Review on Alopecia Areata in the Middle East and Africa: Landscape and Unmet Needs

Abstract

Background

Alopecia areata (AA) is an autoimmune disease characterized by non-scarring hair loss in adults and children. Clinical manifestations range from hair loss in small, well-circumscribed patches to total hair loss on the scalp or any other hair-bearing areas. Although the exact pathogenesis of AA is not fully understood, it is thought that loss of immune privilege caused by immunological dysregulation of the hair follicle is key. Genetic susceptibility also plays a role. Response to currently available treatments is widely variable, causing patient dissatisfaction and creating an unmet need. AA is frequently associated with multiple comorbidities, further affecting patient quality of life.

Aims and Findings

AA causes a significant burden on dermatologists and healthcare systems in the Middle East and Africa. There is a lack of data registries, local consensus, and treatment guidelines in the region. Limited public awareness, availability of treatments, and patient support need to be addressed to improve disease management in the region. A literature review was conducted to identify relevant publications and highlight regional data on prevalence rates, diagnosis, quality of life, treatment modalities, and unmet needs for AA in the Middle East and Africa.

Key Summary Points

There is a lack of awareness, national registries, and consistent treatment access for alopecia areata (AA) in the region.

This review identifies relevant publications to highlight data on prevalence rates, quality of life, and treatment modalities for AA in the Middle East and Africa.

The lack of regional guidelines has led to non-uniform treatment plans among dermatologists.

International guidelines on AA management should be leveraged while developing regional consensus and establishing patient support programs in the region.

Introduction

Alopecia areata (AA) is an autoimmune disease characterized by non-scarring hair loss in well-circumscribed patches [1, 2]. AA can lead to considerable disfigurement and psychosocial distress and is currently reported as the most prevalent autoimmune disease associated with reduced quality of life (QoL) [1, 3]. AA affects both adults and children, occurs at similar rates in men and women, and has an average onset at 20–25 years [1, 4]. The general lifetime incidence of AA is approximately 2% in adults. First-degree relatives are at a 24% increased risk of being affected. It is the third most common dermatologic presentation in children, with a lifetime risk of 1–2% [1, 4, 5]. AA may also be associated with other autoimmune diseases such as vitiligo, psoriasis, thyroid diseases, type 1 diabetes mellitus, atopic dermatitis, celiac disease, and lupus erythematosus [6–8]. AA has an unpredictable disease course. Spontaneous hair regrowth can occur within the first year with or without treatment and sudden relapse may occur at any time [9]. Several hypotheses regarding the etiopathogenesis of AA suggest a possible role of viral and bacterial infections, endocrine, autoimmune, psychological, viral, and genetic factors [1, 4].

A study by Fricke et al. (2015) reported a variation in disease incidence worldwide from 2.1% and 0.7% to 3.8% in the USA, India, and Singapore, respectively [3]. In Africa and the Middle East, regional studies have reported a disease prevalence ranging between 0.2% and 13.8% on the basis of the individual treatment landscape of the countries [10].

The diagnosis of AA is usually based on history taking and clinical examination; skin biopsies are rarely required. The Severity of Alopecia Tool (SALT) is an assessment tool to measure the disease extent in the scalp. SALT scores range from 0 to 100, with 0 indicating no scalp hair loss and 100 indicating complete hair loss on the scalp. It is primarily used in clinical trials studying the response to AA treatments [11].

Despite the advances in new treatment protocols, standardized AA treatment is lacking. Many therapies currently used in clinical practice to induce hair regrowth are not validated by clinical trials. None of these therapies are approved by the Food and Drug Administration (FDA) and are used off-label. A variety of topical, intralesional, systemic, and device treatments exist for the management of AA. Topical, intralesional, and oral steroids remain popular treatments. Other topical treatments include topical immunotherapies such as squaric acid dibutyl ester and diphenylcyclopropenone (DPCP). Systemic immunosuppressants include cyclosporin, azathioprine, and methotrexate. Additionally, topical or systemic minoxidil has been prescribed as adjuvant therapy by some dermatologists. Recent off-label procedural treatment modalities include microneedling, platelet-rich plasma, laser, and stem cell therapy [12–15]. In 2022, the FDA approved the use of baricitinib, an oral Janus kinase inhibitor (JAKi) for adults with severe AA. Currently, baricitinib is the only treatment for AA that has undergone two phase 3 randomized controlled clinical trials; BRAVE-AA1 and BRAVE-AA2. These trials reported an 80% hair regrowth efficacy over 36 weeks for patients treated with baricitinib, proving its efficacy over placebo [16].

There is a lack of established registries, robust epidemiological data, and standardized management guidelines for AA in Africa and the Middle East. This is reflected in the region’s high disease burden and unmet needs for patients with AA. Through this manuscript, we attempt to gain insights into the regional data for AA, focusing on etiopathogenesis, prevalence, and disease burden as measured by disability-adjusted life years (DALYs) and QoL. We also report the psychosocial and economic impact of AA in the region. Finally, we highlight the treatment approaches used in different countries of Africa and the Middle East by analyzing scoring systems, clinician decisions, drug availability, and patient compliance.

Methods

A literature search was conducted via PubMed, Embase, and Web of Science databases. The following search strings were used: (“alopecia areata” AND (“North Africa” OR “Middle East” OR “South Africa”)). Individual country names in the region combined with keywords such as “alopecia”, “hair loss”, “trichoscopy”, and “epidemiology” were also used. The geographical areas of interest were composed of the countries of the Middle East and Africa, including the United Arab Emirates (UAE), Saudi Arabia, Turkey, Jordan, Egypt, Iran, Iraq, Bahrain, Tunisia, Kuwait, Lebanon, and South Africa. Studies published in English between 2010 and 2021 were selected for data extraction. The extracted data were reorganized into the tables presented. Statistical analyses were not feasible due to the heterogeneity of parameters reported in the various studies. To define the epidemiology of AA, articles with data on the prevalence, incidence, and distribution by sex or age were selected. Articles with data on DALYs and associated psychiatric or medical comorbidities were included to assess the disease burden. During the development of this review, the Preferred Reporting Items for Systematic Reviews and Meta-Analyses (PRISMA) 2020 checklist was consulted as a guide; however, not all checklist items were strictly adhered to. The authors declare ethical compliance as this article is based on previously conducted studies and does not contain any new studies with human participants or animals performed by any of the authors.

Outcomes of Literature Search Strategy

The PubMed, Embase, and Web of Science databases were searched for relevant publications. Articles were initially screened by title and abstract according to the following exclusion criteria: abstract-only articles, studies not involving primary data collection, non-clinical studies, and irrelevant study design or outcome assessments. After duplicates were removed, 112 articles were screened via full-text assessment, and 18 were excluded as they were either irrelevant (based on patient population or intervention) or had insufficient subgroup data analysis. In total, 94 publications were selected for the scope of this review.

Results

Etiology and Pathophysiology

AA is a form of non-scarring alopecia that occurs in a patchy, confluent, or diffuse patterns. It may occur as a single, self-limiting episode or recur at varying intervals over the years. The etiology of AA is not fully understood. However, factors that appear to be implicated in etiopathogenesis are the patient’s genetic constitution, atopic state, nonspecific immune and organ-specific autoimmune reactions, and emotional stress [17].

Proinflammatory signals such as substance P, interferon-γ, and reactive oxygen species upregulate the expression of major histocompatibility complex class IA, causing a breakdown of the immune-privileged sites in anagen hair follicles. This subsequently triggers a CD8⁺-driven, Th1-type T-cell autoimmune reaction against anagen hair follicles, resulting in acute hair loss of the growing hair shaft [1, 9].

The onset of AA is typically before the age of 40 years in 70–80% of patients; a substantial proportion of ~ 48% will show clinical signs during their first and second decades, making AA a common cause of hair loss in adolescents and children. Early onset of AA is an important negative prognostic factor frequently overlooked by family members and dermatologists in the early stages. It is associated with a high relapse rate and traditional treatment failure, which can significantly impact a patient’s QoL [18, 19].

Clinical Variants and Signs

The clinical presentation of AA varies depending on the location of lesions and the extent of hair loss. AA can be classified as patchy AA with localized areas of hair loss; ophiasis, which appears as band-like confluent patches in the occipital and temporal regions of the scalp; sisaipho, which occurs as central hair loss in the areas not affected by the ophiasis variant, usually sparing the temporal and occipital regions; alopecia totalis (AT), affecting the entire scalp; and alopecia universalis (AU), affecting the scalp and all body hair [4].

The typical clinical signs of AA include waxing and waning patches of smooth, circular discrete areas of completed hair loss, most commonly on the scalp, but may involve any hair-bearing area such as the eyebrows, eyelashes, beard, or extremities. Dermatoscopic features include yellow dots, black dots, broken hairs, tapering or exclamation point hairs, and short vellus hairs at the margins. Nails may be involved and display fine-stippled pitting; occasionally nail dystrophy can manifest. A characteristic that may be shared by all types of AA is sporadic regrowth of hair in one area of the scalp, which is associated with the appearance of new patches or the expansion of existing patches elsewhere [4, 20].

AA Scale for Diagnosis

In addition to the SALT scoring system, the AA disease severity scale was developed following consensus by an expert panel of 22 board-certified dermatologists from the USA. It was designed to address the unmet need for a scoring system that adequately characterized the clinical spectrum of AA severity and considered eyebrow and eyelash involvement, treatment-refractory disease, and psychosocial impact. It uses the extent of scalp hair loss as the primary basis for a severity rating, in addition to four secondary clinical features, including psychosocial functioning, involvement of eyebrows or eyelashes, inadequate treatment response, and diffuse positive hair pull test. The scores are calculated as mild: 20% or less scalp hair loss; moderate: 21–49% scalp hair loss; and severe: 50–100% scalp hair loss [21, 22].

Prevalence

Global Data

AA affects approximately 2% of the general population, as documented by several epidemiological studies from Europe, North America, and Asia [3]. A study by Lee et al. [23] evaluated the epidemiological data on the global prevalence of different clinical variants of AA and reported an overall prevalence of 1.9% in children [23].

Africa and the Middle East

Table 1 presents the results of AA prevalence studies conducted in Africa and the Middle East.

Table 1.

Regional prevalence and demographic data

Country	Indication of disease prevalence	Female:male ratio	Indication of age demographic	Location of patches	Type of AA
Saudi Arabia [1, 4, 10]	Overall prevalence: 2.3–13.8% Overall prevalence: 2.3%	1.82:1 0.73:1	19.0 years mean onset, with 44.7% of patients aged 11.0–20.0 years 25.6 ± 12.9 years mean onset	Overall: scalp In male patients > 20.0 years: beard Scalp	Not specified Patchy
Nigeria [24]	0.1% of all skin diseases	1.13:1	13.8 ± 2.1 years mean onset	Not specified	Not specified
Tunisia [11]	Not specified	1.46:1	20.0 years mean onset	Not specified	Not specified
South Africa [25]	0.2% of all skin diseases	Not specified	Not specified	Not specified	Not specified
Côte d’Ivoire [26]	0.2%	1:1.47	24.6 years mean onset	Not specified	Not specified
Iraq [27]	66.4% of all hair disorders	0.75:1	45.4% of patients aged 5.0–14.0 years	Not specified	Not specified
Turkey [21, 28]	Military: 5.4% Civilians: 1.7% [28] Overall prevalence: 1–6.7% [21]	Not specified	Military: 26.0 ± 8.4 years mean onset Civilians: 26.7 ± 17.0 years mean onset	Not specified	Not specified
Jordan [29]	26.2%	1:1.5	3.60 years mean onset	Scalp	Patchy

Disease Burden

Disability-adjusted life years (DALYs)

The burden of AA has been measured by DALYs, which combines years lost to disability, including morbidity, and years lost to death, such that 1 DALY represents 1 year of healthy life lost [3].

In the Global Burden of Disease study, the World Health Organization (WHO) measured the global DALYs lost to AA in 2010 to be 1,332,800. The DALYs for AA have been increasing linearly since 1990. A possible limitation of this study was an underestimation of the true population-based prevalence [3]. Another epidemiological study by Karimkhani et al. (2014) reported that AA is often underrepresented during literature searches in databases such as the Cochrane Database of Systematic Reviews when matched with corresponding DALYs for other common skin diseases [30].

A retrospective survey by Wang et al. [31] reported that in 2019, Central Sub-Saharan Africa and the Middle East and North Africa were regions with among the lowest age-standardized DALY rates for AA patients (6.70 and 6.26, respectively) [31].

Health-Related QoL

It has been estimated that over half of the patients with AA experience deterioration in their QoL. Female gender, change in physical appearance, family stress, increased prevalence of mood disorders, and impairment of social life are contributing factors [3, 32]. Several dermatology-specific questionnaires have been developed to evaluate the impact of AA on QoL, especially in the area of mental health. These include Skindex, Dermatology Life Quality Index, dermatology QoL scales, and dermatology categorical QoL scales [33]. Tables 2, 3, 4, 5, 6, 7, 8, 9 describe the results of a literature search for studies conducted in Africa and the Middle East to assess the extent of this impairment caused by AA.

Table 2.

Study assessing the impact of AA on patient QoL in Iran

Questionnaire	Number of patients	Results		Conclusions
		Parameter	Scores based on AA severity
DLQI [34]	176	Symptom and feelings	Mild: 1.6 ± 1.2 Severe: 2.6 ± 1.6	The total score was 5.4 ± 6.8 for mild AA and 10.7 ± 7.5 for severe AA, indicating more pronounced QoL impairment in patients with severe AA
		Daily activities	Mild: 0.77 ± 1.4 Severe: 1.6 ± 1.7
		Leisure	Mild: 0.88 ± 1.6 Severe: 2.5 ± 2.2
		Personal relationships	Mild: 1.05 ± 1.7 Severe: 1.6 ± 1.8
		Work and school	Mild: 0.54 ± 1.09 Severe: 1.01 ± 1.3
		Treatment	Mild: 0.63 ± 0.9 Severe: 1.1 ± 1.1

The Dermatology Life Quality Index (DLQI) questionnaire consists of 10 questions with a score of 0–30, with 0 indicating no impact on QoL and 30 indicating maximum impact on QoL

Table 3.

Studies assessing the impact of AA on patient QoL in Turkey

Questionnaire	Number of patients	Results			Conclusions
		Disease severity	AA-QLI score	DLQI score
AA-QLI, DLQI [32]	100	Patchy	44.86 ± 7.8	12.2 ± 5.7	Total score of DLQI was 10.7 ± 5.9 and AA-QLI was 48.0 ± 9.7, indicating a significant impact on QoL
		Ophiasis	45.2 ± 9.4	9.0 ± 4.8
		Totalis	46.2 ± 14.4	7.4 ± 6.2
		Universalis	52.2 ± 9.2	12.0 ± 7.6

Alopecia Areata-Quality of Life Index (AA-QLI) is a two-part questionnaire scored from 21 to 84, with a higher score marking a higher impact on QoL. The Dermatology Life Quality Index (DLQI) questionnaire consists of ten questions with a score of 0–30, with 0 indicating no impact on QoL and 30 indicating maximum impact on QoL

Table 4.

Studies assessing the impact of AA on patient QoL in Turkey

Questionnaire	Number of patients	Results			Conclusions
		Score	Control	AA patients
RCADS-C, RCADS-P, BAI, BDI [35]	31	RCADS-C	41.5 ± 7.9	49.1 ± 12.9	Patient and parent impairment in QoL increased with AA severity
		RCADS-P	49.4 ± 10.2	56.3 ± 11.1
		BAI	9.0 ± 8.7	11.7 ± 8.8
		BDI	7.5 ± 5.8	10.0 ± 6.7

The Revised Children’s Anxiety and Depression Scale-Children (RCADS-C) questionnaire has 47 questions with subscales scored from 0, indicating minimal impact on QoL, to 3, indicating significant impact on QoL. Additionally, the RCADS-Parents (RCADS-P) questionnaire similarly assesses parents’ reports of a child’s symptoms of anxiety and depression across the same six subscales. Each of the 21 questions in the Beck Anxiety Inventory (BAI) questionnaire is rated on a 4-point scale of distress (0–3) in terms of severity. The scale follows the correspondence: not at all (0); mildly: it did not bother me much (1); moderately: it was very unpleasant, but I could stand it (2); severely: I could barely stand it (3). The Beck Depression Inventory (BDI) questionnaire is a 21-question, multiple-choice, self-report inventory scored as 0–9: minimal depression, 10–18: mild depression, 19–29: moderate depression, 30–63: severe depression

Table 5.

Studies assessing the impact of AA on patient QoL in Turkey

Questionnaire	Number of patients	Results	Conclusions
CDI, STAIc, and PedsQL-P and -C [36]	74	Children had higher scores of state and trait anxiety than parents	AA seems to interfere in the daily life of children and adolescents with AA, especially in the psychosocial area
		Lower parent-related health and total QoL in adolescents with AA

The Children’s Depression Inventory (CDI) questionnaire has 27 questions scored from 0 to 54, with a score of 36 and higher indicating severe depression. The State-Trait Anxiety Inventory for Children (STAIc) questionnaire has a state and trait anxiety subscale scored from 20 to 80, with higher scores correlating to greater anxiety and impact on QoL. The Pediatric Quality of Life Inventory™ (PedsQL-P and -C) questionnaire has 23 questions scored as 0: never a problem; 1: almost never; 2: sometimes; 3: often; and 4: almost always a problem

Table 6.

Studies assessing the impact of AA on patient QoL in Egypt

Questionnaire	Number of patients	Results		Conclusions
		Disease severity	DLQI score
DLQI [37]	2962	Extensive	13.4	Severe forms of AA significantly impacted patient psychosocial well-being
		Totalis	13.5
		Universalis	14.1

The Dermatology Life Quality Index (DLQI) questionnaire consists of 10 questions with a score of 0–30, with 0 indicating no impact on QoL and 30 indicating maximum impact on QoL

Table 7.

Studies assessing the impact of AA on patient QoL in Egypt

Questionnaire	Number of patients	Results	Conclusions
Skindex-16i [38]	500	Mean percentage scores of QoL deterioration: Emotional: 55.5 ± 23.1 Symptoms: 31.7 ± 26.8 Functioning: 29.1 ± 26.8	QoL most deteriorated in the emotional domain, followed by the symptoms and functioning domains

The Skindex questionnaire has 16 questions over three scales scored as never bothered (0) to always bothered (100). Scale scores are calculated as the average of responses to items in each of the three scales

Table 8.

Studies assessing the impact of AA on patient QoL in Egypt

Questionnaire	Number of patients	Results	Conclusions
DLQI, CDLQI [39]	22	Mean values of the scores were 10.4 ± 4.5 before therapy and 3.9 ± 6.2 after therapy	QoL of AA patients improved after treatment with trichloroacetic acid

The Dermatology Life Quality Index (DLQI) questionnaire consists of ten questions with a score of 0–30, with 0 indicating no impact on QoL and 30 indicating maximum impact on QoL. The Children’s Dermatology Life Quality Index (CDLQI) questionnaire has ten questions scored from 0 to 30, with 0 indicating minimal impact on QoL over the last week and 30 indicating significant impact on QoL over the last week

Table 9.

Study assessing the impact of AA on patient QoL in Tunisia

Questionnaire	Number of patients	Parameters assessed	Conclusions
SF-36 [40]	50	Mental health, social functioning vitality, general health	AA patients had a mean score of 68.9 ± 13.1 compared with the general population score of 80.5 ± 91.4, which indicates a significantly altered QoL

The Short Form 36 (SF-36) questionnaire has 36 questions over 8 scales scored on a 0–100 scale; a score of 0 is equivalent to maximum disability and a score of 100 is equivalent to no disability

Psychiatric Morbidity and Social Impact

Studies have shown that despite stress having a minor influence on the initial onset of AA, the condition can affect stress mediators and psychoneuroimmunology pathways, resulting in progressive distress and depression. Additionally, individuals with AA may exhibit elevated hypothalamic–pituitary–adrenal axis activity, which impairs their capacity to adjust to stress-related mediators [41]. A study by Sellami et al. [42] in Tunisian patients aimed to investigate the possible relationship between AA, anxiety, depression, and alexithymia. The results showed a higher prevalence of symptoms of anxiety and depression in AA patients when compared with controls. This was due to low self-esteem and social isolation. In addition, a high prevalence of alexithymia was observed in these patients, affecting their ability to form emotional attachments and maintain an active social life [42, 43]. As a result of the physical disfigurement caused by the disease, pediatric patients are often subjected to social isolation and bullying by peers at school, which severely impacts their QoL.

There are no available large-scale regional studies from Africa and the Middle East evaluating the correlation of AA with psychiatric disorders.

Comorbid Medical Conditions

AA has been associated with atopic diseases such as asthma, hypothyroidism, atopic dermatitis, allergic rhinitis, and autoimmune diseases such as psoriasis, rheumatoid arthritis, vitiligo, celiac disease, and lupus erythematosus [6].

In a study by Bakry et al. [44] on a cohort of Egyptian patients, hypothyroidism was found in 16% of AA patients. Patients had lower levels of thyroid-stimulating hormone, free T3 and T4 hormones, as well as a positive assay for the thyroid peroxidase and thyroglobulin antibodies. The investigators proposed screening all patients with AA for thyroid function abnormalities, even in the absence of clinical signs of hypothyroidism, for the early detection of subclinical thyroid abnormalities [44]. A similar study by Arousse et al. (2019) in Tunisian patients reported the occurrence of atopic disease in 18.1% of patients with AA, whereas hypothyroidism was noted in 12.7% of the patients [11]. Another study by Saif et al. (2016) in Saudi patients reported higher frequencies of thyroid autoantibodies and thyroid peroxidase and thyroglobulin antibodies in patients with AT and AU when compared with those with mild AA [45].

A study by Alamoudi et al. [46] in Saudi patients reported that hypothyroidism was the most common medical comorbidity in patients with AA, followed by atopic diseases, diabetes, and mood disorders. Most of these comorbidities were identified in patients with a patchy type of AA [46]. Similar results were reported by Alshahrani et al. (2020), reporting comorbidities, including hypothyroidism, diabetes mellitus, and atopic diseases, in 32.4% of patients with AA [4].

A retrospective study by Hasan et al. [47] reported that a pediatric patient cohort from Bahrain had a higher risk of developing celiac disease, which can be attributed to common cell-mediated autoimmune mechanisms as the underlying etiopathogenesis [47].

Another interesting study by Marie et al. (2020) in Egyptian patients reported significantly elevated levels of cardiac troponin I and N-terminal pro-B-type natriuretic peptide biomarkers in patients with AA compared with controls. The study suggested a possible association of AA with myocardial inflammation and an increased risk of developing cardiovascular disease [48].

Economic Impact

Many patients with extensive AA, AT, and AU can be dissatisfied with current medical treatments and resort to alternative management resources such as wigs, hairpieces, powders, eyebrow tattoos, or other camouflage modalities. The accumulation of expenses of these alternative resources, in addition to insurance premiums, copayments, deductibles, and lost income, is financially burdensome. Despite the lack of data on the financial impact and reimbursement challenges that patients face in the Middle East, dermatologists are encouraged to be aware of the potential ramifications of treatment costs for patients and consider financial impairment when suggesting treatments. Government-sponsored plans should be implemented to address these issues [49].

Treatment Options

Although the approval of JAKi is a valuable addition to the armamentarium of treatment options for adult patients with severe AA, available options for pediatric and adolescent populations are insufficient [13, 50]. AA management is challenging, especially in Africa and the Middle East, where treatment plans have no region-specific guidelines [51, 52]. Tables 10, 11, 12, 13, 14, 15, 16, 17, 18, 19, 20, 21, 22, 23, 24, 25, 26, 27, 28, 29, 30, 31, 32, 33, 34, 35, 36, 37, 38, 39, 40, 41, 42, 43, 44, 45, 46, 47 provide an overview of selected studies conducted in the region to treat patients with AA.

Table 10.

Studies of topical agents in Iran

Authors	Study type	Agent(s)	Results		Conclusions
Ghandi et al. [51]	Retrospective observational	DPCP (0.0001–2%)	< 12 months of treatment		Significant reductions in SALT scores are indicative of the efficacy of DPCP in treating AA of the scalp
			Baseline SALT	SALT at 6 months
			83.3%	72.8%
			Partial response	Complete response
			5.3%	8.3%
			> 12 months of treatment
			Baseline SALT	SALT at 6 months
			75.1%	52.3%
			Partial response	Complete response
			42.9%	14.3%

DPCP diphenylcyclopropenone; SALT severity of alopecia tool

Table 11.

Studies of topical agents in Iran

Authors	Study type	Agent(s)	Results			Conclusions
			Parameters	DPCP (%)	DPCP + anthralin (%)
Ghandi et al. [53]	Randomized controlled	DPCP (0.001–1%) and anthralin (0.5%)	Complete response	18.7	15.8	There is no statistical difference between DPCP with anthralin and DPCP alone in treating patients with AA of the scalp
			Partial response (> 75%)	25.0	21.0
			Partial response (> 50%)	31.0	47.0

DPCP diphenylcyclopropenone

Table 12.

Studies of topical agents in Iran

Authors	Study type	Agent(s)	Results		Conclusions
			Partial response (%)	Complete response (%)
Abedini et al. [54]	Non-randomized	DPCP (0.0001%)	26.8	14.6	The number of black dots per field was initially negatively correlated to DPCP therapy, and the frequency of dermoscopic findings was reduced during the treatment process for AA of the scalp

DPCP diphenylcyclopropenone

Table 13.

Studies of topical agents in Iran

Authors	Study type	Agent(s)	Results		Conclusions
			Partial response (%)	Complete response (%)
Nasimi et al. [55]	Retrospective observational	DPCP (0.37%)	29.5	60.1	Topical DPCP therapy is a good and safe treatment option with 60.1% response rate for treatment of AA of the scalp

DPCP diphenylcyclopropenone

Table 14.

Studies of intralesional agents in Iran

Authors	Study type	Agent(s)	Results	Conclusion
Khademi et al. [13]	Randomized controlled pilot study	PRP (4 mL)	Most patients showed no hair regrowth on the scalp 2/10 patients showed < 10% hair regrowth	Single dermal injection of PRP did not prove to have any significant effect on hair regrowth in patients with AA of the scalp

PRP platelet-rich plasma

Table 15.

Studies of intralesional agents in Iran

Authors	Study type	Agent(s)	Results			Conclusions
			Parameters	Citalopram (20 mg/day) + triamcinolone (%)	Triamcinolone (5 mg/day) (%)
Abedini et al. [56]	Randomized controlled	Triamcinolone (5 mg/mL), citalopram (20 mg/day) in patients with major depressive disorder	Partial regrowth	23.3	6.7	Combining citalopram with triamcinolone injection is more effective than triamcinolone alone in treating mild scalp AA
			Full regrowth	53.3	16.7

Table 16.

Studies of oral/systemic agents in Iran

Authors	Study type	Agent(s)	Results	Conclusion
Farshi et al. [57]	Randomized controlled	Azathioprine (2 mg/kg)	Mean hair loss percentage before treatment was 72.7% compared with 33.5% after 6 months of azathioprine treatment	Treatment with azathioprine as a systemic monotherapy improves moderate-to-severe AA of the scalp

Table 17.

Studies of oral/systemic agents in Iran

Authors	Study type	Agent(s)	Results				Conclusion
			Parameter	Betamethasone	Methotrexate	Combination
Asilian et al. [58]	Randomized controlled	Pulsed oral steroid betamethasone (3 mg) and methotrexate (15 mg)	SALT score reduction	26%	23%	43%	Steroid pulse therapy and combination therapy were more effective than methotrexate alone in treating AA of the scalp
			Visual analog scale	3 points	4 points	6 points
			Photographic scores	1 point	1 point	2 points

SALT severity of alopecia tool

Table 18.

Studies of topical agents in Turkey

Authors	Study type	Agent	Results		Conclusions
			Complete response (%)	Partial response (%)
Kutlubay et al. [59]	Retrospective observational	DPCP (0.001–2%)	34	16	Topical DPCP immunotherapy is a safe and effective alternative for patients with resistant AA of the scalp

DPCP diphenylcyclopropenone

Table 19.

Studies of topical agents in Turkey

Authors	Study type	Agents	Results			Conclusions
			Parameters	Mometasone furoate only	Mometasone furoate + adapalene
Unal et al. [60]	Non-randomized	Mometasone furoate (0.1% cream) and adapalene (0.1% gel)	Mean % hair regrowth	71.0 ± 18.6	90.5 ± 17.9	Adapalene can be used as a new therapeutic agent in treating AA of the scalp
			Hair regrowth score	3.3 ± 0.9	4.4 ± 0.9

Table 20.

Studies of topical agents in Turkey

Authors	Study type	Agent	Results		Conclusions
			Complete response (%)	Partial response (%)
Ozdemir et al. [61]	Retrospective observational	Anthralin ointment (1%)	36.6	33.4	Anthralin (1%) is a safe treatment choice in children with extensive, chronic, and treatment-refractory AA of the scalp

Table 21.

Studies of topical agents in Turkey

Authors	Study type	Agents	Results			Conclusions
			Parameters	DPCP alone (%)	DPCP + anthralin (%)
Durdu et al. [62]	Retrospective observational	DPCP (0.001–2%) and anthralin (0.5%)	> 50% hair regrowth	54.5	88	The combination therapy with DPCP and anthralin is superior to the DPCP therapy in terms of efficacy
			> 75% hair regrowth	45.4	80

DPCP diphenylcyclopropenone

Table 22.

Studies of topical agents in Turkey

Authors	Study type	Agents	Conclusions
Ucak et al. [63]	Randomized controlled	Clobetasol propionate (0.05%), pimecrolimus (1%)	> 50% recovery (hair regrowth in the scalp) was observed in 53.7% of patients treated with pimecrolimus, establishing efficacy. However, there was no advantage over clobetasol propionate

Table 23.

Studies of oral agents in Turkey

Authors	Study type	Agents	Results			Conclusions
			Parameter	Pre-treatment	Post-treatment
Askin et al. [64]	Case control	Tofacitinib (10 mg/day)	SALT score	100 (50–100)	40 (24–50)	A significant decrease in interleukin levels following tofacitinib treatment supports the idea that interleukins have a role in the pathogenesis of AA

SALT severity of alopecia tool

Table 24.

Studies of oral agents in Turkey

Authors	Study type	Agent	Results		Conclusions
			Parameters	Values
Rota et al. [65]	Retrospective observational	Tofacitinib (10 mg/day)	Improvement in SALT score	61.5%	Tofacitinib seems to be more promising in treating AA of the scalp than AU
			Overall response	76.0–100%

SALT severity of alopecia tool

Table 25.

Studies of oral agents in Turkey

Authors	Study type	Agent	Results		Conclusions
			Parameters	Values
Serdaroglu et al. [66]	Retrospective observational	Tofacitinib (10 mg/day)	Complete response	39.7%	10 mg/day of tofacitinib monotherapy is efficient for long-term management of refractory AA of the scalp
			Overall response	88.0%

Table 26.

Studies of oral agents in Turkey

Authors	Study type	Agents	Results			Conclusions
			Parameter	Continued treatment with tofacitinib (%)	Discontinued treatment with tofacitinib (%)
Askin et al. [67]	Retrospective observational	Tofacitinib (2 × 5 mg/day)	Recurrence rate	6.7	82.7	It is recommended to continue the tofacitinib treatment regime as prescribed to avoid AA relapse

Table 27.

Studies of oral agents in Turkey

Authors	Study type	Agent	Results		Conclusions
			Parameter	Value (%)
Acikgoz et al. [68]	Retrospective observational	Cyclosporine (2.5–6 mg/kg/day)	Hair regrowth	45.4	5 mg/kg/day or higher doses of cyclosporine > 6 months for severe AA of the scalp showed considerable improvements

Table 28.

Studies of intralesional agents in Turkey

Authors	Study type	Agents	Conclusions
Ustuner et al. [69]	Randomized controlled	TCA and betamethasone dipropionate (1/4, 1/8, 1/12 dilutions)	6-month scalp hair regrowth scores, overall treatment success rates, and percentage of terminal hair regrowth were similar in 1/4 dilution of triamcinolone acetonide and betamethasone

TCA triamcinolone acetonid

Table 29.

Studies of oral agents in Kuwait

Authors	Study type	Agent	Results		Conclusions
			Complete response (%)	Partial response (%)
Almutairi et al. [70]	Randomized controlled	Oral JAK inhibitors (ruxolitinib 20 mg/day and oral tofacitinib 5 mg/day)	64–68%	25–74%	Oral JAK inhibitors are considered an effective, well-tolerated treatment for AA of the scalp

JAK Janus kinase

Table 30.

Studies of devices in Iraq

Authors	Study type	Agent	Results			Conclusions
			Overall response (%)	Partial response (%)	Mean SALT score
Hamzawi et al. [7]	Prospective interventional	308-nm excimer lamp	100.0	55.5	Baseline: 20.3 ± 4.8 End of study: 9.1 ± 5.4	308-nm excimer lamp at a maximum dose of 1450 mJ and a minimum dose of 900 mJ was an effective modality for treating AA of the scalp

SALT severity of alopecia tool

Table 31.

Studies of devices in Iraq

Authors	Study type	Agent	Results			Conclusions
			Parameters assessed at follow-up (12 weeks)	Study patches	Control patches
Dhalimi et al. [14]	Interventional case control	Non‐ablative fractional 1540-nm erbium‐glass laser	Mean % hair regrowth	31.1 ± 18.4	23.5 ± 14.2	Erbium‐glass laser seems effective in regrowing hair in AA of the scalp
			Response rate	60.0%	16.0%

Table 32.

Studies of intralesional agents in Jordan

Authors	Study type	Agent	Results			Conclusions
			Parameters	Group 1 (5 mg/mL)	Group 2 (10 mg/mL)
Muhaidat et al. [71]	Retrospective comparative	TCA (5 mg/mL and 10 mg/mL)	Overall response rate	48.0	48.0	For patchy AA, intralesional triamcinolone at 5 mg/mL or 10 mg/mL concentration was equally effective in achieving hair regrowth of the scalp
			Complete response	43.5	53.8

TCA triamcinolone acetonide

Table 33.

Studies of intralesional agents in Lebanon

Authors	Study type	Agent	Results		Conclusions
			Parameters	Value after 6 months
Anderi et al. [72]	Retrospective observational	Stem cell therapy with human autologous adipose-derived stromal cells	Hair diameter	50.1% improvement	The transplantation of autologous adipose-derived stromal vascular cells can be considered a promising cell-based therapy for AA treatment of the scalp
			Hair density	61.2% improvement
			Hair pull test	Reduction in score to 0–1

Table 34.

Studies of topical agents in Lebanon

Authors	Study type	Agent	Results		Conclusions
			Parameter	Value
El Khoury et al. [73]	Retrospective observational	DPCP (0.001–2%)	Overall response	79.4% (majority had a partial response)	DPCP is effective in treating patients with extensive AA of the scalp

DPCP diphenylcyclopropenone

Table 35.

Studies of oral agents in Saudi Arabia

Authors	Study type	Agent	Results		Conclusions
			Partial response (%)	Complete response
AlMarzoug et al. [74]	Prospective cohort	Tofacitinib (5 mg twice daily)	21.4	48.2% at 3 months 62.2% at 6 months	Tofacitinib 5 mg twice daily is an effective and well-tolerated treatment for severe AA of the scalp

Table 36.

Studies of oral agents in Saudi Arabia

Authors	Study type	Agent	Results		Conclusions
			Parameters	Values (%)
Bin Saif et al. [75]	Single-center prospective randomized	Pulsed oral steroid (methylprednisolone) at 15 mg/kg	Adequate response	28.6	Mega pulses of methylprednisolone at 15 mg/kg per day orally for 2–3 days every 2–3 weeks led to scalp hair regrowth in 28.6% of patients within 6–9 months
			Inadequate response	21.4
			Poor response	50.0

Table 37.

Studies of oral agents in South Africa

Authors	Study type	Agent	Results		Conclusions
			Parameter	Values
Ngwanya et al. [76]	Retrospective observational	Dithranol (0.5–3%)	Partial response (> 50% hair regrowth)	61.5% (mild AA) 48.4% (moderate AA) 37.5% (severe AA)	Mild and moderate AA of the scalp may benefit more from dithranol than severe AA

Table 38.

Studies of intravenous/systemic agents in Israel

Authors	Study type	Agent	Results		Conclusions
			Partial response (%)	Complete response (%)
Friedland et al. [77]	Retrospective observational	Pulse corticosteroid therapy (8–10 mg/kg)	29	38	Pulse corticosteroids are effective in treating children with AA of the scalp

Table 39.

Studies of intravenous/systemic agents in Israel

Authors	Study type	Agents	Conclusions
Lyakhovitsky et al. [78]	Retrospective observational	Systemic and intralesional corticosteroids	Systemic corticosteroids were more effective in hair regrowth (complete) for childhood, adult, and late-onset AA than intralesional corticosteroids

Table 40.

Studies of topical agents in Egypt

Authors	Study type	Agents	Results			Conclusions
			Parameter	DPCP (%)	Tacrolimus (%)
Hunter et al. [79]	Non-randomized	DPCP (0.0001–2%) tacrolimus (0.1%)	Hair growth	40	4	DCPC is an acceptable therapeutic modality in the treatment of AA, with a favorable prognosis for patchy hair loss. Tacrolimus could not be considered effective in the treatment of AA
			Partial response	16	16

DPCP diphenylcyclopropenone

Table 41.

Studies of topical agents in Egypt

Authors	Study type	Agents	Results		Conclusions
			Partial response	Complete response
Kamel et al. [80]	Non-randomized	8-MOP (0.1%) UV-A radiation (6 J/cm2 initial dose, increased by 1 J/cm2 until maximum of four sessions)	17%	> 40%	An overall hair regrowth of 57% indicated that phototoxic PUVA therapy with 0.1% 8-MOP is a good treatment option for resistant AA of the scalp

MOP methoxypsoralen, PUVA psoralen and ultraviolet A radiation, UV-A ultraviolet A

Table 42.

Studies of topical agents in Egypt

Authors	Study type	Agents	Results			Conclusions
			Parameter	Corticosteroids (%)	Bimatoprost (%)
Zaher et al. [81]	Randomized controlled	Corticosteroids (0.1%) bimatoprost (0.03%)	Response rate	56.7	83.3	Bimatoprost is more effective than corticosteroids in scalp hair regrowth
			Mean hair regrowth	22.4 ± 20.6	48.9 ± 29.2

Table 43.

Studies of topical agents in Egypt

Authors	Study type	Agents	Results		Conclusions
			Parameter	Efficacy
Elashmawy et al. [82]	Randomized controlled	Latanoprost (0.1%) minoxidil (5%) betamethasone valerate (0.1%)	SALT score reduction	Yes	All three agents effectively treat patchy AA of the scalp and beard
			Reduction in dermoscopic features	Yes

SALT severity of alopecia tool

Table 44.

Studies of intralesional agents in Egypt

Authors	Study type	Agents	Results			Conclusions
			Parameters	I/L methotrexate	I/L steroids
Hamdino et al. [83]	Randomized controlled	Methotrexate (25 mg/mL) steroids (10 mg/mL)	Hair regrowth > 75%	20%	40%	Intralesional MTX in the treatment of localized scalp AA in adults is comparable to intralesional steroids
			SALT score reduction	0–8.4	0–13

I/L intralesional, MTX methotrexate

Table 45.

Studies of intralesional agents in Egypt

Authors	Study type	Agents	Results			Conclusions
			Parameters	PRP (%)	Steroids (%)
Albalat et al. [84]	Non-randomized	PRP (3 mL) steroids (0.1 mL)	RGS1 regrowth	50	30	PRP is safe and could be considered an effective therapeutic alternative to steroids to treat scalp AA
			RGS2 regrowth	30	60
			Increase in pigmented hair	75	70
			Overall improvement	72	65

RGS regulator of G protein

Table 46.

Studies of intralesional agents in Egypt

Authors	Study type	Agents	Results				Conclusions
			Parameters	Minoxidil	TCA	Microneedling
Abdallah et al. [85]	Non-randomized	Minoxidil (5%), TCA (5 mg/mL), microneedling	Mean duration of hair regrowth (weeks)	6.8 ± 2.9	5.0 ± 2.2	7.6 ± 3.3	Monotherapy of intralesional minoxidil is limited in treating non-severe patchy AA of the scalp
			Median regrowth	75%	85%	65%

TCA triamcinolone acetonide

Table 47.

Studies of intralesional agents in Egypt

Authors	Study type	Agents	Results				Conclusions
			Parameters	Carboxy-therapy	TCA	Combination
Metwally et al. [86]	Randomized controlled	TCA 5 mg/mL, 2 mL at a flow rate of 1 cc/s	Modified SALT score	Baseline: 10.9 ± 7.6 Post-treatment: 8.1 ± 6.8	Baseline: 11.0 ± 6.8 Post-treatment: 7.5 ± 6.6	Baseline: 11.3 ± 10.4 Post-treatment: 7.0 ± 8.5	Combination therapy produced the most significant improvement in AA, with 79.2% hair regrowth rate
			Yellow dots	Reduced	Reduced	Reduced

SALT severity of alopecia tool, TCA triamcinolone acetonide

One of the main issues dermatologists face in the absence of region-specific recommendations is the lack of uniformity in treatment regimens. The identified studies highlight this clinical practice gap, making it challenging to compare the efficacies of different treatment modalities.

Guideline Recommendations

There is a lack of local evidence-based guidelines, protocols, or algorithms for the management of AA in Africa and the Middle East. Most local dermatologists follow international guidelines, namely the British [87], Italian [88], German [89], and American guidelines [90].

This section will attempt to provide an overview of some key consensus statements issued by global expert panels that aim to guide future regional AA management guidelines.

International Consensus Statements on AA Treatment

Meah et al. (2020) conducted a comprehensive study to compile a first-of-its-kind consensus on the expert age-wise assessment of AA treatment. A total of 50 hair experts from five continents participated in a three-round Delphi process that included questions regarding the epidemiology, etiopathogenesis, diagnosis, investigation, treatment, and prognosis of AA. An agreement of ≥ 66% was considered a consensus to formulate the Alopecia Areata Consensus of Experts (ACE) guidelines, which are now widely used by dermatologists in clinical practice. These statements are summarized below [91].

Topical Corticosteroids

Topical corticosteroids are the first line of treatment in children < 12 years, irrespective of SALT score.

Intralesional Therapy with Corticosteroids

Inducing hair regrowth and long-term remission with intralesional corticosteroids (ILC) is more effective than topical steroids. Although subdermal or dermal atrophy episodes may complicate the treatment response, the symptoms usually resolve within 8–16 weeks. Adolescents and adult patients should receive 2.5–10 mg/mL (not more than 10 mg/mL) of diluted triamcinolone acetonide as an initial treatment for patchy AA of the scalp, with a maximum dose of 10–20 mg per session.

Systemic Therapies

Prednisolone can be used as a first-line treatment whenever possible. To achieve long-term remission, the initial prednisolone dose is 0.4–0.6 mg/kg/day, with a gradual taper over 12 weeks.

Steroid-Sparing Therapies

Ciclosporin can be used as an effective monotherapy in adult patients. The recommended dose is 3–5 mg/kg/day for a maximum duration of 6–12 months.

Methotrexate can be used as an effective monotherapy for the treatment of severe AA in both adult and adolescent patients aged 13–18 years. However, combination therapy with steroids can be considered on a case-to-case basis. The target dose in adult patients was 15–20 mg/week, whereas in patients aged < 18 years, the target dose was 0.4 mg/kg/week.

JAKi

Although the ACE guidelines were established in 2020 before the global regulatory approval of baricitinib, it is currently the only oral agent approved and licensed by the FDA for the treatment of AA in adults with > 50% of scalp involvement. Thus, it can be considered a first-line treatment for these patients.

First-Line Treatment in Specific Age Groups

Tables 48 and 49 describe ACE treatment guidelines for AA in children and adolescents.

Table 48.

Treatment recommendations for children

Age group	AA severity	Recommended treatment
< 6 years	Acute AA	Topical corticosteroids (irrespective of baseline SALT scores)
7–12 years	Acute AA	On the basis of baseline SALT scores, either topical corticosteroids (0–50% scalp involvement) or topical/oral corticosteroids (> 50% scalp involvement) either as monotherapy or combination therapy ILCs generally not advised
Up to 12 years	Chronic AA	Topical corticosteroids (irrespective of baseline SALT scores)

ILC intralesional corticosteroid, SALT severity of alopecia tool

Table 49.

Treatment recommendations for adolescents

Age group	AA severity	Recommended treatment
13–18 years	Chronic AA	On the basis of baseline SALT scores, ILCs (0–30% scalp involvement), topical or oral corticosteroids (31–50% scalp involvement), and topical or oral corticosteroids as monotherapy (> 50% scalp involvement), either as monotherapy or combination therapy
> 18 years	Chronic AA	Onthe basis of baseline SALT scores, ILCs (0–30% scalp involvement), topical or ILCs (31–50% scalp involvement), and topical or oral corticosteroids (> 50% scalp involvement), as monotherapy or combination therapy

ILC intralesional corticosteroid, SALT severity of alopecia tool

Treatment Discontinuation

Toxicity and incomplete or no response are common reasons for discontinuing systemic treatment. If vellus regrowth fails to convert to terminal hairs, systemic therapy should be continued for 6 months or longer; however, all treatment should be discontinued once complete regrowth is achieved and maintained for 6 months or when regrowth can be adequately managed with topical therapy.

Dermatologists or patients may be compelled to stop treatment due to the financial burden caused by the high cost of treatment on patients.

Current Treatment Algorithm in the UAE

Dermatologists in the UAE have developed the following treatment recommendations on the basis of actual clinical experience, adapting the ACE and American recommendations for local patient care [90, 91]:

In children younger than 12 years, potent topical steroids are initially applied for 2–3 months if the area of involvement is very small.

In children older than 12 years, adolescents, and adults with < 50% of the area of involvement, ILCs are used with or without 5% minoxidil solution, depending on disease severity.

In children, adolescents, and adults with > 50% of the area of scalp involvement, contact immunotherapy with DPCP is used with or without 5% minoxidil solution, depending on disease severity, before considering systemic therapy.

In adults with > 50% of the area of scalp involvement, the oral JAKi baricitinib has now replaced tofacitinib as the first-line treatment in patients who do not respond to topical steroids/ILCs/minoxidil or those with AT and AU.

Unmet Needs

Africa and the Middle East face substantial challenges in improving the diagnosis and treatment landscape for AA. There are no curative treatments and limited treatment options with variations. Finding a standard treatment for this disease is still challenging, despite advancements in the study of the disease pathway and new treatment possibilities. The following are the main obstacles in the management of AA in the region.

Lack of Regional Epidemiological Data

Clinical information on the prevalence, incidence, and treatment of AA in Africa and the Middle East is limited due to the lack of formal registries. Clinical restrictions at healthcare institutions, such as disparities in assessment and treatment protocols, a lack of consensus on treatment algorithms, and ethical limits on taking samples for skin biopsies are challenges. Most regional studies enroll patients from particular socioeconomic backgrounds, have short follow-up periods, and are monocentric with limited data sources and small sample sizes [10, 57, 92].

Availability of Medications

Due to a lack of approved therapies in the region, there is a high prevalence of patients with mild forms of AA and pediatric populations with severe AA [10, 65].

Financial Burden

The biggest obstacle to patients is getting insurance approval for prescription plan coverage because most insurers view AA as a cosmetic condition rather than a serious health issue. When this aspect is coupled with disparities in subsidiary plans among government pharmacies and dispensaries, patients must incur significant out-of-pocket expenses to receive the required prescriptions, which inevitably leads to relapses due to treatment interruption or discontinuation [65].

Lack of Awareness Among Dermatologists and Patients

There is a low level of understanding of AA among family physicians and patients. In many countries, the physical symptoms of the condition are severely stigmatized, discouraging many patients, especially women, from seeking treatment [10, 57].

Lack of Treatment Access

The region’s AA treatment landscape has numerous gaps, particularly in geographically remote locations, due to a lack of access to appropriate diagnostic tools, compassionate use or early access programs, and appropriate therapeutic resources due to heterogeneity across healthcare facilities [93].

Recommendations to Address Unmet Needs

Educational Initiatives

Initiating awareness campaigns for accurate and updated information on the diagnosis and management of AA is essential. This is critical to address the social stigma associated with AA. Education on the efficacy of novel treatments, discouraging self-medication with over-the-counter drugs, and devoting time and resources to patient counseling at hospital or dermatologist clinics are essential strategies [94]. Raising awareness on the background of autoimmunity as the pathogenesis of AA is essential to moving away from labeling it as a cosmetic condition. Additionally, there is a need for specialized alopecia centers and educators to help establish the aforementioned education and awareness initiatives.

Treatment Accessibility

To develop and enhance availability and access to new medications for AA throughout Africa and the Middle East, cooperation between industry, patients, academia, regulators, and payers is necessary. Considerations for commercial success, such as reimbursement and prospective regulatory approval pathways, must be considered from an industrial perspective. However, the lack of efficient, well-tolerated, and licensed treatments for this indication for all severity levels and a lack of reimbursement precedents in comparable dermatological indications that can support further drug research constitute a clear unmet need. Countries should also target expediting the availability of globally approved drugs, such as novel JAKi to treat patients with severe AA [95].

National Registries

We propose leveraging global databases to develop prototype real-time registries specific to the region to provide insights on AA prevalence, disease burden, and available treatment modalities [92].

Reimbursement Strategies

AA has a complicated insurance reimbursement positioning as it is often considered a cosmetic disease with no life-threatening sequelae. As there is a recent shift in paradigm toward clinically meaningful improvement in patient QoL, regulatory bodies can propose the development of targeted therapies as an indicator to justify costs. Furthermore, significant indirect global benchmarks for reimbursement precedent from other dermatological indications, particularly psoriasis and acne, can potentially be applied to this cause [75].

Regional Consensus

Initiatives should be implemented on a large scale to encourage regional experts to meet for consensus-building group sessions. The existing ACE and local UAE guidelines can be used to formulate and adapt local policies to support clinician decision-making processes. It is essential to factor in the regional patient population’s environmental and lifestyle influences into these guidelines.

Patient Support Programs

We recommend creating patient support programs and organizations throughout healthcare facilities to advocate for funding research and to enable access to treatment for patients of all ages and socioeconomic backgrounds [96].

Discussion

This is the first expert review of its kind on the disease burden, treatment landscape, and unmet needs for AA in the Middle East and Africa. Through a comprehensive literature search, we found that Egypt, Iran, Saudi Arabia, and Turkey have conducted controlled studies evaluating and comparing the efficacy of oral, systemic, topical, and intralesional therapeutic options for AA in both adults and pediatric populations. In contrast, minimal data were reported from Israel, Iraq, Lebanon, Jordan, South Africa, UAE, and Kuwait. Since there are currently no standardized treatment protocols that can be shared across regional practitioners, management plans are frequently customized on the basis of hospital facilities, patient preferences, pharmaceutical accessibility, and financial viability. It is unfeasible to undertake an interregional comparison of treatment methods and algorithms due to the lack of established registries and notable differences in the quantity and scope of regional studies conducted across countries.

It was noted that Turkey, Iran, and Egypt investigated therapeutic methods for transepidermal medication delivery, including fractional CO₂ laser, microneedling, cryotherapy, latanoprost, and vitamin D3 injections. On the contrary, data from Saudi Arabia, Iraq, the UAE, Lebanon, and Jordan focused more on traditional treatment modalities, such as topical immunotherapy with squaric acid dibutyl ester, DPCP, minoxidil, and anthralin, as well as oral or ILCs, or systemic immunosuppressive drugs.

Due to a scarcity of approved therapies for each type of AA, many regional patients resort to alternative therapies to temporarily relieve symptoms. The sum of these treatment costs can cause considerable financial stress to patients. National healthcare authorities and stakeholders cannot estimate the total cost to society, and as a result, decide whether present policies for care and treatment adequately meet unmet needs due to a lack of comprehensive regional data on the prevalence and incidence of AA.

While there is a considerable degree of heterogeneity among healthcare systems of nations in the Middle East and Africa marked by disparities in structure and quality of services, the nature of gaps that hinder the optimal management of AA are often similar [97]. Most countries in this region have a public healthcare system that is underfunded and understaffed [98]. This results in limited access to basic healthcare services for patients suffering from AA. Even in countries such as South Africa, Saudi Arabia, and the UAE, where a private healthcare system is available, it is often unaffordable for a significant proportion of the population, thus limiting access to quality healthcare [99–101].

The management of AA in the African and Middle Eastern regions is largely also hindered by limited resources, shortages of healthcare professionals, and lack of infrastructure, such as inadequate hospitals, and limited access to essential medical equipment and medications [93]. Topical and oral medications for AA, such as corticosteroids and immunosuppressants, can be expensive and not widely available, especially in countries with a weak economy [102, 103]. Additionally, in some countries there may be restrictions on importing and using certain medications for AA, further complicating the management of the condition.

The economic status of a country plays a critical role in determining the cost of AA medications. In more economically developed countries, such as Saudi Arabia, the cost of treatment may be higher compared with those with weaker economies. In many African countries, where poverty is widespread, the cost of AA medications may still be prohibitively expensive for many individuals, making it difficult for them to access the necessary treatments for their condition. The combination of high cost and limited resources poses a significant challenge to the effective management of AA in many African and Middle Eastern countries.

The development of regional guidelines is critical for establishing relevant management protocols, particularly for patients with severe AA. It is also advisable to provide focused training to family doctors, specialists, and nurses on the early and accurate diagnosis and treatment of this condition. Other initiatives such as the establishment of patient support programs and development of regional consensus statements to standardize care delivery are also warranted. Due to the various unmet needs in the region for effective, well-tolerated, and convenient therapies for AA, both patients and researchers are likely to be interested in trial participation. This could improve the treatment landscape.

Conclusions

We strongly suggest establishing a regional expert forum to outline disease burden, identify knowledge gaps, and develop management protocols relevant to this population. In addition, raising awareness among the general public and establishing patient support programs is key. We hope that through this manuscript, we can provide directives to dermatologists in Africa and the Middle East on ways to enhance the diagnostic and treatment protocols in their countries and improve the QoL for patients with AA.