Oral treatments tend to be reserved for the more extensive cases of alopecia areata, like Totalis (loss of all scalp hair) and Universalis (loss of scalp hair, eyebrows, eyelashes, and body hair). Treatments include the short-term use of corticosteroids (prednisone, prednisolone, methylprednisolone). Your dermatologist may pair this short-term course of corticosteroids with a longer-term course of immunosuppressant drugs such as methotrexate, cyclosporin, or mycophenolate/mycophenolic acid.

There is a lot of misinformation regarding the use of Immunosuppressant drugs, and it is important that you rely on your dermatologist for the most accurate information. Your dermatologist will monitor you and order monthly blood work while you are taking the immunosuppressants. The major risk that most people worry about with immunosuppressants is developing a lymphoproliferative disorder, which can lead to blood cancers if left unaddressed. If at any point you develop unusual/significant symptoms or a change in blood work results, your dermatologist will terminate the immunosuppressant treatment. Case reports of other oral treatments such as alitretinoin have also been published, but there is not enough data to broadly support its use.

As with any treatment for alopecia areata, the success rate for DPCP/DCP depends on the person. Generally speaking, the chances for success with DPCP/DCP are 40-60%. Moreover, a study by Wiseman et al. (2001) found that around 78% of all patients obtained clinically significant regrowth after using DPCP/DCP for 32 months. The chance of relapse is also a common concern amongst patients. There is no way to determine one’s specific risk of losing the hair they regrew with DPCP/DCP. Wiseman et al. (2001) also found that roughly 63% of patients that experienced clinically significant regrowth relapsed by the 37 month follow up appointment. All this is to say, it is important to speak with your dermatologist about your specific situation.

As with any treatment for alopecia areata, the success rate for intralesional corticosteroids depends on the person. Most patients with one or a few small patches do very well with intralesional corticosteroids. The larger the area of hair loss the less likely injections alone will be successful and other treatments may have to be used in conjunction.  When hair loss involves more than 50% of the scalp area, intralesional corticosteroids may no longer be considered, and more aggressive treatments such as DPCP/DCP or oral therapies may be offered.

Intralesional treatments refer to injections directly into the skin affected by alopecia areata, such as the scalp or eyebrows. Dermatologists do not inject eyelids with steroid to regrow eyelashes – only an ophthalmologist (eye surgeon) can do this, and typically will not do it either as the risk may outweigh the benefit. Intralesional corticosteroid injections (triamcinolone acetonide/Kenalog) are the most commonly used. Patients can decrease the discomfort of these injections by applying numbing cream one hour before treatment. Patients usually receive injections every 4-6 weeks. The exact frequency of injections will be determined by your dermatologist.

Generally speaking, the treatment options available to children under the age of 18 are more limited. Nevertheless, there are still options to choose from, including topical corticosteroids, topical calcineurin inhibitors, and intralesional corticosteroids (if the child is old enough to tolerate them). It is up to the discretion of the dermatologist to determine if it would be appropriate to pursue additional treatments such as oral corticosteroids, oral immunosuppressants, or topical DPCP/DCP.

The efficacy of topical treatments may vary and tend to be less effective for more advanced types of alopecia areata. However, they are often a good starting point.

Topical treatments include corticosteroid creams and lotions such as betamethasone, clobetasol, and halobetasol; calcineurin inhibitor ointments such as tacrolimus and pimecrolimus; minoxidil foam/spray (known commonly as Rogaine, or Equate Minoxidil); or contact irritants like diphenylcyclopropenone/diphencyprone (DPCP/DCP) and anthralin. Less common topical treatments include vitamin D analogues such as calcipotriol/calcipotriene.

Western medicine does not have all the answers. This said, there have not been any natural supplements identified as effective in regrowing hair for alopecia areata patients. Some natural health experts have recommended the use of supplements that are attributed to overall skin, hair, and nail health, such as biotin & other B vitamins, vitamin D, vitamin C, zinc, calcium, omega-3 fatty acids, and probiotics. Always consult with your primary care provider before starting any new supplements as they could interfere with other medications.