Trichozette

In March 2024 NICE published TA958, recommending ritlecitinib for severe alopecia areata in people aged 12 and over, following final draft guidance in February. It was the first time NICE had recommended a medicine for severe alopecia areata. Prescribing sits with dermatology, not trichology, but the recommendation changed what a good trichology referral looks like.

How severity was defined

In July, guidance from the British Association of Dermatologists and the British Hair and Nail Society, developed with Alopecia UK, set out how clinicians should apply the NICE decision. It defined severe alopecia areata as at least 50 per cent scalp hair loss, for example a Severity of Alopecia Tool (SALT) score of 50 or more. It also recognised that the percentage alone does not capture the whole burden of the condition.

• Limited loss was described as 1 to 20 per cent of the scalp, moderate as 21 to 49 per cent, and severe as 50 to 100 per cent.
• Moderate disease could be rated severe if there was a negative psychological impact, noticeable eyebrow or eyelash involvement, an inadequate response after at least six months of treatment, or a diffusely positive pull test suggesting rapid progression.
• The guidance advised against using disease duration to decide eligibility.
• Treatment response is reviewed at week 36, and patients should be told that regrowth is likely to be lost if treatment stops.

What this means in the clinic

A trichologist is often the professional who sees a client with alopecia areata most regularly. Accurate, dated records of extent, of eyebrow and eyelash involvement, and of the effect on the client's life can help the dermatologist. The guidance even notes that, where someone started a JAK inhibitor privately, earlier severity may be estimated from images or the patient's description.

In October 2024 the BAD's living guideline for managing alopecia areata appeared online in the British Journal of Dermatology. A living guideline is designed to be updated as new evidence emerges, so it is worth checking the current version rather than relying on memory.