Alopecia areata: Emerging therapies and up-to-date management strategies

Alopecia areata (AA) is an autoimmune hair disease with variable presentations necessitating individualized, stepwise management given patient age, extent of involvement, comorbidities, and treatment tolerability. Historically, severity was defined by percentage of scalp hair loss using the Severity of Alopecia Tool (SALT), with SALT≥50 defining severe disease and systemic therapy eligibility. Recently, severity assessment has expanded beyond scalp involvement with the AA Scale for Clinical Use (AASc), incorporating eyebrow/eyelash involvement, psychosocial impairment, and treatment response to better capture disease burden. First-line therapy for mild-to-moderate AA (SALT<50) includes topical or intralesional corticosteroids, often with topical or oral minoxidil. Observation may be appropriate in select cases given potential for spontaneous regrowth. FDA approval of oral Janus kinase inhibitors (JAKis) for severe AA (SALT≥50) has changed the therapeutic landscape. Selection among baricitinib, ritlecitinib, and deuruxolitinib is guided by patient age, safety considerations, comorbidities, laboratory monitoring, and insurance coverage. Switching between JAKis may still be beneficial after nonresponse to one agent. Adjunctive and alternative therapies include topical immunotherapy, systemic immunosuppressants, emerging biologic/targeted therapies, and procedural modalities, such as platelet-rich plasma, laser- and light-based therapies, and microneedling. This review synthesizes current evidence on AA treatment and offers a practical, contemporary framework for AA management.