Since FDA-approved treatments for severe alopecia areata became available in 2022, there has been renewed hope for hair regrowth for individuals living with this autoimmune disease. To guide care, leading dermatologists partnered with the National Alopecia Areata Foundation (NAAF) and the American Hair Research Society (AHRS) to develop the first expert consensus on treatment recommendations for adults with severe disease.

The recommendations were developed using a modified Delphi method, a structured survey conducted over multiple rounds to reach group consensus. The final consensus statement was published in JAMA Dermatology.

These guidelines help dermatologists and other healthcare providers, patients, and insurers understand recommended treatments and what quality care should look like. They also recognize that alopecia areata affects more than hair—highlighting the importance of emotional well-being and encouraging discussions about options such as medical wigs (cranial prostheses) as part of overall care.

Understanding Severity

Doctors use different tools to understand how severe alopecia areata is. One common tool is called the Severity of Alopecia Tool (SALT). It measures the percentage of hair loss on the scalp, using a scale from 0 to 100:

• 0 = no scalp hair loss
• 100 = complete scalp hair loss

In general, a SALT score of 50 or higher is considered severe.

However, SALT only looks at scalp hair loss. It does not take into account hair loss on the eyebrows, eyelashes, or body—or how the condition affects a person’s daily life.

To provide a more complete picture, researchers developed a newer tool in 2022 called the Alopecia Areata Severity Scale (AASc). The new treatment recommendations use this updated scale, which looks at multiple factors, including:

• Scalp hair loss
• Eyebrow and eyelash loss
• Body hair loss
• How well treatments are working
• The impact on a person’s daily life and well-being

By considering all of these factors, doctors can better understand each person’s experience and choose the most appropriate treatment.

The consensus recommendations utilize the AASc, meaning that a patient may be considered to have severe alopecia areata if they have:

50% or more scalp hair loss;

OR

20–49% scalp hair loss plus one or more of the following:

• • Significant emotional or social impact
  • Noticeable eyebrow or eyelash loss
  • Hair loss that has not improved after 6 months of treatment
  • Rapidly progressing hair loss

This is important because it recognizes the tremendous impact of eyebrow and eyelash loss and the emotional toll that the disease has on a patient.

Learn more about how severity is determined.

Initial (First-Line) Treatment Recommendations

Experts recommend that FDA-approved oral JAK inhibitors be used as the initial treatment for adults with severe alopecia areata. These medications are now considered the standard of care.

NOTE: Dupilumab (Dupixent) may be considered for people with severe AA who also have atopic conditions, such as eczema, allergic asthma or allergic rhinitis.

What this means for patients:

• Patients may be prescribed an FDA-approved JAK inhibitor treatment as an initial treatment for their severe alopecia areata. The treatment should be taken for at least 6 to 12 months to see how well it works
• If it’s helping, the recommendation is for patients to stay on it long-term
• If one FDA-approved JAK inhibitor doesn’t work well enough, your provider may switch you to a different JAK inhibitor

What are the FDA-approved JAK inhibitors?

Read more about current FDA-approved JAK Inhibitors.

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Adjunctive Therapies

In addition to recommending JAK inhibitors as primary treatment for severe alopecia areata, the consensus statement also notes adjunctive (add-on) therapies to support regrowth. These include:

Treatments That Are No Longer Recommended

Experts reached consensus that several older medications should not be part of standard treatment for severe AA in adults because of limited evidence for safety and effectiveness.

These include medications such as:

• Methotrexate
• Cyclosporine
• Azathioprine
• Mycophenolate
• Long-term oral steroids

This is an important change. In the past, people were often required to try older treatments that didn’t work as well before they could access newer therapies. Today, there is a clearer path to treatments that are supported by stronger evidence.

Wigs, Camouflage, and Mental Health Matter

The recommendations also formally recognize that supportive care is an important part of treatment for alopecia areata.

Healthcare providers are encouraged to discuss options such as cranial prostheses (wigs) and other camouflage approaches, provide letters of medical necessity to support insurance coverage, and address the emotional and mental health impact of the condition. When appropriate, providers may also refer patients to mental health services and connect them with advocacy organizations, such as NAAF, for additional support.

These recommendations emphasize a key point: hair loss is not “just cosmetic.” The emotional and psychological effects of alopecia areata are real, and these guidelines recognize the importance of treating the whole patient.

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Why Are These Recommendations Significant?

These recommendations provide a nationally recognized standard of care for adults with severe alopecia areata. They identify FDA-approved oral JAK inhibitors as first-line treatment and recognize that severe disease may include not only significant scalp hair loss but also eyebrow or eyelash loss and the emotional burden associated with the condition.

The recommendations also highlight that patients should not automatically be required to try older medications with limited evidence before accessing newer therapies. Additionally, they recognize that wigs (cranial prostheses) and mental health support are valid and essential parts of care. These recommendations currently apply to adults with severe alopecia areata; they do not yet include treatment options for children, pregnant individuals, or those with mild-to-moderate disease, as further research is still needed.

For the first time in the U.S., there is clear, expert agreement on how to treat severe alopecia areata. This clarity helps patients advocate for insurance coverage, supports clinicians in making informed treatment decisions, and helps policymakers and insurers better understand the current standard of care.

If you have questions about your treatment options or are facing challenges with insurance coverage, discuss them with your healthcare provider and visit NAAF’s resources, including “Partnering with Your Healthcare Provider” and “Understanding Treatment and Insurance”.