BACKGROUND/OBJECTIVES:To estimate the lifetime and point prevalence of alopecia areata (AA) among Australians aged ≥ 15 years. METHODS:A cross-sectional survey was conducted from August to September 2024 in a quota-balanced sample of the Australian population, aged ≥ 12 years (exploratory objective included participants aged 12-14 years). Participants completed the Alopecia Assessment Tool (ALTO) to identify AA. Participants with AA completed the Scalp Hair Assessment Patient-Reported Outcome to assess hair loss and a questionnaire on hair loss experience. Lifetime prevalence was calculated as the proportion of participants with AA per the ALTO, and point prevalence was calculated as the proportion of participants with AA per the ALTO and current scalp hair loss. RESULTS:Of 8,256 participants, 194 had potential AA, and of those, 188 were aged ≥ 15 years. The lifetime prevalence (95% CI) of AA among those aged ≥ 15 years ranged from 1.2% (1.08-1.32) to 2.3% (2.13-2.47), with a point prevalence (95% CI) of 0.9% (0.79-1.01) to 1.4% (1.27-1.53). Of 194 participants with potential AA, 125 had healthcare provider (HCP)-diagnosed AA and 69 had self-diagnosed AA. More self-diagnosed participants had active hair loss than HCP-diagnosed participants. Thirty-nine HCP-diagnosed participants (31.2%) were not using any treatment/management approach, and of those, 23.1% were unaware of treatment/management options. Most self-diagnosed participants were using shampoos/conditioners recommended for hair loss (62.3%). CONCLUSIONS:There is a need for improved AA education in Australia to increase awareness, given that approximately 36% of participants were self-diagnosed and 31% of HCP-diagnosed participants were not using treatment or a management approach.

BACKGROUND:Alopecia areata (AA) affects all ages, genders, and ethnicities. AA severely impacts patients' quality of life. Treatments indicated for AA have only been approved since 2022/2023. While some Asia Pacific (APAC) countries/regions have national or regional guidelines, many lack AA-specific guidance or have not updated existing guidelines to incorporate recently approved treatments. METHODS:To better inform treatment decisions, 18 dermatologists from Australia, China, India, Korea, Malaysia, Singapore, Taiwan, and Thailand completed a three-round Delphi-based consensus process involving survey completion, open discussion, and statement voting. A consensus for Likert-type and multiple-choice statements was defined as ≥ 70% agreement or disagreement. RESULTS:Consensus was achieved on 140 statements. The panel recognizes that AA is clinically heterogeneous and imposes a considerable burden on patients and their families. Trichoscopy is deemed essential for diagnosing and monitoring AA, while skin biopsy is reserved for when the cause of hair loss is unclear. In terms of disease severity, moderate AA is defined as 21%-49% hair loss and severe AA as ≥ 50% hair loss. Regarding treatment, topical corticosteroids are recommended in children < 12 years. For patients aged ≥ 12 years, topical and intralesional corticosteroids could be used for mild-to-moderate AA, while Janus kinase inhibitors and systemic corticosteroids have a role in moderate-to-severe AA. Adjuvant minoxidil could also be used in chronic AA. CONCLUSIONS:This 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.

BACKGROUND:As the incidence of frontal fibrosing alopecia (FFA) continues to rise, there is a need for an optimal treatment algorithm for FFA. OBJECTIVES:To produce an international consensus statement on the treatment modalities and prognostic indicators of FFA. METHODS:Sixty-nine hair experts from six continents were invited to participate in a three-round Delphi process. The final stage was held as a virtual meeting facilitated via Zoom. The consensus threshold was set at ≥66%. RESULTS:Of 365 questions, expert consensus was achieved in 204 (56%) questions following completion of the three rounds. Three additional questions were included at the final meeting. The category with the strongest consensus agreement was disease monitoring (9; 100%). Questions pertaining to physical therapies achieved the least category consensus (15; 40%), followed by systemic therapy (45; 43%). LIMITATIONS:The study lacked sufficient representation from Africa and South America. CONCLUSIONS:SOFFIA highlights areas of agreement and disagreement among experts. Robust research is warranted to provide evidence-based treatment recommendations.

Over 5000 patients are newly diagnosed with Alopecia areata (AA) in Australia each year. AA severity varies from a single small patch to complete loss of scalp hair, body hair including eyelashes and eyebrows. Approximately 40% of affected individuals experience only a single patch and achieve spontaneous, complete and durable remission within 6 months (acute AA). A further 27% develop additional patches but still attain complete remission within 12 months (chronic AA). Chronic persistent AA (CPAA) is defined by an episode duration of > 12 months and occurs in approximately 33% of patients. Without systemic treatment, 55% of individuals with CPAA will have persistent multifocal relapsing and remitting disease, 30% will progress to alopecia totalis (AT) and 15% will ultimately develop alopecia universalis (AU). The physical disfigurement, unpredictable course, social isolation and rejection contribute to the psychological distress attributable to AA. A wide range of topical, intralesional and systemic agents used to treat AA were evaluated in the 2018 Australian expert consensus statement. In 2020, the international Alopecia Areata Consensus of Experts (ACE) publication stated that if reimbursed, Janus Kinase inhibitors (JAKi's) would be an ideal systemic treatment for adults with AA. TGA approval of baricitinib in 2023 and ritlecitinib in 2024 for severe AA is the first step on the pathway for these systemic medications to be reimbursed on the Australian Government Pharmaceutical Benefits Scheme (PBS). Reimbursement would significantly transform the Australian therapeutic landscape for AA. The purpose of this 2025 Update on the Australian Expert Consensus Statement on the treatment of chronic, moderate to severe AA is to augment the 2018 treatment algorithm to include these TGA-approved medications and to address indications for initiation, continuation and dose titration of systemic JAKi treatment, appropriate choice of agent, satisfactory outcome measures and to provide guidance on when to discontinue successful or unsuccessful treatment.

BACKGROUND/OBJECTIVES:Janus kinase inhibitors (JAKis) have been approved by the Therapeutic Goods Administration for severe alopecia areata (AA) in Australia. However, access is limited as JAKis are not currently subsidised on the Pharmaceutical Benefits Scheme for this indication. This study aimed to establish expert consensus on criteria for initiating and continuing subsidised JAKi therapy for AA. METHODS:An eDelphi study was conducted with 26 Australian specialists in hair and scalp disorders, who participated in two online survey rounds. A third round, held as a virtual meeting, facilitated discussion. Consensus was defined as ≥ 75% agreement or disagreement. RESULTS:Twenty-six, twenty-two, and twenty-five experts completed the first, second, and third rounds, respectively. Experts agreed that JAKis were nearly always the best treatment for cases with ≥ 50% scalp hair loss and usually the best treatment for 21%-49% scalp hair loss. The most important additional factors when assessing eligibility for JAKis were refractory disease, rapid progression, psychosocial morbidity, poorly camouflaged hair loss, ophiasis pattern, and impaired quality of life. Treatment failure was defined as < 50% improvement in scalp hair loss after 12 months of therapy. Indicators of remission included achieving SALT 0, regrowth of facial hair, improved DLQI scores, patient satisfaction, negative hair pull test, and reduced psychosocial impairment. CONCLUSIONS:This expert consensus provides a framework for determining eligibility for subsidised JAKi therapy in Australian AA patients. Future research, supported by patient registries, should incorporate patient perspectives to further refine these criteria, ensure equitable access to treatment, and assess real-world impact, safety, and effectiveness.

Anti-aging trends in Australia have changed considerably since the country emerged from the lockdowns associated with the SARS-Cov2 pandemic. People now rely on social media influencers for skin care advice and skin care products, including professional skin care treatments that can be purchased on Internet platforms. The quest for the perfect 'zoom face' led to a 300% rise in cosmetic procedures across Australia in the year to April 2021. People now want to use less products on their skin, while looking healthy and natural (termed 'skin minimalism'). The popularity of retinoid derivatives for preventing wrinkles has been superseded by non-irritating actives like hyaluronic acid (HA) and niacinamide that provide skin barrier protection, skin hydration, plumping and anti-inflammatory effects. Botulinum toxin injections remain the most popular non-surgical cosmetic procedure, followed by HA fillers, and biostimulators that promote the synthesis of collagen and give longer lasting but more gradual results than HA fillers. Laser resurfacing is widely used for epidermal resurfacing and skin tightening, as well as non-ablative lasers, intense pulsed light and radiofrequency or ultrasound skin tightening devices. Superficial chemical peels are still popular because they are relatively gentle, inexpensive, and require no downtime, whereas medium-to-deep chemical peels have largely been superseded by laser technology. However, the most efficient approach to prevent skin aging is adopting a healthy lifestyle and taking action against all factors of the skin aging exposome.

Importance Current measures of alopecia areata (AA) severity, such as the Severity of Alopecia Tool score, do not adequately capture overall disease impact. Objective To explore factors associated with AA severity beyond scalp hair loss, and to support the development of the Alopecia Areata Severity and Morbidity Index (ASAMI). Evidence ReviewA total of 74 hair and scalp disorder specialists from multiple continents were invited to participate in an eDelphi project consisting of 3 survey rounds. The first 2 sessions took place via a text-based web application following the Delphi study design. The final round took place virtually among participants via video conferencing software on April 30, 2022. Findings Of all invited experts, 64 completed the first survey round (global representation: Africa [4.7%], Asia [9.4%], Australia [14.1%], Europe [43.8%], North America [23.4%], and South America [4.7%]; health care setting: public [20.3%], private [28.1%], and both [51.6%]). A total of 58 specialists completed the second round, and 42 participated in the final video conference meeting. Overall, consensus was achieved in 96 of 107 questions. Several factors, independent of the Severity of Alopecia Tool score, were identified as potentially worsening AA severity outcomes. These factors included a disease duration of 12 months or more, 3 or more relapses, inadequate response to topical or systemic treatments, rapid disease progression, difficulty in cosmetically concealing hair loss, facial hair involvement (eyebrows, eyelashes, and/or beard), nail involvement, impaired quality of life, and a history of anxiety, depression, or suicidal ideation due to or exacerbated by AA. Consensus was reached that the Alopecia Areata Investigator Global Assessment scale adequately classified the severity of scalp hair loss. Conclusions and Relevance This eDelphi survey study, with consensus among global experts, identified various determinants of AA severity, encompassing not only scalp hair loss but also other outcomes. These findings are expected to facilitate the development of a multicomponent severity tool that endeavors to competently measure various disease impact. The findings are also anticipated to aid in identifying candidates for current and emerging systemic treatments. Future research must incorporate the perspectives of patients and the public to assign weight to the domains recognized in this project as associated with AA severity.

ImportanceCurrent measures of alopecia areata (AA) severity, such as the Severity of Alopecia Tool score, do not adequately capture overall disease impact.ObjectiveTo explore factors associated with AA severity beyond scalp hair loss, and to support the development of the Alopecia Areata Severity and Morbidity Index (ASAMI).Evidence ReviewA total of 74 hair and scalp disorder specialists from multiple continents were invited to participate in an eDelphi project consisting of 3 survey rounds. The first 2 sessions took place via a text-based web application following the Delphi study design. The final round took place virtually among participants via video conferencing software on April 30, 2022.FindingsOf all invited experts, 64 completed the first survey round (global representation: Africa [4.7%], Asia [9.4%], Australia [14.1%], Europe [43.8%], North America [23.4%], and South America [4.7%]; health care setting: public [20.3%], private [28.1%], and both [51.6%]). A total of 58 specialists completed the second round, and 42 participated in the final video conference meeting. Overall, consensus was achieved in 96 of 107 questions. Several factors, independent of the Severity of Alopecia Tool score, were identified as potentially worsening AA severity outcomes. These factors included a disease duration of 12 months or more, 3 or more relapses, inadequate response to topical or systemic treatments, rapid disease progression, difficulty in cosmetically concealing hair loss, facial hair involvement (eyebrows, eyelashes, and/or beard), nail involvement, impaired quality of life, and a history of anxiety, depression, or suicidal ideation due to or exacerbated by AA. Consensus was reached that the Alopecia Areata Investigator Global Assessment scale adequately classified the severity of scalp hair loss.Conclusions and RelevanceThis eDelphi survey study, with consensus among global experts, identified various determinants of AA severity, encompassing not only scalp hair loss but also other outcomes. These findings are expected to facilitate the development of a multicomponent severity tool that endeavors to competently measure disease impact. The findings are also anticipated to aid in identifying candidates for current and emerging systemic treatments. Future research must incorporate the perspectives of patients and the public to assign weight to the domains recognized in this project as associated with AA severity.

Actinic keratoses are pre-malignant skin lesions that require personalized care, a lack of which may result in poor treatment adherence and suboptimal outcomes. Current guidance on personalizing care is limited, notably in terms of tailoring treatment to individual patient priorities and goals and supporting shared decision-making between healthcare professionals and patients. The aim of the Personalizing Actinic Keratosis Treatment panel, comprised of 12 dermatologists, was to identify current unmet needs in care and, using a modified Delphi approach, develop recommendations to support personalized, long-term management of actinic keratoses lesions. Panellists generated recommendations by voting on consensus statements. Voting was blinded and consensus was defined as ≥ 75% voting 'agree' or 'strongly agree'. Statements that reached consensus were used to develop a clinical tool, of which, the goal was to improve understanding of disease chronicity, and the need for long-term, repeated treatment cycles. The tool highlights key decision stages across the patient journey and captures the panellist's ratings of treatment options for attributes prioritized by patients. The expert recommendations and the clinical tool can be used to facilitate patient-centric management of actinic keratoses in daily practice, encompassing patient priorities and goals to set realistic treatment expectations and improve care outcomes.

Eyebrows and eyelashes serve important anatomical and social functions, and hair loss at these sites can impact patients significantly. Acquired eyebrow and eyelash loss (madarosis) may be due to a variety of underlying local or systemic disease processes; in other cases it may be idiopathic. There is a dearth of literature relating to eyebrow and eyelash loss, and there is limited guidance to help clinicians treat these clinical presentations in comparison with scalp alopecia. Here, we discuss the acquired causes of eyebrow and eyelash alopecia, our clinical approach to diagnosis and review treatment options for clinicians.

Background: We previously reported the Alopecia Areata Consensus of Experts study, which presented results of an international expert opinion on treatments for alopecia areata. Objective: To report the results of the Alopecia Areata Consensus of Experts international expert opinion on diagnosis and laboratory evaluation for alopecia areata. Methods: Fifty hair experts from 5 continents were invited to participate in a 3-round Delphi process. Consensus threshold was set at greater than or equal to 66%. Results: Of 148 questions, expert consensus was achieved in 82 (55%). Round 1 consensus was achieved in 10 of 148 questions (7%). Round 2 achieved consensus in 47 of 77 questions (61%). The final face-to-face achieved consensus in 25 of 32 questions (78%). Consensus was greatest for laboratory evaluation (12 of 14 questions [86%]), followed by diagnosis (11 of 14 questions [79%]) of alopecia areata. Overall, etiopathogenesis achieved the least category consensus (31 of 68 questions [46%]). Limitations: The study had low representation from Africa, South America, and Asia. Conclusion: There is expert consensus on aspects of epidemiology, etiopathogenesis, clinical features, diagnosis, laboratory evaluation, and prognostic indicators of alopecia areata. The study also highlights areas where future clinical research could be directed to address unresolved hypotheses in alopecia areata patient care.

Importance A recent expert consensus exercise emphasized the importance of developing a global network of patient registries for alopecia areata to redress the paucity of comparable, real-world data regarding the effectiveness and safety of existing and emerging therapies for alopecia areata. Objective To generate core domains and domain items for a global network of alopecia areata patient registries. Evidence Review Sixty-six participants, representing physicians, patient organizations, scientists, the pharmaceutical industry, and pharmacoeconomic experts, participated in a 3-round eDelphi process, culminating in a face-to-face meeting at the World Congress of Dermatology, Milan, Italy, June 14, 2019. Findings Ninety-two core data items, across 25 domains, achieved consensus agreement. Twenty further noncore items were retained to facilitate data harmonization in centers that wish to record them. Broad representation across multiple stakeholder groups was sought; however, the opinion of physicians was overrepresented. Conclusions and Relevance This study identifies the domains and domain items required to develop a global network of alopecia areata registries. These domains will facilitate a standardized approach that will enable the recording of a comprehensive, comparable data set required to oversee the introduction of new therapies and harness real-world evidence from existing therapies at a time when the alopecia areata treatment paradigm is being radically and positively disrupted. Reuse of similar, existing frameworks in atopic dermatitis, produced by the Treatment of Atopic Eczema (TREAT) Registry Taskforce, increases the potential to reuse existing resources, creates opportunities for comparison of data across dermatology subspecialty disease areas, and supports the concept of data harmonization.

Background: A systematic review failed to identify any systemic therapy used in alopecia areata (AA) where use is supported by robust evidence from high-quality randomized controlled trials. Objective: To produce an international consensus statement on the use and utility of various treatments for AA. Methods: Fifty hair experts from 5 continents were invited to participate in a 3-round Delphi process. Agreement of 66% or greater was considered consensus. Results: In the first round, consensus was achieved in 22 of 423 (5%) questions. After a face-to-face meeting in round 3, overall, consensus was achieved for only 130 (33%) treatment-specific questions. There was greater consensus for intralesional treatment of AA (19 [68%]) followed by topical treatment (25 [43%]). Consensus was achieved in 45 (36%) questions pertaining to systemic therapies in AA. The categories with the least consensus were phototherapy and nonprescription therapies. Limitations: The study included a comprehensive list of systemic treatments for AA but not all treatments used. Conclusion: Despite divergent opinions among experts, consensus was achieved on a number of pertinent questions. The concluding statement also highlights areas where expert consensus is lacking and where an international patient registry could enable further research.

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British Journal of DermatologyVolume 182, Issue 2 p. 481-482 PerspectivesToken Access Allergy to sunscreen and leave-on facial products is not a likely causative mechanism in frontal fibrosing alopecia: perspective from contact allergy experts C. Felmingham, Corresponding Author clairefelmingham@gmail.com orcid.org/0000-0002-3443-8065 Skin and Cancer Foundation – Occupational Dermatology Research and Education Centre, Carlton, VIC, AustraliaSearch for more papers by this authorL. Yip, orcid.org/0000-0001-7120-6610 Bulimba Dermatology, Brisbane, QLD, AustraliaSearch for more papers by this authorM. Tam, Skin and Cancer Foundation, Carlton, VIC, Australia St Vincent's Hospital, Fitzroy, VIC, AustraliaSearch for more papers by this authorR.L. Nixon, Skin and Cancer Foundation – Occupational Dermatology Research and Education Centre, Carlton, VIC, AustraliaSearch for more papers by this author C. Felmingham, Corresponding Author clairefelmingham@gmail.com orcid.org/0000-0002-3443-8065 Skin and Cancer Foundation – Occupational Dermatology Research and Education Centre, Carlton, VIC, AustraliaSearch for more papers by this authorL. Yip, orcid.org/0000-0001-7120-6610 Bulimba Dermatology, Brisbane, QLD, AustraliaSearch for more papers by this authorM. Tam, Skin and Cancer Foundation, Carlton, VIC, Australia St Vincent's Hospital, Fitzroy, VIC, AustraliaSearch for more papers by this authorR.L. Nixon, Skin and Cancer Foundation – Occupational Dermatology Research and Education Centre, Carlton, VIC, AustraliaSearch for more papers by this author First published: 01 August 2019 https://doi.org/10.1111/bjd.18380Citations: 7 Conflicts of interest: none to declare. Read the full textAboutPDF ToolsRequest permissionExport citationAdd to favoritesTrack citation ShareShare Give accessShare full text accessShare full-text accessPlease review our Terms and Conditions of Use and check box below to share full-text version of article.I have read and accept the Wiley Online Library Terms and Conditions of UseShareable LinkUse the link below to share a full-text version of this article with your friends and colleagues. Learn more.Copy URL Share a linkShare onEmailFacebookTwitterLinked InRedditWechat No abstract is available for this article.Citing Literature Volume182, Issue2February 2020Pages 481-482 RelatedInformation

We present a series of 13 patients with clinical and histological features of both folliculitis decalvans (FD) and lichen planopilaris (LPP), either concomitantly, or sequentially as the clinical phenotype changed over time. This biphasic presentation of FD-LPP is not as uncommon as would be expected from the lack of description in the literature. We discuss current theories about the pathogenesis of both LPP and FD, and speculate how abnormal immune responses may either predispose to secondary bacterial infection or be influenced by dysbiosis of the skin/hair follicle microbiome, resulting in inflammation and permanent hair follicle damage.

Alopecia areata (AA) severity varies from a single small patch to complete loss of scalp hair, body hair, eyelashes and eyebrows. While 40% of all affected individuals only ever get one patch and will achieve a spontaneous complete durable remission within 6 months, 27% will develop additional patches but still achieve complete durable remission within 12 months and 33% will develop chronic AA. Without systemic treatment, 55% of individuals with chronic AA will have persistent multifocal relapsing and remitting disease, 30% will ultimately develop alopecia totalis and 15% will develop alopecia universalis. The unpredictable course and psychological distress attributable to AA contributes to the illness associated with AA. Numerous topical, intralesional and systemic agents are currently used to treat AA; however, there is a paucity of data evaluating their use, effectiveness and tolerability. Topical therapy, including topical glucocorticosteroids, minoxidil and immunotherapy, can be used in cases of limited disease. There are no universally agreed indications for initiating systemic treatment for AA. Possible indications for systemic treatment include rapid hair loss, extensive disease (≥50% hair loss), chronic disease, severe distress or a combination of these factors. Currently available systemic treatments include glucocorticosteroids, methotrexate, ciclosporin, azathioprine, dapsone, mycophenolate mofetil, tacrolimus and sulfasalazine. The optimal treatment algorithm has not yet been described. The purpose of this consensus statement is to outline a treatment algorithm for AA, including the indications for systemic treatment, appropriate choice of systemic treatment, satisfactory outcome measures and when to discontinue successful or unsuccessful treatment.