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).

First-line treatment for alopecia areata with extensive hair loss (including Alopecia Universalis and Totalis) is generally a JAK inhibitor.

In January 2024, Health Canada approved the JAK inhibitor baricitinib (Olumiant^®) for the treatment of severe alopecia areata in adults (50% hair loss or more). This is the first time Health Canada approved an oral drug as a treatment for alopecia areata. Baricitinib was first approved in 2018 to treat rheumatoid arthritis. Olumiant is an oral medication taken once daily.

In November 2023, Health Canada approved a JAK inhibitor ritlecitinib (Litfulo^®) for the treatment of severe alopecia areata in adults and adolescents ages 12 years and older. Litfulo is the first approved treatment for individuals under the age of 18. Litfulo is an oral medication taken once daily.

If you are interested in learning more about whether a JAK inhibitor is right for you, please speak with a dermatologist or healthcare professional who is experienced in the diagnosis and treatment of alopecia areata. If you do not have a dermatologist, try using the Find a Dermatologist tool to find practitioners in your area.

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 limited. In November 2023, Health Canada approved Pfizer’s medication ritlecitinib (Litfulo®). It is the first and only approved treatment for adolescents aged 12 years and up with severe alopecia areata.

Other options for children include topical corticosteroids, topical calcineurin inhibitors, and corticosteroid injections. Some dermatologists, depending on their experience and other clinical factors, may discuss additional treatment options including oral corticosteroids, oral immunosuppressants, or topical allergen treatment.

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.

As JAK inhibitors have only recently become available for prescription by a dermatologist or healthcare professional experienced in the diagnosis and treatment of alopecia areata, the reimbursement situation is evolving. It may take some time for insurance companies to add Olumiant® and/or Litfulo® to their list of covered prescription drugs. Private and public drug plans may require some time to develop reimbursement policies for this treatment. If you submit private insurance coverage through your employer and your provider denies coverage, consider submitting again in three months to see if your coverage has changed.

If you are prescribed one of the newer JAK inhibitors, your healthcare professional may provide you with the details of any patient support programs and/or resources provided by the drug’s manufacturer which can help you with reimbursement.

Pfizer offers assistance programs for some patients who cannot afford out-of-pocket medication costs despite their insurance coverage. Please speak to your health care provider about Pfizer’s assistance programs. Please direct any Litfulo® specific question to Pfizer’s medical information line (including questions about public/private coverage): 1-800-463-6001. More information can be found on the Pfizer website. 

Lilly offers a Patient Support Program for eligible patients. Patients with questions regarding Olumiant® and/or its coverage can call the Lilly Customer Response Centre at 1-888-545-5972.