A Delphi process asked 31 US alopecia areata experts, over three anonymous survey rounds in 2025, whether they agreed with each of 29 treatments for adults with severe disease, after systematic literature reviews of each. Consensus required 70% agreement.
Oral Janus kinase (JAK) inhibitors reached consensus as the primary, long-term therapy for all adults with severe alopecia areata. Dupilumab was the alternative for patients with comorbid atopy. Oral and topical minoxidil, intralesional, oral and high-potency topical corticosteroids, and topical JAK inhibitors and prostaglandins were agreed as supplements for specific body sites. Patient support should accompany treatment.
Until now there has been no structured US guidance for severe disease, and treatment has ranged from repeated steroid pulses to long courses of immunosuppressants. This statement positions JAK inhibition as long-term therapy rather than a short rescue.
It is expert opinion built on the evidence, not a trial, and it explicitly excludes children, pregnancy, mild to moderate disease and patients with significant comorbidities.
- Grade severity with a formal tool (SALT or the Alopecia Areata Scale) before choosing therapy.
- Discuss oral JAK inhibition as long-term, since relapse after stopping is common.
- Screen before JAK inhibitors: infection, TB, lipids, blood counts, thrombosis and cardiovascular risk.
- Consider dupilumab in patients with active atopic disease.
- Offer patient support resources, not only medication.
Why it matters
It frames severe alopecia areata as a chronic disease needing maintenance therapy, not repeated short rescue courses.
Don't overread it
This is a US expert consensus, not a trial or a formal guideline, and it does not apply to children, pregnancy or milder disease.
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