A Clear Road Map for Severe Alopecia Areata

For the first time, dermatology clinicians treating adults with severe alopecia areata (AA) have an expert consensus that defines what counts as severe

disease, what to prescribe first, and how long to wait before changing course. Published in September, the Delphi consensus statement designates oral Janus kinase (JAK) inhibitors as first-line, long-term therapy for all adults with severe disease.¹

The 31 US-based experts on the panel, convened by the National Alopecia Areata Foundation (NAAF) and the American Hair Research Society, voted on 29 treatments across 3 survey rounds, with consensus defined as at least 70% agreement. The need was both practical and clinical, the authors wrote, noting, "The absence of standardized treatment guidelines may lead to poor treatment outcomes and payer coverage."¹

"These are not meant to replace clinician interest, clinician intuition, or clinician decision-making, but really to suggest that we have a much more clear road map for patients with severe alopecia areata than we had before," senior author Arash Mostaghimi, MD, MPA, MPH, vice chair of clinical trials and innovation at Brigham and Women's Hospital, said in an interview with Dermatology Times.

Redefining "Severe" to Support More Patients

The panel adopted the Alopecia Areata Scale (AASc) to define severity. The scale starts with the Severity of Alopecia Tool (SALT) score: A score of 20 or less indicates mild disease, 21 to 49 is moderate disease, and 50 or more indicates severe disease. Severity increases by 1 level if any of 4 features are present: negative psychosocial impact, noticeable eyebrow or eyelash involvement, inadequate response after at least 6 months of treatment, or a diffuse positive hair pull test suggesting rapidly progressive disease.²

The SALT-50 cutoff used in pivotal trials "really doesn't match what we see in the clinical setting," Mostaghimi said. "For example, today I saw a patient with 40% scalp hair loss. I don't think that if she went to 50% that she'd feel bad, and at 40%, she was totally fine." Under the AASc, a patient with 25% scalp loss and significant brow and lash involvement qualifies as severe.

Victoria Garcia-Albea, NP, director of the hair loss clinic at Lahey Hospital & Medical Center in Burlington, Massachusetts, said the scale also solves a usability problem. "In clinical practice, it may be difficult to accurately calculate SALT scores, and the SALT score may not indicate true AA disease burden," she told Dermatology Times. "According to the AASc, I believe many more patients [with AA] will qualify for treatment with oral JAK inhibitors."

Start a JAK inhibitor, and Start Early

"Oral Janus kinase inhibitors represented the primary, long-term therapy for all patients, with dupilumab as an alternative option for patients with comorbid atopy," according to the consensus guidelines.¹ FDA-approved agents (eg, baricitinib, ritlecitinib, and deuruxolitinib) are preferred. A fourth, upadacitinib, is under FDA review for severe AA.

Timing matters, Mostaghimi stressed. "Alopecia areata is different from other conditions in that you have a window throughout which you can treat these patients. If you don't treat them within that window, you're likely to have slower regrowth and less complete regrowth," he said. That window begins to close around 3 to 4 years, he added. "This isn't like psoriasis, where you can take a year or 2 to the side and try some topicals and figure it out."

For clinicians new to JAK inhibitors, his advice is to pick one and learn it. "If you're not comfortable with one, do it with a buddy," he said. "If you're not comfortable prescribing the JAK inhibitor, it really is your responsibility to get your patient somewhere where they can access that medication."

Consider Adjuncts, Retire Older Options

The consensus suggests considering site-specific adjuncts: oral and topical minoxidil; intralesional, oral, and high-potency topical corticosteroids; and topical JAK inhibitors and prostaglandin analogs.¹ Topical sensitizers, methotrexate, azathioprine, and cyclosporine did not make the list. "While there [are] data for these medications, given the development of JAK inhibitors and their success, it's hard to justify the benefit of the medications in the context of the risks or the difficulty in taking these medications," Mostaghimi told Dermatology Times, although he noted they may still suit a small group of patients in exceptional situations.

Patients know that trial and error too well. Brandi Jones was diagnosed with AA at 18 months old in 1972. Over nearly 5 decades, she tried steroid injections, prednisone, methotrexate, platelet-rich plasma, and squaric acid, which burned her badly enough that she missed work, she told Dermatology Times. Jones started a JAK inhibitor in a clinical trial in January 2021, saw visible regrowth by month 2, and remains on treatment 5.5 years later.

“I had nearly given up hope. I was 50 years old and convinced in my lifetime I would never find anything that worked, until I happened upon a clinical trial in January 2021," Jones said. "I was a broken shell of myself. It was everything in my power to hide it. I wouldn't even take my topper off at home in front of my boyfriend."

Measure Progress in Months

Because medications take longer to work, clinicians need to set appropriate expectations with patients. "We've become accustomed to medications in atopic dermatitis or psoriasis, where outcomes are measured in sometimes hours or days or even weeks. We do not have medications that work that quickly in alopecia areata," Mostaghimi told Dermatology Times.

He tells patients starting treatment in September: "It won't be until St Patrick's Day in March or Easter in April that we're really going to understand whether or not this treatment works for you or not."

The consensus calls for at least 6 months of continuous treatment, with responders staying on the same drug at the same dose without interruption. For an incomplete response after 6 months or more, clinicians should consider dose adjustment, switching JAK inhibitors, or adding adjuncts.¹

Ask How the Patient Is Doing

"Patient support resources should be offered alongside medical treatment," the authors wrote, recommending that clinicians explore mental health and refer when indicated.¹

No formal instrument is needed, Mostaghimi told Dermatology Times. "It's simply a ‘How are you doing? How is this impacting you?’" Regrowth itself "can be quite emotional, and there's a lot of lingering psychosocial impact that can last for an extended period of time," he added. Wigs, camouflage, and forgoing treatment remain valid choices for patients who prefer them.

For Jones, that question came late. The first time a clinician asked how AA affected her relationships and work was on a questionnaire at the trial enrollment, nearly 5 decades after her diagnosis. "I was a broken shell of myself. It was everything in my power to hide it," she told Dermatology Times.

As a result of the successful treatment, Jones said that she found strength she didn't know she had. She now runs an online support group of approximately 23,000 members and has a message for clinicians who say their patients with AA aren't bothered by it: "Well, if it doesn't bother them, then why did they wait 6 months to get into your office?”

What Comes Next

The consensus does not address children, patients who are pregnant, people with mild to moderate AA, or those with underlying comorbidities.¹ The field also needs more options. "It's like going into an ice cream store that has excellent ice cream, but there's 4 flavors and they're all vanilla," Mostaghimi said, pointing to biologics, nonimmunosuppressive agents, therapies with durable off-drug responses, and better topicals in development.

Garcia-Albea already puts the document to work. "As new treatments become available, the guidelines will need to be updated, but for now, this is a great resource that I use in my clinical practice to justify treatment to insurers, and to explain the disease management to patients and families," she told Dermatology Times.

SIDEBAR: Key Takeaways

• Reassess severity. Patients with SALT scores under 50 may qualify as severe if their brows or lashes are involved, their disease affects them psychosocially, their disease has not responded adequately to at least 6 months of treatment, or their disease is progressing fast.
• Go JAK first. All adults with severe AA are candidates. Consider dupilumab for patients with atopy.
• Don't wait. Response may fall off after 3 to 4 years of disease.
• Give it 6 months. Then adjust, switch, or add an adjunct. Keep responders on continuous therapy.
• Ask, validate, refer. Check in on mental health and point patients to advocacy groups such as the NAAF.

References

1. Gregoire S, Dewey E, Biba U, et al. Delphi consensus statement on treatment of severe alopecia areata in US adults. JAMA Dermatol. Published online September 2, 2026. doi:10.1001/jamadermatol.2026.2336
2. King BA, Mesinkovska NA, Craiglow B, et al. Development of the alopecia areata scale for clinical use: results of an academic-industry collaborative effort. J Am Acad Dermatol. 2022;86(2):359-364. doi:10.1016/j.jaad.2021.08.043
3. AbbVie submits application to FDA for upadacitinib (Rinvoq) for adults and adolescents with severe alopecia areata. News release. AbbVie. April 28, 2026. https://news.abbvie.com/2026-04-28-AbbVie-Submits-Application-to-FDA-for-Upadacitinib-RINVOQ-R-for-Adults-and-Adolescents-with-Severe-Alopecia-Areata