What Works for Patients with Alopecia Areata

Alopecia areata (AA) has moved from an era of therapeutic nihilism, when effective, predictable treatments were lacking, to a more practical period of targeted oral therapy. Today, dermatology providers have reproducible outcomes that patients understand, such as achieving at least 80% or 90% scalp hair coverage, and a clearer view of how to deliver those results safely and equitably across the population of patients with AA.

AA Burden in the US

AA affects roughly 1 in 300 people in the US, or about 1.1 million individuals at a given time. Prevalence is higher in females than in males, with a peak in early adulthood, and there is marked state-level variation.¹ These numbers translate to real human impact. Patients report social withdrawal, workplace and school challenges, and physical symptoms when brows and lashes are absent. The epidemiology underscores why timely diagnosis, access to effective treatment, and continuity of care are necessary across all regions and life stages.

The Current Regulatory Landscape

Three oral small-molecule inhibitors of the Janus kinase (JAK)/signal transducers and activators of transcription (STAT) signaling pathway (JAK inhibitors) are approved in the US for severe AA: Baricitinib (Olumiant; Eli Lilly) for adults, ritlecitinib (Litfulo; Pfizer) for patients aged 12 years and older, and deuruxolitinib (Leqselvi; Sun Pharma) for adults.

Most pivotal trials report outcomes using the Severity of Alopecia Tool (SALT), a simple way to describe how much scalp hair is missing on a 0 to 100 scale. SALT 0 means no scalp hair loss. SALT 100 means complete scalp hair loss. In practice, clinicians and patients often use 2 clear targets:

SALT 20 or less — about 80% or more of the scalp is covered with hair

SALT 10 or less — about 90% or more of the scalp is covered with hair

These targets translate well for counseling and payer communication.

Patients want hair, not hope. Measure what matters.

AbbVie recently reported topline phase 3 results for upadacitinib (Rinvoq), a JAK1 selective inhibitor already approved for atopic dermatitis (AD) and psoriatic arthritis, with the highest week-24 hair regrowth outcomes disclosed to date in a pivotal AA program.² If regulatory review is favorable, upadacitinib could be an important, game-changing therapeutic addition to the armamentarium of treatments for patients with AA.

AA and AD

AA often coexists with AD, particularly in adolescents and in those with more severe hair loss.³ Screening for eczema history, itch, and barrier impairment should be routine during a baseline exam. When appropriate, a single drug strategy that addresses both conditions is ideal. Upadacitinib is already approved in the US to treat AD for ages 12 years and older and has shown strong AA regrowth signals in topline data. This could simplify counseling, adherence, and prior authorization while focusing on outcomes that matter to patients experiencing both AA and AD.

Safety and Monitoring in Practice

Monitoring patients on oral JAK inhibitor therapies is straightforward and familiar to dermatology teams that manage AD and/or AA; to date, these patients have experienced a high degree of safety using JAK inhibitors. Start with a simple baseline checklist: infection and vaccination history, pregnancy planning, and standard laboratory tests such as complete blood count, liver enzymes, and lipids, per the product label. Then tailor follow-up to the patient. Many patients can be reassessed at routine visits, with additional laboratory testing at reasonable intervals.

Frame safety as a partnership. Confirm vaccinations, optimize modifiable risks, and document shared decisions. For adolescents, include caregivers in the discussion and agree on practical steps for adherence and handling missed doses. The goal is the confident use of effective medicines with clear, predictable monitoring.

Access and Equity

The most significant barrier for many patients is access to these life-changing medications. Standardize how your team documents severity, psychosocial impact, and function, and attach photographic SALT estimates to prior authorizations. Use clear language that frames AA as an autoimmune disease that impacts patient identity and daily function. Provide bilingual materials when needed and connect patients with mental health and camouflage resources. Health care equity and access is not a side project, it is part of care quality.

Practical steps for managing AA hairloss in clinic

Set treatment targets in plain language. Use 80% and 90% scalp coverage alongside SALT numbers and show photo references, when available.

Pick a decision date in advance. If your checkpoint is week 24 or week 36, schedule that counseling visit today and tell the patient when decisions will be made.

Build a template. Include laboratory results, infection review, vaccination status, reproductive planning, and a brief risk summary that maps to payer requirements.

Look for atopic comorbidity. Ask about itch, rash, and barrier issues, and consider a therapy that can treat both AA and AD when appropriate.

Plan for continuity. Tell patients how you will handle interruptions and whether a rapid re-response is likely if therapy is paused and restarted.

Unanswered Questions in AA treatment

Durability and maintenance. How long to continue therapy after reaching SALT 20 or better? Which tapering strategies maintain control? What are relapse kinetics and the speed of re-response after treatment interruption?

Early response rules. Which early timepoints predict later success? When to escalate the dose, switch therapy, or add local measures?

Who responds and why. Which clinical predictors such as pattern of loss, duration, nail disease, atopy, and overlapping autoimmune disease matter most? Is there a need for biomarkers or genetic signatures to guide treatment selection?

Patient-centered outcomes. Do the patient’s goals include standardized capture of brow and lash regrowth, reduction in ocular irritation, camouflage independence, and return to work or school?

Adolescents and family-centered care. What is the long term safety data in younger patients? Is there adherence support mechanisms? Is there practical guidance for fertility and pregnancy planning?

Real-world effectiveness and sequencing. What is the persistence, adherence, outcomes with step edits, and comparative effectiveness across agents (using common definitions)?

Dose optimization. What are the start, escalation, and de-escalation windows? When and how should a clinician
de-escalte after control is achieved? What is the role of combination approaches?

Equity and access science. What documentation elements shorten time to therapy? How do outcomes vary by race, ethnicity, and geography? What practical interventions reduce treatment delays?

Non-scalp disease. What are measurement and treatment strategies for eyebrows, eyelashes, beard, and body hair that align with patient priorities?

Bottom line

Dermatology providers are practicing in a new era equipped with effective and safe advanced systemic therapies that can treat severe AA. Modern AA care is measurable, patient-centered, and achievable in routine practice. With careful monitoring and attention to access, we can deliver hair regrowth and restore confidence for many of our patients.

References

1. Akbarialiabad H, Bunick CG, Mesinkovska N, Taghrir M, Grada A. Alopecia areata in the United States: national and state-level epidemiologic trends (2010–2021). J Invest Dermatol. 2025;145(8):S195. doi: 10.1016/j.jid.2025.06.1397

2. AbbVie announces positive topline results from phase 3 UP-AA trial evaluating upadacitinib (Rinvoq) for alopecia areata. News release. AbbVie. July 30, 2025. Accessed August 17, 2025. https://news.abbvie.com/2025-07-30-AbbVie-Announces-Positive-Topline-Results-from-Phase-3-UP-AA-Trial-Evaluating-Upadacitinib-RINVOQ-R-for-Alopecia-Areata

3. Bunick CG, Armstrong AW, Grada A, et al. The epidemiology of atopic dermatitis among adults and adolescents with alopecia areata in the United States. J Invest Dermatol. 2025 doi: 10.1016/j.jid.2025.06.1578