Alopecia

Alopecia - general

Alopecia is a common condition and in most cases can be managed in primary care with reassurance and topical treatments when indicated. Please see links below for further guidance on management and when to consider referral.

Local Clinicians recommend following guidelines:

Primary Care Dermatology Society (PCDS): Alopecia - an overview

National Institute of Health and Social Care Excellence (NICE) CKS-

Alopecia areata- cks.nice.org.uk/alopecia-areata

Alopecia –Androgenetic;

FEMALE: https://cks.nice.org.uk/topics/female-pattern-hair-loss-female-androgenetic-alopecia/

MALE: https://cks.nice.org.uk/topics/male-pattern-hair-loss-male-androgenetic-alopecia/

Differential diagnosis:

All types of alopecia are difficult to treat. Referral may be indicated to help confirm a specific diagnosis but it is important to manage patient expectations when referring.

Red Flags

Scarring Alopecia:

Patients with scarring alopecia should be considered for referral as once hair loss presents with this condition, it is irreversible – see referrals section below

Wigs and hair loss correction

BNSSG ICB offers treatment for the correction of hair loss where the hair loss is the result of previous surgery or trauma, including burns (e.g. reconstruction of the eyebrow following cancer or trauma).

Hair pieces and wigs for patients experiencing total or severe hair loss as a result of alopecia totalis, cancer treatment, previous surgery or trauma are available from local NHS Trusts through commissioned pathways*. Referral is not restricted for these patients.

BNSSG ICB does not commission treatments for the correction of male or female pattern baldness as it is a normal process of ageing and any treatment would be considered cosmetic.

For other causes of hair loss, BNSSG ICB does not routinely commission hair transplantation or the use of the ‘Interlace’ or other hair systems, regardless of gender, for cosmetic reasons.

For further details please see link to the funding policy below:

Wigs, Hairpieces and Hair Replacement Systems Exceptional Funding Request Policy

*Referral for wigs

Primary care can refer directly to the Orthotics service at the Centre of Enablement to request a wig for patients meeting the criteria. There are no details regarding this service on their website but we have been advised that the orthotics referral form can be used (available in EMIS - search othotic or enablement). This form can then be emailed to orthotics@nbt.nhs.uk or you can also telephone for advice: 0117 4144900.

Referral

Advice and guidance

Please consider using the Dermatology advice and guidance service for more specific advice on treatment. 

Secondary Care Referral

Secondary care referral should only be considered if diagnosis is in doubt or there is significant persistent hair loss that has not responded to treatment in primary care.

Patients with scarring alopecia should be considered for prompt referral for consideration of biopsy as once scarred the alopecia is irreversible 

Patients with non-scarring alopecia may also need referring as follows:

• Diagnostic uncertainty
• Some cases of alopecia areata 
• Management issues eg trichotillomania
• If associated with moderate-severe emotional distress

Patients with alopecia areata and SALT score >50 can be referred for consideration of treatment with Ritlecitinib (see further details in section below)

Sirona - Community Dermatology Service 

Options for treatment in the community are limited so referral to the community dermatology service is not recommended.

Ritlecitinib

Ritlecitinib for treating severe alopecia areata in people 12 years and over (updated November 2024)

Ritlecitinib is a hospital only RED traffic light drug and can now be prescribed in secondary care inline with NICE guidelines (1).

Referrals can be made to the UHBW Dermatology team to consider ritelcitinib if criteria are met (NBT are not currently accepting referrals requesting ritlecitinib but hope to be able to in the future - this page will be updated when this changes).

Patients must have at least 50% hair loss determined by the Severity of Alopecia Tool (SALT) to be eligible for ritlecitinib in addition to other criteria assessed by the Dermatology Team. Where it is unclear whether hair loss meets a SALT score of at least 50% please provide photos (left side, right side, top and back of head) for the Dermatology team to assess or request Dermatology advice and guidance.

Referrals for patients with androgenetic alopecia (male or female pattern baldness) will not be accepted.

Referrals should not be made to the community service as ritlecitinib can only be prescribed in secondary care.

(1) NICE guidelines 

Ritlecitinib for treating severe alopecia areata in people 12 years and over | Guidance | NICE

Patient information

Ritlecitinib information for patients - Anticipated Questions and Answers | Alopecia UK

Resources

Alopecia UK- Organisation who provide support on an individual and group basis. They also provide advice and support, promoting self-confidence and helping to support emotional wellbeing where this is needed. alopecia.org.uk/ 

British Association of Dermatology – Patient information leaflets on different types of alopecia. bad.org.uk/for-the-public/patient-information-leaflets 

National Alopecia Areata Foundation naaf.org/ 

Changing faces – Advice and support helpline for patients. changingfaces.org.uk/adviceandsupport

DERMNET NZ- Information for health Care Professionals: dermnetnz.org/

Ritlecitinib information for patients - Anticipated Questions and Answers | Alopecia UK

Efforts are made to ensure the accuracy and agreement of these guidelines, including any content uploaded, referred to or linked to from the system. However, BNSSG ICB cannot guarantee this. This guidance does not override the individual responsibility of healthcare professionals to make decisions appropriate to the circumstances of the individual patient, in consultation with the patient and/or guardian or carer, in accordance with the mental capacity act, and informed by the summary of product characteristics of any drugs they are considering. Practitioners are required to perform their duties in accordance with the law and their regulators and nothing in this guidance should be interpreted in a way that would be inconsistent with compliance with those duties.

Information provided through Remedy is continually updated so please be aware any printed copies may quickly become out of date.