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IMPORTANCE Contact immunotherapy with diphenylcyclopropenone or squaric acid dibutyl ester is a preferred treatment for severe alopecia areata; however, the defined criteria for therapeutic hair regrowth and regrowth rate have been highly heterogeneous across studies. OBJECTIVE To summarize the clinical outcomes of contact immunotherapy for alopecia areata according to standardized criteria for therapeutic hair regrowth and several prognostic factors.

Alopecia areata is a chronic, recurrent and non-scarring alopecia. The prognoses of patients are very diverse. The larger the area of hair loss, the poorer the treatment response and greater the probability of chronic disease progression. Numerous treatments have been introduced, but curative treatments have yet to be established. The long-term efficacy of the current treatments is minimal, and the therapeutic response varies widely. Recent clinical trials have attempted to apply therapeutic metrics, such as the Severity of Alopecia Tool, and many have been designed as randomized controlled studies, enabling a more precise evaluation of existing treatments. There have been updates in practice, efficacy or indications of therapeutics that have been previously used. Moreover, the use of novel treatments such as biologics has recently been introduced. Commonly, the most important factor in determining the treatment modality for alopecia areata has been the extent of hair loss. However, if the disease activity is high and likely to progress, combination therapy with adjuvant modalities will be more desirable. This review will discuss the therapeutic effects of existing and newly-introduced treatments based on their quantity, quality of evidence and expected complications. In addition, an algorithmic approach to management of alopecia areata is proposed according to clinical subtype, severity, onset and activity of the disease.

Human hairs experience damage and restoration processes consistently because of various external and internal factors. To analyze degrees of hair damage, morphological studies based on electron microscopy (EM), and biochemical studies based on protein and lipid analysis have been proposed and are widely used. Among them, morphological analysis through EM is a fundamental method in understanding the degree of damage and restoration. EM has been very useful in assessing extrinsic and intrinsic damage of hair and various pathological alopecias and also in estimating the efficacy of various kinds of products related to hair care. However, morphological studies have some limitations because they have been described using varying terms and subjective descriptions by different researchers. To establish an objective classification of damaged hair using uniform terms and standardizations. We analyzed over 2000 scanning electron microscopic and transmission electron microscopic findings of normal and of various kinds of damaged hairs to develop a standard grading system for the damaged hairs. After reviewing the results of the electron microscopic pictures, we proposed a standard grading system based on scanning electron microscope and transmission electron microscope. We developed and proposed an easy, objective, and useful standard grading system of damaged hairs.