Asia-Pacific panel puts JAK inhibitors first-line in severe alopecia

By Tom Whitfield

An 18-member Asia-Pacific panel reached consensus on 140 of 183 statements on alopecia areata in a modified Delphi study, leaving 43 unresolved. The panel endorsed approved JAK inhibitors as first-line systemic therapy for severe disease in patients aged 12 and older, rather than reserving them as a last resort.

The panel comprised dermatologists from Australia, China, India, the Republic of Korea, Malaysia, Singapore, Taiwan and Thailand. Every participant had at least 10 years of experience in alopecia areata.

Over three rounds, the panel completed an initial online survey, held an in-person discussion and conducted additional online voting. Statements used Likert-type and multiple-choice formats, with consensus defined as at least 70% agreement or disagreement. Forty-three of 183 statements failed to reach consensus, mainly where regional practice, treatment access or evidence remained unsettled.

Why did the panel issue regional guidance?

The panel targeted a gap created by recent drug approvals and uneven national guidance. No treatment had been specifically indicated for alopecia areata before the FDA’s 2022 approval of baricitinib.

The agency then approved ritlecitinib and deuruxolitinib, with deuruxolitinib approved on July 26, 2024. Across the three approvals, indications covered adults, adolescents or both with severe disease.

China, Japan, the Republic of Korea and Taiwan have national alopecia areata guidelines. Many other Asia-Pacific countries lack disease-specific guidance or have not updated recommendations to reflect the new approvals.

The authors chose a region-focused consensus rather than guidance developed for North American or European health systems.

What does the consensus recommend for severe disease?

• Patients aged 12 and older with severe disease: Use approved JAK inhibitors as first-line systemic therapy, not as a last resort.
• Rapidly progressive, widespread disease: Use short-term systemic corticosteroids only to temporarily halt progression.
• Adults with moderate disease: Start with intralesional corticosteroids, administered at intervals of 3 to 6 weeks.
• Patients aged 12 and older with active mild disease: Use intralesional corticosteroids alone or combined with a topical corticosteroid.
• Chronic cases: Add minoxidil as adjuvant treatment.

How did the panel define severity and diagnosis?

Moderate alopecia areata involves 21% to 49% scalp hair loss; severe disease involves 50% or more. Eyebrow, eyelash or beard involvement with significant quality-of-life impairment can qualify a patient as moderate to severe regardless of the scalp percentage.

Trichoscopy was deemed essential for diagnosis and monitoring. Skin biopsy was reserved for cases in which the cause of hair loss was unclear. The panel also noted that no validated diagnostic biomarkers yet exist.

The authors framed the consensus as region-focused. “The modified Delphi-based consensus provides a practical, region-focused framework to standardize the diagnosis and management of AA across diverse APAC healthcare settings in hope of improving patient outcomes,” the researchers wrote.

How should clinicians treat younger children?

The panel could not agree on short-term systemic corticosteroids as a first-line option in children younger than 12 with severe disease, citing a lack of real-world evidence in that age group. That differs from a separate international consensus, which recommended oral corticosteroids as first-line therapy for children aged 7 to 12 during an acute flare.

Members also reached no consensus on whether a multidisciplinary care model was necessary or on topical immunotherapy and other off-label local treatments. Several of those treatments were not widely available across the represented countries.

Can patients access the recommended treatments?

The authors cautioned that their recommendations assume all treatments approved by the FDA or European Medicines Agency are accessible throughout Asia-Pacific. Regulatory approval status, health care infrastructure and cost vary considerably by country. A treatment recommendation therefore does not guarantee patient access.

The consensus gives clinicians an algorithm tailored to local practice rather than one borrowed from Western guidelines. For payers and health systems, its central limitation is clear: identifying preferred treatment does not resolve unequal access.

Lead author Rodney Sinclair, MD, disclosed extensive industry relationships, including serving as a director of a company holding patents on minoxidil for hair loss. He also reported investigator or advisory roles with dozens of pharmaceutical companies, and several coauthors disclosed industry relationships.

The recommendations appeared as “Epidemiology, diagnosis and management of alopecia areata: an Asia-Pacific modified Delphi expert panel recommendations” in the International Journal of Dermatology, 2026;65(10):2091-2101. The DOI is 10.1111/ijd.70335.

The next test is whether country-level approvals, affordability and health care infrastructure can support the panel’s first-line positioning of JAK inhibitors for severe alopecia areata.