How do you manage patients with alopecia totalis who are not candidates for JAK inhibitors?

Severe forms of alopecia areata are very difficult for the patient and provider. The first step in management is to assess where the patient is emotional. How are they managing? What support systems are in place? Once this is addressed, I discuss my treatment ladder. Initial options include class I steroid ointment under occlusion (common side effect folliculitis), and contact sensitization therapy (not suitable for dark-skinned individuals). I try to avoid systemic steroids but have used a 1mg/kg taper over 3 months for acutely worsening disease (with mixed results). Other options are weekly pulsed oral steroids and steroid/methotrexate combination therapy. The issue with systemic steroids is not that they don’t work, but that they often d...