Topical steroids Expand Topical steroids are creams, ointment, lotions, or foams that are applied directly to the scalp or skin surface. The aim of topical steroids is to reduce the inflammation within the skin. Topical steroids are one of the first-line treatment options for people with some types of alopecia. There are different strengths and formulations available. Usually, a potent, or very potent, topical steroid is needed to treat alopecia. Topical steroids are often a first-line treatment option that can be offered by GPs. Topical steroids will not be offered as a regular long-term treatment option as prolonged use can lead to thinning of the skin (known as skin atrophy). Topical steroids might be prescribed to patients with the following alopecia types: alopecia areata, frontal fibrosing alopecia (FFA), lichen planopilaris (LPP), central centrifugal cicatricial alopecia (CCCA), traction alopecia.
Intralesional steroids (steroid injections) Expand Intralesional steroids, or steroid injections, are steroids that are injected just underneath the skin using a fine needle. Small amounts of steroid are injected roughly 1cm apart. When used to treat alopecia areata, the injections are given into the patch of hair loss and at the patch margins. For scarring alopecias such as frontal fibrosing alopecia or LPP, the injections are generally directed at the active margins of patches where the hairs are still present. The aim is to reduce inflammation around the hair follicle. The treatment may be repeated several times over a number of months. This type of treatment is usually only used on smaller areas of hair loss and not typically offered to those with extensive hair loss such as alopecia totalis or universalis. Intralesional steroids are unlikely to be offered by GPs and will most likely be provided within a dermatology setting. There is a risk of skin-thinning or indents on the scalp. In recent years, some have found challenges accessing steroid injections. Our webpage Steroid Injections - Navigating Supply Issues may be helpful for those wishing to try this treatment. Intralesional steroids might be prescribed to patients with the following alopecia types: alopecia areata, frontal fibrosing alopecia (FFA), lichen planopilaris, central centrifugal cicatricial alopecia (CCCA).
Systemic steroids Expand Systemic steroids are taken orally as a pill or in an intramuscular injection. Systemic steroids mimic the effects of hormones produced by the adrenal glands. They have anti-inflammatory and immunosuppressive properties. Systemic steroids are generally only used as a short-term measure to try to stop the hair from falling rapidly. Long-term use is usually avoided as there can be serious side effects when taken for longer periods. Systemic steroids might be prescribed to patients with the following alopecia types: alopecia areata (including totalis and universalis), lichen planopilaris (LPP)
JAK inhibitors Expand Janus kinase (JAK) inhibitors are a class of medication that modulate the activity of the Janus kinase family of enzymes. These enzymes play a critical role in the signalling pathways of various cytokines involved in immune function and inflammation. JAK inhibitor medications aim to block the activity of the JAK enzymes, interfering with the signalling pathways and decreasing inflammation. Baricitinib (brand name Olumiant) and ritlecitinib (brand name LITFULO) are the only licensed treatments for severe alopecia areata (more than 50% hair loss). Baricitinib is only licensed for those aged over 18 whilst ritlecitinib is licensed for patients aged 12 and over. Currently baricitinib has not been recommended for routine NHS commissioning by NICE (England, Wales and NI) or SMC (Scotland). This means baricitinib is only available to patients with severe alopecia areata via a private prescription. Ritlecitinib was recommended by NICE and SMC in Spring 2024 meaning that patients with severe alopecia areata should be able to access this treatment via NHS pathways. We have a dedicated ritlecitinib webpage designed to help people understand more about the treatment and how to access it on the NHS. Before starting a JAK inhibitor, a number of baseline tests are usually required. These tests are generally undertaken for patients before starting any medications that act on the immune system. These tests may include blood samples to check liver & kidney function, blood count, blood fats, for evidence of serious viral infections (hepatitis & HIV) and tuberculosis (TB). Evidence that you are immune to the chickenpox virus is also checked. A chest X-ray may also be carried out. As there is an increased risk of developing shingles while taking JAK inhibitors, those aged over 50 may be recommended for shingles vaccination. You are likely to be advised to have a vaccination for pneumococcal infection, annual flu vaccines and covid vaccines. Women who can become pregnant must be on an effective form of contraception if sexually active, as JAK inhibitors should not be taken during pregnancy or breast-feeding. Not all patients will be suitable for JAK inhibitors due to other health issues. Not all patients will develop an adequate response to JAK inhibitor treatment and the treatment may be stopped. JAK inhibitors are a long-term treatment, and patients need regular blood tests to monitor for side effects. JAK inhibitors might be prescribed to patients with the following alopecia types: severe alopecia areata (hair loss of greater than 50%, including totalis and universalis). Clinical trials are currently ongoing to explore new JAK inhibitor medications for alopecia areata. There are also clinical trials exploring JAK inhibitors for the treatment of some scarring alopecias such as frontal fibrosing alopecia and lichen planopilaris.
Contact immunotherapy (DPCP) Expand Contact immunotherapy is a form of treatment designed to induce a local allergic skin reaction (contact dermatitis) that stimulates hair re-growth by “distracting” the immune system from attacking hair follicles. In the UK, diphenylcyclopropenone (DPCP) is the most used contact immunotherapy treatment. The treatment is initially applied at a higher concentration to a small area of the scalp or the arm, in a process called sensitisation – this makes the person allergic to the solution being applied. After sensitisation, a much lower concentration of DPCP is applied weekly to the affected areas of the scalp. Usually half of the head is treated until hair growth is demonstrated, then the whole scalp is treated. The concentration of DPCP is gradually increased over time, depending on the level of reaction. This type of treatment requires prolonged courses, sometimes more than one year. There are only a small number dermatology departments in the UK which offer this treatment. Contact immunotherapy might be prescribed for patients with the following alopecia types: alopecia areata (including totalis and universalis)
Systemic immunosuppression Expand Systemic immunosuppressant medications can help to suppress the immune system to reduce any inflammation occurring around hair follicles. In the UK, methotrexate, ciclosporin and azathioprine are the most used systemic immunosuppressants for alopecia. Before starting an immunosuppressive treatment, a number of baseline tests are usually required. These tests may include blood samples to check liver & kidney function, blood count, blood fats, for evidence of serious viral infections (hepatitis & HIV) and tuberculosis (TB). Evidence that you are immune to the chickenpox virus is also checked. A chest x-ray may also be carried out. You are likely to be advised to have a vaccination for pneumococcal infection, annual flu vaccines and covid vaccines. Women who can become pregnant may require to be on an effective form of contraception if sexually active, as some immunosuppressive treatments (e.g. methotrexate) should not be taken during pregnancy. Regular blood tests are essential to monitor the effectiveness of the treatment and check for any potential side effects. Systemic immunosuppression might be prescribed to patients with the following types of alopecia: alopecia areata (including totalis and universalis), frontal fibrosing alopecia (FFA), lichen planopilaris (LPP).
Minoxidil Expand Topical minoxidil is licensed for the treatment of androgenetic alopecia (pattern hair loss) in men and women. It keeps hair follicles in the growing phase (anagen) for longer and restarts the growth phase of resting (telogen) follicles. It is not clear exactly how minoxidil causes these effects. The treatment is unlikely to be helpful if the scalp is completely bald. Minoxidil is not prescribed for patients with androgenetic alopecia through the NHS. Topical minoxidil is sometimes suggested for other types of alopecia ‘off-label’ as an ‘adjuvant’ treatment – meaning something that supports the effect of another treatment. Minoxidil might be offered alongside another treatment to improve hair density. Oral minoxidil tablets are sometimes prescribed in a low dose to treat severe female pattern hair loss. Minoxidil is a blood pressure tablet and there can be side effects from taking the drug as a tablet. It is also sometimes prescribed as adjuvant therapy (see above) for other types of alopecia. Minoxidil might be suggested for people with the following alopecia types: androgenetic alopecia (male and female pattern hair loss), alopecia areata, lichen planopilaris (LPP), frontal fibrosing alopecia (FFA), central centrifugal cicatricial alopecia (CCCA), traction alopecia.
Antiandrogen treatments Expand Antiandrogen treatments are sometimes used in the treatment of male pattern hair loss. In men, testosterone is converted by an enzyme called 5 alpha reductase (5AR) to dihydrotestosterone (DHT) in hair follicles. Susceptible follicles react to the hormone by producing smaller finer hairs. Antiandrogen treatments, such as finasteride and dutasteride, can help to lower the level of DHT and reduce the androgenic effect that leads to hair loss. Antiandrogen treatments can be prescribed via a private prescription but not through the NHS. There have been concerns about the side effects of these drugs. Older men taking drugs such as finasteride must let their doctor know if they have a blood test for their prostate (PSA), as these drugs can artificially lower the levels of this protein in their blood. The role of androgens in causing female pattern hair loss is uncertain. However, antiandrogen treatments can be used to treat female pattern hair loss, although usually most women have no evidence of excessive androgens. In women, antiandrogen treatments which may be used include oestrogen-containing oral contraceptive pills and spironolactone. Antiandrogen treatments might be prescribed for people with the following alopecia types: androgenetic alopecia (male and female pattern hair loss)
Antibiotics Expand Antibiotics can help some people with scarring alopecias, particularly when the condition is associated with bacterial infection or inflammation. Antibiotics can reduce the bacterial load in conditions where bacteria play a role in inflammation and follicular damage. Some antibiotics, particularly tetracyclines, have anti-inflammatory properties that can help to reduce the inflammation associated with scarring alopecias. Antibiotics used to treat scarring alopecias include tetracycline and doxycycline. Antibiotics might be prescribed to people with the following alopecia types: frontal fibrosing alopecia (FFA), lichen planopilaris (LPP), central centrifugal cicatricial alopecia (CCCA), dissecting cellulitis, folliculitis decalvans.
Topical calcineurin inhibitors Expand Topical calcineurin inhibitors can reduce inflammation and reduce local immune responses in people with scarring alopecias. These medications may help to halt the progression of the condition but will not be able to restore any lost hair. They may also help to manage symptoms like itching, redness, and inflammation. As they are not steroids, they can be safely used on the face. Topical calcineurin inhibitors might be prescribed for people with the following alopecia types: frontal fibrosing alopecia (FFA), lichen planopilaris (LPP), central cicatricial centrifugal alopecia (CCCA)
Hydroxychloroquine Expand Hydroxychloroquine is an antimalarial drug which can reduce inflammation. It reduces the activity of immune cells and helps to reduce the autoimmune and inflammatory processes that lead to follicular damage in scarring alopecias. Regular follow-ups are essential to monitor effectiveness and side effects. Prolonged treatment with higher doses of this drug can rarely cause damage to the eyes. Hydroxychloroquine might be prescribed to people with the following alopecia types: frontal fibrosing alopecia (FFA), lichen planopilaris (LPP), central centrifugal cicatricial alopecia (CCCA).
Prostaglandin analogues Expand Prostaglandin analogues are used to treat glaucoma. A side effect of these medicines is the darkening, thickening and lengthening of eyelashes. As such, some dermatologists will offer topical prostaglandin analogues for the treatment of eyelash or eyebrow loss in people with alopecia areata where eyelashes/eyebrows have been affected. Prostaglandin analogues include latanaprost and bimataprost. When treating eyelashes, the treatment is only applied to the skin of the upper eyelid margin at the base of the eyelashes. There is the possibility of irreversible discolouration of the iris and darkening of the skin of the eyelids. Prostaglandin analogues might be prescribed to people with the following alopecia types: alopecia areata (where eyelashes or eyebrows are affected); frontal fibrosing alopecia (FFA - where eyelashes or eyebrows are affected)
Low level laser light treatment Expand Low level laser light (LLLL) treatment may help improve hair growth. It is not clear how the treatment might work but it may promote the growing (anagen) phase of the hair cycle, resulting in longer and thicker hairs. There are different types of devices which deliver LLLL such as caps, helmets and combs. The devices can be expensive and the treatment needs to be used 3 - 4 x per week on a regular basis. The treatment is usually well tolerated but mild scalp irritation can occur. Low level laser light treatment might be suggested for people with the following alopecia types: androgenetic alopecia (male and female pattern hair loss)