Alopecia areata.

Alopecia areata (AA) is characterized by hair loss on the scalp and body, significantly impacting patients' quality of life based on its severity. This study aims to identify crucial factors influencing the perception of severe AA from the patients' viewpoint. A web-based survey was conducted among AA patients attending dermatology departments at 21 university hospitals in Korea. The survey comprised 17 criteria, exploring both clinical characteristics of AA patients and subjective determinants of disease severity. A total of 791 AA patients and their caregivers participated in the survey. Approximately 30% of respondents developed AA during childhood, with 43.5% experiencing chronic courses lasting over 3 years. Half of the participants exhibited more than 20% scalp hair loss, and 42% reported additional hair loss on other body parts, such as eyelashes and nose hair. Most respondents agreed that patients with ≥20% scalp hair loss should be categorized as having severe AA. They also identified longer disease duration, involvement of non-scalp body hair, treatment refractoriness, and social or mental impairment requiring medical intervention as factors indicating increased disease severity. This survey underscores the significant impact of AA on patients' quality of life and highlights existing unmet needs in current treatment modalities.

Alopecia areata (AA) is a chronic autoimmune disorder characterized by non-scarring hair loss, which may extend to total scalp (AA totalis) or whole-body hair loss (AA universalis). Nail involvement, though often underestimated, occurs in up to 66% of cases, especially in severe forms and in children. This retrospective study evaluated the efficacy of baricitinib 4 mg/day, a Janus kinase 1/2 inhibitor, in treating nail manifestations associated with severe AA. Thirty-seven patients with very severe AA (Severity of Alopecia Tool [SALT] score > 50) and nail involvement were treated with baricitinib for 48 weeks. Nail changes assessed included trachyonichia, pitting, leukonychia, and others. Clinical assessments were performed at baseline and at 12, 24, 36, and 48weeks using the SALT score, onychoscopy, and the Clinician Reported Outcome (ClinRO) for nail appearance. A significant improvement in both hair regrowth and nail abnormalities has been shown. The mean SALT score decreased from 100 to 16.3, and the average number of affected nails reduced from 6.4 to 2.1 (p < 0.001). ClinRO scores also significantly improved (p < 0.001). However, the correlation between hair and nail improvement was weak and not statistically significant (r = 0.15, p = 0.6). This suggests differential responsiveness of hair and nail units. The findings support baricitinib as a promising treatment for nail involvement in AA, highlighting the need for routine nail assessment and development of more refined evaluation tools. Limitations include small sample size and lack of long-term data.

Alopecia areata (AA) can negatively affect quality of life (QoL) and is associated with increased prevalence of anxiety and depression (vs people without AA). This study compared physician-assessed and patient self-rated severity of AA in a European sample and described the patient-reported burden of AA stratified by physician-assessed severity. Real-world data were collected from the Adelphi Real World AA Disease Specific Programme™, a retrospective point-in-time cross-sectional survey of dermatologists and their adult patients with AA in five European countries (France, Germany, Italy, Spain, UK). Physicians provided clinical data and an AA severity assessment, according to their own definition of 'mild', 'moderate' and 'severe'. Patients were invited to provide their perception of AA severity and completed patient-reported outcome (PRO) questionnaires, including Skindex-16 for AA (Skindex-16 AA), EuroQol-5-dimension questionnaire 5-level (EQ-5D-5L), Hospital Anxiety and Depression Scale and the Work Productivity and Activity Impairment Questionnaire. Data for 2083 patients were collected by 239 physicians; 561 of these patients completed PRO questionnaires. In 78.5% of cases with available data (N = 549), there was alignment between patient and physician-rated AA severity (severity was rated higher by physicians in 15.7% of cases, by patients in 5.8% of cases). Data from all PRO instruments showed an increase in patient-reported burden and work and activity impairment with increasing physician-rated AA severity. For the Skindex-16 AA, the Emotions scale had the worst scores; anxiety/depression was the EQ-5D-5L dimension with the highest percentages of patients reporting any perceived problem. These data highlight the significant impact that AA can have beyond hair loss, especially for patients with severe AA. There was substantial physician-patient alignment on severity assessment. Higher physician-rated AA severity was associated with higher levels of patient-reported disease burden, including anxiety and depression, and work and activity impairment. These data may help inform appropriate treatment strategies.

Lay Summary Alopecia areata (AA) is a long-term condition that can occur in both children and adults. AA can appear as patches of baldness on the scalp. Sometimes, nail growth is also affected. Hair on other parts of the body may also fall out, such as the beard, eyebrows and eyelashes. Alopecia totalis is the name for total loss of scalp hair. Alopecia universalis is complete loss of scalp, facial and body hair. This is the second version of the guideline. The British Association of Dermatologists gathered a group of experts in managing people of all ages with AA. The group consisted of eight consultant dermatologists, one dermatology specialist registrar, one general practitioner, one psychologist, two people with AA and a team with expertise in preparing guidelines. This group of experts reviewed relevant studies published until 11 July 2025. Using the evidence, the group produced recommendations using rigorous standards for guideline development. The guideline development group produced 56 recommendations for management of people with AA. They also made 9 recommendations for future research and suggested 11 audit points for hospitals. Based on the guideline, a patient information leaflet is also available on the British Association of Dermatologists’ website (https://www.skinhealthinfo.org.uk/condition/alopecia-areata).

Alopecia areata after CoronaVac vaccination.

BackgroundTherapeutic management of hair loss is frequently complicated by a lack of high‐quality evidence and reliant on the use of unlicensed therapies. Treatment decision‐making is predominantly based on expert opinion, local availability, personal experience, and cost, which make informed choices challenging for clinicians and patients in this area.ObjectivesThe aims were to determine prescribing patterns amongst UK Dermatologists with a special interest in hair disorders, when treating mild‐moderate alopecia areata (AA), severe AA (including alopecia totalis/alopecia universalis), female pattern hair loss (FPHL) and frontal fibrosing alopecia (FFA).MethodsConsultant members of the British Hair and Nail society, a special interest group affiliated to the British Association of Dermatologists, were invited to participate from across the United Kingdom. Participants were questioned on their current prescribing patterns in both NHS and private practice, were asked to rank their first‐to‐fifth line treatments for each condition and highlight the treatment they perceive as most effective for each disorder.ResultsTwenty‐six Consultant Dermatologists completed the questionnaire, from twenty‐three institutions. For treatment of mild‐moderate AA, topical corticosteroids were used first line amongst 65% (n = 17) of respondents, and 82% (n = 23) reported that intralesional corticosteroids were the most effective treatment. For severe AA, oral corticosteroids were used first line amongst 38% (n = 10) of respondents, and 25% (n = 8) reported that oral corticosteroids were the most effective treatment. For FPHL, topical minoxidil was used first line amongst 84% (n = 25) of respondents, and 42% (n = 10) reported that oral minoxidil was the most effective treatment. For FFA, topical corticosteroids were used first line amongst 62% (n = 16) of respondents, and 37% (n = 14) reported that hydroxychloroquine was the most effective treatment.ConclusionsThis study reports real‐world prescribing practices amongst dermatologists treating common hair loss conditions. These results aim to support clinicians with decision making for managing hair loss conditions.

Introduction: Alopecia areata (AA) is a chronic, autoimmune condition affecting hair follicles, and its occurrence in the paediatric population is associated with poorer prognosis and limited treatment options compared to adults. Treatment with oral methotrexate (MTX) has been documented in adults, but there is a paucity of data for its use in the paediatric population. We aimed to study the efficacy and tolerability of MTX in severe paediatric AA. Methods: We performed a retrospective review on paediatric patients with severe AA who were treated with MTX in our centre from January 2019 to December 2020. Results: Thirteen patients were included (6 boys and 7 girls) aged between 4 and 16 years at the initiation of MTX (mean age of 8.8 years). The interval from diagnosis of AA to commencement of MTX was between 8 months and 9 years (mean duration of 3.3 years). Oral MTX was administered once weekly with a mean maximal dose of 0.4 mg/kg/dose. Out of 12 assessable patients, 5 were considered treatment success as they had more than 50% regrowth, while the other 7 were treatment failures. No serious side effects were reported. Conclusion: MTX was shown to have variable efficacy for the treatment of paediatric AA with overall good tolerability. MTX can be considered in the treatment of severe refractory AA for children.

Alopecia areata is a non-scarring alopecia that can present as patches of hair loss (areata, AA), complete scalphair loss (totalis, AT) or complete scalp and body hair loss (universalis, AU). It is an autoimmune disease mediated via CD8+ T-cell activation and NKG28 signaling targeting the hair bulb. Previous reports indicate that systemic treatment with methotrexate (MTX) benefits patients with AT or AU when used alone or with systemic corticosteroid administration. This study evaluates the utilization of MTX as a treatment modality in patients with alopecia areata who have greater than 50% hair loss.

Alopecia areata (AA) is an autoimmune disease that has a complex underlying immunopathogenesis characterized by nonscarring hair loss ranging from small bald patches to complete loss of scalp, face, and/or body hair. Although the etiopathogenesis of AA has not yet been fully characterized, immune privilege collapse at the hair follicle (HF) followed by T-cell receptor recognition of exposed HF autoantigens by autoreactive cytotoxic CD8+ T cells is now understood to play a central role. Few treatment options are available, with the Janus kinase (JAK) 1/2 inhibitor baricitinib (2022) and the selective JAK3/tyrosine kinase expressed in hepatocellular carcinoma (TEC) inhibitor ritlecitinib (2023) being the only US Food and Drug Administration-approved systemic medications thus far for severe AA. Several other treatments are used off-label with limited efficacy and/or suboptimal safety and tolerability. With an increased understanding of the T-cell-mediated autoimmune and inflammatory pathogenesis of AA, additional therapeutic pathways beyond JAK inhibition are currently under investigation for the development of AA therapies. This narrative review presents a detailed overview about the role of T cells and T-cell-signaling pathways in the pathogenesis of AA, with a focus on those pathways targeted by drugs in clinical development for the treatment of AA. A detailed summary of new drugs targeting these pathways with expert commentary on future directions for AA drug development and the importance of targeting multiple T-cell-signaling pathways is also provided in this review.

ABSTRACTOver 5000 patients are newly diagnosed with Alopecia areata (AA) in Australia each year. AA severity varies from a single small patch to complete loss of scalp hair, body hair including eyelashes and eyebrows. Approximately 40% of affected individuals experience only a single patch and achieve spontaneous, complete and durable remission within 6 months (acute AA). A further 27% develop additional patches but still attain complete remission within 12 months (chronic AA). Chronic persistent AA (CPAA) is defined by an episode duration of > 12 months and occurs in approximately 33% of patients. Without systemic treatment, 55% of individuals with CPAA will have persistent multifocal relapsing and remitting disease, 30% will progress to alopecia totalis (AT) and 15% will ultimately develop alopecia universalis (AU). The physical disfigurement, unpredictable course, social isolation and rejection contribute to the psychological distress attributable to AA. A wide range of topical, intralesional and systemic agents used to treat AA were evaluated in the 2018 Australian expert consensus statement. In 2020, the international Alopecia Areata Consensus of Experts (ACE) publication stated that if reimbursed, Janus Kinase inhibitors (JAKi's) would be an ideal systemic treatment for adults with AA. TGA approval of baricitinib in 2023 and ritlecitinib in 2024 for severe AA is the first step on the pathway for these systemic medications to be reimbursed on the Australian Government Pharmaceutical Benefits Scheme (PBS). Reimbursement would significantly transform the Australian therapeutic landscape for AA. The purpose of this 2025 Update on the Australian Expert Consensus Statement on the treatment of chronic, moderate to severe AA is to augment the 2018 treatment algorithm to include these TGA‐approved medications and to address indications for initiation, continuation and dose titration of systemic JAKi treatment, appropriate choice of agent, satisfactory outcome measures and to provide guidance on when to discontinue successful or unsuccessful treatment.

Current patient-reported burden measures, which guide decision-making, may not be sensitive to pertinent impacts of alopecia areata (AA). The UK public previously valued patient/caregiver vignettes using the time trade-off (TTO) method in interviews; however, the public may not fully understand the impact of AA. Therefore, this study aimed to evaluate the content validity of the vignettes using TTO interviews with patients with AA and to compare patient-derived utilities for each health state with the utilities derived from the UK public. To understand their perspective surrounding trade-offs between quantity and quality of life, and to confirm the UK public's utility values, adult participants in the UK with AA currently experiencing scalp hair loss or with no scalp hair loss but experiencing hair loss in the last 12 months were recruited. In total, five AA vignettes that described health states by hair loss and its impacts and one caregiver vignette describing caring for an adolescent patient (aged 12-17 years) with AA were presented to participants in interviewer-guided sessions. Participants imagined themselves in the health state or as a caregiver, then valued each state using a visual analog scale (VAS) and traded time from 10 years in full health in 6-month increments to avoid living in each health state to evaluate the TTO utilities (0 [dead] to 1 [full health]). Among participants (N = 50), mean VAS scores (Severity of Alopecia Tool [SALT] 0-10: 74.3; SALT 11-20: 59.0; SALT 21-49: 39.4; SALT 50-100: 29.6; SALT 50-100 [no eyebrows/eyelashes]: 26.0; and caregiver [adolescent SALT 50-100]: 58.6) and TTO utility values (SALT 0-10: 0.93; SALT 11-20: 0.87; SALT 21-49: 0.67; SALT 50-100: 0.54; SALT 50-100 [no eyebrows/eyelashes]: 0.45; and caregiver [adolescent SALT 50-100]: 0.81) were lower for states with greater hair loss, similar to the mean UK public utility values. Over a 10-year time horizon, the average patient with AA was willing to trade approximately 5 years of life (mean TTO utility, 0.537 [standard deviation, 0.448]) to avoid impacts associated with 50-100% scalp hair loss. This is the first known study to evaluate how patients with AA would make trade-offs between quantity of life and disease-specific quality of life. A high willingness to trade off duration of life was observed, consistent with the UK public study and supporting a high disease burden of AA.

Introduction. Following the initial BRAVE-AA1 clinical trial, a study addendum was added in which Black patients with severe alopecia areata (AA) were entered into open label treatment with baricitinib 4 mg for 52 weeks. Photographs were taken at screening to confirm eligibility and were reviewed by a central expert reviewer. These photographs provide an opportunity to examine diagnostic challenges in AA, in Black patients, especially women. Methods. In the BRAVE-AA1 addendum 5 study, photographs of five planes of the scalp (left, right, posterior, frontal, and top of head) were obtained at screening and post-baseline. Camera equipment and a study-specific photography manual was provided to all sites, personnel were trained to conduct photography under similar lighting conditions and magnifications. Images were taken with polarization and cross-polarization lenses and reviewed for compliance with standardization procedures. At screening, all images were reviewed centrally by the external reviewer to determine consistency with AA. For this disclosure, images of both AA and non-AA cases were selected by the authors to illustrate key signs that can aid in differentiating AA, from the other alopecias that were observed in the screened patient population. Results. Of the 36 patients with photographs reviewed by the central expert reviewer, 12 (33%) were diagnosed with CCCA or other scarring alopecia; 11 of these patients were female. Based on photography review, presentations involving the vertex, midscalp and parietal scalp, with sparing of the occipital scalp was suggestive of CCCA. The presence of scalp hypopigmentation and hyperpigmentation reflected the inflammatory processes and scarring associated with CCCA. The presence of “fringe sign” suggested traction alopecia; while AA was characterized by the presence of asymmetrically distributed, circular smooth bald patches. The photographic images portrayed the complexities of hair loss patterns that can occur within a single patient, and some patients had co-occurrence of more than one pattern of alopecia. Scalp biopsies were not performed which is limitation of these data. Conclusions. Misdiagnosis of AA can occur in some patient populations with other forms of hair loss that mimic the disease. More than one type of hair loss can co-occur in a single patient, thereby limiting the maximal potential improvement a patient may experience with treatment. While photographic evidence alone may not conclusively determine the diagnosis, the present disclosure provides visual examples of helpful signs that can assist dermatologists to diagnose and to support an appropriately tailored treatment plan.

SALT II: A new take on the Severity of Alopecia Tool (SALT) for determining percentage scalp hair loss

Introduction Alopecia areata (AA) is an inflammatory and autoimmune form of hair loss, which can present with one patch of hair loss, but in more extreme cases can lead to total body hair loss. There are limited therapeutic options and no cure, but medication can sometimes induce sustained remission. Disease control cannot be guaranteed; even those who regrow all hair on treatment can experience relapse. There are no FDA approved systemic treatments; therefore, an unmet need for safe, and effective treatments exists. Few treatments have been evaluated by randomized controlled trials. Case reports and series indicate oral Janus Kinase (JAK) inhibitors as a potential therapy. Ritlecitinib is a novel oral JAK3-selective inhibitor being investigated as an AA treatment. Areas covered This article introduces ritlecitinib as treatment for AA and considers the mechanism of action, pharmacodynamics, pharmacokinetics, clinical efficacy, and safety [reporting data from a 24-week, phase 2a double-blinded placebo-controlled trial of ritlecitinib in patients with AA who have more than 50% scalp hair loss]. Expert opinion Ritlecitinib offers a novel mode of action, rapid onset, and the capacity for a superior safety profile over other JAK inhibitors. If approved, ritlecitinib will be widely prescribed by physicians overseeing the more severe AA patients for the foreseeable future. As JAK inhibitors regulate the hair growth cycle and have anti-inflammatory effects, the implementation of ritlecitinib in hair loss disorders other than AA, may prove beneficial.

Baricitinib is an oral selective Janus kinase 1/2 inhibitor that has achieved clinically meaningful outcomes for scalp, eyebrow, and eyelash hair regrowth in patients with severe alopecia areata (AA) at week 36 of treatment. Treatment with baricitinib, 4 mg, has resulted in higher response rates than baricitinib, 2 mg, at weeks 36 and 52. To determine the efficacy of uptitration to baricitinib, 4 mg, for 24 weeks in patients who had previously not responded to baricitinib, 2 mg (Severity of Alopecia Tool [SALT] score of >20). BRAVE-AA1 and BRAVE-AA2 are multicenter, placebo-controlled, phase 3 randomized clinical trials that were initiated on September 24, 2018, and July 8, 2019, respectively, with follow-up to 200 weeks (data cutoffs of November 11, 2021, and November 5, 2021, respectively). This pooled analysis reports long-term extension data up to week 76. At baseline, 1200 adult patients with severe AA (SALT score ≥50) were randomly assigned in a 3:2:2 ratio to receive baricitinib, 4 mg; baricitinib, 2 mg; or placebo. Patients treated with baricitinib remained on the same treatment dose until week 52. Patients were considered nonresponders to baricitinib, 2 mg, if they had a SALT score greater than 20 after 52 weeks of therapy. The proportions of patients achieving a SALT score of 20 or lower and clinician-reported outcome for eyebrow hair loss and eyelash hair loss scores of 0 or 1 (full coverage or minimal gaps) with 2-point or higher improvements from baseline (among those with baseline scores ≥2 [significant gaps to no notable hair]) were analyzed through week 76. At week 52, of the 340 patients (mean [SD] age, 38.4 [12.9] years; 212 [62.4%] female) treated with baricitinib, 2 mg, 212 (62.4%) had a SALT score higher than 20 and were uptitrated to baricitinib, 4 mg. Two-thirds of these patients (142 of 212 [67.0%]) had a baseline SALT score of 95 to 100, indicating very severe AA. At week 76, 55 of the 212 patients (25.9%) had achieved a SALT score of 20 or lower. During the same period, response rates for clinician-reported outcome scores of 0 or 1 increased from 19.3% (31 of 161 patients) to 37.9% (61 of 161 patients) for eyebrows and from 24.1% (33 of 137 patients) to 40.9% (56 of 137 patients) for eyelashes. In this pooled analysis of the BRAVE-AA1 and BRAVE-AA2 trials, uptitration of baricitinib, 2 mg, to baricitinib, 4 mg, in those who did not respond to the 2-mg dose resulted in meaningful improvement of response rates over the subsequent 24 weeks for scalp, eyebrow, and eyelash hair loss. ClinicalTrials.gov Identifiers: NCT03570749 and NCT03899259.