Even if you are unfortunately diagnosed with alopecia areata, treatment based on the Japanese Dermatological Association’s Psychosomatic Guidelines for Alopecia Areata now allows for more effective approaches than in the past.

First, let’s review the guidelines introduced here to understand what kind of treatment you will receive.

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Guidelines for the Diagnosis and Treatment of Alopecia Areata

Alopecia areata is the most common acquired hair loss disorder, affecting 0.1 to 0.2% of the total population in the United States. It is believed to occur at a similar rate in Japan. Consequently, the Japanese Dermatological Association and The Society for Hair Science Research established a joint committee, which included dermatologists deeply involved in treating hair disorders. This committee developed the Alopecia Areata Clinical Practice Guidelines. The recommendation levels in the table below are determined based on data obtained from experiments and other sources. Please note that the highest recommendation level for each treatment is “B,” meaning that even with further research, there is no treatment that is strongly recommended.

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Recommended level classification

※Evidence: Proof, basis, trace

Level Recommendation Level Comment
Ａ Strongly recommended (with at least one level I or high-quality level II evidence demonstrating effectiveness)
Ｂ Strongly recommended (with at least one level of evidence demonstrating effectiveness: low-quality Level II, good-quality Level III, or very good-quality Level IV evidence)
Ｃ1 It may be considered, but there is insufficient evidence (low-quality Level III–IV, multiple high-quality Level V studies, or Level IV evidence approved by the committee).
Ｃ2 Not recommended due to lack of evidence (no valid evidence exists, or evidence exists that is invalid)
Ｄ Not recommended (due to high-quality evidence indicating it is ineffective or harmful)

Levels of evidence classification

Level Recommendation level comment
Ⅰ Systematic review※1/Meta-analysis※2
Ⅱ One or more randomized controlled trial※3
Ⅲ Randomized controlled trial
Ⅳ Analytical epidemiological studies※4 (Cohort studies※5 and Case-control studies※6)
Ⅴ Descriptive research※7 (Case reports※8 and Case series studies※9)
Ⅵ Opinions from specialized committees and individual experts plus

※1 Systematic review: A systematic review involves collecting clinical trial papers and summarizing and evaluating their content.

※2 Meta-analysis: Integrates and analyzes data from multiple trials.

※3 Randomized controlled trial: A research study method designed to avoid evaluation bias and objectively assess treatment efficacy.

※4 Analytical epidemiological study: A method for confirming the statistical association between suspected factors and disease, thereby estimating the causality of the factors.

※5 Cohort study: A research method that tracks a group exposed to a specific factor and a group not exposed to it over a set period, compares disease incidence rates, investigates the association between the factor and disease occurrence, and observes the development of diseases of concern in the future.

※6 Case-control study: A research method that observes and investigates exposure factors in a group of individuals who have developed a disease, and then similarly investigates the exposure history to specific factors in a control group of individuals who have not developed the disease.

※7 Descriptive research: A research method that observes and describes in detail and with accuracy the epidemiological characteristics of a disease (incidence, distribution, related information) by person, place, and time.

※8 Case Report: A detailed account of a patient’s diagnosis, treatment, and progression within an “observational study”—a type of research that monitors disease progression or investigates treatment effects and impacts. While it may lead to discoveries of new prevention methods, diagnostic approaches, or treatments, it lacks rigor due to significant potential for bias and chance factors.

※9 Case series study: A research method that involves measuring and investigating the characteristics of a disease in a group of patients with that disease or in a series of patients who received the same treatment, without comparing them to a control group.。

Steroid injection → Recommendation level = B

Steroids are injected directly into the scalp at the site of hair loss (alopecia patch).

Steroids suppress inflammation and aim to improve symptoms caused by autoimmune disorders. Alopecia areata has different causes than AGA (androgenetic alopecia), and steroid treatment, which has anti-inflammatory and immunosuppressive effects, is fundamental.

However, treatment methods vary depending on the duration of onset and the size of the balding area. While improvement effects from local injection therapy are high, side effects such as diabetes and hypertension from long-term use have also been noted.

Local immunotherapy → Recommendation level = B

Apply medication to the affected area to induce mild inflammation (irritation) and promote hair growth.

It is considered suitable for extensive alopecia areata. Reliable evidence indicates it reduces the extent of hair loss. For cases classified as “S2” or higher (multiple patches covering 25%–49% of scalp area), total scalp loss, or diffuse loss, it should be the first-line treatment regardless of age.

 

※Multifocal: Multiple circular bald patches appear.
Total: Nearly all hair is lost.
Universal: Coin-sized bald patches suddenly appear on the head one day, and in the early stages, all body
hair—including eyebrows, eyelashes, and pubic hair—is lost. = Total alopecia

Intravenous steroid pulse therapy via drip infusion → Recommendation level = C1

Intravenous steroids are administered at higher concentrations (typically 10 to 20 times higher) than oral medications.

This treatment is approved for adults whose symptoms rapidly progressed within six months of onset. Methylprednisolone 500mg/day or 8mg/kg/day is administered via intravenous drip for three consecutive days, and it has been confirmed to reduce the extent of hair loss compared to pre-treatment levels.

However, its safety in children has not been established, so it is not recommended.

Oral steroids or oral steroid pulse therapy → Recommendation level = C1

This treatment is considered acceptable for adults experiencing rapid hair loss progression.

While oral medication shows efficacy, it has been confirmed that hair loss frequently recurs after discontinuation and that side effects such as obesity, diabetes, and menstrual irregularities may occur.

Although oral steroid pulse therapy achieved high hair regrowth rates even in severe cases, the rationale for its use is considered questionable, as the side effects often outweigh the therapeutic benefits.

Topical Steroids → Recommendation level = C1

Steroids are commonly used as topical medications for skin conditions, including atopic dermatitis.

While recommended as the first-line treatment for all disease types, although some recovery effects are recognized, their beneficial efficacy has not been conclusively proven.

Furthermore, reports indicate they are not expected to be effective for totalis or universalis types. Steroid treatment promotes hair growth by suppressing inflammation caused by autoimmune disorders, but the following side effects are a concern;
・Side Effect 1: Increased risk of infection
・Side Effect 2: Development of steroid-induced diabetes
・Side Effect 3: Hypertension

Minoxidil→Recommendation level=C1

Originally used as a vasodilator to alleviate hypertension, it was later discovered to have hair growth effects sufficient for treating alopecia, and is now widely recognized as a hair growth ingredient. While evidence exists showing a significant reduction in hair loss area compared to placebo, the degree of this effect is considered weak. Guidelines state it is ineffective for extensive hair loss.

Oral minoxidil tablets are gaining attention for potentially surpassing topical treatments since they deliver the medication directly to the scalp from within the body. A notable side effect of minoxidil tablets is increased body hair growth. This is thought to occur because the medication travels through the body to reach hair follicles, leading to hair growth effects beyond just the scalp. Other possible side effects include nausea, abdominal pain, and decreased libido. Adhering to the prescribed dosage is crucial, and caution should be exercised against applying too much topical minoxidil.

Related Articles: What are the AGA Treatment Effects of Minoxidil?

Cephalexin→Recommendation level=C1

This medication, primarily containing the active ingredient alkaloid, is used to treat alopecia.

It is believed to suppress allergies and improve blood flow. Alkaloids are components with a long history of use as herbal medicines. They were also used as cocaine and morphine in the 19th century.

Notably, it is used to treat radiation-induced leukopenia, alopecia areata, and pityriasis capitis. Its vasodilatory effect improves peripheral circulation, facilitating smoother nutrient supply to hair follicles, which is said to be effective for thinning hair.

However, while reports indicate oral administration may reduce the extent of hair loss, this has not reached scientific validation and remains unproven at this stage.

※Pityriasis capitis: A form of alopecia combining “dandruff” and “hair loss,” often accompanied by scalp itching and rashes. It commonly appears in males after puberty.

Second-generation antihistamines → Recommendation level = C1

Antihistamines released after 1983 are referred to as second-generation drugs.

They are said to have fewer side effects than first-generation drugs and are generally used as antiallergic agents. In cases involving atopic factors, they have demonstrated a certain degree of effectiveness as part of combination therapy, and there is sufficient evidence supporting their hair growth effects.

Glycyrrhizin, Methionine, Glycine Complex → Recommendation level = C1

Glycyrrhizin and methionine are said to restore liver function and suppress skin inflammation, while glycine is reported to have antidepressant effects and improve sleep.

It is considered acceptable to use them in combination therapy for both single and multiple cases; however, case studies primarily using glycine compounds are scarce, and evaluations of treatment efficacy and recurrence rates remain unknown.

Carpronium chloride → Recommendation level = C1

There are oral and topical types available. Like minoxidil, it dilates blood vessels and promotes blood flow, positively affecting hair and scalp health, making it useful for treating AGA (androgenetic alopecia).

While evidence shows it has a significant hair growth effect compared to a placebo, the degree of this effect is considered weak. It is fundamentally a component suited for those with mild thinning hair, and its use in combination with finasteride is recommended.

When starting calprolium chloride solution, hair shedding may temporarily increase in very rare cases. This is evidence of the medication’s effectiveness and is generally considered a positive reaction. The amount of shedding typically returns to normal within a few days to weeks. Applying calprolium chloride solution after bathing is said to increase the likelihood of side effects such as chills, nausea, sweating, and irritation. If concerned, consult a healthcare provider.

Linear polarized near-infrared irradiation therapy (Super raiser therapy) → Recommendation level = C1

This treatment uses specialized equipment to deliver infrared light deep into the skin, targeting the affected area to suppress internal inflammation.

It is simple to administer and has mild side effects, making it suitable for treating both single-spot and multiple-spot alopecia. Weak evidence suggests that combining it with carpronium chloride or cepharanthin may shorten the hair regrowth period. However, data indicates it is ineffective for frontal or diffuse alopecia.

PUVA therapy → Recommendation level = C1

One form of phototherapy, it artificially increases ultraviolet absorption and involves exposure to ultraviolet A (UVA) light for a set period.

It is considered a good treatment option for adults with total or generalized vitiligo who have not responded to topical immunotherapy. Weak evidence suggests a reduction in the extent of depigmentation compared to before treatment. Considering it is a standard treatment, it is acceptable to use it as one of the treatment options.

Cooling therapy→Recommendation level=C1

Also known as cryotherapy, this treatment involves applying dry ice to the affected area for a set period or using spray application to artificially induce inflammation, thereby promoting hair growth.

While not suitable for severe cases like total alopecia, it is appropriate for use in combination with single-spot or multiple-spot cases. Weak evidence suggests that applying liquid nitrogen or dry ice may reduce the extent of hair loss compared to previous methods.

Cyclosporine A (CyA) → Recommendation level = C2

It is used as a treatment for atopic dermatitis. While weak evidence suggests that oral CyA reduces the extent of hair loss, it is not currently recommended because hair loss often recurs after discontinuation and it carries a high risk of causing hypertension and renal impairment.

Anthralin topical → Recommendation level = C2

There is weak evidence suggesting that topical application of anthralin, used as a psoriasis treatment, may reduce the extent of hair loss compared to previous methods and promote hair regrowth even in severe cases.

However, since this medication is not approved in Japan for the treatment of common psoriasis, it is advisable not to use it.

Tranquilizers→Recommendation level=C2

There is weak evidence suggesting that taking tricyclic antidepressants (such as Amoxan) may reduce the extent of hair loss.

However, the descriptions in clinical trials remain ambiguous, and the evaluation has not reached the required standard, so it cannot be definitively stated that they are effective. Therefore, their use is not recommended in routine clinical practice.

Traditional Chinese Medicine→Recommendation level＝C2

The use of traditional chinese medicines such as Saiko-Ryukotsu-Boreito has been shown to reduce the extent of hair loss in all types of alopecia—common, total, and diffuse.

However, there are no comparative studies or reports against other treatments, leaving questions about its efficacy. Until further clinical trials provide verification, routine use is not recommended.

Hypnotherapy → Recommendation level = C2

Hypnotherapy is used as one treatment for anxiety and depression. There are records of it being used for alopecia areata when stress was considered the cause.

While there is weak evidence suggesting a reduction in the area of hair loss, the scientific evaluation is unclear and its effectiveness has not been proven. Furthermore, since hypnotherapy is outside the specialty of psychiatrists, it is advisable to refrain from using it until verification results from future clinical trials become available.

Acupuncture and moxibustion treatment → Recommendation level = D

While several case reports cite hair regrowth effects from acupuncture, these lack conditions such as the extent of hair loss or post-treatment records.

Consequently, they are considered to lack medical evidence and do not meet evaluation criteria. At present, discussions regarding its efficacy have not reached a conclusive stage.

Therefore, acupuncture should not be performed for the purpose of hair regrowth or hair growth.

Molecular targeted therapy → Recommendation level = D

Weak evidence suggests that administering immunomodulatory synthetic proteins that impair memory T cells, anti-interferon gamma antibodies, and similar agents may reduce the extent of hair loss.

However, as clinical trials are in their early stages and insufficient data has been obtained, this treatment should not be used.

Wig→Recommendation level＝C1

Wigs are used to alleviate feelings of immaturity in behavior, emotional instability (such as stress), complexes caused by hair loss, and a sense of loss. They are also recommended to protect the scalp from UV rays and prevent injury. In Sweden, wigs are recognized as medical devices and covered by health insurance, leading to comments that Japan should also recognize them under its Medical Care Act.

How was that? Let’s resolve your concerns about alopecia areata with an effective approach following the guidelines. Please consider using this as a reference.