Alopecia areata acquired effective drugs faster than it acquired guidance on how to use them. This Delphi consensus set out to fill that gap for adults with severe disease in the United States.
Thirty-one US-based experts completed three rounds of anonymous iterative surveys between May and November 2025, with consensus predefined at 70% agreement. Systematic literature reviews covered all known therapies to December 2024, restricted to randomised or observational studies in adults with moderate-to-severe disease defined by a Severity of Alopecia Tool score above 20%. Panellists rated 29 treatments, and those reaching consensus were then explored for positioning, regimen and long-term management.
Oral Janus kinase inhibitors emerged as the primary, long-term therapy for all patients, with dupilumab as an alternative where there is comorbid atopy. Supplemental treatments reaching consensus were oral and topical minoxidil; intralesional, oral and high-potency topical corticosteroids; and topical JAK inhibitors and prostaglandins, with body-site-specific indications. The panel also agreed that patient support resources should be offered alongside medical treatment — a rare and welcome inclusion in a treatment consensus.
The exclusions are as important as the recommendations. These do not apply to children, to pregnant patients, to mild-to-moderate disease, or to patients with underlying comorbidities, and the panel says so explicitly.
For Indian practice the framing is the useful part rather than the drug list, since oral JAK inhibitor cost puts it beyond most patients. Knowing that intralesional and topical corticosteroids, and topical and oral minoxidil, are supplemental rather than primary therapy is still worth having: it sets expectations honestly for a patient who cannot access the primary option.
- Oral JAK inhibitors are the consensus primary long-term therapy for severe alopecia areata in adults
- Consider dupilumab as an alternative where there is comorbid atopy
- Treat minoxidil, corticosteroids, topical JAK inhibitors and prostaglandins as supplemental, not primary
- Do not extend these recommendations to children, pregnancy, mild-to-moderate disease or significant comorbidity
- Offer patient support resources alongside drug treatment — the panel reached consensus on this too
The statistics, in plain English
A Delphi consensus measures agreement among experts, not effect size, and the 70% agreement threshold is a convention rather than a statistical property — a treatment reaching 71% agreement is not meaningfully different from one reaching 69%. The panel was 31 US-based experts, so this reflects US practice patterns and US drug availability, both of which shape what gets endorsed. Its value lies in the therapeutic positioning — which drug is primary and which supplemental — because that ordering is exactly what trials do not test, since head-to-head comparisons in alopecia areata are almost entirely absent.
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