Expert consensus on systemic treatment activation and grading evaluation for alopecia areata

Alopecia areata (AA) is a nonscarring autoimmune disorder characterized by patchy, asymptomatic hair loss affecting the scalp and other hair-bearing areas, prevalent across demographics. According to the Global Burden of Disease (GBD) study, AA is among the top 15 dermatological conditions globally, with China exhibiting a higher disease burden than the global average.[1] Besides cosmetic concerns, AA is often associated with other autoimmune conditions and significantly impacts psychological health, leading to depression, anxiety, and reduced quality of life.[2] Current clinical practice predominantly uses the Severity of Alopecia Tool (SALT)[3] to evaluate disease severity. However, this scalp hair loss-based method alone does not fully capture AA’s broader clinical impact. Recent international efforts, including the Global Registry of Alopecia Areata Disease Severity and Treatment Safety and the Alopecia Areata Severity and Morbidity Index studies,[4,5] have introduced multidimensional assessment frameworks but fall short in addressing specific clinical characteristics and patient needs within the Chinese population. Considering the variability in treatment strategies among clinicians and patient responses in China, this consensus seeks to establish evidence-based recommendations suited to the national context. It aims to standardize AA severity grading, guide timely initiation of systemic treatment, and support individualized patient management, ultimately enhancing patient outcomes. The consensus was developed using the Delphi method, a structured iterative approach to achieve expert consensus [Supplementary Figure 1, https://links.lww.com/CM9/C660]. An initial online seminar with 23 senior Chinese dermatology and hair disorder professionals refined preliminary indicators. Subsequently, 15 of these experts completed three rounds of Delphi questionnaires, rating items on clarity, relevance to the enhancement of AA severity grading, and appropriateness for initiating systemic treatment using a 5-point Likert scale. The final round specifically assessed the clinical applicability and importance of items for patients with SALT scores between 20 and 50. Consensus was defined as achieving ≥66% expert agreement, and also indicated by scores of 4 or 5 during the first two rounds. Following the preliminary expert panel discussion, a total of 129 items were initially evaluated in the first round of the Delphi process. Consensus (≥66% expert agreement) was reached on 45 items, including definitions and classifications. The second round identified 9 additional items, bringing the total consensus items to 54 relevant for AA assessment and management. After these rounds, experts finalized 8 key definitions and classifications. Furthermore, consensus was reached on 24 items related to upgrading AA severity and 22 items concerning the initiation of systemic treatment. In the final round, experts specifically assessed the clinical applicability and importance of these items for patients with intermediate SALT scores (20–50), resulting in consensus on 13 items for initiating systemic treatment. Items with a minimum clinical importance score of 7 out of 10 were retained, resulting in a refined and consolidated framework of 7 severity grading items and 6 items for systemic treatment initiation. The key points of the consensus are summarized below. For the full content, please refer to the Supplementary Material, https://links.lww.com/CM9/C660. Basic indicators The initial selection of basic indicators for AA severity grading was based on the SALT score to establish a clear classification framework. Experts reached consensus on the following SALT-based severity thresholds: Mild (SALT <20), moderate (20 ≤SALT <50), severe (50 ≤SALT <95), and very severe (95 ≤SALT ≤100). For patients categorized as severe or very severe, the consensus recommendation was to initiate systemic treatment directly, reflecting the urgency of managing more advanced stages of the disease. Indicators and outcomes: Achieving final consensus Hair loss patterns The initial selection of indicators for hair loss patterns was based on the subtypes of AA. The experts reached a unanimous consensus that when the subtype is ophiasis, diffuse, alopecia totalis, or alopecia universalis, there should be a consideration for an upgrade in the AA severity classification. These subtypes, often associated with more extensive and potentially progressive forms of the disease, warrant closer attention in the severity grading process. For patients with a SALT score between 20% and 50% (exclusive), the initiation of systemic treatment may be considered if the AA subtype is reticular, ophiasis, or diffuse. These subtypes often present with more challenging disease patterns, making them suitable candidates for more aggressive treatment approaches, especially when localized treatments fail to provide adequate control. AA disease history and treatment history Experts reached consensus on the definition of AA relapse, which was defined as: “the reappearance of AA-related hair loss following complete clinical remission (SALT = 0)”. This study did not further stratify relapse severity. While experts agreed that relapse of AA three or more times could be considered an indication to upgrade the severity classification and to initiate systemic treatment, this item ultimately did not pass the importance score threshold for inclusion. Regarding prior treatment history, the study further refined definitions of treatment modalities and inadequate response to topical and or intralesional agents and systemic agents. Topical and or intralesional agents included corticosteroids, contact immunotherapy, minoxidil, and calcineurin inhibitors (such as tacrolimus and pimecrolimus). Systemic agents included systemic corticosteroids (oral, intramuscular, or intravenous), azathioprine, cyclosporine, methotrexate, Janus kinase (JAK) inhibitors, biologics (e.g., dupilumab), and other small-molecule targeted drugs (e.g., PDE4 inhibitor apremilast). Definition of inadequate response to topical agents: <50% hair regrowth in target scalp areas after 6 months of treatment with any 3 or more topical agents (or 2 or more topical corticosteroids). Definition of inadequate response to systemic agents: <50% hair regrowth in target areas after 6 months of treatment with 2 or more systemic agents (or adequate use of 2 or more systemic corticosteroids). An inadequate response to either “topical and or intralesional” or “systemic” agents was considered a reason to upgrade AA severity. In cases of inadequate topical and or intralesional agents’ response, systemic treatment initiation may be considered. Nonscalp involvement The expert panel determined that complete loss of either one or both eyebrows or eyelashes could serve as a critical criterion for upgrading the severity of AA. Specifically, in the case of unilateral or bilateral eyebrow or eyelash loss, systemic treatment initiation may also be considered. This is particularly relevant as the loss of these facial features often results in more noticeable and socially disruptive consequences, which may affect a patient’s emotional well-being.[6,7] Beard/body hair loss and nail involvement were included in the Delphi panel. However, these forms of involvement were not recommended as standalone criteria for the initiation of systemic treatment, as their effects on overall functioning may vary considerably among patients in China, while still clinically relevant. Consequently, the decision to initiate systemic treatment in such cases should be personalized rather than universal, considering the patient’s individual preferences and the overall impact of the disease on daily life. Disease activity The active phase of AA was defined by the expert panel as the presence of expanding hair loss patches, either through visible enlargement of existing patches or an increase in the number of patches. This phase is also often associated with broken hairs at the lesion margins and a positive hair-pull test, which can confirm ongoing disease activity. There is no consensus on whether the severity of AA should be increased or systemic treatment should be initiated if only the features of the active phase are shown by trichoscopy. However, when the patient shows a positive diffuse in hair-pull test, the severity of AA can be increased and systemic treatment can be considered. Patient self-reported outcomes Self-reported outcomes play an important role in understanding the impact of AA on patients’ psychological well-being, social interactions, and daily functioning. In addition, patient self-assessment of symptom improvement after 3 months of treatment is an important measure in evaluating treatment efficacy. Experts agreed that when patients reported frequent or consistent (using a 5-point simplified scale with an 80% consensus agreement rate: never, rarely, sometimes, frequently, constantly affected) psychosocial distress or functional impairment due to AA, this could support upgrading the severity classification and initiating systemic treatment. Furthermore, if patients reported worsening of symptoms after three months of treatment, either somewhat or significantly, this may prompt a review of severity classification. In cases of significant symptom worsening, initiation of systemic treatment may be considered necessary to better address disease progression and improve patient quality of life. Severity grading evaluation and systemic treatment activation system construction Based on the research findings outlined above, when assessing the severity of AA, patients are initially classified according to their SALT score. For patients initially rated as mild, moderate or severe, an upgrade by one severity level was recommended if any of the following seven criteria were present: (1) positive diffusely in hair-pull test; (2) ophiasis AA or diffuse AA; (3) inadequate response to previous topical and or systemic agents; (4) complete eyebrow or eyelash loss (unilateral or bilateral); (5) involvement of beard or other body hair; (6) self-reported significant symptom worsening after 3 months of treatment; or (7) frequent or constant psychosocial and daily life impairment. Systemic treatment initiation is recommended when the SALT score is ≥50. For patients with SALT score between 20 and 50 (exclusive), systemic treatment is also recommended if any of the above criteria are presented, excluding “involvement of beard or other body hair” and “inadequate response to previous systemic agents”. These criteria ensure that treatment decisions are based on a comprehensive evaluation of both the severity of hair loss and the presence of factors that may indicate the need for more aggressive intervention [Supplementary Figure 2, https://links.lww.com/CM9/C660]. This approach aims to provide personalized care, ensuring that patients receive appropriate treatment based on the progression of their disease and specific clinical factors. In conclusion, this study has developed a simplified multidimensional assessment scale for AA in China. The scale achieved expert consensus on both the factors contributing to the severity classification of AA and the criteria for initiating systemic treatment. It not only offers clinically relevant indicators for assessing AA severity among Chinese patients but also defines the conditions under which systemic treatment should be initiated. The introduction of this multidimensional, simplified AA assessment scale provides a solid foundation for the diagnosis and management of AA in China and contributes Chinese data and experience to the global AA research. Funding This study was supported by grants from the National Natural Science Foundation of China (No. 82373504), the Natural Science Foundation of Beijing Municipality (No. 7254439). Conflicts of interest None declared.

Récupéré en direct depuis OpenAlex et désinversé. Les résumés ne sont pas conservés dans cette base de données : les index inversés représentent 8,6 Go des 9,3 Go de texte de la base, et le serveur dispose de 13 Go libres.