Preferred Treatment in Pediatric Alopecia Areata

With a paucity of pediatric treatment evidence, researchers sought to evaluate current treatment for pediatric alopecia areata.

In children with alopecia areata (AA), topical corticosteroids are the first choice in treatment and contact immunotherapy the second most prescribed treatment, according to study results published in the Journal of the American Academy of Dermatology.

Although nearly 80% of patients with patchy AA recover spontaneously, AA still affects a significant population, up to 2% worldwide. This nonscarring hair loss disorder can easily result in psychological trauma, with children slightly more prone to this disease than adults. With a paucity of pediatric treatment evidence, researchers sought to evaluate current treatment for pediatric AA.

To accomplish this, they conducted a systematic review of the PubMed database for articles published before November 2019 that discussed AA treatment in patients younger than 18 years of age. They found 2 case-control studies, 2 randomized controlled trials, 4 prospective comparative cohorts, 31 case reports, and 83 case series that between them, assessed treatment that included aloe, apremilast, anthralin, anti-interferon gamma antibodies, botulinum toxin, corticosteroids, contact immunotherapies, cryotherapy, hydroxychloroquine, hypnotherapy, imiquimod, Janus kinase inhibitors, laser and light therapy, methotrexate, minoxidil, phototherapy, psychotherapy, prostaglandin analogs, sulfasalazine, topical calcineurin inhibitors, topical nitrogen mustard, and ustekinumab, and included 1032 pediatric patients.

Topical corticosteroids, including those with high-potency, are believed a safe treatment inchildren with patchy AA, with high-potency having greater efficacy than low-potency topical corticosteroids, and they can be used as adjunctive therapies. Side effects are usually minimal and may include skin atrophy, spider veins, and inflamed hair follicles. Intralesional corticosteroids are often the first choice of treatment in adult patients with patchy AA, although treatment pain makes it an infrequent choice for pediatric patients.

Contact immunotherapy—treatment with diphenylcyclopropenone (DPCP)—is painless so a popular choice in pediatric populations. Response rates are up to 33% of cases, however relapse rates range as high as 58%. A single case-control study suggested imiquimod might potentially improve efficacy. Side effects of DPCP include eczematous reactions, itchy skin, regional LAD, and blistering.

Study limitations include only full text articles in English were considered, and meta-analysis was not performed.

Although a majority of patchy pediatric AA cases will clear spontaneously, the disease trajectory is still uncertain, but often resulting in a significant psychosocial shock. Researchers concluded that, “Although topical corticosteroids remain the preferred first-line treatment for pediatric AA, RCTs, and prospective comparative studies are needed to help define treatment guidelines.”


Barton VR, Toussi A, Awasthi S, Kiuru M. Treatment of pediatric alopecia areata: A systematic review. J Am Acad Dermatol. Published online April 30, 2021; 86(6):1318-1334. doi:10.1016/j.jaad.2021.04.077