Seeing new hair growth after treatment for alopecia areata is encouraging. But when patchy hair loss still affects a significant portion of the scalp and beard, improvement does not always mean treatment is finished.
Many patients in this situation ask:
“My alopecia areata is getting better with steroid injections, so why am I still developing bald patches—and what can I try next?”
Recently, a 42-year-old man returned to our dermatology practice for alopecia areata involving the scalp and beard.
He had experienced focal hair loss for years and had already received intralesional Kenalog (ILK) injections. Since his previous treatment, his condition had improved.
However, alopecia areata still involved approximately 30% of his scalp, with multiple discrete, non-scarring patches affecting the scalp and facial/beard areas.
Because of the extent and chronic nature of his condition, we discussed a broader range of treatment options, including topical tofacitinib, additional steroid injections, squaric acid, oral minoxidil, red-light therapy, PRP, and potentially systemic JAK inhibitor therapy in the future.
After reviewing these options, he chose a combination of:
Compounded topical tofacitinib 2%
Oral minoxidil 2.5 mg daily
Red-light therapy
Another round of intralesional Kenalog injections
He will return in approximately six weeks for his next ILK treatment.
What Is Alopecia Areata?
Alopecia areata is an autoimmune form of hair loss.
Unlike androgenetic alopecia, which gradually miniaturizes susceptible follicles, alopecia areata typically produces discrete patches of non-scarring hair loss.
The immune system targets hair follicles and interrupts normal hair production.
It can affect:
The scalp
Beard
Eyebrows
Eyelashes
Other hair-bearing areas
Some patients develop only one or two small patches. Others experience more extensive disease.
This patient had involvement of both his scalp and beard/facial areas, with approximately 30% of the scalp affected.
Can Alopecia Areata Last for Years?
Yes.
Alopecia areata can behave very differently from one patient to another.
Some patients experience one episode followed by regrowth. Others have recurrent patches that appear, improve, and return over many years.
That unpredictability is one of the most challenging aspects of the condition.
Even when treatment produces regrowth, alopecia areata can recur.
This patient's disease had been present for years, making long-term management an important part of his treatment plan.
If Steroid Injections Are Working, Why Does He Need More Treatment?
This patient had improved after intralesional Kenalog, which is encouraging.
However, he still had substantial involvement.
When alopecia areata affects multiple areas or a significant percentage of the scalp, a dermatologist may discuss combining therapies rather than relying exclusively on injections.
The goal is not simply to treat one visible bald spot at a time. The broader strategy may involve controlling active disease while supporting regrowth.
For this patient, that meant continuing ILK while adding other therapies.
What Are Intralesional Kenalog Injections?
Intralesional Kenalog, or triamcinolone, is a corticosteroid injected directly into areas affected by alopecia areata.
The medication is intended to reduce the localized inflammatory immune response affecting the hair follicles.
During this visit, the patient received his second ILK treatment.
A total of:
16 lesions were injected
using:
Kenalog 2.5 mg/cc
with a:
Total volume of 3.0 cc
The injections were placed into multiple areas of patchy hair loss involving the scalp and facial regions.
What Are the Risks of Steroid Injections for Alopecia Areata?
One of the important risks of intralesional corticosteroid injections is skin atrophy, or localized thinning/indentation of the skin.
That risk was reviewed with this patient before treatment.
The amount and concentration of medication must therefore be selected carefully.
Patients generally return at intervals so the dermatologist can assess regrowth, disease activity, and any treatment-related changes before additional injections are performed.
How Many Steroid Injection Sessions Will He Need?
The current plan is to complete two rounds of ILK injections and reassess his response.
He will return in approximately six weeks for his next treatment.
If improvement remains inadequate, additional treatment options may be considered.
Those could include:
Squaric acid
PRP
Systemic JAK inhibitor therapy
Treatment is adjusted according to response rather than assuming every patient needs the same number of sessions.
What Is Topical Tofacitinib?
The patient also elected to begin compounded topical tofacitinib 2%, applied to affected scalp areas twice daily.
Tofacitinib belongs to a medication class known as Janus kinase (JAK) inhibitors.
The JAK signaling pathway is involved in immune activity associated with alopecia areata.
Topical compounded tofacitinib represents a different approach from steroid injections because it attempts to influence inflammatory signaling directly at treated areas.
The evidence and absorption profile for compounded topical JAK inhibitors are not identical to those of FDA-approved systemic JAK inhibitor treatments for alopecia areata, and response can vary.
Why Discuss JAK Inhibitors for Alopecia Areata?
JAK inhibitors have changed the treatment landscape for patients with more extensive alopecia areata.
For patients with substantial or persistent disease, systemic treatment may eventually be considered.
In this case, systemic immunomodulatory treatment was discussed as a possible future option, rather than started immediately.
The patient preferred to proceed first with topical tofacitinib, ILK, oral minoxidil, and red-light therapy.
If the response is inadequate, systemic JAK inhibitor treatment may be revisited.
Why Add Oral Minoxidil if Alopecia Areata Is Autoimmune?
This is an important distinction.
Minoxidil does not treat the autoimmune cause of alopecia areata.
Instead, it may be used as an adjunct to support hair growth while treatments directed at the inflammatory process address the underlying disease.
This patient was prescribed:
Oral minoxidil 2.5 mg once daily.
It is therefore part of a combination strategy rather than a replacement for immune-directed treatment.
What Are the Risks of Oral Minoxidil?
Oral minoxidil is used off-label for hair loss.
Potential adverse effects can include:
Unwanted facial or body hair growth
Dizziness or lightheadedness
Low blood pressure
Increased heart rate or palpitations
Headaches
Ankle swelling
Fluid retention
Patients taking oral minoxidil should follow their prescribing clinician's instructions and report concerning symptoms.
Can Red-Light Therapy Help Alopecia Areata?
Low-level red-light therapy was also incorporated into this patient's plan.
Light-based therapy is noninvasive and may be considered as an adjunctive approach, but it should not be viewed as a guaranteed substitute for established immune-directed treatment.
With approximately 30% scalp involvement, this patient's plan was intentionally multi-modal rather than dependent on red-light therapy alone.
What Is Squaric Acid Treatment?
This patient had previously undergone squaric acid treatment and remembered having a significant skin reaction.
That reaction understandably made him hesitant about trying it again.
Squaric acid is used as a form of contact immunotherapy.
Treatment intentionally creates an allergic contact dermatitis response in an effort to alter the immune activity associated with alopecia areata.
Therefore, some inflammation is expected.
However, treatment reactions can vary in intensity, and significant reactions should be managed by the treating dermatologist.
For this patient, squaric acid remains a possible future option if his current treatment strategy does not provide sufficient improvement.
Could PRP Be Used for Alopecia Areata?
PRP was also discussed.
The patient was counseled that approximately three to four PRP sessions may be performed before assessing response.
However, PRP should not be confused with established immune-directed treatments for alopecia areata.
Evidence for PRP in alopecia areata is more limited than for some established therapies, and individual responses vary.
It should not be presented as a guaranteed method for preventing recurrence.
For this patient, PRP remains an option that may be reconsidered depending on his response to the current plan.
Why Does Having 30% Scalp Involvement Matter?
The extent of alopecia areata helps guide treatment discussions.
A patient with one small patch may have very different treatment needs from someone with numerous patches affecting a substantial portion of the scalp.
This patient had approximately 30% scalp involvement, as well as facial/beard disease.
That is why broader treatment options—including systemic therapy—were discussed even though he had experienced some improvement with ILK.
Does His Thyroid History Matter?
This patient had previously undergone a thyroidectomy for papillary thyroid cancer and was reported as not currently taking thyroid supplementation.
That medical history is relevant when evaluating the patient as a whole.
However, the chart does not establish that his thyroid cancer or thyroidectomy caused his alopecia areata.
Alopecia areata is an autoimmune disease, and treatment decisions should be based on the complete clinical and medical picture rather than assuming a single medical event caused the hair loss.
What Happens if This Treatment Plan Doesn't Work?
The next step will depend on how much improvement is seen after the planned treatment period.
For now, the patient will use:
Topical tofacitinib 2% twice daily
Oral minoxidil 2.5 mg daily
Red-light therapy
and
Intralesional Kenalog
He will return in approximately six weeks for another ILK session.
If his alopecia areata remains inadequately controlled, options such as squaric acid, PRP, or systemic JAK inhibitor therapy may be reconsidered.
When Should You See a Dermatologist for Patchy Hair Loss?
Consider a dermatologic evaluation if:
You suddenly develop smooth bald patches
Bald spots are appearing in your beard as well as your scalp
Existing patches are becoming larger
New patches continue appearing
Hair grows back and repeatedly falls out again
Steroid injections are helping but significant disease remains
Alopecia areata affects a substantial portion of your scalp
You want to discuss JAK inhibitors or other treatments
Not every case of patchy hair loss is alopecia areata, so establishing the correct diagnosis is important.
Alopecia Areata Improving but Still Affecting 30% of the Scalp? Treatment May Need More Than Steroid Injections
For this 42-year-old man, intralesional Kenalog had already produced improvement.
However, he continued to have multiple non-scarring patches involving approximately 30% of his scalp as well as facial and beard areas.
During this visit, 16 lesions were treated with his second round of ILK, using Kenalog 2.5 mg/cc with a total volume of 3 cc.
After discussing multiple treatment strategies, he also elected to begin:
Compounded topical tofacitinib 2% twice daily
Oral minoxidil 2.5 mg daily
Red-light therapy
He will return in approximately six weeks for additional ILK treatment. If his response remains inadequate, squaric acid, PRP, or systemic JAK inhibitor therapy may be considered.
His case illustrates an important point:
Improvement does not always mean alopecia areata is fully controlled. When patchy hair loss remains extensive or repeatedly returns, combining localized treatment with a broader management strategy may be appropriate.
At Village Dermatology in Houston and Katy, Texas, we evaluate patchy scalp and beard hair loss and develop individualized treatment plans for alopecia areata based on disease extent, previous response, medical history, and patient preferences.
If bald patches continue to appear despite treatment—or steroid injections are helping but significant hair loss remains—a dermatologic hair-loss evaluation can help determine what treatment options may be appropriate next.
