European expert consensus statement on the systemic treatment of alopecia areata

Abstract

Alopecia areata is an autoimmune form of non‐scarring hair loss. It is usually characterized by limited areas of hair loss. However, the disease may progress to complete scalp and body hair loss (alopecia totalis, alopecia universalis). In patients with alopecia areata hair loss significantly impacts the quality of life. Children and adolescents with alopecia areata often experience bullying, including physical aggression. The disease severity evaluation tools used in clinical practice are: the Severity of Alopecia Tool (SALT) score and the Alopecia Areata Scale (AAS). A SALT score equal to or greater than 20 constitutes a commonly accepted indication for systemic therapy in alopecia areata. When using the AAS, moderate to severe alopecia areata should be considered a medical indication for systemic treatment. Currently, the only two EMA‐approved medications for alopecia areata are baricitinib (JAK 1/2 inhibitor) for adults and ritlecitinib (JAK 3/TEC inhibitor) for individuals aged 12 and older. Both are EMA‐approved for patients with severe alopecia areata. Other systemic medications used off‐label in alopecia areata include glucocorticosteroids, cyclosporine, methotrexate and azathioprine. Oral minoxidil is considered an adjuvant therapy with limited data confirming its possible efficacy. This consensus statement is to outline a systemic treatment algorithm for alopecia areata, indications for systemic treatment, available therapeutic options, their efficacy and safety, as well as the duration of the therapy.

Pathogenesis of Alopecia Areata and Vitiligo: Commonalities and Differences

“…AA is an acquired non-scarring hair loss with or without autoimmune comorbidities including vitiligo, atopic dermatitis, thyroid disease, celiac disease, and type 1 diabetes mellitus [7,8]. AA can be subclassified into patchy AA, alopecia totalis (complete loss of scalp hair), and alopecia universalis (complete loss of hair on the scalp and the body), although clear definitions have not yet been finalized [9].…”

A ranking of treatment efficacy in alopecia areata is not possible without head‐to‐head studies

“…In particular, the efficacy may be significantly lower in patients with a higher SALT (Severity of Alopecia Tool) score. 2,3,5 Fourth, the authors 1 point to a very interesting observation, that there is a significant variation in the efficacy of placebo between the studies.…”

“…In alopecia areata, many medications show efficacy that increases slowly over time. 3 Thus comparing the treatment efficacy of one drug at week 24 to another drug at week 36 or 52 can lead to practically not applicable conclusions. In particular, it has been shown in the case of JAK inhibitors, that some patients are very slow responders, achieving treatment efficacy as late as at week 36.…”

Alopecia areata: Time for position statement to include new systemic therapeutic advances

“…A European group of experts has produced a consensus statement for using systemic agents in AA management. 5 The treatment algorithm prioritizes systemic JAK inhibitors as a first-line therapy for patients requiring a systemic agent, aligning with recent FDA and EMA approvals for moderate to severe AA. Other immunomodulating agents, such as cyclosporine, methotrexate or azathioprine, are considered as next lines in case of contraindications, failure, and/or side effects of systemic JAK inhibitors.…”