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Introducing New Standards in Assessing and Tracking Alopecia Areata

Consensus on an unpredictable, inconsistent disease

Man with alopecia areata on head, Spot Baldness, Hair fall problem

Alopecia areata (AA) is an unpredictable disease. Hair loss can occur in only a few spots or all over the head (alopecia areata totalis), or all over the body (alopecia areata universalis). In some patients, hair grows back. In others, hair grows back but then falls out again. Generally the hair follicles are not totally lost.


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In addition to inconsistent presentation, there has been no consensus on how to treat the condition — although multiple (off-label) treatments are available.

With today’s electronic medical records and collaborative databases, as well as the potential for FDA approval of new medications for AA, the time is ripe to collect comparative clinical data. But clinicians can’t do it without setting some standards first, says Wilma Bergfeld, MD, senior dermatologist and Emeritus Director of Dermatopathology at Cleveland Clinic.

Dr. Bergfeld was part of a group of hair disorder experts that recently published their recommended standards for diagnosing, assessing and tracking treatment outcomes of patients with AA in the Journal of the American Academy of Dermatology.

How to evaluate and assess AA

Based on literature review and the group’s expert opinions, the new recommendations outline standards for diagnosing AA, based on characteristic and supportive features, such as exclamation point hairs and fine pitting of nails.

Recommendations for evaluation include:

  • Patient history. The group lists eight potentially negative prognostic factors — such as childhood onset, atopy, type 1 diabetes and autoimmune disorders — which may affect treatment decisions and outcomes.
  • Physical examination. Important factors are severity of hair loss (including body hair loss), pattern of hair loss (patchy, diffuse, ophiasis or totalis), activity of hair loss (as determined by presence of exclamation point hairs and hair pull) and nail involvement (even if not affecting all 20 nails).
  • Scalp biopsy.

To assess AA progression and/or treatment outcomes, the group recommends using one or more of these methods:

  • Global assessment (for patients using systemic or whole-scalp therapies). Severity of Alopecia Tool (SALT) and Alopecia Density and Extent (ALODEX) scores can help quantitatively assess percentage or extent of scalp hair loss. The Alopecia Areata Progressive Index calculates percentage of hair loss by quadrant, based on hair pull and dermoscopic examination.
  • Half-head assessment (to compare treated vs untreated sides of a patient’s scalp). SALT and ALODEX scores still apply.
  • Lesion assessment (when treating patches of hair loss). This involves selecting one to three patches of hair loss and recording their area and density as determined by Lesional Area and Density (LAD) score.
  • Adjuvant measurements. This can include recording the percentage of nondyed hair before and after treatment, percentage of vellus hair (using SALT or ALODEX scores) and activity of hair loss.


“In addition to assessing the condition, it’s important to assess patient expectations and quality of life,” says Dr. Bergfeld. “That can involve helping patients self-assess their hair loss — which can vary by their perception of it and ability to camouflage it.”

Because hair loss and regrowth occur gradually, photographing the patient’s progression is also important, she notes.

Determining end points

Determining end points is another variable and highly subjective area, yet one that must be quantified in order to accurately assess outcome. The group defines the primary end point as change in hair growth from baseline, as assessed by the physician.

“Achieving 100 percent hair regrowth isn’t always feasible because the targeted therapies may not be precise enough,” says Dr. Bergfeld. “Instead, we suggest a 50 percent improvement in SALT or ALODEX score as a reasonable target for AA treatment.”

How long it takes hair to regrow varies by treatment: three to four months for topical medications like corticosteroids, four to six weeks for intralesional steroids, although growth may not be uniform. Systemic medications can provide more consistent overall growth in four to six weeks.

“It takes at least 12 weeks to determine the efficacy of an AA treatment,” says Dr. Bergfeld. “So, don’t stop treatment too soon.”

A first step in establishing best practices

Setting standards for assessing hair loss and growth, including treatment response criteria and end points, is the first step toward establishing best practices in managing AA.

“With these standards, we’ll be able to collect more meaningful data on the disease and its treatment outcomes,” says Dr. Bergfeld. “Comparative data will help guide future use of therapeutic agents for certain subtypes of AA in clinical practice and trials.”


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