US Expert Consensus Positions Oral JAK Inhibitors as Primary Therapy for Severe Alopecia Areata

A Delphi consensus statement in JAMA Dermatology addresses treatment of severe alopecia areata in US adults. Systematic PubMed reviews covered randomized trials and observational studies published in English through December 2024, including adults with moderate to severe disease and Severity of Alopecia Tool scores above 20%. Thirty-one US experts assessed 29 treatments across three anonymous survey rounds from May through November 2025; consensus required at least 70% agreement.

For severe disease defined by the Alopecia Areata Scale, the panel positioned oral Janus kinase (JAK) inhibitors as primary long-term therapy, with dupilumab as an alternative for patients with comorbid atopy. Supplemental options included oral and topical minoxidil; intralesional, oral, and high-potency topical corticosteroids; and topical JAK inhibitors and prostaglandins, with body site–specific indications. Experts also recommended offering patient support resources alongside medical treatment.

The statement provides an expert-established treatment framework, not new evidence of comparative efficacy. The authors call for higher-quality studies in subpopulations and head-to-head comparisons. They state that the recommendations do not apply to children, pregnant patients, mild to moderate disease, or patients with underlying comorbidities. The abstract does not clarify how that last exclusion aligns with the recommendation for comorbid atopy; full-text review is needed to resolve the scope.