Real-world evidence in alopecia areata treatment: A narrative review

Abstract Alopecia areata (AA) is a complex autoimmune disorder causing non-scarring hair loss, from localized patches to total scalp or body hair loss. It significantly impacts quality of life, with an unpredictable course that challenges effective management. Traditional treatments like such as corticosteroids, systemic immunosuppressives, and contact immunotherapy are commonly used but are often associated with high relapse rates and inconsistent efficacy. Real-world evidence emphasizes individualized strategies, particularly for severe cases and pediatric populations. Off-label medications such as methotrexate and sulfasalazine, though potentially beneficial, are limited to second-line use due to insufficient high-quality evidence for optimal dosing and intervals. Novel therapies such as Janus kinase inhibitors have emerged, targeting immune pathways with promising results in severe AA. However, these require long-term use to maintain efficacy and prevent relapse. Innovations such as fractional laser-assisted drug delivery and microneedling have shown encouraging outcomes in preliminary studies, though statistically significant results remain limited. Combination therapies, such as systemic corticosteroids with immunomodulators or topical agents, show promise in refractory cases. While advancements have expanded AA treatment options, further research is essential to validate their long-term safety, efficacy, and standardize protocols. A personalized approach that integrates traditional and emerging therapies may achieve more durable outcomes and enhance patient quality of life. This review highlights current and novel strategies, focusing on efficacy, safety, and real-world applicability.