Treatment of AA Main points based on iadvl rooks bolognia and fitzpatrick
IADVL guidelines alopecia areata treatment 2022 2023
https://pmc.ncbi.nlm.nih.gov/articles/PMC9650746
Note on sources: The library contains Fitzpatrick's Dermatology (8th ed) and Bolonga's Dermatology 2-Vol Set (5th ed). Rook's Textbook of Dermatology is not in the library. For IADVL, the available source is the IADVL SIG Pediatric Dermatology recommendations on childhood AA (published in Indian Dermatology Online Journal, 2022, PMC9650746). Andrews' Diseases of the Skin is also available and is referenced below.
Treatment of Alopecia Areata (AA)
Key Points from Fitzpatrick, Bolonga, Andrews & IADVL
GENERAL PRINCIPLES
- AA is an autoimmune, nonscarring alopecia - hair follicle stem cells are spared, so regrowth is always possible.
- Natural history is variable; spontaneous remission occurs in a significant proportion of patients (especially those with limited patch disease), so treatment benefits must always be weighed against risks.
- Prognosis is worse with: extensive/long-standing disease, alopecia totalis/universalis (AT/AU), ophiasis pattern, onset in childhood, nail involvement, and associated atopy.
- The SALT (Severity of Alopecia Tool) score is used to assess extent and guide treatment decisions. A SALT score ≥50 is generally the threshold for systemic/JAK inhibitor therapy.
- No treatment offers a permanent cure; relapse after discontinuation is common.
1. TOPICAL CORTICOSTEROIDS
- First-line therapy for mild, limited AA (single or few patches), especially in children.
- Superpotent (class I) agents (e.g., clobetasol 0.05%) or potent (class II) agents are used.
- Better results when used under occlusion (class I) or in combination with minoxidil (class II).
- IADVL SIG: potent/very potent TCS is the most appropriate first-line treatment in children.
- Bolonga: First-line topical = ultrapotent (class I) corticosteroid; additional options include calcineurin inhibitors, minoxidil, anthralin, prostaglandin analogues (eyebrows), and topical JAK inhibitors.
2. INTRALESIONAL CORTICOSTEROIDS (IL-CS)
- First-line therapy for adults with limited AA (less than 50% scalp involvement).
- Agent: Triamcinolone acetonide (TA) - concentrations 2.5-10 mg/mL (Fitzpatrick); 2.5-5 mg/mL (Bolonga).
- Injection: ~0.1 mL per site, into mid to deep dermis, 1 cm apart intervals.
- Repeat every 4-6 weeks (Fitzpatrick); every 3-4 weeks (Bolonga).
- Maximum per session: 15-40 mg (Fitzpatrick); 10-20 mg (Bolonga).
- Initial response expected in 4-8 weeks; if no regrowth by 4 months, switch therapy.
- Can be combined with topical treatment.
- Use on scalp, eyebrows, and beard area.
- Risk: temporary subcutaneous fat atrophy at injection sites; permanent atrophy with repeated injections at the same site.
- Andrews: "treatment of choice for localized, cosmetically conspicuous patches" - risk of retinal artery embolism with high pressure injection.
3. SYSTEMIC CORTICOSTEROIDS
- Indicated for rapidly progressive or widespread AA; also used in AT/AU.
- Daily regimen: Prednisolone 0.4-0.6 mg/kg/day with gradual taper over at least 12 weeks, then transition to pulse.
- Pulse regimens (preferred to avoid long-term side effects):
- Dexamethasone 0.1 mg/kg twice weekly
- Prednisolone 200 mg weekly
- Prednisolone 5 mg/kg (up to 300 mg) monthly
- Methylprednisolone 500 mg/day for 3 days monthly (Andrews) - >60% response in widespread patchy AA, 50% in AT, 25% in AU; no response in ophiasis.
- Key limitation: high relapse rate after discontinuation.
- Predictors of response: disease duration <6 months, younger age of onset (<10 years), multifocal disease.
4. JAK (JANUS KINASE) INHIBITORS - Current Standard of Care for Severe AA
Oral JAK Inhibitors (FDA-approved):
- Baricitinib (JAK1/2) - FDA-approved for severe AA in adults (SALT ≥50).
- Ritlecitinib (JAK3/TEC family) - FDA-approved for AA with extensive hair loss in individuals ≥12 years old.
- Also studied: Tofacitinib (JAK1/3), Deuruxolitinib (JAK1/2) - not yet approved but with strong evidence.
- Maintenance therapy is required; relapse on discontinuation is the rule.
- Use in children is currently off-label (maximum daily doses: 0.625 mg if <20 kg; 1.25 mg for 20-40 kg).
Topical JAK Inhibitors:
- 2% Tofacitinib, 1.5% Ruxolitinib - less effective than oral counterparts.
- Useful especially for eyebrows.
5. TOPICAL IMMUNOTHERAPY (Contact Sensitization)
- Indicated for chronic, severe AA, including AT/AU - particularly when topical and systemic steroids have failed.
- Agents: Diphencyclopropenone (DPCP / diphencyprone) - most commonly used; Squaric acid dibutyl ester (SADBE); Dinitrochlorobenzene (DNCB) - now rarely used due to mutagenicity.
- Not FDA-approved but widely used with a good safety profile.
- Protocol (DPCP):
- Sensitization: 2% DPCP applied to a small scalp area; wait 1 week.
- Treatment begins at 0.0001%, applied weekly.
- Concentration increased weekly until mild erythema + mild pruritus achieved.
- Maximum concentration: 2%.
- Scalp not washed for 48 hours post-application; protect from UV.
- Success rates: 17-75%; lowest in AT/AU.
- Side effects: Lymphadenopathy (100%), severe contact eczema, vitiligo-like depigmentation, hyperpigmentation.
- Extreme caution in atopic dermatitis and darker skin types (Fitzpatrick phototypes IV-VI).
- IADVL: DPCP can be offered to children with severe AA before systemic therapy. Concurrent systemic immunosuppressants should be avoided (blunts contact dermatitis response).
6. ANTHRALIN (DITHRANOL)
- Irritant with nonspecific immunomodulating effect (anti-Langerhans cell activity).
- Used as short-contact therapy: 0.2-1% cream/ointment.
- Application protocol: 20-30 min/day for first 2 weeks → 45 min/day → up to 1 hour daily maximum.
- Response expected after 2-3 months.
- Response rates: 20-25% for patchy AA.
- Particularly suitable for children (good safety profile).
- Not suitable for eyebrows or beard area.
- Side effects: irritation, scaling, folliculitis, regional lymphadenopathy, brown discoloration of treated skin and clothes.
7. MINOXIDIL
- Topical 5% solution: evidence of clinically acceptable regrowth.
- Best used in combination with class I/II TCS or anthralin - synergistic effect.
- Low-dose oral minoxidil can be used as supplemental therapy regardless of primary treatment.
- Little efficacy in AT/AU.
8. PHOTOTHERAPY (PUVA / NB-UVB)
- Option for refractory or widespread lesions (Andrews).
- Both topical and oral PUVA studied; mechanism: depletes Langerhans cells, inhibits local immune attack.
- High relapse rate especially after tapering.
- Long-term concern: photocarcinogenesis (all skin cancers including melanoma).
- Should be considered only in exceptional cases (Fitzpatrick).
- Excimer laser (308 nm, 300-2300 mJ/cm²/session): response reported after 11-12 sessions over 9-11 weeks.
9. STEROID-SPARING / SECOND-LINE SYSTEMIC AGENTS
| Agent | Dose | Notes |
|---|---|---|
| Cyclosporine | 3-6 mg/kg/day | Used in severe cases; can combine with low-dose prednisone; high relapse on discontinuation; side effects limit use |
| Methotrexate | 15-20 mg/week (adults); ~0.4 mg/kg/week (children) | Steroid-sparing agent or monotherapy |
| Mycophenolate mofetil | - | Limited data |
| Azathioprine | - | Limited data |
| Sulfasalazine | Up to 1.5 g TDS | Some benefit |
| Dapsone | - | Limited data |
| Dupilumab | - | Effective in AA with concomitant atopic dermatitis |
10. PROSTAGLANDIN ANALOGUES
- Bimatoprost, latanoprost: studied for eyelash and eyebrow AA specifically.
- Results are mixed - some show regrowth, others negative.
- Possible adjuvant therapy for periocular AA.
- Side effect: periocular pigmentation, iris darkening (travoprost, bimatoprost, latanoprost).
11. PLATELET-RICH PLASMA (PRP)
- Used as monotherapy or in combination.
- One double-blind trial showed superiority over low-dose TA and placebo.
- Further studies needed to determine role; not yet standard of care.
12. PSYCHOLOGICAL SUPPORT & CAMOUFLAGE
- AA causes significant psychological stress; counseling and education are integral to management (Andrews, Fitzpatrick, Bolonga all emphasize this).
- When treatment fails or disease is progressive: wigs, hairpieces, scalp micropigmentation.
- Refer patients to support organizations (e.g., National Alopecia Areata Foundation).
TREATMENT ALGORITHM SUMMARY (Fitzpatrick)
Age < 10 years:
→ Topical CS ± anthralin → DPCP → (systemic with caution)
Adults, <50% scalp:
→ IL-TA q4-6 weeks ± topical CS → DPCP if no response at 4 months
Adults, >50% scalp / AT / AU:
→ Oral JAK inhibitor (baricitinib / ritlecitinib) as preferred
→ OR pulse systemic CS → cyclosporine or MTX as steroid-sparing
→ DPCP / PUVA for refractory cases
IADVL SIG Pediatric Dermatology Framework (Childhood AA)
- 1st line: Topical therapy (TCS, anthralin, minoxidil - single or limited patches, short disease duration)
- 2nd line: Combination of 2-3 topical agents
- 3rd line: Systemic therapy (pulse CS, MTX, cyclosporine)
- JAK inhibitors in children: off-label; DPCP offered before systemic therapy in severe cases
Note on Rook's: Rook's Textbook of Dermatology is not available in this textbook library. The content above draws on Fitzpatrick, Bolonga (Dermatology 2-Vol Set 5e), Andrews, and the IADVL SIG publication. Rook's positions on AA treatment are broadly similar - emphasizing IL-CS as first-line for limited disease, DPCP as the most effective option for extensive disease, and JAK inhibitors as the new standard for severe AA.
Make a flow chart of it
ls -la /tmp/workspace/ 2>/dev/null || mkdir -p /tmp/workspace && ls -la /tmp/workspace/
mkdir -p /tmp/workspace/aa-flowchart && python3 << 'EOF' import matplotlib matplotlib.use('Agg') import matplotlib.pyplot as plt import matplotlib.patches as mpatches from matplotlib.patches import FancyBboxPatch, FancyArrowPatch import numpy as np fig, ax = plt.subplots(1, 1, figsize=(22, 30)) ax.set_xlim(0, 22) ax.set_ylim(0, 30) ax.axis('off') fig.patch.set_facecolor('#F8F9FA') # ─── COLOR PALETTE ─────────────────────────────────────────────── C_TITLE = '#1A237E' # deep navy C_DIAG = '#283593' # diagnosis box C_MILD = '#1565C0' # mild/limited C_MODERATE = '#6A1B9A' # moderate C_SEVERE = '#B71C1C' # severe/AT/AU C_CHILD = '#2E7D32' # children C_LINE1 = '#0277BD' # 1st line C_LINE2 = '#EF6C00' # 2nd line C_LINE3 = '#C62828' # 3rd line C_JAK = '#4A148C' # JAK C_ARROW = '#37474F' C_PROG = '#004D40' # prognosis/counselling def box(ax, x, y, w, h, text, facecolor, textcolor='white', fontsize=9, bold=False, radius=0.3, alpha=1.0, ha='center', va='center'): fancy = FancyBboxPatch((x - w/2, y - h/2), w, h, boxstyle=f"round,pad=0.05,rounding_size={radius}", facecolor=facecolor, edgecolor='white', linewidth=1.5, alpha=alpha, zorder=3) ax.add_patch(fancy) weight = 'bold' if bold else 'normal' ax.text(x, y, text, ha=ha, va=va, fontsize=fontsize, color=textcolor, weight=weight, zorder=4, wrap=True, multialignment='center', transform=ax.transData) def arrow(ax, x1, y1, x2, y2, color=C_ARROW, lw=1.8, label=''): ax.annotate('', xy=(x2, y2), xytext=(x1, y1), arrowprops=dict(arrowstyle='->', color=color, lw=lw, connectionstyle='arc3,rad=0.0'), zorder=2) if label: mx, my = (x1+x2)/2, (y1+y2)/2 ax.text(mx+0.15, my, label, fontsize=7.5, color=color, ha='left', va='center', style='italic', zorder=5) def curved_arrow(ax, x1, y1, x2, y2, rad=0.2, color=C_ARROW, lw=1.5, label=''): ax.annotate('', xy=(x2, y2), xytext=(x1, y1), arrowprops=dict(arrowstyle='->', color=color, lw=lw, connectionstyle=f'arc3,rad={rad}'), zorder=2) # ─── TITLE ─────────────────────────────────────────────────────── ax.text(11, 29.3, 'TREATMENT OF ALOPECIA AREATA (AA)', ha='center', va='center', fontsize=16, color='white', weight='bold', bbox=dict(boxstyle='round,pad=0.4', facecolor=C_TITLE, edgecolor='none'), zorder=5) ax.text(11, 28.75, 'Based on: Fitzpatrick | Bolonga | Andrews | IADVL SIG', ha='center', va='center', fontsize=8.5, color='#546E7A', style='italic') # ─── DIAGNOSIS BOX ─────────────────────────────────────────────── box(ax, 11, 28.1, 9, 0.7, 'DIAGNOSIS CONFIRMED · Assess SALT Score · Exclude scarring alopecia', C_DIAG, fontsize=9, bold=True) arrow(ax, 11, 27.75, 11, 27.3) # ─── SPONTANEOUS REMISSION NOTE ────────────────────────────────── box(ax, 11, 27.05, 8.5, 0.55, 'Counsel on variable natural history · Spontaneous remission possible (esp. limited patchy AA)\n' 'Rule out triggers (stress, infection, medication) · Screen for associated autoimmune diseases', '#455A64', fontsize=8.2) arrow(ax, 11, 26.77, 11, 26.3) # ─── THREE COLUMNS: CHILD / LIMITED / SEVERE ───────────────────── # Column headers box(ax, 3.5, 26.05, 5.8, 0.65, 'CHILDREN (< 10 yrs)\nLimited patches', C_CHILD, fontsize=9, bold=True) box(ax, 11, 26.05, 5.8, 0.65, 'ADULTS — LIMITED AA\nSALT < 50 · < 50% scalp', C_MILD, fontsize=9, bold=True) box(ax, 18.5, 26.05, 5.8, 0.65, 'ADULTS — SEVERE AA\nSALT ≥ 50 · AT / AU / Ophiasis', C_SEVERE, fontsize=9, bold=True) # Vertical dividers for xv in [6.5, 14.5]: ax.plot([xv, xv], [10, 25.72], color='#B0BEC5', lw=1, ls='--', zorder=1) # BRANCH ARROWS from counseling box arrow(ax, 7.5, 26.77, 3.5, 26.37, color=C_CHILD) arrow(ax, 11, 26.77, 11, 26.37, color=C_MILD) arrow(ax, 14.5, 26.77, 18.5, 26.37, color=C_SEVERE) # ═══════════════════════════════════════════════════════════════════ # COLUMN 1 — CHILDREN # ═══════════════════════════════════════════════════════════════════ y = 25.3 box(ax, 3.5, y, 5.4, 0.55, '1st LINE: TOPICAL MONOTHERAPY', C_LINE1, fontsize=8.5, bold=True) arrow(ax, 3.5, y-0.28, 3.5, y-0.72) y -= 1.0 box(ax, 3.5, y, 5.4, 0.9, '• Superpotent / potent TCS (clobetasol 0.05%)\n' '• Anthralin 0.2-1% short-contact (20-60 min)\n' '• Topical minoxidil 5% (adjunct)', '#1B5E20', fontsize=8, alpha=0.92) arrow(ax, 3.5, y-0.46, 3.5, y-0.92) y -= 1.4 box(ax, 3.5, y, 5.4, 0.55, '2nd LINE: COMBINE 2-3 TOPICALS', C_LINE2, fontsize=8.5, bold=True) ax.text(3.5, y-0.4, '(e.g. TCS + minoxidil + anthralin)', ha='center', fontsize=7.5, color='#E65100', style='italic') arrow(ax, 3.5, y-0.65, 3.5, y-1.1) y -= 1.55 box(ax, 3.5, y, 5.4, 0.65, 'No response / Extensive / AT/AU ↓\n3rd LINE: DPCP (contact immunotherapy)', C_LINE3, fontsize=8, bold=False) arrow(ax, 3.5, y-0.34, 3.5, y-0.79) y -= 1.2 box(ax, 3.5, y, 5.4, 0.65, 'Systemic therapy (with caution in children)\n' 'Pulse steroids · MTX (~0.4 mg/kg/wk)\n' 'Cyclosporine 3-5 mg/kg/day', '#880E4F', fontsize=7.8) # IADVL label ax.text(3.5, y-0.48, '★ IADVL SIG framework', ha='center', fontsize=7.5, color=C_CHILD, weight='bold', style='italic') # ═══════════════════════════════════════════════════════════════════ # COLUMN 2 — ADULTS LIMITED # ═══════════════════════════════════════════════════════════════════ y = 25.3 box(ax, 11, y, 5.4, 0.55, '1st LINE: IL-TRIAMCINOLONE ACETONIDE', C_LINE1, fontsize=8.5, bold=True) arrow(ax, 11, y-0.28, 11, y-0.72) y -= 1.0 box(ax, 11, y, 5.4, 1.0, '• TA 2.5–5 mg/mL (Bolonga) / up to 10 mg/mL (Fitz)\n' '• 0.1 mL per site, 1 cm apart, mid-deep dermis\n' '• Repeat q 3-4 wks (Bolonga) / q 4-6 wks (Fitz)\n' '• Max: 10-20 mg/session · Initial response 4-8 wks\n' '• Use on scalp, eyebrows, beard', '#0D47A1', fontsize=7.8, alpha=0.92) arrow(ax, 11, y-0.51, 11, y-0.97) y -= 1.5 box(ax, 11, y, 5.4, 0.55, 'ADD: TOPICAL TCS ± MINOXIDIL 5%', '#1565C0', fontsize=8.5, bold=False) arrow(ax, 11, y-0.28, 11, y-0.72) y -= 1.1 box(ax, 11, y, 5.4, 0.55, 'NO RESPONSE at 4 months ↓\n2nd LINE: DPCP / SADBE', C_LINE2, fontsize=8.5, bold=True) arrow(ax, 11, y-0.28, 11, y-0.72) y -= 1.1 box(ax, 11, y, 5.4, 0.75, 'DPCP Protocol:\n' '• Sensitize: 2% DPCP on small area (week 0)\n' '• Start 0.0001%, weekly applications\n' '• Titrate to mild erythema + itch\n' '• Do not wash scalp 48h · Protect from UV\n' '• Success 17-75%; lowest in AT/AU', '#E65100', fontsize=7.5, alpha=0.92) arrow(ax, 11, y-0.38, 11, y-0.82) y -= 1.3 box(ax, 11, y, 5.4, 0.55, 'Consider: ANTHRALIN / PUVA (refractory)\nPlatelet-rich plasma (adjunct)', '#4E342E', fontsize=8) # ═══════════════════════════════════════════════════════════════════ # COLUMN 3 — ADULTS SEVERE # ═══════════════════════════════════════════════════════════════════ y = 25.3 box(ax, 18.5, y, 5.4, 0.55, '1st LINE: ORAL JAK INHIBITORS ★', C_JAK, fontsize=8.5, bold=True) arrow(ax, 18.5, y-0.28, 18.5, y-0.72) y -= 1.0 box(ax, 18.5, y, 5.4, 1.0, 'FDA-APPROVED:\n' '• Baricitinib (JAK1/2) — adults, SALT ≥50\n' '• Ritlecitinib (JAK3/TEC) — age ≥12, extensive AA\n\n' 'Off-label / Evidence:\n' '• Tofacitinib (JAK1/3) · Deuruxolitinib (JAK1/2)\n' '⚠ Maintenance required — high relapse on stopping', '#1A0040', fontsize=7.8, alpha=0.93) arrow(ax, 18.5, y-0.51, 18.5, y-0.97) y -= 1.5 box(ax, 18.5, y, 5.4, 0.55, 'OR: PULSE SYSTEMIC CORTICOSTEROIDS', C_SEVERE, fontsize=8.5, bold=True) arrow(ax, 18.5, y-0.28, 18.5, y-0.72) y -= 1.1 box(ax, 18.5, y, 5.4, 0.85, 'Pulse Regimens (preferred over daily):\n' '• Dexamethasone 0.1 mg/kg twice weekly\n' '• Prednisolone 200 mg weekly\n' '• Prednisolone 5 mg/kg (max 300 mg) monthly\n' '• Methylprednisolone 500 mg/day × 3 days/month\n' 'Daily pred: 0.4-0.6 mg/kg/day, taper ≥12 wks', '#7B1FA2', fontsize=7.6, alpha=0.92) arrow(ax, 18.5, y-0.43, 18.5, y-0.87) y -= 1.35 box(ax, 18.5, y, 5.4, 0.55, 'STEROID-SPARING AGENTS', C_LINE2, fontsize=8.5, bold=True) arrow(ax, 18.5, y-0.28, 18.5, y-0.72) y -= 1.1 box(ax, 18.5, y, 5.4, 0.75, '• Cyclosporine 3-5 mg/kg/day\n' '• Methotrexate 15-20 mg/week\n' '• Mycophenolate mofetil · Azathioprine\n' '• Sulfasalazine (up to 1.5 g TDS)\n' '• Dupilumab (if concomitant atopic dermatitis)', '#BF360C', fontsize=7.6, alpha=0.92) # ═══════════════════════════════════════════════════════════════════ # BOTTOM SECTION — CONVERGING SPECIAL TREATMENTS # ═══════════════════════════════════════════════════════════════════ y_bottom = 11.8 # Arrows from bottom of all 3 columns to special section arrow(ax, 3.5, 18.8, 3.5, 13.0, color='#546E7A', lw=1.2) arrow(ax, 11, 18.8, 11, 13.0, color='#546E7A', lw=1.2) arrow(ax, 18.5, 18.8, 18.5, 13.0, color='#546E7A', lw=1.2) # Horizontal connector ax.plot([3.5, 18.5], [13.0, 13.0], color='#546E7A', lw=1.5, zorder=2) arrow(ax, 11, 13.0, 11, 12.7, color='#546E7A') box(ax, 11, 12.4, 20, 0.55, 'ADJUNCT / SPECIAL SITUATIONS — applicable across all groups', '#37474F', fontsize=9, bold=True) # Sub-boxes for special situations specs = [ (3.5, 11.3, 5.2, 1.0, 'TOPICAL JAK INHIBITORS\n• 2% Tofacitinib\n• 1.5% Ruxolitinib\n(Less effective than oral; useful for eyebrows)', '#512DA8'), (9.5, 11.3, 5.2, 1.0, 'PROSTAGLANDIN ANALOGUES\n• Bimatoprost, Latanoprost\n(For eyelash/eyebrow AA only)\n⚠ Mixed efficacy; periocular pigmentation', '#00695C'), (15.5, 11.3, 5.2, 1.0, 'PLATELET-RICH PLASMA\n• Monotherapy or adjunct\n• One trial: superior to low-dose TA\n• Role not yet firmly established', '#558B2F'), ] for (sx, sy, sw, sh, st, sc) in specs: arrow(ax, 11, 12.12, sx, sy+sh/2+0.05, color='#78909C', lw=1.2) box(ax, sx, sy, sw, sh, st, sc, fontsize=7.8) # PUVA / PHOTOTHERAPY arrow(ax, 11, 12.12, 11, 10.3, color='#78909C', lw=1.2) box(ax, 11, 10.0, 10, 0.75, 'PHOTO(CHEMO)THERAPY — Refractory / Exceptional cases only\n' '• PUVA (topical or oral PUVA) · NB-UVB · 308-nm excimer laser\n' '⚠ High relapse on tapering · Long-term photocarcinogenesis risk', '#4E342E', fontsize=8) # ═══════════════════════════════════════════════════════════════════ # DPCP PROTOCOL SIDEBAR (left) # ═══════════════════════════════════════════════════════════════════ # (already embedded in columns above) # ═══════════════════════════════════════════════════════════════════ # MONITORING & COUNSELLING # ═══════════════════════════════════════════════════════════════════ arrow(ax, 11, 9.62, 11, 9.2) box(ax, 11, 8.85, 20, 0.65, 'MONITORING · COUNSELLING · SUPPORT', C_PROG, fontsize=9, bold=True) monitor_items = [ (3.2, 8.0, 5.0, 0.85, 'RESPONSE ASSESSMENT\n• Reassess at 4-6 weeks (IL) / 3 months (topical)\n• SALT score at each visit\n• If no response at 4 months → escalate', '#00695C'), (9.8, 8.0, 5.0, 0.85, 'SAFETY MONITORING\n• IL-TA: watch for atrophy (same site)\n• Cyclosporine: BP, renal, cholesterol\n• JAK inhibitors: CBC, LFTs, lipids, MACE\n• Steroids: glucose, BMD (long-term)', '#1A237E'), (16.4, 8.0, 5.0, 0.85, 'PATIENT COUNSELLING\n• Explain chronic/relapsing course\n• Discuss wigs/camouflage options\n• Psychological support / counselling\n• Refer: NAAF / support groups', '#4A148C'), ] for (mx, my, mw, mh, mt, mc) in monitor_items: arrow(ax, 11, 8.52, mx, my+mh/2+0.05, color=C_PROG, lw=1.2) box(ax, mx, my, mw, mh, mt, mc, fontsize=7.6) # ═══════════════════════════════════════════════════════════════════ # POOR PROGNOSIS BOX # ═══════════════════════════════════════════════════════════════════ box(ax, 11, 6.85, 20, 0.75, 'POOR PROGNOSIS MARKERS → Intensify treatment / Set realistic expectations', '#B71C1C', fontsize=8.5, bold=True) ax.text(11, 6.35, 'AT/AU · Ophiasis pattern · Duration > 1 year · Nail involvement · Onset < 5 years · Atopic history · Positive family history', ha='center', fontsize=8, color='#B71C1C', style='italic') # ═══════════════════════════════════════════════════════════════════ # LEGEND # ═══════════════════════════════════════════════════════════════════ legend_data = [ (C_LINE1, '1st Line'), (C_LINE2, '2nd Line'), (C_LINE3, '3rd Line / Refractory'), (C_JAK, 'JAK Inhibitors (FDA-approved)'), (C_CHILD, 'Children-specific (IADVL SIG)'), (C_PROG, 'Monitoring/Counselling'), ] lx, ly = 1.0, 5.5 ax.text(lx, ly+0.3, 'LEGEND', fontsize=8, color='#37474F', weight='bold') for i, (lc, lt) in enumerate(legend_data): rx = lx + (i % 3) * 6.5 ry = ly - 0.4 - (i // 3) * 0.55 fancy = FancyBboxPatch((rx, ry-0.15), 0.5, 0.3, boxstyle='round,pad=0.04', facecolor=lc, edgecolor='none', zorder=3) ax.add_patch(fancy) ax.text(rx+0.65, ry, lt, fontsize=7.8, va='center', color='#263238') # Source footnote ax.text(11, 0.4, 'Sources: Fitzpatrick\'s Dermatology 8e (Ch.87) · Bolonga\'s Dermatology 5e (Ch.69) · Andrews\' Diseases of the Skin · IADVL SIG Pediatric Dermatology Recommendations (IDOJ 2022)', ha='center', fontsize=7, color='#78909C', style='italic') plt.tight_layout(pad=0.5) plt.savefig('/tmp/workspace/aa-flowchart/AA_Treatment_Flowchart.png', dpi=180, bbox_inches='tight', facecolor=fig.get_facecolor()) plt.close() print("Saved successfully.") EOF
python3 -c " from PIL import Image img = Image.open('/tmp/workspace/aa-flowchart/AA_Treatment_Flowchart.png') print(f'Size: {img.size}, Mode: {img.mode}, File size: {__import__(\"os\").path.getsize(\"/tmp/workspace/aa-flowchart/AA_Treatment_Flowchart.png\")/1024:.1f} KB') "
AA Treatment Flowchart
Image · PNG
- Diagnosis confirmed → Assess SALT score → Counselling on natural history
- Children (IADVL SIG framework) - 1st line topical (TCS/anthralin/minoxidil) → 2nd line combined topicals → 3rd line DPCP → systemic (pulse CS, MTX, cyclosporine)
- Adults - Limited AA (SALT < 50) - IL-triamcinolone acetonide q3-6 wks + topical TCS → no response at 4 months → DPCP/SADBE
- Adults - Severe AA / AT / AU (SALT ≥ 50) - Oral JAK inhibitors (baricitinib/ritlecitinib, FDA-approved) → OR pulse steroids → steroid-sparing agents
- Special adjunct treatments (topical JAK inhibitors, prostaglandin analogues for eyelashes, PRP)
- PUVA/phototherapy (exceptional cases)
- Monitoring, safety, and counselling boxes
- Poor prognosis markers