Background

Alopecia areata (AA) affects all ages, genders, and ethnicities. AA severely impacts patients' quality of life. Treatments indicated for AA have only been approved since 2022/2023. While some Asia Pacific (APAC) countries/regions have national or regional guidelines, many lack AA-specific guidance or have not updated existing guidelines to incorporate recently approved treatments.

Methods

To better inform treatment decisions, 18 dermatologists from Australia, China, India, Korea, Malaysia, Singapore, Taiwan, and Thailand completed a three-round Delphi-based consensus process involving survey completion, open discussion, and statement voting. A consensus for Likert-type and multiple-choice statements was defined as ≥ 70% agreement or disagreement.

Results

Consensus was achieved on 140 statements. The panel recognizes that AA is clinically heterogeneous and imposes a considerable burden on patients and their families. Trichoscopy is deemed essential for diagnosing and monitoring AA, while skin biopsy is reserved for when the cause of hair loss is unclear. In terms of disease severity, moderate AA is defined as 21%-49% hair loss and severe AA as ≥ 50% hair loss. Regarding treatment, topical corticosteroids are recommended in children < 12 years. For patients aged ≥ 12 years, topical and intralesional corticosteroids could be used for mild-to-moderate AA, while Janus kinase inhibitors and systemic corticosteroids have a role in moderate-to-severe AA. Adjuvant minoxidil could also be used in chronic AA.

Conclusions

This modified Delphi-based consensus provides a practical, region-focused framework to standardize the diagnosis and management of AA across diverse APAC healthcare settings in hope of improving patient outcomes.

Keywords: Asia Pacific; Delphi; Janus kinase inhibitors; alopecia areata; consensus; diagnosis; expert panel; management; recommendations; treatment algorithms.

1. Spano, F., & Donovan, J. (2015). Alopecia areata: Part 1: Pathogenesis, diagnosis, and prognosis. Canadian Family Physician, 61(9), 751–755.
2. Zhou, J., Liang, L., Zhang, H., Wang, Y., & Chen, X. (2025). Global burden of alopecia areata and associated diseases: A trend analysis from 1990 to 2021. Journal of Cosmetic Dermatology, 24(3), Article e70076. https://doi.org/10.1111/jocd.170076
3. Ma, T., Zhang, T., Miao, F., Liu, Y., & Wang, G. (2025). Alopecia areata: Pathogenesis, diagnosis, and therapies. MedComm, 6(2), Article e70182. https://doi.org/10.1002/mco2.70182
4. Sy, N., Mastacouris, N., Strunk, A., & Garg, A. (2023). Overall and racial and ethnic subgroup prevalences of alopecia areata, alopecia totalis, and alopecia universalis. JAMA Dermatology, 159(4), 419–423. https://doi.org/10.1001/jamadermatol.2023.0016
5. Thompson, A., Tziotzios, C., Nesnas, J., Randall, R., Czachorowski, M., & Messenger, A. (2024). Lifetime incidence and healthcare disparities in alopecia areata: A UK population-based cohort study. British Journal of Dermatology, 191(6), 924–935. https://doi.org/10.1093/bjd/ljae265
6. Lee, H., Gwillim, E., Patel, K. R., Hua, T., Rastogi, S., Ibler, E., & Silverberg, J. I. (2020). Epidemiology of alopecia areata, ophiasis, totalis, and universalis: A systematic review and meta-analysis. Journal of the American Academy of Dermatology, 82(3), 675–682. https://doi.org/10.1016/j.jaad.2019.08.032
7. Wang, H., Pan, L., & Wu, Y. (2022). Epidemiological trends in alopecia areata at the global, regional, and national levels. Frontiers in Immunology, 13, Article 874677. https://doi.org/10.3389/fimmu.2022.874677
8. Muntyanu, A., Gabrielli, S., Donovan, J., Gooderham, M., Guenther, L., Jack, C. S., & Netchiporouk, E. (2023). The burden of alopecia areata: A scoping review focusing on quality of life, mental health and work productivity. Journal of the European Academy of Dermatology and Venereology, 37(8), 1490–1520. https://doi.org/10.1111/jdv.18926
9. Finner, A. (2011). Alopecia areata: Clinical presentation, diagnosis, and unusual cases. Dermatologic Therapy, 24(3), 348–354. https://doi.org/10.1111/j.1529-8019.2011.01413.x
10. Moussa, A., Bokhari, L., & Sinclair, R. (2022). Alopecia areata: A review of diagnosis, pathogenesis and the therapeutic landscape. Wound Practice & Research, 30(1), 24–33. https://doi.org/10.33235/wpr.30.1.24-33
11. Rudnicka, L., Arenbergerova, M., Grimalt, R., Vogt, A., Ioannides, D., Malinaricova, E., Tosti, A., & Messenger, A. (2024). European expert consensus statement on the systemic treatment of alopecia areata. Journal of the European Academy of Dermatology and Venereology, 38(4), 687–694. https://doi.org/10.1111/jdv.19768
12. Yang, C. C., Chen, C. C., Lin, T. K., Chen, Y. J., Wu, Y. H., & Chiu, H. Y. (2025). Taiwanese Dermatological Association consensus on the diagnosis and management of alopecia areata. Dermatologica Sinica, 43(1), 26–35. https://doi.org/10.4103/ds.ds_89_24
13. Harries, M., Ascott, A., Asfour, L., Chiu, W. S., Geffen, L., Gawkrodger, D. J., Goodfield, M., Holmes, S., Macfarlane, S., Messenger, A. G., Takwale, A., Thomson, J., Wall, D., Savage, K., Champaneria, R., Exton, L. S., & Levell, N. J. (2025). British Association of Dermatologists living guideline for managing people with alopecia areata 2024. British Journal of Dermatology, 192(2), 190–205. https://doi.org/10.1093/bjd/ljae387
14. Park, H., Kim, J., Choi, J., Huh, C. H., Lew, B. L., Lee, W. S., Shin, H., Kang, H., Kim, M. B., & Kim, D. W. (2023). Guidelines for the management of patients with alopecia areata in Korea: Part II systemic treatment. Annals of Dermatology, 35(3), 205–216. https://doi.org/10.5021/ad.22.215
15. Cranwell, W., Lai, V., Photiou, L., Goodman, G., & Sinclair, R. (2019). Treatment of alopecia areata: An Australian expert consensus statement. Australasian Journal of Dermatology, 60(2), 163–170. https://doi.org/10.1111/ajd.12941
16. Katakam, B., Behera, B., Ranugha, P., Dhar, S., Srinivas, S. M., Valia, A. R., & Shah, B. J. (2022). IADVL SIG Pediatric Dermatology (Academy) recommendations on childhood alopecia areata. Indian Dermatology Online Journal, 13(6), 710–720. https://doi.org/10.4103/idoj.idoj_222_22
17. Alopecia Areata Management Guideline Committee, Oyama, M., Ito, T., Inui, S., Ohyama, M., Kishimoto, S., Kono, M., Tsuruta, D., Nakagawa, H., & Manabe, M. (2024). Alopecia areata management guidelines 2024. Japanese Journal of Dermatology, 134(11), 2491–2526. https://doi.org/10.14924/dermatol.134.2491
18. Chinese Hair Research Society. (2020). China alopecia areata management guidelines (2019). Clinics in Dermatology, 49(1), 69–72.
19. Asfour, L., De Brito, M., Al-Janabi, A., Exton, L. S., Messenger, A. G., & Harries, M. (2023). Global Guidelines in Dermatology Mapping Project (GUIDEMAP): A systematic review of alopecia areata clinical practice guidelines. Clinical and Experimental Dermatology, 48(2), 100–107. https://doi.org/10.1093/ced/llac017
20. Gregoire, S., & Mostaghimi, A. (2023). Effective counseling of patients with hair loss. Journal of the American Academy of Dermatology, 89(3S), S40–S42. https://doi.org/10.1016/j.jaad.2023.04.053
21. King, B., Mesinkovska, N., Craiglow, B., Wyrwich, K. W., Hareendran, A., Edson-Heredia, E., McDearmon, B., & Holzwarth, K. (2022). Development of the Alopecia Areata Scale for clinical use: Results of an academic–industry collaborative effort. Journal of the American Academy of Dermatology, 86(2), 359–364. https://doi.org/10.1016/j.jaad.2021.08.043
22. ASAMI Consensus Survey Study Group, Moussa, A., Bennett, M., Tziotzios, C., Messenger, A. G., Wall, D., & Sinclair, R. (2024). The Alopecia Areata Severity and Morbidity Index (ASAMI) study: Results from a global expert consensus exercise on determinants of alopecia areata severity. JAMA Dermatology, 160(3), 341–350. https://doi.org/10.1001/jamadermatol.2023.5869
23. Xia, E., Li, S., Drake, L., Wyrwich, K. W., Edson-Heredia, E., & Mostaghimi, A. (2023). An assessment of current clinician-reported and patient-reported outcome measures for alopecia areata: A scoping review. Journal of Investigative Dermatology, 143(7), 1133–1137.e12. https://doi.org/10.1016/j.jid.2022.12.023
24. Chernyshov, P., Tomas-Aragones, L., Finlay, A. Y., Manolache, L., Marron, S. E., Salavastru, C., Suru, A. C., & Augustin, M. (2021). Quality of life measurement in alopecia areata. Position statement of the European Academy of Dermatology and Venereology Task Force on Quality of Life and Patient Oriented Outcomes. Journal of the European Academy of Dermatology and Venereology, 35(8), 1614–1621. https://doi.org/10.1111/jdv.17290
25. Toussi, A., Barton, V. R., Le, S. T., Agbai, O. N., & Kiuru, M. (2021). Psychosocial and psychiatric comorbidities and health-related quality of life in alopecia areata: A systematic review. Journal of the American Academy of Dermatology, 85(1), 162–175. https://doi.org/10.1016/j.jaad.2020.06.047
26. Maloh, J., Engel, T., Natarelli, N., Nong, Y., Zufall, A., & Sivamani, R. (2023). Systematic review of psychological interventions for quality of life, mental health, and hair growth in alopecia areata and scarring alopecia. Journal of Clinical Medicine, 12(3), Article 964. https://doi.org/10.3390/jcm12030964
27. Campos-Alberto, E., Hirose, T., Napatalung, L., & Ohyama, M. (2022). Prevalence, comorbidities, and treatment patterns of Japanese patients with alopecia areata: A descriptive study using Japan Medical Data Center claims database. The Journal of Dermatology, 50(1), 37–45. https://doi.org/10.1111/1346-8138.16599
28. Tsai, T. F., Huang, Y. H., Wei, C. Y., Chen, Y. C., & Tang, C. H. (2024). Epidemiology, treatment patterns, and healthcare resource utilization study of patients with alopecia areata in Taiwan's National Health Insurance Research Database. Value in Health Regional Issues, 43, Article 101007. https://doi.org/10.1016/j.vhri.2024.101007
29. Gregoire, S., McIntosh, B., Sanchez, K., Biba, U., & Mostaghimi, A. (2025). Local corticosteroids for alopecia areata: A narrative review. Dermatology and Therapy, 15(7), 1607–1631. https://doi.org/10.1007/s13555-025-01421-x
30. Yee, B., Tong, Y., Goldenberg, A., & Hata, T. (2020). Efficacy of different concentrations of intralesional triamcinolone acetonide for alopecia areata: A systematic review and meta-analysis. Journal of the American Academy of Dermatology, 82(4), 1018–1021. https://doi.org/10.1016/j.jaad.2019.11.053
31. Contento, M., Cline, A., & Russo, M. (2021). Steroid phobia: A review of prevalence, risk factors, and interventions. American Journal of Clinical Dermatology, 22(6), 837–851. https://doi.org/10.1007/s40257-021-00622-y
32. Majewski, M., Gardaś, K., Waskiel-Burnat, A., Ordak, M., & Rudnicka, L. (2024). The role of minoxidil in treatment of alopecia areata: A systematic review and meta-analysis. Journal of Clinical Medicine, 13(24), Article 7712. https://doi.org/10.3390/jcm13247712
33. Kwon, O., Senna, M. M., Sinclair, R., Atkinson, S. N., Gao, H., Dutronc, Y., & King, B. (2023). Efficacy and safety of baricitinib in patients with severe alopecia areata over 52 weeks of continuous therapy in two Phase III trials (BRAVE-AA1 and BRAVE-AA2). American Journal of Clinical Dermatology, 24(3), 443–451. https://doi.org/10.1007/s40257-023-00764-1
34. King, B., Senna, M. M., Mesinkovska, N. A., Mostaghimi, A., Kwon, O., Guttman-Yassky, E., Cassella, J., & Zwillich, S. H. (2024). Efficacy and safety of deuruxolitinib, an oral selective Janus kinase inhibitor, in adults with alopecia areata: Results from the Phase 3 randomized, controlled trial (THRIVE-AA1). Journal of the American Academy of Dermatology, 91(5), 880–888. https://doi.org/10.1016/j.jaad.2024.06.098
35. Piliang, M., Soung, J., King, B., Mesinkovska, N. A., Sinclair, R., Guttman-Yassky, E., Wolfe, F., Tripathy, S., Napatalung, L., & Zhang, X. (2025). Efficacy and safety of the oral Janus kinase 3/tyrosine kinase expressed in hepatocellular carcinoma family kinase inhibitor ritlecitinib over 24 months: Integrated analysis of the ALLEGRO Phase IIb/III and long-term Phase III clinical studies in alopecia. British Journal of Dermatology, 192(2), 215–227. https://doi.org/10.1093/bjd/ljae373
36. Liu, M., Gao, Y., Yuan, Y., Yang, K., Shi, W., & Zhang, C. (2023). Janus kinase inhibitors for alopecia areata: A systematic review and meta-analysis. JAMA Network Open, 6(6), Article e2320351. https://doi.org/10.1001/jamanetworkopen.2023.20351
37. King, B., Soung, J., Tziotzios, C., Piliang, M., Sinclair, R., Napatalung, L., & Tripathy, S. (2024). Integrated safety analysis of ritlecitinib, an oral JAK3/TEC family kinase inhibitor, for the treatment of alopecia areata from the ALLEGRO clinical trial program. American Journal of Clinical Dermatology, 25(2), 299–314. https://doi.org/10.1007/s40257-023-00836-2
38. Tegtmeyer, K., Zhao, J., Maloney, N., Atassi, G., Besstrum, M., & Lio, P. (2021). Off-label studies on tofacitinib in dermatology: A review. Journal of Dermatological Treatment, 32(4), 399–409. https://doi.org/10.1080/09546634.2019.1673872
39. Su, X., Ou, Y., Ruan, S., Chen, L., Zhang, H., & Lin, Z. (2025). Risk of serious infection with JAK inhibitors in immune-mediated inflammatory skin diseases: A meta-analysis of randomized clinical trials. Journal of Dermatological Treatment, 36(1), Article 2474507. https://doi.org/10.1080/09546634.2025.2474507
40. Ireland, P., Jansson, N., Spencer, S., Braden, J., & Sebaratnam, D. (2024). Short-term cardiovascular complications in dermatology patients receiving JAK-STAT inhibitors. JAMA Dermatology, 160(3), 281–289. https://doi.org/10.1001/jamadermatol.2023.5683
41. Smanuel, C., Cornman, H., Kambala, A., & Kwatra, S. (2023). A review on the safety of using JAK inhibitors in dermatology: Clinical and laboratory monitoring. Dermatology and Therapy, 13(3), 729–749. https://doi.org/10.1007/s13555-023-00892-2
42. Levine, J., Islam, R. K., Mo, L., Li, S., Mostaghimi, A., & Barbieri, J. S. (2025). Short-term malignancy risk of JAK inhibitors in severe alopecia areata: A multicenter cohort study. Archives of Dermatological Research, 317(1), Article 757. https://doi.org/10.1007/s00403-025-03712-4
43. Meah, N., Wall, D., York, K., Bhoyrul, B., Bokhari, L., Sigurdsson, V., Ekelem, C., & Sinclair, R. (2020). The Alopecia Areata Consensus of Experts (ACE) study: Results of an international expert opinion on treatments for alopecia areata. Journal of the American Academy of Dermatology, 83(1), 123–130. https://doi.org/10.1016/j.jaad.2020.03.004
44. Rastaghi, F., Kaveh, R., Yazdanpanah, N., Sahaf, A. S., & Ahramyanpour, N. (2023). The efficacy and adverse effects of corticosteroid pulse therapy in alopecia areata: A review article. Dermatology Practical & Conceptual, 13(3), Article e2023255. https://doi.org/10.5826/dpc.1303a255
45. Senila, S., Danescu, S., Ungureanu, L., Candrea, E., & Cosgarea, R. (2015). Intravenous methylprednisolone pulse therapy in severe alopecia areata. Indian Journal of Dermatology, Venereology and Leprology, 81(1), Article 95. https://doi.org/10.4103/0378-6323.148600
46. Egeberg, A., Linsell, L., Johansson, E., Durand, F., Yu, G., & Vañó-Galván, S. (2023). Treatments for moderate-to-severe alopecia areata: A systematic narrative review. Dermatology and Therapy, 13(12), 2951–2991. https://doi.org/10.1007/s13555-023-01048-y
47. Deshmukh, C. (2007). Minimizing side effects of systemic corticosteroids in children. Indian Journal of Dermatology, Venereology and Leprology, 73(4), 218–221. https://doi.org/10.4103/0378-6323.33633
48. Lai, V., & Sinclair, R. (2020). Utility of azathioprine, methotrexate and cyclosporine as steroid-sparing agents in chronic alopecia areata: A retrospective study of continuation rates in 138 patients. Journal of the European Academy of Dermatology and Venereology, 34(11), 2606–2612. https://doi.org/10.1111/jdv.16335
49. Leis-Dosil, V., & Prats-Caelles, I. (2018). Practical management of immunosuppressants in dermatology. Actas Dermo-Sifiliográficas, 109(1), 24–34. https://doi.org/10.1016/j.ad.2017.07.012