British Association of Dermatologists’ guidelines for the management of alopecia areata 2012

Abstract

The guidelines have been revised and updated in accordance with a predetermined scope, based on that used in the 2003 guidelines. Recommendations in these guidelines supersede those in the 2003 guidelines. The objectives of the guidelines are to provide up‐to‐date recommendations for the management of alopecia areata in adults and children and a summary of the evidence base. This guidance has been written by dermatologists and a patient representative. The draft guideline was made available for consultation and review by the British Association of Dermatologists’ (BAD) membership, the Primary Care Dermatological Society (PCDS), the British Dermatological Nursing Group (BDNG) and the board of Alopecia UK, a patient support organization. The final document was peer‐reviewed by the Clinical Standards Unit of the BAD (made up of the Therapy and Guidelines subcommittee) prior to publication. These guidelines have been developed using the BAD’s recommendations1 and also with reference to the AGREE (Appraisal of Guidelines Research and Evaluation) instrument.2 PubMed, MEDLINE and EMBASE databases were searched from January 2002 to January 2012 and full relevant papers in the English language obtained. Additional, targeted searches were also carried out across these three databases, as well as a search on the Allied and Complementary Medicine Database (AMED); details of the search strategy are available as an Appendix online (see Supporting Information). The recommendations made are those that are currently considered best practice. Where possible they are based on randomized controlled trials (RCTs). However, in view of the limited evidence from RCTs, guidance is also based on less rigorously controlled studies, uncontrolled studies, on clinical experience, and on patient experience. These recommendations will be modified at intervals in light of new evidence. This document has been prepared on behalf of the BAD and is based on the best data available when the document was prepared. It is recognized that under certain conditions it may be necessary to deviate from the guidelines, and that the results of future studies may require some of the recommendations herein to be changed. Failure to adhere to these guidelines should not necessarily be considered negligent, nor should adherence to these recommendations constitute a defence against a claim of negligence. The proposed revision date for this set of recommendations is scheduled for 2017; where necessary, important interim changes will be updated on the BAD website. Alopecia areata is a chronic inflammatory disease that affects the hair follicle and sometimes the nail. The onset may be at any age and there is no known race or sex preponderance. Alopecia areata usually presents as patches of hair loss on the scalp but any hair‐bearing skin can be involved. The affected skin may be slightly reddened but otherwise appears normal. Short broken hairs (exclamation mark hairs) are frequently seen around the margins of expanding patches of alopecia areata. The nails are involved in about 10% of patients referred for specialist advice. Hair follicles are preserved in alopecia areata and the potential for recovery of hair growth is maintained, even in longstanding disease. One study from Japan reported that spontaneous remission within 1 year occurred in 80% of patients with a small number of circumscribed patches of hair loss.3 Data from secondary and tertiary referral centres are less favourable indicating that 34–50% of patients will recover within 1 year. Almost all will experience more than one episode of the disease, and 14–25% progress to total loss of scalp hair (alopecia totalis, AT) or loss of the entire scalp and body hair (alopecia universalis, AU), from which full recovery is unusual (< 10%).4, 5 Disease severity at presentation is the strongest predictor of long‐term outcome. In an Italian study, 191 patients with alopecia areata who presented to a university dermatology clinic between 1983 and 1990 were contacted by telephone in 2005 to give self‐reports of their clinical status.6 Patients with less severe disease at presentation were more likely to report being free of disease at follow‐up (68% with less than 25% hair loss initially; 32% with 25–50% hair loss initially; 8% with more than 50% hair loss initially). Patients with more severe disease initially were also more likely to report worsening patterns of alopecia such as AT and AU. The prognosis is also less favourable when onset occurs during childhood4, 7–9 and in ophiasis.9 The concurrence of atopic disease has been reported to be associated with a poor prognosis3, 9 but this has been disputed.10 About 20% of people with alopecia areata have a family history of the disease indicating a genetic predisposition.11 Associations have been reported with a variety of genes, including major histocompatibility complex (MHC) and cytokine genes, suggesting that the genetic predisposition is multifactorial in n