What criteria should I use to decide when to refer a patient with alop

Guideline-aligned answer with reasoning, red flags and references. Clinically reviewed by Dr Kola Tytler MBBS CertHE MBA MRCGP.

You should consider referring a patient with alopecia areata to a dermatologist based on several key criteria:

When intralesional steroid injections are considered for limited hair loss in adults, as this treatment typically requires a dermatology referral .
If the disease is not responding to treatments available in primary care .
If there is diagnostic uncertainty, as a specialist may need to perform a scalp biopsy to clarify the diagnosis .
For extensive, long-term, or refractory disease, to allow for consideration of specialist treatments .
Before starting treatment for children, due to the potential for adverse effects from potent corticosteroids and the recommendation for specialist supervision in this age group .
Before starting treatment for women who are pregnant or breastfeeding, as the limited benefit of topical corticosteroid use may not outweigh potential risks .

What criteria should I use to decide when to refer a patient with alopecia areata to a dermatologist?