used as part of a combination approach.
How to Use Minoxidil for Alopecia Areata
Topical minoxidil (5% solution or foam) is applied twice daily to affected patches. It works by increasing blood flow to follicles, extending the growth phase of the hair cycle, and increasing hair shaft diameter.
Minoxidil is most effective when combined with corticosteroid injections or other immune-targeting treatments. As a standalone treatment, it can produce some regrowth in mild cases but does not address the autoimmune process.
Important Limitation
Minoxidil does not prevent new patches from forming. It supports regrowth in existing patches where the immune attack has subsided or is being controlled by other treatments. If the autoimmune process remains active, new patches may develop even while minoxidil promotes regrowth elsewhere.
Topical Immunotherapy
Contact immunotherapy using diphencyprone (DPCP) or squaric acid dibutylester (SADBE) is a specialized treatment typically reserved for extensive alopecia areata.
How It Works
A sensitizing chemical is applied to the scalp to create a deliberate allergic contact dermatitis. This redirects the immune system's attention away from attacking hair follicles and toward the applied allergen. The treatment is administered weekly in a dermatologist's office with gradually increasing concentrations.
Evidence and Effectiveness
Response rates for topical immunotherapy range from 50 to 60% for patients with extensive alopecia areata. The treatment requires commitment, as weekly office visits are needed for several months. Side effects include scalp itching, redness, blistering, and lymph node swelling.
Medications That Do Not Work for Alopecia Areata
Finasteride
Finasteride is not effective for alopecia areata. Finasteride blocks the conversion of testosterone to DHT, the hormone responsible for androgenetic alopecia (pattern baldness). Alopecia areata is an autoimmune condition unrelated to DHT, so blocking this hormone provides no benefit. Patients with alopecia areata should not take finasteride expecting it to treat their condition.
Dutasteride
Like finasteride, dutasteride is a 5-alpha reductase inhibitor that blocks DHT. It has no role in treating alopecia areata for the same reason: the condition is autoimmune, not hormonal.
Choosing the Right Medication
The appropriate medication depends on several factors including disease severity and extent of hair loss.
Treatment by Severity
For limited patchy disease (less than 50% scalp involvement), intralesional corticosteroid injections are the standard first-line approach, often combined with topical minoxidil. Topical corticosteroids may be added for maintenance.
For moderate disease (50 to 75% scalp involvement), options include intralesional corticosteroids for accessible patches, topical immunotherapy, or discussion of JAK inhibitors if other treatments have failed.
For severe disease (greater than 75% scalp involvement, alopecia totalis, or alopecia universalis), JAK inhibitors such as baricitinib or ritlecitinib are appropriate options. Topical immunotherapy is another consideration. Systemic corticosteroid pulses may be used for rapidly progressing cases.
Key Factors in Treatment Selection
Age plays a role, as JAK inhibitors and intralesional injections are typically reserved for adults and older adolescents. Children are usually treated with topical corticosteroids and minoxidil. Duration of hair loss matters because treatments are generally more effective for recent-onset patches than for longstanding disease. Patient preference regarding injection tolerance, pill versus topical formulations, and risk tolerance also influences the decision. Learn more about non-surgical hair loss treatments for additional context.
Monitoring Treatment Response
Most medications for alopecia areata require 3 to 6 months before meaningful regrowth is visible. Patients should document their starting point with photographs, attend regular follow-up appointments, and discuss treatment adjustments if there is no response after an adequate trial period. Switching between medications or adding combination approaches is common in managing this condition.
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