Alopecia areata - need for a revision in morphological classification and scoring

Abstract

Background: Scalp hair is believed to be the commonest site involved in Alopecia Areata (AA), and the morphological classification and scoring of the disease mainly concentrate on scalp hair involvement.

Objectives: This study aims to assess terminal hair involvement across different body sites in patients with alopecia areata (AA), evaluate the current classification and scoring systems, and propose potential revisions and solutions.

Methods: Data of patients of AA registered over 4 years at our institute from April 2021 to March 2025 was analyzed for the site(s) of involvement, morphological type of disease, and associated cutaneous/medical disorders. The data was analyzed to assess whether all the patients could be classified into any one of the currently known morphological types and scored in an ideal fashion.

Results: A total of 1010 patients with alopecia areata (AA) were seen over 4 years, including 602 males and 408 females. Scalp involvement alone was observed only in 488 patients (48.3%) patients while 522 patients (51.7%) had terminal hair involvement beyond the scalp. Among the 602 males, 394 were older than 18 years, and in this subgroup, approximately 63% (248/394) had beard hair involvement, either alone or along with scalp hair. The multifocal type was the most common morphological pattern of AA observed. However, some patients with extensive involvement of the scalp, beard, and body hair could not be classified into any known morphological type. For this pattern, we propose the term alopecia subuniversalis.

Conclusions: Given that beard hair is affected as commonly as scalp hair, we propose the use of a composite scoring system to assess the severity of alopecia areata (AA) involving the beard, eyebrows, and eyelashes. Additionally, we propose a new morphological subtype—alopecia subuniversalis—to describe scalp AA with extensive involvement of the other hair-bearing areas of the face and body.