How is the severity of alopecia areata assessed?
Alopecia areata severity can be assessed in daily clinical practice using the recently developed AA scale.13 This scale classifies AA severity as mild, moderate, or severe, based on the extent of scalp hair loss of less than or equal to 20%, 21% to 49%, and 50% to 100%, respectively. In addition, the scale incorporates 4 secondary clinical features that contribute to disease severity - eyebrow and eyelash involvement, treatment-refractory disease, psychosocial impact of AA, and diffuse rapid hair loss - for a more comprehensive disease severity assessment (Table 1).13 The presence of any of these secondary features increases the severity level. This AA scale is simple and easy to administer, allowing for an informative and consistent assessment of AA patients in clinical practice.
Alopecia areata severity is assessed in clinical trials using the Severity of Alopecia Tool (SALT) score.14 This score exclusively measures the extent and density of scalp hair loss. The score is determined by combining the visually estimated percentage of hair loss in each of the 4 quadrants of the scalp (left side, right side, top, and back). Five subgroups of hair involvement are identified based on the score: S0 = no hair loss, S1 = < 25% hair loss, S2 = 25% to 49% hair loss, S3 = 50% to 74% hair loss, S4 = 75% to 99% hair loss, S5 = 100% hair loss. The SALT score is inherently limited by the omission of other clinical features of AA that contribute to disease severity. For daily clinical practice use, mapping out the scalp's surface area to determine the SALT score could be time-consuming. Clinicians, however, need to understand the SALT score to interpret clinical trial results that use this score.14
What advice do you offer patients before initiating treatment?
Patients need to be informed upfront that there is no cure for AA.10 In addition, currently available treatments do not prevent relapse and do not appear to alter the long-term clinical course of AA.15 Spontaneous remission can occur, but it is highly variable and dependent on disease severity at presentation.16 Small lesions of < 25% scalp have a greater probability of spontaneous resolution, seen in up to 68% of cases. Large lesions of > 50% scalp involvement have a poorer prognosis, with spontaneous resolution occurring in 8% of cases. Most patients, however, do worsen over time. The possibility of spontaneous remission may lead to watchful waiting and treatment delays.12 Although watchful waiting may be reasonable in mild cases, treatment should be considered in moderate-to-severe cases where spontaneous resolution is less likely or when hair loss significantly impacts the patient's quality of life or causes undue anxiety.10 Counseling patients on the likelihood of spontaneous remission is important as this would help patients to make informed treatment decisions. Further, patients should be informed that treatment response with current therapies takes time. Even with the most effective therapies, substantial hair regrowth may take months.
Patients need to be informed upfront that there is no cure for AA.10 In addition, currently available treatments do not prevent relapse and do not appear to alter the long-term clinical course of AA.15 Spontaneous remission can occur, but it is highly variable and dependent on disease severity at presentation.16 Small lesions of < 25% scalp have a greater probability of spontaneous resolution, seen in up to 68% of cases. Large lesions of > 50% scalp involvement have a poorer prognosis, with spontaneous resolution occurring in 8% of cases. Most patients, however, do worsen over time. The possibility of spontaneous remission may lead to watchful waiting and treatment delays.12 Although watchful waiting may be reasonable in mild cases, treatment should be considered in moderate-to-severe cases where spontaneous resolution is less likely or when hair loss significantly impacts the patient's quality of life or causes undue anxiety.10 Counseling patients on the likelihood of spontaneous remission is important as this would help patients to make informed treatment decisions. Further, patients should be informed that treatment response with current therapies takes time. Even with the most effective therapies, substantial hair regrowth may take months.
What are the current treatments for alopecia areata and their limitations?
Current evidence-based treatments for AA include intralesional corticosteroids, topical corticosteroids, oral corticosteroids, JAK inhibitors, minoxidil, and topical immunotherapy. Treatment choice is guided by the severity of hair loss and patient age.10 Generally, mild-to-moderate disease is treated with topical agents, and moderate-to-severe disease is treated with systemic therapies. In our study, most patients were prescribed topical minoxidil (47%), followed by intralesional (32%), topical (32%), and oral corticosteroids (16%). The efficacy, safety, and place of current therapies are briefly summarized.
Intralesional corticosteroids are the standard of care in limited patchy AA and cosmetically sensitive areas, such as the eyebrows.10,17 They can also be an adjunctive treatment in extensive disease. In limited patchy AA, monotherapy with intralesional corticosteroids has led to > 50% hair regrowth in more than 80% of patients after 3 months of treatment.18
In clinical practice, their use is limited by the number of in-jections a patient can tolerate. Usually, a SALT score of 30% is the upper limit for injections.19 In our survey, one-third of dermatologists overestimated the AA severity where intra-lesional corticosteroids are effective. Since injections are placed 1 cm to 2 cm apart, alopecia affecting 30% of the scalp requires treating about 210 cm2, which implies almost
