Available Treatments

Corticosteroids, frequently called steroids, help decrease inflammation around the hair follicles to encourage hair growth. They are often used with other treatments for alopecia areata for maximum effect. The most common treatment for adults is intralesional injections. The medication is injected with a very fine needle directly into the areas where hair is missing on your scalp or face. The injections can also be used in newly forming patches of alopecia areata.  Some people don’t feel too uncomfortable when they get the injections, while others find them ​​painful. The treatment is best for people with less than 25% hair loss because larger areas require more injections. This can become painful and time-consuming.

Whether the injections are uncomfortable depends a lot on the drug concentration (how strong it is), if there is any scar tissue in the target area, or if the spot is in a particularly sensitive part of the body. Some dermatologists recommend a topical anesthetic, like lidocaine, to numb the skin before the procedure. If you use a numbing medication, ask your dermatologist when you should apply it before your treatment. Usually, it is a couple of hours before.

Not everyone can have intralesional injections. For example, you should not get them if you have an active infection in the area, such as cellulitis. Some adults can’t tolerate the injections, and they are generally not used for children.

You may see new hair growth within six to eight weeks if the injections are successful. They can be repeated every four to six weeks, stopping treatment when the hair regrows. If there is no regrowth after six months, treatment should stop.

Corticosteroid injections don’t prevent further hair loss. Some people develop temporary depressions or “dents” (called dells) from the injections.

TOPICAL CORTICOSTEROIDS

Corticosteroid topical treatment with either lotion, foam, cream, or ointment is usually the first choice for children and adults who can’t have intralesional injections. The medication, which comes in different strengths, is applied directly to the skin where the hair is missing. The advantages to these treatments for alopecia areata is that they can be applied at home. The drugs also provide high concentrations directly to the affected areas and they can be applied to larger areas than the injections. Highly potent (strong) doses seem to improve hair regrowth by about 25%. They frequently provide good results for children with alopecia areata. However, for the face (beard and eyebrows), the medication has to be a weaker concentration. Stronger doses can cause the delicate skin to atrophy, or break down.

Finally, how well the topical corticosteroids work is limited by how well the scalp absorbs them.

Minoxidil (Rogaine®) solutions are one of the few drugs approved to help treat hair loss, though not specifically for alopecia areata. The FDA first approved topical minoxidil​​ in 2006 for hair loss in men and in 2014 for women. It can be combined with intralesional injections.

Minoxidil is applied at home, once or twice a day, to help stimulate hair regrowth on the scalp, eyebrows, and beard area. There are 2% and 5% topical minoxidil solutions. They are often used in combination with topical corticosteroids.

This medication is considered easy to use. However, topical minoxidil is generally not effective on its own for the treatment of extensive hair loss.

Minoxidil (Rogaine®) was approved several years ago for topical use to treat hair loss. There is also an oral form, a tablet, that is FDA-approved to treat hypertension, high blood pressure. Although not FDA-approved for alopecia areata, some dermatologists prescribe it off-label. Studies have shown that low doses of oral minoxidil have helped hair regrow.

Researchers aren’t sure why the treatment works for some people, but it may help suppress the overactive immune response. It is frequently used in conjunction with other therapies to enhance hair regrowth.

A pill is easier for people to take than applying a cream or ointment. It’s cleaner and it’s also more portable. This helps increase compliance, meaning that someone with alopecia areata may be more likely to take the medication consistently. This increases their chances of hair regrowth.

Like with mild alopecia areata, people with moderate disease may respond to oral minoxidil. (See treatment for mild alopecia areata for specifics.)

Pulse corticosteroids are corticosteroids given by mouth or intravenously (by IV) at regular intervals, not continuously.

Oral steroids cause side effects like weight gain, thinning bones (osteoporosis), rising blood sugar levels, and high blood pressure, among others. Pulsed steroids ​​appear to have fewer of these side effects.

There are some drawbacks to this treatment, most of all convenience. Intravenous medications must be given in a doctor’s office or clinic. This means returning for treatment for the duration of the therapy. It is also not for everyone. Pulse corticosteroids should not be given to people with uncontrolled high blood pressure or who are pregnant or nursing.

Topical immunotherapy, also called contact immunotherapy, is used to treat more extensive alopecia areata, ​​​​​​​​but may be used for milder disease as well.

The immunotherapy agents cause an allergic rash (allergic contact dermatitis) where they are applied. This changes your body’s immune response around the hair follicles, though researchers don’t understand why this promotes hair regrowth. The rash can look like poison oak or ivy. The drugs most commonly used include:

• Squaric acid dibutyl ester (SADBE)
• Diphencyprone (DPCP)

​​​This treatment can be effective. There are reports that 40 to 55% of patients experience significant regrowth. If hair regrowth is successful, treatment usually needs to continue to maintain the regrowth. The treatment can be uncomfortable, causing redness and rash where it is applied. Topical immunotherapy is typically performed and prescribed by dermatologists.

After decades of no new treatments, there is hope for people with moderate to severe alopecia areata:  Janus kinase (JAK) inhibitors. These are immunomodulatory drugs. They modify the immune system by curbing certain enzymes called cytokines.

When you have alopecia areata, your immune system attacks your hair follicles, disrupting the hair growth cycle. JAKs are blood protein messengers that stimulate the immune cells, producing blood proteins called cytokines. If there are too many cytokines, you get inflammation. By taking a JAK inhibitor, you decrease the number of cytokines, decreasing inflammation. If the inflammation decreases enough, the hair may grow back.

A case report published in 2014,  was the first to show a JAK inhibitor, tofacitinib (Xeljanz®), could successfully treat alopecia areata. Since then, many studies have shown that JAK inhibitors can be effective in promoting hair regrowth in alopecia areata.

Doctors already prescribe JAK inhibitors for a number of conditions including rheumatoid arthritis, atopic dermatitis, and ulcerative colitis. Recently, the FDA approved one JAK inhibitor, baricitinib, as a treatment for alopecia areata (see below). Other JAK inhibitors are currently in clinical trials or under review at the FDA for alopecia areata.

JAK inhibitors are sometimes used in combination with other treatments, such as oral minoxidil or intralesional corticosteroids.

In June 2022, the FDA approved the JAK inhibitor baricitinib (​Olumiant®), a daily pill, for adults with severe alopecia areata. Studies showed ​​that 17% to 35% of patients with extensive alopecia areata who took baricitinib had hair regrowth. Some had almost 80% coverage. This is the first time the FDA specially approved an oral drug as a treatment for alopecia areata. Baricitinib was first approved in 2018 to treat rheumatoid arthritis. In 2020, the FDA granted emergency authorization to give the drug to some people with COVID-19.

Read frequently asked questions about Olumiant.

Baricitinib (Olumiant®) is the first approved JAK inhibitor for the treatment of alopecia areata, but others are expected. Following completion of late-stage clinical trials, two other JAK inhibitors might be soon available. Ritlecitinib is under FDA review and it’s expected that deuruxolitinib will be submitted 2023. Tofacitinib (Xeljanz®), another JAK inhibitor, is an older medication still prescribed off-label for alopecia areata.

Although JAK inhibitors are not currently approved as a treatment for alopecia areata in children, they may be prescribed off label. There are a number of investigations in children showing their effectiveness. Clinical trials of ritlicitinib included patients as young as 12 and more clinical trials in children are expected.

Learn more about JAK inhibitor treatments

• Watch NAAF’s webinar from July 2022: Alopecia Areata Treatment Update: A New Future Awaits

• Watch NAAF’s webinar from October 2022: Pediatric Alopecia Areata: Treatment Options for Children 
• Watch NAAF’s webinar from January 2023: JAK Inhibitor Treatment for Alopecia Areata: Understanding Side Effects and Monitoring

About ​​one-third of people with alopecia areata also have atopic dermatitis, or eczema. Dupilumab (Dupixent), a monoclonal antibody drug, is FDA-approved for atopic dermatitis for adults and children as young as six months. Dermatologists may prescribe dupilumab as first-line treatment for alopecia areata for people who also have atopic dermatitis or a family history of atopic dermatitis.