What to Do When First-Line Treatment Has Not Achieved Hair Regrowth in Moderate-to-Severe Alopecia Areata

This protocol addresses adults and young people with alopecia areata involving 21–100% of the scalp — classified as moderate-to-severe disease — in whom an adequate first-line treatment course has not produced the target degree of terminal hair regrowth.

Previous treatment & failure condition

This next-line step applies after a trial of potent or very potent topical corticosteroid, diphenylcyclopropenone (DPCP), or oral Janus kinase inhibitor — continued for at least 6 months — has not achieved sufficient improvement in hair regrowth from baseline, with the aim of complete terminal hair regrowth unmet.

Next-line approach — partial overview

The next step moves to systemic oral therapy. The protocol identifies more than one category of agent, and includes guidance on when monotherapy versus a combination approach is appropriate. Specific agents, sequencing, and eligibility criteria are detailed in the full regimen.

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References

DOI: 10.1093/bjd/ljae385

The AA severity definitions used in this living guideline are based primarily on the extent of scalp hair loss, with limited (mild) hair loss representing 1–20% scalp involvement, moderate hair loss representing 21–49% scalp involvement and severe hair loss representing 50–100% scalp involvement.
Consider a course of oral corticosteroids (e.g. prednisolone 0.5 mg kg−1 per day tapering over 6–12 weeks) in people with moderate-to-severe AA.
Consider ciclosporin, azathioprine or methotrexate as monotherapy or in combination with oral corticosteroids as treatment options in people with moderate-to-severe AA, balancing benefits, risks of adverse effects, and patient risk factors.
Ultimately, the aim of treatment is complete terminal hair regrowth on the scalp and any other body site affected.

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