Alopecia areata is an autoimmune form of non-scarring hair loss. It is usually characterized by limited areas of hair loss. However, the disease may progress to complete scalp and body hair loss (alopecia totalis, alopecia universalis). In patients with alopecia areata hair loss significantly impacts the quality of life. Children and adolescents with alopecia areata often experience bullying, including physical aggression. The disease severity evaluation tools used in clinical practice are: the Severity of Alopecia Tool (SALT) score and the Alopecia Areata Scale (AAS). A SALT score equal to or greater than 20 constitutes a commonly accepted indication for systemic therapy in alopecia areata. When using the AAS, moderate to severe alopecia areata should be considered a medical indication for systemic treatment. Currently, the only two EMA-approved medications for alopecia areata are baricitinib (JAK 1/2 inhibitor) for adults and ritlecitinib (JAK 3/TEC inhibitor) for individuals aged 12 and older. Both are EMA-approved for patients with severe alopecia areata. Other systemic medications used off-label in alopecia areata include glucocorticosteroids, cyclosporine, methotrexate and azathioprine. Oral minoxidil is considered an adjuvant therapy with limited data confirming its possible efficacy. This consensus statement is to outline a systemic treatment algorithm for alopecia areata, indications for systemic treatment, available therapeutic options, their efficacy and safety, as well as the duration of the therapy.

1st Department of Dermatology Venereology Aristotle University Medical School Thessaloniki Greece

2nd Department of Dermatology and Venereology National and Kapodistrian University of Athens Medical School Attikon General University Hospital Athens Greece

Centre de Santé Sabouraud Hopital Saint Louis Paris France

CEReSS EA 3279 Research Centrer in Health Services and Quality of Life Aix Marseille University Dermatology Department Universitary Hospital Timone Assistance Publique Hôpitaux de Marseille APHM Marseille France

CUF Descobertas Hospital Lisbon Portugal

Department of Dermatology Medical University of Warsaw Warsaw Poland

Department of Dermatovenereology 3rd Faculty of Medicine Charles University and Královské Vinohrady University Hospital Prague Czech Republic

Department of Dermatovenerology Sarajevo School of Science and Technology Sarajevo Bosnia and Herzegovina

Department of Infectious Diseases and Clinical Immunology of the 5 N Karazin Kharkiv National University Kharkiv Ukraine

Department of Medical and Surgical Sciences University of Bologna Italy School of Specialization Dermatology and Venereology Department of Medical and Surgical Sciences University of Bologna Bologna Italy

Department Ramon y Cajal Hospital IRYCIS Grupo Pedro Jaén Clinic TricoHRC Research Group University of Alcala Madrid Spain

Dermatology Unit IRCCS Azienda Ospedaliero Universitaria di Bologna Bologna Italy

Universitat Internacional de Catalunya Barcelona Spain

Zobrazit více v PubMed

Rakowska A, Rudnicka L, Olszewska M, Bergler‐Czop B, Czuwara J, Brzezińska‐Wcisło L, et al. Alopecia areata. Diagnostic and therapeutic recommendations of the polish dermatological society. Part 1. Diagnosis and Severity Assessment. Dermatol Rev. 2023;110:89–100.

Muntyanu A, Gabrielli S, Donovan J, Gooderham M, Guenther L, Hanna S, et al. The burden of alopecia areata: a scoping review focusing on quality of life, mental health and work productivity. J Eur Acad Dermatol Venereol. 2023;37:1490–1520.

Lintzeri DA, Constantinou A, Hillmann K, Ghoreschi K, Vogt A, Blume‐Peytavi U. Alopecia areata – current understanding and management. J Dtsch Dermatol Ges. 2022;20:59–90.

Lyakhovitsky A, Gilboa S, Eshkol A, Barzilai A, Baum S. Late‐onset alopecia areata: a retrospective cohort study. Dermatology. 2017;233:289–294.

Waśkiel A, Rakowska A, Sikora M, Olszewska M, Rudnicka L. Trichoscopy of alopecia areata: an update. J Dermatol. 2018;45:692–700.

Alkhalifah A. Alopecia areata update. Dermatol Clin. 2013;31:93–108.

Goh C, Finkel M, Christos PJ, Sinha AA. Profile of 513 patients with alopecia areata: associations of disease subtypes with atopy, autoimmune disease and positive family history. J Eur Acad Dermatol Venereol. 2006;20:1055–1060.

Holmes S, Harries M, Macbeth AE, Chiu WS, de Lusignan S, Messenger AG, et al. Alopecia areata and risk of atopic and autoimmune conditions: population‐based cohort study. Clin Exp Dermatol. 2023;48:325–331.

Kridin K, Renert‐Yuval Y, Guttman‐Yassky E, Cohen AD. Alopecia areata is associated with atopic diathesis: results from a population‐based study of 51,561 patients. J Allergy Clin Immunol Pract. 2020;8:1323–1328.e1.

Waśkiel‐Burnat A, Kotowska M, Dorobek W, Smyk JM, Gąsecka A, Niemczyk A, et al. Patients with alopecia areata are at risk of endothelial dysfunction: results of a case–control study. Clin Exp Dermatol. 2022;47:1517–1522.

Conic RRZ, Chu S, Tamashunas NL, Damiani G, Bergfeld W. Prevalence of cardiac and metabolic diseases among patients with alopecia areata. J Eur Acad Dermatol Venereol. 2021;35:e128–e129.

Al‐Dhubaibi MS, Alsenaid A, Alhetheli G, Abd Elneam AI. Trichoscopy pattern in alopecia areata: a systematic review and meta‐analysis. Skin Res Technol. 2023;29:e13378.

Fatani MIA, Alkhalifah A, Alruwaili AFS, Alharbi AHS, Alharithy R’, Khardaly AM, et al. Diagnosis and Management of Alopecia Areata: a Saudi expert consensus statement (2023). Dermatol Ther (Heidelb). 2023;13:2129–2151.

Olsen EA, Hordinsky MK, Price VH, Roberts JL, Shapiro J, Canfield D, et al. Alopecia areata investigational assessment guidelines–part II. National Alopecia Areata Foundation. J Am Acad Dermatol. 2004;51:440–447.

King BA, Mesinkovska NA, Craiglow B, Kindred C, Ko J, McMichael A, et al. Development of the alopecia areata scale for clinical use: results of an academic‐industry collaborative effort. J Am Acad Dermatol. 2022;86:359–364.

Rakowska A, Rudnicka L, Olszewska M, Bergler‐Czop B, Czuwara J, Brzezińska‐Wcisło L, et al. Alopecia areata. Diagnostic and therapeutic recommendations of the polish Society of Dermatology. Part 2: treatment. Dermatol Rev. 2023;110:101–120.

Han JJ, Desai S, Li SJ, Lee KJ, Mita C, Joyce C, et al. Placebo group regrowth rate in alopecia areata clinical trials: a systematic review and meta‐analysis. J Am Acad Dermatol. 2022;87:389–390.

Kar BR, Handa S, Dogra S, Kumar B. Placebo‐controlled oral pulse prednisolone therapy in alopecia areata. J Am Acad Dermatol. 2005;52:287–290.

Cranwell WC, Lai VW, Photiou L, Meah N, Wall D, Rathnayake D, et al. Treatment of alopecia areata: an Australian expert consensus statement. Australas J Dermatol. 2019;60:163–170.

Vano‐Galvan S, Hermosa‐Gelbard A, Sanchez‐Neila N, Miguel‐Gómez L, Saceda‐Corralo D, Rodrigues‐Barata R, et al. Pulse corticosteroid therapy with oral dexamethasone for the treatment of adult alopecia totalis and universalis. J Am Acad Dermatol. 2016;74:1005–1007.

Nowaczyk J, Makowska K, Rakowska A, Sikora M, Rudnicka L. Cyclosporine with and without systemic corticosteroids in treatment of alopecia areata: a systematic review. Dermatol Ther (Heidelb). 2020;10:387–399.

Husein‐ElAhmed H, Steinhoff M. Efficacy and predictive factors of cyclosporine a in alopecia areata: a systematic review with meta‐analysis. J Dermatolog Treat. 2021;1‐30:1643–1651.

Berth‐Jones J, Exton LS, Ladoyanni E, Mohd Mustapa MF, Tebbs VM, Yesudian PD, et al. British Association of Dermatologists guidelines for the safe and effective prescribing of oral ciclosporin in dermatology 2018. Br J Dermatol. 2019;180:1312–1338.

Joly P, Lafon A, Houivet E, Donnadieu N, Richard MA, Dupuy A, et al. Efficacy of methotrexate alone vs methotrexate plus low‐dose prednisone in patients with alopecia areata Totalis or universalis: a 2‐step double‐blind randomized clinical trial. JAMA Dermatol. 2023;159:403–410.

Altun E, Yayli S, Arica DA, Selcuk LB, Bahadir S. Retrospective analysis of methylprednisolone treatment alone and in combination with methotrexate in patients with extensive alopecia areata. Dermatol Ther. 2022;35:e15776.

Royer M, Bodemer C, Vabres P, Pajot C, Barbarot S, Paul C, et al. Efficacy and tolerability of methotrexate in severe childhood alopecia areata. Br J Dermatol. 2011;165:407–410.

Hammerschmidt M, Mulinari Brenner F. Efficacy and safety of methotrexate in alopecia areata. An Bras Dermatol. 2014;89:729–734.

Chartaux E, Joly P. Long‐term follow‐up of the efficacy of methotrexate alone or in combination with low doses of oral corticosteroids in the treatment of alopecia areata totalis or universalis. Ann Dermatol Venereol. 2010;137:507–513.

Anuset D, Perceau G, Bernard P, Reguiai Z. Efficacy and safety of methotrexate combined with low‐ to moderate‐dose corticosteroids for severe alopecia areata. Dermatology. 2016;232:242–248.

Landis ET, Pichardo‐Geisinger RO. Methotrexate for the treatment of pediatric alopecia areata. J Dermatolog Treat. 2018;29:145–148.

Phan K, Ramachandran V, Sebaratnam DF. Methotrexate for alopecia areata: a systematic review and meta‐analysis. J Am Acad Dermatol. 2019;80:120–127.e2.

Lai VWY, Sinclair R. Utility of azathioprine, methotrexate and cyclosporine as steroid‐sparing agents in chronic alopecia areata: a retrospective study of continuation rates in 138 patients. J Eur Acad Dermatol Venereol. 2020;34:2606–2612.

King B, Ohyama M, Kwon O, Zlotogorski A, Ko J, Mesinkovska NA, et al. Two phase 3 trials of Baricitinib for alopecia areata. N Engl J Med. 2022;386:1687–1699.

King B, Guttman‐Yassky E, Peeva E, Banerjee A, Sinclair R, Pavel AB, et al. A phase 2a randomized, placebo‐controlled study to evaluate the efficacy and safety of the oral Janus kinase inhibitors ritlecitinib and brepocitinib in alopecia areata: 24‐week results. J Am Acad Dermatol. 2021;85:379–387.

King B, Zhang X, Harcha WG, Szepietowski JC, Shapiro J, Lynde C, et al. Efficacy and safety of ritlecitinib in adults and adolescents with alopecia areata: a randomised, double‐blind, multicentre, phase 2b‐3 trial. Lancet. 2023;401:1518–1529.

Hordinsky M, Hebert AA, Gooderham M, Kwon O, Murashkin N, Fang H, et al. Efficacy and safety of ritlecitinib in adolescents with alopecia areata: results from the ALLEGRO phase 2b/3 randomized, double‐blind, placebo‐controlled trial. Pediatr Dermatol. 2023;40:1003–1009.

Peeva E, Guttman‐Yassky E, Banerjee A, Sinclair R, Cox LA, Zhu L, et al. Maintenance, withdrawal, and re‐treatment with ritlecitinib and brepocitinib in patients with alopecia areata in a single‐blind extension of a phase 2a randomized clinical trial. J Am Acad Dermatol. 2022;87:390–393.

Liu M, Gao Y, Yuan Y, Yang K, Shen C, Wang J, et al. Janus kinase inhibitors for alopecia areata: a systematic review and meta‐analysis. JAMA Netw Open. 2023;6:e2320351.

Mao MQ, Ding YX, Jing J, Tang ZW, Miao YJ, Yang XS, et al. The evaluation of JAK inhibitors on effect and safety in alopecia areata: a systematic review and meta‐analysis of 2018 patients. Front Immunol. 2023;14:1195858.

Wei D, Chen Y, Shen Y, Xie B, Song X. Efficacy and safety of different JAK inhibitors in the treatment of alopecia areata: a network meta‐analysis. Front Immunol. 2023;14:1152513.

Papierzewska M, Waskiel‐Burnat A, Rudnicka L. Safety of Janus kinase inhibitors in patients with alopecia areata: a systematic review. Clin Drug Investig. 2023;43:325–334.

Chen Y, Zhu H, Shen Y, Zhu Y, Sun J, Dai Y, et al. Efficacy and safety of JAK inhibitors in the treatment of alopecia areata in children: a systematic review and meta‐analysis. J Dermatolog Treat. 2022;33:3143–3149.

Ytterberg SR, Bhatt DL, Mikuls TR, Koch GG, Fleischmann R, Rivas JL, et al. Cardiovascular and cancer risk with tofacitinib in rheumatoid arthritis. N Engl J Med. 2022;386:316–326.

Talty R, Damsky W, King B. Sisaipho alopecia areata treated with tofacitinib and oral minoxidil. JAAD Case Rep. 2022;29:41–42.

Hebert V, Joly P. Major improvement of very severe alopecia aerata in patients treated with the combination of baricitinib and low doses of corticosteroids: an 8‐case series. Clin Exp Dermatol. 2023;48:1258–1259.

Zhang W, Li X, Chen B, Zhang J, Torres‐Culala KMT, Zhou C. Oral tofacitinib and systemic corticosteroids, alone or in combination, in patients with moderate‐to‐severe alopecia areata: a retrospective study. Front Med (Lausanne). 2022;9:891434.

Waśkiel‐Burnat A, Rakowska A, Sikora M, Olszewska M, Rudnicka L. Alopecia areata predictive score: a new trichoscopy‐based tool to predict treatment outcome in patients with patchy alopecia areata. J Cosmet Dermatol. 2020;19:746–751.

Trüeb RM, Dias MFRG. Alopecia areata: a comprehensive review of pathogenesis and management. Clin Rev Allergy Immunol. 2018;54:68–87.

Meah N, Wall D, York K, Bhoyrul B, Bokhari L, Sigall DA, et al. The alopecia areata consensus of experts (ACE) study: results of an international expert opinion on treatments for alopecia areata. J Am Acad Dermatol. 2020;83:123–130.