Alopecia (young people)

Alopecia treatments: an overview of steroid treatments

Corticosteroid treatments, often referred to as just ‘steroids’, are used to treat various types of alopecia such as alopecia areata. Many people we talked to had tried steroid treatments. Topical steroids (applied on top of the skin) were usually tried first and, if these didn’t help, some people moved on to steroid injections and oral steroids (swallowed as tablets). Meghan saw this as a “scale” of treatments which she had moved up over several years. People often said the decision to try steroid treatments and which ones depended on how much alopecia areata they had and whether it had worked for them in the past. Emily says her hair loss is too severe for steroid injections and Grace had to stop this treatment when her bald patches became “too big”. Topical and injection steroid treatments were often offered to help hair regrowth on the scalp, but can be used for other areas of hair loss such as the eyebrows. Sometimes people had two types of steroid treatment at the same time. Arti and Hannah both continued using steroid creams daily alongside regular steroid injections.

Steroids help control alopecia areata by reducing the inflammation and suppressing the immune system, to stop the body from attacking the hair follicles. There are different types of steroids, such as hydrocortisone and betamethasone butyrate, and treatments can have different strengths (how much steroid the product contains). Steroid treatments are usually prescribed or, in the case of steroid injections, the procedure is performed by a medical professional. Rochelle was shocked to find out that some beauty product creams she had bought and previously thought of as ‘natural’ actually contain steroids.

Professor Moss talks about steroid treatments (creams, injections, tablets) for alopecia areata.

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Sex: Female

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The first line treatment for alopecia is with steroids. And usually we start off with a cream. Of course before that we need to make sure that the person needs and wants treatment. And I would always explain that sometimes it gets better by itself, that treatments are not a hundred percent reliable, we do not have a perfect treatment for alopecia. And some, sometimes there’s a scenario where the child is actually not that fussed about it, and maybe the parent feels very strongly they must have treatment. And so obviously we’re cautious in that situation, that it’s what is right for the child, rather than right for the parent. But often people do want treatment. Even if we think well it’s quite a small patch, and they can cover it with their hair. But just the fact of having it makes people want to have it treated, they don’t like to have it there. So we would start off with steroid treatment. Now we would use a steroid cream, which is the sort of thing that’s used in eczema, they’re very widely used. There’s a lot of anxiety about using steroids, because if you over-use steroids they can thin the skin, they can cause-, they can increase the risk of infections on the skin. And if you put them on a large part of the body, they can get absorbed and cause the same sort of effects as taking steroids by mouth. But these things really do not apply when we’re using steroids on a small patch on the scalp. It’s really unlikely that any of those side effects would occur. So we would use a moderately potent steroid. We would advise for it to be put on twice a day. And I always suggest a limited period. The simplest thing is to say, “Well, I’ll prescribe a 30 gram tube, a small tube of steroid, use it twice a day. And at the end of that time, if you’ve finished the tube or if you’ve got to a month and absolutely nothing has happened, it’s really not worth persevering. And on the other hand, if it has provoked some regrowth, then again it’s not really worth persevering because you’ve kind of kicked the system back into play, and the immune system is suppressed now and it’s starting to regrow”. And what the steroid is doing, is it’s suppressing the immune cells in the skin in that location, that are attacking the hair follicles.

So if we’ve tried steroid treatment and it doesn’t work, then we might consider moving onto steroid injections. Now the problem with steroid injections is that they’re painful. And obviously the more you do, the more it hurts. And they only really work where you inject. It’s not like having a vaccination in your arm that affects your whole body. The steroid injections just work where you inject. So if you’ve got lots of patches and you want them all treated, then it’s lots of injections. We can use an injecting device which sort of squirts things into the skin under high pressure, without the needles. And you get several points injected at the same time. Which is slightly less painful than a needle, but it still hurts. So that’s the main drawback. It is more effective than a cream. It usually needs to be done on more than one occasion. So, each session there’d be several injections in all the places affected. Need to come back and have more treatments. See how it goes. If it’s working well, then we would continue, and if it’s not working at all after four or five injections we probably would advise not continuing.

Some people prescribe steroids by mouth. There’s no doubt that a course of high dose steroids does improve alopecia areata. But firstly the improvement is not always maintained, so when you come off it, which you have to do, the hair would stop regrowing and may come out again. And, of course, oral steroids have all sorts of side effects. And they can affect the body’s immune system. They can affect children’s growth. They can make people put on weight and gain fluid. And lots of adverse effects. So, in general, we feel that it’s not justified to give oral steroids for alopecia areata. But having said that, some people are so distressed by their alopecia areata that they’re very keen, even if it has side effects. So often that’s a difficult conversation to have with people, to try and make clear, make sure that they understand the risk-benefit ratio.

There were mixed experiences of steroid treatments. Some people found they worked well, such as Michael who is pleased that steroid injections have helped his eyebrows to regrow. Sometimes steroid treatments worked and hair regrew but then fell out again when treatment stopped. This happened for Hannah after using topical steroids. Others felt frustrated by using steroid treatments with no improvement. Not everyone was interested in trying steroid treatments or some people, like Annie Y, hadn’t tried any for many years. Some of the reasons people didn’t want to try steroid treatments or stopped using them include:

Low expectations about the treatment working. Imogen says she doesn’t “see the point” in trying steroid treatments as she’s heard they often don’t work and that the hair can fall out again once treatments stop.
Emotional impacts it could have if it didn’t work. As Emma said, “Am I just building my hopes up to knock them back down again?”
Worries about side effects and risks of treatment, such as skin thinning with topical steroids and weight-gain with tablet steroids.
Being time-consuming and ongoing. As Kayla explained, “I’m used to my wigs and I would rather just [be] comfortable… I don’t wanna have to take something for the rest of my life”. Annie X decided to focus on trying alternative therapies instead.

Some people who continued to use steroid treatments still had doubts about it. Elizabeth had a bald patch regrow when she was age 7. Her doctors put it down to steroid creams but she thinks it was a coincidence that her hair grew back at the same time. Becky says she’s “not entirely convinced” by steroids but uses them because doing a treatment helps her “feel in control”. Michael finds it hard to tell if steroid treatments make a difference as his hair loss and regrowth is in an ongoing cycle.

Emily explains some of her concerns about steroid treatments for alopecia.

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Age at interview: 20

Sex: Female

Age at diagnosis: 19

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Like a lot of the treatments involve steroids which obviously steroids aren’t necessarily the most healthy thing to have in your body. And also in terms of long term effects they’re not great. And with something like alopecia because it can keep happening throughout your life, I didn’t want to have to become reliant on something in order to have hair. I’d rather it just all comes out then like get, get hope kind of by having like steroid injections or something ‘cos I think you can have oral cortisone, but I think that is quite rare to be prescribed because obviously it’s oral. And steroid injections are quite common, but I think you can, I mean for how extensive mine is I don’t think it would be recommended but I would probably have to have about 80 injections into my scalp which I’m not too keen on. It sounds quite painful. So I know a lot of people do go for that option but for me it, it with the amount of hair that I’d lost and the fact that I’m still losing my hair I don’t want to have injections in the patches that are there, and then have other patches form and then when I stop having injections for that hair to fall out. So I figured just leave it and let it do its thing.