Synopsis
Recognise immune-mediated non-scarring hair loss, exclude infection and follicular destruction, grade extent and impact, and use topical or systemic treatment with realistic relapse and safety counselling.
- Alopecia areata causes sharply defined smooth patches of non-scarring hair loss; follicular openings remain visible and the scalp is usually neither markedly inflamed nor scaly.
- Exclamation-mark hairs, black dots, broken hairs, yellow dots and short tapered regrowth support active disease but no single dermoscopic feature is mandatory.
- Examine eyebrows, eyelashes, beard, body hair and nails; pitting or rough trachyonychia supports the diagnosis and extensive loss changes prognosis and treatment eligibility.
Key red flags
Loss of follicular openings, scalp pain, perifollicular scale, pustules, boggy inflammation, a rapidly enlarging mass or systemic illness is not uncomplicated alopecia areata and requires urgent infection, scarring-alopecia or tumour assessment.
Absent openings, perifollicular erythema or scale, pustules, pain and shiny atrophy point away from alopecia areata toward scarring disease.
Investigation priorities
Confirm non-scarring loss and measure anatomic extent beyond the reported patch.
Management branches
One or a few smooth patches are present without infection or scarring features.
- Examine scalp, brows, lashes, body hair and nails, use trichoscopy where available and sample fungus only when scale or exposure supports it.
- Explain spontaneous regrowth, variable recurrence and prognostic factors, then offer observation, camouflage or a defined topical corticosteroid course according to age, site and preference.
Key medicines
Potent topical corticosteroid for limited scalp diseaseApply the prescribed scalp formulation thinly once daily for a defined course, commonly reviewed after six to twelve weeks before any continuation or break.
BaricitinibEligible adults take the specialist-selected oral dose once daily, usually 4 mg or 2 mg when age, risk, interactions or tolerability favour the lower dose.