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Alopecia areata — Clinical Guidelines

Overview

Alopecia areata is a non-scarring autoimmune disorder characterized by the sudden appearance of round or oval patches of hair loss on the scalp and other body areas. It affects individuals of all ages and can significantly impact quality of life 4 22.

Diagnosis

Clinical Presentation: Round or oval patches of hair loss, often with normal skin 19.

Differential Diagnosis: Includes other forms of nonscarring alopecia, such as telogen effluvium and androgenetic alopecia 19.

Laboratory Tests: Not routinely required but may include nail assessment for pitting or dystrophic changes, and sometimes autoantibody screening 11.

Histopathology: Characterized by perifollicular lymphocytic infiltration around anagen hair bulbs 19.

Management

First-Line Treatments:

- Intralesional Corticosteroids: Commonly used, typically triamcinolone acetonide at doses of 4-6 mg/mL 1 18. - Topical Corticosteroids: For localized disease 3.

Adjunctive Treatments:

- Janus Kinase (JAK) Inhibitors: Tofacitinib, baricitinib, ritlecitinib, and upadacitinib show promise but require monitoring for adverse effects like infections and gastrointestinal issues 1 5 6. - Contact Immunotherapy: Diphencyprone (DPCP) for recalcitrant cases 18. - Platelet-Rich Plasma (PRP): Emerging nonsteroid-based procedural therapy 16.

Other Therapies:

- Dupilumab: Monoclonal antibody targeting IL-4 receptor, showing potential in clinical trials 8. - Systemic Corticosteroids: Short-term use for severe cases, with caution due to potential side effects 17.

Special Populations

Pediatrics: Methotrexate can be considered with careful monitoring of efficacy and safety 12.

Comorbidities: Caution with lithium therapy as it may trigger alopecia areata 24.

Key Recommendations

Use Intralesional Corticosteroids for Mild to Moderate Cases: Effective first-line treatment with well-established efficacy (Evidence: Strong 1 18).

Consider JAK Inhibitors for Severe Alopecia Areata: Beneficial but monitor for adverse events (Evidence: Moderate 1 5 6).

Evaluate and Manage Quality of Life: Utilize instruments like DLQI to assess impact on patients (Evidence: Moderate 10).

Consult Expert Guidelines for Treatment Selection: Tailor treatment based on severity and patient-specific factors (Evidence: Expert opinion 2 3).

References

1 Zhan J, Lei Z, Xu Y, Cen J, Tang X, Wan M. Post-marketing safety signals of four JAK inhibitors for alopecia areata: an indication-restricted FAERS pharmacovigilance study. The Journal of dermatological treatment 2026. link 2 Ohyama M, Ito T, Amoh Y, Inui S, Imanishi H, Ueki R et al.. Japanese Dermatological Association's Clinical Practice Guidelines for Alopecia Areata 2024: A Complete English Translated Version. The Journal of dermatology 2025. link 3 Müller Ramos P, Anzai A, Duque-Estrada B, Melo DF, Sternberg F, Santos LDN et al.. II Consensus of the Brazilian Society of Dermatology for the treatment of alopecia areata. Anais brasileiros de dermatologia 2025. link 4 . What is alopecia areata?. Pediatric dermatology 2025. link 5 Huang Y, Ke C, Chen M. Safety Assessment of Ritlecitinib Based on the FDA Adverse Event Reporting System (FAERS) Database: A Real-World Pharmacovigilance Study. The Journal of dermatology 2025. link 6 Kong L, Liu X, Feng Y. Comparative safety profiles of baricitinib and tofacitinib in the treatment of adult alopecia areata: a pharmacovigilance study based on the FAERS database. Frontiers in public health 2025. link 7 Asfour L, De Brito M, Al-Janabi A, Haw WWY, Johnson A, Flohr C et al.. Global Guidelines in Dermatology Mapping Project (GUIDEMAP): a systematic review of alopecia areata clinical practice guidelines. Clinical and experimental dermatology 2023. link 8 Guttman-Yassky E, Renert-Yuval Y, Bares J, Chima M, Hawkes JE, Gilleaudeau P et al.. Phase 2a randomized clinical trial of dupilumab (anti-IL-4Rα) for alopecia areata patients. Allergy 2022. link 9 Abdelkader HA, Amin I, Rashed LA, Samir M, Ezzat M. Histone deacetylase 1 in patients with alopecia areata and acne vulgaris: An epigenetic alteration. The Australasian journal of dermatology 2022. link 10 Chernyshov PV, Tomas-Aragones L, Finlay AY, Manolache L, Marron SE, Sampogna F et al.. Quality of life measurement in alopecia areata. Position statement of the European Academy of Dermatology and Venereology Task Force on Quality of Life and Patient Oriented Outcomes. Journal of the European Academy of Dermatology and Venereology : JEADV 2021. link 11 Meah N, Wall D, York K, Bhoyrul B, Bokhari L, Asz-Sigall D et al.. The Alopecia Areata Consensus of Experts (ACE) study part II: Results of an international expert opinion on diagnosis and laboratory evaluation for alopecia areata. Journal of the American Academy of Dermatology 2021. link 12 Phan K, Lee G, Fischer G. Methotrexate in the treatment of paediatric alopecia areata: Retrospective case series and updated meta-analysis. The Australasian journal of dermatology 2020. link 13 Broadley D, McElwee KJ. A "hair-raising" history of alopecia areata. Experimental dermatology 2020. link 14 Ramos PM, Anzai A, Duque-Estrada B, Melo DF, Sternberg F, Santos LDN et al.. Consensus on the treatment of alopecia areata - Brazilian Society of Dermatology. Anais brasileiros de dermatologia 2020. link 15 Gupta M, Lotti T, Goldust M. Alopecia areata and isotretinoin; coincidence or causal relation. Dermatologic therapy 2020. link 16 Marchitto MC, Qureshi A, Marks D, Awosika O, Rengifo-Pardo M, Ehrlich A. Emerging Nonsteroid-Based Procedural Therapies for Alopecia Areata: A Systematic Review. Dermatologic surgery : official publication for American Society for Dermatologic Surgery [et al.] 2019. link 17 Jahn-Bassler K, Bauer WM, Karlhofer F, Vossen MG, Stingl G. Kombinierte Hoch-/Niedrig-Dosis-Therapie mit systemischen Glukokor-tikoiden bei schweren Verlaufsformen der Alopecia areata im Kindesalter. Journal der Deutschen Dermatologischen Gesellschaft = Journal of the German Society of Dermatology : JDDG 2017. link 18 Lamb RC, Young D, Holmes S. Retrospective review of diphencyprone in the treatment of alopecia areata. Clinical and experimental dermatology 2016. link 19 Estefan J, Ribeiro M, Abad E, Saintive S, Ramos-e-Silva M. Alopecia areata--Part II: diagnosis and pathology. Skinmed 2015. link 20 Farhangian ME, McMichael AJ, Huang KE, Feldman SR. Treatment of Alopecia Areata in the United States: A Retrospective Cross-Sectional Study. Journal of drugs in dermatology : JDD 2015. link 21 Price VH. Therapy of alopecia areata: on the cusp and in the future. The journal of investigative dermatology. Symposium proceedings 2003. link 22 Sahn EE. Alopecia areata in childhood. Seminars in dermatology 1995. link80033-1) 23 Zlotogorski A, Weinrauch L, Brautbar C. Familial alopecia areata: no linkage with HLA. Tissue antigens 1990. link 24 Silvestri A, Santonastaso P, Paggiarin D. Alopecia areata during lithium therapy. A case report. General hospital psychiatry 1988. link90083-7) 25 Romoli M, Cudia G. Alopecia areata and homolateral headache due to an impacted superior wisdom tooth. International journal of oral and maxillofacial surgery 1987. link80088-7) 26 De Weert J, Temmerman L, Kint A. Alopecia areata: a clinical study. Dermatologica 1984. link 27 Wilkin JK. Trichotillomania associated with alopecia areata. Cutis 1983. link

Alopecia areata