Alopecia Areata

Document distribution, extent, activity, eyebrow/eyelash and body-hair involvement, nail findings, and scalp symptoms. Alopecia areata is a nonscarring autoimmune alopecia; preservation of follicular openings supports this branch, whereas inflammatory follicular lesions, scale, or a clinically unexpected course should prompt reconsideration of infection, lupus erythematosus, lichen planopilaris, or another cicatricial alopecia. Nature+1Nature‌Global burden of alopecia areata from 1990 to 2019 and emerging treatment trends analyzed through GBD 2019 and bibliometric data | Scientific ReportsOxford AcademicDual improvement of alopecia areata and immune thrombocytopenia with baricitinib: a case report | Skin Health and Disease | Oxford Academic

Perform trichoscopy at the alopecic patch and active edge when the clinical diagnosis is uncertain. Yellow dots are characteristic of alopecia areata. Trichoscopy can also direct biopsy selection when lesions are follicular, atypical, or fail expected treatment, although overlapping dermoscopic findings prevent reliance on a single sign to exclude other scalp disorders. JAMA+1JAMAReflectance Confocal Microscopy of the Yellow Dot Pattern in ...NatureClinical and trichoscopic features in 18 cases of Folliculotropic Mycosis Fungoides with scalp involvement | Scientific Reports

Biopsy an active, representative lesion when scarring alopecia, cutaneous lupus, lichen planopilaris, folliculotropic mycosis fungoides, or another mimic remains plausible after examination and trichoscopy. Dermoscopy-guided biopsy is particularly useful for follicular lesions behaving unexpectedly or not responding to treatment. Nature+1NatureClinical and trichoscopic features in 18 cases of Folliculotropic Mycosis Fungoides with scalp involvement | Scientific ReportsWHO[PDF] Dermoscopy in selected disorders of scarring alopecia

Calculate and record the Severity of Alopecia Tool score at baseline; SALT has been validated for alopecia areata trials and routine practice. Use serial SALT measurements rather than an unstructured impression of density to determine whether localized therapy is adequate or whether severe disease warrants systemic discussion. ScienceDirectScienceDirectObjective outcome measures: Collecting meaningful data on alopecia areata - ScienceDirect

Classify complete scalp hair loss clinically as alopecia totalis and complete scalp and body hair loss as alopecia universalis. These phenotypes begin with SALT 100 and are represented among patients treated with ritlecitinib in long-term studies; severe baseline burden should prompt early discussion of systemic options rather than prolonged cycles of painful focal injections. WileyWileySALT score distribution with ritlecitinib treatment up to 24 months in alopecia areata - Reguiai - Journal of the European Academy of Dermatology and Venereology - Wiley Online Library

Ask directly about functional and psychosocial impact, including anxiety, depression symptoms, concealment burden, and occupational or social impairment. Alopecia areata is associated with lower quality of life and psychiatric comorbidity, and structured assessment can change the urgency of treatment escalation and behavioral-health referral. Nature+2Nature‌Global burden of alopecia areata from 1990 to 2019 and emerging treatment trends analyzed through GBD 2019 and bibliometric data | Scientific ReportsScienceDirectLifetime prevalence of psychiatric disorders in patients with alopecia areata - ScienceDirectPubMedAlopecia Areata: Pathogenesis, Diagnosis, and Therapies

Order testing when it is triggered by a plausible mimic, symptoms or signs of an associated autoimmune disease, or intended systemic treatment. Expert consensus addresses laboratory evaluation in alopecia areata, but real-world testing remains variable and often extends to thyroid disease, coeliac disease, pernicious anemia, iron, zinc, and vitamin D assessment. Wiley+1WileyCOLLAB: A Global Survey of Clinical and Laboratory Assessment in Alopecia Areata by Hair Specialists - O'Connor - 2025 - JEADV Clinical Practice - Wiley Online LibraryScienceDirectThe Alopecia Areata Consensus of Experts (ACE) study part II: Results of an international expert opinion on diagnosis and laboratory evaluation for alopecia areata - ScienceDirect

When secondary syphilis, tinea capitis, or lupus is clinically plausible, direct testing toward that alternative diagnosis rather than labeling the patient with alopecia areata on morphology alone. A positive mimic workup changes treatment selection and may preclude or defer immunosuppressive therapy. WileyWileyCOLLAB: A Global Survey of Clinical and Laboratory Assessment in Alopecia Areata by Hair Specialists - O'Connor - 2025 - JEADV Clinical Practice - Wiley Online Library

Before prescribing a systemic JAK inhibitor, obtain the baseline and ongoing safety evaluation required for that drug and follow current U.S. product labeling. The literature identifies screening and monitoring for contraindications and adverse effects of JAK inhibitors as a distinct indication for laboratory testing in alopecia areata. WileyWileyCOLLAB: A Global Survey of Clinical and Laboratory Assessment in Alopecia Areata by Hair Specialists - O'Connor - 2025 - JEADV Clinical Practice - Wiley Online Library

For active patchy alopecia areata, intralesional triamcinolone acetonide is regarded as first-line treatment. Use concentrations of 2.5-10 mg/mL, limit total dose to 10-20 mg per session, and repeat at 2-6-week intervals. The cited consensus identifies 10 mg/mL on the scalp as producing an optimal response with acceptable adverse reactions, but concentration and cumulative exposure should be individualized to site and atrophy risk. Wolters KluwerWolters KluwerTaiwanese Dermatological Association consensus on... : Dermatologica Sinica

Assess for regrowth and local toxicity at each visit. Pain, bleeding, headache, systemic absorption, dyschromia, and reversible local cutaneous atrophy are recognized adverse effects; repeated injections may also produce transient rather than durable responses. JAMA+1JAMAAlefacept for Alopecia AreataWolters KluwerTaiwanese Dermatological Association consensus on... : Dermatologica Sinica

Stop a nonresponsive injection strategy after 6 months and reassess the diagnosis, disease extent, treatment feasibility, and systemic options. This threshold also prevents indefinite exposure to injection pain and local atrophy in a patient who is unlikely to benefit from continued focal treatment. Wolters KluwerWolters KluwerTaiwanese Dermatological Association consensus on... : Dermatologica Sinica

For adults with severe alopecia areata, baricitinib is FDA approved. In the BRAVE-AA1 and BRAVE-AA2 phase 3 trials, SALT scores of 20 or less at week 52 occurred in 40.9% and 21.2% of patients receiving 4 mg and 2 mg, respectively, in BRAVE-AA1 and in 36.8% and 24.4%, respectively, in BRAVE-AA2. These results support expectation-setting: meaningful scalp regrowth occurs in a subset, not all treated patients. Nature+1Nature‌Global burden of alopecia areata from 1990 to 2019 and emerging treatment trends analyzed through GBD 2019 and bibliometric data | Scientific ReportsOxford AcademicDual improvement of alopecia areata and immune thrombocytopenia with baricitinib: a case report | Skin Health and Disease | Oxford Academic

For severe alopecia areata in patients aged 12 years or older, ritlecitinib is an FDA-approved option. In ALLEGRO, 23% receiving ritlecitinib 50 mg achieved SALT 20 or less at week 24 versus 1.5% with placebo; continued daily 50-mg treatment was associated with progressive improvement in SALT distribution through 24 months. Nature+2Nature‌Global burden of alopecia areata from 1990 to 2019 and emerging treatment trends analyzed through GBD 2019 and bibliometric data | Scientific ReportsWileySALT score distribution with ritlecitinib treatment up to 24 months in alopecia areata - Reguiai - Journal of the European Academy of Dermatology and Venereology - Wiley Online LibraryWolters KluwerTaiwanese Dermatological Association consensus on... : Dermatologica Sinica

Use current U.S. prescribing information for agent-specific contraindications, pretreatment screening, dose modification, and adverse-effect monitoring. Do not substitute off-label JAK inhibitors or conventional systemic immunosuppressants for an approved agent without documenting the rationale, because evidence quality and optimal dosing for agents such as methotrexate and sulfasalazine remain limited. Wiley+1WileyCOLLAB: A Global Survey of Clinical and Laboratory Assessment in Alopecia Areata by Hair Specialists - O'Connor - 2025 - JEADV Clinical Practice - Wiley Online LibraryWolters KluwerReal-world evidence in alopecia areata treatment:... : Dermatologica Sinica

At each follow-up, repeat SALT scoring, compare standardized photographs, inspect for active new patches and regrowth, and document local adverse effects when injections are used. For systemic therapy, incorporate the treatment-specific safety monitoring required by current labeling alongside clinical response assessment. Wiley+2WileyCOLLAB: A Global Survey of Clinical and Laboratory Assessment in Alopecia Areata by Hair Specialists - O'Connor - 2025 - JEADV Clinical Practice - Wiley Online LibraryScienceDirectObjective outcome measures: Collecting meaningful data on alopecia areata - ScienceDirectWolters KluwerTaiwanese Dermatological Association consensus on... : Dermatologica Sinica

Escalate from local to systemic discussion when disease is extensive, totalis/universalis is present, injections are impractical, patient burden is high, or there is no improvement after 6 months of intralesional therapy. Re-biopsy rather than merely escalating immunosuppression if the morphology becomes inflammatory, follicular, scarring, or otherwise discordant with alopecia areata. Nature+1NatureClinical and trichoscopic features in 18 cases of Folliculotropic Mycosis Fungoides with scalp involvement | Scientific ReportsWolters KluwerTaiwanese Dermatological Association consensus on... : Dermatologica Sinica

Include mental-health screening and referral when distress, anxiety, depression symptoms, or impaired function is identified. Psychiatric comorbidity and reduced quality of life are documented in alopecia areata and should be managed as treatment-relevant disease burden rather than an incidental reaction to cosmetic change. Nature+2Nature‌Global burden of alopecia areata from 1990 to 2019 and emerging treatment trends analyzed through GBD 2019 and bibliometric data | Scientific ReportsScienceDirectLifetime prevalence of psychiatric disorders in patients with alopecia areata - ScienceDirectPubMedAlopecia Areata: Pathogenesis, Diagnosis, and Therapies