A 3-round Delphi consensus process (May–November 2025) among 31 US-based alopecia areata (AA) experts evaluated 29 treatments for adults with severe AA (defined as ≥50% scalp hair loss, or 20–49% loss with psychosocial impact, eyebrow/eyelash involvement, treatment failure, or rapid progression), informed by systematic PubMed literature reviews through December 2024.
Consensus (≥70% agreement) was reached on a treatment framework: oral JAK inhibitors (FDA-approved preferred; 96.6% inclusion in Round 1) serve as primary long-term therapy for all patients, with dupilumab as an alternative for those with comorbid atopic disease (93.3% inclusion). Supplemental therapies with consensus included oral minoxidil (100%), topical minoxidil (90%), intralesional corticosteroids (90%), oral corticosteroids (76.7%), high-potency topical corticosteroids (71%), and topical JAK inhibitors and prostaglandins for facial hair loss. Cyclosporine, mycophenolate mofetil, azathioprine, hydroxychloroquine, UV phototherapy, low-level laser, methotrexate, ezetimibe-simvastatin, and dietary supplements (without deficiency) were excluded by consensus.
Consensus reflects expert opinion, not head-to-head RCT data; recommendations apply only to US adults with severe AA and cannot be generalized to children, pregnant patients, mild-to-moderate disease, or those with significant comorbidities. Panel was small (n=31) and predominantly academic (87%).
For adults with severe AA, start an FDA-approved oral JAK inhibitor as long-term primary therapy; if the patient has active atopic disease, dupilumab is a reasonable alternative. Add intralesional corticosteroids, minoxidil (oral or topical), and site-specific adjuncts as needed, and always offer referral to patient advocacy and mental health resources.
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