Alopecia areata has never had standardised treatment guidelines, which the authors note has led both to poor outcomes and to payers refusing cover. This Delphi study assembled 31 US-based experts with recent research and substantial clinical experience, who rated 29 treatments across three rounds of anonymous iterative surveys, with consensus set at 70% agreement and informed by systematic review.
Consensus was reached for adults with severe disease, defined by the Alopecia Areata Scale. Oral Janus kinase inhibitors are the primary long-term therapy for all such patients, with dupilumab as an alternative where there is comorbid atopy. Supplemental treatments include oral and topical minoxidil; intralesional, oral and high-potency topical corticosteroids; and topical JAK inhibitors and prostaglandins, each with body-site-specific indications. The panel also states that patient support resources should be offered alongside drug treatment.
Read the exclusions as carefully as the recommendations. This does not apply to children, pregnant patients, mild-to-moderate disease, or patients with underlying comorbidities — which excludes a large share of a real clinic. It is also explicitly a US consensus, so the positioning of expensive oral JAK inhibitors as first-line for everyone will not transfer directly to settings where access is the binding constraint. Its most exportable contribution is the framing of alopecia areata as a disease with a defined severity threshold and a treatment ladder, rather than a cosmetic problem.
- Oral JAK inhibitors: primary long-term therapy for severe disease in adults
- Dupilumab an alternative where there is comorbid atopy
- Minoxidil, corticosteroids, topical JAK inhibitors and prostaglandins as supplements
- Excludes children, pregnancy, mild-moderate disease and significant comorbidity
The statistics, in plain English
A Delphi consensus is expert opinion made systematic, not evidence: the 70% agreement threshold measures how far specialists concur, not how well the treatments work. That matters most for the supplemental therapies, several of which have thin trial evidence and reached consensus largely on experience. The JAK inhibitor recommendation is the one backed by randomised data; treat the rest as informed practice rather than proven benefit.
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