Delphi Consensus Statement on Treatment of Severe Alopecia Areata in US Adults

Alopecia areata (AA) is an autoimmune hair loss disorder that affects more than 7 million people in the US. Before US Food and Drug Administration-approved trials of Janus kinase inhibitors, numerous treatments had been explored, with variable efficacy and quality of evidence. The absence of standardized treatment guidelines may lead to poor treatment outcomes and payer coverage.

To establish a consensus on treatment for adults with severe AA in the US.

Systematic literature reviews for all known therapies used for treating AA were performed in PubMed from inception to December 2024. Inclusion criteria required studies to be randomized clinical trials or have an observational design, evaluate adult (≥18 years old) participants with moderate to severe AA (defined by Severity of Alopecia Tool scores >20%), and be published in English. Studies were excluded if they included patients with non-AA hair loss or if they exclusively evaluated pediatric participants or those with mild AA (Severity of Alopecia Tool scores ≤20%). Three rounds of anonymous, iterative online surveys were administered from May through November 2025. Consensus was predefined at an agreement threshold of 70% or greater. A definition of AA severity was proposed for determining patient eligibility. Experts with recent AA-related research and extensive clinical experience treating adults with severe disease indicated their agreement or disagreement with the use of 29 treatments for adults with severe AA. Treatments that reached consensus for inclusion were further explored with respect to therapeutic positioning, treatment regimens, and long-term management.

Thirty-one US-based AA experts completed 3 rounds of iterative surveys. Consensus was achieved on treatment of adults with severe alopecia areata, as defined by the Alopecia Areata Scale. Oral Janus kinase inhibitors represented the primary, long-term therapy for all patients, with dupilumab as an alternative option for patients with comorbid atopy. Supplemental treatments included oral and topical minoxidil; intralesional, oral, and high-potency topical corticosteroids; and topical Janus kinase inhibitors and prostaglandins, with body site-specific indications. Patient support resources should be offered alongside medical treatment.

This study defines expert-established consensus on treatment of adults with severe AA in the US. Additional high-quality investigations are needed to establish the efficacy of existing therapies in subpopulations and enable head-to-head comparisons of new and existing interventions. These recommendations are not indicated for children, pregnant patients, patients with mild to moderate disease, or those with underlying comorbidities; additional research is needed to inform treatment guidelines for these specific patient populations.