Alopecia Areata Is a Medical Disease: Treatment Options and Defining Severity

Welcome back to another Dermatology Times Case-Based Peer Perspectives series. In "Alopecia Areata Is a Medical Disease: Treatment Options and Defining Severity," Benjamin Ungar, MD opens the series on alopecia areata,

Dr. Ungar opens by introducing himself as Assistant Professor at the Icahn School of Medicine at Mount Sinai and Director of the Alopecia Center of Excellence. He begins with a core misconception: that alopecia areata is cosmetic rather than medical. He argues that the psychosocial impact extends far beyond more cosmetic forms of hair loss, such as androgenetic alopecia, and dominates multiple aspects of patients' lives. He adds that moderate to severe disease behaves as a systemic inflammatory condition, with increased inflammation in the blood and very high inflammation in the skin where hair falls out. Clinicians should therefore start by acknowledging this as a medical disease.

The discussion then turns to treatment options, which depend on severity. Topical therapies are not routinely effective in adults, with a possible exception in younger pediatric patients, and their efficacy is inconsistent at best. Intralesional steroid injections can work well in mild disease, although atrophy, slow response, and incomplete efficacy are limitations. In moderate to severe disease, dozens of injections over months become burdensome, which prompts a move to systemic therapy.

Dr. Ungar then explains how severity is defined. Clinical trials use the SALT score, which reflects the percentage of scalp hair involvement, with SALT 50 or greater defining severe disease. In practice, he prefers the alopecia areata scale because it also weighs eyebrow and eyelash involvement, quality of life impact, rapid progression, and lack of response after six months of treatment. Patients in the severe range are clear candidates for systemic therapy, while moderate disease remains a gray area.

The next episode in this series, "Case 1: Assessing Psychosocial Burden and Realistic Goals in a Patient with Alopecia Areata," begins with a 33-year-old man whose wedding in six months makes timing central.