guidelines

alopecia areata: diagnosis, counselling, and primary care actions

nice cks overview for patchy non-scarring hair loss: confirming the diagnosis, screening for associated autoimmune disease where relevant, counselling, and referral thresholds.

last reviewed: 2026-02-13
based on: NICE CKS Alopecia areata (last revised Sep 2024) + dermatology primary care pathways
reviewer: Dr Kola Tytler MBBS CertHE MBA MRCGP
view official NICE source

Executive summary

  • Typical presentation: sudden-onset patchy, well-demarcated, non-scarring hair loss ± exclamation-mark hairs.
  • Common differentials: tinea capitis, traction alopecia, trichotillomania, androgenetic alopecia, telogen effluvium.
  • Key GP job: confirm likely diagnosis clinically, counsel on prognosis (often regrowth), address psychosocial impact, and refer when extensive/severe or patient preference.

Assessment (fast but complete)

  • Pattern of hair loss (patchy vs diffuse), scalp symptoms (itch/pain), nail changes (pitting), atopy and autoimmune history.
  • Examine scalp for scaling/broken hairs (tinea), scarring, or traction pattern; check eyebrows/beard/body hair.
  • Consider targeted tests if clinically indicated (e.g., thyroid symptoms/history), rather than blanket testing for everyone.

Counselling that prevents harm (and repeat visits)

  • Prognosis: many with limited patchy disease regrow hair within months; recurrence can happen.
  • Psychological impact is real: offer supportive resources and consider mood screening where appropriate.
  • Cosmetic support: camouflage advice, wig signposting, eyebrow solutions; validate distress.

Therapy landscape has changed

Severe alopecia areata now has NICE technology appraisals for systemic options in eligible patients via specialist pathways (e.g., baricitinib TA926; ritlecitinib TA958). Primary care role is early recognition, documentation of severity/impact, and timely dermatology referral.

Frequently asked questions

When should I refer?
Refer if extensive loss (e.g., multiple large patches, eyebrows/beard involved), rapid progression, significant distress, or diagnostic uncertainty (including possible tinea/scarring alopecia).
Do topical treatments work?
Some patients benefit from dermatology-led therapies (e.g., intralesional corticosteroids for limited disease). Evidence varies and spontaneous regrowth is common; referral decisions should consider severity and patient preference.

Transparency

This page is an educational, clinician-written summary of publicly available NICE guidance intended for trained healthcare professionals. It uses original wording (not copied text) and should be used alongside the full NICE source, local pathways, and clinical judgement. Doses provided are for general reference; always check the BNF/SPC.